1. Electrical modalities Summer Kepley, OTS

2. Definition Different forms of energy, dependent on the specific modality, which can penetrate through the skin, the muscles or even the neurological system of the human body, in order to provide relief from swelling and/or pain, muscle stimulation or to promote healing of different body structures, caused from an acute or chronic injury or condition, (Larson, 2007).

3. Different Levels Cellular Level Modify skin Increase movement Facilitate wound healing Modulate acute pain Tissue Level Increase tissue extensibility healing Reeducate muscles Modulate acute pain Decrease muscle disuse atrophy Increase movement Segmental Level Increase movement Decrease edema/inflammation Facilitate fracture healing Modulate a pain Systemic Level Modulate chronic pain

4. General Purpose Modulate pain (acute and chronic) Increase tissue extensibility healing Modify skin Decrease edema/inflammation Reeducate muscles Increase movement Decrease muscle disuse atrophy Facilitate fracture and wound healing

5. When are EM’s used? “…in preparation for or concurrently with purposeful and occupation-based activities or interventions that ultimately enhance engagement in occupation” (McPhee, 2008).

6. Who can use EM’s? According to the AOTA, only occupational therapists and occupational therapy assistants with the proper training and skills to integrate the chosen modalities skillfully and safely, and be able to implement them correctly within a proposed occupational therapy program.

7. General Precautions Never place the electrodes- On each temple On or near the eyes In the mouth On the front of the neck On the groin On numbed areas of the skin, or decreased sensation On wounds On or near the uterus of a woman who is or may be pregnant. (Effects are generally unknown, but may induce labor.)

8. General Contraindications Pacemaker Cardiac conditions Exposed metal implants Severe obesity Increased sensitivity to electrical stimulation Epilepsy

9. General Evaluation Guidelines Clean the skin surface of the body area to be treated. Avoid extremely hairy areas of the body, or where there is a wound. Shaving is not recommended: Micro abbreviation Inspect the electrode cords and electrode pads for wear. If they are not in good condition, they should be replaced. If they are acceptable, then insert the cord pins into each electrode pad. Never re-use an electrode pad. Peel away the paper backing of the disposable electrode and place it on the body carefully and securely. Loose electrodes can contribute to burning and irritation of the skin. There are 3 basic pad placements: Monopolar- one electrode running from one channel Bipolar- two electrodes running from one channel Quadripolar- four electrodes running from two channels Monopolar and Bipolar should be used when treating a relatively small area and Quadripolar for a larger area. An example of a larger area is the thigh.

10. TENS Transcutaneous Electrical Nerve Stimulation Transcends an electrical current, to provide constant electrical stimulation to the peripheral nerves, in a specified area of the body, to modulate pain.

11. Purpose Decrease pain Acute Persists less than 6 months and is associated with tissue damage, irritation, inflammation or a disease. Prevent the acute pain reaction cycle from occurring. Example Chronic Stop the pain cycle described above, after it has already started.

12. TOOLS For Client Use Portable- can clip on belt or put in a pocket, and control pain as needed or recommended. For Therapist Use Must have at least 2 electrodes to pass current, but usually comes with 4. Electrodes are thin flexible pads covered with a gelatin-like substance. The electrodes are connected to a lead wire and a relatively flat, electrical impulse-distribution portion. The connector is attached via the lead wire to a stimulator.

13. Evaluation Guidelines Pulse Frequency If you increase the pulse frequency, you are increasing the amount of energy being delivered to the body. Pulse Amplitude The higher the amplitude, the more energy released to your body. Pulse width The longer the pulse, the more total energy each individual pulse generates. “Low Fire” Setting Endogenous opiates and endorphins are released and reduce the sensation of pain. “High Frequency” Setting Gate control theory The electrical current goes through the peripheral nerves to close the gate in the dorsal horn, and blocks the perception of pain at the level of the spinal cord.

15. Precautions Allergic reactions Decreased sensation of the skin Open wounds Pain is the body’s way of telling an individual to react to a harmful stimuli or occurrence. Therefore, if the individual is no longer perceiving pain, they may become careless with an injured area and further damage it. Nerve impingement

16. Contraindications Epilepsy Cardiac pacemaker or other metal implants Extreme obesity

17. MENS Microcurrent Electrical Nerve Stimulation MENS was designed to mimic the electrical, weak currents produced by tissue healing. Uses micro-amperage current These devices deliver a level of stimulation below the threshold of peripheral nerve excitation.

18. General Purpose Aids in the healing process while relieving pain. Whereas TENS is generally used for pain relief, MENS works more on a cellularlevel and aids in the healing process while relieving pain.

19. TOOLS Portable version Similar to TENS Generally only has 2 electrodes Wave forms- lower than TENS Pulse frequency- lower than TENS Amplitude- lower then TENS

20. Evaluation Guidelines Either short pulse durations or a constant current is used. The Amplitude is much lower than the TENS unit, and is set by the therapist. Guidelines follow the same as the TENS, but is safer then the TENS unit, due to weaker currents passed.

