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.

This book has been published in good faith that the material provided by author is original.
Every effort is made to ensure accuracy of material, but the publisher, printer and author
will not be held responsible for any inadvertent error(s). In case of any dispute, all legal
matters are to be settled under Delhi jurisdiction only.
First Edition : 2006
ISBN 81-8061-620-7
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A 14, Sector 60, Noida
 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,
0 Handbook of Practical Electrotherapy

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 1
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 move-ments 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
forms—static electricity and electrical current.
Points to Ponder
0 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 (–).
0 The objects capable of loosing electrons
develop positive charge.
1 The objects capable of accepting loose
electrons develop negative charge.
2 Static electric charge tends to distribute
uniformly over a spherical surface and
concentrate on pointed surfaces of the
charged objects (Fig. 1.1).
3 Like charges repel and opposite charges
attract each other (Fig. 1.2)
4 Static electric charge creates a sphere of
influence around itself. This is known as an
electrical field.
5 The direction of the line of forces is directed
away from the positively-charged body and
towards the negatively-charged body.
6 Static electricity does not mean its sta-tionary.
A bolt of lightening strikes the earth when the
static electric
7 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.
8 An electrical current is the flow of electrons
through a conductor, from a region of
0 Handbook of Practical Electrotherapy
Fig. 1.1: Static electricity & electrical field—Static
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.
0 By convention, the direction of flow of
electrons is opposite to the direction of flow
of the current (Fig. 1.2)
1 The rate of flow of electrons is measured in
Amperes.
2 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 conduc-tor and is
measured in Volts.
3 The force opposing the flow of electrons
through a medium is known as resistance or
impendence and is measured in Ohms.
4 The domestic electric supply is an Alter-
nating Current (AC) having a sine wave at 50
Hz frequencies.
Fig. 1.2: Behaviour of electrical fields—Opposite
charges attract each other, thus flow of electron
takes place from negatively-charged pole to the
positively-charged 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
0 The supply line has a phase, a neutral and an
earth connection.
1 The phase carries the current, the neutral
completes the circuit and the earth provi-des
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

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 answer—Bioelectri-
city.
All living cells are like miniature batteries,
constantly charging and discharging as it goes
about living. All of the cell’s 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
battery—dead.
The mystery behind this electrical pheno-
menon 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-
Fig. 1.3: A typical nerve cell
Review of Basic Concepts in Electricity 3
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. Dend-rites 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-
0 Handbook of Practical Electrotherapy

Fig. 1.4: Resting membrane potential in a nerve cell—The relative concen-

+ +
tration 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
positively-charged. 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 0 The inside of the cell becomes progres-sively
resting cell is called resting membrane potential. more negative as compared to the outside as
+
the K ions gradually diffuse out.

Points to Ponder 1 This creates a difference of potential across

the cell membrane, which is known as resting
0 The cell membrane is selectively more
+ + membrane potential, which is –70 mV in case
permeable to K ions, as compared to Na of a nerve cell and -90 mV for a muscle (Fig.
ions. 1.4)
+
1 K ions can enter or leave the cell by 2 Due to passive diffusion, the cell cons-tantly
+
diffusion while the Na ions cannot do so. + +
+
looses K ions and some Na ions gain entry
2 At rest, K ions and other negatively charged to maintain the electrical equilibrium.
protein ions are concentrated inside the cell
+ +
giving it a net negative charge and Na ions 3 The cell again expels these Na ions and the
in the fluid outside giving it a net positive +
lost K ion is reabsorbed through active
charge.
+ transport mechanism of sodium-pota-ssium
3 In a living cell, the number of Na ions are pump mechanism, at the expense of ATP.
+
far greater than K ions

0 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 poten-tial (Fig.
1 sation of the cell till it reaches critical threshold of –
1.5).
A typical action potential has threshold
potential, depolarisation, repolarization and
sometimes hyperpolarisation. An AP is an all or
none phenomenon. Once a nerve appro-aches
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 milli-second they appear as a vertical
line.
Any excitable cell like the nerve or muscle
cannot maintain its resting membrane poten-tial
indefinitely, since it’s bombarded conti-nuously
with environmental stimuli, prog-ressively
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-
Review of Basic Concepts in Electricity 5
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 depolari-
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
0 All excitable cells try to retain normal resting
membrane potential (Fig. 1.5, stage 1)
1 Any stimulus, mechanical or electrical, makes
+
the cell membrane more permeable to Na
ions.
+
2 As the gates at the cell membrane open, Na
ions rush into the cell, trying to change its
polarity (Fig. 1.5, stage 2).
0 Handbook of Practical Electrotherapy
0 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).
1 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)
+
2 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)
3 The inside of the cell becomes positively
charged as compared to the outside, as a
result of flow of ions.
4 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 oscillo-scope.
The spikes in an ECG are a common example
of the action potential generated in the heart
muscle (Fig. 1.5, stage 4)
5 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.
6 Sooner the peak of the action potential is
+ +
reached the Na channels close and the K
+ The orthodromic propagation of action
channels open wide, letting the cell loose K
ions rapidly, making the trans-memb-rane
potential progressively more nega-tive. This
process is called repolarisation
and the phase of relative refraction (Fig. 1.5,
stage 5).
ᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ̀̀ĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ
+
ĀᜀĀᜀ0 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
hyperpolari-sation (Fig. 1.5, stage 6)
ᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ̀̀ĀȀ⸀ĀᜀĀᜀĀᜀĀᜀĀᜀĀᜀ
+
ĀᜀĀᜀ1 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 propa-
gation of action potential takes place towards the
sensory cortex and the antidromic conduc-tion
takes place towards the peripheral sensory
receptors on the skin.
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
 Review of Basic Concepts in Electricity 7

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. Messa-ges
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 sti-mulation, i.e. sensory
nerves. For the motor nerve to be stimulated
effectively, due to its
0 Handbook of Practical Electrotherapy
higher threshold, the frequency of stimulation
must be low and strong enough to produce
2
muscle contraction.
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 gene-rated by motor nerves
are similar in nature and can spread its effect to
the neighbouring muscles throught he process of
3
excitation.
Points to Ponder
0 Creation of an action potential at one
segment of the cell membrane triggers
depolarisation of the neighbouring seg-ments
of the cell membrane.
1 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.
2 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 conduc-
tion. The speed of such conduction is
inversely proportional to the diameter of the
cell fibre.
3 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.
0 An action potential generated in a nerve may
propagate along the axon of the nerve in
either direction.
1 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
2 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.
3 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 pro-ducing
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 electro-magnetic
induction.

Understanding the electrical characteri-stics 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 bio-electrical
properties of the cell and their response to
various forms of electrical energy. Thus the
foundation of all electro-therapy modalities is
based on the bio-electrical 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 bio-electrical tests that
provide relevant information regarding the
electrical func-tioning 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.
Review of Basic Concepts in Electricity 9
Physiotherapist may use this information to
assess, prognosticate and treat specific
disorders pertaining to the musculo-skeletal
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 know-ledge is also
essential to under take various tests and
interpret the results and protocols for
electrodiagnosis. Therefore, an exhaus-tive
knowledge of bioelectricity and
electrophysiology is the key to turn the
physiotherapist from a technician to a fully
fledged clinician
REFERENCES
Alberts B, Bray D, Lewis J, Ra HM, Roberts K,
Watson JD. Molecular Biology of the Cell. Garland
Publishing Inc: New York, 1983.
Walsh JC. Electrophysiology. In Electrophysical
Agents in Physiotherapy: Therapeutic and
Diagnostic Use (Wadsworth H, Chanmugan APP,
Eds) Science Press: Marrickville, NSW Australia,
1988.
Charmen RA. Bioelectricity and electrotherapy-
Towards a new paradigm? Part 1-4. Physio-therapy
1990;76(9,10,11):503-730.
Handbook of Practical Electrotherapy
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 induc-tance
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 appli-cation 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

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 patient’s 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 insu-lated
footwear (rubber or plastic) in absence of
insulated flooring.
Always use wooden plinths and insulated
equipment trolley (metal frame with sun
Introduction to Electrotherapy 11
mica/glass top) in an electrotherapy
department.
Engage a qualified electrician to check your
electric supply lines periodically, paying
maximum attention to the affec-tivity of the
earth line and proper calibra-tion of the mains
fuse.
All electrotherapy equipments must be isolated
electrically from each other and the patient,
to minimize the risk of acci-dents, 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 domes-tic 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 periodi-cally check
the earth-free nature of the secondary current
supply in all electro-
Handbook of Practical Electrotherapy
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 techni-
cian.
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

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, parti-
cularly 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 gene-
rated 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 unneces-sarily 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
Introduction to Electrotherapy 13
if the patient feels any unexpected sensa-tion
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 micro-wave
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
Handbook of Practical Electrotherapy
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 insu-rance
paid up to date.
 3
Therapeutic
Electrical Stimulation
Definition Nature of Such stimulus may be mecha-nical,
like a sharp tap on the nerve or the tendon;
Electrical stimulation involves application of
chemical, like the discharge of neurotransmitters
suitably modified electric current to stimulate
taking place at the neuro-muscular junction or an
excitable tissues like nerves and muscles, with
electrical impulse. Once the depolarisation of
the aim of producing physiological reactions that
theses cells reach a critical level the chain
have clear therapeutic benefits.
reaction takes over till an action potential is
The application of electrical stimulation, as
created. Since nerves have a lower threshold they
an integral part of electrotherapy, has come a
are stimulated faster than the muscles. The
long way since the times of Benjamin Franklin.
required intensity of the stimulus is lower in the
With the advent of computerized stimu- nerves than in the muscles (Fig. 3.1).
lators, with idiot proof features, it has now
become an effective modality in the arsenal of
Points to Ponder
the therapists, with carefully modulated impulses
that cause minimum irritation and discomfort to Intensity of each stimulus or pulse ampli-tude
the patient, while getting maxi-mum response must be strong enough to cause the resting
from nerves and muscles. membrane potential to be lowered sufficiently
However, to be able to use this therapeutic to achieve the critical thres-hold, which is the
hardware, one must be well conversant with the point of no return for the nerve/muscle to
characteristics of electrical stimulation, depolarise comp-letely. However, once the
necessary to initiate depolarisation in excit-able cell depolarises, repetition of the stimulus of
tissues like nerves and muscles. same or greater intensity will not provoke any
response till the cell has re-polarized. Nerve
HOW DOES ELECTRIC
cells work on the principles of all or none
STIMULATION WORK?
law.
Nerves and muscles are excitable tissues that
respond to any sharp and sudden stimulus that The duration of each stimulus or pulse duration
can cause depolarisation in these cells. must be long enough to produce
Handbook of Practical Electrotherapy
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 res-ponse but
for a muscle this is too short a duration. A
muscle cell devoid of nerve supply needs 100
to 300 msec pulse dura-tion 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 environ-ment
to prevent depolarisation.
To stimulate a muscle devoid of nerve supply a
slow-rising current is most sui-table.
The rate of rise of a stimulus is usually reflected
in pulse shape.
Fig. 3.2: Types of electrical impulses: Types of
electri-cal 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 depola-rization. Fast-rising impulses can be
square, rectangu-lar 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 environ-ment. 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, rect-angular or
spike-shaped.
Slow-rising impulses are trapezoidal, triangular
or saw-tooth in shape. Slow-rising 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 stimu-lating 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 fre-quency RELATIONSHIP BETWEEN STRENGTH

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 neuro-muscular
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 dura-tion of 100 to 300 msec.
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
Handbook of Practical Electrotherapy
Fig. 3.4: Strength duration curve indicates the rela-
tionship 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 respec-
tively.
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
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
Rheobase is the intensity of current required to
produce a minimal perceptible response in a
nerve/muscle with a stimu-lus 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 inner-vated muscle is
less than 1 msec.
A strength-duration curve (SD curve) is plotted
to determine whether a muscle is innervated,
denervated or partially dener-
vated/innervated.
TYPES OF THERAPEUTIC CURRENT
Therapeutic currents can broadly categorised as
stimulating and ionising currents. Stimu-lating
currents are classified on the basis of Frequency,
duration and shape of the stimu-lating 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 appro-
priate 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
Therapeutic Electrical Stimulation 19
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 inter-
rupted 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 Smart-Bristow
coil and are not used nowadays
Subtypes of Low Frequency
Stimulating Currents
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 Handbook of Practical Electrotherapy

motor point detection in innervated muscles.

b. Faradic type of current Faradic type of

current is very short duration monophasic
interrupted galvanic current, with fre-
quency 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.
c. 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. Fig. 3.7: Current forms used in TENS:
d. Transcutaneous electrical nerve stimulation • Conventional TENS current consists of biphasic
(TENS) Transcutaneous electrical stimu- very short duration impulses at very high
lation uses ultrashort duration (50 to 300 frequency, with intensity just at the level of sensory
threshold. This type of TENS is called HI-TENS,
micro second) impulses at a frequency of 1 used for relief of acute pain.
to 300 Hz, used mainly for relief of pain • Selectively TENS may also be applied through
through stimulation of sensory nerves. The acupuncture points, with longer duration impulses
impulses may be asymmetrical biphasic or at low frequency, with high intensity almost to the
level of pain threshold. Such TENS is called LO-
monophasic (Fig. 3.7). TENS, used for relief of chronic pain.
e. Iontophoresis Continuous direct current, • Burst mode TENS combines the characteristics
used at low voltage and intensity, with the of both HI and LO TENS, using train of impulses
aim of transferring therapeutically useful of HI-TENS repeated at a preset discrete interval
ions, through the skin or mucous memb- are available in two-pole or four-pole format
rane to the body.
(Fig. 3.8).
MEDIUM FREQUENCY CURRENT Subtypes of Interferential Currents
These types of currents are commonly called
a. Two-pole medium frequency current
interferential currents and are in the frequency (2000-4000 Hz)
range of 2000 to 4000 Hz. These types of 1. Russian current (2000 Hz)
currents have a strong sensory effect and are 2. Medium frequency surge current
used for stimulation of deep muscle through (4000 Hz)
an interference pattern producing low fre- b. Four-pole medium frequency/interference
quency stimulation at a very high intensity, current (4000-4100 Hz)
bypassing the sensory barrier of the skin. Such 1. Classical interferential current
treatment modality is broadly referred to as 2. Isoplaner vector current
interferential therapy. The interferential currents 3. Dipole vector current

