Handbook of Practical Electrotherapy

i
Handbook of
Practical Electrotherapy
Handbook of
Practical Electrotherapy
Pushpal Kumar Mitra

Lecturer in Physiotherapy
NIOH, Kolkata
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Handbook of Practical Electrotherapy
2006, Pushpal Kumar Mitra
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system,
or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or
otherwise, without the prior written permission of the author and the publisher.
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are to be settled under Delhi jurisdiction only.
First Edition : 2006
ISBN 81-8061-620-7
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To
My dear departed
Mother, in her memory
Preface
The scientific art of Physiotherapy has grown by leaps & bounds over the last few decades,
gaining credibility as an established drug-less discipline of modern medicine. The public at
large, especially in India, has become wary of the indiscriminate use of potentially harmful
drugs for even trivial complaints. More and more people are being drawn towards
physiotherapy, recognising it as an effective alternative to conventional drug based treatment.
Though the discipline of physiotherapy has been in practice for over half a century, physicians,
particularly in India, had been traditionally recommending physiotherapy, only as a
supplementary measure to the drug based regime of disease management.
Of late, due to wide coverage given by the media to such issues like the free availability
of over the counter drugs and the dangers of unmonitored use of such potentially harmful
agents, have created awareness among the population regarding the dangers of excessive
dependence on drugs. Physicians have of late begun to realize that physiotherapy can be
extremely effective for the treatment of many disorders, as a complementary force-multiplier
to their own efforts.
The role of physiotherapy in diverse areas of patient care, such as rheumatology,
orthopaedics, sports medicine, paediatrics, neonatology, geriatrics, neurology, gynaecology,
obstetrics, pulmonology, cardiology, etc. is now established beyond doubt and is accepted by
the medical fraternity worldwide. So much so, it has led to a change in the definition of
physiotherapy by the World Health Organisation.
This acceptance has led to a boom in physiotherapy education in India. Physiotherapy has
come of age as a viable career option, either as a self employed professional or as a part of
healthcare infrastructure, in India or abroad, drawing the best and the brightest students in
India. Major universities all over the nation are now offering physiotherapy as speciality
training, at undergraduate and postgraduate level.
In my capacity as a teacher and examiner spanning over two decades, I have had the
opportunity to interact closely with a wide spectrum of student community. The feedback
given by these students regarding problems that they face in pursuing a course curriculum
in Physiotherapy unanimously boils down to the lack of precise volumes that cover relevant
details of the subject, highlighting the applied aspect of the science in a format and language
that can be easily understood by them. This problem is easy to understand, since most of the
publications available on the subject are by foreign authors. Though very well researched and
descriptive, contents of these volumes are usually expressed in an English that is far beyond
the comprehension of the average Indian student, particularly if he/ she have had his/her
basic education in vernacular medium.
The genesis of this hand book on practical aspect of electrotherapy owes its origin to the
need among students for simple volumes, oriented to the practical application of the science,
viii
with adequate text, backed up with plenty of illustrations, in easily understood format and
language. Happily enough, several young authors, involved with undergraduate teaching in
India, being actively encouraged by publishers with the vision, like the J.P.Brothers, are now
coming forward with excellent volumes that will go a long way to encourage many teachers
like me to do their bit for this noble cause. This is volume is a humble attempt to bridge the
gap between the text and the applied aspect of Electrotherapy. With no pretence of being a
magnum opus, it may provide an easy updater for the student or practitioner working in a
clinical setting.
The entire gamut of electrotherapeutics has been divided into three major sections, i.e.
therapeutic electrical stimulation, thermo therapy and actino therapy. Each section commences
with a review of the relevant biophysics. The applied aspects of the modalities considered
under each section have been listed under the headings of Points to Ponder, for quick review
of the essential information. This will be useful for bus stop revisions at exam time. The text
in this volume has been deliberately kept simple and short, with liberal use of illustrations to
project a word picture of the essentials in electrotherapy. Every effort has been made to make
the contents of this volume easy to understand and framed to stimulate the reader to try
using the techniques in a step-by-step manner during practice/clinical sessions. It is also
expected to help fledgling teachers of Physiotherapy, to impart basic training in electrotherapy,
with confidence, projecting the fundamentals firmly in front of their pupil, without too much
technical jargon, which often tends to confuse the teacher and the taught alike.
Among many unique features presented in this volume, I would like to highlight the sections
on precise dosing parameters for each modality. This can be an excellent guide for the beginner
in clinical practice. Each section concludes with a comprehensive chart that details all aspects
of practical application for individual modalities. Placement of electrodes, optimum dosage,
equipment settings, patient position, etc. has been detailed for each region of the body or for
specific clinical condition. Several advanced applications of electrotherapy, yet to be
mainstreamed in clinical practice in India, such as functional electrical stimulation or the
combination therapy, have been presented for the appraisal of the reader. The volume also
contains a section on frequently asked questions during the viva examinations, along with
short and to the point answers. The students can use this section as a means of complete
revision at exam time, since each modality has been explored separately through short question
and answers.
My effort has been directed towards de-mystifying the science and makes it user friendly
for the budding professionals in physiotherapy. I have made every effort to make the volume
as free of factual errors as possible. However, I realise that there is still a lot of scope for
improvement in this volume. I shall be indebted to the reader for any valuable input to make
the further editions more useful.
Pushpal Kumar Mitra
Acknowledgements
This volume would not have seen the light of the day without active participation of my
students in this project. My students, past and present, have been the friend, philosopher and
guide in this maiden venture. Their feedback, advice and quality assessment, though not always
flattering, have been the prime mover behind this effort. In this context I would like to convey
my sincere thanks to Ms. Bani Laha, my erstwhile pupil and present assistant, for the
motivation, backup support and secretarial assistance. I would also like to put on record my
appreciation for Mr. Devidutt Pathak, Mr. Ravishankar, Ms. Richa Kashyap and Mr. Prosenjit
Patra and Mr. Sapan Kumar, all Internees of physiotherapy at NIOH, for literature review
proof reading and research, to make this volume as foolproof as possible. Special mention
must be made for Ms. Divya and Ms. Suravi, visiting internees from GNDU, Amritsar for
organising the photo shoots. Finally I wish to convey my appreciation and thanks to my
teachers, colleagues and patients for their inspiration.
Contents
1. Review of Basic Concepts in Electricity
2. Introduction to Electrotherapy
10
3. Therapeutic Electrical Stimulation
15
4. Low Frequency Stimulation of Nerves and Muscles (NMES)
24
5. Getting Started with Low Frequency Electrical Stimulation
30
6. Pain Modulation Transcutaneous Electrical Nerve Stimulation (TENS)
50
7. Advanced Applications of Low Frequency Electrical Stimulation
57
8. Medium Frequency Currents
65
9. Therapeutic Heat
76
10. Deep Heat Therapy
85
11. Therapeutic Ultrasound (US Therapy)
98
12. Therapeutic Cold
119
13. Therapeutic Light (Actinotherapy/Heliotherapy)
130
14. Frequently Asked Questions in Practical: Viva Examination
142
Index
149
1
Review of Basic
Concepts in Electricity
Definition
Electricity is a form of physical energy that
exists in nature due to excess or deficit of
electrons in any living or non-living object.
In modern times, electricity is the lifeline
of human civilisation. Our world is so
dependent on electrical energy, that failure in
the power grid assumes proportions and
significance of a national disaster.
It will be wise to remember that the living
cell also works on definite electrical principles
like a car battery. Electrical potentials are
generated across the membrane of a living
cell, which governs movement of essential
ions in and out of the cell. Such ionic movements control the physiology and therefore
the life of the cell.
Physical principles of electricity remain the
same in either context. In order to understand
the effect of electrical energy on the living cell
it is important to review the fundamentals of
electricity once again.
Electrical energy exists in nature in two
formsstatic electricity and electrical current.
Points to Ponder
Static electricity is the charge that develops
in any object that has free electrons, other
than a conductor. The nature of static charge

may be positive (+) or negative ().
The objects capable of loosing electrons
develop positive charge.
The objects capable of accepting loose
electrons develop negative charge.
Static electric charge tends to distribute
uniformly over a spherical surface and
concentrate on pointed surfaces of the
charged objects (Fig. 1.1).
Like charges repel and opposite charges
attract each other (Fig. 1.2)
Static electric charge creates a sphere of
influence around itself. This is known as
an electrical field.
The direction of the line of forces is
directed away from the positively-charged
body and towards the negatively-charged
body.
Static electricity does not mean its stationary. A bolt of lightening strikes the
earth when the static electric
Charge generated in a body of cloud
becomes too great for the cloud to hold,
generating intense heat that creates the
thunderclap by overheating the air in the
atmosphere.
An electrical current is the flow of electrons
through a conductor, from a region of
Fig. 1.1: Static electricity & electrical fieldStatic

electric charge tends to spread over the surface of
the charged objects. Concentrations of charge are
greater on any pointed area. Positively-charged
objects have deficiency of electrons, hence try to
attract electrons. Negatively-charged objects have
surplus electrons; hence try to give up the excess
electrons. This imbalance in electron content creates
a sphere of influence around the charged objects,
which is known as the electrical field
higher concentration to a zone of lower

concentration.
By convention, the direction of flow of
electrons is opposite to the direction of
flow of the current (Fig. 1.2)
The rate of flow of electrons is measured
in Amperes.
The force that drives electrons through a
conductor is known as Electromotive Force
(EMF), arises from the difference of
potential between two points in a conductor and is measured in Volts.
The force opposing the flow of electrons
through a medium is known as resistance
or impendence and is measured in Ohms.
The domestic electric supply is an Alternating Current (AC) having a sine wave
at 50 Hz frequencies.
Fig. 1.2: Behaviour of electrical fieldsOpposite

charges attract each other, thus flow of electron takes
place from negatively-charged pole to the positivelycharged pole, which is known as electric current. The
direction of flow of the electric current by convention
is opposite to the direction of flow of electrons, i.e.
positive to negative pole
The supply line has a phase, a neutral and

an earth connection.
The phase carries the current, the neutral
completes the circuit and the earth provides the escape route for any electrons from
that may have escaped the circuit. A fuse
or circuit breaker is essential as a safety
feature in any circuit to break the flow of
current in case of any over load.
INTRODUCTION TO BIOELECTRICITY
AND ELECTROPHYSIOLOGY
Definition
Bioelectricity can be defined as the inherent
electrical energy present in a living cell and
the manifestation of this electrical energy in
day-to-day functions of the cell is called
electrophysiology.
Have you ever thought why the fire fly
glows in the dark? Or how can the electric eel
Review of Basic Concepts in Electricity 3
kill its prey with a shock? Or for that matter

why does the physician order an ECG for a
heart patient?
All have one common answerBioelectricity.
All living cells are like miniature batteries,
constantly charging and discharging as it goes
about living. All of the cells physiological
functions revolve around its electrical status.
A healthy cell is the one that can hold a normal
level of electrical charge and sustain a fixed
potential difference between the cell and its
environment. Any change in this normal
electrical charge can render the cell, like a
batterydead.
The mystery behind this electrical phenomenon is hidden in the composition of the cell.
Nearly 90 per cent of a living cell is made up
of water, in which are dissolved a number of
salts. Like the acid solution in a storage
battery, the dissolved salts in the cellular fluid
provide the ions, which give the cell its
requisite electrical charge. Throughout its life
this electrical potential of the cell changes
simultaneously with all life sustaining
processes, always to regain its resting poten-
tial. Such changes of electrical potentials are

greater and more frequent in sensitive cells
like nerves or muscles.
For ease of understanding, here after all
references to cellular potentials, will be in
context of a human nerve cell, since these cells
has the highest excitability among all the cells
in the body. The neuron is composed of four
basic parts: the soma or cell body, the axon,
presynaptic terminals and the dendrites
(Fig. 1.3). The soma surrounds the nucleus.
The axon can be part of the spinal cord,
connect with muscle nerves or sensory nerves,
or branch into small fibres. The presynaptic
terminals branch off from the axon and send
the action potential to nearby neurons. Dendrites sense information from neighbouring
cells.
RESTING MEMBRANE POTENTIAL
Definition
At rest, every living cell tries to maintain an
electrical equilibrium across its cell membrane
that allows it carry out common minimum
physiological functions. The potential diffe-
Fig. 1.3: A typical nerve cell
Fig. 1.4: Resting membrane potential in a nerve cellThe relative concentration of positively-charged ions like Na+ and K+ is greater outside the cell
membrane than the inside of the cell. The inside of the cell has a large number
of negatively-charged ions like Cl etc. This makes the intracellular
environment negatively-charged and the extracellular environment positivelycharged. Hence -70 mV potential difference exists across the cell membrane
of a nerve cell at rest
rence thus existing across the cell membrane

of a resting cell is called resting membrane
potential.
Points to Ponder
The cell membrane is selectively more
permeable to K+ ions, as compared to Na+
ions.
K+ ions can enter or leave the cell by
diffusion while the Na+ ions cannot do so.
At rest, K + ions and other negatively
charged protein ions are concentrated
inside the cell giving it a net negative charge
and Na+ ions in the fluid outside giving it
a net positive charge.
In a living cell, the number of Na+ ions are
far greater than K+ ions
The inside of the cell becomes progressively more negative as compared to the
outside as the K+ ions gradually diffuse
out.
This creates a difference of potential across
the cell membrane, which is known as
resting membrane potential, which is
70 mV in case of a nerve cell and -90 mV
for a muscle (Fig. 1.4)
Due to passive diffusion, the cell constantly looses K+ ions and some Na+ ions
gain entry to maintain the electrical
equilibrium.
The cell again expels these Na+ ions and
the lost K+ ion is reabsorbed through active
transport mechanism of sodium-potassium pump mechanism, at the expense of
ATP.
The resting membrane potential creates an

electrical field that allows the cell to draw
essential elements and throwout or avoid
unwanted elements.
A cell with normal resting membrane potential
(-70 mV in case of nerves and -90 mV in case of
muscle cell) is regarded as healthy and one with
abnormal resting membrane is regarded as sick.
ACTION POTENTIAL (AP)
Definition
An action potential may be defined as the
momentary electrical activity taking place in
a cell, as a result of a stimulus, signifying a
sudden reversal of resting membrane potential (Fig. 1.5).1
A typical action potential has threshold
potential, depolarisation, repolarization and
sometimes hyperpolarisation. An AP is an all
or none phenomenon. Once a nerve approaches threshold potential, depolarisation
occurs. Open channels for sodium to rush into
the cell characterize depolarisation. An
increase in the conductance of sodium is
observed and the sodium is driven to Nernst
potential. The membrane voltage peaks and
is repolarised by the outward movement of
potassium ions through open channels. An
action potential is often referred to as a spike
because on time scales greater than millisecond they appear as a vertical line.
Any excitable cell like the nerve or muscle
cannot maintain its resting membrane potential indefinitely, since its bombarded continuously with environmental stimuli, progressively lowering its state of polarisation.
When such stimuli of sufficient intensity
hits the cell, a critical threshold of the potential
difference is crossed that leads to sudden
depolarisation of the cell. The sudden depola-
Fig. 1.5: Action potential: An action potential is

generated when the resting membrane potential is
reversed due to any stimulus that upsets the resting
ionic balance of the cell
Stage 1. Resting membrane potential (RMP)-70 mV.
Stage 2. A weak stimulus causes partial depolarisation of the cell till it reaches critical threshold of
55 mV.
Stage 3. Sudden depolarisation of the cell takes place,
with rapid reversal of the RMP.
Stage 4. The cell is completely depolarised and
reversal of the RMP takes place from -70 to +30 mV.
This change is instantaneous creating a sharp spike
potential.
Stage 5. The cell begins the process of recovery to
its RMP
Stage 6. The momentum of repolarisation makes the
cell hyperpolarised.
Stage 7, 8, 9, 10. The cell searches for the mean
RMP by losing or gaining ions as required through
the selectively permeable cell membrane
risation of the cell creates a spike of electrical

potential called the action potential.
Points to Ponder
All excitable cells try to retain normal
resting membrane potential (Fig. 1.5,
stage 1)
Any stimulus, mechanical or electrical,
makes the cell membrane more permeable
to Na+ ions.
As the gates at the cell membrane open,
Na+ ions rush into the cell, trying to change
its polarity (Fig. 1.5, stage 2).
If the stimulus is of small duration and

intensity, the degree of depolarisation is
minimal and the cell soon regains its
resting membrane potential by throwing
out excess Na + ions to reduce its +ve
charge (Fig. 1.5, stage 8 to 10).
An action potential is generated only when
the intensity and the duration of the
stimulus is such that sufficient number of
Na+ ions enter the cell to reduce the resting
membrane potential to a critical threshold
value (-55 mV in case of nerve cell). Such
a stimulus is called liminal stimulus (Fig.
1.5, stage 3)
At this point, the voltage sensitive Na+
channels open wide to allow a flood of Na+
ions to enter the cell, completely reversing
the resting membrane potential from-70
mV to +35 mV. This process is called
depolarisation (Fig. 1.5, stage 2 to 4)
The inside of the cell becomes positively
charged as compared to the outside, as a
result of flow of ions.
This state of reversal of potential lasts for
a very short time (1msec) and the electrical
changes are reflected as a sharp spike
potential when seen through an oscilloscope. The spikes in an ECG are a common
example of the action potential generated in the
heart muscle (Fig. 1.5, stage 4)
Once the depolarisation starts the cell does
not respond to any stimulus till the cell has
repolarised to certain extent (Fig. 1.5, stage
2 to 5). This state of the nerve is called
absolute refractory phase.
Sooner the peak of the action potential is
reached the Na+ channels close and the K+
channels open wide, letting the cell loose
K+ ions rapidly, making the trans-membrane potential progressively more negative. This process is called repolarisation
and the phase of relative refraction (Fig. 1.5,

stage 5).
The K+ channels remain open long enough
to repolarise the cell to 10 to 20 mV below
the resting potential value of -70 mV. This
process is called the phase of hyperpolarisation (Fig. 1.5, stage 6)
K + channels soon close and through
passive diffusion the cell returns to its
normal resting potential (Fig. 1.5, stage 7).
PROPAGATION OF ACTION
POTENTIAL (AP)
Definition
An action potential tends to move along the
body a nerve or a muscle cell, from its point
of origin, like a wave or ripple in a pool of
water. This is called the propagation of action
potential.
An action potential generated in a nerve
may propagate along the axon of the nerve in
either direction (Fig. 1.6).
In a motor nerve, propagation of action
potential takes place proximally towards the
CNS (anterior horn cells in the spinal cord)
and distally towards the peripheral end organ
i.e. the muscle. Action potentials travelling
proximally towards the CNS are known as
antidromic conduction and those travelling
distally towards the neuromuscular junction
are known as orthodromic conduction.
In a sensory nerve, the orthodromic propagation of action potential takes place towards
the sensory cortex and the antidromic conduction takes place towards the peripheral
sensory receptors on the skin.
The orthodromic propagation of action
potential produces the desired effect in its
target end organ where as the antidromic
conduction is believed to be blocked at the
next node of Ranvier from its point of origin.
The character of conduction of an action
Fig. 1.6: Propagation of action potential: An action potential (AP) generated in a non-myelinated nerve cell
spreads throughout the nerve cell membrane by cyclic local circuit depolarisation. The AP is conducted through
the axon to the motor neuron junction from where it is passed on to the muscle fibres, causing them to contract.
In a myelinated nerve the AP jumps from one node of Ranvier to the next, increasing the nerve conduction
velocity considerable. This is known as staltatory conduction
potential along a nerve varies according to the

type of the nerve being stimulated.
In a myelinated nerve, the action potential tends
to jump from one node of ranvier to the next.
Jumping conduction of the action potential
from node to node makes it travel very fast
and such conduction is called staltatory
conduction.
In a non-myelinated nerve, the action
potential travels by successive and progressive
depolarisation of the nerve membrane adjacent
to its point of origin. Such conduction is known
as local circuit conduction and is much slower
as compared to that in a myelinated nerve.
Any action potential is a message. Messages are sent to contract desired muscles, to
signal pain, or to maintain ideal temperature,
etc. The message carried by an action potential

depends on the rate of firing of the action
potentials. The higher the frequency of action
potential firing, the more intense will be the
strength of muscle contraction or intensity of
sensation and the shorter the intervals
between action potentials the weaker the
contraction or the sensation.
This is often referred to as frequency
modulation (Deutsch and Deutsch, 1992).
When generating action potentials artificially
by electrical stimulation, the desired effect
depends on the frequency of the stimulus. At
higher frequency the effects are limited to
those nerves with a low threshold of stimulation, i.e. sensory nerves. For the motor
nerve to be stimulated effectively, due to its
higher threshold, the frequency of stimulation

must be low and strong enough to produce
muscle contraction.2
Every action potential is characterized by
a specific active one hundred millivolt signal
that does not decrease in amplitude over time
(Kendal et al, 1991). Each of the fifteen sensory
receptors of the body sends its message
through a different path in the body. This is
how one sensory message is differentiated
from the other. The action potentials generated by motor nerves are similar in nature
and can spread its effect to the neighbouring
muscles throught he process of excitation.3
Points to Ponder
Creation of an action potential at one
segment of the cell membrane triggers
depolarisation of the neighbouring segments of the cell membrane.
This wave of depolarisation moves along
the surface of the nerve or muscle cell, by
local circuit conduction, until the entire cell
has been covered. The nature and rate of
conduction of the action potential varies
according to the type of the tissue.
In non-myelinated nerve and muscle fibres
the action potential spreads via successive
depolarisation of the neighbouring sites of
the cell membrane in local circuit conduction. The speed of such conduction is
inversely proportional to the diameter of
the cell fibre.
In myelinated nerves, the ion exchange
takes place at the nodes of Ranvier, which
are breaks in the myelin sheath of the
nerve. Conduction of an action potential
takes place from one node of Ranvier to
the next. This type of jumping conduction
is called staltatory conduction. The speed
of such conduction is much faster than local
circuit conduction.
An action potential generated in a nerve

may propagate along the axon of the nerve
in either direction.
Action potentials travelling proximally
towards the CNS are known as antidromic
conduction and those travelling distally
towards the neuromuscular junction are
known as orthodromic conduction
The orthodromic propagation of action
potential produces the desired effect in its
target end organ where as the antidromic
conduction is believed to be blocked at the
next node of Ranvier from its point of
origin.
The effect of an action potential depends
on the rate of firing or the frequency of the
action potentials, the amplitude being
constant for a given type of nerve producing the action potential.
WHAT IS THE SIGNIFICANCE OF
THIS BIOELECTRICAL DRAMA
TO THE PHYSIOTHERAPIST?
In the preceding chapter we have seen that
the living cell generates and maintains
detectable electrical potentials. This
electrical potential existing in the living
cell is subject to change, with every
physiological activity of the cell. The
cellular electrical potentials are so essential
for the survival of the cell, that any
disturbance in the balance of electrical
potentials in the cellular environment can
make the cell sick. Conversely, restoring
normal electrical potential of a sick cell can
cure the disorder of the cell. Since a living
cell, like the storage battery, is basically an
electrical entity, it can be charged to an
optimum potential by exposure to an
external electrical energy source, either
directly or indirectly through an electrical
field generated by electrostatic or electromagnetic induction.
Understanding the electrical characteristics of excitable cells like nerve and

muscle helps the physiotherapist
To identify external electrical energy
sources that can effectively influence the
electrophysiological function of these cells
and derive a therapeutic benefit out if such
exposure. Different methods treatments
for different malfunction in bodily tissues
have been devised based on the bioelectrical properties of the cell and their
response to various forms of electrical
energy. Thus the foundation of all electrotherapy modalities is based on the bioelectrical drama being enacted in the living
cell throughout its lifetime.
Apart from the therapeutic application,
bioelectricity also serves an important
diagnostic implication. Sensitive electrodes
are used to pick up the electrical potentials
generated by the cell. These tiny electrical
potentials are amplified and modulated to
produce discreet waveforms, which project
reproducible information regarding the
electrical functioning of the tissue. The
waveforms are then projected on to a
cathode ray tube for visual analysis. Any
malfunction in the tissue is reflected in the
waveform generated by the tissue. For
example, ECG, EEG and EMG are bioelectrical tests that provide relevant
information regarding the electrical functioning of the heart, brain and the skeletal
muscles respectively, indicating the state of
health of these organs. Nerve conduction
velocity (NCV) study indicates the rate of
conduction in a nerve. Results of these tests,
when compared to normal values, may
help in diagnosis of any disorder in these
organs or tissues.
Physiotherapist may use this information

to assess, prognosticate and treat specific
disorders pertaining to the musculoskeletal system. EMG biofeedback is a
form of treatment that uses the electrical
potentials generated by the skeletal
muscles. The patient can be shown the
pattern generated by maximal effort by a
normal muscle, which acts as a target. The
patient is then asked to focus his effort in
the effected muscles to reproduce the
pattern generated by the normal muscle.
Such feedback reinforces the activity in
affected muscles helping in re-education
of function, which is useful in treatment
of upper motor neuron lesions.
To summarise, for the physiotherapist, the
knowledge of bioelectrical principals and
its effects on the physiology of the living
tissue serves as the corner stone for
selection of appropriate electrotherapy
modality and application of the same for
different disorders. Further, this knowledge is also essential to under take various
tests and interpret the results and protocols
for electrodiagnosis. Therefore, an exhaustive knowledge of bioelectricity and
electrophysiology is the key to turn the
physiotherapist from a technician to a fully
fledged clinician
REFERENCES
1. Alberts B, Bray D, Lewis J, Ra HM, Roberts K,
Watson JD. Molecular Biology of the Cell.
Garland Publishing Inc: New York, 1983.
2. Walsh JC. Electrophysiology. In Electrophysical
Agents in Physiotherapy: Therapeutic and
Diagnostic Use (Wadsworth H, Chanmugan
APP, Eds) Science Press: Marrickville, NSW
Australia, 1988.
3. Charmen RA. Bioelectricity and electrotherapyTowards a new paradigm? Part 1-4. Physiotherapy 1990;76(9,10,11):503-730.
10
2
Introduction to
Electrotherapy
Definition
Application of electrical energy to the living
tissue for remedial purposes is known as
electrotherapy.
Such therapeutic application of electrical
energy can be done:
Directly, through amplitude or frequency
modulation of electric current to stimulate
excitable tissues like nerves and muscles,
commonly known as low or medium
frequency stimulation.
Indirectly, using the capacitance or inductance properties of living tissue, subjected
to high frequency electrical field, to
generate heat in the tissues, commonly
known as short wave or microwave
diathermy.
By converting high frequency electric
current into high frequency sound energy,
to produce mechanical micro-massage,
heat generation and protein synthesis,
commonly known as ultrasound therapy.
The first-ever recorded attempt at application of electrotherapy is credited to the
ancient Greek, who used live electric eel
placed in a shallow tub of water to soak the
feet in, as a treatment for gouty arthritis.
Benjamin Franklin, philosopher, scientist

and one of the authors of the Constitution of
United States of America was probably the
first person to deliberately apply electrical
charge to a paralysed limb, with shocking
results. The experiment however had to be
prematurely discontinued due to extreme
reluctance on the part of the patient to be
subjected to such torture.
Even today, most patients turn pale or
even miraculously recover, whenever low
frequency electrical stimulation is discussed
as a therapeutic option. I have often found
many seasoned therapists to be reluctant to
test the electrical stimulators on themselves,
and choose to ignore an essential safety
checklist, just because of its close association
to an electric shock.
The situation however reverses and the
patient becomes readily compliant, if the
same electrotherapy involves application
of high frequency current to generate heat,
as in SWD or ultrasound therapy.
Safety considerations in electrotherapy
ELECTRICAL SAFETY
Dear reader, please pay close attention to the
following passage and really think about the
Introduction to Electrotherapy
points to ponder, as this may save a life some

day. Under the oath of Hippocrates, health
care professionals are debarred from,
knowingly or unknowingly, harming their
patients. This stricture holds good for the
physiotherapists, particularly when using a
lethal energy source like electricity. Every
possible precaution must be taken to prevent
accidental injury to the patient while applying
electrotherapy
You must remember that electricity is a
potentially lethal energy source that can kill
or injure the careless.
Safety in application and maintenance of
all electrotherapy equipments should be given
first priority, particularly if they are used in
close physical contact of the patient, with the
body being arranged as a part of the circuit.
The Environment of the
Electrotherapy Unit
Electrical energy, in spite of its uses, is
potentially lethal in nature.
Safety-first should be the primary concern
behind the design of any electrotherapy unit.
The common sense dictates that if you are
playing with a potentially lethal energy, your
primary concern should be to avoid risks that
could endanger your and your patients life
and well being.
Points to Ponder
The environment of the electrotherapy unit
must be dry and damp free, with insulated
flooring having vinyl tiles or linoleum.
The therapist and patient must use insulated footwear (rubber or plastic) in
absence of insulated flooring.
Always use wooden plinths and insulated
equipment trolley (metal frame with sun
11
mica/glass top) in an electrotherapy

department.
Engage a qualified electrician to check
your electric supply lines periodically,
paying maximum attention to the affectivity of the earth line and proper calibration of the mains fuse.
All electrotherapy equipments must be
isolated electrically from each other and
the patient, to minimize the risk of accidents, signal interference and malfunction.
Equipment Safety in
the Electrotherapy Unit
Any machine has the freedom to malfunction
and the electrotherapy equipments are no
exception. Moreover since the nature of
electrical energy is potentially lethal, its use
on living human beings calls for extreme
caution.
Electrotherapy equipments are electronic
devices that usually operate on the domestic AC power supply. Some of these
equipments may be battery operated.
As a safety feature, all electrotherapy
equipments use earth free DC current. The
primary current is obtained from domestic
AC current supply. A suitable voltage is
then obtained by subjecting the AC current
to a step down Trans former. From the
secondary coil of a step-down transformer,
an earth free AC current is obtained. This
earth free AC current is then routed
through a full wave rectification circuit to
obtain an earth-free DC current (Fig. 2.1).
Earth-free current used in electrotherapy
equipments eliminate the risk of earth
shock. It is therefore essential to periodically check the earth-free nature of the
secondary current supply in all electro-
12
Fig. 2.1: Converting AC current to earth-free DC

current: Alternating current from the domestic outlet
is subjected to full wave rectification and smoothing
to obtain monophasic earth-free DC current which is
utilised to operate electrotherapy equipments
therapy equipments by a qualified technician.

Any electricity that leaks from the circuit
between the live and the neutral terminal
from the primary circuit is diverted to the
earth through the earth terminal. Hence a
qualified electrician should check the
proper functioning of the earth terminal
provided with the domestic supply outlet.
If the earth line is defective the equipment
body.
Points to Ponder
The electrotherapy equipments must be
stored in damp proof wooden cabinets.
The electrotherapy equipments must have
matched internal fuses. Fuses of less or
larger calibre may damage the equipment.
All leads and cables must be checked
frequently for any crack or damage.
Always store leads and cables in a loose
coil and avoid trailing them on the floor,
kinking or bending them.
Always make a visual check before using

any electrotherapy equipment and test the
machines periodically on yourself. Any
defective equipment must be taken out of
circulation immediately and sent for
repair.
The service engineer must certify repaired
equipments in writing, before being put to
use on patients. This will save you from
legal action in case of an accident involving
repaired equipment.
Preventive maintenance includes yearly
checkups by qualified service engineer.
Do not handle equipments with wet
hands.
Safe Application Procedure of
Electrotherapy Modalities
This should be clearly understood that the
electrotherapy modalities are applied on the
surface of the skin. Hence, the energy derived
from these modalities are have to travel
through the skin to the under lying tissues to
produce the desired effects.
The skin is the largest organ in the body,
covering the entire surface of the body, which
has largely a protective role to play. As such
the skin has five layers of cell, four of the top
layers being composed of dead cells and only
the lower most layers having living cells. This
arrangement of cellular layers is useful in
making the skin impervious to heat, cold,
water, corrosive chemicals, friction and
electrical charge. The electrical resistance
offered by dry skin is in the region of 5000
Ohms. For applying electrical stimulation, a
large volume of electrical energy will be
needed to over come this resistance and reach
the underlying muscles and nerves. The
sensory receptors of the patient may not be
able to tolerate such high intensities of
Introduction to Electrotherapy
electrical current. Hence, prior to application

of electrical charge, in the form of electrical
stimulation to the body tissues, the skin
resistance must be brought down to at least
1000 Ohms. This procedure of lowering the
skin resistance is applicable to any form of
electrotherapy or electrodiagnosis that utilises
direct application/transducing of electrical
charge to or from the body. It is not relevant
for other applications of electrotherapy like
thermotherapy, insonation or actinotherapy.
Points to Ponder
Ensure the body surface of the patient is dry
before giving high frequency current, particularly in humid conditions, because of the risk
of scald due to concentration of current over
moist areas.
Moisten the part carefully before low or
medium frequency current therapy, to
lower the skin resistance or the patient is
likely to feel intense burning sensation.
Make sure the patient does not have a pace
maker while entering an electrotherapy
section, because the electrical field generated by the electrotherapy equipments are
likely to interfere with the function of the
pace maker within a range of 3 meters.
Switch off and remove any mobile phones
and hearing aids, while applying high
frequency modalities.
Warn the patient not to move unnecessarily or touch the equipment body while
being treated.
Be careful not to keep any lead or cable in
contact with the body of the patient.
Explain to the patient in detail, the
expected reaction or sensation produced
by a specific modality, before application.
Stay close by while the patient is under
going electrotherapy. You may be needed
13
if the patient feels any unexpected sensation like too much heat, prickling or
burning.
Keep an alarm bell near the patient in case
you are needed to be called.
In case of the very old or very young or
mentally retarded patients, avoid the use
of deep heat or prolonged cooling. The
reaction threshold of these patients may be
inappropriate and you may be informed
of any discomfort too late to prevent
damage.
In pregnant or menstruating patients
avoid exposure of the pelvic region to deep
heat modalities like short wave or microwave diathermy. In case of a male avoid
exposure to testes.
Do not give any electrotherapy over eyes
and heart.
Always use protective goggles while
applying any light modality like infrared,
ultraviolet or laser.
Keep a detailed record of any adverse reaction,
like allergy or rash or burn that may occur
in spite of precautions and seek medical
advice if the reaction is severe.
Management of electrical accidents
Accidents may still occur in spite of your
best efforts to avoid them. In case of an
unfortunate incident when someone suffers
an electric shock follow the following points
carefully.
Points to Ponder
Disconnect the mains supply to the
equipment.
Disconnect the patient from the machine
circuit.
Lay down the patient if in shock and turn
the head to one side if the patient is
unconscious; this will do to prevent the
tongue from falling back (and so prevent
14
any blockade of the airways). To position

the tongue away from the windpipe, it
must be tied to the lower jaw with a
handkerchief, to prevent it from falling
over the entrance of the airway. Start
cardiopulmonary resuscitation (CPR) if
breathing has stopped. Send for medical
assistance while you try to stabilize the
patient.
Do not leave the patient alone.

In case of a scald or burn, apply cold water
to the site. Do not spill water on the
equipment.
Prescribe a topical antibiotic cream like
silver sulphadiazine (silverex) in case of
blister formation.
Keep your professional indemnity insurance paid up to date.
3
Therapeutic
Electrical Stimulation
Definition
Electrical stimulation involves application of
suitably modified electric current to stimulate
excitable tissues like nerves and muscles, with
the aim of producing physiological reactions
that have clear therapeutic benefits.
The application of electrical stimulation,
as an integral part of electrotherapy, has come
a long way since the times of Benjamin
Franklin.
With the advent of computerized stimulators, with idiot proof features, it has now
become an effective modality in the arsenal
of the therapists, with carefully modulated
impulses that cause minimum irritation and
discomfort to the patient, while getting maximum response from nerves and muscles.
However, to be able to use this therapeutic
hardware, one must be well conversant with
the characteristics of electrical stimulation,
necessary to initiate depolarisation in excitable tissues like nerves and muscles.
HOW DOES ELECTRIC
STIMULATION WORK?
Nerves and muscles are excitable tissues that
respond to any sharp and sudden stimulus
that can cause depolarisation in these cells.
Nature of Such stimulus may be mechanical, like a sharp tap on the nerve or the
tendon; chemical, like the discharge of
neurotransmitters taking place at the neuromuscular junction or an electrical impulse.
Once the depolarisation of theses cells reach
a critical level the chain reaction takes over
till an action potential is created. Since nerves
have a lower threshold they are stimulated
faster than the muscles. The required intensity
of the stimulus is lower in the nerves than in
the muscles (Fig. 3.1).
Points to Ponder
Intensity of each stimulus or pulse amplitude must be strong enough to cause the
resting membrane potential to be lowered
sufficiently to achieve the critical threshold, which is the point of no return for
the nerve/muscle to depolarise completely. However, once the cell depolarises,
repetition of the stimulus of same or
greater intensity will not provoke any
response till the cell has re-polarized.
Nerve cells work on the principles of all
or none law.
The duration of each stimulus or pulse
duration must be long enough to produce
16
Fig. 3.1: Nature of electrical stimulus: Electrical

stimulation is an artificial electrical stimulus of specific
pulse duration, intensity and shape, applied to an
excitable tissue to generate a response. It is first given
at low intensity, which is then gradually increased till
the critical threshold of the excitable is crossed, to
produce a response in the target tissue, i.e. nerve or
muscle
depolarisation of the cell membrane. In

case of nerve, pulse duration between
0.01 to 1 msec is adequate to produce a response but for a muscle this is too short a
duration. A muscle cell devoid of nerve
supply needs 100 to 300 msec pulse duration to provoke a contraction.
The rate of rise of the stimulating current
from zero to peak must be adequately
matched to the response threshold of the
target tissue to produce a satisfactory
response (Fig. 3.2)
To stimulate a nerve the rate of rise must
be fast enough to prevent accommodation.
Accommodation is the rapid adjustment
of the nerve to changing electrical environment to prevent depolarisation.
To stimulate a muscle devoid of nerve
supply a slow-rising current is most suitable.
The rate of rise of a stimulus is usually
reflected in pulse shape.
Fig. 3.2: Types of electrical impulses: Types of electrical impulses commonly used in electrical stimulation
are fast-rising or slow-rising in nature. In a fast-rising
impulse the intensity rises from zero to peak within a
very short period of time. This rapid rise does not allow
the nerve to be accommodated, causing depolarization. Fast-rising impulses can be square, rectangular or spike-shaped. Slow-rising impulses, as the name
suggests, rise from zero to peak intensity with
sufficient time lag which allows the nerves to be
accommodated to the changing electrical environment. Hence, with such slow-rising impulses, higher
intensity stimulus can be used to stimulate denervated
muscles, which have much higher threshold than the
nerves
A fast-rising impulse have square, rectangular or spike-shaped.

