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Physiotherapy 97 (2011) 319326

Penetration and spread of interferential current in cutaneous,


subcutaneous and muscle tissues
Abulkhair Beatti a , Anton Rayner b , Lucy Chipchase a, , Tina Souvlis a,c
a Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland 4072, Australia
b School of Mathematics and Physics, The University of Queensland, Brisbane, Queensland 4072, Australia
c Allied Health Clinical Education and Training Unit, Queensland Health, Brisbane, Queensland 4000, Australia

Abstract
Objectives To investigate the penetration depth of interferential current (IFC) through soft tissue and the area over which it spreads during
clinical application.
Design A laboratory-based study of healthy participants.
Setting A university research laboratory.
Participants Twelve healthy subjects.
Interventions Premodulated IFC at 90 Hz and true IFC at frequencies of 4, 40 and 90 Hz were applied via four electrodes, in a quadrant
setting, to the distal medial thigh of each participant on separate occasions.
Main outcome measure Voltage induced by tested currents was measured at three locations (middle of the four electrodes, in line with one
circuit and outside the four electrodes) and three depths (skin, subcutaneous and muscle tissues) using three Teflon-coated needle electrodes
connected to a Cambridge Electronic Design data acquisition system.
Results All voltages were greater at all depths and locations compared with baseline (P < 0.001): premodulated IFC [mean difference 0.112,
95% confidence interval (CI) 0.065 to 0.160], 4 Hz (mean difference 0.168, 95% CI 0.106 to 0.229), 40 Hz (mean difference 0.165, 95% CI
0.107 to 0.223) and 90 Hz (mean difference 0.162, 95% CI 0.102 to 0.221). Voltages decreased with depth. Lower voltages of all currents
were recorded in the middle of the four electrodes, with the highest voltage for true IFC being recorded outside the four electrodes (mean
difference 0.04, 95% CI 0.01 to 0.029; P = 0.011). The premodulated IFC had the highest voltage in line with one circuit.
Conclusions IFC passed through soft tissues, with the highest voltages recorded in superficial tissue and the lowest voltages recorded in
muscle. For true IFC, the current spread outside the electrodes at higher voltages compared with the intersection of the four electrodes. The
premodulated IFC had the highest voltage in line with one circuit. In terms of higher recorded voltages, true IFCs were more efficient than
the premodulated IFC when targeting deeper tissues. However, further studies with larger samples are required to confirm the results of this
study.
Crown Copyright 2011 Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. All rights reserved.

Keywords: Interferential therapy; Interferential current; Current depth penetration; Current spread

Introduction a low frequency beat effect in the tissue thought to be capable


of producing similar physiological effects to low frequency
Interferential current (IFC) was introduced in the 1950s currents with less discomfort [2,3]. The use of two currents at
by Nemec, an Austrian physicist [1], as a means of applying around 4 kHz was claimed to overcome skin impedance and
electrical stimulation for the management of musculoskeletal permit current penetration into the deeper tissues [3,4].
conditions. The underlying premise of IFC was the use of two Currently, two types of IFC are available: true IFC and
medium frequency circuits (e.g. 4000 and 4100 Hz) creating premodulated IFC. True IFC is produced when four elec-
trodes are used; two medium frequency alternating currents
Corresponding author. Tel.: +61 7 3365 4507; fax: +61 7 3365 1622. are applied to the skin surface through two isolated circuits
E-mail address: l.chipchase@uq.edu.au (L. Chipchase). with the currents purportedly interfering inside the tissue.

0031-9406/$ see front matter. Crown Copyright 2011 Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. All rights reserved.
doi:10.1016/j.physio.2011.01.008
320 A. Beatti et al. / Physiotherapy 97 (2011) 319326

