Additional Therapeutic Uses of ES
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Transcript of Additional Therapeutic Uses of ES
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() Lecture8:
AdditionalTherapeuticUsesofElectricity
100 1
AdditionalTherapeuticUsesof
Electricity
Woundmanagement
Osteogenesis
Edemareduction
Peripheralcirculation
Incontinence
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ESforWoundManagement
Wound abreakinthecontinuityofsofttissuecausedbyphysical,
chemicalorbiologicalinsult
Complications:chronicinflammation,infection,andscarring
associatedwithotherimpairments,suchaspain,decreasedmobilityandmotorfunction
ES asdirectintervention,oradjunctstootherwound
management
PatientsreferredtoPTforEStreatmentareusually: Chronicwoundnotresponsivetoothertreatment:Neuropathic
ulcer,pressureulcer
Orneedtoacceleratehealingprocess
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PhasesofWoundHealing Phase1
Inflammatoryphase(day1 6)
Initialvascularconstriction:decreaselocalblood
flow,allowmoreefficientclotting
Vasodilation:deliverchemicals,cells,nutrientsandoxygentoinjuredtissue
Promotecapillarypermeability
Chemotaxis:bodilycells,bacteria,andothersinglecell
ormulticellularorganismsdirecttheirmovements
accordingtocertainchemicalsintheenvironment
Increasefibroblastandmacrophageactivity
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PhasesofWoundHealing Phase2
Proliferativephase(day3 20)
Reepithelialization:regrowskinoverthewound
Toprovideaprotectivebarriertopreventfluidandelectrolytelossandtodecreasetheriskofinfection
Fibroblastsarriveandbegintoproducecollagentorebuildthesiteofinjury
Neovascularization Developmentofanewbloodsupplytotheinjuredarea
Newvesselsareneededtosupplyoxygenandnutrientstotheinjuredandhealingtissue
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PhasesofWoundHealing Phase3
Remodelingphase(day9on)
Maturationphase
Continuedfibroblasticandcollagenactivity
Collagenundergoesbothsynthesisandlysis
balancebetweenthesetwoprocessesdetermines
theeventualamountofscarformation
Thisphaseischaracterizedbyscarcontractionand
mayalsoincludescarhypertrophy
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RationalesForUsingESForWound
Management
Skinbattery¤tofinjury
Galvanotaxis
Speeduphealingprocess
Antimicrobialeffect
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SkinBattery
Transepithelial potentialbetweenthedermisandepidermis
Whentheskinisdamaged,thedifferenceinpotentialisbelievedtobethesourceofthecurrentofinjury
Thiscurrentisatriggertowoundhealingandalsoassociateswiththemoistwoundhealingprocess
Ifwoundsarepermittedtodry
ceasethecurrentofinjury UseEStoinfluencethecurrentofinjuryandthelateralelectricfield
thatexistsinareasofskindisruption
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Galvanotaxis Cellwithchargeattractedtoanelectricfield
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SpeedUpHealingProcess Augmentationofcollagensynthesisandproliferationof
fibroblasts Fibroblastsnormallymigrateintothehealingwound,especially
duringtheproliferativephase
ESincreasesDNAsynthesisandcollagensynthesis
Promoteangiogenesisandwoundmicroperfusion EScouldstimulatecapillaryregrowthintothewound
Enhancedmicrocirculation inchronicwoundinresponsetoES
Enhancingtherateofepithelialization Fasterepithelialization
Evidenceshowedthatifwoundstreatedwithanode7days,orwithcathodeonthefirstdayandanodefortheremaining6days
Enhancingbloodflowtowounds Enhancingbloodflowtowoundsbytheuseofelectrical
stimulationappliednearthewound10
Antimicrobialeffect
Electricalstimulationhasbacteriostatic(inhibitgrowth)orbactericidal(killbacteria)effectsonvariouspathogenicorganismsthatarecommonlyfoundtoinfectwounds
Electrodepolarityforantimicrobialeffects CathodeforPseudomonasaeruginosa ()
BothanodeandcathodeforStaphylococcusaureus()
Electrodecompositionforantimicrobialeffects Electrodesconsistingofsilverwireshowedsuperior
effectswhencomparedwithstainlesssteel,platinum,orgoldwireelectrodes
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ESForWoundManagement
Cleansewoundthoroughly,removedead
tissuesandpetrolatumproducts
Cover/fillwoundspacewithgauzepads
soakedinsalineorhydrogel
Placeanelectrodeonthegauzepacking,cover
withdrygauze,holditwithbandagetape
Dispersiveelectrodeusuallyproximaltothe
wound
12Source:Woundcareinformationnetwork,SUSSMANPHYSICALTHERAPYINC.