Fig. 3.8: Current forms used in medium frequency
sti-mulation 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 other’s 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
Long wave (Frequency 1 MHz, wave-length 3
Km)
Short wave (Frequency 27.12 MHz, wave-length
11.3 m)
Therapeutic Electrical Stimulation 21
Microwave diathermy (Frequency 1-10 GHz,
wavelength 3-300 cm).
Points to Ponder
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 fre-quency 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 fre-quency 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 galva-nic 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 indi-vidual
rotary selectors. The intensity controls are
separate for either type of current (Fig. 3.9).
Handbook of Practical Electrotherapy
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 sti-
mulating 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
alternating current, used in surged faradic or
asymmetrical alternating current, used in
high voltage galvanic stimulation.
Polyphasic pulses Biphasic current produc-ing
three or more phases in a single phase, used
in Russian or interferential current.
MODULATION OF STIMULATING
CURRENTS
Modulation of a stimulating current is the
changes in the characteristics of the stimu-lating
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 gene-ration equipments,
to suit the response thre-shold 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 unvary-ing
flow of electrons, used in Ionto-phoresis.
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 excita-bility 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
Therapeutic Electrical Stimulation 23
Anatomically, it is defined as the point where the
motor nerve enters an inner-vated muscle.
When the nerve supply has been dest-royed, 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, it’s most convenient to
use interrupted galvanic current, at pulse
duration of 1 msec in case of inner-vated
muscles and 100 msec in case of deneravted
muscles.
Once the skin has been prepared and the
electrodes have been positioned in appro-
priate 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:
Plotting of a SD curve of a muscle.
Giving interrupted galvanic stimula-tion to
denervated muscles.
Locating the general area for electrode
placement for surged faradic stimula-tion
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.
Handbook of Practical Electrotherapy
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, parti-cularly
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 stimu-lation.
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 proper-ties in
the muscle, neuromuscular electrical
stimulation (NMES) also helps to acce-lerate
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 effec-tive
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 tempo-rarily 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
1
engaging in any real activity. 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 quad-riceps 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 anterior-cruciate 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
athlete’s thigh had actually increased, sugges-
ting that hypertrophy had occurred in the target
muscles, instead of the usual immobi-lisation—
associated 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
2 motor neurons become active. This order of
was able to immediately return to competition.
Research has shown that NMES is effective
in preventing decreases in muscle strength,
muscle size, and even the oxygen-consump-tion
capabilities of thigh muscles after knee
immobilisation.
There is a fair amount of scientific evidence
that NMES can enhance functional perform-ance
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
1
cells to respond in a signi-ficant way.
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
activation from smaller to larger motor-nerve
cells has been termed the ‘size principle’ of
4
muscle-cell recruitment.
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 neu-rons. 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-re-cruited, 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 stimu-lated first
rather than last and the slow-oxidative 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.
Handbook of Practical Electrotherapy
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
3 threshold. This threshold probably needs to be as
elite athletes. If Kots’ findings were valid,
athletes could improve their power while
sleeping, simply by placing the right electro-des
over the key muscles involved in their sport!
Subsequently, devices for electrical sti-
mulation 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
manufacturer’s recommendations, while the
control group underwent concur-rent
4
placebostimulation sessions. The mus-cles
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
high as 60% of max-voluntary-contrac-tion
strength in case of well-trained athletes and 30%
6
in case of sedentary persons. In addition, NEMS
should be utilised at the minimum threshold of at
least 60% of max-voluntary-contraction
7
strength. Unfortu-nately, 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 mach-ine 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.
 Low Frequency Stimulation of Nerves and Muscles (NMES) 27
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 milli-second is sufficient.
The pulses delivered tend to be asym-
metrical 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 mecha-
nisms, 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:
Reduce pain—using 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.
Reduce muscle spasm—using faradic stimu-
lation, 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.
Handbook of Practical Electrotherapy
Increase or maintain joint range of motion—
using surged faradic stimulation, some-times
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.
Re-education of muscle action—using surged
faradic stimulation, by actively assisting
muscle action to complete a movement.
providing visual and proprioceptive feedback
to the brain, to re-educate for-gotten
pattern of movement.
improving co-ordination of voluntary
movements.
Prevent disuse atrophy—using 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 pro-perties, retard
disuse atrophy and promote early repair of
the damaged nerve.
Reduce swelling of extremities—using surged
faradic current under compression and
elevation.
Promote repair of soft tissue/wound—by
increasing supply of blood carrying O 2 and
nutrients, produced by pumping action in
muscles due to surged faradic stimulation.
WHEN NOT TO USE ELECTRICAL
STIMULATION?
Though it’s 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 fractures—may lead to dis-
placement of fractured bone ends.
However, if the fracture is stabilized
internally or in a plaster cast, stimu-lation
may be applied through win-dows cut into
the cast, to prevent disuse atrophy of
muscles.
Recent haemorrhages—may lead to further
bleeding.
Malignant tumours—may lead to spread of
cancer cells.
Acute infective focus/carbuncle/cellulites—
may lead to spread of infection to the
blood stream.
Deep vein thrombosis—may lead to
embolism of clot.
Superficial metal implants, as in ORIF of
superficial bones—may cause concen-
tration of charge and cause burn of the
neighbouring tissue.
Muscle of pharynx or voice box—may lead to
problem in swallowing, cause choking or
impair speech.
Pregnant uterus—may cause sponta-neous
abortion.
Electrical stimulation is absolutely prohi-bited in
patients with demand type pacemakers or
diseases of hearts muscles like myocardial
infarction.
Be careful while giving electrical stimu-lation
over:
Loss of superficial skin sensation—sti-
mulation 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. It’s useless to
 Low Frequency Stimulation of Nerves and Muscles (NMES) 29
apply TENS for relief of pain, in a case of
sensory loss, like in diabetic neuro-pathy
or any other sensory nerve involvement,
since the sensory path-ways are not
working and no relief of pain will be
obtained.
Massive swelling—may lead to break-down
of skin, which is devitalised due to poor
blood circulation. This is parti-cularly
important in chronic oedema following
radical mastectomy or chro-nic
circulatory failure of lower limbs in
varicose veins or burger’s disease.
Always use effleurage massage to reduce
the superficial oedema sub-stantially
before applying faradism
under pressure, keeping the limb in
elevation.
REFERENCES
Muscle electric stimulation in sports medicine. Rev
Med Liege 2001;56(5):391-95.
High intensity electric stimulation—Effect on thigh
musculature during immobilisation for knee sprain.
A case report physical therapy 1987;67(2):219-22.
Neuromuscular electric stimulation—An over-view
and its application in the treatment of sports
injuries. Sports Medicine 1992;13(5): 320-36.
Effects of electric stimulation on body compo-sition,
muscle strength, and physical appear-ance. Journal
of Strength and Conditioning Research
2002;16(2):165-72.
Handbook of Practical Electrotherapy
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 stimu-lation 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), neuro-muscular
stimulator (NMS), TENS (for pain control),
functional electrical sti-mulator (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 stimu-lators
offering surged faradic and inter-rupted
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 stimu-lators are
marketed in two basic models, therapeutic
and diagnostic.
Therapeutic model is cheaper than diag-nostic
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 para-meters 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 sepa-rate
colour coded output for interrupted galvanic
and faradic type current. The
 Getting Started with Low Frequency Electrical Stimulation 31
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 impor-tant to
pay close attention to the following ten
points:
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.
The face plate of the equipment must be
made of polypropylene sheet or other
non-conductive materials. The
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 ade-quate
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 regard-ing
smoothness and consistency, at each
duration setting and surge dura-tion. 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 commis-sion
discounted.
Remember that small scale local manu-
facturers can often give you custom
designed equipment, with maximum
number of useful features at a reason-
Handbook of Practical Electrotherapy
able cost, rather than established
manufacturers, because their overhead
cost is much less.
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.
After sales service is the most impor-tant
consideration for any equipment
purchased. Most equipments carry one-
year warranty period. Negotiate for post-
warranty annual maintenance contract,
before concluding the deal for purchase.
The supplier should prefer-ably 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 treat-ment 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
contrac-tion will be felt in case of faradic
current.
Please let the current flow for one minute and
ensure the current out put flows in
 Getting Started with Low Frequency Electrical Stimulation 33
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 adver-sely
affect the compliance of the patient. This is
particularly important with young children and
nervous patients. Start with an expla-nation 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 treat-ment
session is essential.
Question the patient to rule out any abso-lute
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 sti-mulation
Dry skin has a resistance of 5000 ohms, since the
epidermis is made up of five layers of dead
cells soaked in oily seba-ceous 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: Electro-des
used for therapeutic stimulation are
Handbook of Practical Electrotherapy
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 place-ment: 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.
Monopolar placement—Two electrodes of
different sizes are needed to com-plete 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.
Bipolar placement—Sometimes two
electrodes of same size may be used,
usually while applying surged faradic
stimulation to a group of muscles (Fig.
5.3, Plate 1).
Colour coding—The active electrode is
connected to the + terminal colour coded
red and the passive electrode to the –
terminal colour coded black.
Shape of electrodes—In 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.
 Getting Started with Low Frequency Electrical Stimulation 35
Fig. 5.4: Top—Vaginal electrode; Bottom—Rectal
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 appro-priate 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, co-mmonly 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.
Handbook of Practical Electrotherapy
Stimulating current is delivered to the excitable
tissues through a pair of electro-des.
The electrode connected to the positive terminal
of the stimulator is commonly known as the
passive/dispersive/collect-ing electrode.
The electrode connected to the negative terminal
of the stimulator is commonly known as the
active/stimulating/direct-ing 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
muscle—at 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
Electrical Stimulation
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 appro-priate
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 stimu-lation 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. Dis-connect 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
stabi-lizing time.
 Getting Started with Low Frequency Electrical Stimulation 37
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 under-standing of the
principles of clinical applica-tion 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 peri-pheral 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 cont-ractions, to
promote exchange of blood.
Fresh blood carries nutrient and oxygen to the
paralysed muscle, to keep its proper-ties of
contractility, excitability and extensibility
intact, till the nerve re-grows to take over the
function of muscle contrac-tion.
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-edu-cation 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 move-ment, 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
Handbook of Practical Electrotherapy
disorder, along with tips on suitable adjunc-tive
therapy, have been covered for easy reference.
Techniques of Low Frequency
Stimulation in Bell’s Palsy
Clinical condition: Bell’s palsy.
Nerve involved: Facial nerve or VIIth cranial
nerve.
Muscles involved: Facial muscles—Frontalis,
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.
Functional problems: Loss of facial expressions
and symmetry, drooling, conjunctivitis.
Type of current used: Interrupted galvanic
current, rectangular pulses at 100 ms duration at1
pulse per second. As the condition imp-roves, the
pulse duration can be progressively reduced to
30, 10, 3, 1 ms and the rate of repeti-tion can be
increased to 3 pulses per second.
Type of technique: Monopolar technique, with
passive electrode of 5 sq cm carbon rubber plate,
active electrode with 1 sq cm disc on holder.
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).
Fig. 5.7: Stimulation of facial muscles in Bell’s 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.
Duration of treatment: Thirty to sixty contrac-
tions to each muscle.
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.
Contraindications: Do not stimulate in presence
of severe acne or skin rashes.
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.
 Getting Started with Low Frequency Electrical Stimulation 39
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
Technique of Low Frequency
Stimulation in Wryneck
(Paracervical Muscle Spasm)
Clinical condition: Wryneck—muscle spasm of
neck and upper back muscles.
Nerve involved: Spinal accessory nerve (root
value—C1-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.
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.
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.
Fig. 5.10: Placement of electrodes for surged
faradic stimulation to relieve spasm of muscle of the
neck-Carbon rubber plate electrodes of equal size
are placed on either side over the posterior-lateral
muscles of the cervical column
Handbook of Practical Electrotherapy

Technique of Low Frequency

Stimulation in Fibromyositis
of Trapezius Muscle
Clinical condition: Fibromyalgia of para-
scapular muscles or T4 syndrome.
Nerve involved: Dorsal scapular, supra-scapular
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
Fig. 5.11: Placement of electrodes for surged faradic
periarthritis of the shoulder joint. stimulation to relieve spasm of suprascapular muscles.
Type of current used: Surged faradic current Carbon rubber plate electrodes of equal size are
placed on the affected side, covering the upper fibres
Type of technique: Bi-polar stimulation. of trapezius muscles at its proximal and distal ends