In premodulated IFC, the interference of the two medium Methods and materials
frequency currents takes place in the machine, and the resul-
tant wave (an amplitude-modulated current) is transmitted Subject details
to the tissue through a single pair of electrodes [2]. Some
researchers argue that true IFC is more comfortable than Twelve (10 men, two women) healthy university students
premodulated IFC and produces deeper effects with less sen- and employees volunteered to participate in this study. Their
sory stimulation [3,5,6]. Others believe that premodulated mean age was 31.7 [standard deviation (SD) 5.4] years and
IFC is more easily applied, safer, more effective and more mean body mass index was 25.89 (SD 3.71) kg/m2 . Since
comfortable than true IFC [2,7,8]. no data were available in the literature, data obtained from
Since its introduction, IFC has been used in clinical the first four subjects were used to determine the sample
practice for reducing pain and other symptoms following size, which estimated that a minimum of 10 subjects was
musculoskeletal injury [9,10]. Despite its clinical popularity required. This sample size calculation was based on the
[1113], there have been limited studies assessing its efficacy mean difference between voltages induced by 90 Hz and
[14]. In fact, there is still controversy surrounding the depth baseline voltages (1 2 ) and their common SD(s) with
efficiency and whether voltages can be induced in deep tis- a significance level of 0.05 and a confidence level 1 of
sues by IFC [15,16]. Indeed, some authors believe that IFC 95%. Potential participants were excluded if they had any
is prevented from reaching deep tissues by the impedance of contraindications or precautions to the use of electrical stim-
the skin and subcutaneous tissues [15,17]. ulation, such as broken skin, circulation insufficiency and
Only one published study to date has evaluated the dis- sensory loss of tested area [25].
persion of IFC through superficial and deep tissues [18].
Petrofsky et al. [18] measured the voltage from the quadriceps
muscle of healthy subjects via surface and needle electrodes Procedure
placed between the IFC electrodes. The strongest signal was
found to be in the skin (2 to 5 V), with less energy recorded Once the subjects had consented to participate and were
in deeper muscles. However, the results of this study were fully informed of the invasive procedure of the experiment,
limited by the use of an amplifier with a cut-off frequency they were positioned in a comfortable sitting position with
of 500 Hz. Therefore, the amplifier would not have recorded their left thigh exposed. The skin overlying the vastus medi-
signals from the 4000-Hz carrier frequency used [19]. This alis muscle and the anterior aspect of the left leg was cleaned
suggests that the data were likely to be confounded by noise. with an alcohol swab.
Similarly, the spread of IFC when it penetrates deeper tis-
sues has not been well investigated. Generally, it is assumed
that IFC produces stimulation within the borders of the four Interferential application
electrodes [1,17,20]. It is also believed that maximum stimu-
lation takes place deep at the intersection of the two pairs of An IFC unit (Vectorsurge 5 Interferential/TNS Therapy
electrodes in the case of true IFC, and superficially, close Unit, Model VS 470, Metron Medical, Victoria, Australia)
to the electrodes, in the case of premodulated IFC [5,6,21]. was used to deliver the current to the medial quadriceps area.
Only one previous study has tested the maximum and mini- The machine produces a modulated rectangular waveform,
mum stimulation of true IFC [22]. Treffene [22] tested the with 50% duty cycle and selectable carrier frequency of 2.5,
IFC spread in a homogenous water medium. Minimum stim- 4 or 10 kHz and a beat frequency range of 0 to 300 Hz. Unlike
ulation occurred at the intersection of the two circuits (90 the sine wave where parts of the stimulation will be below
angle), and maximum stimulation occurred along the diago- the threshold and parts will be above it, the rectangular wave
nals (45 angle) between the two circuits [22]. Whether IFC will either fully stimulate or not stimulate the tissue [17].
behaves in the same way in human tissues has not been elu- Therefore, the rectangular waveform is claimed to be stan-
cidated. This is important as biological tissue, unlike water, dard delivery mode of electrical stimulation [26,27] while
is a heterogeneous medium [2] and offers uneven resistance preserving the essential features of Nemecs original design
to electric current [23]. Thus, when IFC is applied to biolog- [2]. Also, it is considered to be the best waveform for stim-
ical tissue, the heterogeneity, nerve fibre orientation under ulating nerves, since the stimulation threshold rises quickly
the electrodes and impedance characteristics of the biologi- [21], and is common in clinical practice as these types of
cal tissue could result in a complex and completely different generators are cheap to manufacture [28].
pattern of current flow than that in a water medium [2,17,24]. Four pre-wired adhesive square electrodes (BioStim,
In summary, the penetration depth and spread of IFC Biomedical Life Systems, California, USA), 4.5-cm wide,
through the skin and subcutaneous tissues has not been fully were attached to the skin of the left vastus medialis muscle
investigated. Therefore, this study aimed to investigate the equidistant from the mid anatomical point of the muscle,
penetration of IFC through different tissue depths, the dis- based on individual surface anatomy landmarks [29]. The
tribution of current over the area of application and the distance between each pair of electrodes was approximately
maximum stimulation region of IFC. 5 cm.
A. Beatti et al. / Physiotherapy 97 (2011) 319326 321

insertion for clinical and experimental purposes, to ensure


that the principal investigator was consistently able to detect
different soft tissue layers.