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Microcurrent ES Polarity&electrochemicalreaction
Cathode(negative):raisethepHtoalkalinityformingmaybeusedforitsbactericidaleffectorasanadjuncttodebridementbecauseofitssclerolytic ability(decreaseproteindensity)tosolubilizethrombiandnecrotictissue
Anode(positive):lowerthepHtoacidityformingmaybeusedforitseffectofsclerosing tissueandcoagulatingbloodleakingfromsmallvesselsmayalsoaugmentclosureofthewoundbyproducingacongealedscar
Ifinfectionwithorganisms,suchasEcoliandPseudomonas
aeruginosa (
)ispresent,thenegativeelectrodeshouldbeleftinthewoundareauntilthesignsofinfectionarenotevident.Thenegativeelectroderemainsinthewoundfor3daysaftertheinfectionclears.
IfthewoundisinfectedwithbacteriasuchasStaphylococcusaureus (),thepositivepolemaybeamoreappropriatechoice
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Microcurrent ESApplication Thenegativeelectrodeispositionedinthewoundareafor
thefirst3days;after3daysthepolarityisreversed
Ifthewoundsizestopsdecreasing,thenreturnthenegativeelectrodetothewoundareafor3days
Ingeneral,thesecondelectrodeisapproximatelythesamesizeastheactiveelectrodeandisplacedat15to30cmawayfromthewound
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RecommendedProtocol
Currentintensity
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PolarityConsideration&Protocol Selectionofpolarity
Usuallyinitiatedwiththecathodeastheactiveelectrode
Afterseveraldaysoftreatmenttheelectrodepolarityisreversedtothepositivecharge
Negativepolarityisusedifmicroorganismsarepresentcontinuetousenegativepolarityuntilthewoundisculturefreefor3days
Positivepolarityisusedifthewoundisculturefreeoris
usedafterthewoundisculturefreefor3days Recommendedprotocol
Frequency:30 130pps
Amplitude:subthresholdtomusclecontraction
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ESForWoundHealing HighVoltage
PulseCurrent
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ESForWoundHealing HighVoltage
PulseCurrent Signsofadverseeffects
Skinirritationortinglingundertheelectrodes
Pain
Precautions Transcerebralstimulation
Stimulationovertheeyes Youngchildrenunderage3years
Contraindications
Presenceofmalignancy
Activeosteomyelitis
Topicalsubstancescontainingmetalions:povidoneiodine,zinc,silversulfadiazine,mercurochrome
Electronicimplants
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ESForOsteogenesis
10%ofthe7.9millionannualfracturepatientsintheUnited
Statesexperiencenonunionand/ordelayedunions
Severalmethodshavebeenusedtopromotebonehealing Electricalstimulation
Lowintensitypulsedultrasound
Electromagneticstimulation
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StagesofBoneHealing Inflammatorystage
Repairstage
Remodelingstage
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Hematoma
Cartilaginous
callus Bonycallus Remodeling
1.Inflammatorystage Hematomaformswithinthefracturesite(first
fewhourstodays)
Cleanupdeadtissues
Callusformation
Thisstagelasts2 4weeks,overlapswiththe
nextstage
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2.Repairstage
Cartilaginouscallus
Painandswellingsubsideasthebonyfragmentsunitedby
cartilaginoustissue
Osteoclastsremovedeadbonefragments
Hardcallus Cartilagehardening fromeachendoffracturetowardthecenter
Thisstagelasts1 2months
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3.Remodelingstage
Weak strongbonmaterial
Bonereturnstoitsoriginalshapeand
structure
Remodelingoftheboneoccursslowlyover
monthstoyearsandishelpedbymechanical
stress(i.e.weightbearing).