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 move-ments
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.
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 stimu-
lation 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
 Getting Started with Low Frequency Electrical Stimulation 41
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 expo-sure
to cold for at least one hour after the treatment.
Technique of Low Frequency
Stimulation in Crutch Palsy
Nerve involved: Axillary nerve (root value-C5).
Muscles involved: Deltoid muscle (Ant, mid and
post. fibres)
Nature of impairment: Flaccid paralysis of
deltoid muscle due to compression of axillary
nerve.
Functional deficit: Loss of shoulder abduction,
flexion and extension.
Type of current used: Interrupted galvanic
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 #.
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 exer-cises or pendular
suspension must be given simultaneous with
faradic stimulation to obtain quick gain in power.
Technique of Low Frequency
Stimulation in Erb’s/Klumpke’s Palsy
Clinical condition: Brachial plexus injury
Erb’s palsy
Klumpke’s palsy
Nerves involved:
Erb’s palsy—Lesion of C5 root, sometimes C6
root, caused due to traction injury between
head and shoulder girdle, mainly during
forceps delivery.
Klumpke’s palsy—Lesion 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.
Muscles involved
In Erb’s palsy—Deltoid, rhomboids,
supraspinatus, infraspinatus, teres minor,
biceps brachi, brachialis.
In Klumpke’s palsy—Long 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 Erb’s palsy, (C5)—Loss of shoulder
abduction, external rotation, elbow flexion
Handbook of Practical Electrotherapy
and forearm supination and with (C6)-wrist
extension; typical deformity- Police-man’s
tip.
In Klumpke’s palsy – Loss of grip (C8) and fine
movements of hand; with (T1) typical
deformity—Claw hand or ape hand.
Type of current used: Interrupted galvanic
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 re-educate
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.
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 faradic—10 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 Erb’s 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
essential when the plexus has been repai-red
surgically. Axial suspension is the method of
choice for exercising the affec-ted limb. Once
the re-innervation starts, manually-guided
active exercises must be given simultaneous
with faradic stimula-tion to obtain quick gain
in power.
In Klumpke’s palsy, early splinting of the
affected hand must be done to prevent
irreversible clawing of fingers.
It’s wise to repeat SD curve at the beginn-ing 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 it’s so much cheaper than EMG/NCV
tests.
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.
 Getting Started with Low Frequency Electrical Stimulation 43
Fig. 5.16: Placement of electrodes for interrupted
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
rd
side over the lower 1/3 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.
Techniques of Low Frequency
Stimulation in Foot Drop/Flail Foot
Clinical condition: Foot drop.
Nerve involved:
Lateral popliteal (common peroneal) nerve, most
commonly involved.
Anterior tibial nerve
Muscles involved:
Lat popliteal nerve—Muscles of the anterior-
lateral compartment of the leg (Tib.ant, EHL,
EDL, EDB, Peronei).
Anterior tibial nerve—As above except Peronei.
Nature of impairment:
Flaccid paralysis of muscles and loss of
sensation over the dorsum of foot, usually
due to compression of the nerve against
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 tibio-fibular
ligament.
Anterior tibial nerve may be damaged during
insertion of tibial pin during appli-cation of
skeletal traction.
Functional problems: Dropped foot compen-
sated with high stepping gait.
Type of current used: Interrupted galvanic
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 contrac-
tions 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.
Handbook of Practical Electrotherapy
Fig. 5.18: Placement of electrodes for surged faradic
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.
The passive electrode is placed on the affected 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.
Fig. 5.19: Placement of electrodes for interrupted
galvanic stimulation of planter flexor muscle groups–
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 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.
 Getting Started with Low Frequency Electrical Stimulation 45
Fig. 5.20: Placement of electrodes for surged
stimulation of planter flexor 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.
The passive electrode is placed on the affected side
over the popliteal area, covering the posterior
tibial nerve at its superficial most point.
The active (negative) electrode is placed on the
rd rd
junction of proximal 1/3 and the distal 2/3 of
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 stimu-
lation.
In cases with milder presentation or with late
detection, like in the teen age, faradic
footbath forms the first choice of therapeutic
manage-ment, 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,
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
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 pro-duced 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 dura-tion 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 simulta-neously along
with the current flow and relax during surge
interval.
The treatment should be given for 15-30 min.
Handbook of Practical Electrotherapy
Precaution: Do not allow the patient to touch the
equipment or the wall during treatment.
2. Faradism Under Pressure
Indication: Oedema or swelling of extre-mities.
Points to Ponder
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 pum-ped out
due to lack of muscle contraction. Elevation
of the limb and frequent move-ments are
enough for physiological oedema.
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 perma-nently
lost.
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.
Plan of Management
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 circula-tion,
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.
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.
 Getting Started with Low Frequency Electrical Stimulation 47
Equipment and Type of Current Used
Standard low frequency stimulator, offer-ing
surged faradic current with separate controls
for surge duration and intervals
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.
Application of Pressure
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.
Application of Current
Surged faradic current, with surge dura-tion of 30
sec and interval of 90 sec is applied.
The intensity should be enough to produce
visible contraction of muscles of the creating
clenching of toes/fingers.
Patient should be asked to do active movement
simultaneously with the cu-rrent 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 pre-
sence 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
Plan of Management
Such contractures develop in major muscle
groups of the extremities, like the quadri-ceps
or elbow flexor group leading to restriction of
knee flexion or elbow exten-sion, mostly after
prolonged immobilisa-tion following
fractures.
Conventionally, such tightened muscles and soft
tissue are mobilized by forced
Handbook of Practical Electrotherapy
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 in-creasing
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.
Equipment and Type of Current Used
Standard low frequency stimulator, offer-ing
surged faradic current with separate controls
for surge duration and intervals.
Type of Electrodes
Bipolar carbon rubber electrodes, rec-tangular
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
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
Fig. 5.21: Placement of electrodes for surged
stimulation under tension to the quadriceps 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.
The passive electrode is placed on the affected side
over the proximal 1/3rd of the quadriceps.
The active (negative) electrode is placed on the
junction of proximal 2/3rd and the distal 1/3rd of
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.
 Getting Started with Low Frequency Electrical Stimulation 49
with a 6”wide 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 contrac-ture 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.
Application of Current
Surged faradic current, with surge dura-tion of
30 sec and interval of 90 sec is applied.
The intensity should be enough to produce
visible contraction of the muscles.
Patient should be asked to do active movement
simultaneously with the cu-rrent 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 pre-
sence of open wound or skin rashes.
Handbook of Practical Electrotherapy

6
Pain Modulation—
Transcutaneous
Electrical Nerve
Stimulation (TENS)
The activated interneuron produces inhibition
of transmission through pain carrying A-
It is a modern, non-invasive, drug-free pain
delta and C fibres.
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.
 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
The Endorphin Release theory states that:
Noxious stimulus causes production of
endorphins in the pituitary gland.
Endogenous opiates are also synthe-sized 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 body’s own pain killing
1
chemicals or endogenous opiates.
EQUIPMENT AND THE NATURE OF
TENS CURRENT
Points to Ponder
Externally applied electrical potential from
TENS must produce evolved potentials in
 Pain Modulation—Transcutaneous Electrical Nerve Stimulation (TENS) 51
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 capacitance—does 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
Light myelination, slower conduction velocity
High capacitance—longer latency
Fibres are unexcitable with pulse widths below
10 microseconds
To excite A-delta fibres, low-frequency
stimulation, with longer pulse width is used.
DIFFERENT TYPES OF TENS USED IN
CLINICAL APPLICATION
1. High Rate TENS
Most common mode of TENS, used in acute or
chronic stage of pain syndrome. Modula-tion of
pain takes place by activation of the gate control
mechanism by inhibition of pain carrying fibres
by large diameter fibres. Effect
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 applica-tion,
particularly while working, is recom-mended.
Uses: Relief of acute and postoperative pain, and
in areas of hypersensitivity or increased
muscle tone.
2. Low Rate TENS
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 sup-press the pain
receptors in the cerebral cortex. Effect is
relatively slow but lasts longer, i.e. more than
2
hours after treatment.
Points to Ponder
Rate: 1-5 Hz
Pulse width: 150-300 microseconds
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.
Handbook of Practical Electrotherapy
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 move-ments of
joints or passive stretching of soft tissue
contractures. Relief of pain is tempo-rary.
Points to Ponder
Rate: 80-150 Hz
Pulse width: 50-250 microseconds
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.
4. Burst Mode TENS
This form combines the characteristics of high
and low TENS, leading to release of endo-
genous opiates. The stimulation is well-tolerated
by patients, even on prolonged application, with
slower onset of pain relief as compared to low
TENS.
Points to Ponder
Rate: 50-100 Hz, delivered in bursts, of 1–4
pulses per second.
Pulse width: 50-200 microseconds
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 musculoskele-tal
and neurogenic pain of chronic nature, e.g.
sciatic syndrome.
WAVEFORMS OF TENS
Points to Ponder
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 bi-phasic and
are balanced so that there is a net zero DC
component, to prevent build-up of ion
concentrations beneath the electrodes.
MODULATION OF TENS
Points to Ponder
Modulation of electrical parameters (pulse rate,
pulse width) is offered on some TENS
machines in order to prevent accommoda-
tion 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.
 Pain Modulation—Transcutaneous Electrical Nerve Stimulation (TENS) 53
PARAMETERS FOR OPTIMAL
STIMULATION
An optimal stimulation/site should be:
Strong enough to stimulate the CNS.
Suitable for proper placement of electro-des, 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
3 4
(Figs 6.2 and 6.3).
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 situa-tions.
Before prescribing the therapist should ensure the
following:
Patient can understand and follow ope-rating
instructions perfectly. Do not pres-cribe 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.
Handbook of Practical Electrotherapy

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.
 Pain Modulation—Transcutaneous Electrical Nerve Stimulation (TENS) 55

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
Handbook of Practical Electrotherapy

APPLICATIONS OF TENS IN COMMON DISORDERS

Disease conditions Type of current Current parameters Electrode placement

Tension Headache Burst Pulse duration—50 microsecond Crossed 4 pole, 2 each over the
Pulse frequency—100 Hz origin and insertion of bilateral
Burst frequency—10 Hz Trapezius muscle upper fibres,
Dose—15 Minutes strong tingling felt.
Frozen Shoulder Burst Pulse duration—40 microsecond Cross 4 pole around the
(chronic Stage) Pulse frequency—100 Hz shoulder joint
Burst frequency—2 Hz
Dose—15 Minutes
Postherpetic Burst Pulse duration—50 microsecond 4 Pole method: 2 over the
Neuralgia Pulse frequency—100 Hz affected area and 2 above
Burst frequency—10 Hz and below the exit nerve
Dose—15 Minutes root.
Neuralgia Continuous Pulse duration—42 microsecond 2 or 4 Pole method over the
Pulse frequency—100 Hz affected area.
Dose—10-15 Minutes

Reflex Sympathetic Continuous Pulse duration—42 microsecond 4 Pole method: a) U/L: 2

Dystrophy Pulse frequency—160 Hz
Dose—10-15 Minutes
Electrodes at paravertebral
region of C-8 to T-9 and 2
electrodes over levator
scapulae and lateral part of
spine of scapula.
L/L: 2 Electrodes over para-
vertebral region of T-10 to L-2 and
2 electrodes over the iliac crest and
lateral part of buttock.

Postoperative Pain Continuous Pulse duration—40 microsecond 4 Pole method: 2 proximal and
Pulse frequency—100 Hz 2 distal to operated area.
Dose—10-15 Minutes

Menstruation Pain Continuous Pulse duration—100 microsecond 2 Pole method: over the
Pulse frequency—80 Hz sacrum bilaterally.
Dose—15 Minutes
Stress Incontinence Surge Pulse duration—100 microsecond 2 Pole method
Pulse frequency—60 Hz
Dose—15 Minutes

REFERENCES Walsh D, Baxter D. Transcutaneous electrical nerve

Walsh D. TENS: Clinical Applications and Related
Theory. Churchill Livingstone, 1997.
Ellis B. A retrospective study of long-term users of
TNS. British Journal of Therapy and Rehabi-
litation 1996;3(2):88-93.
stimulation—A review of experimental studies.
European Journal of Medical Rehab 1996;6(2):42-
50.
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
Electrical Stimulation
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 applica-tions like the high
voltage pulsed galvanic stimulation and
functional electrical stimu-lation 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
water-soluble 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 pri-marily
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.
Handbook of Practical Electrotherapy
The specific duration and voltage require-ments
vary depending upon the condition being
treated.
Effects and Uses of HVPGS
Application of HVPGS tends to produce
comfortable tingling sensation and paras-
thesia that closely resembles high fre-quency
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 infec-tion 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 charac-
teristics 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 produc-ing
controlled titanic contraction of muscles,
 Advanced Applications of Low Frequency Electrical Stimulation 59
which generates adequate torque to produce
functional movements, in the absence of
adequate voluntary contraction.
It is widely used to:
Prevent or correct disuse atrophy,
Improve ROM in stiff joints, reduce muscle
spasm or spasticity,
Re-education of new muscle action in case of
muscle or tendon transfers
Most commonly used for trial, supple-
mentation or substitution of orthosis.
Instrumentation of FES
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.
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.
Electrodes:
Self-adhesive pre-gelled electrodes.
Carbon rubber electrodes.
Application of FES in
Hemiplegic’s 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
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 parameters—Asymmetrical, bi-phasic,
square wave pulses with conti-nuous
modulation may be used, applied from a
standard faradic stimulator or rechargeable
battery operated portable stimulator.
Electrode placement—Bipolar 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
The patient is placed in high sitting on a
wooden chair, with the arm sup-ported in
front, on a wooden plinth.
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.
The skin is prepared, the equipment is tested
and the electrodes are fixed to the skin
with straps or adhesive tapes.
The intensity should be adequate to produce
tetanic contraction of target muscle,
within the limit of patient’s tolerance.
Patients with CVA may be hypertensive.
Therefore special care
Handbook of Practical Electrotherapy
should be taken not to cause any distress
to patient.
The pulse rate is adjusted to 12 to 25 pulses
per second.
The on-off ratio between surge dura-tion 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.
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 side-ways
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 prog-ressive
deformity, when the spinal curva-ture (Cobb’s
angle) is between 20 and 45°.
Current parameters—Interrupted mono-phasic
rectangular pulses with pulse
duration of 225 microseconds are used,
applied from a rechargeable battery operated
portable stimulator.
Electrode placement—Bipolar surface
electrodes, carbon rubber type may be used.
In case of single curve—Place 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.
In case of a ‘S’ curve—Place 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
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.
The electrodes are positioned as detailed above
under the straps of the brace and then the
straps are tightened to give opti-mum tension
on the curvature and maxi-mum contact to
skin.
The intensity is increased within the limit of
tolerance, to produce titanic contraction of
paravertebral muscles.
The pulse rate is adjusted to 25 pulses per
second.
The surge duration/interval ratio should be 1:1,
i.e. 6 seconds on and 6 seconds off.
The duration of the treatment may be up to 8
hours. The patient must be encoura-ged to
perform the self-stretch exercise with braces
on, while undergoing FES, to get best results.
 Advanced Applications of Low Frequency Electrical Stimulation 61
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 hemi-plegic
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 parameters—Asymmetrical bi-phasic or
square wave pulses with pulse duration of 20
to 250 microseconds, app-lied from a
rechargeable battery operated portable
stimulator.
Electrode placement—Bipolar surface
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:
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 acti-vities.
The electrodes are positioned as de-tailed
above under the straps of the brace and
then the straps are tightened to give
maximum contact to skin.
The intensity is increased within the limit of
tolerance, to produce titanic contraction of
target muscles.
The pulse rate is adjusted to 30 to 300 pulses
per second.
The flow of current is turned on during the
swing phase to produce dorsifle-
xion of the ankle as preparation to heel
strike.
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.
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 stimu-
lation 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 treated—a 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 medica-tion’s ion is
connected to electrode.
Handbook of Practical Electrotherapy
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 oppositely-charged 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 conti-nuous
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:
Duration of treatment
Current density or current intensity per square
cms area of the electrodes.
Concentration of ions in the medium used in
iontophoresis.
Based on the above the formula to cal-culate
quantity of substances introduced through
iontophoresis is:
I × T × ECE = grams of substances intro-
duced through skin, where,
I—stands for intensity of direct current in
amperes
T—stands for duration of application in hours
ECE—stands for standardized ionic trans-fer
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.
 Advanced Applications of Low Frequency Electrical Stimulation 63
Quick and effective surface anaesthesia with a
local aesthetic.
To treat hyperhydrosis or excessive sweat-ing 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 super-ficial
local inflammations, such as ten-donitis,
bursitis, and fasciitis.
Administration of cortisone using ionto-phoresis
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 anti-
inflammatory 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 tendo-nitis,
inflamed ligaments of knee, bicepital
tendonitis, shoulder rotator cuff tendo-
nitis/tenosynovitis, carpal tunnel syn-drome
etc.
Application of Iontophoresis in
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 injec-tions, wound
dressing or taking blood/ tissue samples.
The skin is as anaesthetized within 10 minutes of
iontophoresis, as compared to 60 minutes
with local anaesthetic cream.
Application of Iontophoresis in
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, iontopho-resis can
be used to treat axillary hyper-hidrosis as
well.
In addition to simple tap water, anticholi-nergics
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 water-soluble
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.
Handbook of Practical Electrotherapy