Testing process

Voltages from individual IFCs were measured at three


depths, in three locations, sequentially. At each depth, a base-
line reading was taken while the IF machine was switched on
but with no output signal. The current was then switched on
and increased to achieve a strong but comfortable sensa-
tion without motor stimulation [33,34] and maintained for
30 seconds, as this intensity is commonly used in clinical
practice for pain management [35].
Measurements of the voltage in the tissues from the IFC,
delivered with different frequencies, were taken. The stimu-
Fig. 1. Recording, ground and interferential current (IFC) electrode attach-
ment. IFC electrodes were placed in a quadrant with distance between lation intensity was switched off after each individual current
adjacent electrodes of approximately 5 cm. Recording electrodes were situ- frequency measurement for 2 minutes, including between
ated in different locations relative to the IFC electrodes: (A) in the middle true IFC and premodulated IFC, to avoid recording any
of the IFC electrodes, (B) in line with one circuit close to the electrode, and possible calcium-based action potentials from the previous
(C) outside of the four electrodes (5 cm proximal to the electrode border).
stimulation [36].
Ground electrodes were attached to the anterior aspect of the left leg via a
universal electrode pad. In addition to the premodulated IFC at 90 Hz, three true
IFC frequencies were tested: high, medium and low beat fre-
quencies (90, 40 and 4 Hz) at 4-kHz carrier frequency. These
Voltage recording
beat frequencies cover the proposed effects of IFC via dif-
ferent suggested mechanisms, such as stimulation of the pain
Three Teflon-coated disposable monopolar needle elec-
gate mechanism, sedation and muscle relaxing action and
trodes (25 0.4 mm, Medtronic, Minneapolis, MN, USA)
activation of the opioid mechanisms [37,38]. To avoid any
were used to measure the voltage in the tissues during each
possible contamination from the mains current and the sur-
application of IFC. The needles were insulated and the tips
rounding equipment, IFC frequencies of 50 and 100 Hz were
were exposed by 1 mm to ensure that the voltage reading
not tested in this study.
was taken from the tissue of interest [3032]. The nee-
At the end of the procedure, the IF machine was switched
dles were connected to a filter unit of a CED Power 1401
off, the needles and electrodes were removed, and the skin
[Cambridge Electronic Design (CED) data acquisition sys-
was cleaned with alcohol swabs then dried with gauze.
tem, Cambridge, UK], and the filter was connected to the
analogue-to-digital converter unit of the CED system. The
Data acquisition
wire connecting the needle to the filter of the CED system
had two branches; one branch was connected to the needle
The signals were analogue-to-digital converted at a sam-
and the other was clipped to the ground electrode attached to
pling frequency of 10 kHz with 5 V ranges using a Version
the anterior aspect of the left leg (Fig. 1).
6.2, CED 1401 analogue-to-digital converter and Spike2 data
The skin overlying the vastus medialis muscle was
collection software (Cambridge Electronic Design, Cam-
swabbed with an antiseptic skin preparation with chlorhex-
bridge, UK). CED and Spike software are reliable tools to
idine (BD Persist Plus, Franklin Lakes, NJ, USA), and three
record electrophysiological signals [39,40].
needles were inserted (Fig. 1):
Prior to signal acquisition, a 50-Hz notch filter was used to
(A) at the junction of the two current channels (between four avoid interference of any of the surrounding equipment by the
electrodes); mains current. The signals obtained at different depths and
(B) in line with one channel, close to the electrode; and locations were filtered with a pass band of 20 to 50,000 Hz.
(C) 5 cm from the borders of the four electrodes outside the The signals were digitised and transferred to Spike2 labora-
hypothesised distribution area of the IFC [17,20]. tory software for display and storage.