Slow-rising impulses are trapezoidal,
triangular or saw-tooth in shape. Slowrising impulses are also called selective
impulses. Frequency or rate of repetition
of a stimulus is the third most important
parameter in the biophysics of a stimulating current.
Lesser the frequency of a stimulus the
greater will be its effect on nerves and
muscles and vice versa.
Frequency of a stimulating current is
inversely proportional to pulse duration.
The greater the frequency, smaller the
pulse duration
Therapeutic Electrical Stimulation 17
Fig. 3.3: Motor unit A motor unit is the fundamental building block of
the neuromuscular complex. A motor unit consists of one motor nerve
cell, its axon and muscle fibres supplied by the axon filaments. Many
such motor units combine together to make an innervated muscle. The
response threshold of such a muscle is equal to that of the motor nerve
supplying it
Motor nerve or a motor unit has a frequency threshold between 1 to 150 Hz

with optimum pulse duration of 0.01 to
1 msec.
WHAT IS A MOTOR UNIT?
A motor unit is composed of one neuron,
its axon, dendrites and the muscle fibres
supplied by the axon (Fig. 3.3).
It forms the building block of the neuromuscular complex. The entire motor unit
shares the response threshold of the motor
neuron. Sensory nerves have a response
threshold up to 4000 Hz, with very small
pulse duration, because their response
threshold is much lower than motor
nerves.
Muscle tissue, without a nerve supply;
have a very high response threshold
requiring a large amount of current to be
stimulated. It needs a pulse frequency
from 1 to 3 Hz, with optimum pulse duration of 100 to 300 msec.
RELATIONSHIP BETWEEN STRENGTH

AND DURATION OF AN ELECTRICAL
STIMULUS: THE SD CURVE
The SD curve, a graph in which the X-axis
refers to the intensity and the Y-axis refers to
the duration of the stimulus with which the
nerve/muscle is stimulated, determines the
close relationship between the intensity and
the duration of an impulse (Fig. 3.4).
The nerve/muscle is first stimulated at the
longest duration, i.e. 300 msec and the intensity
required in mAmp/mVolts to produce the minimal
perceptible contraction is recorded. This is known
as the rheobase value. The duration is then
progressively lowered to 100, 30, 10, 3, 1, 0.3,
0.1, 0.03, 0.01 ms and the minimum intensity
needed to produce a response is recorded. The
values of intensity are then plotted against
respective pulse durations on a standard graph
paper. The resultant plotting is known as the
SD curve. The first recording of the SD curve
should be done at least three weeks after the
suspected nerve injury. A series of recordings are
18
then taken, preferably on the same graph

paper, at an interval of one week each. The
shifting of the curve will indicate the status of
nerve recovery (Fig. 3.5).
Points to Ponder
Fig. 3.4: Strength duration curve indicates the relationship between the intensity/strength of an electrical
stimulus and the duration of the stimulating electrical
impulse
Electrical response of any excitable tissue, like
an innervated muscle, depends on the intensity,
the duration and the rate of rise of the stimulus
applied to it.
While plotting a SD curve the target muscle or
nerve is stimulated with a rectangular interrupted
galvanic stimulus with pulse duration of 300 msec.
The intensity required to produce a minimum
perceptible response at maximum duration is
recorded, which is known as the rheobase.
The duration is then progressively shortened to
100, 30, 10, 3, 1, 0.3, 0.1, 0.03, 0.01 msec respectively.
The intensity required eliciting response at each
of these pulse durations are recorded.
The pulse duration that is needed to elicit a
response at intensity double the rheobase is
known as the chronaxie.
In the above example, at the maximum pulse
duration of 300 msec, the minimum intensity
required is 5 mv.
This remains constant even though the pulse
duration is progressively shortened up to the pulse
duration of 1 msec.
The required intensity then rises sharply as the
pulse duration is further shortened to 3, 0.1, 0.03
and 0.01 msec. Such SD curve is typical of a
normally innervated muscle
Rheobase is the intensity of current

required to produce a minimal perceptible
response in a nerve/muscle with a stimulus of infinite duration, i.e. 300 msec.
Chronaxie is the shortest pulse duration
required to produce a minimal perceptible
response in a muscle, at twice the intensity
of Rheobase. Normal chronaxie for innervated muscle is less than 1 msec.
A strength-duration curve (SD curve) is
plotted to determine whether a muscle is
innervated, denervated or partially denervated/innervated.
TYPES OF THERAPEUTIC CURRENT
Therapeutic currents can broadly categorised
as stimulating and ionising currents. Stimulating currents are classified on the basis of
Frequency, duration and shape of the stimulating impulse. They may be either low
frequency or medium frequency currents,
which have stimulating effects on nerves and
muscles. The ionising currents usually have
a high frequency range and have mostly
heating effects on the body tissues.
Low Frequency Currents
Electrical current impulses having pulse
frequency between 1 and 250 Hz, used for
stimulation of nerve or muscles, are known
as low frequency currents (Fig. 3.6).
Fig. 3.5: Relationship between strength and duration

of an electrical stimulus to predict improvement or
worsening of nerve supply to a muscle
Strength duration curve, when plotted repeatedly,
at intervals of one week, can give a picture of
progressive innervations or denervations taking
place in a muscle.
The graph at extreme right shows a picture of
complete denervation in the muscle, with the
required intensity rising sharply as the pulse
duration is shortened beyond 100 msec.
When the graph is plotted subsequently after
some time, the required intensity rises sharply till
up to 10 msec and then levels off creating a kink
at 10 msec.
Thereafter the required intensity remains same
as the pulse duration is progressively shortened
to 3 msec.
This kink is indicative of partial innervations of the
muscle. Subsequent graph plotted at an appropriate interval indicates normal nerve supply.
In case of progressive denervation the kink shifts
towards the right upper corner of the graph, till a
full deneravtion pattern emerges. In case of
progressive innervations, the kink shifts towards
the lower left hand corner of the graph, till a normal
pattern emerges.
Thus the SD curve can be used to predict the rate
and the potential for recovery of muscle function,
as a convenient tool of electrodiagnosis for the
physiotherapist.
Site of lesion extent of denervation not detected
by SD curve
Fig. 3.6: Low frequency current forms

Low frequency currents are basically of two types,
interrupted galvanic current and faradic current.
Monophasic rectangular pulses, with durations
ranging from 10.01 to 300 msec are called interrupted galvanic current.
Ultrashort duration interrupted galvanic impulses,
shaped like a spike, available in trains of impulses,
are known as faradic type current.
Such train of impulses can be modulated to
produce a wave-like pattern, is known as surged
faradic current.
Biphasic impulses, with a shallow positive phase

and a sharp negative phase is called pure faradic
current. Such currents are produced by the SmartBristow coil and are not used nowadays
Subtypes of Low Frequency

Stimulating Currents
a. Interrupted galvanic current Interrupted
galvanic current is a monophasic direct or
galvanic current, broken at preset intervals
and allowed to flow for a preset pulse
duration with a frequency between 1 and
6 Hz, and a pulse duration between 1 and
300 msec. These are also known as long
duration currents, specifically used for
stimulation of de-nervated muscles or
20
b.
c.
d.
e.
motor point detection in innervated

muscles.
Faradic type of current Faradic type of
current is very short duration monophasic
interrupted galvanic current, with frequency between 50 and 100 Hz and Pulse
duration between 0.01 and 1 msec. These
are also known as short duration current,
specifically used as surged faradic current
for stimulation of innervated muscles.
Pure faradic current Pure faradic current is
a biphasic current with a sharp negative
spike of 1 msec, followed by a gentle
positive trough of 4 msec; with a frequency
of 50 Hz. Traditionally it was produced by
the Smart-Bristow coil, though not used
any more.
Transcutaneous electrical nerve stimulation
(TENS) Transcutaneous electrical stimulation uses ultrashort duration (50 to 300
micro second) impulses at a frequency of 1
to 300 Hz, used mainly for relief of pain
through stimulation of sensory nerves. The
impulses may be asymmetrical biphasic or
monophasic (Fig. 3.7).
Iontophoresis Continuous direct current,
used at low voltage and intensity, with the
aim of transferring therapeutically useful
ions, through the skin or mucous membrane to the body.
MEDIUM FREQUENCY CURRENT

These types of currents are commonly called
interferential currents and are in the frequency
range of 2000 to 4000 Hz. These types of
currents have a strong sensory effect and are
used for stimulation of deep muscle through
an interference pattern producing low frequency stimulation at a very high intensity,
bypassing the sensory barrier of the skin. Such
treatment modality is broadly referred to as
interferential therapy. The interferential currents
Fig. 3.7: Current forms used in TENS:

Conventional TENS current consists of biphasic
very short duration impulses at very high
frequency, with intensity just at the level of sensory
threshold. This type of TENS is called HI-TENS,
used for relief of acute pain.
Selectively TENS may also be applied through
acupuncture points, with longer duration impulses
at low frequency, with high intensity almost to the
level of pain threshold. Such TENS is called LOTENS, used for relief of chronic pain.
Burst mode TENS combines the characteristics
of both HI and LO TENS, using train of impulses
of HI-TENS repeated at a preset discrete interval
are available in two-pole or four-pole format

(Fig. 3.8).
Subtypes of Interferential Currents
a. Two-pole medium frequency current
(2000-4000 Hz)
1. Russian current (2000 Hz)
2. Medium frequency surge current
(4000 Hz)
b. Four-pole medium frequency/interference
current (4000-4100 Hz)
1. Classical interferential current
2. Isoplaner vector current
3. Dipole vector current
c. Microwave diathermy (Frequency 1-10

GHz, wavelength 3-300 cm).
Points to Ponder
Fig. 3.8: Current forms used in medium frequency stimulation or IFT:
Medium frequency currents produce significantly

less irritation than low frequency currents and
therefore can be used at much higher intensities,
with deeper effect.
Most commonly two independent medium
frequency currents are used, at frequencies slight
out of phase.
Such current when crossed with each others field
produces a beat frequency deep within the body
tissue.
The beat frequency thus achieved has all features
and effects similar to low frequency stimulation.
HIGH FREQUENCY CURRENTS

These are used mainly for deep heating and do
not have any direct stimulating effect on
nerves or muscle due to extremely high
frequency in the range of 10,000 Hz to 3 MHz.
With proportionately small pulse duration,
that does not cause depolarisation but creates
oscillation of ions and molecules of the cell
releasing energy as heat.
Subtypes of High Frequency Currents
a. Long wave (Frequency 1 MHz, wavelength 3 Km)
b. Short wave (Frequency 27.12 MHz, wavelength 11.3 m)
Stimulating currents are those that can

generate response in excitable tissues like
nerves and muscles.
Low frequency and medium frequency
currents are capable of generating such
response in nerves and muscles. This is
because the pulse duration in low frequency and medium frequency currents
are large enough to cause depolarisation
in excitable tissues.
High frequency currents cannot generate
such response because their pulse duration
is too small. They are used primarily for
heating tissues. Energy from high frequency current is transferred to the tissue
through molecular agitation as heat.
Nerves are more sensitive than muscles.
Nerves need smaller pulse duration than
the muscle to produce a response.
PRODUCTION OF LOW FREQUENCY
STIMULATING CURRENT
Basic circuit used to produce stimulating
current is based on the multivibrator circuit,
which can interrupt a smooth monophasic DC
current to produce interrupted galvanic
current. Most modern electrical stimulators
use a dual circuit with separated +ve and ve
terminals colored red and black respectively.
The equipment also offers interrupted galvanic current with pulse durations of 300, 100,
30, 10, 3, 1, 0.3, 0.1, 0.03 and 0.01 msec
available through a rotary step selector, as
well as faradic type of current with adjustable
surge duration and interval, through individual rotary selectors. The intensity controls
are separate for either type of current
(Fig. 3.9).
22
alternating current, used in surged faradic

or asymmetrical alternating current, used in
high voltage galvanic stimulation.
Polyphasic pulses Biphasic current producing three or more phases in a single phase,
used in Russian or interferential current.
MODULATION OF STIMULATING
CURRENTS
Fig. 3.9: Production of stimulating currents using a
multivibrator circuit: A multivibrator circuit is an
oscillating circuit that is used to break smooth
monophasic DC current into discrete impulses of
different pre-selected pulse durations with different
pre-selected repetition rates
WAVE PATTERNS OF STIMULATING

CURRENTS
The shape, polarity and the arrangement of
the electrical impulse used in therapeutic
stimulation is critical to the response it
produces and is called its wave pattern.
Response of excitable tissue to the stimulating current varies according to the
shape of the stimulating current. Specific
types of current impulses are needed to
produce desired response in specific type of
tissues.
Points to Ponder
Monophasic pulses Unidirectional flow of
electrons, interrupted at preset duration
and repetition rate, producing square,
rectangular, trapezoidal, triangular, used
in Interrupted Galvanic Current or spike
shaped pulses used in Faradic Type of
Current.
Biphasic pulses Bidirectional flow of
electrons, with one half of the cycle in
+ direction and the other in direction of
the isoelectric line, producing symmetrical
Modulation of a stimulating current is the

changes in the characteristics of the stimulating current, which occurs at a preset rate
and limit, to avoid accommodation of nerves
during stimulation.
Nerves have the ability to rapidly adapt
to any changed electrical environment. This
makes a stimulating electrical impulse
ineffective, if applied for a long duration. As
such, the type of the impulses are altered or
modulated automatically by present generation equipments, to suit the response threshold of a nerve and the clinical result desired.
Different forms of therapeutic stimulating low
frequency currents are listed below along with
their usual application in therapy.
Points to Ponder
Continuous direct current Smooth unvarying flow of electrons, used in Iontophoresis.
Interrupted direct/galvanic current Sharp
interruption of current flow at preset
intervals after a preset duration of flow,
used in stimulation of denervated muscle.
Surged faradic current Wave-like gradual
increase and decrease over a preset
duration and interval, used in stimulation
of innervated muscles.
Ramped current Sloping rise in intensity
to a preset peak, within preset pulse
duration, followed by a gradual or sudden

drop to zero, may be used in TENS, FES
etc.
THE MOTOR POINT
The motor point is that point on the surface
of the body, where if applied, electrical
stimulation can produce maximum response
in the underlying muscle.
Once the type of current has been selected
it is important to identify the most suitable
spot on the body, to apply it. The skin over
entire muscle does not have equal sensitivity.
The electrical stimulation should be applied
through only those spots that produce
maximum response with minimum intensity
of current, i.e. the motor point (Fig. 3.10).
Points to Ponder
Electrophysiologically, the motor point can
be defined as the area of greatest excitability on the skin overlying any superficial
muscle that can produce maximum muscle
contraction with minimum amount of
current.
Fig. 3.10: Motor point:

Anatomically, the motor point may be defined as
the spot where the motor nerve axon enters the
muscle.
Electrophysiologically, it may be defined as the
spot on the skin surface over the muscle belly,
where strongest muscle twitch can be obtained
with minimum current intensity
Anatomically, it is defined as the point

where the motor nerve enters an innervated muscle.
When the nerve supply has been destroyed, the motor point is located slightly
distal to its original spot, towards the
insertion of the muscle.
A motor point is usually found on a
muscle, at the junction of the proximal
1/3rd and the distal 2/3rd of the belly or
the fleshy part of the muscle.
To trace a motor point, its most convenient
to use interrupted galvanic current, at
pulse duration of 1 msec in case of innervated muscles and 100 msec in case of
deneravted muscles.
Once the skin has been prepared and the
electrodes have been positioned in appropriate surface location over a given
muscle, the intensity of the stimulus
should be increased just enough to elicit a
minimal perceptible twitch contraction in
the muscle. The active electrode is moved
over the approximate area of the motor
point till the maximum response for a
given stimulus is observed. This is the
motor point, which should be marked with
indelible pencil for future reference.
Tracing of a motor point is essential for:
1. Plotting of a SD curve of a muscle.
2. Giving interrupted galvanic stimulation to denervated muscles.
3. Locating the general area for electrode
placement for surged faradic stimulation of innervated muscles.
The main advantage of stimulating a
muscle through its motor point is that, the
current intensity required to produce muscle
contraction is minimum, compared to any
other area on the muscle belly, thus causing
mild sensory irritation.
24
4
Low Frequency Stimulation of
Nerves and Muscles (NMES)
INTRODUCTION
Electrical stimulation has been widely used
for many years for a variety of therapeutic
purpose on different types of excitable tissues.
In case of normal skeletal muscles, electric
stimulation provides artificial exercise by
producing sustained contraction, particularly when the muscle is unable to
contract actively due to pain, weakness or
restrictions like a plaster cast. For getting
best results, the muscle must be contracted
voluntarily, along with electrical stimulation.
In case of denervated muscles, electric
stimulation is used to slow down the
process of disuse atrophy and shorten the
recovery time. Apart from gaining strength
or maintaining the physiological properties in the muscle, neuromuscular electrical
stimulation (NMES) also helps to accelerate blood supply and drainage of
metabolic wastes from the muscles
through pumping action it induces during
muscle contractions. Such pumping action
helps relieve swelling of soft tissue, reduce
muscle spasm and hypertonus.
Electric stimulation is also widely used on
the sensory nerves for management of
acute and chronic pain, because its effective and cheap, without any of the adverse
side effects of the pain killing drugs.
HOW DOES NMES WORK IN BUILDING
MUSCLE STRENGTH AND PREVENTING
DISUSE ATROPHY?
High-intensity electrical stimulation is a
proven way to maintain size, and even
function in muscles, which may temporarily be rendered inactive due to injury
or immobilisation.
The idea may sound a little shocking, but
a number of scientific studies have confirmed
that the right type of electrical stimulation can
keep muscles relatively sound, even when
they are not being stimulated by the nervous
system or engaging in any real activity.1 In one
of the earliest published studies on the effects
of electrical stimulation, on the maintenance
of size and strength in immobilised muscles,
researchers electrically stimulated the quadriceps and hamstrings muscles in the leg of
an athlete daily, who was immobilised in a
lower-extremity cast for 3 weeks, because of
Grade-II medial-collateral and anteriorcruciate ligament sprains in his knee. On the
day the cast was removed, the girth of the
Low Frequency Stimulation of Nerves and Muscles (NMES) 25
athletes thigh had actually increased, suggesting that hypertrophy had occurred in the
target muscles, instead of the usual immobilisationassociated atrophy. In addition,
single-leg, vertical-leap height was 92% as
great in the immobilised leg following cast
removal, compared with the uninjured leg,
and the athlete was able to immediately
return to competition.2
Research has shown that NMES is effective
in preventing decreases in muscle strength,
muscle size, and even the oxygen-consumption capabilities of thigh muscles after knee
immobilisation.
There is a fair amount of scientific evidence
that NMES can enhance functional performance in a number of different strength-related
tasks, in skeletal muscles and produce effects
similar to those associated with physical
training?
One theory is simply that NMES produces
high-intensity muscle contractions which
are similar to those occurring during
standard, low-repetetion, high-resistance
strength training, and that as a result
muscles respond to NMES in ways which
are similar to the adaptations which occur
during normal training. NMES imposes
specific patterns of muscle recruitment and
a particular metabolic solicitation which
forces muscle cells to respond in a significant way.1
However, there may be other factors at
work.
It is known, for example, that NMES
produces what is called a reversal of
voluntary recruitment order. At the
beginning of many volitional sporting
activities, the central nervous system
ordinarily first activates the smallest
alpha motor neurons. These nerve cells

originate in the spinal cord and have
relatively thin branches, which run out to
muscle cells, which can stimulate muscle
fibres to become active. As exercise
continues and more force production by
muscles is required, increasingly larger
diameter alpha motor neurons become
active. This order of activation from
smaller to larger motor-nerve cells has
been termed the size principle of musclecell recruitment.4
The size of the alpha motor neuron is closely
related to the type of muscle cell it innervates.
Slow-oxidative (Type-I) muscle fibres are
usually recruited first, by the small alpha
motoneurons, whereas fast-glycolytic
(Type-II) muscle cells are ordinarily much
more difficult to recruit and generally
depend on the biggest alpha motor neurons. This helps to explain why someone
who is exhausted during prolonged
endurance exercise, will suddenly feel
capable of further effort, if he/she actually
forces himself/herself to exercise much
more intensely. In such cases, non-recruited, non-fatigued, fast-glycolytic
muscle cells can be brought into the action,
providing a big boost to exercise tolerance.
During NEMS of muscles, the order of
muscle-fibre recruitment is often reversed,
with the fast-glycolytic muscle fibres stimulated first rather than last and the slowoxidative muscle fibres recruited later.
Because Type-II muscle fibres have a higher
specific force than Type-I muscle cells,
selective augmentation of Type-II fibres
through strong electrical stimulation may
actually increase the overall strength of a
muscle or group of muscles.
26
Understandably, there has been a keen

interest in whether NMES might work for
healthy athletes or average person. The early
work of Y. Kots in the former Soviet Union
suggested that in certain cases NMES could
be significantly more effective than exercise
training itself in strengthening the muscles of
elite athletes.3 If Kots findings were valid,
athletes could improve their power while
sleeping, simply by placing the right electrodes over the key muscles involved in their
sport!
Subsequently, devices for electrical stimulation have been marketed to athletes and
the general public, with the devices claiming
that they can improve muscle strength;
decrease body weight and body fat, and
upgrade muscle firmness and overall tone.
Sales of the NMES contraptions appear to be
red-hot, with a large number of people buying
the concept that they can build rock-hard
buttocks and flat stomach while watching TV
or relaxing at home.
Recent, well-controlled scientific research
carried out at the University of Wisconsin,
scientists assigned 27 college-age volunteers
into either a NMES group (16 subjects) or a
control group (11 individuals). The NMES
group were stimulated three times a week,
following manufacturers recommendations,
while the control group underwent concurrent placebostimulation sessions.4 The muscles stimulated included the biceps femoris,
quadriceps femoris, biceps brachii, triceps
brachii, and abdominals (rectus abdominis
and obliques).
The study showed that NMES had no
significant effect on body weight, body
fatness, fat weight, lean body weight, arm
girths, waist girths, thigh girths, isometric
strength, isokinetic strength, or even the

appearances of the subjects, compared with
the placebotreatments.
Why such disappointing results?
In order for muscles to improve their strength,
they must be stimulated beyond a critical
threshold. This threshold probably needs to
be as high as 60% of max-voluntary-contraction strength in case of well-trained athletes
and 30% in case of sedentary persons.6 In
addition, NEMS should be utilised at the
minimum threshold of at least 60% of maxvoluntary-contraction strength. 7 Unfortunately, the over-the-counter device tested in
this Wisconsin study produced a force equal
to less than 20% of max-voluntary contraction.
Importantly, too, the over-the-counter machine produced current frequencies of 90 to 151
pulses per second; whereas 50 to 75 pulses are
considered optimal (overly high frequencies
may induce too-early muscle fatigue). In
addition, the on-off ratio (the ratio of time
stimulated to recovery time) was only 1:3.5,
even though about 1:5 is considered optimal
because considerable recovery is needed
between bouts of electrical stimulation to
allow muscle cells to overcome fatigue.
HOW DOES TRANSCUTANEOUS
ELECTRICAL NERVE STIMULATION
RELIEVE PAIN?
TENS is a method of electrical stimulation,
which provides a degree of relief symptomatic
pain by specifically exciting sensory nerves.
It can be used in several different ways, each
being best suited to different mechanisms of
pain production. Extent of pain relief would
be in the region of 60%+ for acute pains and
40%+ for more chronic pains.
The technique is non-invasive and has few

side effects when compared with drug
therapy. The most common complaint is an
allergic type skin reaction (about 2% of
patients) and this is almost always due to the
material of the electrodes, the conductive gel
or the tape employed to hold the electrodes
in place.
The current intensity in the range of 0 to
80 mA is used, though some machines may
provide outputs up to 100 mA, which is easily
tolerated by the patient.
The machine delivers pulses of electrical
energy, and the rate of delivery of these pulses
(the pulse frequency) will normally be
variable from about 1 or 2 pulses per second
(pps) up to 200 or 250 pps. In addition to the
stimulation rate, the duration (or width) of
each pulse may be varied from about 40 to
250 microseconds (A microsecond is a
millionth of a second).
The reason that such short duration pulses
can be used to achieve these effects is that the
targets are the sensory nerves that tend to
have relatively low thresholds, i.e. they are
quite easy to excite and that they will respond
to a rapid change of electrical state. There is
generally no need to apply a prolonged pulse
in order to force the nerve to depolarise,
therefore stimulation for less than a millisecond is sufficient.
The pulses delivered tend to be asymmetrical biphasic modified square wave
pulses. The biphasic nature of the pulse means
that there is usually no net DC component,
thus minimising any skin reactions due to the
build up of electrolytes under the electrodes.
Mechanism of Action of TENS
This type of stimulation excites different
elements of the sensory nerve system, and by
so doing; activate specific natural pain relief

mechanisms. There are two primary relief
mechanisms that can be activated: the spinal
gate control mechanism and the endogenous
opiate system.
Pain relief by means of the spinal gate
mechanism involves excitation of the A-beta
sensory fibres, and by doing so, reduces the
transmission of the noxious stimulus from the
c fibres, through the spinal cord and hence on
to the higher centres. The A-beta fibres appear
to appreciate being stimulated at a relatively
high rate (in the order of 90-130 Hz or pps).
To activate the indigenous opiate mechanisms, the A-delta fibres must be stimulated.
These neurons respond preferentially to a
much lower rate of stimulation (in the order
of 2 - 5 Hz), which will, and provide pain relief
by causing the release of an endogenous
opiate (encephalin) in the brain, which will
reduce the feeling of pain.
Points to Ponder
Therapeutic electric stimulation is used to:
a. Reduce painusing T.E.N.S, causing
Activation of the spinal gate control
mechanism of pain modulation as per
Malzack and Wall.
Release of indigenous opiates of the
body at pain receptors of the brain.
b. Reduce muscle spasmusing faradic stimulation, by
inducing muscle fatigue, through
titanic contraction for several minutes,
produced by continuous faradic
current stimulation.
pumping of muscles, increasing the
metabolic turnover, temperature, blood
circulation and drainage of metabolic
waste, through cyclic contraction and
relaxation, produced by surged faradic
current stimulation.
28
c. Increase or maintain joint range of motion

using surged faradic stimulation, sometimes under tension, causing:
stretching of tightened soft tissue
around a stiff joint, caused due to weak
muscle action.
release spastic muscle by induced
fatigue or by reciprocal inhibition.
reduction of pain inhibition, to permit
muscle contraction and allow joint
movement.
d. Re-education of muscle actionusing surged
faradic stimulation, by actively assisting
muscle action to complete a movement.
providing visual and proprioceptive
feedback to the brain, to re-educate forgotten pattern of movement.
improving co-ordination of voluntary
movements.
e. Prevent disuse atrophyusing surged
faradic stimulation to exercise a muscle,
with intact nerve and blood supply, but
unable to contract due to inhibition or
immobilisation. This can be done even if a
muscle is enclosed in plaster cast.
Using interrupted galvanic stimulation
to give contractions to a denervated
muscle, to maintain its physiological properties, retard disuse atrophy and promote
early repair of the damaged nerve.
f. Reduce swelling of extremitiesusing surged
faradic current under compression and
elevation.
g. Promote repair of soft tissue/woundby
increasing supply of blood carrying O2
and nutrients, produced by pumping
action in muscles due to surged faradic
stimulation.
WHEN NOT TO USE ELECTRICAL
STIMULATION?
Though its a versatile modality, certain
precautions must be taken while applying
electrical stimulation and in some conditions

its application is strictly contraindicated.
Points to Ponder
Do not apply electrical stimulation over Healing fracturesmay lead to displacement of fractured bone ends.
However, if the fracture is stabilized
internally or in a plaster cast, stimulation may be applied through windows cut into the cast, to prevent disuse
atrophy of muscles.
Recent haemorrhagesmay lead to
further bleeding.
Malignant tumoursmay lead to spread
of cancer cells.
Acute infective focus/carbuncle/cellulites
may lead to spread of infection to the
blood stream.
Deep vein thrombosismay lead to
embolism of clot.
Superficial metal implants, as in ORIF of
superficial bonesmay cause concentration of charge and cause burn of the
neighbouring tissue.
Muscle of pharynx or voice boxmay
lead to problem in swallowing, cause
choking or impair speech.
Pregnant uterusmay cause spontaneous abortion.
Electrical stimulation is absolutely prohibited in patients with demand type
pacemakers or diseases of hearts muscles
like myocardial infarction.
Be careful while giving electrical stimulation over:
Loss of superficial skin sensationstimulation may cause burn or itching of
the skin due to overdose, which the
patient will not be able to tell you. In
such cases, look for strength of muscle
contraction to guide you. Its useless to
apply TENS for relief of pain, in a case

of sensory loss, like in diabetic neuropathy or any other sensory nerve
involvement, since the sensory pathways are not working and no relief of
pain will be obtained.
Massive swellingmay lead to breakdown of skin, which is devitalised due
to poor blood circulation. This is particularly important in chronic oedema
following radical mastectomy or chronic circulatory failure of lower limbs in
varicose veins or burgers disease.
Always use effleurage massage to
reduce the superficial oedema substantially before applying faradism
under pressure, keeping the limb in

elevation.
REFERENCES
1. Muscle electric stimulation in sports medicine.
Rev Med Liege 2001;56(5):391-95.
2. High intensity electric stimulationEffect on
thigh musculature during immobilisation for
knee sprain. A case report physical therapy
1987;67(2):219-22.
3. Neuromuscular electric stimulationAn overview and its application in the treatment of
sports injuries. Sports Medicine 1992;13(5):
320-36.
4. Effects of electric stimulation on body composition, muscle strength, and physical appearance. Journal of Strength and Conditioning
Research 2002;16(2):165-72.
30
5
Getting Started with Low
Frequency Electrical
Stimulation
Know your stimulator, because it is very easy
for a fresh graduate to be lost in the hype,
created by the equipment manufacturers;
keen to sell their equipments in a cutthroat
market. Most often people end up buying
equipments with useless features for a
ridiculous price. To avoid such pitfalls, here
are some tips on how to select the right machine
for your need.
Points to Ponder
Electrical stimulators are used for stimulation of excitable tissues like nerves and
muscles, for therapeutic benefits.
Depending upon the nature of application,
an electrical stimulator may be called
electrical muscle stimulator (EMS), neuromuscular stimulator (NMS), TENS (for
pain control), functional electrical stimulator (FES), high voltage galvanic
stimulator or interferential therapy unit,
though its basic function remains same, i.e.
to apply electric charge to excitable tissues
of the body, through neural pathways.
For routine work, low frequency stimulators offering surged faradic and interrupted galvanic current are used.
All modern low frequency stimulators use
a basic circuit to produce interrupted
galvanic current, with a wide range of
pulse duration and frequency modulation.
The latest models have microprocessor for
accuracy of the pulse and frequency
modulation
Modern low frequency electrical stimulators are marketed in two basic models,
therapeutic and diagnostic.
Therapeutic model is cheaper than diagnostic model, but it does not have full
range of pulse durations of IG current and
a digital or analog meter to show the
intensity of the current. These two parameters are essential to plot SD curve. My
suggestion would be to buy the diagnostic
model because it gives the equipment a
wide range of clinical application.
A diagnostic stimulator must have separate colour coded output for interrupted
galvanic and faradic type current. The
Getting Started with Low Frequency Electrical Stimulation 31
3.
Fig. 5.1: A diagnostic electrical stimulator. The set of

controls on the top row are for interrupted galvanic
current. On the extreme left is a voltmeter indicating
the intensity of the stimulating current (this being a
constant current stimulator). To its right are the control
knobs for pulse duration, pulse repetition rate and
current intensity respectively. To the extreme right are
LED indicators and two output terminals for galvanic
current. The controls on the bottom row are dedicated
for faradic current. From left to right are the main switch
with integrated pilot lamp, toggle switch to determine
the sensitivity of the voltmeter (30/120 volts), control
knobs for surge duration, surge interval and intensity
respectively. On the extreme right are LED indicators
and two outlets for faradic current
pulse durations for IG current should be

in the range of 0.01, 0.03, 0.1, 0.3, 1, 3, 10,
30, 100, 300 ms as well as continuous DC
current. The faradic circuit should offer
both continuous and surged currents with
separate controls to modulate surge
duration and intensity (Fig. 5.1).
While selecting the stimulator it is important to pay close attention to the following
ten points:
1. Always opt for a model with fibre or
powder coated metal body shell, to
minimize the risk of body shock. Check
the body for signs of crack or rust.
2. The face plate of the equipment must
be made of polypropylene sheet or
other non-conductive materials. The
4.
5.
6.
7.
8.
display must be clearly and accurately

printed under each control knob and
output terminals.
The switches and knobs must not have
any extra play and be of good quality.
The leads and cables must have adequate conductors, insulation and be
pliable. The electrodes must have no
rough edges. Good quality accessories
and exteriors with careful finish may
indicate reasonable quality of the inner
components.
Always check the make, model, and
serial number is printed at the rear
plate of the equipment casing.
Check the fuse type, calibration and the
site of the fuse socket. Unusual fuses
and awkward location of fuse sockets
may leave you needlessly dependant
on the service engineer.
Always test the machine on your self
before the decision to buy it, looking
for quality of the output current regarding smoothness and consistency, at
each duration setting and surge duration. Any sharpness and burning
sensation felt, means poor quality of
modulation of the stimulating current
and automatic disqualification of the
equipment.
Shop extensively for the best deal. Ask
for the trade price as well as the MRP
from the supplier. For equipments
made in India, negotiate directly with
the Manufacturer. Manufacturers often
quote a price with the dealer commission discounted.
Remember that small scale local manufacturers can often give you custom
designed equipment, with maximum
number of useful features at a reason-
32
able cost, rather than established

manufacturers, because their overhead
cost is much less.
9. For imported equipments, contact the
main importer rather than sub-dealers,
because the importers can give you a
better deal, as well as, provide quality
spares and service, due to their tie-up
with the foreign principals. Insist on
complete installation and training at
the cost of the supplier.
10. After sales service is the most important consideration for any equipment
purchased. Most equipments carry oneyear warranty period. Negotiate for
post-warranty annual maintenance
contract, before concluding the deal for
purchase. The supplier should preferably have a local service centre manned
by qualified service engineer and off
the shelf spares should be available.
The response time in any case should
not be more than 48 hours. Always
withhold 50% of the AMC amount till
the completion of the contract period.
Renew the contract only on getting
satisfactory service. Approach the
consumer forum for redressal in case
of any default by the supplier.
MACHINE PREPARATIONS
Electrical stimulators are compact electronic
devices that can be operated with 220 volts
domestic AC electric supply. Some stimulators
have dual mode of operation, i.e. they can
work with mains, as well as, 9 volts battery
power supply. Before commencing the treatment the therapist must be familiar with the
controls and test the apparatus on him/her.
This is essential to avoid any nasty surprises
for the patient during treatment.
Points to Ponder
Read the operating manual carefully to
familiarize you with new equipment.
Perform a visual check in case of old
equipments.
All electrotherapy equipment has two
functional components, the machine
circuit and the patient circuit.
After checking the leads and mains cable
for breaks or cuts, connect two carbon
rubber electrodes of 5 sq cm size, with red
and black leads each, to the output
terminal of the IG/Faradic current. The red
lead should be connected to the + terminal
and the black-lead to the terminal.
Connect the equipment to the domestic
three pin wall socket, turn all knobs to
zero, and keep the electrodes side by side
on a wooden surface away from each other
and switch on the power switch of the
equipment. See the pilot lamp is glowing.
This confirms the OK working of the
machine circuit. Switch off the equipment
from the power switch.
Wet your left hand and place it on the
electrodes so that part of the hand connects
with each of the electrodes, while the
electrodes do not touch each other. This
way your left hand becomes a part of the
patient circuit. Make sure that your right
hand is dry. Select 100 ms duration of IG
at one pulse per second or middle level
surge duration through the selectors on the
equipment. Turn on the equipment power
and slowly increase the intensity till you
feel electric impulses flow through your
hand. Twitch contraction will be produced
in case of IG current and a titanic contraction will be felt in case of faradic current.
Please let the current flow for one minute
and ensure the current out put flows in
uniform pulses and cause no burning

sensation, then turn the intensity to zero
and switch off the equipment.
Test the machine on yourself, preferably
in front of the patient. It will not only
confirm the OK status of the equipment,
but also will also give confidence to the
patient to undertake the treatment.
PATIENT PREPARATIONS
Low frequency electrical stimulation is
potentially painful procedure and can adversely affect the compliance of the patient. This
is particularly important with young children
and nervous patients. Start with an explanation to the patient as to why is it important
for him/her to undergo the procedure and
what are the nature and intensity of sensation
he/she is likely to feel. If the patient is still
apprehensive you may do the equipment
testing on yourself in front of the patient. This
is likely to remove any lingering apprehension
in the mind of the patient.
Points to Ponder
Counselling the patient before the treatment session is essential.
Question the patient to rule out any absolute contraindication and identify any
precaution that you must take. Assess the
feasibility of electrical stimulation yourself
even if it has already been prescribed.
Explain to the patient why it is necessary
to give stimulation and type of sensation
that will be felt during the treatment, best
described as tapping/tingling/ant bite etc.
The treatment should be carried out in an
area with optimum privacy, having good
tangential light, which will make it easy
for you to see contraction of muscles.
In case of upper limb stimulation, place the

patient in high sitting on a wooden chair
with the limb resting in front of the patient
on a wooden plinth.
In case of lower limbs and back, place the
patient on supine/prone on a wooden
plinth.
Expose the part to be treated and cover the
rest of the body with a sheet.
Therapeutic electrical stimulation is
usually applied transcutaneous or through
the skin, to the nerves and muscles
underneath. Skin resistance can be a major
problem in application of electrical stimulation
Dry skin has a resistance of 5000 ohms,
since the epidermis is made up of five
layers of dead cells soaked in oily sebaceous fluid, all of which resist flow of
electric current.
High skin resistance will need a large
intensity of electric charge to reach the
tissues below, which may be very painful
to the patient.
Preparation of the skin over the area to be
stimulated must be done to lower the skin
resistance to approx 1000 ohms.
The skin should be washed with soap/
savlon to remove oil and dirt, rubbed
vigorously with moist lint to remove dead
skin cells and lower the skin resistance and
then soaked in saline to provide ions that
will help in carrying the current to the
subcutaneous layers.
If there is a break in the skin, sterile
petroleum jelly should be applied over the
broken portion to avoid concentration of
the electric charge.
SELECTION AND PREPARATION OF
STIMULATING ELECTRODES
Points to Ponder
Nature of stimulating electrodes: Electrodes used for therapeutic stimulation are
34
strips of conductive material of sizes and

shapes may vary from discs to rectangular
or square plates depending on the site of
placement and type of use.
Types of stimulating electrodes (Fig. 5.2):
May be shaped as pads or discs or pin
points.
Made of conducting material such as
lead, steel, zinc or carbonised rubber.
Sizes range from pin-point, 1 sq cm to
10 sq cm discs or pads.
To avoid direct contact of the metal on the
skin the metallic conductive material
should be covered by at least 8 layers of
absorbent lint or a 1/2 cm thick envelope
of sponge.
Fig. 5.2: Different types of electrodes used in low

frequency electrical stimulation:
At the top is a disc electrode mounted on a
penholder.
Below that, clock-wise from the top left are
stainless steel ball electrode, point electrode, disc
electrode, steel plate electrodes and black carbon
rubber plate electrodes of different sizes.
The ball, point and disc electrodes are used for
detecting and stimulating motor points of muscles
of different sizes.
The steel electrodes must always be covered with
cotton and lint layer and must be soaked in water
before use. Rubber electrode can be applied
directly to the skin over a thin film of electrode
gel.
The covering of lint/sponge should be

soaked in tap water and squeezed to
remove excess water. The conductive plate
is then introduced in to the layer of moist
lint or sponge, which helps to absorb
corrosive ions produced by electrolysis
due to passage of electric current through
the electrodes.
Polarities and types of electrode placement: The stimulating electrodes must
have two polarities, + and - to complete
the circuit, so that pulse of electrical
current may flow between them. Any
excitable tissue interposed between the
two polarities will then be affected by the
electrical stimulus.
1. Monopolar placementTwo electrodes
of different sizes are needed to complete the patient circuit, usually during
stimulation through the motor point.
The larger one of the two is called the
passive electrode and the smaller one
is called the active electrode. The
difference in size between passive and
active electrode must be 3:1.
2. Bipolar placementSometimes two
electrodes of same size may be used,
usually while applying surged faradic
stimulation to a group of muscles
(Fig. 5.3, Plate 1).
3. Colour codingThe active electrode is
connected to the + terminal colour
coded red and the passive electrode to
the terminal colour coded black.
4. Shape of electrodesIn monopolar
stimulation the passive electrode is
usually a carbon rubber pad and the
active electrode is a metal disc or point,
attached to a pen holder. In Bipolar
stimulation of muscle groups, two pads
of equal sizes may be used.
Fig. 5.4: TopVaginal electrode; BottomRectal

electrode: These are specialized electrodes used for
stimulation of the muscles of the vaginal and anal
sphincters. Surged faradic current or two pole medium
frequency current may used for such stimulation
Special Type of Electrodes

Specific areas like the vaginal and the anal
sphincter muscles may need to be stimulated
in case of bladder and bowel incontinence.
Special types of electrodes that incorporate
both positive and the negative polarities in
one cylindrical body is used for this purpose
(Fig. 5.4).
THUMB RULES FOR ELECTRODE
PLACEMENT
In low frequency stimulation, the electrical
impulses are applied from the surface,
through the skin, to the nerves and muscles
underneath. Optimum effect of electrical
stimulation can only be obtained when the
stimulating electrodes are placed at appropriate spots on the skin surface. A few thumb
rules must be remembered, in the following
order of preferences, to obtain best result. The
passive or + electrode is used to complete the
patient circuit and it should be placed pre-
ferably over the proximal attachment of a

muscle or muscle group being stimulated. For
example, to stimulate the wrist and finger
flexor muscles, the passive electrode should
be placed over the medial epicondyle of
humerus, covering the common flexor origin.
If such a spot is not easy to reach in other
muscles, + electrode may be placed on the
point where the motor nerve supplying the
target muscle is most superficial or at the
spinal root level of the motor nerve e.g.
passive electrode may be placed over the
lumbosacral junction to stimulate the muscles
supplied by the sciatic nerve. If the above
three options are not convenient, the
+ electrode may be placed at any spot on the
body, close to the site of stimulation, e.g. for
stimulation of facial muscles, the most
appropriate location of the passive electrode
is underneath the neck of the patient, in
supine position. The active electrode, commonly having the negative polarity, is used
to deliver the electrical charge to the excitable
tissues, preferably through the motor point,
since maximum stimulation can be obtained
with minimum current intensity can be
obtained. However in case of a denervated
muscle the motor point may not be at the
original location and may have shifted
proximally on the muscle belly.
When stimulating a muscle or a group of
muscles, the active electrode should be placed
at the junction of proximal 1/3rd and the
distal 2/3 of the fleshy belly of the muscle.
Points to Ponder
Low frequency stimulation is given on the
surface of the skin.
Excitable tissues underneath the skin are
stimulated through the transcutaneous
route.
36
Stimulating current is delivered to the

excitable tissues through a pair of electrodes.
The electrode connected to the positive
terminal of the stimulator is commonly
known as the passive/dispersive/collecting electrode.
The electrode connected to the negative
terminal of the stimulator is commonly
known as the active/stimulating/directing electrode.
The passive electrode is either larger than
or of the same size as that of the active
electrode.
The passive electrode may be placed on the
origin or insertion of a muscle or muscle
group, over the motor nerve supplying the
muscleat its most superficial spot, over
the spinal segment of the motor nerve or
any other location close to the point of
stimulation.
The active electrode is placed over the
motor point of the muscle, usually located
over the junction of the proximal 1/3 and
the distal 2/3 of the fleshy belly of the
muscle.
The Checklist to follow in Application of
Counsel the patient, explaining in details
why the stimulation is needed, how it will
be given and what sort of sensation to
expect.
Follow the checklist of contraindications
and cautions.
Make the patient comfortable on a wooden
plinth, in a well-lit room with privacy to
undress or expose the part to be treated.
Prepare the skin of the target area to
minimize skin resistance and therefore the
discomfort.
Test the equipment on yourself before the

patient. This helps in building confidence.
Select and prepare appropriate electrodes,
check the connecting leads and jacks of any
damage.
The passive electrode is secured to appropriate spot on the body with an elastic
strap or Velcro fastener.
The active electrode is placed on the
general location of the motor point of a
superficial muscle in case of monopolar
stimulation or junction of the proximal
1/3 and distal 2/3 of the muscle group in
case of bipolar stimulation (Figs 5.5 and
5.6, Plate 1).
In case of deep muscles, the motor point
may not be at the designated spot. The
stimulus will spread to the overlying
superficial muscles, with little benefit to
the target deep muscle. In such case, the
active electrode should be placed at a spot
where any portion of the deep muscle
which is at the surface, e.g. the tendon.
Set appropriate frequency, waveform and
modulation rate of the stimulating current
depending on the desired effect and the
nature of target tissue.
Gradually increase intensity till the desired
effect is felt, i.e. contraction of muscles for
motor stimulation or tingling sensation for
sensory stimulation. The level of stimulation should never be too uncomfortable
or the patient may not comply with the
treatment. At end of treatment, gradually
decrease the intensity to zero before lifting
the active electrode from the skin. Disconnect the electrodes from the patient and
inspect the skin for any adverse reaction.
Make a record of the treatment. Allow the
patient go after a few minutes of stabilizing time.
CLINICAL APPLICATIONS OF LOW

FREQUENCY STIMULATION
Low frequency electrical stimulation is the
modality of choice in any paralytic conditions.
The visual impact of a flail part, that was so
far useless and lifeless, suddenly being
rejuvenated at the touch of the electrode, is
tremendous. The electrical stimulation can do
to the morale of the patient, what words of
counselling from the therapist fail to achieve.
Hence there is always a temptation among the
therapist to use this modality more frequently
than warranted clinically. A clear understanding of the principles of clinical application of electrical stimulation is essential to
prevent this modality from becoming a
gimmick.
Points to Ponder
Low frequency stimulation, using IG
current can be applied in all major peripheral nerve injuries,
The aim of preserving the physiological
properties of the muscles supplied by the
dysfunctional nerve.
The rationale is to provide exercise to the
muscle through artificially-induced contractions, to promote exchange of blood.
Fresh blood carries nutrient and oxygen to
the paralysed muscle, to keep its properties of contractility, excitability and
extensibility intact, till the nerve re-grows
to take over the function of muscle contraction.
Once the muscle has started contracting
actively, stimulating current may be
changed to surged faradic, should be
applied simultaneously with voluntary
contraction.
This helps in better recruitment of motor

units of weak muscles, thereby producing
stronger contractions and quicker gain in
power.
Further, since faradic stimulation produces
titanic contraction similar to voluntary
contraction, it is very useful in re-education of movements, in lesion of upper
motor neuron.
Through biofeedback the patient regains
normal function of the muscle.
Some patients cannot initiate muscle
contraction voluntarily to produce movement, due to inhibition or hysterical
paralysis, though there is nothing wrong
with their muscles.
In such cases faradic stimulation may be
used to facilitate muscle contraction and
movement of the body part, to break the
inhibition.
This principle is also used in re-education
of new muscle action, in cases where a
muscle or tendon has been transferred
from its original location to different spot,
to perform a different function.
In presence of swelling in the extremities,
application of faradic stimulation assists
in drainage of fluids.
TECHNIQUES OF LOW FREQUENCY
STIMULATION IN SOME COMMON
CLINICAL CONDITIONS
In the following pages I have dealt with some
common clinical conditions that need low
frequency electrical stimulation. The students
are likely to face such cases during the course
of their supervised clinical practice. Details of
the technique of application, as well as,
outline of the specific pathophysiology of the
38
disorder, along with tips on suitable adjunctive therapy, have been covered for easy
reference.
1. Techniques of Low Frequency
Stimulation in Bells Palsy
Clinical condition: Bells palsy.
Nerve involved: Facial nerve or VIIth cranial
nerve.
Muscles involved: Facial musclesFrontalis,
corrugators, orbicularis oculi and oris, levator
labi superioris and inferioris, nasalis, risorius
and mentalis.
Nature of impairment: Flaccid paralysis of
muscles of one side of the face due to
compression of the facial nerve, trapped the
under zygomatic arch, where it emerges from
the bone.
Fig. 5.7: Stimulation of facial muscles in Bells palsy Note the stainless steel point active electrode
being used, since the muscle involved is small in
size, to stimulate the motor point of Risorius or
the smile muscle.
The positive passive electrode with eight layers
of lint cover placed under the neck.
Functional problems: Loss of facial expressions

and symmetry, drooling, conjunctivitis.
Duration of treatment: Thirty to sixty contractions to each muscle.
Type of current used: Interrupted galvanic

current, rectangular pulses at 100 ms duration
at1 pulse per second. As the condition improves, the pulse duration can be progressively
reduced to 30, 10, 3, 1 ms and the rate of repetition can be increased to 3 pulses per second.
Special precautions: Facial skin is delicate and

subject to rashes and itching on prolonged
stimulation. Use Betamethasone and zinc
oxide based cream in case of rashes or itching.
All facial must be shaved. Use a moisturizing
lotion after treatment.
Type of technique: Monopolar technique, with

passive electrode of 5 sq cm carbon rubber
plate, active electrode with 1 sq cm disc on
holder.
Contraindications: Do not stimulate in presence

of severe acne or skin rashes.
Patient position: Supine on a wooden plinth.