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 electro-des 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 + Lidocaine/Xylocaine gel Local anaesthesia
Salicylate – Sodium salicylate gel Relief of pain and inflammation
Acetate – Acetic acid Dissolve calcification of soft tissue
Zinc + Zinc oxide solution Skin ulcers
Copper + Copper sulphate solution Fungal infection
Calcium + Calcium chloride Muscle spasm
Magnesium + Magnesium sulphate do
Dexamethasone + Dexamethasone 1% gel Soft tissue inflammation

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 fre-quency
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 fre-quency, the
greater the resistance to the passage of the
current and so, more discomfort is
experienced.
The skin impedance at 50 Hz is approxi-mately
3200 ohms whilst at 4000 Hz it is reduced to
approximately 40 ohms.
Medium Frequency Currents 65
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 discom-fort.
TYPES OF MEDIUM FREQUENCY
CURRENT
Medium frequency current can be broadly
categorized in to two forms:
Medium frequency surge current
Interferential current
Medium frequency surge current is a two-
pole 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;
Russian current with carrier frequency of
2500 Hz
MF surge current with carrier fre-quency of
4000 Hz.
Handbook of Practical Electrotherapy
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 contrac-
tion 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 con-traction,
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 cur-rents.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 other’s
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, construc-tive
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 inter-ference 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 resul-tant
beat frequency would be the diffe-rence of
the two carrier frequencies i.e. 100 Hz,
spreading in a typical clover leaf pattern (Fig.
8.2B).

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.
Medium Frequency Currents 67
Modern machines usually offer frequen-cies 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 appro-priate
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 mani-pulation of
the currents, i.e. the inter-ference occurs
within the machine. This is suitable for small
areas like sinus, tem-poro-mandibular joints
etc.
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.
Handbook of Practical Electrotherapy

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 pri-mary aims of
the treatment.
Main clinical applications of IFT are:
Pain relief
Muscle stimulation Fig. 8.2A: Advanaced Interferential equipment: The
Increased blood flow Phyaction 787 stimulator with microprocessor
Reduction of oedema controlled circuits is a later generation equipment that
Tissue healing and repair. offers a wide range of stimulating current selection in
Since IFT acts primarily on the excitable tissues low and medium frequency range, with ultrasonic
therapy module which can be used for combination
like nerves and muscles, the strongest effects
therapy or as an independent modality (courtesy M/ S
are likely to be those produced by such Hintek Electronics, New Delhi). Note four channel
stimulation, i.e. pain relief and muscle conventional carbon rubber plate electrodes connected
contraction. to the machine through colour-coded leads. On the left
The other effects like drainage of fluid and of the plate electrodes are four sockets for vacuum
reduction in muscle spasm are secondary suction electrodes. Unlike the plate electrodes, the
vacuum suction electrodes do not need straps to hold
consequences of the primary effects.
them in place, hence are easy to apply over irregular
surfaces.
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 Fig. 8.2B: Advanaced interferential equipment: The
LCD display of Phyaction 787 in classical interference
in the AMF value that is desired; setting the
current mode, showing amplitude modulated frequency
AMF at 100 Hz and spectrum at 50 Hz will at 100 Hz, nil spectrum or sweep frequency, sweep
give an AMF variation from 100 Hz upto150 time of 1sec and a rise or fall rate of surge at 67 per
Hz and back to 100 Hz.The spectrum is cent. The clover leaf pattern of the classical
useful in preventing accom-modation in interference current is also shown along with intensity
nerves (Fig. 8.2B). 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 sti-mulation.
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
Medium Frequency Currents 69
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, provid-ing 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 stimu-lation
of the reticular formation at fre-quencies 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-
Handbook of Practical Electrotherapy
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 appli-cation 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 stimu-lation (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 fre-quency) 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 physio-logical
effect desired.
In acute conditions, shorter treatment times of 5
to 10 minutes may be sufficient to achieve the
effect. In other circum-stances, 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 exacer-bation.
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.
 Medium Frequency Currents 71

TYPES OF INTERFERENTIAL CURRENTS

(FOUR POLE APPLICATION)
Classical Interference Current
Interference occurs between two unmodu-lated
currents, crossing each other’s 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 sti-mulation
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 Fig. 8.6: Clover leaf pattern of electrical field in IFT
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 stereo-phonic sound
system.
The Clover Leaf Pattern
Isoplaner Vector Field
Applied through four electrodes like classical
interference current (Fig. 8.7).
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.
Handbook of Practical Electrotherapy

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 con-
ditions 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
Fig. 8.10: Placement of electrodes for application of IFT to
to a specific area through static vector mode the sciatic root
or rotate the field like the lights of a
lighthouse, stimulating tissues cyclically in muscled areas like painful shoulder, low back
all directions between the four electrodes, in pain and, pain of the thighs etc (Figs 8.8A and
a dynamic vector mode. B and 8.9, Plate 5).
The static vector mode is most useful in case of
longitudinal structures, e.g. bra-chioradialis Two pole Medium Frequency Current
or rectus femoris muscles. A band of This type of current gives the same type of
maximum intensity may be set up between stimulation as compared to four pole
the poles of the electrodes to target a specific interferential method
structure along its entire length, avoiding Current modulation depth is 100 per cent in all
unnecessary stimulation of adjacent direction. Maximum stimulation is produced
structures. in the tissues lying between the electrodes,
The dynamic vector has deionising effect on along the lines of forces con-necticting the
acute muscle spasm of large muscular areas electrodes and 0 per cent perpendicular to the
because of the massaging effect it creates and lines of forces.
its soothing nature of stimu-lation. Application is simpler due to less number of
electrodes, though in depth effect is
Cyclic contraction and relaxation creates comparable to the four-pole method.
pumping in muscles, increasing venous Suitable for localized smaller areas like the
drainage, reducing oedema, and improv-ing temporomandibular joints, muscles of the
blood circulation. hand, paracervical muscles, etc. It is
This type of current is most suitable for the specifically used to achieve relief of pain in
treatment of muscle spasm of heavily sciatic neuralgia.
 Medium Frequency Currents 73

Clinical Applications of Interferential Current

Disease condition Type of current Current parameter Electrode placement

Tension headache Dipole vector field AMF-100 Hz, Crossed 4 pole, 2 each over
Autosweep-3 sec the origin and insertion of
Contour-40%, bilateral Trapezius muscle
Dose-15 minutes upper fibres, strong tingling
felt
Periarthritis of Dipole vector field AMF-100 Hz Crossed 4 pole method
shoulder, with Spectrum-50 Hz, Channel A Anterior-
generalized pain and Manual sweep posterior of shoulder,
spasm around the Contour-40%, Channel B over deltoid
joint and restriction Dose-15 minutes tubercle and acromion
of ROM at end range arch, light rhythmic
contraction seen (Fig.
8.8A, Plate 5)
Periarthritis of 2 Pole medium AMF-100 Hz 2 Poles of a single channel,
shoulder, with Frequency field Spectrum-50 Hz, AP placement across the
localized tenderness Manual sweep-3 sec shoulder covering the
and no significant Contour-40%, tender spot, light rhythmic
restriction of ROM Dose-15 minutes contrac-tion seen

Frozen shoulder or a. Isoplaner vector field a. AMF-100 Hz; 1 min. Crossed 4 pole method
adhesive capsulitis, b. Dipole vector field b. AMF-100 Hz, Channel A Anterior-
with gross restriction Autosweep-3 sec posterior of shoulder,
of ROM and night Contour-40%, Channel B over deltoid
pain, especially in Dose-12 minutes tubercle and acromion
diabetics arch, light rhythmic
contraction seen (Fig.
8.8A, Plate 5)
Peripheral oedema Isoplaner vector field AMF-50 Hz Crossed 4 pole method
of transudate type Spectrum-50 Hz, Cover the entire oedema,
Manual sweep-1 sec elevate the limb, strong
Contour-01%, vibration felt
Dose-10 minutes
Lumbago a. Isoplaner vector field a. AMF-200 Hz; 2 min. Crossed 4 pole method
b. Dipole vector field b. AMF-100 Hz, Electrodes placed on either
Autosweep-3 sec side of the vertebral column
Contour-40%, covering the muscle painful
Dose-12 minutes region, light rhythmic
contrac-tion seen (Fig. 8.4,
Plate 5)
Muscle contusion Dipole vector field AMF-100 Hz, Crossed 4 pole method
Autosweep-3 sec Cover the entire lesion
Contour-40%, support the limb, light
Dose-07 minutes rhythmic contraction seen
(Fig. 8.9, Plate 5)

Contd....
Handbook of Practical Electrotherapy

Contd...

Disease condition Type of current Current parameter Electrode placement

OA hip joint Isoplaner vector field AMF-50 Hz Crossed 4 pole method

Spectrum-50 Hz, Channel A Anterior-
Sweep-6 sec posterior of the hip,
Contour-67%, Channel B dorsal to greater
Dose-15 minutes trochanter and the groin,
light rhythmic contraction
seen
Tennis elbow or 2 Pole medium AMF-80 Hz 2 Poles of a single channel,
Golfer’s elbow Frequency field Spectrum-40 Hz, mediolateral placement
Manual sweep-3 sec across the elbow covering
Contour-75%, the tender spot, light
Dose-10 minutes rhythmic contraction seen
Weakness of Dipole vector field AMF-30 Hz,
Crossed 4 pole method
abdominal muscles Autosweep-5 sec Electrodes placed on either
Contour-0%, side of the midline covering
Dose-15 minutes the muscles, light rhythmic
contraction seen

Post immobilization Isoplaner vector field AMF-25 Hz Crossed 4 pole method

contractures of large Spectrum-10 Hz, Electrodes placed on either
joints Sweep-2 sec side covering the joint,
Contour-10%, light rhythmic contraction
Dose-15 minutes felt (Fig. 8.7)
Post immobilization 2 Pole medium AMF-25 Hz Trans-arthral 2 pole
contractures of small frequency field Spectrum-10 Hz, method
joints Sweep-2 sec Electrodes placed on
Contour-10%, either side covering the
Dose-10 minutes joint, deep stimulation
Atonic bladder Classical interferential AMF- 1 Hz felt
Crossed 4 pole,
current Spectrum-99 Hz, 2 large electrodes over the
Sweep-3 sec buttock just lateral to the SI
Contour-50%, joint and 2 smaller electrodes
Dose-10 minutes on either side just above the
Myalgia of large Dipole vector field AMF-100 Hz, symphysis pubis, strong
tingling felt.
Crossed 4 pole, electrodes
muscle groups Autosweep-2 sec covering the whole muscle
Contour-40%, group, along with the
Dose-08 minutes antagonists (Fig. 8.5, Plate
Myalgia of small Medium frequency AMF-100 Hz, 5)
2 Electrodes over the
muscle groups surge currents Surge duration -3 sec muscle belly.

Contd....
 Medium Frequency Currents 75

Contd...