Measurements were taken from the superficial layer of Analysis of raw data
the skin, the subcutaneous layer and the muscle tissue. Inser-
tion of the needles into the three different tissue levels was An in-house Matlab program (The Mathworks, Version
performed using different tissue firmness as a guide. This R2008b, Natick, MA, USA) was used to determine the peak-
was practised with diagnostic ultrasound guidance under the to-peak amplitude of obtained signals to represent the voltage
supervision of TS, who has extensive experience in needle recorded from currents applied at each depth and location
322 A. Beatti et al. / Physiotherapy 97 (2011) 319326

Fig. 2. Matlab interpreting sample. The X-axis shows the sampling frequency and the Y-axis represents the voltage measured (peak-to-peak amplitude). Upper
and lower asterisks on signals represent the maximum and minimum amplitudes of the signal.

[41]. The program applied a maximising/minimising kernel Results


to the raw signal. This effectively placed an envelope around
the extremities of the signal (Fig. 2). The amplitude (maxi- The data obtained from this study (Table 1) were analysed
mum minimum) was calculated and reported as the mean in four sections. First, the baseline voltages recorded at all
and SD. depths and locations were analysed. Voltage readings taken
from all volunteers were grouped according to depths and
locations, and averaged to serve as references for voltages
recorded from tested currents at the same depths and loca-
Data analysis
tions. Second, the transmissions from all tested IFCs at all
depths were analysed. Third, the transmissions of all tested
Data were entered into Statistical Package for the Social
IFCs at all locations were analysed. Fourth, the behaviours of
Sciences GradPack 17 (SPSS Inc., Chicago, IL, USA). Statis-
different tested IFC frequencies (premodulated IFC of 90 Hz
tical analyses were performed to determine the distribution of
and true IFC of 90, 40 and 4 Hz) were analysed with respect
IFC at all depths and locations using the general linear model
to the voltages recorded at all depths and in all locations. Fig. 3
repeated measures analysis of variance followed by pairwise
summarises the average voltage measurements at all depths
comparison tests with P 0.05.
and locations, as well as the behaviours of the different IFC
Prior to data analysis, a descriptive normality test was
frequencies in the tested tissues.
conducted to check the distribution of the data [42]. The
histogram showed a non-normal distribution of data which
appeared as a strong positive skew (1.701) of the distri-
bution curve. To solve non-normality in the distribution
of the data and to limit the influence of outliers [42], a
BoxCox transformation [43] was run prior to data analy-
ses. BoxCox transformation has sufficient power to detect
linkages between variables, and reduces the likelihood of
rejecting a type I error with no inflation [44]. After BoxCox
transformation of the data, the skewness was resolved (close
to zero), indicating an approximately normal distribution.
The voltage was determined as the difference in voltage
at all depths and locations compared with the baseline volt-
Fig. 3. Average voltage measurements for all subjects recorded from all
age readings from the same position. Descriptive statistics of depths and locations; taken before switching on the interferential current
raw data are presented as medians and interquartile ranges. (IFC) (baseline) and at different frequencies (premodulated IFC at 90 Hz
Averages of recorded voltages are presented from the raw and true IFC at 4, 40 and 90 Hz). The Y-axis shows the average recorded
data to reflect the tested IFC beat frequency behaviour at voltages and the X-axis shows the depths and locations at which the voltages
all depths and locations. Statistical analysis was undertaken were recorded. Electrode 1, recording electrode positioned in the middle of
the four IFC electrodes; Electrode 2, recording electrode positioned in line
on the transformed data (BoxCox transformed). Multiple with one circuit of IFC; Electrode 3, recording electrode positioned outside
data comparisons were adjusted with Bonferronis correction the borders of the four IFC electrodes; depth 1, skin; depth 2, subcutaneous
factor. tissue; depth 3, muscle.
A. Beatti et al. / Physiotherapy 97 (2011) 319326 323

Table 1
Raw recorded voltages (V) from different interferential currents compared with baseline voltages at all depths and locations. Data are expressed as medians
and interquartile ranges.
Location Current