Placement of electrodes: With the patient in
supine position positive electrode placed
under the neck, negative electrode placed on
the motor points of individual muscles
(Figs 5.7; 5.8, Plate 2; 5.9).
Remarks: Easiest of cases to stimulate, but

counsel the patient before the treatment.
Facial massage and exercise to the facial
muscles are essential for faster recovery and
should be demonstrated to the patient to be
practiced at home.
Chewing gum or sipping water through
straw is also effective form of home exercise.
Patient position: Sitting on a wooden chair

Placement of electrodes: + ve electrode at the
nape of the neck ve electrode on the muscle
belly on affected side of the neck (Fig. 5.10).
Duration of treatment: 5-10 min.
Special precautions: The skin preparation must,
to minimize skin resistance, since treatment
time is prolonged. Should use adequate water
in the electrode cover.
Fig. 5.9: Position of the patient and the therapist during

facial stimulation
The stimulator should be within easy reach of the
therapist so that the controls can be operated
comfortably.
The ambient light should be tangential to detect
slightest contraction of the smallest muscle
2. Technique of Low Frequency

Stimulation in Wryneck
(Paracervical Muscle Spasm)
Clinical condition: Wryneckmuscle spasm of
neck and upper back muscles.
Contraindications: The blood pressure of the

patient with neck stiffness must be checked
before treatment. Neck stiffness may be due
to high blood pressure, where electrical
stimulation should not to be given because it
may increase blood pressure.
Remarks: Moist hot packs and gentle manual
mobilization of the neck, with mild traction
component in the pain free range of the neck
may be given as an adjunct to electrical
stimulation.
The patient must be asked to avoid
exposure to cold for at least one hour after the
treatment.
Nerve involved: Spinal accessory nerve (root

valueC1-C4)
Muscles involved: Trapezius upper fibres
Nature of impairment: Muscle spasm and pain
inhibition of neck movement due to postural
stress or cervical spondylosis.
No primary nerve involvement.
Functional deficit: Pain and stiffness of neck
and scapular movements.
Type of current used: Surged faradic current,
with surge duration of 10 sec and surge
interval of 30 sec.
Type of technique: Bi-polar technique, both
electrodes 5-8 sq cm carbon rubber plates.
Fig. 5.10: Placement of electrodes for surged faradic

stimulation to relieve spasm of muscle of the neckCarbon rubber plate electrodes of equal size are
placed on either side over the posterior-lateral
muscles of the cervical column
40

Stimulation in Fibromyositis
of Trapezius Muscle
Clinical condition: Fibromyalgia of parascapular muscles or T4 syndrome.
Nerve involved: Dorsal scapular, suprascapular and thoraco-dorsal nerve (C4-8).
Muscles involved: Rhomboids, supra and
infraspinati, teres major, subscapularis.
Nature of impairment: Muscle spasm resulting
in ischemia producing fibromyalgia.
Functional deficit: Inhibition of scapular and
shoulder movements, often misdiagnosed as
periarthritis of the shoulder joint.
Type of current used: Surged faradic current
Type of technique: Bi-polar stimulation.
Patient position: Sitting on a wooden chair, with
head and the upper girdle resting on a plinth.
Placement of electrodes: Positive electrode at the
nape of the neck. Negative electrode at the
medial border of scapula on the affected side
(Fig. 5.11).
Duration of treatment: Surged faradic at 10 sec
duration and 50 sec interval for 5 min
Special precautions: Nothing specific
Contraindications: Nothing specific
Remarks: Manually-guided scapular movements must be given after faradic stimulation
to obtain quick gain in power. Moist hot packs
and local ultrasound therapy to fibromyalgic
nodules are useful as adjunctive modalities for
relief of pain. Deep friction massage applied
with the tip of the thumb is also very effective
in reducing fibromyalgic nodules.
Type of current used: Surged faradic current,
with surge duration of 10 sec and surge
interval of 30 sec.

stimulation to relieve spasm of suprascapular muscles.
Carbon rubber plate electrodes of equal size are
placed on the affected side, covering the upper fibres
of trapezius muscles at its proximal and distal ends
Type of technique: Bi-polar technique, both

electrodes 5-8 sq cm carbon rubber plates.
Patient position: Sitting on a wooden chair
Placement of electrodes: + ve electrode at the
nape of the neck ve electrode on the muscle
belly on affected side of the neck.
Duration of treatment: 5-10 min.
Special precautions: The skin preparation must,
to minimize skin resistance, since treatment
time is prolonged. Should use adequate water
in the electrode cover.
Contraindications: The blood pressure of the
patient with neck stiffness must be checked
before treatment. Neck stiffness may be due
to high blood pressure, where electrical stimulation should not to be given because it may
increase blood pressure.
Remarks: Moist hot packs and gentle manual
mobilization of the neck, with mild traction
component in the pain free range of the neck

may be given as an adjunct to electrical
stimulation.
The patient must be asked to avoid exposure to cold for at least one hour after the
treatment.
Stimulation in Crutch Palsy
Nerve involved: Axillary nerve (root value-C5).
Remarks: As long as the deltoid is devoid of

nerve supply, shoulder joint needs to be
protected from subluxation with a sling or
Bobath cuff. Axial suspension can be given
when the power is between Gr.I II. Once the
re-innervation starts, manually-guided exercises or pendular suspension must be given
simultaneous with faradic stimulation to
obtain quick gain in power.
Muscles involved: Deltoid muscle (Ant, mid

and post. fibres)

Stimulation in Erbs/Klumpkes Palsy
Nature of impairment: Flaccid paralysis of

deltoid muscle due to compression of axillary
nerve.
Clinical condition: Brachial plexus injury

1. Erbs palsy
2. Klumpkes palsy
Functional deficit: Loss of shoulder abduction,

flexion and extension.
Nerves involved:
Erbs palsyLesion of C5 root, sometimes
C6 root, caused due to traction injury
between head and shoulder girdle, mainly
during forceps delivery.
Klumpkes palsyLesion of C8-T1 roots,
caused due to traction injury between arm
and trunk, caused by sudden pull of the
body weight on the arm, when a person
grabs something to prevent falling from a
height or trying to get up on a moving bus
or train.

current, rectangular pulses at 100 ms pulse
duration at 1 pulse per second.
After re-innervations, surged faradic
current may be used to build strength.
Type of technique: Monopolar for IG and
bi-polar for surged faradic stimulation.
Patient position: Sitting on a wooden chair, arm
resting on wooden plinth.
Placement of electrodes: +ve electrode at the
nape of the neck, -ve electrode at the common
motor point of deltoid, 2 cm above the deltoid
tubercle (Fig. 5.12, Plate 2).
Duration of treatment: 60-90 contractions in one
sitting for IG stimulation.
Surged faradic stimulation at 10 sec
duration and 50 sec interval for 5 min
Special precautions: Nothing specific.
Contraindications: Presence of superficial metal
implant in case of #.
Muscles involved
In Erbs palsyDeltoid, rhomboids,
supraspinatus, infraspinatus, teres minor,
biceps brachi, brachialis.
In Klumpkes palsyLong flexor muscles
of the wrist and fingers and intrinsic
muscles of the hand.
Nature of impairment: Flaccid paralysis of the
muscles with significant sensory loss.
Functional deficit:
In Erbs palsy, (C5)Loss of shoulder
abduction, external rotation, elbow flexion
42
and forearm supination and with (C6)wrist extension; typical deformity- Policemans tip.
In Klumpkes palsy Loss of grip (C8) and
fine movements of hand; with (T1) typical
deformityClaw hand or ape hand.
current, rectangular pulses at 100-300 ms
pulse duration, or selective trapezoidal pulses
for prolonged stimulation, at 1 pulse per second.
After re-innervations, surged faradic
current may be used to build strength or reeducate muscle action following muscle transfer
surgery.
Type of technique: Monopolar for both I.G. and
surged faradic stimulation.
Patient position: Sitting on a wooden chair with
the affected extremity resting on a plinth in
front of the patient.
essential when the plexus has been repaired surgically. Axial suspension is the
method of choice for exercising the affected limb. Once the re-innervation starts,
manually-guided active exercises must be
given simultaneous with faradic stimulation to obtain quick gain in power.
In Klumpkes palsy, early splinting of the
affected hand must be done to prevent
irreversible clawing of fingers.
Its wise to repeat SD curve at the beginning of electrical stimulation and then
repeat at weekly intervals. It may create a
reference point of prognosis, to decide for
surgical intervention if the progress is not
as expected and its so much cheaper than
EMG/NCV tests.
Placement of electrodes: +ve electrode at the

para-cervical area on the affected side, -ve
electrode at the motor point of each affected
muscle (Figs 5.13, Plate 2, 5.14, Plate 3; Figs
5.15 and 5.16).
Duration of treatment: 60 contractions in one
sitting for each muscle or group with I.G.
Surged faradic10 sec duration and 50 sec
interval for 5 min.
Special precautions: No traction should be
applied to the affected limb while handling
because it may cause further injury to the
plexus.
Contraindications: Presence of superficial metal
implant within the field of stimulation, in case
of # of the shoulder girdle bones.
Remarks:
In Erbs palsy, as long as the girdle muscles
are devoid of nerve supply, shoulder girdle
needs to be supported with a sling or
airplane splint, to protect the plexus from
traction. Such support is particularly
Fig. 5.15: Placement of electrodes for interrupted

galvanic stimulation of forearm flexor muscle group
A stainless steel plate covered with eight layers
of lint is used as the passive (positive) electrode.
The passive electrode is placed on the affected
side over the medial epicondyle of elbow, covering
the common flexor origin and the proximal
portions of wrist and finger flexor muscles.
The active (negative) electrode is a lint padded
metal disc electrode mounted on a penholder. It
is placed on the belly of individual muscles of the
flexor compartment of the forearm, one after the
other, to give each muscle the required number
of contractions.
fibular neck due to crossed leg sitting,

sleeping on side lying on a hard surface,
tight leg cuff of orthosis or BK plaster cast,
applied with knee in hyperextension or a
ganglionic growth on the proximal tibiofibular ligament.
2. Anterior tibial nerve may be damaged
during insertion of tibial pin during application of skeletal traction.
galvanic stimulation of intrinsic muscles of the hand A stainless steel plate covered with eight layers
of lint is used as the passive electrode.
The passive (+) electrode is placed on the affected
side over the lower 1/3rd of the forearm on the
flexor aspect, covering the median and ulnar
nerves at its superficial most point.
The active (-) electrode, stainless steel point
electrode mounted on a penholder. It is placed
on the belly of individual intrinsic muscle of the
hand, one after the other, to give each muscle
the required number of contractions.
6. Techniques of Low Frequency

Stimulation in Foot Drop/Flail Foot
Clinical condition: Foot drop.
Nerve involved:
1. Lateral popliteal (common peroneal) nerve,
most commonly involved.
2. Anterior tibial nerve
Muscles involved:
1. Lat popliteal nerveMuscles of the
anterior-lateral compartment of the leg
(Tib.ant, EHL, EDL, EDB, Peronei).
2. Anterior tibial nerveAs above except
Peronei.
Nature of impairment:
1. Flaccid paralysis of muscles and loss of
sensation over the dorsum of foot, usually
due to compression of the nerve against
Functional problems: Dropped foot compensated with high stepping gait.

current, rectangular pulses at 100 ms pulse
duration, 1 pulse per second.
Type of technique: Monopolar technique,
passive 5 sq cm carbon rubber plate, active
1 sq cm disc on pen holder.
Patient position: Supine on a wooden plinth, a
roll under the knee to keep the knee in 10-15
degrees in flexion.
Placement of electrodes: +ve electrode over the
neck of the fibula.
-ve electrode on the motor points of
individual muscles (Figs 5.17, Plate 3; 5.18
to 5.20).
Duration of treatment: Thirty to sixty contractions to each muscle.
Special precautions: Rashes and etching on
prolonged stimulation are common. Use
Betamethasone and zinc oxide based cream
in case of rashes or etching. The leg must be
shaved before treatment to minimize skin
resistance. Use a moisturizing lotion after
treatment.
Contraindications: Do not stimulate in presence
of open wound or skin rashes.
Remarks: Easiest of cases to stimulate, but
counsel the patient before the treatment.
44

stimulation of dorsiflexor and evertor muscle groups
Two stainless steel plate covered with eight layers
of lint of equal sizes are used as the passive
(positive) and active (negative) electrode
electrodes.
side over the neck of the fibula, covering the
common peronial nerve at its superficial most
point.
The active (negative) electrode is placed on the
junction of proximal 2/3rd and the distal 1/3rd of
the belly of muscles on the anteriolateral
compartment of the leg, to give all the muscle the
required number of contractions.
SPECIALISED TECHNIQUES USED IN

LOW FREQUENCY STIMULATION
1. Faradic Footbath
Indication: Flat feet or pes planus, due to
weakness of intrinsic muscles of the feet,
resulting in dropped medial longitudinal
arches of the feet.
Points to Ponder
Primary cause is usually congenital, due to
cramped space for the foetus within the
pelvis of the mother. Parents usually detect
it as the child begins to walk.
Secondary causes may be childhood
obesity, paralysis of foot muscles or
derangement of the bones of the foot due
to injury.

galvanic stimulation of planter flexor muscle groups
A stainless steel plate covered with eight layers of
lint is used as the passive (positive) electrode.
side over the popliteal fossa, covering the posterior
tibal nerve at its superficial most point.
The active (negative) electrode is a lint padded
metal disc electrode mounted on a penholder. It is
placed on the belly of individual muscles of the
posterior compartment of the leg, one after the
other, to give each muscle the required number of
contractions.
Functional Problem
Pain in the feet and legs on prolonged
standing and walking.
Secondary knock-knee may appear as the
child begins to walk for longer durations.
It may be a cause for disqualification for
defence services.
Plan of Management
The primary management in the case of
flat feet depends on the age of detection.
If the case is detected as early as 12 months
the defect can be corrected reasonably by
giving the child corrective foot wears with
medial arch support and exercises like sand
walking, tip toeing, to develop the intrinsic
muscles of the feet, etc.
particularly when there is correctible bony

derangement of the feet.
Equipment and Type of Current Used
Standard low frequency stimulator, offering
surged faradic current with separate controls
for surge duration and intervals.
Type of Electrodes
Fig. 5.20: Placement of electrodes for surged

stimulation of planter flexor muscle groups
electrodes.
side over the popliteal area, covering the posterior
tibial nerve at its superficial most point.
the belly of muscles on the posterior compartment
of the leg, to give all the muscle the required
number of contractions.
When the child is little older, say 3-5 years,

this therapy may be complimented with
faradic footbath, with a little coaxing to
create acceptance of the electrical stimulation.
In cases with milder presentation or with late
detection, like in the teen age, faradic footbath
forms the first choice of therapeutic management, along with medial arch support
shoes and exercise like toe curling.
The Rationale Behind Faradic Footbath
The intrinsic muscles of the foot form the
dynamic support system for the arches of
the feet. Building up the strength of these
muscles with surged faradic stimulation
helps to stabilize the arches of the feet,
Bipolar metal or carbon rubber electrodes,

rectangular plates of 3 7 cm.
The passive and active electrodes are of the
same size.
No lint or sponge electrode cover is needed
since the treatment is done under water,
which allows free conduction of current
while washing off any electrolyte produced under the electrodes.
Placement of Electrodes
The electrodes are placed in a shallow bath
of water, the positive under the heel and
the negative under the ball of toes.
The level of water should be up to the
junction of the dorsal and planter skin of
the foot. This will ensure that the current
passes easily through the intrinsic muscles
in the sole of the foot and does not spread
to the dorsum.
Application of Current
Surged faradic current, with surge duration of 10 sec and interval of 30 sec is
applied.
The intensity should be enough to produce
visible contraction of intrinsic muscles of the
foot creating clenching of toes. Patient
should be asked to curl toes simultaneously along with the current flow and
relax during surge interval.
The treatment should be given for 15-30
min.
46
Indication: Oedema or swelling of extremities.
Collection of fluid in tissue interstitial

space also interferes with supply of
nutrition and oxygen to the tissue through
blood stream. This may lead to further
complications like skin breakdown and tissue
necroses.
Points to Ponder
Plan of Management
Such oedema develops in the distal end of

limbs due to collection of fluid in the tissue
interstitial space.
Common pathological causes are soft tissue
injury like sprain and strain, inadequate
lymph or blood drainage due damage to
the vessels like deep vein thrombosis or
following radical mastectomy or systemic
disorders like congestive heart or kidney
failure etc. Therapy is indicated for such
pathological oedema
Physiological or gravitational oedema may
develop in the legs if the limbs hang down
for long periods without any movement,
e.g. as in long bus or air journey. The
gravitational force pulls fluid down in to
the lower extremities, which is not pumped out due to lack of muscle contraction.
Elevation of the limb and frequent movements are enough for physiological
oedema.
The primary goal in the management of

pathological oedema is to remove the fluid
from the site of oedema as quickly as
possible.
This can be achieved by the combination
of elevation, compression and isometric
muscle contraction.
Elevation of extremities utilizes the gravity
to drain the fluid to the systemic circulation, provided the limb is elevated above
the level of the heart.
Compression applied with crepe bandage
or pressure stockings and isometric muscle
contraction helps to push the fluid from
the tissue interstitial space in to the blood
or lymphatic vessels.
Precaution: Do not allow the patient to touch

the equipment or the wall during treatment.
2. Faradism Under Pressure
Functional Problem
The girth of the limb increases and it
becomes heavy, creating problems in joint
movements and locomotion.
If allowed to remain undisturbed for long,
oedema, which is initially soft and pitting
under finger pressure, may consolidate or
harden. If this happens around a joint, the
movement of the joint may be permanently lost.
Rationale Behind Faradism

Under Pressure
The process of fluid drainage can be made
more effective by application of surged
faradic current to major muscle groups to
generate stronger contractions that creates
a pumping action on the muscles and the
blood vessels.
When the limb is maintained under
pressure during such induced contraction,
the recoil force of the muscle contraction
acting against the force of compression
makes the drainage more effective, further
assisted by gravity if the limb is kept in
elevation.
Standard low frequency stimulator, offering surged faradic current with separate
controls for surge duration and intervals
applied.
visible contraction of muscles of the
creating clenching of toes/fingers.
Patient should be asked to do active
movement simultaneously with the current flow and relax during surge interval.
The treatment should be given for 30 min.
Type of Electrodes
Bipolar carbon rubber electrodes, rectangular
plates of 3 5 cm with sponge electrode
cover. The passive and active electrodes
are of the same size.
Placement of Electrodes
The skin must be cleaned and moistened
adequately before treatment. Placement of
electrodes varies from site to site:
For oedema of the leg, ankle and foot, the
active electrode is placed on the calf,
approximately at the centre of the fleshy
belly of the muscles. The passive electrode
is placed on the sole of the foot.
For oedema of hands and forearm the
active electrode is placed on the flexor
aspect of the forearm, approximately at the
junction o the proximal 1/3rd and the
distal 2/3rd of the muscle belly. The
passive electrodes may be placed on the
palm or on the cubital fossa.
The electrodes are fixed to the skin with
straps or adhesive tapes.
Special Precautions
Skin rashes are common on prolonged
stimulation.
Use Betamethasone and zinc oxide based
cream in case of rashes.
The body hair must be shaved before
treatment to minimize skin resistance.
Use a moisturizing lotion after treatment.
Contraindications: Do not stimulate in presence of open wound or skin rashes.
3. Faradism Under Tension
Indication: Shortening of Contractile soft tissue
like muscles and some type of connective
tissues in and around joints.
Points to Ponder
Application of Pressure
Plan of Management
With the patient in supine position on a

wooden plinth, the limb is elevated above
the level of the heart, using pillows.
The pressure bandage or garment is
applied over the electrodes, keeping
maximum pressure at the distal most end
of the limb, becoming progressively less
proximally.
Such contractures develop in major muscle

groups of the extremities, like the quadriceps or elbow flexor group leading to
restriction of knee flexion or elbow extension, mostly after prolonged immobilisation following fractures.
Conventionally, such tightened muscles
and soft tissue are mobilized by forced
48
passive movements, which is an extremely

painful procedure.
Rationale Behind Faradism Under Tension
Titanic contraction induced by surged
faradic stimulation generates intrinsic
tension in the myofibril, which is made to
contract against external traction force
trying to stretch them apart.
The interplay of opposing forces pulls apart
the shortened myofibrils, gradually increasing their length, with much less pain
than would be felt with forced passive
movement.
The patient is asked to try and contract the
tightened muscle as hard as possible in
time with the surge of faradic stimulation.
This adds to the intrinsic contractile force
of the myofibrils, leading to quicker
releases of contracture, as well as power
gain.
and active over distal 1/3rd over front of

the thigh.
In contracture of the elbow flexors, passive
electrode is placed over proximal 1/3rd
and active over distal 1/3rd over front of
the arm
Application of Tension
In case restriction of knee flexion due to
contracture of quadriceps muscle group
the patient is positioned on wooden plinth,
with the legs hanging down. A roll of towel
is placed below the knee to prevent
posterior translation of the tibia over
femur. The thigh is strapped to the plinth

Standard low frequency stimulator, offering surged faradic current with separate
controls for surge duration and intervals.
Type of Electrodes
Bipolar carbon rubber electrodes, rectangular plates of 5 10 cm with sponge
electrode cover.
The passive and active electrodes are of the
same size.
The skin must be shaved, cleaned and
moistened adequately before placement of
electrodes, which varies from site to site.
Placement of Electrodes (Fig. 5.21)
In contracture of the quadriceps, passive
electrode is placed over proximal 1/3rd
Fig. 5.21: Placement of electrodes for surged

stimulation under tension to the quadriceps muscle
groups
electrodes.
side over the proximal 1/3rd of the quadriceps.
the belly of the muscle.
The limb is kept at its limit of flexion to give the
muscle the required degree of stretch and then
the required number of titanic contractions is given
to the muscle under tension.
with a 6wide canvas strap. Tension to the

affected knee joint is applied with a sand
bag or weighted belt (1/2-3kg) attached to
the front of the ankle.
In case restriction of elbow due to contracture of elbow flexor muscle group, the
patient is positioned supine on a wooden
plinth. A roll is placed under the elbow, just
proximal to the joint. The arm is stabilized
with a sand bag placed on the lower end
of the arm, keeping the elbow free to move.
Tension to the muscle is applied with a
sand bag or weighted belt (1/2-1 kg)
strapped to the anterior aspect of the wrist.
applied.

visible contraction of the muscles.
Patient should be asked to do active
movement simultaneously with the current flow and relax during surge interval.
The treatment should be given for 30 min.
Special Precautions
Skin rashes are common on prolonged
stimulation.
Use Betamethasone and zinc oxide-based
cream in case of rashes.
The body hair must be shaved before
treatment to minimize skin resistance.
Use a moisturizing lotion after treatment.
Contraindications: Do not stimulate in presence of open wound or skin rashes.
50
6
Pain Modulation
Transcutaneous Electrical
Nerve Stimulation (TENS)
It is a modern, non-invasive, drug-free pain
management modality, designed to provide
afferent stimulation, used for relief of acute
or chronic pain.
TENS is frequently used to relieve muscle
pain in the neck, back or joint pain of knee,
shoulder, etc, arising from work or sport
related injuries, e.g. carpal tunnel syndrome,
RSI (repetitive strain injuries), as well as,
postural musculo-skeletal problems related to
faulty working environment.
PHYSIOLOGICAL EFFECT OF TENS
Two theories are used to justify the relief of
pain achieved by TENS.
Points to Ponder
A. The Gate Control theory by Malzack and
Wall in 1972 postulated that:
Activation of A-beta fibres simulates
the inhibitory interneuron in substantia
gelatinosa located in the dorsal horn of
the spinal cord.
The activated interneuron produces
inhibition of transmission through pain
carrying A-delta and C fibres.
This pre-synaptic inhibition of the T

cells closes the spinal pain gate to
prevent the painful impulses from
reaching the sensory cortex, where the
pain is felt.
Pain modulation is thus achieved by
activation of central inhibition of pain
transmission
B. The Endorphin Release theory states that:
Noxious stimulus causes production of
endorphins in the pituitary gland.
Endogenous opiates are also synthesized in periaquductal grey matter,
midbrain and thalamus.
Painful stimulus causes release of these
opiates in the pain receptor sites in the
brain.
Pain modulation can thus be achieved
through the descending pathways
generating bodys own pain killing
chemicals or endogenous opiates.1
EQUIPMENT AND THE NATURE OF
TENS CURRENT
Points to Ponder
Externally applied electrical potential from
TENS must produce evolved potentials in
Pain ModulationTranscutaneous Electrical Nerve Stimulation (TENS)
underlying peripheral sensory nerve(s) or

receptors on the skin.
To do this, there must be an adequate
stimulus to cause depolarisation of the
nerve cell membrane.
Relief of pain by selectively stimulating the
nerve fibres of choice, either large diameter
A-Beta fibres or small diameter A-Delta
fibres by adjusting the parameters of the
machine.
Characteristics of A-Beta Fibres
Large diameter, densely myelinated, with
rapid conduction velocity
Low capacitancedoes not maintain
depolarised state for long
Fibres remain excitable to pulse widths as
short as two microseconds
To excite A-beta fibres, high-frequency
impulses with short pulse widths is used.
Characteristics of A-Delta Fibres
is rapid but transient, i.e. no pain is felt as long

as the current is on.
Points to Ponder
Rate: 50-100 Hz
Pulse width: 50-100 microseconds
Pulse shape: Bipolar asymmetric spike
potentials.
Duration of treatment: 20-60 min in one
sitting may be given continuously for 8 hrs
if required.
Intensity: Between the first threshold of
tingling and less than an intensity at which
slight discomfort/muscle contraction is
felt.
Frequency of treatment: Relief only as long
as current applied, hence repeated application, particularly while working, is recommended.
Uses: Relief of acute and postoperative
pain, and in areas of hypersensitivity or
increased muscle tone.
Light myelination, slower conduction

velocity
High capacitancelonger latency
Fibres are unexcitable with pulse widths
below 10 microseconds
To excite A-delta fibres, low-frequency
stimulation, with longer pulse width is
used.
2. Low Rate TENS
DIFFERENT TYPES OF TENS USED IN

CLINICAL APPLICATION
Points to Ponder
1. High Rate TENS

Most common mode of TENS, used in acute
or chronic stage of pain syndrome. Modulation of pain takes place by activation of the
gate control mechanism by inhibition of pain
carrying fibres by large diameter fibres. Effect
51
This is acupuncture like strong low-frequency

stimulus, useful in relief of chronic pain.
Modulation of pain takes place through
release of endogenous opiates, which suppress the pain receptors in the cerebral cortex.
Effect is relatively slow but lasts longer, i.e.
more than hours after treatment.2
Rate: 1-5 Hz
Pulse shape: Monophasic pulses
Intensity: Sufficient to cause visible muscle
twitches within comfortable tolerance
level of the patient.
Duration of treatment: 20-30 minutes per
sitting.
52
Frequency of treatment: Once or twice a

day, depending on duration of pain relief
Uses: Relief of chronic pain, effective over
area of tissue or skin disturbance where
destruction of large fibres means that a
long pulse width is needed to achieve the
effect, e.g. diabetic Neuropathy, neuralgia.
3. Brief Intense TENS
Potentially painful, intense stimulation used
to provide rapid short-term pain relief during
painful procedures like tooth extraction,
wound debridement and dressing of wounds,
deep friction massage, forced passive movements of joints or passive stretching of soft
tissue contractures. Relief of pain is temporary.

Pulse shape: Asymmetrical biphasic
Intensity: Comfortable with intermittent
tingling sensation
Duration of treatment: 20-30 minutes
Uses : Suitable for relief of chronic muscle
spasm or a combination of musculoskeletal and neurogenic pain of chronic nature,
e.g. sciatic syndrome.
WAVEFORMS OF TENS
Points to Ponder
Rate: 80-150 Hz
Pulse shape: Monophasic pulses
Intensity: Strong to the level of pain
threshold
Duration of treatment: 15 minutes
Frequency of treatment: S.O.S.
Uses: To suppress pain during potentially
painful procedures.
There is no definitive work or publication

to support the claim that one waveform is
better than the others.
Both basic waveforms, asymmetrical
biphasic or monophasic pulses, are used
in TENS stimulation.
The spike and the square waveforms are
most effective, having a sharp rate of rise,
which sufficiently depolarizes the target
sensory nerve.
Most popular waveforms used are biphasic and are balanced so that there is a
net zero DC component, to prevent buildup of ion concentrations beneath the
electrodes.
4. Burst Mode TENS
MODULATION OF TENS
This form combines the characteristics of high

and low TENS, leading to release of endogenous opiates. The stimulation is welltolerated by patients, even on prolonged
application, with slower onset of pain relief
as compared to low TENS.
Points to Ponder
Points to Ponder
Points to Ponder
Rate: 50-100 Hz, delivered in bursts, of
14 pulses per second.
Modulation of electrical parameters (pulse

rate, pulse width) is offered on some TENS
machines in order to prevent accommodation of the nerve and receptors to the
stimulus.
Its clinical value remains to be assessed,
apart from a pulsation, which some
patients find more comfortable.
PARAMETERS FOR OPTIMAL

STIMULATION
An optimal stimulation/site should be:
Strong enough to stimulate the CNS.
Suitable for proper placement of electrodes, free of bony or hairy area.
Segmentally-related to the source, as well
as, the site of pain.
Anatomically-distinct, like specific spinal
segment or the nerves.
ELECTRODE PLACEMENT
Since the modality of TENS is still under
exploration, placement of electrodes in TENS
is controversial. A basic thumb rule is that the
negative electrodes should be placed distal to
the positive electrodes. The positive electrodes
may be located as close to the representative
spinal segment as possible (Fig. 6.1).
The negative electrodes may be located at:
Acupuncture sites
Dermatome of the involved nerves
Over the painful spot
Proximal and distal to the pain site
Segmentally-related myotomes
Trigger points
The exception to the rule is pain due to
surgical incisions, where the electrodes must
be placed parallel to each other on either sides
of the suture line. Placements rules have to
be adapted with multiple channel application
to ensure maximum coverage of large affected
area (Figs 6.2 and 6.3).3
53
CONTRAINDICATIONS FOR TENS

TENS is an inexpensive patient friendly
modality having a wide range of application
with superb safety record. However in some
types of cases the application of the modality
should be withheld.
Patients with demand type pace makers
Over the chest wall of cardiac patients
Over the eyes, larynx, pharynx over
mucosal membrane
Over the head or neck of a patient with
recent history of stroke or epilepsy.
PRECAUTIONS FOR HOME
PRESCRIPTION
Being a patient friendly device, due to its easy
battery operation, compact size and negligible
weight, TENS units may be used by patient
constantly, like a hearing aid, to have effective
pain control while working or at home. High
TENS is the current of choice in such situations. Before prescribing the therapist should
ensure the following:
Patient can understand and follow operating instructions perfectly. Do not prescribe it for very old or young.
The desired pulse width and rate must be
set by the therapist and then locked in, so
that these parameters cannot be changed
by accident. The patient should only have
access to the intensity control and be able
to adjust the strength of the stimulation to
his level of tolerance.
The therapist must coach the patient on
basic maintenance of the equipment,
which is similar to a mobile phones.4
54
Fig. 6.1: General rules for placements of electrodes for application of TENS:
Carbon rubber plate electrodes of equal sizes (2 cm 3 cm) are commonly used.
The electrodes may have two or four pole arrangement, depending upon the extent of area to be covered
and the type of equipment available.
As a thumb rule, the positive electrode is placed proximally over the spinal segment representing the
neural supply of the target area.
The active electrodes may be placed over the distal most point of the target nerve or over the dermatome
of the target segment.
Fig. 6.2: Specific placement of electrodes for application of TENS for various
painful conditions on the posterior surface of the body
Fig. 6.3: Specific placement of electrodes for application of TENS for various
painful conditions on the anterior surface of the body
55
56
APPLICATIONS OF TENS IN COMMON DISORDERS

Disease conditions
Tension Headache
Type of current
Burst
Current parameters
Electrode placement
Pulse duration50 microsecond

Pulse frequency100 Hz
Burst frequency10 Hz
Dose15 Minutes
Crossed 4 pole, 2 each over the

origin and insertion of bilateral
Trapezius muscle upper fibres,
strong tingling felt.
Frozen Shoulder
(chronic Stage)
Burst

Burst frequency2 Hz
Dose15 Minutes
Cross 4 pole around the

shoulder joint
Postherpetic
Neuralgia
Burst

Burst frequency10 Hz
Dose15 Minutes
4 Pole method: 2 over the

affected area and 2 above
and below the exit nerve
root.
Neuralgia
Continuous

Dose10-15 Minutes
2 or 4 Pole method over the

affected area.
Reflex Sympathetic
Dystrophy
Continuous

Dose10-15 Minutes
4 Pole method: a) U/L: 2

Electrodes at paravertebral
region of C-8 to T-9 and 2
electrodes over levator
scapulae and lateral part of
spine of scapula.
b) L/L: 2 Electrodes over paravertebral region of T-10 to L-2
and 2 electrodes over the iliac
crest and lateral part of buttock.
Postoperative Pain
Continuous

Dose10-15 Minutes
4 Pole method: 2 proximal

and 2 distal to operated area.
Menstruation Pain
Continuous
Pulse duration100 microsecond 2 Pole method: over the

sacrum bilaterally.
Dose15 Minutes
Stress Incontinence
Surge
Pulse duration100 microsecond 2 Pole method

Dose15 Minutes
REFERENCES
1. Walsh D. TENS: Clinical Applications and
Related Theory. Churchill Livingstone, 1997.
2. Ellis B. A retrospective study of long-term users
of TNS. British Journal of Therapy and Rehabilitation 1996;3(2):88-93.
3. Walsh D, Baxter D. Transcutaneous electrical

nerve stimulationA review of experimental
studies. European Journal of Medical Rehab
1996;6(2):42-50.
4. Roche P, Wright A. An investigation into the
value of TENS for arthritic pain. Physiotherapy.
Theory and Practice 1990;6:25-33.
Advanced Applications of Low Frequency Electrical Stimulation
57
7
Advanced Applications
of Low Frequency
Ongoing research and the constant quest
among professional working in the field, for
effective modalities to achieve quick results
have yielded different applications of low
frequency currents. Some of theses applications like the high voltage pulsed galvanic
stimulation and functional electrical stimulation are results of such quests. Advent of
microprocessor technology has been at the
root of designing sate of the art stimulators
at affordable prices that has helped to
popularise these applications.
Few applications, like the iontophoresis
had been in use in the past decades but had
fallen out of favour due to lack of suitable
water soluble ionic mediums in those times.
Nowadays, due to the progress made in
pharmacy sciences many therapeutically
useful active ions are available in watersoluble gel form, which are easily absorbed
by the body through the skin and are suitable
for use in iontophoresis. Due to this there is
resurgence in interest among therapists
towards this time-tested modality.
HIGH VOLTAGE PULSED GALVANIC