Disease condition Type of current Current parameter Electrode placement

Surge interval-3 sec Minimum perceptible

Contour 30% contraction.
Dose- 10 minutes
Haemoarthrosis of Isoplaner vector field AMF-80 Hz Crossed 4 pole method
knee joint (up to Spectrum-40 Hz, Channel A Anterior-posterior
grade-II) Sweep-1 sec of the joint, Channel B
Contour-10%, Medio-lateral to the joint,
Dose-12 minutes light rhythmic contraction
seen (Fig. 8.5, Plate 5)
Tenosinovitis Medium frequency AMF-20 Hz 2 Pole: One over the muscle
current Spectrum-100 Hz, belly and one over the
Sweep-1 sec tendon.
Contour-1%, Definite alternating
Dose-17 minutes sensations felt.
Cellulites Dipole vector AMF- 50 Hz 4 Pole placement over
Sweep- 3 sec the affected area. Clear
Dose- 15 minutes rhythmical contractions
Rheumatoid arthritis Isoplanar vector field AMF- 100 Hz felt.
4 Pole placement around the
Spectrum- 50 Hz affected joint (Fig. 8.7)
Sweep time- 3 Sec
Contour- 67 %
Dose- 10 minutes
Chronic constipation Classical interferential AMF- 20 Hz Crossed 4 pole method: 2
current Spectrum- 20 Hz electrodes placed on the
Sweep time- 4 sec abdominal wall, over the
Contour- 33% iliac fossa on either side:
Dose- 30 minutes other two placed under the
SI region.
Handbook of Practical Electrotherapy
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 identi-fied, 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.
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

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.
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).
Fig. 9.1: Position of the patient and the relative
position of the infrared lamp for application of
Physiological Effect of Superficial Heat
superficial heat to the nape of the neck.
Superficial heat has different kinds of effects
depending on the nature of application. Increased interstitial fluids turn over and
Generalized heating of large areas of the body
better drainage due to higher capillary
surface, like the entire upper or lower limbs,
permeability.
whole back or whole body, with whirlpool
Increased flexibility of capsules,
bath, Hubbard’s tank or heated hydrotherapy
ligaments and tendons due to grea-ter
pool, produces following effects:
elasticity of collagen fibres.
Increased physiological reactions: Raised
cardiac output, metabolic rate, pulse rate, Increased metabolic rate due to increase
respiratory rate and super-ficial blood in cellular oxidation.
circulation due to dilatation of capillary Decreased physiological reactions:
network. Decreased joint stiffness due to greater
Decreased physiological reactions: Lowered flexibility of collagen tissue.
blood pressure, muscle spasm, blood Decreased muscle torque due to
supply to internal organs and muscles and suppression of glycol breakdown.
stroke volume of the heart. Decreased muscle spasm due to
diminished neural activity.
Local heat application to small areas of the Decreased pain due to pre-synaptic
body, like the knee or shoulder joint, neck, inhibition of pain transmission.
low back region, with infrared lamp, Paraffin
wax bath, moist hot packs, electric heating Indications for Superficial Heat
pads or hot water bags, produces following
effects. Superficial heat is the modality of choice, to raise
a. Increased physiological reactions: the general or local temperature of the body
Increased local blood flow due to tissues, as a preparatory step before appli-cation
vasodilatation. of active movements, passive mobi-lisation,
massage or electrical stimulation to
Handbook of Practical Electrotherapy
the musculoskeletal system, particularly in
presence of:
Joint stiffness and pain
Muscle spasm and pain
Painful chronic lesions—Posttraumatic,
degenerative or inflammatory
Rheumatism of the skeletal and soft tissue.
Contraindications for Superficial Heat
Acute traumatic and inflammatory lesions of the
musculoskeletal system
Infections—local 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 ½ hour.
Expose the part to be treated; rest of the body
should be covered with a sheet.
Check for rashes, cuts, bruises and dis-coloration
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. Alzheimer’s 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 over-heating 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 treat-
ment and precautions to be observed in
thermotherapy are same for most forms of
superficial heat or deep heat or cold modali-ties.
Specific modalities have few specific concerns
that need attention, covered under the heading of
‘special points’.

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 bio-physics, under the
section of superficial heat, with the luminous
variety detailed under the section of therapeutic
light in this volume.
Moist Hot Packs—Hydrocollator
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
to 60° C, heated electrically and regula-ted by
a thermostat.
Method of heating—Conduction of heat from hot
water to silica gel.
Method of application—
For small and medium-sized packs—Fold 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.
Therapeutic Heat 79
For large-sized packs—Fold 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 treatment—20 to 30 minutes in a
sitting may be repeated twice a day in acute
conditions.
Effective in—Superficial 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 disinfec-tant solution
once a week.
HYDROTHERAPY FOR SUPERFICIAL
HEATING—WHIRLPOOL BATH/
HUBBARD’S 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
Handbook of Practical Electrotherapy
add on services like massage, steam bath or
sauna, for treatment of stress and musculo-
skeletal 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 becom-ing
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 (Archi-medes
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 1°C. 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,
Hubbard’s tank and steam bath or sauna.
Method of Application of Whirlpool Bath
A. Whirlpool bath is immersion of an extre-mity
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.
Whirlpool bath consists of a oblong-sha-ped
stainless steel tank, usually 3’deep x 3’long x
2’wide in size, mounted on four castor
wheels, fitted with a thermostat-controlled,
immersion type electric heating coil and an
air-jet pump with nozzle.
The tank is filled with water, leaving a gap of 6’
to 8’ from the top. The water is heated to 35°
to 40°C. A disposable plastic liner may be
used and any common disinfec-tants like
sodium hypochlorite at dilution of 200 parts
per million (ppm), povidone-iodine at 4 ppm
or savlon at 100 ppm may be added while
treating burn injuries and infected wounds.

The patient is assisted to immerse the body part
in the tank, after sitting down comfor-tably on
a height-adjustable stool placed beside the
tank.
Adjust the direction and force of the air-jet 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.
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.
Method of Application of
Hubbard’s Tank
Hubbard’s tank is immersion of the whole body
in a pool of circulating heated water, suitable
for the treatment of acute or sub-acute
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.
Hubbard’s tank consists of a butterfly-shaped
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.
The tank is filled with water to the desired level
(see whirlpool), which is then heated to the
desired temperature. A disposable
Therapeutic Heat 81
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 accusto-med 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, includ-ing 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.
Handbook of Practical Electrotherapy
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 hydro-therapy
consists of an insulated chamber made of
laminated waterproof ply wood or man made
fibres, large enough accom-modate 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 45°C.
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 treat-ment.
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 pro-duced by
prolonged exposure to heat and excessive
sweating.
PARAFFIN WAX BATH
Paraffin wax bath is the therapeutic appli-cation
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”× 8”in 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 45°C and is self-steri-lizing in nature. The
temperature is sus-tained 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.
Method of Application
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.

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 HEAT–INFRARED RAYS
Radiant heat is the therapeutic application of
radiant electromagnetic energy, obtai-ned
either as invisible infrared from any heat
source or in combination with visible light
and ultraviolet rays from an incan-descent
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 infra-red
electromagnetic rays in the frequency range
of 1500 to 12000 Angstrom units, having a
penetration of 2 mm in the epi-dermis.
Heat transmission with infrared radiation is
governed by following physical prin-ciples:
Lambert’s cosine law, which states that the
angle incidence of radiation is
Therapeutic Heat 83
directly proportional to the extent of
radiation absorbed. Optimal absorp-tion is
possible only when the source of radiation
is perpendicular to skin.
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.
Method of Application
The non-luminous lamp is turned on
approximately 5-10 minutes before appli-
cation 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 36”from 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.
Handbook of Practical Electrotherapy

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
Infrared Superficial muscle spasm
and localized pain of neck
and trunk
Paraffin wax Stiffness of joints and pain
bath due to degenerative disorders,
Soft tissues contractures
following immobilisation
Whirl pool/ Multiple joint stiffness and
Hubbard’s tank pain, disuse atrophy, wound
debridement in burn, paralytic
conditions
• Reusable and cost
effective
• Safe for delicate skin,
• Prolonged analgesia,
• Circumferential heating.
Easy to apply
Better localization of heat.
Cost effective for home
management
• Circumferential heating,
• Improves the texture of
the skin
• Increases pliability of
soft tissue
• Prolonged analgesia.
• Reusable and cost
effective
• Applicable for whole or
part of the body
• Induces relaxation, relief
of pain and spasm
• Exercise can be done
easily due to buoyancy
• Initially expensive,
• Risk of scalds
• Risk of fungal
infections
Risk of burn if source is too
close to the skin
Risk of eye injury in
luminous I.R
Effect is transient
• Messy application
procedure,
• Regulation of tempera-
ture difficult and may
cause burn,
• Highly inflammable
composition, hence fire
hazard
• Expensive to install
and run
• Needs more space
• Extensive preparation
and constant super-
vision needed
• Messy operation
• Risk of electrical
accidents
 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 short-wave—diathermy,
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 electro-
magnetic (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 radio-frequencies 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:
Capacitor or condenser field method
Inductance or magnetic field method.
Capacitor or Condenser Field
Method of Application
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 oscillat-ing 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
Handbook of Practical Electrotherapy
circuit, as a di-electric medium, and are
subjected to these lines of forces.
High frequency oscillating current pro-duces
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 mole-cules
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 subcuta-neous 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 pene-tration are
determined by the shape and the distance
between the electrodes.
Inductance or Magnetic Field
Method of Application
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 produ-ces 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, secon-dary
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 conduc-tivity 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 circuit–Consists 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 conden-ser,
electrode connecting cables, electrodes

Fig. 10.1: Short-wave diathermy unit
Deep Heat Therapy 87
Fig. 10.2: The circuit configuration of the high-
frequency 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 full-
bridge 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
Handbook of Practical Electrotherapy
and the body part which act as the dielec-tric
of the variable condenser.
Transfer of energy—Maximum transfer of energy
from the machine circuit to the patient circuit
takes place when the product of the
capacitance and the induc-tance 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 patient’s 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 auto-matic
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 super-ficial 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 pro-
duced 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 vasodila-
tation.
Decreased physiological reactions: Low-ered
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, lumbo-
sacral region produces following local effects,
which have significant therapeutic value.
Increased reactions
Increased local blood flow due to vaso-dilatation,
leads to tissue healing, relief of muscle spasm
and pain.
Increased interstitial fluids turn over and better
drainage due to higher capillary permeability,
leads to reduction of swell-ing.
Increased flexibility of capsules, ligaments and
tendons due to greater elasticity of collagen
fibres lead to greater mobility of joints.
Increased metabolic rate leads to activation of
dormant tissue.
Increased pain threshold due to sedation of the
pain carrying nerve fibres resulting in pain
relief.
Decreased reactions
Decreased joint stiffness due to greater flexibility
of collagen tissue.
Decreased muscle torque due to suppres-sion of
glycol breakdown.
 Deep Heat Therapy 89

Decreased muscle spasm due to dimini-shed Bleeding disorder

neural activity. Severe swelling
Decreased pain due to pre-synaptic inhibi-tion of Impaired cognition or inability to assess the
pain transmission. degree of heat being felt.
Very young and very old patients.
INDICATIONS FOR SHORT-WAVE
DIATHERMY METHODS OF APPLICATION OF
SWD is effective in management of pain and SHORT-WAVE DIATHERMY
inflammation associated with the following Preparation of the Equipment
disorders:
The equipment is connected to the mains
Musculoskeletal system disorders, e.g.
The electrodes/cable are attached to the output
spondylosis, osteoarthritis, rheumatoid
terminal of the machine.
arthritis, degenerative joint diseases and
The equipment is turned on and warmed up for at
postural or posttraumatic muscle spasm and
least 2 minutes.
pain.
The therapist places one hand between the
Pelvic inflammatory disorders, e.g. pelvic
electrode plates/over the coil of the cable
endometriosis.
electrode, increases the intensity at least two
Inflammation of body cavities, e.g. Sinu-sitis.
steps from the minimum. The machine is then
tuned by turning the tuning knob in one
Using non-thermal effect of pulsed SWD for
direction till maximum deflection shows on
healing of wounds.
the tuning meter. A comfortable warmth
should be felt after a minute or so, indicating
CONTRAINDICATIONS OF
that the machine output is adequate for
SHORT-WAVE DIATHERMY
treatment and it’s safe for patient application.
SWD should not be applied in following
conditions: After testing the machine output the intensity is
Presence of metal implants or ornaments within returned to zero level and hand removed from
the field of the lines of forces. the electrodes.
Patients with pace-maker
Pregnant women should not be given SWD in Application of Treatment with
the region of low-back or lower abdomen. Short-Wave Diathermy
The patient is positioned in a comfortable
Acute traumatic and inflammatory lesions of the position on a wooden plinth, part exposed and
musculoskeletal system the rest of the body draped with a sheet.
Infections—local or general
Circulatory deficiency The part may be wrapped double layer of
Diminished thermal sensation Turkish towel to absorb sweat produced
Deep vein thrombosis during the treatment and acts as spacer with
Malignancy air-space.
Handbook of Practical Electrotherapy
What are Spacers?
Spacers are insulating material containing air-
spaces, 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
SHORT-WAVE DIATHERMY
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
SHORT-WAVE DIATHERMY
The condenser type electrodes may be, either
pads made of flexible metal plates covered with a
layer of heat resistant rubber or air-spaced 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. Extra-
spacing, if required, may be provided by using
several layers of Turkish towel or extra-felt pad
spacers. Before application of elect-rodes, 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).
Contraplaner placement: This is the prefer-red
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).
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).
Cross-fire placement: This method of elect-rode
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.
Asymmetrical placement: These are speciali-zed
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 compart-ment
syndrome or chronic spasm of calf
muscles or as a preparatory step before
stretching of the calf muscles.
Deep Heat Therapy 91
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 wrapp-ing 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 concen-tration
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 heavily-muscled and
highly vascular areas like the calf, thigh,
upper arm etc.
APPLICATION OF TREATMENT WITH
SHORT-WAVE DIATHERMY
After the machine circuit has been warmed up
for at least 2 minutes, the intensity knob
Handbook of Practical Electrotherapy
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 automati-cally.
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 pre-caution 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 possi-
bilities.
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 short-wave 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 magnet-ron
produces MWD. The magnetron con-sists 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
 Table 10.1: Technique of application of short wave diathermy in few specific disease conditions
Condition Patient position Method of choice Electrode Duration of Specific Supplementary
placement treatment precaution therapy

Low Back Pain Prone lying on Condenser field, Coplaner 15-30 minutes
Sacroiliitis Avoid exposure 10 minutes of
a padded- using 8”×10” covering the with mild heat, during menstrua- surged faradic
wooden plinth, pads affected area, once a day, on tion or upper GI stimulation
with pelvic and or use felt spacers alternate days bleeding before SWD
Lumbago ankle support Inductance field under pads or or daily for gives better
with rolls of using a cable air-spacing with 10-15 sittings result in relief
towel or hinged drum drum electrodes of pain and
Knee Joint electrodes muscle spasm.
Long sitting or Condenser field, Transarthral contra- 15-20 min once
Osteoarthritis Avoid exposure Effect of SWD
Rheumatoid supine on a using 6”× 8” planer/cross-fire a day, on alternate in acute infla- can be magnified
arthritis padded-wooden pad or 6” method days or 10-15 min mation severe by prior applica-
Trauma plinth with a roll diameter disk Hinged-drum once a day, daily osteoporosis, tion of surged
under the knee electrodes or covering the top suspected faradic stimula-
Inductance field and both sides of fracture tion, at sex
using a cable or the joint or cable surges per
hinged drum coiled around the second, for 10
electrodes joint minutes.
SWD may be
followed up
with pain-killing
gel massage and
Knee Joint IR for 10 minutes
Inductance field Hinged-drum

Deep Heat Therapy 93

Chondromale- As above As above As above As above
cia, patella using a cable covering the top
chronic or hinged-drum and both sides
synovitis electrodes of the joint or
cable coiled
around the joint
Contd...
 94 Handbook of Practical Electrotherapy
Contd...