Baseline Premodulated 4 Hz 40 Hz 90 Hz
Middle of the four electrodes
Skin 0.03 (0.02 to 0.04) 0.09 (0.06 to 0.16) 0.18 (0.13 to 0.50) 0.17 (0.11 to 0.47) 0.16 (0.11 to 0.42)
Subcutaneous 0.03 (0.02 to 0.04) 0.10 (0.04 to 0.15) 0.20 (0.12 to 0.57) 0.17 (0.13 to 0.45) 0.16 (0.12 to 0.43)
Muscle 0.03 (0.02 to 0.03) 0.11 (0.05 to 0.14) 0.19 (0.12 to 0.45) 0.17 (0.10 to 0.37) 0.17 (0.11 to 0.39)
In line with one circuit
Skin 0.03 (0.02 to 0.04) 0.23 (0.08 to 0.57) 0.47 (0.25 to 1.00) 0.46 (0.22 to 0.97) 0.42 (0.22 to 0.83)
Subcutaneous 0.03 (0.02 to 0.04) 0.17 (0.07 to 0.51) 0.33 (0.17 to 0.92) 0.40 (0.17 to 0.74) 0.36 (0.16 to 0.79)
Muscle 0.03 (0.02 to 0.04) 0.14 (0.12 to 0.36) 0.27 (0.15 to 0.70) 0.23 (0.12 to 0.59) 0.25 (0.12 to 0.63)
Outside the four electrodes
Skin 0.03 (0.02 to 0.04) 0.20 (0.09 to 0.30) 0.32 (0.28 to 1.00) 0.32 (0.23 to 0.99) 0.30 (0.24 to 0.98)
Subcutaneous 0.03 (0.02 to 0.03) 0.16 (0.09 to 0.27) 0.27 (0.24 to 1.00) 0.28 (0.21 to 0.86) 0.24 (0.19 to 0.84)
Muscle 0.03 (0.02 to 0.04) 0.14 (0.06 to 0.22) 0.27 (0.22 to 1.18) 0.23 (0.19 to 0.91) 0.24 (0.19 to 0.87)

Depths voltages (Fig. 3). With the exception of premodulated IFC,


the highest voltages were recorded from the outside nee-
Voltages from all tested currents were recorded at all dle and the lowest voltages were recorded from the middle
depths and were statistically greater than the baseline volt- needle (Fig. 5). This difference was statistically significant
ages (P < 0.001); premodulated IFC [mean difference 0.112, between the middle and in-line needles (mean difference
95% confidence interval (CI) 0.065 to 0.160], 4 Hz (mean
difference 0.168, 95% CI 0.106 to 0.229), 40 Hz (mean dif-
ference 0.165, 95% CI 0.107 to 0.223) and 90 Hz (mean
difference 0.162, 95% CI 0.102 to 0.221) (Fig. 3). The magni-
tude of effect between baseline voltages and voltages induced
by IFCs was large, with effect sizes (Cohens d) ranging
between 1.26 and 2.01. Reliability testing of needle place-
ment and measurement was studied on recordings taken
from the middle needle using Cronbachs alpha test. This
revealed adequate agreement: recording from skin (single
measures 0.876, 95% CI 0.747 to 0.956, P < 0.001; average
measures 0.972, 95% CI 0.937 to 0.991, P < 0.001), record-
ing from subcutaneous tissue (single measures 0.859, 95% CI
0.718 to 0.950, P < 0.001; average measures 0.968, 95% CI Fig. 4. Comparison of average recorded voltages at different depths, repre-
0.927 to 0.990, P < 0.001), and recording from muscle (single sented by recording from the middle needle. Highest voltages were recorded
measures 0.869, 95% CI 0.728 to 0.957, P < 0.001; average from the skin and lowest voltages were recorded from the muscle; the dif-
measures 0.971, 95% CI 0.930 to 0.991, P < 0.001). ference between them was not statistically significant (Bonferroni-adjusted
pairwise comparisons: skin and subcutaneous P = 0.606, skin and muscle
Recorded voltages from all tested frequencies decreased P = 1, subcutaneous and muscle P = 0.45).
as the current penetrated deeper tissue (Fig. 4). The highest
voltages for all frequencies were recorded in the skin and the
lowest voltages were recorded in the muscle (Fig. 4). This
difference was not statistically significant when all depths
were compared: skin and subcutaneous tissue (mean differ-
ence 0.009, 95% CI 0.011 to 0.029, P = 0.606), skin and
muscle (mean difference 0.004, 95% CI 0.014 to 0.021,
P = 1), and subcutaneous tissue and muscle (mean difference
0.006, 95% CI 0.005 to 0.017, P = 0.45). When recorded
from the middle and outside of the electrodes, the highest
voltages for the premodulated IFC were recorded in the sub-
cutaneous tissue instead of the skin, and the lowest voltages Fig. 5. Comparison of recording locations, represented by average voltage
were recorded in the muscle (Fig. 4). recorded from muscle tissue, showed the highest voltage to be recorded
from the outside needle and the lowest voltage to be recorded from the
Locations middle needle. Bonferroni-adjusted pairwise comparisons showed statistical
significance between the middle and in-line needles (P = 0.025), and middle
Voltages from all tested currents were recorded at all and outside needles (P = 0.011), but not between the in-line and outside
locations and were greater than the corresponding baseline needles (P = 0.1).
324 A. Beatti et al. / Physiotherapy 97 (2011) 319326