21. Indications Symptomatic relief and management of chronic pain Adjunctive treatment for post-surgical and post-traumatic acute pain Very low pain tolerance Scarring of the skin Decreased ROM due to scarring of the skin, or scar tissue close to the skin’s surface Wound

22. Precautions Allergic reactions Pain relief causing exacerbation of the injured site. N. impingement

23. Contraindications Epilepsy Cardiac pacemaker or other metal implants Extreme obesity

24. IFC Interferential Current Therapy Crossing two slightly different medium frequency alternating currents within the tissue, a third frequency current of greater intensity is created in the deeper tissue 4 electrodes total Allows for centralized concentration of current Maximized by electrode placement so that intensity is perceived in area of pain “Carryover Effect”

25. Purpose Pain Increase blood circulation Interferential current uses very high pulse rate, usually 4001 - 4150 pulses per second. Provides more analgesic, or nerve blocking effect.

26. TOOLS Because of such frequency, these devices will require a lot of power, and thus, batteries will not last long. AC Adapters are usually provided with device. Applies two medium-frequency currents simultaneously Interference creates a “beat” mode Sweep frequency Reduce accomodation The system can arrange electrodes in either the same plane (for areas such as the back), or in different planes (in areas such as the shoulder).

27. Evaluation Guidelines Electrode placement should be in an "X" pattern Steps to follow: 1. Increase current until the patient feels a definite prickling, and leave for one minute for it to decrease 2. Increase current again until the patient reports a slight muscular contraction, then decrease until contraction stops Duration of Treatment 10-15 minutes treatment at a normal intensity should not be given to one area for longer than 20 min. if more than one area is to be treated, total time should not exceed 30 min.

28. Precautions Allergic reactions Decreased sensation of the skin Open wounds Pain relief causing exacerbation of the injured site.

29. Contraindications Epilepsy Cardiac pacemaker or other metal implants Extreme obesity

30. NMES Neuromuscular Electrical Stimulation A non-invasive means of muscle rehab after injury, surgery or with disease, that applies customized, low level electrical stimulus to cause a muscle to contract. The brain tells muscles to contract by sending electrical signals or impulses to them. NMES can act like the brain by sending similar electrical signals through the skin to the muscles telling them to contract. The client must have an intact or partially intact peripheral nerve.

31. Indications CVA, TIA, TBI Muscular Disorders Neurological degenerative diseases/syndromes Contractures Decreased ROM Edema Decreased blood flow “ Functional electrical stimulation (FES) is a type of NMES that is used to enhance the ability to walk in patients with spinal cord injuries or stroke. FES attempts to replace stimuli from destroyed nerve pathways with computer-controlled sequential electrical stimulation of muscles, (NMES PDF, 2006).”

32. TOOLS A stimulator transcends an electrical signal that flows through leads to electrodes placed on motor points over a targeted muscle or muscle group. This causes an electrical reaction in the specified motor nerves and results in muscle contraction. Stimulus parameters include: Pulse rate/frequency- Tension of mm. Pulse amplitude- The amplitude is increased until strong maximal contraction is obtained, upon tolerance of the client. Pulse waveform: Symmetrical- allows both electrodes to be active, and results in a hard and fast contraction of the muscle or muscle group Asymmetrical- allows the selective recruitment of smaller muscle fibers

33. Evaluation Guidelines Electrodes are attached over a muscle that needs help to contract. Bipolar placement tends to be used most often in NMES, because for a given intensity of stimulation, more current reaches the muscle to be stimulated. For optimal bipolar positioning, the clinician should place the muscle at resting length or in a slightly lengthened range, avoiding any close-packed positions of the limb or joint. A rest cycle that is 5 to 6 times as long as the hold cycle allows the muscle adequate time to recover between contractions and produces same amount tension on each subsequent contraction. Treatment should be provided daily, or at least every other day, for approximately 15 minutes, total time.

34. Precautions Muscle fatigue Peripheral n. pathology Patient tolerance Patients with severe dementia, inability to follow directions and verbalization Allergic reactions Decreased skin sensation Open wounds The patient must have a non-neurological reason for disuse atrophy

35. Contraindications Cardiac pacemakers, metal implants Pregnancy Neuromuscular or neurological disorders in which fatigue has a negative impact on the disorder Severe Obesity Active bleeding

36. Russian Electrical Stimulation Similar concept as the NMES, but with medium frequency waveforms. Russian Stimulation is a specific type of electrical muscle stimulation utilizing a higher carrier frequency of 2500 Hz. The system is designed to stimulate motor nerves, resulting in muscle contraction. Originally used for strength training, but currently being used for muscle strengthening, and reduction in muscle spasms and reducing edema.