STIMULATION (HVPGS)
HVPGS is relatively uncommon form of
stimulating current modulation, used primarily to achieve stimulation of deeper
tissues, useful for sensory stimulation for pain
relief and to assist in wound healing.
Parameters of HVPGS Current
HVPGS current consists of monophasic,
twin peak pulses of 7 to 200 microseconds
duration, delivered at 300 to 500 volts.
The twin peak pulse are spike-shaped,
rising and falling rapidly
As pulses rise and fall rapidly, the second
spike cancels out the irritation produced
by the first spike.
The modulation may be continuous,
pulsed at 80 to 100 pulses per second or
surged.
The passage of HVGS is relatively easy
because it is offered little resistance by the
skin due to higher frequency.
58
The specific duration and voltage requirements vary depending upon the condition
being treated.
Effects and Uses of HVPGS
Application of HVPGS tends to produce
comfortable tingling sensation and parasthesia that closely resembles high frequency TENS.
It is used for relief of neurogenic pain
through stimulation of trigger points,
relaxation of deep muscle spasm and
wound healing.
Instrumentation of HVPGS
HVPGS therapy is applied through high
voltage direct current generators, capable
of producing extremely short duration
pulses (microseconds), generally in the
range of 300 to 500 volts.
Standard electrodes used for low voltage
low frequency stimulation, is used for
HVGPS.
The protocol for electrode placement and
treatment is similar to low frequency or
TENS for relief of muscle spasm and
trigger point pain.
It is more specifically used for wound
healing.
Application of HVPGS in Wound Healing
The patient is positioned comfortably on
a plinth. The wound is exposed with the
rest of the body covered.
Inspect the wound closely for any slough.
The wound must be cleaned and debrided
before application of HVPGS, since infection may interfere with the beneficial effect
of HVPGS.
Cover the clean wound with several layers

of sterile gauze soaked in saline.
Place the active electrode over the gauze.
If the wound has chronic infection, to get
antibiotic effect, the active electrode
should have negative polarity.
If the wound is free of infection, to promote
healing, the active electrode should have
positive polarity.
The passive electrode must be three times
the size of active electrode and placed
proximal to the active electrode.
The intensity must be gradually increased
to a comfortable level.
The duration of treatment should be 30 to
60 minutes, for one sitting, on alternate
days.
FUNCTIONAL ELECTRICAL
STIMULATION (FES)
Functional electrical stimulation, also known
as functional neuromuscular stimulation, is an
adapted version of motor stimulating current
modulation, similar in physiological characteristics to the surged faradic stimulation,
used for activation of innervated muscles.
Parameters of FES Current
The current used is asymmetrical bi-phasic with
high amplitude negative phase followed by low
amplitude positive phase.
The pulse frequency is in the range of
12 to 100 Hz, with continuous modulation.
Intensity of current: 90 to 200 milli ampere.
Pulse duration: 20 to 300 microsecond.
Voltage: 50 to 120 volts.
Effects and Uses of FES
This type of current is suitable for producing controlled titanic contraction of muscles,
which generates adequate torque to produce

functional movements, in the absence of
adequate voluntary contraction.
It is widely used to:
1. Prevent or correct disuse atrophy,
2. Improve ROM in stiff joints, reduce
muscle spasm or spasticity,
3. Re-education of new muscle action in
case of muscle or tendon transfers
4. Most commonly used for trial, supplementation or substitution of orthosis.
Instrumentation of FES
1. Stimulator: Specialized FES stimulators are
rechargeable battery operated compact
devices, providing option for continuous
modulation of pulse amplitude, duration
and frequency, which can be carried by the
patient like a hearing aid. The slandered
surged faradic stimulator may be used for
treating of localized complaints that
involve no mobility.
2. Leads: Flexible and thin, such leads are
0.5 to 1.5 meters in length and have a high
degree of resistance to torsion and strain.
3. Electrodes:
a. Self-adhesive pre-gelled electrodes.
b. Carbon rubber electrodes.
Application of FES in
Hemiplegics Shoulder
Hemiplegic patients with one-sided
paralysis of the body may have flaccid
paralysis of deltoid and supraspinatus
muscle, resulting in subluxation of the
glenohumeral joint.
The force of gravity tends to pull the
unsupported upper extremity downwards
causing stretching of the rotator cuff,
resulting in ischemia, that produces severe
59
pain and inhibition of movement in the

upper extremity.
Conservative management of such painful
shoulder involves a supportive cuff
(Bobath cuff) to relive the stretch on the
rotator cuff tendons and ligaments.
FES is used as supplement to the Bobath
cuff, in such subluxated shoulder to
increase the supportive action of the key
muscles of the rotator cuff and relieve the
painful structures of constant painful
stretch.
Current parametersAsymmetrical, biphasic, square wave pulses with continuous modulation may be used, applied
from a standard faradic stimulator or
rechargeable battery operated portable
stimulator.
Electrode placementBipolar surface
electrodes, carbon rubber type may be
used. One electrode is placed on the
supraspinatus muscle belly just above the
spine the scapula and the other should be
placed on the posterior fibres of deltoid
muscle.
Treatment procedure
1. The patient is placed in high sitting on
a wooden chair, with the arm supported in front, on a wooden plinth.
2. The arm and the shoulder girdle are
exposed. The procedure and its poten
tial benefits are explained to remove
any anxiety felt by the patient.
3. The skin is prepared, the equipment is
tested and the electrodes are fixed to
the skin with straps or adhesive tapes.
4. The intensity should be adequate to
produce tetanic contraction of target
muscle, within the limit of patients
tolerance. Patients with CVA may be
hypertensive. Therefore special care
60
should be taken not to cause any

distress to patient.
5. The pulse rate is adjusted to 12 to 25
pulses per second.
6. The on-off ratio between surge duration and surge interval should start
with 1:3, i.e. 2 seconds on and 6 seconds
off. The patient must be encouraged to
contract the muscle voluntarily with
the current surge. The ratio is gradually
progressed to 12:1, i.e. 24 seconds on
and 2 seconds off as the muscles gain
power.
7. The duration of treatment should be for
15 to 30 minutes in one sitting and
should be repeated twice initially. Later
the treatment may be given daily for
up to 6 to 8 hours.
Application of FES in Idiopathic Scoliosis
Idiopathic scoliosis is the gradual sideways curving (Lateral curve) of the
vertebral column, commonly seen in
growing children.
Teenage girls are the commonest victims
of this disorder, which can result in severe
spinal deformity.
Before the bony maturity has taken place,
such disorder can be rectified with CTLSO
spinal brace.
CTLSO spinal brace or Milwaukee brace
works on the principal of a static brace
with dynamic correction.
FES can be used in cooperative candidates,
to supplement the corrective function of
the brace, by encouraging the contraction
of posterior spinal muscles, in a progressive deformity, when the spinal curvature (Cobbs angle) is between 20 and 45.
Current parametersInterrupted monophasic rectangular pulses with pulse
duration of 225 microseconds are used,

applied from a rechargeable battery
operated portable stimulator.
electrodes, carbon rubber type may be
used.
1. In case of single curvePlace two
electrodes from a single channel machine
2 lateral to the spine, on the convex side
of the curve, placed above and below the
ribs attached to the vertebra at the apex of
the curvature.
2. In case of a S curvePlace four
electrodes from a two channel machine,
placed convexity, on either side, placed
above and below the ribs attached to the
vertebra at the apex of the curvature.
Treatment Procedure
1. FES in scoliosis should be applied, with the
brace on, with a portable stimulator, which
the patient can continue to use while
performing normal activities.
2. The electrodes are positioned as detailed
above under the straps of the brace and
then the straps are tightened to give optimum tension on the curvature and maximum contact to skin.
3. The intensity is increased within the limit
of tolerance, to produce titanic contraction
of paravertebral muscles.
4. The pulse rate is adjusted to 25 pulses per
second.
5. The surge duration/interval ratio should
be 1:1, i.e. 6 seconds on and 6 seconds off.
6. The duration of the treatment may be up
to 8 hours. The patient must be encouraged to perform the self-stretch exercise
with braces on, while undergoing FES, to
get best results.
Application of FES in Foot Drop

Inability to dorsiflex the ankle voluntarily
results in foot drop.
During the heel strike of the gait cycle, foot
drop is the most important cause of gait
deviation i.e. circumduction gait, in hemiplegic patients.
FES, if applied to the affected leg during
walking, can be used to control foot drop
by stimulating the action of dorsiflexors of
the ankle and evertors of the foot, at the
swing phase of gait.
Current parametersAsymmetrical biphasic or square wave pulses with pulse
duration of 20 to 250 microseconds, applied from a rechargeable battery operated
portable stimulator.
electrodes, self-adhesive pre-gelled type
may be used. One electrode placed on the
peroneal nerve at the neck of fibula and
the other should be placed on the muscles
of anterior-lateral compartment of the leg.
Treatment procedure:
1. FES in foot drop can be applied, with a
portable stimulator, with the brace/
AFO on, which the patient can continue
to use while performing normal activities.
2. The electrodes are positioned as detailed above under the straps of the
brace and then the straps are tightened
to give maximum contact to skin.
3. The intensity is increased within the
limit of tolerance, to produce titanic
contraction of target muscles.
4. The pulse rate is adjusted to 30 to 300
pulses per second.
5. The flow of current is turned on during
the swing phase to produce dorsifle-
61
xion of the ankle as preparation to heel

strike.
6. As soon as the heel comes in contact
with the ground, pressure sensitive feet
switch cuts off the flow of the current,
allowing the foot-flat to take place
during the stance phase.
7. The duration of the treatment may be
up to 8 hours, during walking. The
patient must be encouraged to perform
the exercises for dorsiflexon with
braces on, while undergoing FES, to get
best results.
IONTOPHORESIS: ION TRANSFER
WITH DIRECT CURRENT
It a specialized technique of electrical stimulation that uses electrical polarity of continuous
direct current to ionize medicinal agents placed
beneath surface electrodes and transfers them
into the body through the skin or mucous
membrane.
How does Iontophoresis Work?
With iontophoresis, weak electric current
is used to introduce medication through
the intact skin to the underlying tissue.
The medication is supplied directly in to
the area that will be treateda form of
pharmacological sharp-shooting.
Systematic affect is reduced to a minimum
and no adverse effects have been reported.
Iontophoresis is an effective and pain-free
treatment method.
It is based on the principle that, electrical
stimulation affects the ions in a solution
so they may move, depending on their
charge.
With iontophoresis the polarity that
corresponds with the charge of the medications ion is connected to electrode.
62
This entails the repelling of the active

pharmaceutical ion, which results in the
medication being introduced down
through the skin.
Biophysics of Iontophoresis
Transfer of ions depends on the principle
of Like poles repel and opposite poles
attract each other.
Dissolved acids, bases, salts or alkaloids
in a watery solution break down into
charged particle or ions.
Ions are charged particles, with positive or
negative charge, that can be pushed
through the skin by a similar charge
applied to the electrode placed over it or
pulled through the skin by a oppositelycharged electrode placed away from it
These ions, on entering through the skin,
combines with other ions and radicals present
in the blood stream to form new compounds
that are therapeutically valuable in specific
disease conditions.
Selection of suitable ionic compounds and
placing them under appropriately charged
electrode is the key to the success of
iontophoresis.
Low voltage (<100V) monophasic continuous direct current, applied at low
intensity (<5 mA), applied over low ionic
concentration (1-5%) in the iontophoresis
medium is most effective in producing
desired result.
Direct current applied is not the treatment,
but only the means of ion transfer.
Efficacy of the treatment will depend on
selection of specific ionic medium, aimed at
producing a specific reaction, to treat a
specific disorder.
Dosimetry of Iontophoresis
The number of ions transferred through the
skin depends on:
1. Duration of treatment
2. Current density or current intensity per
square cms area of the electrodes.
3. Concentration of ions in the medium used
in iontophoresis.
Based on the above the formula to calculate quantity of substances introduced
through iontophoresis is:
I T ECE = grams of substances introduced through skin, where,
Istands for intensity of direct current in
amperes
Tstands for duration of application in
hours
ECEstands for standardized ionic transfer coefficient with fixed current and time
factors.
The dosimetry of iontophoresis is fairly
controversial, due to conflicting reports.
It has been reported that low ampere
current has a better effect in ion transfer
because of less resistance offered by the
than high intensity current.
It has also been suggested that lower
concentration of active-charged ions in the
iontophoresis medium is far more effective
because of less repelling going on between
the like-charged ions themselves, which
allows better penetration.
By and large, for effective ion transfer it is
recommended to use maximum 5 m. amp
current applied over a medium with active
ion concentration of 1-5%.
Indications for Iontophoresis
There are three main areas of treatment for
iontophoresis:
Cortisone treatment of superficial local
inflammations.
Quick and effective surface anaesthesia with

a local aesthetic.
To treat hyperhydrosis or excessive sweating in the palm of the hands, soles of the
feet or axilla.
Application of Iontophoresis in
Local Inflammation
Iontophoresis has shown good results in
treatment of acute and sub-acute superficial local inflammations, such as tendonitis, bursitis, and fasciitis.
Administration of cortisone using iontophoresis is a pleasant alternative to
cortisone injections.
The anti-inflammatory effect is achieved
while avoiding the adverse effects for
systemic or injected cortisone.
Effective alternative to treatment with antiinflammatory tablets or NSAIDs.
With iontophoresis a higher concentration of
the medication is obtained locally in the tissue
while systemic effect is avoided.
Commonest sites of application are medial
and lateral epicondylitis, Achilles tendonitis, inflamed ligaments of knee, bicepital
tendonitis, shoulder rotator cuff tendonitis/tenosynovitis, carpal tunnel syndrome etc.
Local Anaesthesia
With iontophoresis, superficial local
anaesthesia can be achieved quickly and
effectively by supplying the drug, without
needles and without pain.
The method is faster and penetrates deeper
than local anaesthesia and is excellent
alternative for anaesthetizing before injections, wound dressing or taking blood/
tissue samples.
63
The skin is as anaesthetized within 10

minutes of iontophoresis, as compared to
60 minutes with local anaesthetic cream.
Hyperhydrosis
Tap water iontophoresis is considered by
many dermatologists to be the first line of
treatment for hyperhidrosis of the palms and
soles.
Although more cumbersome, iontophoresis can be used to treat axillary hyperhidrosis as well.
In addition to simple tap water, anticholinergics and other drugs can be introduced
to areas affected by hyperhidrosis.
Which Medications may be
Used as Ionising Agents?
Medications or mediums that are used with
iontophoretic treatment must be watersoluble and ionisable.
Local Inflammation
Hydrocortisone in a water-soluble base or gel
at 1-10% concentration by volume may be
used. This medium has a negative charge, so
the negative pole (black) must be connected
to the medication electrode.
Local Anaesthesia
Xylocaine hydrochloride solution or gel used
for local anaesthesia, at 1% concentration is
recommended medium. Xylocaine has a
positive charge, so the positive pole (red) must
be connected to the medication electrode.
Electrodes for Iontophoresis
The electrodes used in iotophoresis have to
be specifically tailor made for a specific site
and patient.
64
Use aluminium foil, cut in square or round

shape, large enough to cover the entire
skin surface of the target area.
The active electrode should be bigger than
the passive, to provide for low current
density, which helps in better penetration
of ions.
The aluminium foil electrodes are covered
with 8 to 10 layer of tissue paper, which
can be discarded after single use.
The active electrode is soaked in the active
ingredient solution made of distilled
water.
The passive electrode is soaked in tap
water. In case of hyperhydrosis both
electrodes are soaked in tap water.
Technique of Application Iontophoresis
Clean and soak the skin to reduce the skin
resistance. If there are cuts or break in the
skin, apply a thin layer of sterile petroleum
jelly on the spot.
Position the patient on a wooden plinth.
Support the area to be treated with pillows.
Rub the medium containing the active
ingredient on the skin over the spot to be
treated.
Active electrode having the same polarity
as the active ion is placed on the area to be
treated. Special medicated active electrodes are available readymade in the market,
though these are much more expensive

than aluminium foil electrodes.
The passive electrode is placed at a site
away from the site of stimulation.
Electrodes are secured with straps or
adhesive tapes (Figs 7.1A and B, Plate 4)
Calculate the dosage as per the guidelines
given above. Remember that the safe limit
for positive active electrode is 1.0 mA/sq
cm and negative active electrode is 0.5
mA/sq cm.
Turn the intensity gradually to the safe
limit.
Keep close watch over the treatment area.
Inspect the site after every 5 mins. If there
is itching or burning stop treatment
immediately.
After 20 to 30 min of treatment slowly turn
the intensity to zero.
Remove the electrodes; inspect the area for
rash or reddening. Slight reddening is
expected.
Wash the area thoroughly with water and
allow the patient to leave.
Contraindications of Iontophoresis
Impaired skin sensation

Allergy or rashes
Recent scar
Broken skin
Metal in the treatment area.
Ions commonly Used in Iontophoresis and Their Clinical Indications

Ions
Polarity
Source
Indications
Lidocaine/Xylocaine
Salicylate
Acetate
Zinc
Copper
Calcium
Magnesium
Dexamethasone
+
+
+
+
+
Lidocaine/Xylocaine gel
Sodium salicylate gel
Acetic acid
Zinc oxide solution
Copper sulphate solution
Calcium chloride
Magnesium sulphate
Dexamethasone 1% gel
Local anaesthesia
Relief of pain and inflammation
Dissolve calcification of soft tissue
Skin ulcers
Fungal infection
Muscle spasm
do
Soft tissue inflammation
Medium Frequency Currents 65
8
Medium Frequency
Currents
Sine wave current, in the frequency range
of 2000 to 5000 Hz, modulated to produce
physiological response in nerves are called
the medium frequency currents.
The basic advantage of medium frequency
stimulation over conventional surged
faradic current, is its ability to produce the
strong physiological effects of low frequency electrical stimulation, in much
deeper muscle and nerve tissues, without
the associated painful and unpleasant
sensation of low frequency stimulation.
To produce low frequency effects at
sufficient intensity at depth, most patients
experience considerable discomfort in the
superficial tissues (i.e. the skin).
This is due to the resistance (impedance)
of the skin being inversely proportional to
the frequency of the stimulation. In other
words, the lower the stimulation frequency, the greater the resistance to the
passage of the current and so, more
discomfort is experienced.
The skin impedance at 50 Hz is approximately 3200 ohms whilst at 4000 Hz it is
reduced to approximately 40 ohms.
The result of applying such medium

frequency current is that it will pass more
easily through the skin, requiring less
electrical energy to reach the deeper
tissues, therefore producing less discomfort.
TYPES OF MEDIUM FREQUENCY
CURRENT
Medium frequency current can be broadly
categorized in to two forms:
1. Medium frequency surge current
2. Interferential current
Medium frequency surge current is a twopole interference current, which increases and
decreases in intensity over a set duration and
interval, like the surged faradic current.
It is far well-tolerated by the patient than
faradic stimulation and the etching effect of
IG stimulation are not seen
It is available in two formats;
1. Russian current with carrier frequency
of 2500 Hz
2. MF surge current with carrier frequency of 4000 Hz.
66
Russian Current
It is a polyphasic sine wave continuous
current having a basic or carrier frequency
of 2500 Hz.
The current is frequency modulated to
produce a train of pulses with a pulse
duration of 10 ms and a pulse interval of
10 to 50 ms.
Such frequency modulation produces 50
to 10 pulses in one second, each pulse
lasting for 10 ms.
It is applied in bi-polar mode, usually with
carbon rubber or vacuum electrodes.
It is effective in muscle strengthening and
for relief of muscle spasm.
Method of Application
For muscles strengthening, the intensity is
adjusted to produce strong titanic muscle
contraction, using a pulse rate of 50 to 70
pulses per second with pulse duration of 150
to 200 microseconds. The current is applied
during volitional activities like isometric
contractions in different ROM, slow speed
isokinetic and short arc isotonic movements.
Primary effects are to build up muscle power
delivery in different range of motion or
mobilize stiff joints. The stimulation is applied
to produce contraction for 15 seconds and
relaxation for 50 seconds.
For relief of muscle spasm, titanic contraction is produced to the limit of tolerance a
pulse rate of 50 to 70 pulses per second, with
pulse duration of 50 to 170 microseconds. The
stimulation is applied to provide brief
isometric contractions for 5 to 12 seconds and
8 to 15 seconds of relaxation.
MEDIUM FREQUENCY SURGE CURRENT
It is a polyphasic sine wave continuous
current having a basic or carrier frequency
of 4000 Hz.
It is more useful for relief of pain and

improving circulation in muscles.
Though it causes significant muscle contraction, it is less powerful than produced
with Russian current.
INTERFERENTIAL CURRENT
Interferential current utilizes two amplitude
modulated medium frequency sinusoidal
currents; in the frequency range of 4000 to
5000 Hz. These are called the carrier currents.The carrier current in both channels has
the same amplitude but the frequencies of are
kept slightly out of synchronization.The
carrier currents are passed through the tissues
simultaneously, so that their paths cross and
interfere with each others field deep within
the tissues.This interference gives rise to
amplitude modulated frequency, like the
strings of a sitar, to produce a pulsing effect
or beat; wherever they cross each other. When
the two carrier waves are in phase, constructive interference takes place. The resultant
beat frequency has an amplitude (intensity)
that is the sum total of the amplitudes of the
carrier currents when the carrier waves are
180 degree out of phase, destructive interference cancels out the carrier amplitudes. The
resultant beat frequency has amplitude
(intensity) of zero. The beat frequency current
has the characteristics of low frequency
stimulation (Fig. 8.1).
The exact frequency of the beat frequency
can be controlled by the input frequencies
If one carrier current is at 4000 Hz and its
companion current at 3900 Hz, the resultant beat frequency would be the difference of the two carrier frequencies i.e. 100
Hz, spreading in a typical clover leaf
pattern (Fig. 8.2B).
Modern machines usually offer frequencies of 1 to 150 Hz, though some offer a
choice of up to 250 Hz or more.
To a greater extent, the therapist does not
have to concern themselves with the input
frequencies, but simply with the appropriate beat frequency, which is selected
directly from the machine.
In 2 pole interferential stimulation, where
there is clearly no interference within the
body, is made possible by electronic manipulation of the currents, i.e. the interference occurs within the machine. This is
suitable for small areas like sinus, temporo-mandibular joints etc.
Fig. 8.1: Principle of interference using two
channels of medium frequency currents
The amplitude modulated beat frequency

may be constant or variable.
Constant beat current is obtained when
both the carrier frequencies remain fixed.
Variable beat current is obtained when one
carrier remains fixed and the other keeps
on changing in frequency at regular
intervals from a lower to a higher level and
back, known as sweep.
This produces a spectrum of frequencies
in the beat current at regular sweep.
Such sweep prevents accommodation of
nerves.
By careful manipulation of the input
currents it is possible to achieve any beat
frequency to use clinically.
Classical interferential (static) field is
generated when the beat current remains
constant.
Vector current (dynamic) field is produced
when the interferential field rotates by 45
in clockwise or anticlockwise direction
within the tissue, constantly changing the
stimulation zone.
Physiological Effects of
Interferential Current
Excitable tissues can be stimulated by low
frequency alternating currents.
All tissues in this category will be affected
by a broad range of stimulations
Savage in 1984 postulated that different
tissues will have an optimal stimulation
band, which can be estimated by the
conduction velocity of the tissue, its
latency and refractory period.
These are detailed below:
Sympathetic nerve: 1 to 5 Hz
Parasympathetic nerve: 10 to 150 Hz
Motor nerve: 10 to 50 Hz
Sensory nerve: 90 to 100 Hz
Nociceptive fibres: 90 to 150 Hz
Smooth muscle: 0 to 10 Hz.
Therapeutic Effects of
Interferential Current
The clinical application of IFT therapy is
based on response threshold and the
physiological behaviour of stimulated
tissues.
68
Selection of a wide treatment band can be

considered less efficient than a smaller
selective band because by treating with a
frequency range of say 1 to 100 Hz, the
appropriate treatment frequencies can be
covered, but only for a relatively small
percentage of the total treatment time.
Additionally, some parts of the range
might be counterproductive for the primary aims of the treatment.
Main clinical applications of IFT are:
1. Pain relief
2. Muscle stimulation
3. Increased blood flow
4. Reduction of oedema
5. Tissue healing and repair.
Since IFT acts primarily on the excitable
tissues like nerves and muscles, the
strongest effects are likely to be those
produced by such stimulation, i.e. pain
relief and muscle contraction.
The other effects like drainage of fluid and
reduction in muscle spasm are secondary
consequences of the primary effects.
Instrumentation of IFT
Most modern IFT units (Figs 8.2A and 8.3)
allow the therapist to get tailor made current,
suitable to treat a specific disorder, which may
be built in to the memory of the software
based equipments or by adjustment of
following machine parameters:
Amplitude modulation parameter (AMF),
to choose the basic value of the low
frequency modulation that is desired.
Spectrum parameter, to set the range of
variation in the AMF value that is desired;
setting the AMF at 100 Hz and spectrum
at 50 Hz will give an AMF variation from
100 Hz upto150 Hz and back to 100 Hz.The
spectrum is useful in preventing accommodation in nerves (Fig. 8.2B).
Fig. 8.2A: Advanaced Interferential equipment: The

Phyaction 787 stimulator with microprocessor
controlled circuits is a later generation equipment that
offers a wide range of stimulating current selection in
low and medium frequency range, with ultrasonic
therapy module which can be used for combination
therapy or as an independent modality (courtesy M/
S Hintek Electronics, New Delhi). Note four channel
conventional carbon rubber plate electrodes
connected to the machine through colour-coded
leads. On the left of the plate electrodes are four
sockets for vacuum suction electrodes. Unlike the
plate electrodes, the vacuum suction electrodes do
not need straps to hold them in place, hence are easy
to apply over irregular surfaces.
Fig. 8.2B: Advanaced interferential equipment: The

LCD display of Phyaction 787 in classical interference
current mode, showing amplitude modulated
frequency at 100 Hz, nil spectrum or sweep
frequency, sweep time of 1sec and a rise or fall rate
of surge at 67 per cent. The clover leaf pattern of the
classical interference current is also shown along with
intensity of each channel and the treatment timer
Fig. 8.3: Overall arrangement of the interferential

therapy instrumentation (equipment and electrodes)
in a clinical setting
Sweep time parameter sets the time period for

the AMF to change from base to peak
frequency. Faster the sweep less painful is
the stimulation. However, if strong muscle
contraction or sensory input is desired,
then the sweep must be slow, to ensure
aggressive stimulation.
Contour parameter sets the rate of change of
the AMF from base to peak frequency. This
is expressed in percentage of time taken
to reach from base to peak of AMF. Greater
the percentage, the gentler is the stimulation.
Rotation parameter is applicable in case of
vector currents only and sets the rate of
rotation and the direction of change of the
AMF field within the tissues.
Treatment Parameters to Achieve
Pain Relief with IFT
Electrical stimulation for pain relief has
widespread clinical use.
Direct research evidence for the use of IFT
in pain relief is limited.
One could use the higher frequencies
(90-150 Hz) to stimulate the pain gate
mechanisms and thereby mask the pain

symptoms for the duration of application.
Alternatively, stimulation with lower
frequencies (1-5 Hz) can be used to activate
the release of indigenous opiates, providing long-term relief of pain.
These two different modes of action can
be explained physiologically. Each has
different latent periods and varying
duration of effect.
Relief of pain may be achieved by stimulation of the reticular formation at frequencies of 10 to 25 Hz or by blocking C
fibre transmission at frequencies greater
than 50 Hz.
Treatment Parameters to Achieve Muscle
Stimulation with IFT
Stimulation of the motor nerves can be
achieved with a wide range of frequencies.
Stimulation at low frequency (e.g. 1 Hz)
will result in a series of twitches:
Stimulation at 50 Hz will result in a titanic
contraction.
The choice of treatment parameters will
depend on the desired effect.
To combine muscle stimulation with an
increase in blood flow and a possible
reduction in oedema, selecting a frequency
range which does not produce strong
sustained titanic muscle contraction.
In such cases, a sweep of 10 to 25 Hz is often
used, to produce pumping effect on the
target muscles, which will help in drainage
of fluid from the interstitial space.
There is no primary nervous control of
oedema re-absorption and the direct
electrical stimulation of blood flow is
limited in its effectiveness.
It is suggested therefore, that in order to
achieve these effects, suitable combina-
70
tions of muscle stimulation should be

made.
Treatment Techniques
Preparation of the patient and the machine
is done, as before any low frequency
electrical stimulation
The same local precautions, general
contraindications, environment and the
safety considerations apply for IFT, as in
case of low frequency stimulation.
The IFT is usually applied through four
carbon rubber electrode plates between
5 and 15 sqcm in size. These are applied on
the prepared skin, with a coating of
conductive electrode gel and fixed with
elastic strap.
Some IFT machines have built-in or
optional vacuum suction pumps, for application of vacuum cup electrodes, with moist
sponge fillers to maintain electrical contact
with the skin. Fixing such electrodes is
easy, particularly over odd-shaped areas
like the shoulder joint.
Electrode positioning should ensure
adequate coverage of the area for stimulation (Fig. 8.4, Plate 5)
In some circumstances, a bipolar method
is preferable if a longitudinal zone requires
stimulation rather than an isolated tissue
area.
Placement of the electrodes should be such
that a crossover effect is achieved in the
desired area.
If the electrodes are not placed so that a
crossover is achieved, the physiological
effects of I/F cannot be achieved.
Nerves will accommodate to a constant
signal and,
A sweep (or gradually changing frequency) is often used to overcome this
problem (as well as generating a range of

effects).
The sweep (range) should be appropriate
to the desired physiological effects, though
again it is suggested that an excessive
range may minimise the clinical effect.
The mode of delivery of the selected sweep
varies with machines.
The most common application is the 6
second rise and fall between the pre-set
frequencies.
For example, if a 10 to 25 Hz range has
been selected, the machine will deliver a
changing frequency, starting at 10 Hz,
rising to 25 Hz over a 6 second period.
Once this upper limit has been achieved,
the frequency will once again fall, over a 6
second period to its starting point at 10 Hz.
This pattern is repeated throughout the
treatment session
Treatment times vary widely according to
the usual clinical parameters of acute/
chronic conditions and the type of physiological effect desired.
In acute conditions, shorter treatment
times of 5 to 10 minutes may be sufficient
to achieve the effect. In other circumstances, it may be necessary to stimulate
the tissues for 20 to 30 minutes.
It is suggested that short treatment times
are initially adopted especially with the
acute case in case of symptom exacerbation.
These can be progressed if the aim has not
been achieved and no untoward side
effects have been produced.
There is no research evidence to support
the continuous progression of a treatment
dose in order to increase or maintain its
effect.
TYPES OF INTERFERENTIAL CURRENTS

(FOUR POLE APPLICATION)
Classical Interference Current
Interference occurs between two unmodulated currents, crossing each others path
within the target tissue (Fig. 8.5, Plate 5)
In this classical form of interference
current, modulation depth is 0 per cent at
the axis of two electrodes of pole. In this
direction no stimulation takes place.
100 per cent modulation takes place only
at a diagonal, creating a field of stimulation perpendicular to the lines of
forces between two electrodes of a single
pole.
Since the lines of forces of two poles are
crossed within the tissues, a four armed
(chatuevuj) field is generated. This type of
pattern is called the Clover Leaf Pattern
(Fig. 8.6)
The effect of this type of field produced
by four pole application is very dependant
on the direction of electrode placement
and the resultant field.
It is vital to position the crossing area of
the currents at the correct location to
ensure the accurate alignment of the field
of 100 per cent stimulation, with the target
tissue.
Since the stimulation is optimal only in
two directions, the position of the four
electrodes must be done with great care.
Fine tuning of the spread of stimulation
can be done with the balance control. It
works like the balance knob of a stereophonic sound system.
The Clover Leaf Pattern
Isoplaner Vector Field
Applied through four electrodes like
classical interference current (Fig. 8.7).
Fig. 8.6: Clover leaf pattern of electrical field in IFT
Fig. 8.7:
Isoplaner vector
field application
to the knee joint
Gives a stimulus, which is equal in all

directions instead of clover leaf pattern.
The depth of modulation is 100 per cent
and the current is same in all directions,
making sure that all tissue between the
four electrodes will receive effective
treatment.
72
Suitable for large joints like the knee,

particularly when swollen and when the
complaint is diffuse and hard to localize.
Because of the mildness of isoplaner field
stimulation, it is best suited for acute conditions like sciatica (Fig. 8.10).
Dipole Vector Field
Though applied through four electrodes,
the distribution of current in one direction
is 100 per cent and the other is 0 per cent.
This enables the current to be applied
selectively to a specific area through static
vector mode or rotate the field like the
lights of a lighthouse, stimulating tissues
cyclically in all directions between the four
electrodes, in a dynamic vector mode.
The static vector mode is most useful in
case of longitudinal structures, e.g. brachioradialis or rectus femoris muscles. A
band of maximum intensity may be set up
between the poles of the electrodes to
target a specific structure along its entire
length, avoiding unnecessary stimulation
of adjacent structures.
The dynamic vector has deionising effect
on acute muscle spasm of large muscular
areas because of the massaging effect it
creates and its soothing nature of stimulation.
Cyclic contraction and relaxation creates
pumping in muscles, increasing venous
drainage, reducing oedema, and improving blood circulation.
This type of current is most suitable for the
treatment of muscle spasm of heavily
Fig. 8.10: Placement of electrodes for application

of IFT to the sciatic root
muscled areas like painful shoulder, low

back pain and, pain of the thighs etc
(Figs 8.8A and B and 8.9, Plate 5).
Two pole Medium Frequency Current
This type of current gives the same type
of stimulation as compared to four pole
interferential method
Current modulation depth is 100 per cent
in all direction. Maximum stimulation is
produced in the tissues lying between the
electrodes, along the lines of forces connecticting the electrodes and 0 per cent
perpendicular to the lines of forces.
Application is simpler due to less number
of electrodes, though in depth effect is
comparable to the four-pole method.
Suitable for localized smaller areas like the
temporomandibular joints, muscles of the
hand, paracervical muscles, etc. It is
specifically used to achieve relief of pain
in sciatic neuralgia.
Clinical Applications of Interferential Current

Disease condition
Type of current
Current parameter
Electrode placement
Tension headache
Dipole vector field
AMF-100 Hz,
Autosweep-3 sec
Contour-40%,
Dose-15 minutes
Crossed 4 pole, 2 each

over the origin and
insertion of bilateral
Trapezius muscle upper
fibres, strong tingling felt
Periarthritis of
shoulder, with
generalized pain and
spasm around the
joint and restriction
of ROM at end range
Dipole vector field
AMF-100 Hz
Spectrum-50 Hz,
Manual sweep
Contour-40%,
Dose-15 minutes
Crossed 4 pole method

Channel A Anteriorposterior of shoulder,
Channel B over deltoid
tubercle and acromion
arch, light rhythmic
contraction seen
(Fig. 8.8A, Plate 5)
Periarthritis of
shoulder, with
localized tenderness
and no significant
restriction of ROM
2 Pole medium
Frequency field
AMF-100 Hz
Spectrum-50 Hz,
Manual sweep-3 sec
Contour-40%,
Dose-15 minutes
2 Poles of a single
channel, AP placement
across the shoulder
covering the tender spot,
light rhythmic contraction seen
Frozen shoulder or
adhesive capsulitis,
with gross restriction
of ROM and night
pain, especially in
diabetics
a. Isoplaner vector field

b. Dipole vector field
a. AMF-100 Hz; 1 min.

b. AMF-100 Hz,
Autosweep-3 sec
Contour-40%,
Dose-12 minutes

Channel A Anteriorposterior of shoulder,
Channel B over deltoid
tubercle and acromion
arch, light rhythmic
contraction seen
(Fig. 8.8A, Plate 5)
Peripheral oedema
of transudate type
Isoplaner vector field
AMF-50 Hz
Spectrum-50 Hz,
Manual sweep-1 sec
Contour-01%,
Dose-10 minutes

Cover the entire oedema,
elevate the limb,
strong vibration felt
Lumbago
a. Isoplaner vector field

b. Dipole vector field
a. AMF-200 Hz; 2 min.

b. AMF-100 Hz,
Autosweep-3 sec
Contour-40%,
Dose-12 minutes

Electrodes placed on
either side of the vertebral
column covering the
muscle painful region,
light rhythmic contraction seen (Fig. 8.4, Plate 5)
Muscle contusion
Dipole vector field
AMF-100 Hz,
Autosweep-3 sec
Contour-40%,
Dose-07 minutes

Cover the entire lesion
support the limb, light
rhythmic contraction seen
(Fig. 8.9, Plate 5)
Contd....
74
Contd...
Disease condition
Type of current
Current parameter
Electrode placement
OA hip joint
AMF-50 Hz
Spectrum-50 Hz,
Sweep-6 sec
Contour-67%,
Dose-15 minutes

Channel A Anteriorposterior of the hip,
Channel B dorsal to
greater trochanter and
the groin, light rhythmic
contraction seen
Tennis elbow or
Golfers elbow
2 Pole medium
Frequency field
AMF-80 Hz
Spectrum-40 Hz,
Manual sweep-3 sec
Contour-75%,
Dose-10 minutes
2 Poles of a single
channel, mediolateral
placement across the
elbow covering the tender
spot, light rhythmic
contraction seen
Weakness of
abdominal muscles
Dipole vector field
AMF-30 Hz,
Autosweep-5 sec
Contour-0%,
Dose-15 minutes

either side of the midline
covering the muscles,
light rhythmic contraction
seen
Post immobilization
contractures of large
joints
AMF-25 Hz
Spectrum-10 Hz,
Sweep-2 sec
Contour-10%,
Dose-15 minutes

either side covering the
joint, light rhythmic
contraction felt (Fig. 8.7)
Post immobilization
contractures of small
joints
2 Pole medium
frequency field
AMF-25 Hz
Spectrum-10 Hz,
Sweep-2 sec
Contour-10%,
Dose-10 minutes
Trans-arthral 2 pole
method
either side covering the
joint, deep stimulation
felt
Atonic bladder
Classical interferential
current
AMF- 1 Hz
Spectrum-99 Hz,
Sweep-3 sec
Contour-50%,
Dose-10 minutes
Crossed 4 pole,
2 large electrodes over the
buttock just lateral to the
SI joint and 2 smaller
electrodes on either side
just above the symphysis
pubis, strong tingling felt.
Myalgia of large
muscle groups
Dipole vector field
AMF-100 Hz,
Autosweep-2 sec
Contour-40%,
Dose-08 minutes
Crossed 4 pole, electrodes

covering the whole
muscle group, along with
the antagonists (Fig. 8.5,
Plate 5)
Myalgia of small
muscle groups
Medium frequency
surge currents
AMF-100 Hz,
Surge duration -3 sec
2 Electrodes over the

muscle belly.
Contd....