tissue (muscle). The present results are also consistent with


the findings of Petrofsky et al. [18] that established the ability
of IFC to penetrate deeper tissues, despite the limitations of
that study.
The second major finding of this study was the spread of
IFC outside the borders of the four electrodes. To the authors
knowledge, this is the first study to report the spread of IFC
in human subjects. Generally, it is believed that IFC produces
stimulation within the borders of the four electrodes, with the
greatest stimulation occurring at the intersection of the two
Fig. 6. Comparison between average voltages from tested currents at all pairs of electrodes [1]. However, in this study, the outside
depths and locations, represented by recording from the middle needle. The recording electrode was situated 5 cm away from the elec-
highest voltage was recorded from the 4-Hz current and the lowest volt- trode borders, yet it recorded voltages from all applied current
age was recorded from the premodulated interferential current (IFC). The frequencies. This suggests that IFC stimulation extends out-
difference between premodulated IFC and true IFC was statistically sig-
side the four electrodes much more than originally believed
nificant [Bonferroni-adjusted pairwise comparisons: 4 Hz (P = 0.001), 40 Hz
(P = 0.002) and 90 Hz (P = 0.004)]. No statistical significance was found [17,20]. This finding raises the possibility of IFC affecting tis-
between true IFC of 4 Hz and 40 Hz (P = 1), and 4 Hz and 90 Hz (P = 0.507) sues outside the electrode borders that may not be intended to
[Bonferroni-adjusted pairwise comparisons], and significance was marginal be treated. Therefore, further investigation into the maximum
between 40 Hz and 90 Hz (P = 0.047). spread distance of IFC is required.
The third finding of this study was that the lowest volt-
0.043, 95% CI 0.006 to 0.018, P = 0.025), and the middle ages of true IFC were recorded from the middle of the four
and outside needles (mean difference 0.04, 95% CI 0.01 to electrodes, and the highest voltages were recorded from the
0.029, P = 0.011), but not between the in-line and outside outside location at all depths. These findings contradict the
needles (mean difference 0.004, 95% CI 0.025 to 0.033, widespread belief that maximum stimulation of true IFC
P = 0.1). The highest voltages for the premodulated IFC were takes place in and close to the intersection point of the four
recorded from the in-line needle, and the lowest voltages electrodes [5,6,45]. These results support the findings of Tre-
were recorded from the middle needle, similar to the true ffene [22], who found that the smallest beating modulation
IFC (Fig. 5). occurred at the intersection of the two circuits (90 angle)
with the highest stimulation at the diagonal paths (45 angle)
Currents between the two circuits. However, in the present study, the
outside needle was placed in a diagonal path (45 angle)
All tested frequencies were able to pass through different between the two circuits but outside the borders of the elec-
tested layers and reach the muscle tissue (Fig. 3). The volt- trodes. As voltage strength along the diagonal path within the
ages obtained from true IFC were greater than that of the electrodes was not examined, it is unclear if the same amount
premodulated IFC at all depths and locations (Fig. 6), and this of voltage was outside the electrodes. For efficient stimula-
difference was statistically significant: 4 Hz (mean difference tion, the present findings suggest that the area for treatment
0.055, 95% CI 0.025 to 0.086, P = 0.001), 40 Hz (mean dif- should be located on a diagonal path (approximately 45
ference 0.053, 95% CI 0.02 to 0.086, P = 0.002) and 90 Hz angle) between the IFC circuits, outside the electrode bor-
(mean difference 0.049, 95% CI 0.016 to 0.083, P = 0.004). der, when arranged to cross at right angles. In the case of
The 4-Hz current induced the largest voltage in all tissues premodulated IFC, the maximum beating modulation was
and locations compared with the other frequencies (Fig. 6). found to be in line with the circuit close to the electrode. This
However, no statistical difference was found between 4 Hz result is in agreement with previous reports which found that
and 40 Hz (mean difference 0.002, 95% CI 0.007 to 0.012, maximum stimulation takes place superficially, close to the
P = 1), and 4 Hz and 90 Hz (mean difference 0.006, 95% CI electrodes [6,21].
0.004 to 0.016, P = 0.507), and marginal significance was A decreasing trend for voltage was identified in this study,
found between 40 Hz and 90 Hz (mean difference 0.004, 95% with the current moving from the superficial to deeper layers;
CI 0.000043 to 0.007, P = 0.047). this trend was more obvious between the skin and muscle tis-
sue. This trend contradicts theoretical claims that maximum
stimulation takes place at depth [6,21]. This means that the
Discussion skin and subcutaneous layers prevent a small proportion of the
current from entering deeper tissue. This finding supports the
This study confirmed the ability of both premodulated IFC results of Petrofsky et al. [18], who reported maximum stim-
and true IFC to penetrate the skin and subcutaneous tissues, ulation in the skin and minimum stimulation in muscle tissue.
and reach targeted deeper tissue (muscle). This supports the Clinically, the difference between the baseline voltage
original claim by Nemec [1] that a medium frequency cur- and induced voltages at different depths indicated sufficient
rent is able to overcome skin resistance to stimulate deep voltage (approximately 0.57 V) to stimulate excitable tissue,
A. Beatti et al. / Physiotherapy 97 (2011) 319326 325