37. Indications Scoliosis CVA, TIA TBI Muscular Disorders Neurological degenerative diseases/syndromes (Ex. Parkinson’s Disease- to increase muscle strength to help reduce fatigue and atrophy). Edema Decreased blood flow

38. TOOLS (May look just like an NMES or other MES systems, and can also be an option on a general MES system) Similarly, the makeup is the same as the described NMES, but the grading options are much higher.

39. Evaluation Guidelines The "10/50/10" Treatment Regimen “Russian electrical stimulation is applied for a 10-second "on" period followed by a 50-second "off" period, with a recommended treatment time of 10 minutes per stimulation session. The objective is to increase a muscle's ability to generate force”, (Russian, 2009)

40. Precautions Muscle fatigue Patient tolerance The nerve supply to the muscle must be intact

41. Contraindications Cardiac pacemakers Previous casting or splinting of the limb Contracture from a burn Hip replacement surgery Patients with severe dementia, inability to follow directions and verbalization DO NOT use on smaller muscles or muscle groups, such as: Muscles of the throat and face Mm. of the hands and feet Neuromuscular or neurological disorders in which fatigue has a negative impact on the disorder

42. Iontophoresis A non-invasive, pain free method of delivering medication into the body using a low electrical current Iontophoresisis able to transcend drug ions through the skin and underlying tissue through a low-level electrical current, (Empi, 2010).

43. General Purpose Provides option for patients reluctant or unable to receive injections Decreases risk or infection Medication is delivered directly to treatment site Decreases tissue damage Delivers medication much quicker, and effects can be felt within minutes, (Empi, 2010). Can be, and is often used in conjunction with other modalities. Often used before therapy to reduce inflammation and pain.

44. TOOLS The majority of units consist of a compact phoresor that operates with a 9-volt battery and two wire leads, each connected to an electrode. One electrode is the drug-delivery electrode, the other is used as a dispersive electrode charged opposite to the first one. When the electrodes contain solutions of ions, negatively charged anions are repelled from the cathode into the body

45. Evaluation Guidelines The inflammation must be near the body surface (Ex. a superficial muscle or tendon rather than a deep muscle tendon bursa). The medication must carry a charge to work with the iontophoresis. Transient erythmia often occurs, but is normal and the patient should be informed prior to treatment. Be sure to start with a mild sensation, so that the client feels only a tingling sensation and is not uncomfortable. Place the negative end of the electric charge on a part of the client’s body, away from the intended area. Apply the medication on the client’s affected area. Put another pad on it for the positive electrical charge. Turn on the electrical source and the charges of the medicine and electricity will push the medicine into the intended area.

46. Precautions Burning of the skin! Electrical discharges (sparks) may occur Do not use in the presence of flammable anesthetics Do not apply over an area where the hair has been shaved in the past 24 hours. Known skin allergies

47. Contraindications Allergic reaction to medication Higher fat content Cardiac pacemakers Known sensitivity to ionic solutions Damaged skin, wounds or recent scar tissue

48. American Occupational Therapy Association. (2004). Roles and responsibilities of the occupational therapist and occupational therapy assistant during the delivery of occupational therapy services. American Journal of Occupational Therapy, 58, 663-667. Bracciano, A.G. (2008). Physical agent modalities: Theory and application for the occupational therapist (2nd ed.). Thorofare, NJ: Slack. eMedicine, Clinical Knowledge Base. (2007). Transcutaneous electrical nerve stimulation. Retrieved January 16, 2010 from http://www.emedicine.com/pmr/topic206.htm#section~introduction Empi: Health care professionals. (2009). DJO, Inc. Retrieved January 15, 2010 from http://www.empi.com/healthcare_professionals/detail.aspx?id=106 Iontophoresis drug delivery electrode insert. (2009). Pain Management. Life Tech, Inc. Retrieved January 17, 2010 from http://www.life-tech.com/pm/meditrodeindications.shtml Larson, J. (2007). Electrical stimulation therapy. Wild Irish Medical Education, Inc. Retrieved January, 15 2010 from http://www.nursingceu.com/courses/211/index_nceu.html McPhee, S.D. (2008). “Physical Agent Modalities: A Position Paper”. American Journal of Occupational Therapy, The. FindArticles.com. Retrieved January 12, 2010 from http://findarticles.com/p/articles/mi_hb5914/is_n32312314/ Modalities. (2009). Occupational Therapy: University Hospitals. Retrieved January 13, 2010 from http://www.uhhospitals.org/tabid/3728/Default.aspx “Neuromuscular electrical stimulation. Fallon Community Health Plan. (2006). Retrieved January 15, 2010 from http://www.fchp.org/NR/rdonlyres/50B823A6-3A65-44C3-A7AE-6C31A7B11A3E/0/NeuromuscularStimulation.pdf Pendleton, H.M. & Krohn, W.S. (2006). Pedretti’s occupational therapy: Practice skills for physical dysfunction (6th ed.). St. Louis, MI: Mosby, Inc. Russian electrical stimulation. (2009). Equinew, LLC. Retrieved January 18, 2010 from http://www.equinew.com/russian.htm