Contd...
Disease condition
Type of current
Current parameter
Electrode placement
Surge interval-3 sec

Contour 30%
Dose- 10 minutes
Minimum perceptible
contraction.
Haemoarthrosis of
knee joint (up to
grade-II)
AMF-80 Hz
Spectrum-40 Hz,
Sweep-1 sec
Contour-10%,
Dose-12 minutes

Channel A Anteriorposterior of the joint,
Channel B Medio-lateral
to the joint, light
rhythmic contraction seen
(Fig. 8.5, Plate 5)
Tenosinovitis
Medium frequency
current
AMF-20 Hz
Spectrum-100 Hz,
Sweep-1 sec
Contour-1%,
Dose-17 minutes
2 Pole: One over the

muscle belly and one over
the tendon.
Definite alternating
sensations felt.
Cellulites
Dipole vector
AMF- 50 Hz
Sweep- 3 sec
Dose- 15 minutes
4 Pole placement over

the affected area.
Clear rhythmical
contractions felt.
Rheumatoid arthritis
Isoplanar vector field
AMF- 100 Hz
Spectrum- 50 Hz
Sweep time- 3 Sec
Contour- 67 %
Dose- 10 minutes
4 Pole placement around

the affected joint (Fig. 8.7)
Chronic constipation
Classical interferential
current
AMF- 20 Hz
Spectrum- 20 Hz
Sweep time- 4 sec
Contour- 33%
Dose- 30 minutes
Crossed 4 pole method: 2

electrodes placed on the
abdominal wall, over the
iliac fossa on either side:
other two placed under
the SI region.
76
9
Therapeutic Heat
Human body seeks warmth, particularly at
the time of distress or while in pain.
Since time immemorial, the humankind
has used heat for various useful purposes,
especially for the treatment of aches and
pains.
Before the discovery of fire, the primary
natural source of heat was the sun. The heat
of the sun still remains a favourite among the
elderly population for giving relief to their
aching bones. This is the first ever application
of therapeutic heat.
With the discovery of fire, mankind found
a new tool for their survival. Apart from
keeping predators away heat from the fire
helped cook food and keep them warm.
Ancient healers used rocks, sand and salt
packs heated on fire for treating many types
of painful disorders. Heated water also
provided an important source of therapeutic
heat.
The ancient Romans first introduced the
concept of heated mud packs, hot bath and
steam bath or sauna to treat muscular and
skeletal rheumatism.
With the progress of science, newer
methods of generating heat has been identified, many of which have been adapted for
application to the human body to derive
therapeutic benefits.
NATURE OF THERAPEUTIC HEAT

Therapeutic heat can be used in two forms,
superficial heat and deep heat. The classification
is done on the basis of depth of penetration
of the thermal effect in to the body tissue. In
either kind of application the intensity of the
heat is first perceived by the thermal receptors
present on the surface of the skin. Therefore
the level of the heat should never exceed a
feeling of comfortable warmth, whether the
mode of application is superficial or deep.
SUPERFICIAL HEAT THERAPY
Superficial heat has a maximum depth of
penetration of 5 mm from the surface of the
skin. The effect is therefore restricted to the
skin and superficial subcutaneous tissues.
Transmission of Superficial Heat
Heating depends on transfer of heat energy
from a point of higher concentration to a point
of lower concentration. Such transmission of
heat energy can occur by three methods.
1. Conduction of heat: Heat energy transferred
from a warmer object to a cooler object by
direct transmission of molecular agitation
through physical contact, e.g. salt packs,
moist packs, and paraffin wax bath.
Therapeutic Heat 77
2. Convection of heat: Heat energy transferred

by movement from a warmer zone of fluid
or air to a cooler area by convection
current, resulting in indirect transmission
of molecular agitation through physical
movement of the molecules over the cooler
body part, e.g. whirl pool bath, warm
saline bath, hydrotherapy.
3. Radiation of heat: Heat energy transferred
from a warmer object to a cooler object by
electromagnetic radiation, without any
heating of the medium of heat transfer, e.g.
infrared radiation (Fig. 9.1).
Physiological Effect of Superficial Heat
Superficial heat has different kinds of effects
depending on the nature of application.
A. Generalized heating of large areas of the
body surface, like the entire upper or lower
limbs, whole back or whole body, with
whirlpool bath, Hubbards tank or heated
hydrotherapy pool, produces following
effects:
Increased physiological reactions:
Raised cardiac output, metabolic rate,
pulse rate, respiratory rate and superficial blood circulation due to dilatation
of capillary network.
Decreased physiological reactions:
Lowered blood pressure, muscle
spasm, blood supply to internal organs
and muscles and stroke volume of the
heart.
B. Local heat application to small areas of
the body, like the knee or shoulder joint,
neck, low back region, with infrared lamp,
Paraffin wax bath, moist hot packs, electric
heating pads or hot water bags, produces
following effects.
a. Increased physiological reactions:
1. Increased local blood flow due to
vasodilatation.
Fig. 9.1: Position of the patient and the relative

position of the infrared lamp for application of
superficial heat to the nape of the neck.
2. Increased interstitial fluids turn

over and better drainage due to
higher capillary permeability.
3. Increased flexibility of capsules,
ligaments and tendons due to greater elasticity of collagen fibres.
4. Increased metabolic rate due to
increase in cellular oxidation.
b. Decreased physiological reactions:
1. Decreased joint stiffness due to
greater flexibility of collagen tissue.
2. Decreased muscle torque due to
suppression of glycol breakdown.
3. Decreased muscle spasm due to
diminished neural activity.
4. Decreased pain due to pre-synaptic
inhibition of pain transmission.
Indications for Superficial Heat
Superficial heat is the modality of choice, to raise
the general or local temperature of the body
tissues, as a preparatory step before application of active movements, passive mobilisation, massage or electrical stimulation to
78
the musculoskeletal system, particularly in

presence of:
Joint stiffness and pain
Muscle spasm and pain
Painful chronic lesionsPosttraumatic,
degenerative or inflammatory
Rheumatism of the skeletal and soft tissue.
Contraindications for Superficial Heat
Acute traumatic and inflammatory lesions
of the musculoskeletal system
Infectionslocal or general
Circulatory deficiency
Diminished thermal sensation
Deep vein thrombosis
Malignancy
Bleeding disorder
Severe swelling
Impaired cognition or inability to assess
the degree of heat being felt.
Very young and very old patients.
PREPARATION OF PATIENT BEFORE
APPLICATION OF HEAT OR COLD
THERAPY
Application of thermal energy to the body
carries the risk of thermal injury, usually to
the skin, sometimes affecting the deeper
tissues. The nature of injury varies with the
intensity and duration of heat applied, the
colour and sensitivity of the skin, presence of
skin rashes or allergies on the area being
treated, sensory acuity or cognitive ability of
the patient etc therefore, before application of
any kind of thermal energy, heat or cold,
adequate preparations must be done.
Thermotherapy must be done personally
or under direct supervision of a qualified
therapist.
Position the patient comfortably so that

he/she can sustain the position for at least
hour.
Expose the part to be treated; rest of the
body should be covered with a sheet.
Check for rashes, cuts, bruises and discoloration of the skin.
Test the thermal sensation of the skin. Take
two test tubes and fill either with hot or
cold water, beyond the sight of the patient.
Place the test tubes by turn against the skin
and ask the patient to identify the type
sensation felt.
Test the awareness level of the patient prior
to application of thermotherapy. Heat
therapy should be avoided in patients with
cognitive dysfunction, e.g. Alzheimers
disease, multiple infarct dementia or
mental retardation.
Make sure the patient understands the
nature and the extent of heat that should
be felt during the treatment. Explain the
possible adverse reactions of overheating,
because some patients may believe that
more heat means quicker relief. A call bell
should be placed near the patient, to
summon the therapist in case of overheating or burning sensation during the
treatment.
Inspect then part closely for any rashes,
blister formation or excessive reddening
after the treatment. Calamine lotion may
be applied over the reddened area or heat
rash and the subsequent sittings deferred
till the skin becomes normal.
Preparation of patient, delivery of treatment and precautions to be observed in
thermotherapy are same for most forms of
superficial heat or deep heat or cold modalities. Specific modalities have few specific
concerns that need attention, covered under
the heading of special points.
Therapeutic Heat 79
TYPES OF SUPERFICIAL
HEAT MODALITIES
A number of superficial heat modalities are
available for the therapist to use. These are
hydrocollator, hydrotherapy, paraffin wax
bath and infrared therapy, which have been
detailed below. Infrared can be obtained from
luminous (visible light) or non-luminous
sources, though its biophysics and effects are
essentially the same. Thus for convenience of
the reader, only the non-luminous variety has
been considered along with the basic biophysics, under the section of superficial heat,
with the luminous variety detailed under the
section of therapeutic light in this volume.
Moist Hot PacksHydrocollator
Points to Ponder
Packs used are made of canvas, filled with
silica gel, which has the capacity to retain
heat for long period of time.
The packs are available ready made in large,
medium, small sizes, as well as for specialized
application of cervical region.
The packs are placed in a double-walled
stainless steel tank, containing hot water at
50 to 60 C, heated electrically and regulated by a thermostat.
Method of heatingConduction of heat
from hot water to silica gel.
Method of application
1. For small and medium-sized packsFold
a large Turkish towel lengthwise into
four folds. Wrap the folded towel
around the heated pack so that both
side of the pack has eight layers of
towel cover. Place the pack over the
area to be treated, e.g. knee, elbow,
wrist or shoulder joint and secure it in
position with a strap.
2. For large-sized packsFold two large

Turkish towels breadth wise in to eight
folds. Place one-folded towel over the
area to be treated, usually covering the
whole back and place the heated pack
on it. Cover the pack with the other
folded towel to prevent heat loss and
place a small sand bag on top to keep
the pack in position. Extra towel layers
may be used if the heat is too much for
comfort.
Duration of treatment20 to 30 minutes in
a sitting may be repeated twice a day in
acute conditions.
Effective inSuperficial muscle spasm and
pain, inhibition and restriction of joint
movement.
Special points: Moist packs and towels are
a potential source for fungal growth. They
must be dried thoroughly before reuse.
Wash all linen and packs in weak disinfectant solution once a week.
HYDROTHERAPY FOR SUPERFICIAL
HEATINGWHIRLPOOL BATH/
HUBBARDS TANK/SAUNA
History
The origin of hydrotherapy can be traced back
to ancient times, when soaking in natural hot
springs were favoured by traditional healers
for treatment of all forms of joint disorders.
Ayurvedas and Charka Samhita has number of
references to the therapeutic application of
whole body submersion in hot springs, as well
as, cold water baths. Ancient Chinese and
Arabs also used hydrotherapy as a method
of treatment in the years B.C. Ancient Roman
and Turkish physicians popularized the
concept of public bath houses, with pools
having variety of water temperatures, with
80
add on services like massage, steam bath or

sauna, for treatment of stress and musculoskeletal disorders. These bath houses soon
became popular meeting ground for the
common man and the ruling elite.
In medieval Europe painful joint disorders
were clubbed together as rheumatism. These
were referred for treatment to health centres
known as Spa located close to natural hot
springs. Over time these places developed
into tourist attractions. Treatment in such
Spas were outrageously expensive and could
be afforded by only the elite of the society.
Many such Spas are still to be found in
countries like Germany, Austria, Italy, Russia,
as well as, in India. The mode of treatment
followed in such naturopathy centres are
based on regular soaking of the entire body
of the patient in the mineral rich water of the
hot springs, supplemented by a natural diet,
massage and exercises. They are still as
expensive.
With the western medical science becoming more cosmopolitan and oriented to the
service of common man, methods were
devised to provide the beneficial effects of the
Spa in a general hospital setting, with
proportionate reduction in cost of treatment.
This is how modern hydrotherapy was born
in mid 19th century in England, soon to be
adopted by the entire Europe and the World.
Points to Ponder
Definition: Hydrotherapy can be defined as
partial or total submersion of the body in
water baths or pools, where the water may
be agitated or mixed with air, to be
directed as jets, against or around the part
to be treated.
The buoyancy of water, an upward thrust
equal to the weight of water displaced by
submersion of a body in water (Archimedes principle), renders the limb or body

weightless making it easy for the patient
to move a weak limb actively or allow him
to stand and walk on weakened legs.
The capacity of water to absorb heat is
known as specific heat, which the amount
of heat needed to raise the temperature of
1 gram of water by 1C. The heat from the
water is transferred to the body by means
of convection giving relief from pain,
muscle spasm and stiffness.
Modern hydrotherapy utilizes three
modes of superficial heat application:
Whirlpool bath, Hubbards tank and steam
bath or sauna.
Method of Application of Whirlpool Bath
A. Whirlpool bath is immersion of an extremity in a pool of circulating heated water,
suitable for treatment of the extremities
only. It is widely used for heating of soft
tissue around joints prior to mobilisation
or debridement and disinfection of burn
wounds.
B. Whirlpool bath consists of a oblong-shaped stainless steel tank, usually 3deep x
3long x 2wide in size, mounted on four
castor wheels, fitted with a thermostatcontrolled, immersion type electric heating
coil and an air-jet pump with nozzle.
C. The tank is filled with water, leaving a gap
of 6 to 8 from the top. The water is heated
to 35 to 40C. A disposable plastic liner
may be used and any common disinfectants like sodium hypochlorite at dilution
of 200 parts per million (ppm), povidoneiodine at 4 ppm or savlon at 100 ppm may
be added while treating burn injuries and
infected wounds.
Therapeutic Heat 81
D. The patient is assisted to immerse the body

part in the tank, after sitting down comfortably on a height-adjustable stool placed
beside the tank.
E. Adjust the direction and force of the airjet to get the desired effect, which may be
to offer resistance or assistance to active
movement or debridement (peeling off) of
dead tissues from the surface of a wound.
Most patients, including those with severe
burns, find the whirlpool bath very
soothing.
F. The duration of treatment is usually 20 to
30 min. After the treatment the part should
be dried and inspected closely for any
adverse reaction from heat.
D.
E.
F.
Method of Application of Hubbards Tank

A. Hubbards tank is immersion of the whole
body in a pool of circulating heated water,
suitable for the treatment of acute or subacute rheumatoid arthritis presenting with
multiple joint pains, whole body burn
injury and paraplegia. It is ideal for
treatment of very ill-patients in unstable
condition, with severe pain or serious
infections, as in extensive burn, since the
patient can be treated with whole body
immersion, in an isolated environment.
B. Hubbards tank consists of a butterflyshaped steel tank having a depth of 3 and
large enough to accommodate the entire
body of the patient, fitted with two
thermostat-controlled, immersion type
electric heating coils and two air-jet pump
with nozzles at either end of the tank.
C. The tank is filled with water to the desired
level (see whirlpool), which is then heated
to the desired temperature. A disposable
G.
liner may be used and disinfectants be

added if a burn patient is to be treated.
The patient, if ambulatory, may be helped
to climb in the tank, using a metal step
stool. Mostly they are transferred into the
tank using a nylon sling and bed side hoist.
The patient should be lowered gradually
into the tank to allow him to get accustomed to the water temperature.
Care should be taken to keep the head of
the patient out of water. This may be done
using an inflatable neck ring and a head
support. The rest of the body may be
allowed to float free in the circulating
water of the tank.
Adjust the direction and force of the air jet
to get the desired effect, which may be to
induce relief of pain or relaxation in spastic
muscle prior to exercises or debridement
(peeling off) of dead tissues from the
surface of a wound. Most patients, including those with severe burns, find tanking
very soothing.
The duration of treatment is usually
20 to 30 min. After the treatment the part
should be dried and inspected closely for
any adverse reaction from heat.
Special Points to Ponder

Since immersion type heating elements are
used, electrical safety of the patient must
be ensured at all times, because in case of
any leakage of current, it is likely to flow
through the body of the patient, to the
ground.
All electrical components like the heating
element; thermostat, turbine etc must be
checked weekly to prevent any leakage of
current and earth fault.
All circuits must have properly calibrated
circuit breakers.
82
Method of Application of
Steam Bath or Sauna
Traditional sauna, used in Scandinavian
countries, Turkey and Russia, as a public
utility service, consists of a sealed room, lined
with wood panels for insulation, with a coal
burning stove with a metal jacket, in the centre
of the room. Water is poured on the heated
metal jacket to generate steam. Clients sit
around on wooden benches surrounding the
stove and enjoy the effects of steam.
The steam bath as used in modern hydrotherapy consists of an insulated chamber
made of laminated waterproof ply wood
or man made fibres, large enough accommodate a person in sitting position.
The patient is asked to strip and a towel
used for preserving the modesty. Total
privacy is essential for this form of
treatment, so that the patient can relax
during the treatment. A female therapist
or a female attendant must treat female
patients.
The chamber is sealed air-tight, leaving the
head of the patient seated inside, through
a head port.
Steam is fed into the chamber from a boiler
situated outside the chamber.
Approximate temperature within the
chamber is maintained at 40 to 45C.
The patient is instructed to call the
therapist in case of any discomfort. A call
bell may be provided for this purpose.
Treatment sessions can be for 20 to 30
minutes.
Physiological effects are same as that
produced by generalized heating.
Therapeutic benefits are relief of stress,
muscle spasm, pains and aches. Claims of
reduction in body weight, as a major effect
of sauna, is mostly temporary due to loss
of water from the body due to sweating,
which is made up with few glasses of
water the patient drinks after the treatment.

Special Points to Ponder
Dehydration is a major risk in steam bath.
Patients with chronic dehydration, like the
elderly, must be given sauna with caution.
All patients must be encouraged to drink
electrolyte-balanced drinks before and
after the therapy.
Patients with hypertension and heart
diseases must not be given sauna because
of adverse physiological responses produced by prolonged exposure to heat and
excessive sweating.
PARAFFIN WAX BATH
Paraffin wax bath is the therapeutic application of molten mixture of paraffin wax
and mineral oils, for relief of pain and joint
stiffness, suitable for peripheral joints like
small joints of hands and feet, ankle, knee
and elbow joints
The paraffin wax bath consists of a double
walled insulated stainless steel bath, 24
12 8in size, heated indirectly by heating
coil.
The mixture of paraffin wax, liquid
paraffin and petroleum jelly, in a ratio of
3:1:1, melts at 42 to 45C and is self-sterilizing in nature. The temperature is sustained by thermostat-controlled heating.
Molten wax mixture solidifies on contact
with the skin, giving up latent heat of
solidification, which is transferred to the
body by conduction.
All jewellery and metal object must be
removed from the part to be treated.
The part should be washed and checked
for any infection, rash or bruises.
Therapeutic Heat 83
The part is repeatedly dipped in the

molten wax mixture, as for hands and feet
or the molten mixture is poured over the
part, as for wrist, ankle, knee and elbow,
to form ten successive layer of wax
coating.
The coated part is then wrapped with a
polyethylene sheet, followed by few layers
of towel to retain the heat.
The part is then placed in a comfortable
position till the feeling of heat ceases. The
solid mixture peels off after cooling and
can be reused again in the wax bath.
Physiological effects are same as that
produced by localized heating.
Therapeutic benefits are relief of reduction
of pain and joint stiffness, which can be
used prior to passive movements
RADIANT HEATINFRARED RAYS
Radiant heat is the therapeutic application
of radiant electromagnetic energy, obtained either as invisible infrared from any
heat source or in combination with visible
light and ultraviolet rays from an incandescent electric bulb or sunlight.
In this section only the non-luminous
infrared has been considered since it is a
superficial heat modality. The luminous
infrared has been covered under the
section of therapeutic light.
Non-luminous infrared contains far infrared electromagnetic rays in the frequency
range of 1500 to 12000 Angstrom units,
having a penetration of 2 mm in the epidermis.
Heat transmission with infrared radiation
is governed by following physical principles:
a. Lamberts cosine law, which states that
the angle incidence of radiation is
directly proportional to the extent of

radiation absorbed. Optimal absorption is possible only when the source
of radiation is perpendicular to skin.
b. Inverse square law, which states that the
intensity of radiation varies inversely
with the square of the distance between
the source of radiation and the skin.
Intensity of the radiation is reduced if
the distance between the source and the
target is increased and vice versa.
The non-luminous lamp is turned on
approximately 5-10 minutes before application to ensure maximum output.
Expose and support the part to be treated
and examine the skin as detailed in general
preparatory methods.
Give the patient a glass of water before and
after the treatment.
After positioning the patient comfortably,
cover the eyes and avert the face from the
source of infrared.
Commence the treatment with the I.R
source placed at a distance of 30 to
36from the surface being treated (Fig. 9.2).
The dosage can be adjusted by shifting the
source closer or away from the treatment
surface, depending on the feeling of
warmth by the patient. The feedback of the
patient is absolutely essential to adjust the
dose, hence the patient must explained in
detail about the expected heat sensation.
This is done by asking the patient to blow
on the back of his hand, holding it close to
the mouth. The amount of heat felt on the
dorsum will be the optimum limit of
warmth to be felt on the skin, with any
form of heat therapy.
Duration of treatment should be 15 to 20
minutes once or twice a day.
84
Fig. 9.2: The arrangement of the lamp and the position

of the patient should be such that the incident rays are
perpendicular to the skin. The intensity of the superficial
heat can be increased or decreased by moving the lamp
closer or away from the skin. The minimum distance
between the source of infrared and the skin should be
50 cm
COMPARATIVE PROFILE OF SUPERFICIAL HEAT MODALITIES

Modality
Most commonly used for
Advantages
Disadvantages
Moist heat
Muscle spasm, pain and

stiffness of major joints of the
extremities, neck and trunk
Reusable and cost

effective
Safe for delicate skin,
Prolonged analgesia,
Circumferential heating.
Infrared
Superficial muscle spasm

and localized pain of neck
and trunk
Easy to apply
Risk of burn if source
Better localization of heat.
is too close to the skin
Cost effective for home
Risk of eye injury in
management
luminous I.R
Effect is transient
Paraffin wax
bath
Stiffness of joints and pain

due to degenerative disorders,
Soft tissues contractures
following immobilisation
Circumferential heating,
Improves the texture of
the skin
Increases pliability of
soft tissue
Prolonged analgesia.
Reusable and cost
effective
Whirl pool/
Hubbards tank
Multiple joint stiffness and

Applicable for whole or Expensive to install
pain, disuse atrophy, wound
part of the body
and run
debridement in burn, paralytic Induces relaxation, relief Needs more space
conditions
of pain and spasm
Extensive preparation
Exercise can be done
and constant supereasily due to buoyancy
vision needed
Messy operation
Risk of electrical
accidents
Initially expensive,
Risk of scalds
Risk of fungal
infections
Messy application
procedure,
Regulation of temperature difficult and may
cause burn,
Highly inflammable
composition, hence fire
hazard
10
Deep Heat Therapy
Heat can be generated deep inside living
tissues by conversion of non-thermal energy
like electromagnetic radiations and sound
absorbed by the body tissue, in to thermal
energy. This conversion of non-thermal energy
into heat energy is achieved using the
interaction between the non-thermal energy
fields and the physical properties of the body
tissues, namely capacitance, inductance and
acoustic impedance. Different modalities
using such energy conversion are shortwavediathermy, microwave diathermy and
therapeutic ultrasound.
SHORT-WAVE DIATHERMY (SWD)
Definition
Short-wave diathermy is the commonest
deep heat modality used in physiotherapy
departments in India. It utilises high
frequency alternating sinusoidal current at
frequency of 27.12 MHz to produce electromagnetic (Radiowaves) with wavelength of
11.3 meters. This wavelength and the
frequency are reserved for therapeutic
purpose by International agreement, to
avoid interference with other radiofrequencies and communication network.
When subjected to the electromagnetic field
generated by the SWD, heat is produced in
living tissues, with clear physiological effects

and therapeutic benefits.
Biophysics of Deep Heating
Using Short-Wave Diathermy
Heating with SWD is achieved by two
methods:
a. Capacitor or condenser field method
b. Inductance or magnetic field method.
Capacitor or Condenser Field
Two electrodes, consisting of flexible metal
plates encased in heat resistant rubber or
air-spaced drums, are connected to the
output terminals of the high frequency
current generator. The metal plates act as
the plates of a condenser, bearing + and
charge.
The charge of the electrodes keeps oscillating at a high frequency of 27.12 MHz,
producing a powerful electromagnetic
field between the two electrodes.
This field of energy is conventionally
described as the lines of forces, which are
imaginary lines connecting the opposing
faces of the electrode plates.
Body tissues placed between the two
electrodes, become a part of the condenser
86
circuit, as a di-electric medium, and are

subjected to these lines of forces.
High frequency oscillating current produces rapid oscillation of the ions, rotation
of the dipoles and distortion of insulators
present at the molecular level of the living
tissues.
This activity at the molecular level of the
living tissue produces displacement
current in tissues with high electrical
resistance and conduction current in
tissues with low electrical resistance.
Resistance to the passage of current deep
within the tissues produces heat.
Dense tissues with closely-packed molecules like the skin, fat, fascia, ligament etc
offer greater resistance to the passage of
the electrical field and become warmer,
than loosely-packed tissues like muscles
and blood.
Subcutaneous fat is an insulator and
therefore the layer of fat absorbs much of
the lines of forces.
Though technically the condenser field
method should be effective for through
and through heating, in reality little heat
reaches to layer deeper than the subcutaneous fat.
This type of application is therefore most
effective when the target tissues do not
have a thick layer of fat covering.
Intensity of heating and depth of penetration are determined by the shape and
the distance between the electrodes.
Inductance or Magnetic Field

An insulated monoaxial cable or hinged
plastic drums each containing a coil of
conductor, is connected to the output
terminals of the high frequency current

generator.
High frequency oscillating current produces an electromagnetic field around the
conductor.
The cable is coiled around the body part
to be treated.
The hinged drum is placed over the body
part, without actually being in contact
with the body surface.
Through electromagnetic induction, secondary Eddy current is induced in the body
tissue placed within the electromagnetic
field, though it is not a part of the circuit.
Resistance to the passage of Eddy current
produces maximum heat in deep tissues
with high electrolyte concentration,
particularly in tissues with high conductivity like blood, nerves and muscles.
Dissipation of heat is much slower and the
effect of heating tends to be prolonged.
Production of High Frequency Current

The machine circuitConsists primarily of the
high frequency current generator, with three
controls on the faceplate of the device. The
intensity knob is a rotary step switch that
controls the amplitude of the high frequency
current and is a part of the machine circuit,
the tuning knob is a constantly variable rotary
switch attached to a variable condenser and
is a part of the patient circuit and auto cut-off
timer to set the duration of treatment and stop
the flow of high frequency current to the
patient circuit on completion of the treatment
duration. It may be either a digital or
analogue stopwatch (Figs. 10.1 and 10.2).
The patient circuit The variable condenser, electrode connecting cables, electrodes
Deep Heat Therapy 87
Fig. 10.1: Short-wave diathermy unit
Fig. 10.2: The circuit configuration of the highfrequency AC link DC-DC converter using secondary
phase-shifted PWM control scheme (below called
proposed control scheme) is shown in Fig.1. This
circuit is composed of the high-frequency inverter, the
high-frequency transformer, the diode rectifier circuit
and the LC filter. A difference between conventional
DC-DC converter and proposed DC-DC converter is
two power devices are newly connected inside the
diode rectifier circuit. Fig.2 shows its switching pattern,
inverter output voltage waveform and output current
waveform. In conventional control scheme, the
converter output voltage was controlled by giving
phase-difference between the right and left arms of
the full-bridge inverter on the primary side. In
proposed control scheme, the converter output
voltage is controlled by giving phase-difference
between the primary side and the secondary side,
which is synchronized with the primary side. From this
reason, between the right and left arms of the fullbridge inverter does not have phase-difference.
Namely, it operates as a square-wave generator like
a symmetrical drive with 50% duty including dead
time. By using proposed control scheme, secondary
switches S5 and S6 are both off during the circulation
interval (t1 < t < t2) in which the power is not supplied
form the primary side. At this point, the circulating
current will flow only the secondary circuits via the
high-frequency transformer. Therefore, the circulating
current cannot flow on the primary side (this state is
called the self circulation interval). As a result, almost
conduction losses are eliminated because circulating
current can be removed. This is the distinctive feature
of proposed control scheme. In addition to this, all
power devices can operate under soft-switching
condition, independent of changing load resistance.
From these reasons, the conversion efficiency
become high compared with conventional DC-DC
converter because proposed control scheme can
effectively solve the problems mentioned above
88
and the body part which act as the dielectric of the variable condenser.
Transfer of energyMaximum transfer of
energy from the machine circuit to the
patient circuit takes place when the
product of the capacitance and the inductance in both the machine and patient
circuits match perfectly or said to Resonate.
This is resonance of two circuits, is called
tuning and it is conventionally achieved by
rotating the tuning knob of the variable
condenser, like tuning an old-fashioned
radio.
The patients body acts as a part of the
variable condenser setup, till the product
of the capacitance and the inductance in
both circuits match.
Most modern SWD machines have automatic tuning, where the machine circuit
automatically searches for and finds
resonance with the patient circuit, like the
push button car radio.
The tuning may be indicated by a neon
tube tuning lamp, which glows brightest
at the point of maximum resonance
between the two circuits.
It may also be an ammeter, the needle of
which shows maximum deflection on
tuning of the circuit.
PHYSIOLOGICAL EFFECTS OF
SHORT-WAVE DIATHERMY
Deep heating produces physiological effects
that are similar to those produced by superficial heat, but its effects are spread much
wider and deeper in the body tissue.
General physiological changes produced
by deep heating with SWD.
Adequate heating of the blood pool is produced on exposure to SWD for 15 to 30
minutes, which produces significant
generalized change in the body. These

changes are as follows:
Increased physiological reactions: Raised
Cardiac output, metabolic rate, pulse rate,
respiratory rate, and generalized vasodilatation.
Decreased physiological reactions: Lowered blood pressure, stroke volume and
blood supply to internal organs.
Local Physiological Effects and
Therapeutic Benefits of Deep
Heating with SWD
SWD application to specific areas of the body like
the knee joint, shoulder joint, neck, lumbosacral region produces following local effects,
which have significant therapeutic value.
Increased reactions
1. Increased local blood flow due to vasodilatation, leads to tissue healing, relief of
muscle spasm and pain.
2. Increased interstitial fluids turn over and
better drainage due to higher capillary
permeability, leads to reduction of swelling.
3. Increased flexibility of capsules, ligaments
and tendons due to greater elasticity of
collagen fibres lead to greater mobility of
joints.
4. Increased metabolic rate leads to activation
of dormant tissue.
5. Increased pain threshold due to sedation
of the pain carrying nerve fibres resulting
in pain relief.
Decreased reactions
1. Decreased joint stiffness due to greater
flexibility of collagen tissue.
2. Decreased muscle torque due to suppression of glycol breakdown.
3. Decreased muscle spasm due to diminished neural activity.

4. Decreased pain due to pre-synaptic inhibition of pain transmission.
INDICATIONS FOR SHORT-WAVE
DIATHERMY
SWD is effective in management of pain and
inflammation associated with the following
disorders:
Musculoskeletal system disorders, e.g.
spondylosis, osteoarthritis, rheumatoid
arthritis, degenerative joint diseases and
postural or posttraumatic muscle spasm
and pain.
Pelvic inflammatory disorders, e.g. pelvic
endometriosis.
Inflammation of body cavities, e.g. Sinusitis.
Using non-thermal effect of pulsed SWD
for healing of wounds.
CONTRAINDICATIONS OF
SWD should not be applied in following
conditions:
Presence of metal implants or ornaments
within the field of the lines of forces.
Patients with pace-maker
Pregnant women should not be given
SWD in the region of low-back or lower
abdomen.
Acute traumatic and inflammatory lesions
of the musculoskeletal system
Infectionslocal or general
Circulatory deficiency
Diminished thermal sensation
Malignancy
Bleeding disorder
Severe swelling
Impaired cognition or inability to assess
the degree of heat being felt.
Very young and very old patients.
METHODS OF APPLICATION OF
Preparation of the Equipment
The equipment is connected to the mains
The electrodes/cable are attached to the
output terminal of the machine.
The equipment is turned on and warmed
up for at least 2 minutes.
The therapist places one hand between the
electrode plates/over the coil of the cable
electrode, increases the intensity at least
two steps from the minimum. The machine
is then tuned by turning the tuning knob
in one direction till maximum deflection
shows on the tuning meter. A comfortable
warmth should be felt after a minute or
so, indicating that the machine output is
adequate for treatment and its safe for
patient application.
After testing the machine output the
intensity is returned to zero level and hand
removed from the electrodes.
Application of Treatment with
Short-Wave Diathermy
The patient is positioned in a comfortable
position on a wooden plinth, part exposed
and the rest of the body draped with a
sheet.
The part may be wrapped double layer of
Turkish towel to absorb sweat produced
during the treatment and acts as spacer
with air-space.
90
What are Spacers?

Spacers are insulating material containing airspaces, like perforated felt pads or Turkish
towels applied in two or more layers
between the pad electrodes and the skin
surface. The spacers increase the distance
between the electrode surface and the skin to
ensure an even distribution of the lines of
forces and therefore the effect of the
heating. For optimum heating, the sum
total of the thickness of the spacers must
be less than the distance between the pad
electrodes, if kept side by side
Drum or disk electrodes used in condenser
field method of application have a hard
plastic shell covering the metal disk
conductor. The air-space within the plastic
shell is used as spacer, which can be varied,
by sliding the metal disk mounted on a
telescoping stalk, within the plastic shell.
(Fig. 10.3).
ELECTRODE PLACEMENT
The electrodes placement varies depending
on the type of application, i.e. condenser field
Fig. 10.3: Disc electrodes used in SWD. The outer

plastic shell has been removed to show the metal
discs within
or induction field method, as well as the area

to be treated and the effect desired from deep
heat therapy.
CONDENSER FIELD METHOD
The condenser type electrodes may be, either
pads made of flexible metal plates covered
with a layer of heat resistant rubber or airspaced drums electrodes. These are available
in different sizes, from 4 6 up to 10 12
and may be round, square, rectangular or
butterfly-shaped for application to the
maxillary and frontal sinuses. The electrodes
are connected to the output terminal of the
high frequency current generator through
insulated co-axial cables. SWD Machines
usually have separate output sockets for
drum/pad/cable type electrodes. Perforated
felt pad spacers are placed on either side of
the pad electrodes and the whole complex is
enclosed in a cotton cloth envelope. Extraspacing, if required, may be provided by
using several layers of Turkish towel or extrafelt pad spacers. Before application of electrodes, all clothing must be removed and the
part must be wrapped in at least one layer of
clean Turkish towel. This towel layer is
recommended for hygienic purpose, as well
as, to absorb any sweat that form while
heating the part (Figs 10.4 and 10.5, Plate 6).
a. Contraplaner placement: This is the preferred method for treating joints like the knee
or elbow or shoulder joints using SWD.
The electrodes are placed on either sides
of the joint, on opposite planes, preferable
on a regular surface, without any bony
prominence underneath the electrodes.
Bony prominences create concentration of
lines of forces, which may lead to burn.

The electrodes are held in position with a
Velcro strap (Fig. 10.6, Plate 6).
b. Coplaner placement: This is the method of
choice for treating large, flat areas like the
back, using SWD. The electrodes are
placed side by side on the same plane,
covering the entire treatment area (Figs
10.7, Plate 6, and 10.8, Plate 7).
c. Cross-fire placement: This method of electrode placement combines the effect of two
contraplaner placements, to heat a large
joint like the knee, from all directions. The
electrodes are first placed on the medial
and lateral aspects of the joint and heat
applied for half of the total treatment time.
Then the electrodes are shifted to superior
and inferior aspect of the joint and heat
applied for the remaining duration. This
way the joint is heated thoroughly from
all directions. This is the method of choice
for treatment of chronic synovitis, when
the entire joint must be heated uniformly.
d. Asymmetrical placement: These are specialized technique of application of SWD for
preferential heating of heavily-muscled
areas like the calf or deep-seated joints like
the hip.
For calf muscles: Patient is placed in high
sitting on a wooden plinth, with the feet
placed on a wooden stool. One pad
electrode is placed under the sole of the
foot and the other on the top of the
flexed knee. With this method, the lines
of forces pass parallel through the calf
and leg muscles, producing maximum
beneficial effect of electromagnetic field
in the muscles themselves, which is
most useful in anterior-lateral compartment syndrome or chronic spasm of
calf muscles or as a preparatory step
before stretching of the calf muscles.
For hip joint: (Figs 10.9 and 10.10,

Plate 7).
CABLE METHOD SHORT-WAVE
DIATHERMY
The cable electrode consists of flexible co-axial
conductor, enclosed in a sheath of heat
resistant rubber.
The length of a cable electrode is 1.5 meter.
Two metal jacks are attached to either ends
of the cable, which are inserted in to the
output sockets of the machine, specifically
earmarked for cable diathermy
The arrangement of the cable in relation to
the body part depends on the relative
density of high or low impedance tissues
present in the part to be treated.
The cable can be applied either by wrapping it around the part to be treated like the
extremities or in the form of a concentric
coil placed over flat areas like the back or
abdomen.
The ends of the cable have greater concentration of electrostatic forces which produces
more heat in high impedance tissues like
skin, fat, fascia, tendon, ligaments, joint
capsules etc. For treatment of parts like
hand, wrist and distal forearm or foot,
ankle and lower leg or joints like the knee
or elbow, the outer 1/3 of the cable on either
side is used.
The middle 1/3 of the cable generates a
strong electromagnetic induction field, which
have greater effect on the low impedance
tissues like muscles and blood vessels.
Hence the segment can be used heavilymuscled and highly vascular areas like the
calf, thigh, upper arm etc.
APPLICATION OF TREATMENT WITH
After the machine circuit has been warmed
up for at least 2 minutes, the intensity knob
92
is turned up one step and the machine

circuit is manually tuned to the patient circuit
by rotating the tuning the tuning knob in
clockwise or anticlock wise direction till
the needle of the tuning indicator shows
maximum deflection. This function may be
automatic in a modern machine.
This indicates that two circuits are now in
tune and maximum transfer of energy is
taking place between the machine circuit
and the patient circuit.
The intensity knob is now turned up
gradually step by step up to 1/3rd to 1/2 mark
from the maximum limit till the should
feels a comfortable sense of warmth in the part
being treated.
The treatment timer is then set for the
desired period, i.e. 10 to 30 minutes. The
patient is reminded to use the call bell to
summon the therapist in case of any over or
under heating or any discomfort.
After the treatment time is over, most
equipments cut-off the power automatically. Turn the intensity knob to zero,
remove the electrodes from the body and
inspect the part closely for any reddening.
Ask the patient to rest on the plinth for 5
minutes after the treatment is over, before
being allowed to get up. SWD creates
pooling of blood in the treated area, lowering
the blood pressure and depriving the brain of
adequate blood supply. This may lead to
positional vertigo if the patient is allowed
to get up suddenly after the treatment.
This precaution is particularly relevant in
pelvic diathermy or cable method where large
volume of blood is heated.
The patient is then allowed to dress and
asked to wait indoor for another 5 to 10
minutes before stepping out. This precaution is essential to avoid sudden exposure,
since there is significant rise in the body
temperature during the treatment and it

must be stabilized before being allowed to
be exposed out side temperature, especially
in winter.
Technique of Application of Short-Wave
Diathermy in Few Specific Disease
Conditions
Short-wave diathermy is a versatile modality
that can be used in many disorders. Its
application, as a deep heat modality, to gain
therapeutic benefit in suitable target tissue,
depends on the ingenuity of the therapist.
Methods of application for few conditions
listed in Table 10.1 should serve as a guide
for the therapist to explore further possibilities.
MICROWAVE DIATHERMY (MWD)
Definition: Microwave diathermy (MWD)
can be defined as a deep heat modality that
is similar in concept, but differs widely in its
bio-physics and application from the shortwave diathermy.
Biophysics
Microwave diathermy utilizes electromagnetic
energy with a frequency of 2450 Hz and
wavelength range of 10 to 12 cm.
A composite oscillator known as a magnetron produces MWD. The magnetron consists of ring-like perforated iron core, with
multiple holes drilled in such a way that,
flow of electrons over theses holes create
a electromagnetic frequency, response that
vary in proportion to the velocity and the
electromotive force moving the electrons.
In the frequency of 2450 Hz it is called the
medical microwave energy.
The electromagnetic energy thus produced
is directed through a co-axial cable to an
Knee Joint
Chondromalecia, patella
chronic
synovitis
Knee Joint
Osteoarthritis
Rheumatoid
arthritis
Trauma
Lumbago
Low Back Pain

Sacroiliitis
Condition
Inductance field
using a cable
or hinged-drum
electrodes
Condenser field,
using 6 8
pad or 6
diameter disk
electrodes or
Inductance field
using a cable or
hinged drum
electrodes
Long sitting or
supine on a
padded-wooden
plinth with a roll
under the knee
As above
Condenser field,
using 810
pads
or
Inductance field
using a cable
or hinged drum
electrodes
Method of choice
Prone lying on
a paddedwooden plinth,
with pelvic and
ankle support
with rolls of
towel
Patient position
Hinged-drum
covering the top
and both sides
of the joint or
cable coiled
around the joint
Transarthral contraplaner/cross-fire
method
Hinged-drum
covering the top
and both sides of
the joint or cable
coiled around the
joint
Coplaner
covering the
affected area,
use felt spacers
under pads or
air-spacing with
drum electrodes
Electrode
placement
As above
15-20 min once

a day, on alternate
days or 10-15 min
once a day, daily
15-30 minutes
with mild heat,
once a day, on
alternate days
or daily for
10-15 sittings
Duration of
treatment
As above
Avoid exposure
in acute inflamation severe
osteoporosis,
suspected
fracture
Avoid exposure
during menstruation or upper GI
bleeding
Specific
precaution
Table 10.1: Technique of application of short wave diathermy in few specific disease conditions
As above
Contd...
Effect of SWD
can be magnified
by prior application of surged
faradic stimulation, at sex
surges per
second, for 10
minutes.
SWD may be
followed up
with pain-killing
gel massage and
IR for 10 minutes
10 minutes of
surged faradic
stimulation
before SWD
gives better
result in relief
of pain and
muscle spasm.
Supplementary
therapy
Patient position
Coplaner method,
covering the
cervicodorsal or
dorsolumbar or
contraplaner
method on the
upper chest. Use
felt-spacers
under pads or
air-spacing with
drum electrodes
Condenser field,
using 8 10
pads
or
Inductance field
using hingeddrum electrodes
COPD
Bronchitis
or Asthma
Prone lying on a
padded-wooden
plinth, with
pelvis and ankle
support
or
side lying
or
Crook lying with
a roll under the
knee.
Pads over the lower

abdomen and under
the buttocks.
Use felt-spacers
under the pads.
Pelvic inflamma- Sitting on a

Condenser field,
tory disorders
wooden arm chair, using 8 10
feet resting on a
pads
rubber foot mat
Supine lying on a
padded-wooden
plinth
Electrode
placement
Hinged-drum
covering the top
and both sides of
the joint
Transarthral placement on the front
and back of the
joint
Method of choice
Inductance fieldusing hingeddrum
Condenser field,
using 6 8
pad or 6
diameter disk
electrodes
Frozen shoulder Sitting on a

wooden chair
with arm rests,
feet resting on a
rubber foot mat
Supine lying on
a padded-wooden
plinth
Condition
Contd...
20 minutes OD
30 minutes OD
15-20 minutes
once a day
Duration of
treatment
10 minutes of
surged faradic
stimulation before
SWD gives
better result in
relief of pain and
muscle spasm.
Supplementary
therapy
Avoid exposure
in acute respiratory distress
or
acute lung
infections
Contd...
Before SWD
exposure, massage
the chest wall with
menthol and
salicilate ointment
and followed
by IR on the chest
for better results.
Avoid exposure Watch for vertigo.

during menstruation or in
presence of IUD.
Watch for bony

prominences
Specific
precaution
94
Method of choice
Condenser field,
using one
butterfly pad
covering the
frontal and the
maxillary sinuses
and a large dispersive pad under
the neck
Inductance field
using hinged
drum electrodes
covering the
frontal and the
maxillary sinuses
Patient position
Sitting on a
wooden arm
chair, feet
resting on a
rubber foot mat
Supine lying on
a padded-wooden
plinth
Condition
Sinusitis
Maxillary and
frontal sinus
inflamation
Contd...
Contraplaner
method
Coplaner method
Electrode
placement
10 minutes of
mild heating
Duration of
treatment
Use two layers
of towel to cover
the forehead,
nose and eyes
are kept clear
of obstruction
Specific
precaution
Kneading massage
to the
neck helps relieve
concurrent
muscle spasm
Supplementary
therapy
96
antenna, mounted inside a hard plastic

shell, known as an applicator. The electromagnetic wave released from the applicator is directed to the target tissue.
There is no need for tuning in MWD, since
the target tissue, unlike in SWD, is not a
part of the circuit.
The intensity levels are constant for
individual applicators and are printed on
the directors for reference during treatment.
The dosage of MWD is governed by the
inverse square law, which implies that
greater the distance from the source of the
radiant energy lesser will be its intensity.
Clinically, the patient should experience a
sensation of comfortable warmth.
The penetration of MWD, like any electromagnetic energy, is directly proportional
to its frequency, though clinically for the
therapist; heat production is more a result
of absorption of energy, than of linear
penetration. Hence its absorption of MWD
is far more relevant to study.
Absorption of microwave energy, like that
of the shortwave, depends on the relative
densities of the tissues and the clinical
effect depends on the type of tissue
involved.
It is believed that MWD is absorbed better
by fat than most other tissues. Since fat is
very superficial, the direct thermal effect
of MWD is restricted to relatively superficial area. Any effect on deeper tissues is
mainly due to heat transfer from the
heated superficial fat layer.
Indications for Microwave Diathermy