as it is known that 15 mV is needed to depolarise peripheral despite training in depth location with ultrasound guidance,
nerves to fire an action potential [46]. This was supported there may have been variations in needle placement due to
statistically with large effect sizes. In addition, the similarity individual anatomical differences. This may have played a
of induced voltages at different depths indicated that the skin role in the differences between subjects. However, testretest
and superficial tissues play very little role in dissipating IFC reliability indicated adequate agreement. Finally, the time
energy during application. between testing each frequency may not have been exactly
At all depths and locations, the voltages recorded from the same between subjects, and this may have affected the
true IFC were higher than the voltages of the premodulated results due to the potential for a carryover effect from the fre-
IFC. These findings are consistent with previous claims of quency tested previously. Little is known about the potential
the superiority of true IFC over premodulated IFC in terms carryover effect of IFC, so this requires further investigation
of depth efficiency of stimulation [21,47,48]. These find- in future studies.
ings raise the question of whether the stimulation efficiency
depends on the amount of voltage induced or the characteris-
tics of the current. It is probably more efficient to achieve
the same level of stimulation with a lower voltage, as in Conclusion
the case for premodulated IFC. Further investigation into the
characteristics of true IFC and premodulated IFC and their In summary, all tested IFCs passed through soft tissues
stimulation efficiency is required to determine this effect. and reached muscle tissue. The highest voltages for all cur-
On the other hand, none of the tested frequencies of true rents were recorded in the superficial tissues and were lower
IFC demonstrated clear superiority over the other frequencies in deeper muscle tissues. Surprisingly, the lowest voltages
in terms of depth efficiency, although the 4-Hz frequency were recorded at the intersection of the four electrodes, and
achieved the highest voltages. This may indicate that any the highest voltages were recorded at the outside location for
of the frequencies tested here could be used as a substi- true IFC. For the premodulated IFC, the highest voltage
tute for the others in terms of voltage induction. This raises was recorded in line with one circuit. Finally, true IFC was
questions about the role of amplitude-modulation frequency more efficient in terms of higher recorded voltages than the
(AMF) [17], whether this has an influence on stimulation, premodulated IFC when targeting deeper tissue.
and whether the stimulatory effect could be accomplished Ethical approval: Committee of the Faculty of Health
by the original current (e.g. 4000 Hz) with no modula- and Rehabilitation Sciences, The University of Queensland,
tion. This study did not measure the voltage induced by Australia (Ref. No. 2007001400).
the original medium frequency current, as it was designed
Conict of interest: None declared.
to investigate AMFs in common use; as such, the authors
cannot be certain that its behaviour in different tissues is
similar to the behaviour of amplitude-modulated currents.
However, previous electrophysiological studies have sug- References
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