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RationaleForUsingESFor
Osteogenesis Chemicalgradientswithinthebone
arethesourceofbioelectricpotentials
Normalbonehaspiezoelectricproperties Highercellularactivity(epiphysial
platearea) morenegative
Bonegenerateselectricalpotentialsinresponsetomechanicalstress Compression Negative
Tension Positive
Thepolaritychangesafterdiaphysisfracture
EScausesionicmigration
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Microcurrent ES Polarityofstimulation
Anegativeelectrodewasplacedclosetobutdistaltothefracturesite
Apositiveelectrodewasplacedproximaltotheimmobilizingdevice
Recommendedprotocol Currentintensity:justperceptibletothepatient
Pulseduration:ContinuousorpulsedDCwithlongest
durationallowedontheunit(100 200msec) Frequency:lowestfrequencyallowedontheunit(5 10
pps)
Treatmentduration:30minutes 1hour
Treatmentfrequency:3 4timesperday
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TENS
Ifthefracturesiteisenclosedinaplastercast,electrodes
shouldbeplacedproximalanddistaltothecast,2or4
electrodesareused
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TENSApplication Ifthefracturesiteisfreeof
casting,3basicpatternsare
available
With2electrodes,oneplacedon
eithersideofthefracturesite,
about6inches(15cm)apart
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TENSApplication With4electrodes,across
pattern,about6inchesapart,
withthecrossingpointdirectly
overthefracturesite
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TENSApplication Ifthefracturesiteisfreeof
casting.With2electrodes,a
sandwichpattern,withthe
fracturesitebetweenthetwo
electrodes
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TENS
Recommendedprotocol Frequency:thehighest
frequencyavailableonunit(120Hz)
Pulsedwidth:thewidestwidth(300 s)
Intensity:thelowestpossible,barelysensedbypatient
Treatmentduration:1hour/session
Treatmentfrequency:4times/day
Sideeffects Analgesiawasreportedby
patientswhocomplainedofpain
asasymptomofthenonunion
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ESForEdemaReduction
Rationale
Polaritymovesnegativelychargessubstancethatcausededema
Sensorylevelstimulation Polarityofelectrode
Tousethepolarityofanelectricalstimulustorepelsimilaritychargedsubstancesfromtheedematousarea
Becausebloodcellsandplasmaproteinscarryanegativecharge anegativeelectrodeplacedoveranedematousareamayrepelthesenegativelychargedsubstancesfromtheareaofstimulation decreasingtheamountofedemathroughafluidshift
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ESForEdemaReduction Rationale 1
Sensorylevelectrical stimulustorepelsimilarity
chargedsubstancesfromtheedematousarea
Bloodcellsandplasmaproteinscarryanegativecharge
anegativeelectrodeplacedoveranedematousarea
mayrepelthesenegativelychargedsubstancesfrom
theareaofstimulation decreasingtheamountof
edemathroughafluidshift
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Rationale 2 Microcurrent stimulationofthelocal
neurovascularcomponents
Amicroamp stimulationmaycausea
vasoconstrictionandreducethepermeabilityof
thecapillarywallstolimitthemigrationofplasma
proteinsintotheinterstitialspaces
Thiswouldretardtheaccumulationofplasma
proteinsandtheassociatedfluiddynamicsofthe
edemaexudate
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Rationale 3
Motorlevelstimulation
Electricallyinducedmusclecontractioncan
effectivelyleadtoareductioninedemaby
mobilizingtheedematomovefromtheinterstitialcompartmenttothebloodvascularsystemand
lymphaticsystem
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ESForEdemaReduction HVPC
Applicationtechnique
Waterimmersionelectrodetechniqueismore
effectivethanusingsurfaceelectrodes
Polarityofstimulation Activeelectrodesisnegative
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HVPCRecommendedProtocol Sensorylevelstimulation
Intensity:10%lessthanneededtoproduceavisiblemusclecontraction
Frequency:high(120pps)
Timeoftreatmentafterinjury:beginimmediatelyafterinjury
Treatmentduration:30minutesevery4hours
Motorlevelstimulation Intensity:strong,comfortablemusclecontractions
Frequency:35 50pps
Ontime:5 10sec;Offtime:5 10sec
Theparttobetreatedshouldbeelevated
AROMmaybeencouragedatthesametimeifitisnotcontraindicated
Treatmentduration:20 30minutes
Treatmentfrequency:2 5timesperday
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ESForPeripheralCirculation Introduction
Mostcommonlyappliedtopreventpostoperative thromboemboliccomplicationsandtoimprovecirculation
Factorscontributingtotheformationofathrombosis Changesinbloodflow
Changesinbloodcoagulability