Broad clinical indication of MWD is
similar to SWD.
It is preferred in cases where more concentrated and localized heating is required in
superficial targets like trigger points,

fibromyositis, epicondylitis etc.
Contraindications for
Microwave Diathermy
MWD is strictly contraindicated in presence of pacemakers or deficit in thermal.
Avoid exposure over genitals, eyes or
gravid uterus.
Technique of Application of
Microwave Diathermy
Patient Preparation
Patient is positioned suitably on wooden
plinth or chair to ensure adequate and easy
access to the target area.
Part to be treated is exposed and rest of
the body is draped with a sheet.
Clean the skin of the target area and
inspect for cuts, skin lesions or bruises.
Selection of Treatment Applicator
Shape of the treatment applicator may be
small circular, large circular or rectangular,
each offering field of radiation in the shape
of the applicator.
Selection of treatment applicator therefore
depends on the shape of the target area.
Since the microwave energy is emitted in
a divergent field, the extent of its divergence and focusing of the field, like the
focusing of a light, depends upon distance
between the applicator and the skin.
A compact fluorescent tube (CFL) may
used by the therapist to detect the concentrated area of focus as well as the periphery
of the field. The lamp will glow the
brightest in the concentrated field and
gradually fade as the CFL is moved to the
periphery of the field.
Selection of Appropriate Power Level and

Application of Treatment
The equipment should be turned on at
least five minutes before the treatment to
allow the magnetron to develop enough
charge to produce adequate emission of
electromagnetic energy.
As per inverse square law, the distance of
the target from the applicator determines
the dosage of microwave.
The distance from the applicator to target
is critical for optimum distribution of the
field, which must be measured with a built
in distance regulator on the treatment
head.
Closer the head to the target lesser the
power level and vice versa.
It is recommended to set the power level
at medium and then adjust the distance of

the applicator from the skin depending
upon the heatfelt by the patient.
The distribution of the field may be
checked using the CFL tube to ensure
adequate distribution and correct focus of
the microwave energy.
The patient feed back should be a sensation localized heat, the intensity of which
can be adjusted simply be moving the
applicator closer or away from the skin.
Alternatively a lower or higher power
setting, if the equipment offers the option
of different intensity levels.
The optimum duration of treatment is in
the range of 10 to 20 minutes for smaller
areas like elbow, wrist or ankle and 25 to
30 minute for large areas like the low back,
knee or shoulder.
98
11
Therapeutic Ultrasound
(US Therapy)
Sound can be defined as a periodic mechanical oscillation of an elastic medium such as
air or water. Sound energy can be produced
from an oscillating source and needs a
medium to transmit. Sound travels through
the transmitting medium in the form of waves
created by alternate bands of compression
(pressing together) and rarefaction (pulling
apart) of the molecules of the medium (Fig.
11.1).
The frequency of the sound wave can be
defined the rate at which such bands of
compression and rarefaction occur in the
medium per second and the wavelength as
the distance between two successive band of
compression or rarefaction.
The velocity at which the sound energy
propagates through the medium depends
upon the physical properties of the medium
such as density, specific gravity etc. The
velocity of sound is 0 in vacuum, 344 m/sec
in air, 1410 m/sec in water and 1540 m/sec in
muscles.
The resistance offered by the medium to
the passage of sound is inversely proportional
to the velocity and is known as acoustic
impedance. Therefore vacuum has the highest
Fig. 11.1: Wave patterns of ultrasound energy
and the muscle has the lowest acoustic

impedance.
Human ear can hear sound with frequency
of 20 kHz, i.e. 20000 cycles/sec, whereas
dogs have hearing range of 50 kHz.
Any sound having frequency greater than
80 to 100 kHz is classified as ultrasound.
Therapeutic Ultrasound (US Therapy) 99
It has extensive uses in industrial, medical

diagnostic and therapeutic purposes.
DEFINITION
Ultrasound is a form of mechanical vibration.
Therapeutic ultrasound can be defined as,
high frequency acoustic energy, available in
longitudinal waveforms in the frequency
range of 0.8 to 3.5 MHz.
The frequencies used in ultrasound therapy
are typically between 0.75 and 3.0 MHz (1
MHz = 1 million cycles per second).
Since sound waves consists of longitudinal
waves consisting of areas of compression and
rarefaction, molecules of any material exposed to a sound wave will oscillate about a
fixed point rather than move with the wave
itself. As the energy within the sound wave is
passed to the material, it will cause oscillation
of the molecules in that material. Clearly any
increase in the molecular vibration in the
tissue will result in heat generation, and
ultrasound (US) can be used to produce
thermal changes in the tissues, though current
usage in therapy does not focus on this
phenomenon.
In addition to thermal changes, the
vibration of the tissues appears to have effects
which are generally considered to be nonthermal in nature, though, as with other
modalities (e.g. pulsed short wave) there must
be a thermal component however small. As
the US wave passes through a material (the
tissues), the energy levels within the wave will
diminish as energy is transferred to the
material. The energy absorption and attenuation characteristics of US waves have been
documented for several types of tissue.
The ultrasound energy is non-electromagnetic in nature and it creates successive
bands of compression and rarefaction in
the conducting medium, producing heat

and mechanical deformation of the medium. When applied to body tissue
ultrasound energy is converted to heat
energy and mechanical micro-massage
within tissues, to produce definite physiological reactions, with definable therapeutic benefits.
Biophysics of Therapeutic Ultrasound
Therapeutic ultrasound is produced by the
high frequency cyclic deformation of a
piezoelectric crystal of natural quartz or
synthetic composite materials like BariumTitanate and Lead Zirconate Titanate, of
specific thickness, bonded to the metal face
plate of a hand held transducer (Figs 11.2
and 11.3).
High frequency electric current is applied
through a co-axial cable to the piezoelectric
Fig. 11.2: Ultrasonic transducers of different types

(top) with fixed head, (bottom) with swivel head.
Modern machines have transducers with contact
indicator. Optimum contact with the skin is essential
for adequate transfer of ultrasonic energy to the body
tissue. Whenever the contact is inadequate, the
contact indicator lamp glows red and the flow of
ultrasonic energy stops. The treatment timer also
stops automatically and is not resumed till the contact
has been re-established
100 Handbook of Practical Electrotherapy
Fig. 11.3: Different sizes of ultrasonic transducer

head(top) 3 sq cm size head is used for very localized treatment area (9 sq cm), usually used with 1
MHz frequency, (bottom) 5 sq cm size head is
indicated for larger areas (max 15 sq cm), commonly
used with 3 MHz frequency
crystal to produce mechanical deformation

of the crystal through reverse piezoelectric
effect. The rate of deformation or resonance of the crystal depends on the frequency of the applied oscillating current.
This cyclic resonance of the piezoelectric
crystal to the applied current frequency
sets up a vibration in the metal face plate
of the transducer, to which the crystal is
bonded.
Air, with acoustic impedance of 1, reflects
ultrasound waves. Hence a conducting
medium like ultrasound gel, degassed
water, glycerine or liquid paraffin, in the
above order of preference, may be used to
eliminate air-space between the metal face
plate of the transducer and the body surface. These mediums are called coupling
mediums, which apart from transmission of
U.S., also reduces friction between the
transducer head and the body surface.
These vibrations, when transmitted
through a conducting medium, produce a
beam of ultrasound waves, with little or

no dispersion of energy.
The ultrasound energy produces mechanical pressure waves in the tissue fluid
medium through which it passes, with
resultant release of heat, micromassage
and acceleration of protein synthesis.
The ultrasound energy has a maximum
penetration of 3 to 5 cm in the living tissue;
however the depth of penetration varies
inversely to the frequency.
Commonly used frequencies of therapeutic ultrasound are 3 MHz and 1 MHz.
At 3 MHz, the depth of penetration is
relatively shallow, with maximum absorption of energy and therefore greater effect,
in the superficial tissues like the capsule
of the ankle, knee or shoulder joint.
At 1 MHz, the depth of penetration is
deeper, with maximum absorption of
energy and therefore greater effect, in the
deep tissues like muscles of the back or
gluteus region.
Therapeutic ultrasound may be applied in
continuous or pulsed mode. In continuous
mode the thermal effect is more pronounced and in pulsed mode the non-thermal
effects are more prominent.
Mark-space ratioThe ratio between the
flow time and off time of ultrasound
energy in pulsed mode application.
Commonly the on time is 2 msec and the
off time varies from 2 to 8 msec.
Points to Ponder
The beam of ultrasound energy is cylindrical in shape, at least in the near field. The
diameter is nearly the same as the diameter of the transducer.
The concentration of the energy is very
irregular in the near field, which becomes
more uniform in the far field.
The near zone of the ultrasound (Fresnel

zone) is therapeutically relevant and it
varies in direct proportion to the square
of the radius of the transducer head and
inversely to the wavelength.
Physiological Effects of Therapeutic
Ultrasound and its Applications
The Thermal Effect
Therapeutic ultrasound, when applied in
continuous mode, at an intensity of 0.5-3
W/cm2, through following mechanisms, produces heat, due to:
1. Absorption of the sound energy in body
tissues, resulting in increased tissue temperature. If the tissue temperature can be
raised to 40-45C for at least 5 minutes, it
produces therapeutic benefits such as
increased pain threshold, increased
collagen extensibility, increased enzyme
activity, increased tissue perfusion and
decreased nerve conduction velocity.
2. The extent of energy absorption depends on
the protein content, blood supply and the
depth of the tissue, as well as the frequency
of the ultrasound used. Tissues with high
protein content like muscles, ligaments,
tendons and blood, tend to absorb more
energy as compared to fat. This deferential
heating of tissues with highly localized
effect is the unique advantage of ultrasound therapy.
3. Depth of heating or penetration, produced by
ultrasound, depends on the half value
distance for a given frequency. The half
value distance is the depth of tissue at
which the intensity of the ultrasound
energy reduces by half. Ultrasound therapy given at 3 MHz has an average half
value distance of 3 to 5 mm and at 1 MHz
it is 11 mm.
4. The ultrasound beam refracts when travelling from one tissue to another, due to
difference in acoustic impedances of
tissues.
5. Reflection of a part of the ultrasound energy
(30%) takes place at tissue interfaces, resulting in release of heat. Tissue interfaces are
adjoining surfaces between two types of
issues, e.g. the bone/peritoneum, fascia/
muscle, muscle/periosteum, bone/ligament or bone/capsule, which become the
sites of heat concentration.
6. Maximum reflection of ultrasound takes
place between the bone/periosteum
interface, causing intense heating, which
may be felt as a sudden sharp ache at the
site of application. This is commonly felt
over areas with minimum soft tissue cover,
like the epicondyles of the elbow, joint line
of the knee and ankle, acromial arch etc.
This can heat the tissues to dangerous
levels, particularly if the tissue has poor
blood supply, e.g. tendons. The intensity
of ultrasound must be reduced immediately if such pain occurs and bony
prominences must be avoided all together.
7. Hot spots may also be created under the
transducers, if inadequate coupling medium is used, resulting in uneven distribution of the sound energy or if the head
is kept stationary, creating standing waves.
The Non-thermal Effect
Ultrasound energy can produce significant
effect in the tissues, without its heat component being used, as in pulsed mode application. Such reactions are due to non-thermal
effect of ultrasound, which can be described
as follows:
1. Mechanical effects: The high frequency
vibrations created by ultrasound energy
produce deformation of the molecular

structures of loosely-bonded substances
like the soft tissues. This produces micromassage of soft tissues which has sclerolytic effect, i.e. it can break down calcification or adhesions in soft tissue, resulting
in relief of muscle spasm, softening of scars
tissues, release of contractures and
adhesions.
2. Cavitations: Kinetic energy of the ultrasound beam is absorbed by tissue fluid,
releasing gas bubbles, due to molecular
agitation. These bubbles resonate with the
ultrasound frequency within and outside
the cell membrane, creating faster transmigration of ions at cellular level, having
beneficial effects on the cell. This is known
as stable cavitations. However, if the gas
bubbles pick up too much energy from the
ultrasound beam, they tend to expand and
form unstable cavitations, accumulating a
lot of heat. After limited degree of expansion, the gas bubbles may burst releasing
a lot of heat deep within the tissues
causing serious damage.
3. Acoustic streaming: Intracellular fluid
moves in the direction of the ultrasound
beam, like rain drops blowing in the
direction of strong wind. Fluid tends to be
stream towards the cell membrane, creating high-pressure areas along the cell
membrane altering the permeability of the
cell membrane temporarily during ultrasound exposure. Free radicals and other
waste products of cell metabolism are
expelled and protein synthesis and repair
process of the cell is activated.
4. Formation of standing waves: A percentage
of the ultrasound energy is reflected when
the beam crosses from one tissue to
another at the interface. The reflected
energy resonates with the incedent energy
to set up a standing wave. The standing

waves have points of maximum and
minimum pressure, known as antinodes
and nodes, at the distance of half a
wavelength. The tissue exposed to the
nodes are benefited by microstreaming
and stable cavitations effects but those
exposed to the antinodes may be seriously
damaged due to excessive microstreaming
and unstable cavitations. To achieve safe
insonation, the therapist must avoid
creating standing waves by moving the
transducer continuously while giving
ultrasound and use minimum intensity
required.
Points to Ponder
Attenuation of ultrasound takes place due
to absorption, reflection and refraction of
ultrasonic energy.
Absorption depends on protein and water
content of individual tissue, as well as, the
wavelength and frequency of the ultrasound.
Reflection and refraction takes place at the
tissue interface and depends on the
relative density of the tissues forming the
interface.
Continuous ultrasound produces mainly
thermal effect on tissues.
Pulsed ultrasound produces non-thermal
effects such as cavitations, acoustic streaming, standing waves and micro massage.
Indications for Ultrasound Therapy
Ultrasound therapy may be used for
following conditions:
Acute soft tissue injuriesIt has now
become a standard practice in sports
physiotherapy to use of ultrasound therapy in acute soft tissue injuries, even in

the sports filed. The reasons are as follows:
1. Mechanical effect of ultrasound helps to
remove post-traumatic exudates and
reduce the risk of adhesion formation.
2. Mild thermal effect of ultrasound helps to
induce relief of pain and allows early
movement of the injured part.
3. Protein synthesis accelerated by biological effect of ultrasound helps in
rapid healing of the damaged tissue.
Inflammation of joint capsules, tendons,
ligaments, bursa associated with acute
exacerbation of chronic degenerative like
osteoarthritis or inflammatory disorders
like rheumatoid arthritis, gout, R.S.I.
(repetitive stress injuries). Mechanical
effect of ultrasound helps to remove postinflammatory exudates, thermal effect of
ultrasound helps to induce relief of pain,
sclerolytic action of ultrasound helps to
break down unwanted calcification of soft
tissue, helping to restore function.
Scar tissue: Sclerolytic action of ultrasound
helps to soften scar tissue, which makes
the contracted scar more pliable and easy
to stretch. Mechanical effect of ultrasound
helps to create micro massage of adherent
scar and free it from the underlying tissue.
Chronic indurate oedema: Mechanical effect of
ultrasound creates micro massage in tissue
with chronic oedema, helping to breakdown adhesions between tissue layers and
allows free circulation of blood and lymph
that accelerates the drainage of chronic
oedema.
Wound healing: Micro-streaming effect of
ultrasound promotes ionic exchange at the
cellular level, creating a favourable
environment for healing of injured tissues
to begin. Protein synthesis effect of ultrasound also helps in growth of granulation

tissue, provided the wound is free of
infection. It further promotes the plasticity
of the newly formed granulation, to mould
it in such a way, that the healed tissue
regains near normal texture.
Points to Ponder
The main therapeutic application of
ultrasound are healing of chronic ulcers,
acute soft tissue lesions, pain relief and
softening of scars and contracture.
Therapeutic ultrasound may be used for
diagnosis of stress fractures by the sharp
pain it will produce immediately from the
site of the fracture. This may prove useful
when radiological findings are inconclusive.
Contraindications for
Ultrasound Therapy
Ultrasound therapy must not be used in
following conditions:
Vascular conditions (Thrombophlebitis or
Phlebothrombosis): A clot may break off
within the blood vessel due to the mechanical effect of ultrasound to create an
embolus.
Poor blood supply: (Burgers disease/
arteries/atherosclerosis/varicose veins):
Burn injury in the deep tissue may arise
due to poor dissipation of heat, generated
by ultrasound energy in tissues with
deficiency of blood supply. Use pulsed
mode U.S. to avoid heating the tissue but
still get its beneficial effect.
Infected lesion: (Carbuncles/cellulites/
abscess): Infected particles may break
loose due to the mechanical effect of ultrasound and enter the blood stream to
spread to other areas or create septicaemia.
Suspected neoplasia: (Benign/malignant):

Cancerous cells may break loose and
spread to other areas creating metastasis
due to the mechanical effect of ultrasound.
The biological effect of US therapy may
initiate growth or change benign tumours
to in to malignancy.
Tissues exposed to radiation: (Deep X-ray
therapy/cobalt therapy) Tissues devitalised by radiation may breakdown when
exposed to the combined effect of heat,
mechanical and biological effect of ultrasound therapy.
Pregnant uterus: Mechanical effect of
therapeutic ultrasound may damage the
foetus. The ultrasound scanning utilizes
different frequency, which is harmless to
the foetus.
Heart diseases: Patients with demand type
pacemaker should not be exposed to
therapeutic ultrasound because the high
frequency electrical field associated with
ultrasound may interfere with the function
of the pacemaker. In those cases without a
pacemaker, ultrasound exposure to cervical region must not be given as it may
cause stimulation of vagus nerve, leading
to arrhythmia of the heart.
connected to the mains by the mains cable

(Fig. 11.4). The transducer jack is fitted and
secured tightly to the output socket.
Keeping all the controls at zero position,
the apparatus is turned on through the
power switch. Timer is set for two minutes,
few drops of water is placed on the
transducer head holding it horizontal
facing up wards and the power is gradually increased by turning the intensity
knob clockwise, till ripple is observed in
the water drops. This is known as the
fountain test, which indicates that the
machine is giving satisfactory output of
ultrasound energy (Fig. 11.5, Plate 8). The
intensity is then reduced to zero by turning
the intensity knob in anticlockwise
direction. The duration of fountain testing
must be limited to few seconds only;
Points to Ponder
Ultrasound is strictly contraindicated in the
presence of:
Neoplasia and malignancy
Pregnant uterus, ovary and testes
Haemorrhage or ischemia
Acute infection
The eyes, ear and exposed nerve.
Ultrasound Therapy
a. Setting up and testing of the ultrasound
therapy equipment is the first step in
application of treatment. The apparatus is
Fig. 11.4: Digital ultrasonic machineon the extreme

left is the digital treatment timer indicating treatment
time in minutes. Below are the timer control switches
for setting and resetting the treatment time. To its right
is the selector switch for continuous and pulsed mode
of ultrasonic application. Next to it is the rotary switch
for intensity control. At extreme right is the digital
display for intensity in W/cm2. Below it is the output
socket to which the jack of a coaxial cable is
connected. The other end of the coaxial cable is
connected to the transducer seen on the top of the
machine
otherwise the quartz crystal may be

damaged due to reflection of ultrasound
from air. After testing, the power may be
turned off or the timer may be reset for the
duration of treatment, if a patient is
available and ready for treatment.
b. Preparation of the patient: The patient is
positioned in a comfortable position, either
sitting on a wooden chair or lying down
on a plinth, depending upon the part to
be treated. The part to be treated is
exposed, well-supported, with the rest of
the body carefully draped with a sheet for
sake of modesty of the patient. While
treating tightened soft tissue or shortened
tendons, ligaments or muscles, the tissue
must be partially-stretched when being
treated. The treatment must be carried out
in a screened off area with good light and
no cross draught of breeze.
c. Technique of application of therapeutic
ultrasound varies depending on the site,
depth of target tissue, underlying pathology and the desired clinical effect.
The commonest method of application is with
direct contact of the transducer on the skin surface over the target tissue (Fig. 11.6, Plate 8).
Indirect application of ultrasound is done
by the water bath and the water bag method,
which are used for specifically for irregular
areas with bony prominences and thin soft
tissue cover.
Specialized applications of ultrasound are
phonophoresis and combined ultrasound and
iontophoresis, which are used for administration of therapeutically useful substances
transcontinuously to the target tissue.
Direct Contact Method
This is the commonest method of ultrasonic
application, suitable for relatively flat surfaces, free of irregularities and bony promi-
nences, with adequate soft tissue cover, like

the back, chest wall, fleshy portions of the
extremities and around various large and
medium-sized joints (Fig. 11.7, Plate 8).
Adequate quantity of coupling medium is
squeezed on to the faceplate of the transducer and on the skin surface over the target area.
The coupling medium is a fluid or gel that
is used to eliminate air-space between the
transducer and the skin to ensure effective
transmission of ultrasound energy. Coupling mediums may be liquid paraffin,
glycerine, aqua-based gel or degassed
water. Different mediums have different
rate of transmission of ultrasound energy.
Liquid paraffin has the lowest rate of
transmission at 19%, degassed water at
59%, glycerine at 67%, while the aquabased sonic gel has the highest rate of
transmission at 72.6%
The transducer is then placed on the skin
surface over the target site, holding the
face plate parallel to the skin surface
firmly.
The transducer is then moved gently over
the skin to apply a thin film of coupling
medium over the skin on the target area.
The timer is then set for the duration of
the treatment and the intensity is gradually increased to the desired level, while
moving the transducer slowly in concentric
circles over the skin.
The speed of movement of the transducer
should not exceed 2 to 3 cm/sec, to ensure
adequate insonation of the target tissue.
Treatment intensity generally used is 0.3
to 3.0 W/cm sq depending on the treatment goal.
For acute conditions or arrears with thin
soft tissue cover, like the hand or wrist,
lower intensities in the range of 0.3 to 0.8
W/cm sq is used. Alternatively pulsed

mode of ultrasound may be preferred if
heating effect is not desired.
For chronic conditions or areas with thick
tissue cover, like the back, higher intensities in the range of 1 to 3 W/cm sq in
continuous mode may be used.
Duration of treatment may be set for 3 to
10 minutes, depending on the area being
covered. For effective treatment the area
covered should never exceed three times
the surface area of the transducer head, i.e.
5 sq cm 3 = 15 sq cm, for every five
minutes of application. Large areas may
be divided in to grids of 15 sq cm each with
a marker pen and then treated.
Specific indications for this method of
application are bursitis, tendonitis, ligament strain or sprain, musculofascial
trigger point (fibromyositis nodules), scars
and keloids, neuromas at the end of stump
of amputed limb and margin of open
wounds.
dose of sound energy, which may cause

irreversible damage to the tissues
(Figs 11.8 to 11.15).
Presence of DVT, acute sepsis or inflammation, healing fracture or osteoporosis,
metal or plastic implant in the treatment
field is strict contraindication to ultrasound therapy.
Care should be taken against overdose
while treating primary repair of tendons,
ligaments and over-grafted skin.
Water Bag Method
This is the method of choice for indirect
application of ultrasound over irregular bony
area like the dorsum of the hands, feet, ankle
joint, epicondyles and olecranon of the elbow.
It is also an alternative method of indirect
application to proximal portions of the body
which cannot be treated by full immersion in
a water bath, e.g. the temporomandibular
Precautions to be Observed in
Direct Contact Method
The patient must be instructed carefully about
the sensation being felt during ultrasonic
therapy.
With continuous mode of ultrasonic
energy, the patient should feel mild
warmth, whereas with pulsed ultrasound
there should never be any feeling of
warmth.
If the transducer is kept stationary momentarily, particularly over a bony prominences, the patient may feel intense heat
sensation at a point. This is due to periosteal pain caused by concentration of
ultrasound energy reflected by the bone in
the periosteum. The therapist must be
alerted immediately if any such feeling
occurs, as this indicates dangerous over-
Fig. 11.8: Application of ultrasonic therapy over the

medial epicondyle of the elbow for the treatment of
medial epicondylitis (golfers elbow). Ultrasonic therapy
is the modality of choice for golfers elbow. Since the
area is bony the ultrasonic should be in pulsed mode.
Care should be taken not to keep the transducer
stationary, because that may create standing waves,
which may produce periosteal irritation and pain. For
best results, ultrasonic application must be followed
up with deep friction massage and stretching of the
common attachment of the flexor tendons
Fig. 11.9: Application of ultrasound to the palmar

fascia for treatment of Dupuytrens contracture.
Ultrasonic therapy in pulsed or continuous mode may
be opted for depending up on whether the condition
is acute or chronic respectively. For best results,
ultrasonic application must be followed up with deep
friction massage and stretching of the soft tissue
contracture
Fig. 11.10: Application of ultrasound to the supraspinatus tendon and subacromial bursa for treatment
of rotator cuff impingement syndrome. Ultrasonic
therapy in pulsed or continuous mode may be opted
for depending up on whether the condition is acute
or chronic respectively. For best results, ultrasonic
application must be followed up with deep friction
massage and stretching of the contracted soft tissue
Fig. 11.11: Application of ultrasound to the temporomandibular joint. Since the area is bony the ultrasonic
therapy should be in pulsed mode. Care should be
taken not to keep the transducer stationary, because
that may create standing waves, which may produce
periosteal irritation and pain
Fig. 11.12: Application of ultrasound to the sternocostal joint for the treatment of costochondritis. Since
the area is bony the ultrasonic therapy should be in
pulsed mode. Care should be taken not to keep the
transducer stationary, because that may create
standing waves, which may produce periosteal
irritation and pain. For best results, ultrasonic
massage and stretching of the contracted pectoral
aponeurosis

lateral epicondyle of the elbow for the treatment of
lateral epicondylitis (Tennis elbow). Ultrasonic therapy
is the modality of choice for tennis elbow. Since the
area is bony the ultrasonic therapy should be in pulsed
mode. Care should be taken not to keep the
massage and stretching of the common attachment
of extensor tendons

carpal tunnel on the ventral aspect of the wrist for the
treatment of carpal tunnel syndrome. Ultrasonic
therapy is the modality of choice for carpal tunnel
syndrome. Since the area is bony the ultrasonic
therapy should be in pulsed mode. Care should be
taken not to keep the transducer stationary, because
that may create standing waves, which may produce
periosteal irritation and pain

tendon of abductor policis longus, extensor policis
brevis and extensor policis longus on the lateral
aspect of the wrist for the treatment of tenosynovitis
(de Quervains disease). Ultrasonic therapy is the
modality of choice for de Quervains disease. Since
the area is bony the ultrasonic therapy should be in
pulsed mode. Care should be taken not to keep the
irritation and pain
joint, acromioclavicular arch, sternocostal

junctions, etc.
A latex rubber surgical glove is filled with
degassed water.
Water is degassed by boiling it for few
minutes which removes all the dissolved
gas bubbles, which otherwise may reflect
ultrasound energy during treatment.
The opening of the gloves closed with a
rubber band.
A thin film of coupling gel is applied over
the part to be treated, as well as, on either
surfaces of the palm portion of the gloves
filled with degassed water. The film of
coupling medium eliminates air-space
between the transducer head and the
surfaces through which the ultrasound has
to pass to reach the body tissue.
The bag is then placed over the target area
and may be fixed in place on the skin with
sticky paper tape at its edges. The water

bag evens out the bony irregularities, thus
avoiding concentration of ultrasound
energy over bony prominences.
Ultrasound is applied by directly on the
outer surface of the water bag. The ultrasound energy passes through two layers
of latex and the degassed water to reach
the target tissue.
Since a significant amount of energy is
absorbed by the layers of latex and water
the intensity of ultrasound used as well as
the duration of the treatment must be 30
to 50 percent more than that used in case
of direct contact method over similar areas.
Water Bag Method
Position of the bag must be accurate in
relation to the target tissue and the
ultrasound head keeping the head as
perpendicular to the skin surface as
possible.
Ultrasound beam refracts while travelling
from one medium to the next. In water bag
method the ultrasound beam has to travel
through first layer of latex, then the layer
of degassed water and then the second
layer of latex before it reaches the skin. So
many layers in the path of the ultrasound
beam cause significant divergence. Allowance should be made for this divergence
of the ultrasound beam by selecting a
target area not larger than the size of the
transducer, i.e. 5 cm sq and the bag has a
tendency to slip over the skin making it
difficult to focus the beam perpendicular
to the skin. Hence the bag must be held in
position with sticky tape.
Water Bath Method

This method is most suitable for indirect
application of ultrasound over bony areas
with irregular surface or with sensitive or
delicate skin, e.g. skin grafts or newly-healed
wound, where direct contact or water bag
method may be unsuitable due to the friction
involved.
A plastic wash tub is filled with degassed
water. Plastic is used because it reflects
minimum amount of ultrasound energy.
The part to be treated is immersed completely in the degassed water.
The transducer head is placed under the
water and held 1 mm away from and
parallel to the skin surface.
As the intensity is increased the head is
moved in small concentric circles at a
speed of 3 cm/sec, covering the entire
surface of the target area as the intensity
is increased to the desired level.
Periodically air bubbles must be wiped off
the body part and the transducer.
Water Bath Method
It will be wise to remember that in this method
a high frequency electrical device is being
used in an environment full of water. Hence
to avoid the electric shock to the patient and
the therapist following points must be
checked.
The power supply must have proper earth
connection and the equipment must not
have any leakage of current to the body of
the machine. The fuses must be properly
calibrated and installed. The transducer
should be completely waterproof. The
floor of the treatment area should have a
rubber or coir floor mat to stand or rest
the feet.
Prolonged soaking in water can devitalise

and damage delicate or grafted skin. This
point must be kept in mind while using
the water bath method. Hence the duration of the immersion of the part should
be limited to only for the period of the
treatment. After the treatment a thin layer
of petroleum jelly or lanolin based skin
cream may be applied on the part.
Phonophoresis
It is the use of ultrasound energy to introduce
molecules of medication through the skin into
the subcutaneous capillary network, from
where these molecules can be carried by the
blood stream to deeper tissues. The molecules
thus introduced dissociate into elements and
radicals within the tissue, which then combine
with the free-radicals existing in the blood
stream, to produce the desired clinical effect.
The available clinical evidence suggests that
the depth of penetration of such molecules is
in the range of 1 to 2 mm.
Fig. 11.16: Application of ultrasound to the clavicular

fossa for treatment of brachial neuralgia. Ultrasonic
therapy in pulsed or continuous mode may be opted
for depending upon whether the condition is acute or
chronic respectively. For best results, ultrasonic
application must be followed up with adverse neural
tension stretching of the brachial roots
Technique of Application
A small quantity of the medication in gel
or cream or ointment form is rubbed in to
the skin over the target area. Gel form
responds well to the passage of ultrasound, whereas cream and ointment may
inhibit the process of insonation. It is
therefore important to use gel form
wherever possible. Wherever cream or
ointment-based medications are the only
option, be sure to massage the medication
thoroughly into the skin before applying
ultrasound (Fig. 11.16).
Same gel or ointment mixed with standard
ultrasound gel is placed over the transducer head as coupling medium.
Ultrasound is then applied to the target
area by the direct contact method
(Fig. 11.17).

medial collateral ligament of the knee for the treatment
of strain, sprain or osteoarthritis of the knee. Ultrasonic
therapy is the modality of choice for medial joint-line
tenderness of the knee. Since the area is bony the
ultrasonic therapy should be in pulsed mode. Care
should be taken not to keep the transducer stationary,
because that may create standing waves, which may
produce periosteal irritation and pain. For best results,
ultrasonic application must be followed up with deep
friction massage over the ligament
Standard treatment intensity used for

phonophoresis may be 1 to 2 w/cm sq.
Standard treatment duration may be
5 to 10 min.
Treatment done with low intensities over
long periods is more effective in introducing the medication through the skin
(Fig. 11.18).
Selection of the medication depends on the
pathophysiology of the disorder being
treated and the desired effect.
Phonophoretic Agents: Indications, Possible
Adverse Reactions and Contraindications
Hydrocortisone gel or ointment 1-10%It
may be used for strong anti-inflammatory
action in acute inflammation of soft tissue.
In rare cases skin rashes may be seen
which is best treated by antihistaminic
(cetrizine) drugss (Figs 11.19 and 11.20).
Lidocaine 4-5% gel (xylocaine)It is very
effective for analgesia and relief of acute
pain with no adverse reactions (Fig. 11.21).
Methyl salicylate 4.8% ointment (Iodex) or
salicylate 10% ointment (Myoflex)As a
basic anti-inflammatory agent salicylate
may be considered for chronic painful
disorders of the musculoskeletal system.
Patients sensitive to aspirin should not be
treated with salicylate (Fig. 11.22).
Iodine 4.7% ointment (Iodex)It is useful as
a vasodilating, anti-inflammatory and
sclrolytic agent in softening of scar tissue,
soft tissue adhesions, calcification of
ligaments and tendons and adhesive
capsulitis of joints. Patients that are allergic
to sea food should not be treated with
iodine. In case of skin irritation and itching
give antihistaminic drugs (Fig. 11.23).
Zinc oxide creams 20% (Siloderm)Zinc is
a healing agent and can be useful in
treatment of open wounds. It can be used

lateral collateral ligament of the ankle for the treatment
of strain or sprain. Ultrasonic therapy is the modality
of choice for ligament strains of the ankle. Since the
area is bony the ultrasonic therapy should be in pulsed
mode. Care should be taken not to keep the
massage over the ligament
Fig. 11.19: Application of ultrasound to fibromyositic

nodule in rhomboids muscle. Since the area is fleshy,
continuous mode of ultrasonic therapy may be used.
For best results, Ultrasonic application must be
followed up with deep friction massage
as a medium for phonophoresis to the

edges of the indolent wounds to promote
healing. Patients who cannot wear metal
wrist watch bands or jewellery due to
Fig. 11.20: Application of hydrocortisone phonophoresis therapy over the retro-calcaneal bursa of the
ankle for the treatment of bursitis with effusion and
acute pain. For best results, ultrasonic application
must be followed up with ice massage over the bursa
Fig. 11.21: Application of Lidocaine phonophoresis

therapy over the lumbo-sacral junction for the
treatment of acute low back pain. For best results,
Ultrasonic application must be preceded by infrared
radiation to the painful spot for 10-15 min
Fig. 11.22: Application of Iodex phonophoresis

therapy over the popliteal bursa of the ankle for the
treatment of chronic bursitis with indurate effusion and
dull pain. For best results, Ultrasonic application must
be preceded with deep heat like SWD over the bursa
Fig. 11.23: Application of ultrasound to the calcaneal

spur. Since the area is fleshy, continuous mode of
ultrasonic therapy may be used. For best results,
Ultrasonic application must be followed up with deep
friction massage
allergic skin reaction are sensitive to metals

and they should not be treated with zinc.
Consult a skin specialist if adverse reaction
does take place.
ledge gained by many practioners in their

clinical practice and should act as a guide to
the future generations of physiotherapists.
Pharmaceutical companies almost on daily
basis are making new drugs, in gel or
ointment form, available. It is recommended
The agents of phonophoresis discussed

above are the fruit of the cumulative know-
that the therapists should experiment with the

application of theses drugs through phonophoresis in suitable disease conditions and
contributes to the data-base of clinical knowledge.
Combination Therapy Using Ultrasound
and Electrical Stimulation
In general terms, combination therapy
involves the simultaneous treatment with
ultrasound and electrical stimulation. In
Europe, the trend is towards using diadynamic currents with ultrasound, but in the UK,
it is most often combined with two-pole
medium frequency current.
Important Considerations
There is a significant lack of published
material in this area. And much of the
information herein is anecdotal or based
on the experience of those who use the
modality frequently.
Broadly, the effects of the combined treatment are those of the individual modalities. There is no evidence at present for any
additional effects, which can only be
achieved when the modalities are used in
this particular way.
By combining US with MF 2 pole current,
the effects of each treatment modality can
be realised, but lower intensities of both
are used to achieve this effect.
The accommodation effects on sensory
nerves that accompany MF treatment are
reduced (or even eliminated)
The therapeutic advantages of combination
therapy are said to be in localising lesions
(especially chronic) i.e. for diagnostic purpose.
Ensuring accurate localisation of the lesion for
application of ultrasound therapy provides
increased accuracy and effectiveness in

treating deeper lesions, especially while
treating trigger points.
Biophysics of Combination Therapy
Ultrasound exposure to a peripheral nerve
reduces its resting membrane potential by
increasing its permeability to various ions,
especially sodium (Na+) and calcium (Ca++).
Due to this altered permeability, the nerve
membrane is taken closer to its response
threshold, though it does not usually make
the nerve fire. The simultaneous application
of MF2 pole current through the nerve
induces the depolarisation, with a much less
current intensity than usual, due to the
sensitization created by ultrasound exposure.
This can easily be demonstrated. If both
the US and MF are being applied and during
the treatment if the intensity of the US is
turned down to zero, the sensation produced
by the MF will diminish even though the MF
intensity has not been changed. The intensity
of sensation produced by the MF intensify as
the intensity of the US is turned up (Fig. 11.24).
Fig. 11.24: Biophysics of combination therapy
In summary, it would appear that by

combining the two treatment modalities, none
of the individual effects of the treatments are
lost, but the benefit is that lower treatment
intensities can be used to achieve the same
results, and there are additional benefits in
terms of diagnosis and treatment times.
Combination Therapy
Combination therapy is a relatively new form
of treatment. The guidelines for application,
as presented below, are derived from experiences and findings of different workers in
the field. Lot of work is still in progress for
fine-tuning the procedure and the parameters
given here are by no means absolute.
It is suggested that a continuous US output
of 0.5W/cm 2 should be used for this
procedure.
A frequency of 1MHz is preferable if
available as it gives more effective penetration into the tissues.
The MF output is most commonly set to
100 Hz using a bipolar output.
a. As a diagnostic tool
Place one of the MF pad electrodes in a
position on the body surface so that the
current can pass through the tissue in
question. As the passive electrode it can
be placed on the same aspect of the
limb for superficial lesions or on the
opposite side of the limb for deeper
lesions.
The other terminal of the MF is connected any metal part of the ultrasound
transducer with the help of an alligator
clip, turning the transducer into an
active electrode. May modern units
offer special sockets built into the
ultrasound machine to connect one
output terminal of the MF two pole
current for combined therapy.
The ultrasound is turned on, the

duration is set and the treatment head
placed along with a liberal coat of
conducting coupling media on the skin.
Intensity is then increased to the
desired level.
The MF is then turned on and the
intensity increased to minimum perceptible level.
Starting with ultrasound the head
distant from the lesion, gradually
increase the MF output intensity until
the patient encounters the normal
tingling.
Move the ultrasound transducer towards the site of the lesion, noting any
areas of increased sensitivity, local or
referred pain.
The point of maximal sensitivity to MF
stimulation is assumed to be the focal
point of the lesion, though it will not
provide information as to the precise
tissue in question, nor to depth
(Fig. 11.25)
This test provides only a geographical
location of the trigger point. This posi-
Fig. 11.25: Localisation of trigger point using

combination therapy
b. As
tion is usually consistent and reproducible.