Condition Patient position Method of choice Electrode Duration of Specific Supplementary

placement treatment precaution therapy

Frozen shoulder Sitting on a Inductance field- Hinged-drum 15-20 minutes Watch for bony 10 minutes of
wooden chair using hinged- covering the top once a day prominences surged faradic
with arm rests, drum and both sides of stimulation before
feet resting on a Condenser field, the joint SWD gives
rubber foot mat using 6” × 8” Transarthral place- better result in
Supine lying on pad or 6” ment on the front relief of pain and
a padded-wooden diameter disk and back of the muscle spasm.
plinth electrodes joint
Pelvic inflamma- Sitting on a Condenser field, Pads over the lower 30 minutes OD Avoid exposure Watch for vertigo.
tory disorders wooden arm chair, using 8” × 10” abdomen and under during menstru-
feet resting on a pads the buttocks. ation or in
rubber foot mat Use felt-spacers presence of IUD.
Supine lying on a under the pads.
padded-wooden
plinth

COPD Prone lying on a Condenser field, Coplaner method, 20 minutes OD Avoid exposure Before SWD
Bronchitis padded-wooden using 8” × 10” covering the in acute respi- exposure, massage
or Asthma plinth, with pads cervicodorsal or ratory distress the chest wall with
pelvis and ankle or dorsolumbar or or menthol and
support Inductance field contraplaner acute lung salicilate ointment
or using hinged- method on the infections and followed
side lying drum electrodes upper chest. Use by IR on the chest
or felt-spacers for better results.
Crook lying with under pads or
a roll under the air-spacing with
knee. drum electrodes

Contd.
..
Contd...

Condition Patient position Method of choice Electrode Duration of Specific Supplementary

placement treatment precaution therapy

Sinusitis – Sitting on a Condenser field, Contraplaner 10 minutes of Use two layers Kneading massage
Maxillary and wooden arm using one method mild heating of towel to cover to the
frontal sinus chair, feet butterfly pad Coplaner method the forehead, neck helps relieve
inflamation resting on a covering the nose and eyes concurrent
rubber foot mat frontal and the are kept clear muscle spasm
Supine lying on maxillary sinuses of obstruction
a padded-wooden and a large dis-
plinth persive pad under
the neck
Inductance field
using hinged
drum electrodes
covering the
frontal and the
maxillary sinuses

Deep Heat Therapy 95

Handbook of Practical Electrotherapy
antenna, mounted inside a hard plastic shell,
known as an applicator. The electro-magnetic
wave released from the appli-cator 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 treat-ment.
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 electro-
magnetic 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 super-ficial 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 concen-trated
and localized heating is required in
superficial targets like trigger points,
fibromyositis, epicondylitis etc.
Contraindications for
Microwave Diathermy
MWD is strictly contraindicated in pre-sence 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 diver-gence
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 concen-trated 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
Deep Heat Therapy 97
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 sensa-tion
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.
Handbook of Practical Electrotherapy

11
Therapeutic Ultrasound
(US Therapy)
Sound can be defined as a periodic mecha-nical
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 Fig. 11.1: Wave patterns of ultrasound energy
density, specific gravity etc. The velocity of
sound is 0 in vacuum, 344 m/sec in air, 1410 and the muscle has the lowest acoustic
m/sec in water and 1540 m/sec in muscles. impedance.
Human ear can hear sound with frequency of 20
The resistance offered by the medium to the kHz, i.e. 20000 cycles/sec, whereas dogs
passage of sound is inversely proportional to the have hearing range of 50 kHz.
velocity and is known as acoustic impedance. Any sound having frequency greater than 80 to
Therefore vacuum has the highest 100 kHz is classified as ultrasound.

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 expo-sed
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 non-thermal 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 attenua-
tion characteristics of US waves have been
documented for several types of tissue.
The ultrasound energy is non-electromag-netic in
nature and it creates successive bands of
compression and rarefaction in
Therapeutic Ultrasound (US Therapy) 99
the conducting medium, producing heat and
mechanical deformation of the me-dium.
When applied to body tissue ultrasound
energy is converted to heat energy and
mechanical micro-massage within tissues, to
produce definite physio-logical reactions,
with definable therapeu-tic 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 Barium-
Titanate 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
Handbook of Practical Electrotherapy
Fig. 11.3: Different sizes of ultrasonic transducer
head–(top) 3 sq cm size head is used for very loca-
lized 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 reso-nance
of the crystal depends on the fre-quency 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 sur-face. 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 mecha-nical
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 therapeu-tic
ultrasound are 3 MHz and 1 MHz.
At 3 MHz, the depth of penetration is relatively
shallow, with maximum absorp-tion 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 pronoun-ced
and in pulsed mode the non-thermal effects
are more prominent.
Mark-space ratio—The 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 cylindri-cal in
shape, at least in the near field. The diameter
is nearly the same as the dia-meter 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
2
continuous mode, at an intensity of 0.5-3 W/cm ,
through following mechanisms, pro-duces heat,
due to:
Absorption of the sound energy in body tissues,
resulting in increased tissue tempe-rature. If
the tissue temperature can be raised to 40-
45°C 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.
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 ultra-sound therapy.
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 the-rapy given at 3 MHz has an
average half value distance of 3 to 5 mm and
at 1 MHz it is 11 mm.
Therapeutic Ultrasound (US Therapy) 101
The ultrasound beam refracts when travel-ling
from one tissue to another, due to difference
in acoustic impedances of tissues.
Reflection of a part of the ultrasound energy
(30%) takes place at tissue interfaces, resul-
ting in release of heat. Tissue interfaces are
adjoining surfaces between two types of
issues, e.g. the bone/peritoneum, fascia/
muscle, muscle/periosteum, bone/liga-ment
or bone/capsule, which become the sites of
heat concentration.
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 imme-diately if
such pain occurs and bony prominences must
be avoided all together.
Hot spots may also be created under the
transducers, if inadequate coupling me-dium
is used, resulting in uneven distri-bution 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 compo-nent being
used, as in pulsed mode appli-cation. Such
reactions are due to non-thermal effect of
ultrasound, which can be described as follows:
Mechanical effects: The high frequency
vibrations created by ultrasound energy
Handbook of Practical Electrotherapy
produce deformation of the molecular
structures of loosely-bonded substances like
the soft tissues. This produces micro-massage
of soft tissues which has sclero-lytic effect,
i.e. it can break down calcifica-tion or
adhesions in soft tissue, resulting in relief of
muscle spasm, softening of scars tissues,
release of contractures and adhesions.
Cavitations: Kinetic energy of the ultra-sound
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 trans-migration 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 expan-sion, the gas bubbles
may burst releasing a lot of heat deep within
the tissues causing serious damage.
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, creat-ing high-pressure areas
along the cell membrane altering the
permeability of the cell membrane
temporarily during ultra-sound exposure.
Free radicals and other waste products of cell
metabolism are expelled and protein
synthesis and repair process of the cell is
activated.
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 ultra-sound.
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 stream-ing,
standing waves and micro massage.
Indications for Ultrasound Therapy
Ultrasound therapy may be used for following
conditions:
Acute soft tissue injuries—It has now become a
standard practice in sports

physiotherapy to use of ultrasound the-rapy
in acute soft tissue injuries, even in the sports
filed. The reasons are as follows:
Mechanical effect of ultrasound helps to
remove post-traumatic exudates and
reduce the risk of adhesion formation.
Mild thermal effect of ultrasound helps to
induce relief of pain and allows early
movement of the injured part.
Protein synthesis accelerated by bio-logical
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 post-
inflammatory 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 break-down
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
Therapeutic Ultrasound (US Therapy) 103
to begin. Protein synthesis effect of ultra-
sound 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 incon-clusive.
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 mecha-
nical effect of ultrasound to create an
embolus.
Poor blood supply: (Burger’s 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 ultra-sound
and enter the blood stream to spread to other
areas or create septicaemia.
Handbook of Practical Electrotherapy
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 devita-lised
by radiation may breakdown when exposed to
the combined effect of heat, mechanical and
biological effect of ultra-sound 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 cervi-cal
region must not be given as it may cause
stimulation of vagus nerve, leading to
arrhythmia of the heart.
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.
Technique of Application of
Ultrasound Therapy
Setting up and testing of the ultrasound therapy
equipment is the first step in application of
treatment. The apparatus is
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
gra-dually 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;
Fig. 11.4: Digital ultrasonic machine—on 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
2
display for intensity in W/cm . 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.
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.
Technique of application of therapeutic
ultrasound varies depending on the site,
depth of target tissue, underlying patho-logy
and the desired clinical effect.
The commonest method of application is with
direct contact of the transducer on the skin sur-
face 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 adminis-tration
of therapeutically useful substances
transcontinuously to the target tissue.
Direct Contact Method
This is the commonest method of ultrasonic
application, suitable for relatively flat sur-faces,
free of irregularities and bony promi-
Therapeutic Ultrasound (US Therapy) 105
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 trans-
ducer and on the skin surface over the tar-get
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. Coupl-ing
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
aqua-based 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 gra-dually
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 treat-ment 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
Handbook of Practical Electrotherapy
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 inten-sities 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, liga-ment
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.
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 mo-mentarily,
particularly over a bony pro-minences, the
patient may feel intense heat sensation at a
point. This is due to peri-osteal 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-
dose of sound energy, which may cause
irreversible damage to the tissues (Figs 11.8
to 11.15).
Presence of DVT, acute sepsis or inflam-mation,
healing fracture or osteoporosis, metal or
plastic implant in the treatment field is strict
contraindication to ultra-sound 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
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 Dupuytren’s 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 supra-
spinatus 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
Therapeutic Ultrasound (US Therapy) 107
Fig. 11.11: Application of ultrasound to the temporo-
mandibular 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 sterno-
costal 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 application must be followed up with deep
friction massage and stretching of the contracted
pectoral aponeurosis
Handbook of Practical Electrotherapy
Fig. 11.13: Application of ultrasonic therapy over
the 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 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 extensor tendons
Fig. 11.14: Application of ultrasonic therapy over
the 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 Quervain’s disease). Ultrasonic
therapy is the modality of choice for de Quervain’s
disease. 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. 11.15: Application of ultrasonic therapy over the
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
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 ultra-sound
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.
Precautions to be Observed in
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. Allow-ance 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.
Therapeutic Ultrasound (US Therapy) 109
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 comple-tely 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.
Precautions to be Observed in
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.
Handbook of Practical Electrotherapy

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 dura-tion 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 Fig. 11.16: Application of ultrasound to the clavicular
subcutaneous capillary network, from where fossa for treatment of brachial neuralgia. Ultrasonic
these molecules can be carried by the blood therapy in pulsed or continuous mode may be opted for
stream to deeper tissues. The molecules thus depending upon whether the condition is acute or
chronic respectively. For best results, ultrasonic
introduced dissociate into elements and radicals
application must be followed up with adverse neural
within the tissue, which then combine with the tension stretching of the brachial roots
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.
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 ultra-sound, 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
Fig. 11.17: Application of ultrasonic therapy over the
thoroughly into the skin before applying medial collateral ligament of the knee for the treatment
ultrasound (Fig. 11.16). of strain, sprain or osteoarthritis of the knee. Ultrasonic
therapy is the modality of choice for medial joint-line
Same gel or ointment mixed with standard tenderness of the knee. Since the area is bony the
ultrasound gel is placed over the trans-ducer ultrasonic therapy should be in pulsed mode. Care
head as coupling medium. should be taken not to keep the transducer stationary,
because that may create standing waves, which may
Ultrasound is then applied to the target area by
produce periosteal irritation and pain. For best results,
the direct contact method (Fig. 11.17). ultrasonic application must be followed up with deep
friction massage over the ligament
 Therapeutic Ultrasound (US Therapy) 111

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 intro-ducing 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
Fig. 11.18: Application of ultrasonic therapy over the
Adverse Reactions and Contraindications lateral collateral ligament of the ankle for the
Hydrocortisone gel or ointment 1-10%—It may treatment of strain or sprain. Ultrasonic therapy is
be used for strong anti-inflammatory action in the modality of choice for ligament strains of the
ankle. Since the area is bony the ultrasonic therapy
acute inflammation of soft tissue. In rare
should be in pulsed mode. Care should be taken not
cases skin rashes may be seen which is best to keep the transducer stationary, because that may
treated by antihistaminic (cetrizine) drugss create standing waves, which may produce
(Figs 11.19 and 11.20). periosteal irritation and pain. For best results,
ultrasonic application must be followed up with deep
Lidocaine 4-5% gel (xylocaine)—It is very
friction massage over the ligament
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. Fig. 11.19: Application of ultrasound to fibromyositic
nodule in rhomboids muscle. Since the area is
Patients that are allergic to sea food should
fleshy, continuous mode of ultrasonic therapy may
not be treated with iodine. In case of skin be used. For best results, Ultrasonic application
irritation and itching give antihistaminic must be followed up with deep friction massage
drugs (Fig. 11.23).
Zinc oxide creams 20% (Siloderm)—Zinc is a as a medium for phonophoresis to the edges
healing agent and can be useful in treatment of the indolent wounds to promote healing.
of open wounds. It can be used Patients who cannot wear metal wrist watch
bands or jewellery due to
Handbook of Practical Electrotherapy
Fig. 11.20: Application of hydrocortisone phono-
phoresis 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. 11.22: 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
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.
The agents of phonophoresis discussed above
are the fruit of the cumulative know-
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. 11.23: 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
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
 Therapeutic Ultrasound (US Therapy) 113

that the therapists should experiment with the increased accuracy and effectiveness in treating
application of theses drugs through phono- deeper lesions, especially while treating trigger
phoresis in suitable disease conditions and points.
contributes to the data-base of clinical know-
ledge. Biophysics of Combination Therapy
Ultrasound exposure to a peripheral nerve
Combination Therapy Using Ultrasound reduces its resting membrane potential by
and Electrical Stimulation increasing its permeability to various ions,
+ ++
In general terms, combination therapy involves especially sodium (Na ) and calcium (Ca ).
the simultaneous treatment with ultrasound and Due to this altered permeability, the nerve
electrical stimulation. In Europe, the trend is membrane is taken closer to its response
towards using diadyna-mic currents with threshold, though it does not usually make the
ultrasound, but in the UK, it is most often nerve fire. The simultaneous application of MF2
combined with two-pole medium frequency pole current through the nerve induces the
current. depolarisation, with a much less current intensity
than usual, due to the sensitization created by
Important Considerations ultrasound exposure.
This can easily be demonstrated. If both the
There is a significant lack of published material US and MF are being applied and during the
in this area. And much of the information treatment if the intensity of the US is turned
herein is anecdotal or based on the
down to zero, the sensation produced by the MF
experience of those who use the modality
will diminish even though the MF intensity has
frequently.
not been changed. The intensity of sensation
Broadly, the effects of the combined treat-ment
produced by the MF intensify as the intensity of
are those of the individual modali-ties. There
the US is turned up (Fig. 11.24).
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
Fig. 11.24: Biophysics of combination therapy
Handbook of Practical Electrotherapy