Changesinthevesselwall
RationaleforusingES Electricalstimulationofthecalfmusclespreventedadecrease
intherateofvenousbloodflowinthelegsduringsurgeryandthereforedecreasedthefrequencyofdeepvenousthrombosis
Increasedcapillarybloodflowinthestimulatedmusclesresultsfromacombinationofreflexivevasodilationandanincreaseincapillarygrowthduringlongtermelectricalstimulation
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ESForPeripheralCirculation
InterferentialcurrentorRussianstimulation Electrodeplacement:Oversensorynerves
Recommendedprotocol Currentintensity:maximumtoleratedtingling(sensorylevelstimulation)
Frequency:50 200bps
Cycleduration:20 100 s
Dutycycle:50%ifRussianstimulation Treatmentduration:20 60minutes
Lowfrequencystimulators Electrodeplacement:Overmotornervesofinnervatedmuscles
Recommendedprotocol Waveform:balancedasymmetricalbiphasicpulsedcurrent
Currentintensity:motorresponse
Frequency:30 100pps
Treatmentduration:30 40minutes
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ESForIncontinence Indications(1)
Stressurinaryincontinence
Involuntarylossofurinewhentheintravesical (withinbladder)pressureexceedsthemaximumurethralclosurepressureintheabsenceofdetrusoractivity
Smallamountsofurinearelostconcurrentwiththeincreasedintraabdominalpressure
Urgeurinaryincontinence Involuntarylossofurineassociatedwithanuninhibiteddetrusor
contractionthatoverwhelmsthesphinctermechanism
Mixedurinaryincontinence
Urinaryfrequencyorhesitancywithpelvicfloordyssynergia
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ESForIncontinence Indications(2)
Fecalincontinencerelatedtopelvicfloorweakness
Levator syndrome Painintheregionofthecoccyx
Painfulspasmsofthemusclesaroundtheanuswithoutknowncause
Althoughbowelmovementsmatnotbepainful,
patientsoftenreportdisturbedbowelfunction,constipation,orfrequency
Interstitialcystitis Aconditionofoversensitivityofthebladder
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ClinicalApplication Purpose
Tohelpthepatientidentifythepelvicfloormuscle
location,provideproprioception,andassistthe
contraction
Toachieveautonomicdampeningofthesebladder
contractionsbyaugmentingsympathetic
dominance
Electrodeselection:Whenpossible,an
internalelectrodeispreferred
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RecommendedProtocols
Vaginal andanalplugstimulation:aanalorvaginalplugwithtwoembeddedringelectrodes
Patientsposition:beginwiththepatientinanantigravityposition(ie,relaxedhooklyingorsidelyingwithoneortwopillowsunderthepelvisorbetweenthelegs)andslowlyprogresstostanding
Themostcomfortablecurrentsaredeliveredbycircularelectrodes,whichareabletodispersecurrentoverlargesurfaceareas
Frequency:5 50Hz Ahigherfrequencyof50Hzismostamenabletoinnervatedmuscle it
workswelltoteachmusclecontraction,proprioception,andawareness
Alowerfrequencyof5 20Hzismostamenabletotreatdetrusorinstabilityandurgency
Treatmentdurationandfrequency:2or3minutesofstimulation1 3timesadayisagoodbeginning,graduallybuildingupto15minutes1 2timesaday
Afterthefirstfewsessions,whenpatienthasbeenabletoidentifythecontraction, askthepatienttocontractwiththecurrent,relaxinginbetween
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InterferentialCurrent
Pelvicfloorstimulation
Electrode:externalelectrodes
Patientsposition:asemireclined positionwiththehipsandkneesflexedandsupported
Electrodeplacement:bipolartechnique Female:oneelectrodewasplacedunderischial tuberositywitha
secondelectrodeovertheanteriorperineum,immediatelyinferiortothesymphysis pubis
Male:electrodesplacedoneachsideoftheglutealcleft,justanteriortotheanus
Currentintensity:50 80mA,maximumlimitofpatientcomfort
Frequency:asweepfrequencyof10 50Hzorafixedfrequencyof50Hz
Treatmentduration:30minutes
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TENS Purpose:
Tobemoreeffectiveinrelievingpelvicandperineal pain
Tobeusefulintreatingdetrusorinstability
Electrodeplacement:Relatedacupuncturepointsareuseful Spleen6(Sp 6):3cmdirectlyabovethetipofthemedial
malleolusontheposteriorborderofthetibia
Spleen10(Sp 10):withkneeflexed,2cmabovethesuperiormedialborderofthepatellaonthebulgeofthemedialportion
ofquadricepsfemoris Largeintestine4(LI4):inthemiddleofthe2ndmetacarpal
boneontheradialside
Acrossedfashionoverthelowerabdomenorlumbarsacralareas
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TENSParameters Mode:conventionalsetting
Currentintensity:sensorylevel
Frequency:60 100Hz
Pulsedduration:100 150 s
Treatmentduration:20 30minutes
Treatmentfrequency:1 5timesaday
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