Once the focal point of a lesion has been
detected further treatment may be
done with only ultrasound therapy or
combined therapy.
a treatment protocol:
Diagnostic and therapeutic uses of
Combination Therapy need not be used
together.
As a treatment, combination therapy is
appropriate when the therapeutic
effects of US and those of MF current
are both justified.
The individual doses for the US and IF
should be those which are appropriate
for the lesion and the therapeutic effects
desired. There is no evidence that
special treatment doses are required.
However, the intensity of the MF
current required to produce desired
effect is likely to be lower than usual.
Manufacturers claim that it is not
necessary to incorporate a sweep
frequency in the MF current as the
effect of accommodation is minimised.
However appropriate MF frequency
sweep can be used if it is appropriate
to the produce the desired effect in the
target tissues.
If the treatment times are dissimilar,
there is a potential problem in that the
US component will usually finish first,
leaving the IF element to continue in
isolation. The therapist should therefore try to match the treatment time for
both modalities by selecting an optimum duration of treatment wherever
possible.
If treatment times are similar, the
combination of the modalities can save
time and effort (even without addi-
tional effect). When they are dissimilar,

it may be more effective to apply as two
separate treatments.
It is important to observe the usual
precautions applicable for both modalities during combination therapy, i.e.
always using a moving treatment head,
maintain effective contact, the perpendicular relationship between the
treatment head and the patients skin
whenever possible.
c. Clinical example:
For a patient with an acute lesion of the
lateral ligament of the ankle joint,
pulsed ultrasound is justified because
it will promote the repair process and
interferential may be used for its effect
in reducing acute pain.
Recommended US dose (based on
normal dose calculations) should be
3 MHz, 0.2 W/cm 2 , Pulse 1:4, 10
minutes.
Recommended interferential dose (for
acute pain) should be 90 to 130Hz,
bipolar, 10 minutes.
Interferential pad as the passive electrode should be placed on the medial
aspect of the ankle joint.
US treatment head should be applied
over the injured component(s) of the
lateral ligament.
The effect of such combined treatment
could be more effective, than either one
modality in isolation, though there is
no evidence to prove that by using
them simultaneously, there is any
advantage over using them sequentially one after the other.
d. Contraindications for combination therapy:
There do not appear to be any specific
contraindications for combination therapy
other than those for the individual modalities.
DOSIMETRY OF ULTRASOUND THERAPY

Appropriate dosage in ultrasonic therapy has
been a subject of controversy ever since the
inception of this modality in therapeutic
practice. Theories abound regarding the
propriety of space-averaged or time-averaged
intensities, the effectiveness of pulsed or
continuous mode of application and the halfvalue distances. For the want of concrete
scientific evidence, the dosing parameters
have for long been based on the clinical
experience of individual therapists. Majority
of established authors have documented only
the general principles and guidelines for dose
calculation in ultrasound therapy, leaving the
actual dosing to the imagination and experience of the individual practioner. In this
section I have made a humble attempt to
simplify this ambiguous picture for the
beginner.
Points to Ponder
The space-averaged intensity of ultrasound is the net output of ultrasound
energy per square centimetre area of the
transducer, expressed as Watts/cm sq. This
is the most commonly used dosing format
of ultrasound therapy, displayed on the
analogue or digital metre available on the
ultrasound therapy equipment.
The time-averaged intensity of ultrasound
is the total output of ultrasound energy
over a specific period of exposure. This is
calculated by multiplying the spaceaveraged intensity with the total surface
area of the transducer and the duration of
exposure in seconds.
The intensity of the ultrasound beam is
reduced by half at a certain depth below
the body surface, known as the half-value

distance. This attenuation takes place due
to reflection, absorption and refraction of
the ultrasound energy, as it travels from
the transducer, through different
mediums, to the target tissue.
To calculate the appropriate dosage the
first thing that must be taken into consideration is the location or depth of the
target tissue, i.e. the number of tissue
layers or interfaces the beam of ultrasound
must cross before it can reach the target.
Thick tissue cover will mean more attenuation of the ultrasound energy and vice
versa.
Hence, for superficial targets lower
intensity and for deeper targets higher
intensities of ultrasound will be needed.
The intensity of the ultrasound can be
further modulated to suit the clinical
condition being treated by using continuous or pulsed beam of ultrasound
energy.
For acute conditions the mechanical and
the biological effects are preferred, hence
pulsed mode of ultrasound given for
shorter periods will be most suitable.
For chronic disorders the heating effect is
desirable, hence continuous mode of
ultrasound applied over longer durations
will be appropriate.
Dosage of ultrasound depends on:
1. ModePulsed mode delivers less
energy than continuous.
2. FrequencyLower frequency has
greater penetration than higher.
3. IntensityUsually used space-averaged intensity measured in Watts/sq
cm.
4. DurationDuration of treatment is
calculated in minutes and varies in
direct proportion to the size of the area
being treated. Always restrict the
maximum area covered to three times
the surface area of the transducer head,
i.e. if the transducer head is 5 sq cm. in
area then maximum area covered for
adequate insonation in one sitting
should not exceed 15 sq cm. Larger
areas may be divided into grids; each
of 15 sq cm and then treated one after
the other.
5. Treatment should be repeated once or
twice daily for acute lesions and less
frequently for chronic lesions.
Dosage for Ultrasound Therapy

For the young practitioner Table 11.1 may act
as a guideline, till such time he/she can build
up his/her own clinical repertoire.
Points to Ponder
Therapeutic ultrasound is commonly
applied through direct contact method
using a coupling medium to eliminate air
space between the treatment head and the
skin surface.
In direct contact method, as far as possible,
the patient should be positioned in such a
way that the transducer head is applied
vertically downwards on the body surface
Table 11.1: Dosage for ultrasound therapy

Condition
Abscess of soft tissue
Bursitis
Cellulitis
Myalgia
Neuralgia
Periarthritis of shoulder
Radiculitis (root pain)
Intermittent claudication
Lumbago
Lymph-oedema
Muscular rheumatism
Sciatica
Stump neuroma
Ulcer
Coxydanea
Myositis ossificance
Polyarthritis
Sudecks osteodystrophy
Tenosynovitis
Dosage in
Watts/cm sq
0.52
0.61.5
12
23
13
0.53
12
13
13
0.52
0.83
12
23
13
13
12
12
13
12
Mode
Duration in
minutes
Pulsed
Continuous
Continuous
Continuous
Continuous
Pulsed/Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
810
810
1015
1015
1015
1015
1015
520
1015
1015
1015
1015
1015
1015
1015
1015
515
1015
1015
being treated. The weight of the treatment

head will contribute to the pressure
applied by the therapist, holding the
treatment head firmly against the body
surface. This position will also make sure
that the coupling medium does not trickle
down the surface of the skin.
Other infrequently used methods of

applications are water bag and water bath
methods.
New methods of application of ultrasonic therapy, such as phonophoresis and
combination therapy is gaining acceptance.
Therapeutic Cold 119
12
Therapeutic Cold
DEFINITION
BIOPHYSICS
Localised cooling of the body surface to

extract body heat from the underlying tissues,
by evaporation or conduction, in order to
lower local tissue temperature and thereby
provoke therapeutically useful physiologic
thermoregulatory reaction is known as cold
therapy or cryotherapy.1
Therapeutic cold can be applied to the skin

through evaporating or conducting modalities
Volatile liquids, when brought in contact
with warm objects, extract heat of vaporisation from the underlying tissue. Most
common evaporative cold modality used
in the sports field is Furio-Methane sprays
Cold substances, when brought in physical
contact with warm body tissues, extract
heat through direct molecular energy
transfer or conduction. Ice is the conductive cold modality most commonly used
for therapeutic purpose. Ice can be applied
to the body in the form of crushed ice
packs, cold water bath or ice massage.
Commercially available reusable cold
packs can also be used, after cooling it to
the appropriate degree in a freezer
On application of such cold source, heat is
drawn @ 333 joules/gram of ice, by
conduction from the subcutaneous tissues
through the skin, to convert the ice to
water. This causes drastic drop in the tissue
temperature
The drop in tissue temperature, i.e. the
degree of cooling achieved in the tissues
DISCUSSION
Generalised cooling of the body, commonly
known as hypothermia, is used to lower the
temperature of the whole body. As a result of
hypothermia the basic metabolic rate, pulse
rate, respiratory rate, venous blood pressure
and therefore the oxygen demand in the
tissues fall to a minimum. There is a rise in
blood flow to internal organs, cardiac output,
stroke volume and arterial blood pressure.
Hypothermia is used during major surgical
interventions to lower the oxygen demand in
tissues and give more operating time to the
surgeons during open-heart surgeries.
Localised cooling of tissues, commonly
known as cryotherapy is used in physiotherapy
as an anti-inflammatory and analgesic agent,
effective in musculo-skeletal disorders.
depends on the rate and duration of

energy extraction, which in turn depends
on the following factors.
1. The difference in temperature between
the coolant and the tissue. Greater the
temperature gradient, faster the
cooling.
2. The heat conduction property of individual tissues. Cooling is greater in
tissues with large water content, i.e.
muscles or blood and relatively less in
tissues like skin or subcutaneous fat
which act as insulators.
3. Temperature of tissue subjected to
localised cooling will continue to drop
till the heat generated in the tissue
equals the heat extracted from.
4. The total surface area of the body
subjected to cooling is directly proportional to the extent of heat loss.
5. The skin temperature can be lowered
significantly with short period of
cooling, though it takes much longer to
lower the temperature of the deeper
tissues like muscles or joints.2
Physiological Effects of Localised Cooling
The therapeutic benefits of cold post-acute
injury, postoperatively, and during rehabilitation are well documented. The physiological
effects of cold include a decrease in tissue
temperature and metabolism. Circulation is
also decreased as a result of vasoconstriction
and increased blood viscosity. Increased tissue
and synovial fluid viscosity will create muscle
stiffness and slightly impair muscular efficiency. Pain and muscle spasms are reduced
as a result of cryotherapys effect on the
nervous system. Cold reduces the rate of
firing in nerves to the point that sensory nerve
conduction is blocked and thermal anaesthe-
sia or numbness is experienced. In addition

to decreasing sensory and motor nerve
conduction velocity, cryotherapy decreases
pain through the stimulation of endorphin
release, reduction in metabolism, and counter
irritation. Furthermore, the decrease in
sensory input inhibits the stretch reflex and
aids in reducing muscle spasms. Reduction in
metabolism to healthy tissues surrounding
the injured area is beneficial in order to
prevent secondary hypoxia.1 Following acute
injury, the build-up of fluid and proteins and
increased interstitial pressure create oedema,
which compromises circulatory integrity,
placing the surrounding tissues at risk for
hypoxia. Slowing tissue metabolism reduces
energy and, therefore, oxygen requirements
of the surrounding tissues, enabling them to
survive without hypoxic damage.
In terms of motor performance, sensory
changes will result in a decrement in manual
dexterity and fine motor activity. However,
most skilled or gross motor tasks performed
immediately following cold application will
not be impaired.
Different body tissues respond differently
to localised application of cold
Skin cools the fastest with maximum drop
in temperature
Subcutaneous tissue cools more slowly
than the skin and shows moderate drop
in temperature
Muscles and bones show minimal changes
in temperature, even on prolonged exposure to cold
Dramatic vasoconstriction of skin capillaries creates blanching (white colour) of
the skin at the point of contact with the
cold source. The skin over the surrounding
area turns red (hyperaemic) due to histamine mediated rebound vasodilatation
If the exposure to cold is prolonged, Lewis

hunting reaction sets in. Lewis hunting
reaction is alternate cyclic vasodilatation
and vasoconstriction, while the body
searches for the mean volume of blood
flow to the cold area to maintain minimum
sustainable circulation to meet the metabolic demand of the tissues
Application of local cooling of the body
tissues trigger following set of negative
physiological responses.
1. Reduced blood flowDue to vasoconstriction of arteries, arterioles and
venules resulting from sympathetic
adrenergic activity.
2. Reduced capillary permeabilityDue to
less fluid in the interstitial tissue.
3. Reduced elasticity of non-elastic soft
tissueDue to decreased elasticity of
collagen.
4. Reduced metabolic rateDue to inhibition of cellular oxidation.
5. Reduced muscle spasmDue to inhibition of tonic extrafusal activity.
6. Reduced strength of muscle contraction
due to inhibition of blood flow to the
muscle and increased muscle protein
viscosity, on application time > 5 to 10
min
7. Reduced spasticityDue to reduce
muscle spindle and gamma motor
activity
Application of local cooling of the body
tissues trigger following set of positive
physiological responses
1. Increased joint stiffnessDue to decreased extensibility of collagen.
2. Increased pain thresholdDue to inhibition of A-delta and C fibres (spinal
gate control mechanism). Breaks the
pain spasm vicious cycle through
inhibition of sympathetic, sensory and

motor conduction.
3. Increased blood viscosityDue to increased adherence of RBC to each other and
walls of blood vessels.
4. Increased strength of muscle contraction
Due to facilitation of alpha neuron
activity, application time < 1-5 min.
Adverse Physiological Effects of
Localised Therapeutic Cooling
Hypersensitivity to cold is mostly related
to release of histamine leading to
1. Cold Urticaria- red wheals on the skin
associated with sever itching.
2. Flushed face.
3. Puffy eyelids.
4. Respiratory distress.
5. Anaphylactic shock and syncope.
TECHNIQUES OF THERAPEUTIC
COOLING
There are many cryo-therapy modalities
available. These include the ice pack, cold
pack, ice massage, cold whirlpool, cryo-cuff,
cold spray, cryo-stretch, and cryo-kinetics
Different Methods of Therapeutic Cooling
Ice Packs
It is the most cost effective method of
therapeutic cooling for joints and smaller
body segments like the hands, feet, knee,
elbow, shoulder etc.
This method of cooling can be practiced
at the clinic or at home, with minimum
inputs in terms of infrastructure, equipment and recurrent expenditure.
A standard refrigerator, ice tray, polythene
bags, hand towel and water are all that is
needed to give effective ice packs.
Ice cubes are placed in the clear polythene

bag, wrapped in moist towel to form a
pack. The pack should be large enough to
cover the target area.
The pack is applied to the body and then
covered with a dry towel to prevent rapid
melting of ice. Heat transfer takes place by
conduction of heat from the body tissue
to the ice packs to supply the latent heat
of melting to the ice.
The part to be treated is exposed and
checked for any cuts, bruises, discoloration, loss of sensation and skin diseases.
Average treatment time with ice packs is
10 to 20 minutes.
The melted ice is retained by the sealed
polythene bag and does not cause a mess.
Ice Towels
This is the method of choice for cooling of
large, flat, predominantly muscular areas
like the back, thigh and calf.
In this method the equipments needed are
the same as in case of ice packs. Water is
added to crushed ice in a tub to form slush.
Two towels, large enough to cover the
target segment are soaked in this slush.
One towel is wrung out and placed in two
folds on the part to be treated.
The towels should be exchanged after
every 1 to 2 minute, till 15 to 20 minutes.
The part to be treated is exposed and the
skin should be checked for any cuts,
bruises, discoloration, and loss of sensation
and skin diseases.
Ice Massage
This is the method of choice for cooling
much-localised spots like a trigger point.
A cone of ice is frozen keeping water in a
paper cup in the freezer. An ice cream stick
or wooden spatula is placed in the cup of

water prior to freezing to provide a
convenient handle for the ice cone.
The ice cone is applied directly to the skin
over the trigger point and massaged with
firm pressure, in a concentric circle just like
an ultrasound transducer.
The maximum area suitable for ice
massage in one sitting should not exceed
4 6. The rate of movement of the ice
cone over the skin should not exceed
2/second.
bruises, discoloration, and loss of sensation
and skin diseases.
During the application of ice massage the
patient will initially feel cold sensation
followed by burning, aching and finally
numbness of the part being treated.
Treatment should be continued till the part
becomes numb. The duration of treatment
is 5 to 10 minutes.
Massaging ice over superficial nerves like
the ulnar nerve at the medial epicondyle
of elbow or common peronial nerve at the
neck of the fibula is contraindicated as it
may interfere with the nerve function.
Commercial Cold Packs

This is the most hassle free form of cold
therapy, since there is no need to make ice
packs, slush or cones, as well as, no mess
created by melting ice.
Commercial cold packs are made of vinyl
casing filled with silica gel, available in
different sizes ranging from 6 8 to
10 14 and are quite expensive as
compared to ice packs described above
and therefore are suitable for hospital
settings only.
Before application, the packs are cooled to

freezing point or below in a deep freezer.
bruises, discoloration, loss of sensation,
etc. and for skin diseases.
One towel, folded width wise, is soaked
in warm water and then wrung out to
remove excess water. The moist towel is
then placed over the part to be treated and
the pack is placed on the moist towel. A
dry towel folded width wise is placed on
top of the pack to slow down warming and
the whole thing secured with a Velcro
strap.
The treatment time is 10 to 20 minutes.
Coolant Spray
It is the cooling modality of choice for use
in the sporting arena, where rapid cooling
is needed in a very short time to provide
temporary relief of pain and spasm, to
allow the athlete to continue to perform.
A non-toxic, non-inflammable, volatile
liquid in form of aerosol spray is used for
this purpose.
The coolant is sprayed on the skin to
reduce muscle spasm and for desensitisation of injured soft tissues or trigger
points.
Heat is extracted from the body tissue for
the evaporation of the volatile liquid.
To apply the coolant, the spray can is first
shaken hard and then inverted, holding
the nozzle 18 away from the skin.
A thin layer of coolant is sprayed at an
angle of 20 to 30 in sweeping strokes to
cover the skin over the affected area.
The speed of the strokes should be 3-4/
second. The liquid should be allowed to
dry completely before applying any
subsequent strokes.
Number of strokes should not exceed 3-5

only, to avoid cold injury to the skin.
In case of muscle spasm, the target muscle
should be stretched to the limit of pain free
range, during and in between each application of spray. The patient must be
encouraged to perform active exercises of
the affected muscle immediately after the
coolant spray.
When a crucial soft tissue like the ligament
or tendon has been injured, the painful site
should be sprayed 2 to 3 times and the
stabilised with elastic tape/bandage/strap
to prevent aggravation of the trauma
during further activity.
It must be realised that coolant spray is
only a temporary pain relieving measure
that allows the athlete to complete the
sporting event. It is essential for the
therapist to examine the injured part
thoroughly after the event to identify any
serious and lasting damage to the involved
tissues and take appropriate remedial
measures.
Contrast Bath
Definition: It is alternating immersion of body
segments, like hands and feet, in warm and
cold water, to produce alternating vasodilatation and vasoconstriction in the peripheral
blood vessels to provide vascular exercise to
the part. For the patient exhibiting psychological intolerance to cryo- kinetics, contrast
baths combined with active exercise may be
a treatment alternative.
Traditionally, contrast baths consists of
alternating immersion of the injured body
part in hot (106F) and cold (50F) water over
a period of 20 to 30 minutes. Immersion time
is typically 4 minutes of hot followed by 1
minute of cold. The comforting sensation of
the warm water, combined with the limited

exposure to the cold water, may enable coldintolerant patients to initiate active exercises
earlier in their rehabilitation program. Active
movement can be incorporated into contrast
baths by adding active exercises as a third
step, immediately after the 1-minute cold
immersion, just before re-immersing the part
into the hot water. This three-step cycle would
then be repeated over a series of four to five
times, ending the treatment with cold water
immersion.
Controversy does exist, however, regarding the universally accepted, but never
demonstrated theory, that oedema reduction
during contrast baths occurs as a result of the
pumping mechanism induced from the
alternation of vasodilatation and vasoconstriction.
The contrast bath serves as an appropriate
treatment alternative, more in the sub-acute,
rather than acute, phase of soft tissue inflammation.
Two-way heat transfer takes place in this
method, i.e. by conduction of heat from the
body tissue to the cold water and from the
hot water to the body tissue.
Two plastic containers or washtubs, large
enough to hold the body part, are filled
with warm and cold water.
The temperature of the hot water should
be 40 to 45C and cold water around 5 to
10C. While instructing the patient for
home programme, explain for the ease of
understanding that the hot water should
be as hot as can be tolerated on the
immersed part and the cold water should
feel ice cold to the skin, without any
discomfort on prolonged immersion.
The treatment commences with hot water.

The part to be treated is first immersed in
hot water for 6 to 10 minutes at a stretch.
If the water feels too hot, some tap water
may be added to the hot tub or if it is not
warm enough, some more hot water may
be added to the tub.
After soaking in warm water the part is
transferred to the cold tub and allowed to
soak for 1 minute. If the water does not
feel cold enough, some more ice cubes may
be added to the tub.
The part is then transferred to warm water
and allowed to soak for 4 minutes.
The cyclic immersion in hot and cold water
in the ratio of 4:1 is continued for 30 minutes.
The treatment cycle ratio of 4:1 is variable,
depending upon the underlying disorder.
In acute conditions, the ratio may be
changed to 2: 1.
In chronic conditions with indurate
oedema, the contrast bath treatment
should commence and end with hot-water
soak. In acute conditions with significant
effusion, treatment should be terminated
with cold-water soak.
Contrast bath is indicated for any condition that needs stimulation of peripheral
circulation. It is a modality of choice for
acute and chronic musculo-skeletal injuries, like sprain, strain, post fracture
stiffness and in peripheral vascular disorders like lymph-oedema, vasculitis,
varicose veins and Burgers disease.
Losses of thermal sensation and arteriosclerosis in advanced stage with chronic
insufficiency of blood supply are strict
contraindication to contrast bath.
APPLIED COLD THERAPY:

CRYO-KINETICS
The combination of therapeutic cold and
exercises, to restore pain-free function, is
known as cryo-kinetics.3
Indications and Advantages of
Cryo-kinetics
Cryo-kinetics consist of numbing an injured
body part to allow the patient to tolerate
progressive, active exercise. This active
exercise is subsequently followed by reapplication of cold and the series is repeated a
number of times. Cryo-kinetics dates back to
the 1960s when rehabilitation specialists at
Brooks Army Medical Hospital reported an
80 per cent success rate in returning soldiers
to unrestricted duty within 3 days of implementing an aggressive cryo-kinetic program.
Perhaps the most appropriate use of cryokinetics is treating patients with acute joint
sprains in which range of motion (ROM),
weight-bearing tolerance, and functional
activity tolerance are limited by pain and
oedema. Following an acute injury, pain often
restricts motion, which prevents patients from
returning to their work or sport. Cryo-kinetics
speeds the recovery process by enabling
patients to participate in pain-free controlled
mobilization sooner than would normally be
tolerated. Cryo-therapy decreases pain to
allow the patient to receive the benefits of
active motion that may otherwise not be
tolerated. The muscle-pumping action of
active motion aids in removal of dead tissue,
pain-inducing substances, and excess fluid
lingering at the injured site. Knight reports
this active pump is aided by exercise-induced
vasodilatation brought about that actually
surpasses circulatory increases stimulated by
the application of therapeutic heat. Furthermore, tissue gliding during early mobilization
minimizes the risk of adhesions while concurrently facilitating scar tissue remodelling.
Finally, active motion helps the patient
overcome the neural inhibition that frequently
accompanies post injury pain and inflammation.
Cryo-kinetics is relatively inexpensive and
easy to implement. Therefore, it is practical
for almost every rehabilitation setting.
Depending on the mode of cryotherapy
chosen, equipment needs may include: buckets, basins or whirlpools, ice that is preferably crushed, cold packs, ice bags or frozen
ice cups, towels, a rubber mat or no slip
surface, and toe or finger caps if needed.
Therapeutic equipment needed vary depending on the individualized exercise programmes.5,6
Treatment Guidelines for Cryo-kinetics
Step One
Prior to initiating treatment, the patient must
be given a thorough explanation of the
purpose and expectations from the treatment.
Patients must be forewarned about the
discomfort associated with cryotherapy while
emphasizing the necessity of the temporary
pain in order to achieve the desired outcome.
The thermal sensation of the patient must be
checked for normalcy before application of
cold.
Step Two
Patients must be instructed on how to
differentiate among the different types of pain
and discomfort that they may experience
during the treatment. They need to be able to
choose from pre-existing pain, due to their
injury or pathology, from cold-induced pain,

as a result of the sensory changes due to the
cold application. The numbing process, which
begins with sensation of cold, followed by
tingling, burning and aching, finally leading
to anaesthesia. On the other hand, exerciseinduced pain, of an anaesthetized foot may
mean the exercise is inducing additional tissue
damage. Pain-free motions are crucial during
the exercise component of cryo-kinetics.
Exercise-induced pain is a signal to the
rehabilitation specialist that the particular
exercise is too strenuous and needs to be
modified if possible or discontinued. The
patient must be able to differentiate between
the return of pre-numbing discomfort and
exercise-induced pain.
Step Three
Treatment is initiated by numbing the body
part with a chosen method of cryotherapy. Ice
immersion, ice water bath or whirlpools, ice
massage, and cold packs are all considered
acceptable means for cryo-kinetics. The length
of time for the cold application varies depending on the modality chosen and the body part
being treated. The patient reporting numbness of the part, determined by a loss of tactile
sensation, serves as the guide for the duration
of treatment. The initial numbing takes
anywhere from 10 to 20 minutes during the
first cold application before exercise. Cooling
the part after exercise takes less than 5 minutes
in most cases.
Step Four
Once numbness is established, active exercise
within the pain free range may commence.
Each exercise set should last approximately 2
to 3 minutes, until the numbness begins to
wear off and sensation returns to the part.

Patients should attempt to perform five to six
sets of active exercise, separated by periods
of cold application to restore numbness.
Exercise progressions in cryo-kinetics are
similar to those in more traditional therapeutic exercise programs.
Exercise-Specific Guidelines
Non-weight-bearing, pain-free, active
ROM should start with single plane and
progress to multi-planar motions. Postural
repositioning and active-assisted stretching may also be introduced for the patient
with low back pain
The weight-bearing exercises include a
progressive shifting from partial weight
bearing to full weight bearing, unilaterally
on the involved lower extremity (LE).
Weight-bearing activities can also be
introduced into upper extremity (UE) by
having the patient lean on a table or wall.
ROM exercises in weight bearing, including closed kinetic chain exercises (CKC),
wall push-ups; biomechanical ankle
platform board (wobble board) exercises
are introduced progressively. If the patient
has not achieved full ROM in the ankle,
weight-bearing stretches such as a standing TA stretch may be incorporated into
this phase of rehabilitation
Progression is made to ambulation, static
cycling, stair climbing and climbing stairs
or ramps. Training should proceed cautiously, with a strong emphasis on proper
form. If the patient is not able to tolerate
full weight bearing, additional tissue
damage may occur if the exercises are
progressed too quickly or performed
incorrectly. Lower extremity activities
should be performed with both shoes off,
as a self-imposed leg length discrepancy

may contribute to faulty biomechanics and
induce additional damage. Furthermore,
caution must be taken during LE cryokinetics to ensure that the limb is adequately dried before exercises are performed. Exercise and gait training must be
performed on a no slip surface such as a
rubber mat. Increasing the speed or
resistance to the movements makes progressions in the exercises
Resistive exercises restore muscular
strength and power and may consist of
progressive resistive exercises (PREs)
using weights, bands, or other available
equipment. Pain-free heel walking and toe
walking utilize the patients body weight
as resistance to movements, in a safe and
controlled manner
For Progression into functional activities
of daily living or sports, specific activities
should be introduced into the cryo-kinetic
program at safe intensities, before attempting them at pre-injury intensities. For a
sedentary person, high speed walking may
progress to jogging and then to slow
running. For athletes, the running speed
can be increased progressively until they
can tolerate short sprints.
Step Five
As numbness wears off, patients sensation
of the pain will return. This is the signal to
reapply the cold and re-numb the affected
area. Re-numbing generally takes between
3 and 5 minutes.
Step Six
The focus of cryo-kinetic documentation
should be on the description and the
amount of time spent on the individual
exercises Progression can be objectively

recorded as an increase in demonstrated
ROM, weight- bearing tolerance, or movement speed. Functional progress is demonstrated through the documented
advancement from basic functional skills
such as ambulating, to the more complicated, sport-specific skills like sprinting and
jumping.4
Step Seven
The final phase of cryo-kinetics involves
allowing the numbness to wear off while
functional activity continues. This enables
the therapist to assess the patients exercise
tolerance. At this stage, sport or work
specific activities can be performed in
more realistic settings such as the work
places or the practice field. During this
phase of rehabilitation, braces, taping,
protective shoes may be utilized to increase safety and support.
Follow-up
Ideally, cryo-kinetics should be performed
two to three times a day for the patient
whose main goal is to return to sport or
work, as soon and as safely as possible.
The therapist should teach the patients
how to carry out the cryo-kinetic program
at home. An adequate quantity of ice is
needed. The patient can use own body
weight through CKC for the resistive
exercise for the home program. In the
sports setting, the athletic trainer can
readily carry out the treatments. Likewise,
for a therapist working in an inpatient
hospital facility treating postoperative
patients or running an outpatient work
hardening program, cryo-kinetic treat-
ments, done twice to three times daily are

realistic and strongly encouraged.
The suitability of cryo-kinetics for a given
patient depends on the location and extent
of the injury. For example, following a
minor ankle sprain, cryo-kinetics can be
initiated within the first 24 to 48 hours.
However, severe joint sprains may be
unsafe for the cryo-kinetics.
Points to Ponder
The physiological effects of local cooling are:
Perception of cold, tingling, burning and
pain due to stimulation of thermal and
pain receptors
Localised vasoconstriction followed by
rebound vasodilatation, which continues
in a cyclic manner due to Lewis hunting
reaction, creating a vascular pumping
action. Reduction of blood flow in the soft
tissue is the long-term result
Lowered metabolic rate as per Vant Hoffs
law, resulting in reduced oxygen consumption, production of metabolites, cellular
activity and rate of healing
Inhibition of peripheral nerves due to
reduced NCV, resulting in reduction of
pain sensation, tone and spasm of skeletal
muscles and the dexterity and speed of
fine motor activity.
The therapeutic uses of local cooling are:
When applied to recent trauma, therapeutic cold limits blood loss due to vasoconstriction and increased viscosity of the
blood, controls formation of soft tissue
oedema or effusion in joints, reduces pain
by inhibition of conduction in pain carrying nerve fibres, reduces metabolic rate of
injured tissue and thereby restricts tissue
necrosis.
When applied in chronic pain, therapeutic

cold helps activate the gate control mechanism of pain relief through sensory
stimulation. The intense cold sensation
also stimulates the release the indigenous
opiates like beta-endorphins in the brain,
which modulates the pain receptors at the
cortical level.
Reduces muscle spasm and spasticity
through stimulation of cutaneous receptors and muscle spindles, which inhibits
stretch reflexes of the spasmodic/spastic
muscle.
Techniques of Local Cooling
Preparation of patients: Explain the reason
for, intensity desired and the nature of cold
application to the patient. This will some
fear and misconception towards application of cold. The patient is told what sensation to expect and to inform the therapist
if there is any increase in pain. The patient
should be interviewed briefly to rule out
any general contraindication like hypertension or cardiac problems and the area
to be treated is examined for any local
contraindication to application to cold.
Preparation of the part: The part to be
treated should be exposed and positioned
with adequate support. The skin should be
examined for abrasions, skin disease, loss
of sensation etc. Sensitive skin may be
coated with liquid paraffin, before immersion in ice water bath. In acute trauma with
swelling, the part should be arranged in
elevation before applying cold packs.
Preparation of the cold source: The temperature of the cold source must be carefully
monitored before and during treatment.
This is particularly important while using

ice-bath. The condensation from the cold
source must be mopped up from plinth or
working surface with an absorbent cloth
or paper towel.
Application of Therapeutic Cold
1. The cold packs should be held firmly
against the skin for optimum heat transfer.
Every 2-3 minutes the packs should be
moved slightly on the skin the avoid
formation of ice layer on the skin, which
may cause frostbite.
2. The desirable temperature of cold therapy
should not be less than 4 to 6C. To lower
the intensity of cold, keep the pack loosely
on the skin. Loosely held packs retain air
pockets between the cold pack and the
skin which act as insulator and therefore
restrict the intensity of cooling.
3. While giving ice water bath treatment ask
the patient to move the part periodically
in the bath. This movement will dissipate
the heat faster and result in uniform
cooling.
4. Cold compression technique is very
effective in reducing swelling. This type of
cooling is applied through an intermittent
compression machine with cold fluid
instead of air in the compression sleeve.
The part must be kept in elevation during
such treatment for getting best results.
Alternatively faradism under pressure

may be applied for 15 to 30 minutes to
mobilise the tissue fluid just before
application of cold therapy.
5. The condition of the skin must be checked
periodically (every 2-3 minutes) during the
treatment, to monitor the onset of vasoconstriction and vasodilatation. If hyper
reaction occurs the treatment should be
terminated immediately.
6. After completion of the treatment the
patient should be advised to avoid heat
exposure or hot bath for at least two hours.
7. The patient should be asked to monitor the
skin condition closely for the next 24 hours
and to report any adverse changes before
the next sitting.
REFERENCES
1. Knight KL. Cryo-therapy in Sport Injury
Management. Champaign, Ill: Human Kinetics;
1995:3-18,59-71, 77, 107-130, 175-177, 217-32.
2. Barnes L. Putting injuries on ice. Physicians
Sports Med 1979;7(6):130-36.
3. Denegar CR. Therapeutic Modalities for Athletic
Training. Champaign, Ill: Human Kinetics;
2000;104-11.
4. Gaydos HF, Dusek ER. Effects of localized hand
cooling versus total body cooling on manual
performance. Journal of Applied Physiology
1958;12:376-80.
5. Hayden CA. Cryo-kinetics in an early treatment
program. Physical Therapy. 1964;44:990-93.
6. Prentice WE. Therapeutic Modalities in Sports
Medicine. Boston: WCB/McGraw-Hill 1999;
187-89.
13
Therapeutic Light
(Actinotherapy/Heliotherapy)
And God said, Let there be light.
The light in the Bible means both visual and
non-visual light. Of all the electromagnetic
radiations striking the earth, approximately
50 per cent is visible light, having wavelengths between 400 and 700 nanometres. (A
nanometre (nm) is the standard measurement
used to express wavelength of electromagnetic radiation. It is equivalent to one
billionth of a meter in length).
Electromagnetic radiation comes in many
forms. The most familiar among them is
visible light. Other forms include X-rays,
ultraviolet (UVR), infrared, microwave and
radio waves. Daylight consists of direct solar
radiation, diffused radiation from the sky (sky
shine) and wavelengths reflected from
surroundings, such as buildings, etc.
Generally the moisture in the atmosphere
absorbs a great deal of ultraviolet radiation
and even more so by smoke and dust particles.
Visible light has seven colours, violet,
indigo, blue, green, yellow, orange and red,
which are only a fraction of all wavelengths
known to mankind. Colour combinations and
blends of hue in this visual range can exceed
100 million.
In physiotherapy, light energy in the form

of ultraviolet, infrared and laser are used for
therapeutic purpose. Since all types of light
originate from the sun, this form of therapy
is called Heliotherapy (Helios means sun in
Greek) or Actinotherapy (Actinos means light
in Latin).
HISTORICAL PERSPECTIVE
Helios is the god of sun in Greek mythology.
Heliopolis, an ancient Greek city was famous
for its temples of sunlight healing. This is
where Heliotherapy or science of therapeutic
sunlight was born. Herodotus, the father of
heliotherapy wrote that exposure to the sun
is essential for a sick persons who needs to
restore his health. In winter, spring and
autumn, the patient should permit the rays
of the sun to fall upon him; but in summer,
because of the excessive heat, this method
should be used in moderation.
In 1877, Downs and Blunt discovered the
dramatic ability of sunlight to destroy and
provide for an effective means of treating
bacterial infections. Another famous practitioner of heliotherapy was Auguste Rollier
MD, whose clinic was at 5,000 feet above sea
Therapeutic Light (Actinotherapy/Heliotherapy) 131
level. Dr. Rollier stated that his patients would

get the best results if they received the highest
amount of ultraviolet light at this altitude.
Ultraviolet intensity increases 4% to 5% every
1000 feet ascended. He apparently substantiated incredible results, which were published in his book La Cure de Soleil, i.e. Curing
with the Sunlight.
Dr. John Otto, the father of modern
photobiology noted that sensible exposure to
sunlight is not only safe but is desirable for
good health. Life on Earth evolved under
natural sunlight and has existed for billions
of years under the full spectrum of light
(visual and non-visual) that it contains. Many
prehistoric tribes and even entire civilizations
like the Mayans and the Persians worshiped
the sun for its healing powers, using its light
to treat physical and mental illnesses. Though
exposure to UV light in large amounts is
harmful; in trace amounts, as in moderate
amounts of natural sunlight, it acts, as a lifesupporting nutrient that is highly beneficial.
WHAT DOES SUNLIGHT THERAPY
ACTUALLY DO?
Sunlight Therapy can have the following effects
on the human body:
1. Increase circulation by formation of new
capillaries to replace damaged ones to
speed up the healing process by carrying
more oxygen as well as more nutrients
needed for healing and carry waste
products away.
2. Stimulate the production of collagen, the
most common protein found in the body
essential for repair of damaged tissue and
to replace old tissue. By increasing
collagen production less scar tissues are
formed at the wounds.
3. Increase RNA and DNA synthesis helping

damaged cells to be replaced more
promptly.
4. Stimulate fibroblastic activity, which aids in
the repair process. Fibroblasts are present
in connective tissue and are capable of
forming collagen fibres.
5. Stimulate tissue granulation and connective tissue projections, which are part of
the healing process of wounds, ulcers or
inflammation.
6. Stimulate the release of adenosine triphosphate (ATP). ATP is the major carrier of
energy to all cells. Increases in ATP allow
cells to accept nutrients and get rid of
waste products faster by increasing the
energy level in the cell.
7. Increase lymphatic drainage. Research has
shown that the lymph vessel diameter
and the flow of the lymph can be doubled
and the venous diameter and the arterial
diameters can also be increased with the
use of light therapy. This means that both
liquid and protein components of
oedema can be evacuated at a much
faster rate to relieve swelling.
8. Relieve pain. Light therapy is successfully
used in pain management, dermatology
and rheumatology with excellent therapeutic effects.
9. Stimulate acetylcholine release and other
parasympathetic effects.
10. Increase phagocytosis, as an important part
of the infection fighting process. Destruction of the infection and clean up must
occur before the healing process can take
place.
11. Induce thermal effect, which raises the
temperature of the tissue being treated,
to kill or disable bacteria and viruses.
Discussion
Modern scientific research claims that sunlight; especially ultraviolet rays can be
hazardous to our body. Controversy exists
over potentially-harmful effects of the invisible ultraviolet frequencies (wavelength 100
to 400 nm), which equal 10 per cent, and
infrared frequencies (wavelength over 700
nm), which are 40 per cent of all radiation
reaching earth. Of course, the fact remains that
without ultraviolet and infrared our world
would not be the same. Infrared provides us
with the required heat that keeps us warm.
Ultraviolet provides us with the ability to
fight off germs in the air (UVC), creates skin
pigmentation as a natural protector (UVB)
and helps in our vitamin and mineral absorption capabilities (UVA). UVC are the shortest
ultraviolet rays and our atmosphere and the
ozone layer absorb virtually all of these
frequencies. The remaining UV light that
reaches the ground is about 10 per cent UVB
and 90 per cent UVA at midday. Overexposure
to sunlight may cause varying degrees of
sunstroke, heat stroke or sunburns and such
symptoms as headache, undue fatigue or
irritability. On the other hand, properly
applied sunshine act as a powerful tonic,
helpful in increasing general powers of
resistance and promoting mental and physical
development. For this reason the duration and
extent of exposure to sunshine should be
carefully graduated and those who do not
pigment efficiently or easily should be
warned to be especially careful.
emitted with a wavelength bandwidth of

180 to 12000 nm. These contain visible light
as well as invisible radiations like UVR and
Infrared. Such radiations are governed by
following laws of physics.
Lamberts cosine law, which states that, the
angle of incidence of radiation determines
the amount of radiant energy absorbed.
In terms of therapeutic application it
means that optimal absorption the radiations should occur when the rays are
perpendicular to the skin surface being
treated.
Inverse square law, which states that, the
intensity of radiation varies inversely with
the square of the distance between the
source of radiation and the surface it falls
In terms of therapeutic application it
means that if the source of radiation is
moved halfway closer to the skin its
intensity will increase four times. Hence
to increase or decrease the intensity of any
type of therapeutic light the distance
between the emitter of radiation and the
skin should be increased or decreased.
TYPES OF THERAPEUTIC LIGHT
Apart from natural sunlight, in physiotherapy,
three types of light energy are used for
treatment of different disorders. These are
ultraviolet radiations, infrared radiations and
LASER. Each of these light energy have
specific effects on the physiology of the
human body and is used to correct specific
disorders.
PHYSICS OF THERAPEUTIC LIGHT
ULTRAVIOLET RADIATION THERAPY

(UVR THERAPY)
Sunlight is the source of all types of light

energy used for therapeutic purpose. Therapeutic lights are electromagnetic radiations
Ultraviolet light is part of the electromagnetic

energy spectrum, which can be classified into
three wavelength ranges:
UV-C : 100 nm - 280 nm;

UV-B : 280 nm - 315 nm;
UV-A : 315 nm - 400 nm.
Points to Ponder
Light is a form of electromagnetic energy
that moves in measurable waves.
The human eye is capable of seeing only a
small segment of the spectrum known as
visible light; shorter and longer wavelengths are not visible.
Shorter length cosmic rays, gamma rays,
X-rays and UV light and the longer length
infrared and radio waves are all invisible
to humans.
UV radiations are between 180 nm and 400
nm wavelengths in the narrow region
between X-rays and the violet end of the
visible light spectrum.
Biophysics of UVR
Fluorescence
More than 3,000 natural and man-made
substances can transform invisible radiated
UV into longer, visible wavelengths that
appear in a variety of colours. These substances react to UV because they are composed of easily excitable molecules. When UV
light strikes one of these molecules, photons
cause each molecule to oscillate violently to
release longer, visible wavelengths that
appear to the human eye as a glow, in the
colour specific to activated substance. This
phenomenon, called fluorescence is instantaneous and ceases the instant the UV light is
removed. Fluorescence lets users detect
otherwise invisible traces that indicate various
quality defects, diseases and contamination.
Luminescence and Phosphorescence