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.
Technique of Application of
Combination Therapy
Combination therapy is a relatively new form of
treatment. The guidelines for application, as
presented below, are derived from expe-riences
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
2
0.5W/cm should be used for this procedure.
A frequency of 1MHz is preferable if available
as it gives more effective pene-tration 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 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 per-ceptible 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 to-wards 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-

The other terminal of the MF is connec-ted

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 Fig. 11.25: Localisation of trigger point using
two pole current for combined therapy. combination therapy

tion is usually consistent and repro-
ducible.
Once the focal point of a lesion has been
detected further treatment may be done
with only ultrasound therapy or combined
therapy.
As 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 there-fore
try to match the treatment time for both
modalities by selecting an opti-mum
duration of treatment wherever possible.
If treatment times are similar, the
combination of the modalities can save
time and effort (even without addi-
Therapeutic Ultrasound (US Therapy) 115
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 moda-
lities during combination therapy, i.e.
always using a moving treatment head,
maintain effective contact, the per-
pendicular relationship between the
treatment head and the patient’s skin
whenever possible.
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
2
W/cm , Pulse 1:4, 10 minutes.
Recommended interferential dose (for acute
pain) should be 90 to 130Hz, bipolar, 10
minutes.
Interferential pad as the passive elec-trode
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 sequen-tially one after
the other.
Contraindications for combination therapy:
There do not appear to be any specific
contraindications for combination therapy other
than those for the individual modalities.
Handbook of Practical Electrotherapy
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 half-value 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 expe-
rience 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 ultra-sound 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 space-averaged 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 consi-deration 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
attenua-tion 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 conti-nuous 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:
Mode—Pulsed mode delivers less energy
than continuous.
Frequency—Lower frequency has greater
penetration than higher.
Intensity—Usually used space-aver-aged
intensity measured in Watts/sq cm.
 Therapeutic Ultrasound (US Therapy) 117

Duration—Duration of treatment is calculated Dosage for Ultrasound Therapy

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.
Treatment should be repeated once or twice
daily for acute lesions and less frequently
for chronic lesions.
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 Dosage in Mode Duration in
Watts/cm sq minutes
Abscess of soft tissue 0.5–2 Pulsed 8–10
Bursitis 0.6–1.5 Continuous 8–10
Cellulitis 1–2 Continuous 10–15
Myalgia 2–3 Continuous 10–15
Neuralgia 1–3 Continuous 10–15
Periarthritis of shoulder 0.5–3 Pulsed/Continuous 10–15
Radiculitis (root pain) 1–2 Continuous 10–15
Intermittent claudication 1–3 Continuous 5–20
Lumbago 1–3 Continuous 10–15
Lymph-oedema 0.5–2 Continuous 10–15
Muscular rheumatism 0.8–3 Continuous 10–15
Sciatica 1–2 Continuous 10–15
Stump neuroma 2–3 Continuous 10–15
Ulcer 1–3 Continuous 10–15
Coxydanea 1–3 Continuous 10–15
Myositis ossificance 1–2 Continuous 10–15
Polyarthritis 1–2 Continuous 5–15
Sudecks osteodystrophy 1–3 Continuous 10–15
Tenosynovitis 1–2 Continuous 10–15
Handbook of Practical Electrotherapy
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 ultra-sonic
therapy, such as phonophoresis and
combination therapy is gaining accep-tance.

12
Therapeutic Cold
DEFINITION
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
1 evaporative cold modality used in the sports
therapy or cryotherapy.
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.
Therapeutic Cold 119
BIOPHYSICS
Therapeutic cold can be applied to the skin
through evaporating or conducting moda-
lities
Volatile liquids, when brought in contact with
warm objects, extract heat of vapori-sation
from the underlying tissue. Most common
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 conduc-tive 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
Handbook of Practical Electrotherapy
depends on the rate and duration of energy
extraction, which in turn depends on the
following factors.
The difference in temperature between the
coolant and the tissue. Greater the
temperature gradient, faster the cooling.
The heat conduction property of indi-vidual
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.
Temperature of tissue subjected to localised
cooling will continue to drop till the heat
generated in the tissue equals the heat
extracted from.
The total surface area of the body subjected
to cooling is directly propor-tional to the
extent of heat loss.
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 immediately following cold application will not
Physiological Effects of Localised Cooling
The therapeutic benefits of cold post-acute
injury, postoperatively, and during rehabili-tation
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 effi-ciency. Pain and muscle
spasms are reduced as a result of cryotherapy’s
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
1
to prevent secondary hypoxia. 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
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 expo-sure to
cold
Dramatic vasoconstriction of skin capil-laries
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 hista-mine 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 meta-bolic demand of
the tissues
Application of local cooling of the body tissues
trigger following set of negative
physiological responses.
Reduced blood flow—Due to vasocons-
triction of arteries, arterioles and venules
resulting from sympathetic adrenergic
activity.
Reduced capillary permeability—Due to less
fluid in the interstitial tissue.
Reduced elasticity of non-elastic soft tissue—
Due to decreased elasticity of collagen.
Reduced metabolic rate—Due to inhi-bition
of cellular oxidation.
Reduced muscle spasm—Due to inhi-bition of
tonic extrafusal activity.
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
Reduced spasticity—Due to reduce muscle
spindle and gamma motor activity
Application of local cooling of the body tissues
trigger following set of positive physiological
responses
Increased joint stiffness—Due to dec-reased
extensibility of collagen.
Increased pain threshold—Due to inhi-bition
of A-delta and C fibres (spinal gate
control mechanism). Breaks the pain
spasm vicious cycle through
Therapeutic Cold 121
inhibition of sympathetic, sensory and
motor conduction.
Increased blood viscosity—Due to increa-sed
adherence of RBC to each other and walls
of blood vessels.
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
Cold Urticaria- red wheals on the skin
associated with sever itching.
Flushed face.
Puffy eyelids.
Respiratory distress.
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, equip-ment and
recurrent expenditure.
A standard refrigerator, ice tray, polythene bags,
hand towel and water are all that is needed to
give effective ice packs.
Handbook of Practical Electrotherapy
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, discolora-tion, 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.
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.
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.
The part to be treated is exposed and the skin
should be checked for any cuts, 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 desensiti-sation 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.
Therapeutic Cold 123
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 appli-
cation 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 vasodila-tation and
vasoconstriction in the peripheral blood vessels
to provide vascular exercise to the part. For the
patient exhibiting psycho-logical 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 (106°F) and cold (50°F) 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
Handbook of Practical Electrotherapy
the warm water, combined with the limited
exposure to the cold water, may enable cold-
intolerant 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, regard-ing
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 vasocons-triction.
The contrast bath serves as an appropriate
treatment alternative, more in the sub-acute,
rather than acute, phase of soft tissue inflam-
mation.
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
45°C and cold water around 5 to 10°C. 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 minu-tes.
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 condi-tion that
needs stimulation of peripheral circulation. It
is a modality of choice for acute and chronic
musculo-skeletal inju-ries, like sprain, strain,
post fracture stiffness and in peripheral
vascular dis-orders like lymph-oedema,
vasculitis, varicose veins and Burger’s
disease.
Losses of thermal sensation and arterio-sclerosis
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
3
as cryo-kinetics.
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 reappli-cation 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 imple-menting an aggressive
cryo-kinetic program. Perhaps the most
appropriate use of cryo-kinetics 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
Therapeutic Cold 125
the application of therapeutic heat. Further-more,
tissue gliding during early mobilization
minimizes the risk of adhesions while concur-
rently facilitating scar tissue remodelling. Finally,
active motion helps the patient overcome the
neural inhibition that frequently accompanies
post injury pain and inflam-mation.
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: buc-kets, basins or
whirlpools, ice that is prefer-ably 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 depend-ing on the individualized exercise
5,6
program-mes.
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
Handbook of Practical Electrotherapy
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, exercise-induced
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 depend-ing
on the modality chosen and the body part being
treated. The patient reporting numb-ness 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 thera-peutic 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 stretch-ing 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, includ-ing
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 stand-ing 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 cautio-usly,
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 cryo-kinetics to
ensure that the limb is ade-quately dried
before exercises are per-formed. 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
prog-ressions 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
patient’s 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 attempt-ing 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, patient’s 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
Therapeutic Cold 127
exercises Progression can be objectively
recorded as an increase in demonstrated
ROM, weight- bearing tolerance, or move-
ment speed. Functional progress is de-
monstrated through the documented
advancement from basic functional skills
such as ambulating, to the more complica-ted,
sport-specific skills like sprinting and
4
jumping.
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 patient’s 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 in-crease 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-
Handbook of Practical Electrotherapy
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 Van’t Hoff’s law,
resulting in reduced oxygen consump-tion,
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, therapeu-tic cold
limits blood loss due to vasocons-triction and
increased viscosity of the blood, controls
formation of soft tissue oedema or effusion in
joints, reduces pain by inhibition of
conduction in pain carry-ing 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 mecha-nism 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 recep-tors 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 applica-tion of
cold. The patient is told what sensa-tion 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 hyper-tension 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 immer-sion 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 tempe-rature
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
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.
The desirable temperature of cold therapy should
not be less than 4 to 6°C. 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.
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.
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.
Therapeutic Cold 129
Alternatively faradism under pressure may be
applied for 15 to 30 minutes to mobilise the
tissue fluid just before application of cold
therapy.
The condition of the skin must be checked
periodically (every 2-3 minutes) during the
treatment, to monitor the onset of vaso-
constriction and vasodilatation. If hyper
reaction occurs the treatment should be
terminated immediately.
After completion of the treatment the patient
should be advised to avoid heat exposure or
hot bath for at least two hours.
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
Knight KL. Cryo-therapy in Sport Injury Management.
Champaign, Ill: Human Kinetics; 1995:3-18,59-71,
77, 107-130, 175-177, 217-32.
Barnes L. Putting injuries on ice. Physicians Sports
Med 1979;7(6):130-36.
Denegar CR. Therapeutic Modalities for Athletic
Training. Champaign, Ill: Human Kinetics;
2000;104-11.
Gaydos HF, Dusek ER. Effects of localized hand
cooling versus total body cooling on manual
performance. Journal of Applied Physiology
1958;12:376-80.
Hayden CA. Cryo-kinetics in an early treatment
program. Physical Therapy. 1964;44:990-93.
Prentice WE. Therapeutic Modalities in Sports
Medicine. Boston: WCB/McGraw-Hill 1999; 187-
89.
Handbook of Practical Electrotherapy
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 wave-lengths between 400
and 700 nanometres. (A nanometre (nm) is the
standard measurement used to express
wavelength of electro-magnetic 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
parti-cles.
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 practi-tioner
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 substan-tiated
incredible results, which were pub-lished 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
life-supporting nutrient that is highly beneficial.
WHAT DOES SUNLIGHT THERAPY
ACTUALLY DO?
Sunlight Therapy can have the following effects
on the human body:
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.
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.
Increase RNA and DNA synthesis helping
damaged cells to be replaced more
promptly.
Stimulate fibroblastic activity, which aids in the
repair process. Fibroblasts are present in
connective tissue and are capable of forming
collagen fibres.
Stimulate tissue granulation and connec-tive
tissue projections, which are part of the
healing process of wounds, ulcers or
inflammation.
Stimulate the release of adenosine triphos-
phate (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.
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.
Relieve pain. Light therapy is successfully used
in pain management, dermatology and
rheumatology with excellent thera-peutic
effects.
Stimulate acetylcholine release and other
parasympathetic effects.
Increase phagocytosis, as an important part of
the infection fighting process. Destruc-tion
of the infection and clean up must occur
before the healing process can take place.
Induce thermal effect, which raises the
temperature of the tissue being treated, to
kill or disable bacteria and viruses.
Handbook of Practical Electrotherapy
Discussion
Modern scientific research claims that sun-light;
especially ultraviolet rays can be hazardous to
our body. Controversy exists over potentially-
harmful effects of the invi-sible 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 absorp-tion
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.
PHYSICS OF THERAPEUTIC LIGHT
Sunlight is the source of all types of light energy
used for therapeutic purpose. Thera-peutic lights
are electromagnetic radiations
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 radia-tions 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 it’s 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.
ULTRAVIOLET RADIATION THERAPY
(UVR THERAPY)
Ultraviolet light is part of the electromagnetic
energy spectrum, which can be classified into
three wavelength ranges:
 Therapeutic Light (Actinotherapy/Heliotherapy) 133
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 wave-lengths 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 sub-stances react to UV
because they are com-posed 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 instan-taneous 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 pro-duced
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
Antibiotic properties of UVR like inacti-vation
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 it’s
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 1900’s, 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-1930’s 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 irradia-tion (UVR) in treating both
bacterial and viral infections, having
demonstrated that ultra-violet light could be used
effectively in the treatment of bloodstream
infections. However with the debut of antibiotics,
it’s ease of
Handbook of Practical Electrotherapy
treatment and its success in treating infec-tions,
it became the treatment of choice, and UVR
therapy fell by the wayside.
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 system’s ability to
fight infections.
• Increase in oxygenation of the blood.
• Activation of steroids.
• Increased cell permeability.
• Release of vasoactive agents in the sub-
cutaneous 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, sulpho-namides,
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 signi-ficant 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, moun-ted 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, it’s 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 treat-ment 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
 Therapeutic Light (Actinotherapy/Heliotherapy) 135
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
Hot quartz type (Alpine Sunlamp), which
produces heat and visible light along with
UVR- A, B and C.
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 dura-tion 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 hista-mines; 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 ½” × ¾” 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.
Handbook of Practical Electrotherapy
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 mar-ked
reddening along with marked peeling,
oedema and pigmentation of the skin lasting
for 72 hours. Second-degree ery-themal 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-
 Therapeutic Light (Actinotherapy/Heliotherapy) 137
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 wave-length
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 pene-trate 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.
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 avail-able
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
Handbook of Practical Electrotherapy
on if there are more patients to treat.
Inspect the skin that has been treated for
any undue reactions. Slight redden-ing 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 cala-mine)
may be applied over exposed skin. It
should be realised that fair skin reddens
more readily as compared to dark skin.
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 pre-paration
and precautions observed are similar to
non-luminous IR applica-tions.
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 (monochro-
matic) light that can be intense enough to
burn/cut tissue or mild enough to only have
1
photobilogical effects on the living tissues.
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 mea-sured
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 suffi-cient to
coagulate or ablate tissue by evapo-ration.
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
2
surgery, etc.
Other reactions of laser exposure are used are
photo biological in nature. In physio-therapy low
powered lasers as used and in ophthalmic
treatments such as capsulotomy photo acoustic
3
effect is used.
Points to Ponder
LASER stands for “light amplification by
stimulated emission of radiation”.
Laser consists of a large number of identi-cal
photons emitted from an energised
 Therapeutic Light (Actinotherapy/Heliotherapy) 139
source called a diode on application of
electrical charge.
Laser radiations have the same wave-length 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)
Candela pumped dye laser:
Dermatology
Neodymium: YAG laser:
Surgery
CO2 Laser:
Obstetrics and Gynaecology
Argon; iris diode lasers:
Ophthalmology
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 hazar-dous.
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-Alumi-nium-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
regar-ded 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
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
4
often serious. 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.
 140 Handbook of Practical Electrotherapy
Table 13.1: Different types of lasers employed for clinical use
Type of Excitable Method of Frequency of Class of laser Colour of Adverse effects Clinical use
clinical laser compound excitation emission and power emitted emission