Luminescence is the emission of light produced by means other than combustion such
as the luminous glow of a watch dial.
Ultraviolet radiation has particular physical
characteristics, which affect such phenomena
as Luminescence and Phosphorescence and
can cause Fluorescence.
Physiological Effects of UVR
1. Antibiotic properties of UVR like inactivation of toxins and destruction of bacteria
or virus are produced by UVR-C, having
wavelengths of 100 nm-280 nm. UVR-C is
widely recognised for its bactericidal and
antiviral properties, useful for sterilization of
infected wounds, medical supplies, surgical
instruments, drinking water and processed
food.
UVR-C has been used as a disinfectant for
many years and is, in fact, still used for that
purpose. In the late 1900s, Niels Ryberg
Finsen used this bactericidal and antiviral
property for a new application and started
using ultraviolet rays from external sources
for the treatment of diseases of the skin and
mucus membrane, for which he was awarded
a Nobel Prize in 1903. By the mid-1930s
treatment with ultraviolet was well accepted
for erysipelas and other skin infections, as
well as for mumps. Other researchers
Hancock and Knott (1942) have demonstrated
the effectiveness of ultraviolet blood irradiation (UVR) in treating both bacterial and viral
infections, having demonstrated that ultraviolet light could be used effectively in the
treatment of bloodstream infections. However
with the debut of antibiotics, its ease of
treatment and its success in treating infections, it became the treatment of choice, and
UVR therapy fell by the wayside.
2. Biotic properties of UVR are beneficial to
the living tissue. Out of the entire spectrum
of UVR, UV-B (280 nm - 315 nm) and UV-A
(315 nm-400 nm) are known to have profound
beneficial effects on the living tissues.
Enhancement of the immune systems
ability to fight infections.
Increase in oxygenation of the blood.
Activation of steroids.
Increased cell permeability.
Release of vasoactive agents in the subcutaneous capillary network resulting in
vasodilatation and reddening of the skin,
known as erythema reaction.
Increased desquamation i.e. peeling of the
skin.
Promote granulation
Activation of cortisone-like molecules,
called sterols, into vitamin D.
Sensitivity to UVR
Individuals vary in their sensitivities to
UVR. Persons with light skin shades are more
affected through tanning, though it is the dark
skinned that run the risk of developing basal
cell carcinoma due to overexposure to UVR.
Certain drugs such as tetracycline, sulphonamides, phenothiazine, quinine and gold
may alter sensitivities of a person to UVR.
Over-dosage with ultraviolet light may
produce severe systemic reactions similar to
allergic reactions and lower the resistance to
bacterial infections. The level of exposure
required for an overdose is not approached
in proper clinical practice.
Instrumentation of UVR therapy
Therapeutic UVR is availed from three types
of sources, air-cooled mercury vapour lamps,
water-cooled kromayer lamps and theractin

tubes.
Air-cooled mercury vapour lamps consist of
a hot quartz tube, mounted on a movable
stand like an operation theatre light. It has
a hemispherical shutter to control the
extent of exposure to the rays. The lamp
produces bright bluish light, containing,
predominantly UVB and UBA with a small
proportion of UVC in the wavelength
range of 240 to 400 nm, along with significant amount of infrared and visible light.
Such lamps need to be warmed up for 5
minutes to ensure maximum output of
UVR and are suitable for superficial
wounds and pressure sores on the skin
surface. Since significant heat is generated
by this type of lamps. Hence the distance
between the lamp and the skin surface
should be 20 to 40 inches.
Water-cooled kromayer lamp contains a
cold quartz mercury vapour tube, mounted in a hand held applicator unit, which
produces invisible UVC in the wavelength
range of 180 to 290 nm. This type of lamp
needs no warm up time. The field covered
by the lamp is just 5 sq cm and therefore,
its suitable for small deeps sores or
sinuses. Since this type of lamp generates
virtually no heat, it is applied in direct
contact with the skin surface.
Theractin tubes consist of specially coated
fluorescent tubes, arranged in a battery of
6 to 8 tubes fitted with in a semicircular
tunnel, which produces visible violet light,
containing UVA in the wavelength of 400
nm. This type of lamp utilises biotic
properties of UVR and is used for treatment of neonatal jaundice, vitamin D
deficiency and as a sunlamp for tanning
the skin. Since no heat is produced and the
desired effect is largely generalised, the
distance of the tube form the skin should

be such that the field covers the entire
body.
Points to Ponder
Therapeutic ultraviolet is produced by
excitation of mercury atoms.
The mercury vapour lamps may be of two
types
1. Hot quartz type (Alpine Sunlamp),
which produces heat and visible light
along with UVR- A, B and C.
2. Cold quartz type (Kromayer Lamp),
which produces mostly UVR-C.
Fluorescent tubes with phosphorescent
coating, producing UVR-A along with
visible light. Arranged in Tunnels, which
is used for whole body exposure.
Ultraviolet Applications
Methods of UVR applications and its dose
depends upon:
The type of ultraviolet source being used.
The selection of the source depends upon
the type of the clinical problem being
treated.
The most critical element in dosimetry of
UVR is the extent of erythema reaction
produced by UVR exposure on the skin.
Erythema Reaction
Definition
Reddening of the skin, which appears a few
hours after the exposure to UVR, is called
erythema reaction. The intensity of the
reaction is directly proportional to the duration of exposure to UVR and varies according
to types of skin tone and sensitivity of the
individual. After appearing, the erythema
reaction increases in intensity for a few hours

and may be associated with superficial
oedema and peeling of the skin on strong
exposure. The reddening of the skin fades
spontaneously after few hours or days.
Mechanism of Erythema Reaction
It is dependent on histamine-mediated
dilatation of the subcutaneous capillaries.
Several anti-inflammatory agents like histamines; kinins are released from the mast cells
following exposure to UVR, which lead to
permanent dilatation of capillary network at
the site of the exposure, resulting in clearly
demarcated area of uniform redness in the
skin. The reddening caused by exposure to
heat is often mottled and diffuse in nature.
Dosimetry of UVR
The skin response to UVR depends on the
quantity of ultraviolet energy applied to per
square inch area of the skin, tone and the
sensitivity of the skin being treated. Since the
sensitivity of UVR varies from person to
person, its optimum dosing parameters are
determined on case-by-case basis, through
trial and error of application. This is known
as the test dose.
Practical Points
Take a 3 wide and 10 long strip of
flexible but opaque cardboard.
Cut three holes in the cardboard
of three different shapes, 3 apart.
Fix the cardboard strip with adhesive tape,
on the flexor surface of the forearm, lower
abdomen or chest of the patient, after
washing and drying the part. Ensure the
test strip is flat on the body surface to
avoid shadows.
Cover the part, along with the test strip

with a towel. The rest of the body of the
patient should be draped with a sheet and
the eyes protected with a UVR resistant
goggles.
The Mercury vapour type UVR lamp
should be placed 30-36 away from and
at right angles to the body surface, so that
the incident rays are perpendicular to the
skin.
The lamp should then be warmed up for
5 to 10 min.
Open the shutter of the lamp and expose
the first cut out on the cardboard for 15
seconds, uncovering the second and the
third cut outs successively at intervals of
15 seconds.
With this procedure the first cut out is
exposed for 45 seconds, the second for 30
seconds and the third for 15 seconds
respectively.
After the exposure is completed the shutter
of the lamp is close and the unit should be
switched off.
While using kromayer lamp preparation
of the patient and the test dose cutouts
remain the same. The distance of the lamp
from the skin should be 1 or less. Three
cutouts are exposed one after another for
15, 30 and 45 seconds respectively.
Interpretation and Use of the Test Dose
The patient is given a card with holes of
similar shapes as that on the test dose card.
The patent is asked to record the time at
which reddening appears on the exposed
spots on the skin and the time at which it
subsides, on the matching holes on the
card.
Minimal erythemal dose, producing a faint
reddening on the Indian skin within 4 to 6
hours, which subsides within 24 hours.

Minimal erythemal doses are used for
generalised applications, useful for
vitamin D synthesis.
First-degree erythema produces mild
reddening along with light peeling of the
skin. It appears within 4 to 6 hours and
lasts for 48 hours. First-degree erythemal
doses are used to treat superficial skin
conditions such as Acne and sub acute
psoriasis
Second-degree erythema produces marked reddening along with marked peeling,
oedema and pigmentation of the skin
lasting for 72 hours. Second-degree erythemal doses are suitable for chronic
psoriasis, where peeling or exfoliation is
desired.
Third-degree erythema produces severe
blistering, peeling and exudation along
with pain. It should be applied only on
open sores or wounds, to destroy infective
organism through UVC component and
promote the granulation through the UVB
and A components.
RED LIGHT THERAPY (INFRARED RAYS)
Definition
It is the therapeutic application of radiant
energy from a visible light source, commonly
referred to as the red light, which emits both
visible light in the wavelength from 400 to 700
nm and invisible wavelengths from the
infrared portion of the electromagnetic
spectrum, in the band width of 700-12000 nm.
Biophysics
Wavelength dependent photo biochemical
reactions occur throughout nature and are
involved in such things as vision, photosyn-
thesis, tanning and vitamin D metabolism.

Application of Red Light therapy has been
shown in over 40 years of independent
research worldwide to deliver powerful
therapeutic benefits to living tissues and
organisms. Such light contains both visible red
(600-700 nm) as well as invisible infrared rays
(700-12000 nm).
Types of Infrared Energy
Infrared energy covers a bandwidth of
760-12000 nm with in the electromagnetic
spectrum.
Near infrared rays or I.R.A have a wavelength range of 760 to 1500 nm and are
emitted along with red visible light. This
the commonest variety of infrared energy
used in physiotherapy. These rays penetrate to the depth of 5 to 10 mm, reaching
the dermis and the subcutaneous tissue
and are emitted by the luminous infrared
lamps. Such lamps produce visible light,
which is passed through a red colour filter
to eliminate undesirable wavelengths like
the UVR from the visible light.
Far infrared rays or I.R.B. and I.R.C. is
emitted by any non-luminous heat source,
like an electric heating coil or a hot water
bottle. These rays have a wavelength range
of 1500-12000 nm and penetrate to a depth
of 2 mm and its effect is restricted only to
the superficial layers of the skin.
Methods of Application of Infrared Ray
Two types of infrared sources are used in
physiotherapy practice.
1. Non luminous infrared lamps: These are
large lamps, similar to operation theatre
lights, mounted on a movable stand. They
have a heating element mounted on a
ceramic cylinder like in an electric room

heater and their working is similar in
nature. The heating coil is mounted in the
front of a parabolic reflector, which directs
the radiations in a parallel beam towards
the target area.
The lamp must be switched on at least
5 minutes before application of the
treatment, to warm up the heating
element and ensure maximum output
of infrared energy.
The area to be treated is exposed and
inspected for any break in the skin or
any skin disease. The thermal sensation
of the skin must also be checked before
application of I.R. the rest of the body
is then draped with a sheet and the eyes
must be protected with a pair of
sunglasses.
The lamp is then positioned 30-36
away from skin. The position of the
reflector should be such that the radiant
energy falls perpendicular to the skin,
to ensure maximum absorption.
The duration of exposure should be 20
to 30 minutes in one sitting. During the
exposure the therapist must be available within easy reach of the patient. If
the patient feels less or more heat the
lamp may be moved closer or away
from the skin as the case may be. It is
wise to remember that the feed back of
the patient is the only guide you have
to give appropriate dosing of I.R.
Hence, ask the patient repeatedly
regarding the extent of heat being felt
and be ready to adjust to the dose to
suit the comfort level of the patient.
After completion of the treatment the
lamp may turned off or moved away
from the skin. The lamp may be kept
on if there are more patients to treat.

Inspect the skin that has been treated
for any undue reactions. Slight reddening of the skin over the exposed area is
to be expected and this should be
explained to the patient.
In case of irritation or severe reddening
of the skin calamine lotion (lacto calamine) may be applied over exposed
skin. It should be realised that fair skin
reddens more readily as compared to
dark skin.
2. Luminous infrared lamps: These are devices
consisting of an incandescent bulb of 150
watts mounted on parabolic reflector,
having portable or stand mounted set-up.
The incandescent lamp has a red filter
placed in front or painted on to the
faceplate of the bulb. This filter helps to
remove the UVR associated with the
visible light produced by the incandescent
bulb. These types of lamps are preferred
by most clinics and for home use because:
No warm-up time needed. The lamp
gives maximum output as soon as it is
turned on.
It has deeper penetration and therefore
greater effect on body tissues.
Face and the eyes need to be protected
strictly due to the presence of visible
and UVR in the luminous I.R. output.
The distance from the lamp to the skin
should be 18-24 and the duration of
exposure should be 15 to 20 minutes.
Procedure of application, patient preparation and precautions observed are
similar to non-luminous IR applications.
THERAPEUTIC LASERS
Lasers are devices for producing light at
specific wavelengths that is therapeutic in
nature. All biological systems have a unique

absorption spectrum, which determines what
wavelengths of radiation will be absorbed to
produce a given therapeutic effect. Lasers are
focused beam single-wavelength (monochromatic) light that can be intense enough to
burn/cut tissue or mild enough to only have
photobilogical effects on the living tissues.1
Laser devices emit an intense, coherent and
highly directional beam of light which may
be infrared, visible or ultraviolet, depending on
the type of the diode being used.
The peak power output of lasers is measured in watts. The primary reaction of laser
on the living tissue is thermal i.e. production
of heat which. Such heat is due to the highly
intense nature of the beam and its ability to
be focussed over small areas. The heat is sufficient to coagulate or ablate tissue by evaporation. However, even with low power
application of laser, significant benefits were
observed in diseased tissue, without any
destruction of the cells. This led to the use and
subsequent popularity of low power laser in
physiotherapy and very low power laser in
dermatology. Effects of such laser exposure
are mainly photo biological in nature. The
peak power output of laser is measured in
watts used frequently for endoscopic surgery
for endometriosis, vascular surgery, etc.2
Other reactions of laser exposure are used
are photo biological in nature. In physiotherapy low powered lasers as used and in
ophthalmic treatments such as capsulotomy
photo acoustic effect is used.3
Points to Ponder
LASER stands for light amplification by
stimulated emission of radiation.
Laser consists of a large number of identical photons emitted from an energised
source called a diode on application of

electrical charge.
Laser radiations have the same wavelength i.e. are mono chromatic in nature.
Laser radiations are coherent in phase and
direction, i.e. has temporal and spatial
coherence.
Laser emitted from a source is collimated
in nature, i.e. parallel to each other.
Laser behaves like light i.e. they can be
reflected, refracted and absorbed.
Different Types of Lasers

Employed for Clinical Use (Table 13.1)
i. Candela pumped dye laser:
Dermatology
ii. Neodymium: YAG laser:
Surgery
iii. CO2 Laser:
Obstetrics and Gynaecology
iv. Argon; iris diode lasers:
Ophthalmology
v. He-Ne; infrared diode lasers:
Physiotherapy
Hazards of Laser Therapy
The principal hazard due to laser is damage
to the eye. Laser radiations in the visible and
near infrared wavelengths can penetrate the
eye and damage the retina permanently,
where as radiation in the ultraviolet and far
infrared wavelengths can cause damage only
to the surface of the eyes. Lasers are divided
into five hazard classes, depending on the
output and the risk of damage from accidental
exposure.The hazard classes of laser used in
clinical practice are:
Class 1 - Intrinsically safe
Class 2 Low power devices emitting visible
light - not completely safe, but the blink reflex
will protect the eye. Positioning lasers used

for aligning patients for radiotherapy, X-rays
and scans are usually Class 2
Class 3a - Similar to Class 2, except that if the
beam is focussed onto the eye, e.g. through
magnifying glasses, beam could be hazardous.
Class 3b Potentially hazardous to the eyes
because either the blink reflex is not fast
enough to prevent damage or the beam is
invisible and therefore the blink reflex cannot
work. Lasers used in physiotherapy produce
invisible infrared beams (Galium-Aluminium-Arsenide Diode) at class 3B.These
equipments also incorporate a visible orange
(Helium-Neon diode) as an aiming laser beam
at lower power, which should also be regarded as hazardous. In scanning laser, the power
density is considerably reduced by the
cylindrical lens, which spreads the beam from
a spot to a line.
Class 4 High power devices capable of
causing immediate injury to the skin, eye or
living tissue - even diffuse reflections may be
hazardous. Most surgical lasers are in Class
4. Damage from Class 4 lasers can occur in a
fraction of a second, far faster than the eye
can blink to shut out the beam. The hazard
can arise from direct exposure to the laser
beam or accidental reflections of the beam
from shiny objects. It must be stressed that eye
damage is the most likely and immediate
injury - thus the operating rules must be
understood and adhered to by all staff
involved. The likelihood of an accident is very
small, but the consequences are often serious.4
Other potential hazards are fire. Lasers can
ignite flammable materials. Laser may cause
explosion of anaesthetic gases or ignite
inflammable substances like surgical ether
causing skin burns.
Synthetic ruby
rod made of
aluminium
oxide
Sealed glass
tube containing
helium and neon
gases
Ruby laser
Helium
Neon laser
Infrared diode Specialized

lasers
light emitting
diodes made
of gallium
aluminium
arsenide
Excitable
compound
Type of
clinical laser
Application of
electrical pulse
to the diode
Helical xenon
tube wound
round the
ruby rod emitting intense
flash of light
Helical xenon
tube wound
round the ruby
rod emitting
intense flash of
light
Method of
excitation
650-1300 nm
continuous
860-904 nm
pulsed mode
632.8 nm
694.3 nm
Frequency of
emission
Class. 3a low
medium >5mW
Class3b medium
power >500mW
Class 2 low
power laser
>1mW
Class 2 low
power laser
< 1mW
Class of laser
and power emitted
Visible red light

with some
infrared
Invisible Infrared
Visible red light
Visible red light
Colour of
emission
Table 13.1: Different types of lasers employed for clinical use
Direct exposure
to the eye
harmful
Reflected
exposure is
dangerous to
the eyes
None, if not
focused directly
on the eye
None
Adverse effects
Bedsores, indolent
wounds, musculoskeletal disorders,
pain relief, etc.
Marker for
application of
invisible lasers
Dermatology
Clinical use
Procedures and Equipment

The Nominal Ocular Hazard Area (NOHA)
is the region around a laser therapy unit,
where eye protection is essential. For therapeutic laser this is the entire room, in which
the laser is being used, but it may be less for
specific lasers, e.g. NOHA is within one metre
of any ophthalmic laser. It is important to
avoid any unexpected entry into a laser area
when the equipment is in use. A laser hazard
sign must be displayed at eye level at all
entrances to the room. The hazard sign must
indicate the classification and type of laser
being used. Ensure that all personnel working
with the laser are adequately instructed on eye
safety measures. Ensure that adequate supply
of protective eyewear for the particular type
of laser is available. Appropriate eye wear
specific to the type of laser being used must
be worn by all staff present during the
treatment procedure, and spare eye wear
must be available for staff wanting to enter
the area. Staff working with lasers, which have
the ability to ignite flammable materials, must
be aware of the location of a nearby fire
extinguisher. The supervisor, in a secure place

when not in use, shall keep the master key
for each laser and an authorised person
should only energise the equipment frequently for endoscopic surgery for endometriosis, vascular surgery, etc. All lasers must
be checked routinely for proper output and
performance prior to each procedure. Faults
should be notified immediately to the Biomedical Engineer in charge.
REFERENCES
1. Lasers and Wound Healing, Albert J. Nemeth,
MD; and Dermatology Centre, Clearwater FL,
Dermatologic Clinics, Vol. 11 #4, 1993.
2. Wound management with Infrared Cold Laser
Treatment, P Gogia; B Hurt and T Zim; AMIPark Plaza Hospital, Houston TX, Physical
Therapy, Vol. 68, No. 8, August 1988.
3. Effects of Low-Level Lasers on the Healing of
Full-Thickness Skin Defects, J Surinchak. MA;
M Alago, BS, R Bellamy, MD; B Stuck, MS and
M Belkin, MD; Lettennan Army Institute of
Research. Presido of San Francisco, CA; Lasers
in Surgery and Medicine, 1983;2:267-74.
4. Effect of Laser Rays on Wound Healing, E
Mester, MD; T Spiry, MD; B Szende. MD and J
Tola; Semmelweis Medical Univ. Budapest, the
American Journal of Surgery 1971;122.
14
Frequently Asked Questions in
Practical: Viva Examination
SECTION 1: DEEP THERMOTHERAPY
Q 1. What do you understand by SWD?
A. It is a method of producing deep heat in
the body tissues using high frequency current
at the frequency of 27.12 MHz and wavelength of 11 meters.
Q 2. What are the effects and uses of SWD?
A. Primary effect of SWD is to generate heat
in body tissues by subjecting it to an oscillating electrical field. Results of such heating are
increased blood circulation, metabolic rate,
protein synthesis and drainage of cellular
waste. These effects are used for relief of pain,
spasm of muscle, stiffness of joints, resolution
of inflammation and tissue healing.
Q 3. What are the types of SWD machines?
A. SWD machines are available with valves
or solid-state circuit.
The valve sets have the advantage of
giving consistent outputs in the range of
400 to 500 watts over long periods of continuous operation without overheating and
therefore, suitable for hospital or clinic use.
The disadvantages of valve sets are that
these units are larger, heavier, have delicate
RT valves that need careful handling and
also are much more expensive than solidstate units.

SWD equipments with solid-state circuit
have an output of 100 to 250 watts over
short periods and are prone to overheating
on continuous use. These units have lightweight, rugged-construction and are
therefore, suitable for portable use.
Q. 4. What are the important features of a
modern SWD machine?
A. Modern SWD machines have individual
controls for input voltage, output intensity,
tuning and autocut timers. Many models have
auto-tuning facility for quick and accurate
tuning of the machine circuits with the patient
circuit. Most modern equipments have
individual output sockets for cable and
condenser electrodes. The equipments should
also have provision for using cable, disc and
pad electrodes, along with flexible disc
electrode mounting arms as standard accessories.
Q. 5. What type of input current is used in
SWD? What is the output current frequency
and wavelength?
A. AC current from a domestic power outlet,
with a voltage range of 220 to 240 volts is used
Frequently Asked Questions in Practical: Viva Examination
143
to operate SWD machines. The output current

is high frequency current with a frequency of
27.12 and wavelength of 11 meters.
Q. 11. How much thickness is appropriate

for spacers?
A. 2 to 4 cm.
Q. 6. What are the common methods of

application of SWD?
A. Condenser field and cable method.
Q. 12. What should be the appropriate

distance between two condenser plate
electrodes?
A. The minimum distance between two
condenser plates should be greater than the
sum total of the thickness of the spacers being
used.
Q. 7. What is condenser field method of

SWD?
A. Body tissue is interposed, as a dielectric
medium, between two condenser electrodes,
metal disks or plates, enclosed in nonconducting covers like plastic or rubber.
Q. 8. Which tissue is heated most in condenser field method?
A. Tissues with minimum water or electrolyte
content, which offers maximum resistance to
oscillating high frequency current, like the
subcutaneous fat or skin, are heated most with
condenser field application of SWD.
Q. 9. What are different techniques of
condenser plate electrode placement used in
SWD?
A. Coplaner, contraplaner and cross-fire
placement.
Q. 10. What are spacers? Name a few spacers.
A. Spacers are layers of insulating material
containing large air-spaces, which are interposed between the condenser electrodes and
the skin surface. The spacers can be perforated
felt pads, Turkish towel or air-space. The
spacers increase the distance of the electrodes
from the skin, eliminating irregularities of the
body surface, for even distribution of the lines
of forces. Concentration of the lines of forces
on a specific spot may cause overheating and
burn.
Q. 13. What is the method of heat production

in cable SWD?
A. Heat is produced by oscillation of ionic
particles present in the tissue due to the effect
of eddy current generated by electromagnetic
induction. Cable method is also called
inductothermy.
Q. 14. Which tissues are best heated by cable
method of SWD?
A. Tissues with high ionic content like blood
or muscles are best heated.
Q. 15. What type of cable is used in cable
method of SWD?
A. Coaxial cable with a flexible conducting
core coated with a layer of heat resistant
rubber.
Q. 16. What is the optimum length of the
cable used in SWD? Why?
A. Since the wavelength of SWD is 11 meters
and resonance of such waves will be possible
in either 1/2 or 1/4 of the wavelength, the
optimum length of the inductothermy cable
should be 2.25 meters or multiples thereof.
Q. 17. When is pulsed SWD recommended?
A. Pulsed SWD is recommended when heat
component of the SWD is not desired but the
electromagnetic field is deemed to be beneficial for any condition like broken bones,
wounds and acute inflammation.
mission of energy from the transducer to the

body. This is essential, since air is a reflector
of ultrasound energy.
Q. 18. How is the dose of SWD calculated?

A. The dose of SWD is delivered based on the
feedback of the patient. Hence, it is mandatory that the patient must have intact
thermal sensation over the area being treated.
The patient should be able to guide the
therapist on the extent of heat being felt, based
on which the output of the equipment is
adjusted.
Q. 23. What effects does ultrasound energy

produce in the body tissue?
A. Mechanical effect, thermal effect and micro
streaming effect.
SECTION 2: ULTRASONIC THERAPY

Q. 19. What do you understand by therapeutic ultrasound?
A. Therapeutic ultrasound is sound energy
beyond the range of human hearing at the
frequency range of 0.8 to 3.8 MHz, applied to
the body tissue through a transducer.
Q. 20. What are the essential components of
ultrasound therapy machine?
A. Therapeutic ultrasound equipment consists of a high frequency current generator, a
transducer with a quartz piezoelectric crystal
and a coaxial cable that transmits the high frequency current from the generator to the
crystal.
Q. 21. What are coupling mediums?
A. Coupling mediums are liquid or gel with
minimum acoustic impedance that transmits
ultrasound energy from the transducer to the
skin, e.g. degassed water, glycerine, aqueous
gel, etc.
Q. 22. What is the role of coupling medium
in application of US therapy?
A. Coupling mediums eliminate air-space
between the faceplate of the ultrasound
transducer and the skin and allow trans-
Q. 24. What are the benefits of ultrasound

application?
A. a. The mechanical effect causes micro
massage at the tissue level. This helps
break down adhesions, soften scar
tissue and release soft tissue contractures.
b. The thermal effect raises tissue temperature that may help in resolution of
inflammation and reduce pain.
c. The micro-streaming effect promotes
protein synthesis at the cellular level
that is useful in the process of repair.
Q. 25. What are the different modes of US
application? How do they differ in character?
A. a. Therapeutic ultrasound can be applied
to the body in continuous or pulsed
mode.
b. In continuous mode the output of U.S.
energy is uninterrupted and has a large
thermal component.
c. If the continuous flow of ultrasound is
interrupted at specific intervals, the
thermal component is reduced significantly, though the other effects like
mechanical and micro streaming
remains intact. This is known as pulsed
U.S.
Q. 26. What is the relevance of mark-space
ratio?
A. Mark-space ratio is relevant to pulsed U.S.
It signifies the ratio between the duration in
milliseconds, of energy flow with the interval

between successive pulses of energy. Usual
mark space ratios used in therapeutic U.S. are
1:4, 1:8 or 1:16, the higher values indicating
lesser thermal content.
Q. 27. What are the dosing parameters of US
therapy?
A. Mode of Ultrasonic- pulsed mode gives
less power than continuous mode
Frequency of Ultrasonic- Lower the frequency of the US greater the penetration.
Intensity of US energy- measured as W/
cm2
Duration of exposure.
Frequency of repetition of treatment- in
acute, superficial lesions, low intensity at
high frequency, in a pulsed mode for a
short duration (<3 min) may be repeated
twice a day for very short duration. For
deep, chronic lesions- high intensity at low
frequency, in a continuous mode for a long
duration (>5 min) may be given on alternate days.
Q. 28. What do you understand by half value
distance of US?
A. The distance at which, from the point of
contact of the transducer on the skin, the value
of the sound energy reduces by half is known
as the half value distance.
Q. 29. What are the factors that determine
the absorption of US energy?
A. Absorption of the US energy depends on
the nature of protein and water content of the
target tissue, frequency and the wavelength
of the ultrasonic energy being used.
Q. 30. What do you understand by attenuation of ultrasound?
A. The loss of energy from the ultrasound
beam in the tissues due to absorption,
145
reflection and refraction is called attenuation.

The extent of energy loss due to absorption is
60%, due to refraction and reflection 25%.
Q. 31. What are the principal therapeutic
uses of ultrasonic therapy?
A. Healing of acute soft tissue injury, relief of
neurogenic and somatogenic pain, increase
pliability of soft tissue contractures and scars
and healing of chronic ulcers.
Q. 32. What are the different methods of
application of therapeutic ultrasound?
A. Therapeutic ultrasonic can be applied:
i. By direct contact method using coupling
gel
ii. In a bath of de-gassed water
iii. Through a water bag
iv. Through a solid sheet of coupling gel.
Q. 33. What are absolute contraindications
for application of ultrasonic therapy?
A. Absolute contraindications for application
of ultrasonic therapy are:
Tumours in precancerous stage or malignant.
Pregnant uterus
Testes and ovary
Acute infective focus like boils and
carbuncles
Tissues that bleeds easily
Over the eyes
Q. 34. What is phonophoresis?
A. Introduction of medicinal substances into
and through the skin using ultrasound energy.
Q. 35. What type of ultrasound energy is
suitable for phonophoresis?
A. Low intensity, low frequency ultrasound,
applied over longer durations (>8 min) is
most suited for phonophoresis.
SECTION 3: THERAPEUTIC
STIMULATING CURRENTS
Q. 36. What are the characteristics of therapeutic direct current?
A. It is a unidirectional flow of electrons
through the tissues that may be continuous
(Galvanic) or interrupted (I.G.) at preset pulse
duration, frequency and pulses intervals.
Q. 37. What are the biophysical properties of
continuous DC?
A. Continuous DC sets up convection current
in the tissues, causes electrolysis under the
electrodes, which can produce transcutaneous
penetration of therapeutically valuable ions
into and through the skin to the subcutaneous
circulation, by the force of ionic dissociation.
Q. 38. What are the physiological effects of
therapeutic DC?
A. Physiological effects of DC are:
Stimulation of sensory nerve ending in the
skin creating a tingling sensation.
Reflex vasodilatation of peripheral capillary network resulting in reddening of the
skin.
Increase sensitivity of peripheral nerve
ending.
Relief of pain by blocking of pain transmission.
Accelerate of tissue healing.
Introduction of drugs through the skinIontophoresis.
Q. 39. What are uses of Iontophoresis?
A. Iontophoresis can be used to introduce
selected drugs through transcutaneous rout
for:
Local anaesthesia by lignocaine/xylocaine
iontophoresis.
Treat hyperhydrosis by water iontophoresis.
Treat infections by copper sulphate iontophoresis.

Treat inflammation and pain by Methyl
salicilate and iodine iontophoresis.
Q. 40. What are the risk factors of iontophoresis?
A. Potential risk of:
Chemical burns.
Electric shock.
Skin irritation and allergic dermatitis.
Anaphylactic shock due to drug allergy.
Q. 41. What do you understand by an electric pulse?
A. An electrical pulse is an isolated electrical
incident, defined by a specific duration in
millisecond, intensity in milliamperes/volts
and rate of repetition/frequency in Hz.
Q. 42. What are the biophysical characteristics of a stimulating electrical pulse?
A. The bio-physical properties of any
stimulating electrical pulse depends on
Phase or direction of current flow- Monophasic or Biphasic.
Waveform or the shape of the pulse on a
cathode ray tube.
Frequency or rate of repetition in PPS or
Hz.
Ramping or progressive increase of intensity in each successive pulse, arriving in a
train of impulses.
Rate of rise and fall from zero to peak
intensity.
Q. 43. How do you classify therapeutic
currents on the basis of pulse frequency?
A. Therapeutic currents can be classified on
the basis of pulse frequency as:
Low frequency- 1 - 1000 Hz.
Medium frequency- 1000-10,000 Hz
High frequency 10, 000- 100, 000, 000 Hz.
Q. 44. How do you classify low frequency

stimulating currents?
A. Low frequency stimulating currents are
classified on the basis of pulse duration as:
Long duration currents- those with pulse
duration > 1 m.sec, includes all types of
muscle stimulating currents, such as
rectangular, square, trapezoidal, triangular
and trapezoidal pulses.
Short duration currents- those with pulse
duration < 1 m.sec, , includes all types of
nerve stimulating currents, such as faradic
current, TENS, HVPGS, etc.
Q. 45. What is the mechanism of action of
low frequency stimulating currents?
A. A single electrical impulse with appropriate pulse duration, strength and shape
triggers an action potential in a nerve. This
action potential spreads through out the nerve
membrane to trigger momentary depolarisation of the nerve. In a motor nerve, this
depolarisation spreads to the muscle, causing
a muscle twitch and in a sensory nerve it
creates a sensory impulse that is carried to the
sensory receptors in the brain as a tingeing
sensation.
Q. 46. What are the requisite parameters to
produce a response with a stimulating
current?
A. To produce a perceptible response in a
nerve or muscle, the stimulating current must
have:
Sufficient intensity, which must be equal
to the rheobase value for long duration
pulses and more than the rheobase value
for short duration pulses.
Adequate rate of rise and fall from zero to
peak intensity and back.
147
Q. 47. What is the expected response to a

series of stimulating current impulses
applied to the skin?
A. The reaction to such stimulation would be:
Stimulation of sensory nerve ending
causing a tingling sensation at liminal
intensity and pain at higher intensity.
Stimulation of motor nerves causing titanic
muscle contraction.
Q. 48. What are the expected responses to
low frequency stimulation at commonly
used rates of repetitions?
A. Responses to low frequency stimulation at
different rates of repetitions commonly used
are:
1Hz- Twitch muscle contraction along with
sharp shock.
10 Hz- Fast twitches of muscles along with
tapping sensation.
30 Hz Rapid twitch contraction of
muscles along with tingling sensation.
100 Hz- Tetanic contractions of muscles
along with strong tingling sensation.
> 100 Hz- Used as TENS for pain modulation.
Q. 49. What are the therapeutic effects and
uses of low frequency stimulation?
A. Therapeutic low frequency stimulation are
used for:
Strengthening of healthy muscles, even
when immobilised.
Preventing atrophy in denervated or
immobilised muscles and retaining functional capability of muscles at risk of
disuse, through enhanced vascular turnover and metabolic activity. Other tissues
in the vicinity are also benefited by
increased drainage and supply of body
fluids.
Building up or retaining voluntary muscle

control.
Maintaining or increasing muscle joint
range of motion.
As a functional aid, promoting voluntary
muscle action, control hyper or hypo tonus
and splint the limbs in functional position
during activities of daily living.
Q. 50. What are the mechanisms of action of
electric charge, in producing therapeutic
effects in the body?
A. Therapeutic effects produced by application of electrical charge to the body are due
to:
Direct current causes chemical changes,
used in phonophoresis.
Low frequency currents cause stimulation
of excitable tissues
High frequency currents cause heating
Low intensity D.C. and different types of
pulsed currents can stimulate repair and
growth in tissues.
Placebo effect
Q. 51. What are the primary considerations

for application of therapeutic electricity?
A. Following issues should be addressed
satisfactorily for selection of any electrotherapy modality:
The effect desired i.e. pain relief, tissue
healing or restoration of motor function.
Modalities must be selected on the basis
of the effect desired.
The extent of safety involved. All modalities have potential hazards.
The cost involved. The selection modality
should be such that it achieves results in
the shortest possible time.
Q. 52. What are the primary mechanisms of
pain modulation by TENS?
A. Pain modulation by TENS is achieved by:
Activation of the spinal gate through
sensory nerve stimulation
Release of indigenous opiates like Bendorphins, through stimulation of the
nociceptors.
Index
A
Absolute refractory phase 6

Actinotherapy 131
physics of 132
Action potential 5
propagation of 6,7
Electrical energy 11
Electrical field 2
behaviour of 2
Electrical impulses, types of 16
Electrical safety 10
Electrical stimulation 20,24, 36
Electrical stimulators 30-36
electrical muscle 30
functional electrical 30
high voltage galvanic 30
interferential therapy unit 30
neuromuscular stimulator 30
TENS 30
Electrical stimulus 16-19
nature of 16
strength duration curve 18
Electrophysiology 2
Electrotherapy unit, equipment
safety in 11
Electrotherapy, safe application
procedure of 12
Endorphin release theory, TENS
50
B
Bioelectrical drama, significance
of 8
Bioelectricity 2
C
Combination therapy 113-115
biophysics of 113
contraindications for 115
important considerations 113
technique of application of 114
treatment protocol of 115
Conduction 6
antidromic 6
local circuit 7
orthodromic 6
Coupling mediums 100
Cryotherapy 119-129
application of therapeutic
cold 129
biophysics of 119
cryo-kinetics 125
exercise-specific guidelines 126
physiological effects of 120
techniques of 121
commercial cold packs 122
contrast bath 123
coolant spray 123
ice massage 122
ice packs 121
ice towels 122
techniques of local cooling 128
D
Deep thermotherapy 142
Depolarisation 6
F
Fluorescence, phenominon 133
Functional electrical stimulation
58-61
application in 59-61
foot drop 61
hemiplegics shoulder 59
idiopathic scoliosis 60
effects and uses of 58
instrumentation of 59
parameters of current 58
G
Gate control theory, TENS 50
H
Heliotherapy 130
High frequency currents 21

production of 86
subtypes of 21
High voltage pulsed galvanic
stimulation 57
application of 58
effects and uses of 58
parameters of current 57
Hyperpolarisation, phase of 6
I
IFT therapy 67-69
advanced interferential
equipment 68
clinical application of 68
clover leaf pattern in 71
electrodes for application
of 72
isoplaner vector field
application 71
treatment parameters to 69
treatment techniques to 70
Inverse square law, radiation 83
Iontophoresis 61-64
application in 63
hyperhydrosis 63
local anaesthesia 63
local inflammation 63
biophysics of 62
contraindications of 64
dosimetry of 62
electrodes for 63
indications for 62
ionising agents 63
ions commonly used in 64
technique of application 64
L
Lamberts cosine law, radiation 83
Low frequency currents 18
production of 21
subtypes of 19
150
M
Medium frequency current 20,
65-73
burst mode TENS 20
conventional TENS 20
current forms used in 21
interferential current 20, 65, 66
clinical applications of 73
clover leaf pattern 71
therapeutic effects of 67
two pole medium
frequency current 72
types of 71
medium frequency surge
current 65,66
Russian current 65
selectively TENS 20
types of 65
Microwave diathermy 92-96
biophysics of 92
indications for 96
Modern low frequency electrical
stimulators 30-47
clinical applications of 37
diagnostic electrical
stimulator 31
diagnostic stimulator 30
electrode placement 35
machine preparations 32
patient preparations 33
rectal electrode 35
selection and preparation,
electrodes 33
special type of electrodes 35
specialised techniques used in
44
faradic footbath 44
faradism under pressure 46
faradism under tension 47
techniques in, clinical
conditions 37
in Bells palsy 38
in crutch palsy 41
in Erbs/klumpkes palsy
41
in fibromyositis of
trapezius muscle 40
in foot drop/flail foot 43

in wryneck 39
therapeutic model 30
vaginal electrode 35
Motor point 23
Motor unit 17
N
Nernst potential 5
Nerve conduction velocity 9
Neuromuscular electrical
stimulation 24
R
Red light therapy 136
biophysics of 136
methods of application of 137
types of 137
Relative refraction, phase of 6
Resting membrane potential 3,4
S
Short-wave diathermy 85-92
application of treatment with
91
biophysics of 85,87
cable method 91
condenser field method 90
contraindications of 89
disc electrodes used in 90
electrode placement 90
indications for 89
method of application 85, 86,
89
technique, specific disease
conditions 92
therapeutic benefits of 88
Static electricity 2
Stimulating current 19, 21
faradic type of current 20
interrupted galvanic current 19
iontophoresis 20
low frequency current forms 19
modulation of 22
production of low frequency 21
production using multivibrator circuit 22
wave patterns of 22
pure faradic current 20
transcutaneous electrical
nerve stimulation 20
Superficial heat therapy 76-84
comparative profile of 84
indications for 77
physiological effect of 77
preparation of patient 78
transmission of 76
types of 79
Hubbards tank 81
hydrotherapy 79
moist hot packshydrocollator 79
paraffin wax bath 82
radiant heatinfrared rays
83
steam bath or sauna 82
whirlpool bath 80
T
Therapeutic current 18
types of 18
Therapeutic heat 76
Therapeutic lasers 138
different types of 139
hazards of 139
procedures and equipment of
141
Therapeutic light 132
types of 132
Therapeutic stimulating currents
146
Therapeutic ultrasound 99-111
biophysics of 99
digital ultrasonic machine 104
dosimetry of 116
indications for 102
phonophoresis 110
phonophoretic agents 111
direct contact method 105
water bag method 106
water bath method 109
ultrasonic transducers 99
Index
Transcutaneous electrical nerve
stimulation 26,50-56
applications in common
disorders 56
current forms used in 20
different types of 51
electrode placement in 53
equipment and the nature of
current 50
general rules, placements of
electrodes for 54
mechanism of action of 27
modulation of 52
parameters for optimal
stimulation of 53
physiological effect of 50
precautions for home
prescription 53
waveforms of 52
when not to use 28
U
Ultrasonic therapy, application
of 106-112, 144
calcaneal spur 112
carpal tunnel ventral aspect
108
clavicular fossa for brachial
neuralgia 110
extensor policis brevis 108
extensor policis longus 108
fibromyositic nodule in
rhomboids muscle 111
hydrocortisone phonophoresis therapy, ankle 112
iodex phonophoresis therapy,
popliteal bursa 112
lateral collateral ligament,
ankle 111
lateral epicondyle 108
lidocaine phonophoresis
therapy 112
151
medial collateral ligament,

knee 110
over the medial epicondyle 106
palmar fascia for Dupuytrens
contracture 107
sternocostal joint for costochondritis 107
subacromial bursa 107
supraspinatus tendon 107
temporomandibular joint 107
tendon of abductor policis
longus 108
Ultrasound energy, wave
patterns of 98
Ultraviolet radiation therapy
132-135
biophysics of 133
dosimetry of UVR 135
erythema reaction 135
sensitivity to 134
ultraviolet, applications of 135

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Pushpal Kumar Mitra