Ruby laser Synthetic ruby Helical xenon 694.3 nm Class 2 low Visible red light None Dermatology
rod made of tube wound power laser
aluminium round the ruby < 1mW
oxide rod emitting
intense flash of
light

Helium – Sealed glass Helical xenon 632.8 nm Class 2 low Visible red light None, if not Marker for
Neon laser tube containing tube wound power laser focused directly application of
helium and neon round the >1mW on the eye invisible lasers
gases ruby rod emit-
ting intense
flash of light

Infrared diode Specialized Application of 650-1300 nm Class. 3a low Visible red light Direct exposure Bedsores, indolent
lasers light emitting electrical pulse continuous medium >5mW with some to the eye wounds, musculo-
diodes made to the diode 860-904 nm Class3b medium infrared harmful skeletal disorders,
of gallium pulsed mode power >500mW Invisible Infrared Reflected pain relief, etc.
aluminium exposure is
arsenide dangerous to
the eyes
 Therapeutic Light (Actinotherapy/Heliotherapy) 141
Procedures and Equipment
The Nominal Ocular Hazard Area (NOHA) is the
region around a laser therapy unit, where eye
protection is essential. For thera-peutic 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 fre-quently for
endoscopic surgery for endo-metriosis, 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 Bio-medical Engineer in charge.
REFERENCES
Lasers and Wound Healing, Albert J. Nemeth, MD; and
Dermatology Centre, Clearwater FL, Dermatologic
Clinics, Vol. 11 #4, 1993.
Wound management with Infrared Cold Laser
Treatment, P Gogia; B Hurt and T Zim; AMI-Park
Plaza Hospital, Houston TX, Physical Therapy, Vol.
68, No. 8, August 1988.
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.
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.
Handbook of Practical Electrotherapy
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 wave-length of 11
meters.
Q 2. What are the effects and uses of SWD?
Primary effect of SWD is to generate heat in
body tissues by subjecting it to an oscilla-ting
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 conti-nuous
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 solid-state
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 light-weight, 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
accesso-ries.
Q. 5. What type of input current is used in
SWD? What is the output current frequency
and wavelength?
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. 6. What are the common methods of
application of SWD?
A. Condenser field and cable method.
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 non-conducting
covers like plastic or rubber.
Q. 8. Which tissue is heated most in con-
denser field method?
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.
9. What are different techniques of condenser
plate electrode placement used in SWD?
Coplaner, contraplaner and cross-fire placement.
10. What are spacers? Name a few spa-cers.
Spacers are layers of insulating material
containing large air-spaces, which are inter-
posed 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. 11. How much thickness is appropriate for
spacers?
2 to 4 cm.
12. What should be the appropriate distance
between two condenser plate electrodes?
The minimum distance between two condenser
plates should be greater than the sum total of the
thickness of the spacers being used.
13. What is the method of heat production in
cable SWD?
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.
14. Which tissues are best heated by cable
method of SWD?
Tissues with high ionic content like blood or
muscles are best heated.
15. What type of cable is used in cable method
of SWD?
Coaxial cable with a flexible conducting core
coated with a layer of heat resistant rubber.
16. What is the optimum length of the cable
used in SWD? Why?
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.
17. When is pulsed SWD recommended?
Pulsed SWD is recommended when heat
component of the SWD is not desired but the
Handbook of Practical Electrotherapy
electromagnetic field is deemed to be bene-ficial
for any condition like broken bones, wounds and
acute inflammation.
Q. 18. How is the dose of SWD calculated?
The dose of SWD is delivered based on the
feedback of the patient. Hence, it is man-datory
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.
SECTION 2: ULTRASONIC THERAPY
19. What do you understand by therapeu-tic
ultrasound?
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.
20. What are the essential components of
ultrasound therapy machine?
Therapeutic ultrasound equipment consis-ts of a
high frequency current generator, a transducer
with a quartz piezoelectric crystal and a coaxial
cable that transmits the high fre-quency current
from the generator to the crystal.
21. What are coupling mediums?
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.
22. What is the role of coupling medium in
application of US therapy?
Coupling mediums eliminate air-space between
the faceplate of the ultrasound transducer and the
skin and allow trans-
mission of energy from the transducer to the
body. This is essential, since air is a reflector of
ultrasound energy.
Q. 23. What effects does ultrasound energy
produce in the body tissue?
Mechanical effect, thermal effect and micro
streaming effect.
24. What are the benefits of ultrasound
application?
a. The mechanical effect causes micro massage at
the tissue level. This helps break down
adhesions, soften scar tissue and release
soft tissue contrac-tures.
The thermal effect raises tissue tempe-rature
that may help in resolution of
inflammation and reduce pain.
The micro-streaming effect promotes protein
synthesis at the cellular level that is useful
in the process of repair.
25. What are the different modes of US
application? How do they differ in charac-ter?
a. Therapeutic ultrasound can be applied to the
body in continuous or pulsed mode.
In continuous mode the output of U.S. energy
is uninterrupted and has a large thermal
component.
If the continuous flow of ultrasound is
interrupted at specific intervals, the
thermal component is reduced signifi-
cantly, though the other effects like
mechanical and micro streaming remains
intact. This is known as pulsed U.S.
26. What is the relevance of mark-space ratio?
Mark-space ratio is relevant to pulsed U.S. It
signifies the ratio between the duration in
 Frequently Asked Questions in Practical: Viva Examination 145
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.
27. What are the dosing parameters of US
therapy?
• Mode of Ultrasonic- pulsed mode gives
less power than continuous mode
Frequency of Ultrasonic- Lower the fre-quency
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 alter-nate days.
28. What do you understand by half value
distance of US?
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.
29. What are the factors that determine the
absorption of US energy?
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.
30. What do you understand by attenua-tion
of ultrasound?
The loss of energy from the ultrasound beam in
the tissues due to absorption,
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?
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.
32. What are the different methods of
application of therapeutic ultrasound?
Therapeutic ultrasonic can be applied:
By direct contact method using coupling gel
In a bath of de-gassed water
Through a water bag
Through a solid sheet of coupling gel.
33. What are absolute contraindications for
application of ultrasonic therapy?
Absolute contraindications for application of
ultrasonic therapy are:
• Tumours in precancerous stage or malig-nant.
• Pregnant uterus
• Testes and ovary
• Acute infective focus like boils and carbuncles
• Tissues that bleeds easily
• Deep vein thrombosis
• Over the eyes
34. What is phonophoresis?
Introduction of medicinal substances into and
through the skin using ultrasound energy.
35. What type of ultrasound energy is suitable
for phonophoresis?
Low intensity, low frequency ultrasound, applied
over longer durations (>8 min) is most suited for
phonophoresis.
Handbook of Practical Electrotherapy
SECTION 3: THERAPEUTIC
STIMULATING CURRENTS
Q. 36. What are the characteristics of thera-
peutic 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.
37. What are the biophysical properties of
continuous DC?
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.
38. What are the physiological effects of
therapeutic DC?
Physiological effects of DC are:
Stimulation of sensory nerve ending in the skin
creating a tingling sensation.
Reflex vasodilatation of peripheral capi-llary
network resulting in reddening of the skin.
Increase sensitivity of peripheral nerve ending.
Relief of pain by blocking of pain trans-mission.
Accelerate of tissue healing.
Introduction of drugs through the skin-
Iontophoresis.
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 iontopho-resis.
Treat infections by copper sulphate ionto-
phoresis.
Treat inflammation and pain by Methyl salicilate
and iodine iontophoresis.
40. What are the risk factors of iontopho-
resis?
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 elec-tric
pulse?
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.
42. What are the biophysical charac-teristics
of a stimulating electrical pulse?
The bio-physical properties of any stimulating
electrical pulse depends on
• Phase or direction of current flow- Mono-
phasic 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 inten-sity in
each successive pulse, arriving in a train of
impulses.
• Rate of rise and fall from zero to peak intensity.
43. How do you classify therapeutic currents
on the basis of pulse frequency?
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.
 Frequently Asked Questions in Practical: Viva Examination 147
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 appro-priate
pulse duration, strength and shape triggers an
action potential in a nerve. This action potential
spreads through out the nerve membrane to
trigger momentary depolari-sation 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.
Q. 47. What is the expected response to a
series of stimulating current impulses applied
to the skin?
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.
48. What are the expected responses to low
frequency stimulation at commonly used rates
of repetitions?
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 modula-tion.
49. What are the therapeutic effects and uses
of low frequency stimulation?
Therapeutic low frequency stimulation are used
for:
• Strengthening of healthy muscles, even when
immobilised.
• Preventing atrophy in denervated or
immobilised muscles and retaining func-
tional capability of muscles at risk of disuse,
through enhanced vascular turn-over and
metabolic activity. Other tissues in the
vicinity are also benefited by increased
drainage and supply of body fluids.
Handbook of Practical Electrotherapy
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.
50. What are the mechanisms of action of
electric charge, in producing therapeutic
effects in the body?
Therapeutic effects produced by appli-cation 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 electro-therapy
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 moda-lities
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?
Pain modulation by TENS is achieved by:
• Activation of the spinal gate through sensory
nerve stimulation
• Release of indigenous opiates like B-
endorphins, through stimulation of the
nociceptors.
 Index

A E High frequency currents 21

Absolute refractory phase 6
Actinotherapy 131
physics of 132
Action potential 5
propagation of 6,7
B Electrical stimulators 30-36
Bioelectrical drama, significance of
8 electrical 30 high voltage
Bioelectricity 2
C stimulator 30 TENS 30
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 H
Deep thermotherapy 142
Depolarisation 6
Electrical energy 11
Electrical field 2
behaviour of 2
Electrical impulses, types of 16
Electrical safety 10
Electrical stimulation 20,24, 36
electrical muscle 30 functional
galvanic 30 interferential
therapy unit 30 neuromuscular
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
F Iontophoresis 61-64
Fluorescence, phenominon 133
Functional electrical stimulation
58-61
application in 59-61
foot drop 61 hemiplegic’s
shoulder 59 idiopathic
scoliosis 60
effects and uses of 58
instrumentation of 59
parameters of current 58
G
Gate control theory, TENS 50
Heliotherapy 130
production of 86 subtypes
of 21
High voltage pulsed galvanic
stimulation 57
application of 58 effects
and uses of 58
instrumentation 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
instrumentation of 68
isoplaner vector field
application 71 treatment
parameters to 69 treatment
techniques to 70
Inverse square law, radiation 83
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
Lambert’s cosine law, radiation 83
Low frequency currents 18
production of 21
subtypes of 19
Handbook of Practical Electrotherapy
M in foot drop/flail foot 43 in
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
physiological effects of 67
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
contraindications for 96
indications for 96
technique of application of 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 Bell’s palsy 38
in crutch palsy 41
in Erb’s/klumpke’s palsy 41
in fibromyositis of
trapezius muscle 40
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 moist hot packs—hydro-
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 T
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
physiological effects of 88
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 multi-
vibrator circuit 22
wave patterns of 22 pure
faradic current 20
transcutaneous electrical
nerve stimulation 20
Superficial heat therapy 76-84
comparative profile of 84
contraindications for 78
indications for 77
physiological effect of 77
preparation of patient 78
transmission of 76 types of
79
Hubbard’s tank 81
hydrotherapy 79
collator 79
paraffin wax bath 82
radiant heat–infrared rays
83
steam bath or sauna 82
whirlpool bath 80
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
contraindications for 103 digital
ultrasonic machine 104
dosimetry of 116 indications for
102 phonophoresis 110
phonophoretic agents 111
physiological effects of 101
technique of application of 104
direct contact method 105
water bag method 106 water
bath method 109
ultrasonic transducers 99

Transcutaneous
electrical nerve
stimulation 26,50-56
applications in common
disorders 56
contraindications for 53
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 rhomboids muscle 111 hydrocortisone
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 medial collateral ligament,
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
phonophore-sis therapy, ankle 112
iodex phonophoresis therapy,
popliteal bursa 112
lateral collateral ligament,
ankle 111
lateral epicondyle 108
lidocaine phonophoresis
therapy 112
Index 151
knee 110
over the medial epicondyle 106
palmar fascia for Dupuytren’s
contracture 107
sternocostal joint for costo-
chondritis 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
instrumentation of 134
sensitivity to 134
ultraviolet, applications of 135