Electrical Modalities
- 1. Electrical modalitiesSummer Kepley, OTS
- 2. Definition Different forms of energy, dependent on the specific modality, which can penetrate through the skin, the muscles or even the neurological system of the human body, in order to provide relief from swelling and/or pain, muscle stimulation or to promote healing of different body structures, caused from an acute or chronic injury or condition, (Larson, 2007).
- 3. Different LevelsCellular LevelModify skinIncrease movementFacilitate wound healingModulate acute painTissue LevelIncrease tissue extensibility healingReeducate musclesModulate acute painDecrease muscle disuse atrophyIncrease movementSegmental LevelIncrease movementDecrease edema/inflammationFacilitate fracture healingModulate a painSystemic LevelModulate chronic pain
- 4. General PurposeModulate pain (acute and chronic)Increase tissue extensibility healingModify skinDecrease edema/inflammationReeducate musclesIncrease movementDecrease muscle disuse atrophyFacilitate fracture and wound healing
- 5. When are EM’s used?“…in preparation for or concurrently with purposeful and occupation-based activities or interventions that ultimately enhance engagement in occupation” (McPhee, 2008).
- 6. Who can use EM’s?According to the AOTA, only occupational therapists and occupational therapy assistants with the proper training and skills to integrate the chosen modalities skillfully and safely, and be able to implement them correctly within a proposed occupational therapy program.
- 7. General PrecautionsNever place the electrodes-On each templeOn or near the eyesIn the mouthOn the front of the neckOn the groinOn numbed areas of the skin, or decreased sensationOn woundsOn or near the uterus of a woman who is or may be pregnant. (Effects are generally unknown, but may induce labor.)
- 8. General ContraindicationsPacemakerCardiac conditionsExposed metal implantsSevere obesityIncreased sensitivity to electrical stimulationEpilepsy
- 9. General Evaluation GuidelinesClean the skin surface of the body area to be treated. Avoid extremely hairy areas of the body, or where there is a wound.Shaving is not recommended: Micro abbreviationInspect the electrode cords and electrode pads for wear. If they are not in good condition, they should be replaced. If they are acceptable, then insert the cord pins into each electrode pad. Never re-use an electrode pad.Peel away the paper backing of the disposable electrode and place it on the body carefully and securely. Loose electrodes can contribute to burning and irritation of the skin.There are 3 basic pad placements:Monopolar- one electrode running from one channelBipolar- two electrodes running from one channelQuadripolar- four electrodes running from two channelsMonopolar and Bipolar should be used when treating a relatively small area and Quadripolar for a larger area. An example of a larger area is the thigh.
- 10. TENSTranscutaneous Electrical Nerve StimulationTranscends an electrical current, to provide constant electrical stimulation to the peripheral nerves, in a specified area of the body, to modulate pain.
- 11. PurposeDecrease painAcute Persists less than 6 months and is associated with tissue damage, irritation, inflammation or a disease.Prevent the acute pain reaction cycle from occurring. Example ChronicStop the pain cycle described above, after it has already started.
- 12. TOOLSFor Client UsePortable- can clip on belt or put in a pocket, and control pain as needed or recommended.For Therapist UseMust have at least 2 electrodes to pass current, but usually comes with 4. Electrodes are thin flexible pads covered with a gelatin-like substance.The electrodes are connected to a lead wire and a relatively flat, electrical impulse-distribution portion. The connector is attached via the lead wire to a stimulator.
- 13. Evaluation GuidelinesPulse FrequencyIf you increase the pulse frequency, you are increasing the amount of energy being delivered to the body.Pulse AmplitudeThe higher the amplitude, the more energy released to your body.Pulse widthThe longer the pulse, the more total energy each individual pulse generates.“Low Fire” SettingEndogenous opiates and endorphins are released and reduce the sensation of pain. “High Frequency” SettingGate control theoryThe electrical current goes through the peripheral nerves to close the gate in the dorsal horn, and blocks the perception of pain at the level of the spinal cord.
- 14. Evaluation Guidelines (cont.)Turn each Intensity Control clockwise and SLOWLY increase the intensity level desired. Wait for tingling sensation2. When you are finished using the unit, turn down each Intensity Control until an audible click is heard and the pointer is on the word "OFF". 3. Remove the electrode pads from the body.
- 15. PrecautionsAllergic reactionsDecreased sensation of the skinOpen woundsPain is the body’s way of telling an individual to react to a harmful stimuli or occurrence. Therefore, if the individual is no longer perceiving pain, they may become careless with an injured area and further damage it. Nerve impingement
- 16. ContraindicationsEpilepsyCardiac pacemaker or other metal implantsExtreme obesity
- 17. MENSMicrocurrent Electrical Nerve StimulationMENS was designed to mimic the electrical, weak currents produced by tissue healing.Uses micro-amperage currentThese devices deliver a level of stimulation below the threshold of peripheral nerve excitation.
- 18. General PurposeAids in the healing process while relieving pain. Whereas TENS is generally used for pain relief, MENS works more on a cellularlevel and aids in the healing process while relieving pain.
- 19. TOOLSPortable versionSimilar to TENSGenerally only has 2 electrodesWave forms- lower than TENSPulse frequency- lower than TENSAmplitude- lower then TENS
- 20. Evaluation GuidelinesEither short pulse durations or a constant current is used.The Amplitude is much lower than the TENS unit, and is set by the therapist.Guidelines follow the same as the TENS, but is safer then the TENS unit, due to weaker currents passed.
- 21. IndicationsSymptomatic relief and management of chronic painAdjunctive treatment for post-surgical and post-traumatic acute pain Very low pain tolerance Scarring of the skinDecreased ROM due to scarring of the skin, or scar tissue close to the skin’s surfaceWound
- 22. PrecautionsAllergic reactionsPain relief causing exacerbation of the injured site.N. impingement
- 23. ContraindicationsEpilepsyCardiac pacemaker or other metal implantsExtreme obesity
- 24. IFCInterferential Current TherapyCrossing two slightly different medium frequency alternating currents within the tissue, a third frequency current of greater intensity is created in the deeper tissue4 electrodes totalAllows for centralized concentration of currentMaximized by electrode placement so that intensity is perceived in area of pain “Carryover Effect”
- 25. PurposePainIncrease blood circulationInterferential current uses very high pulse rate, usually 4001 - 4150 pulses per second.Provides more analgesic, or nerve blocking effect.
- 26. TOOLSBecause of such frequency, these devices will require a lot of power, and thus, batteries will not last long. AC Adapters are usually provided with device.Applies two medium-frequency currents simultaneously Interference creates a “beat” modeSweep frequencyReduce accomodationThe system can arrange electrodes in either the same plane (for areas such as the back), or in different planes (in areas such as the shoulder).
- 27. Evaluation GuidelinesElectrode placement should be in an "X" patternSteps to follow: 1. Increase current until the patient feels a definite prickling, and leave for one minute for it to decrease2. Increase current again until the patient reports a slight muscular contraction, then decrease until contraction stopsDuration of Treatment10-15 minutestreatment at a normal intensity should not be given to one area for longer than 20 min.if more than one area is to be treated, total time should not exceed 30 min.
- 28. PrecautionsAllergic reactionsDecreased sensation of the skinOpen woundsPain relief causing exacerbation of the injured site.
- 29. ContraindicationsEpilepsyCardiac pacemaker or other metal implantsExtreme obesity
- 30. NMESNeuromuscular Electrical StimulationA non-invasive means of muscle rehab after injury, surgery or with disease, that applies customized, low level electrical stimulus to cause a muscle to contract. The brain tells muscles to contract by sending electrical signals or impulses to them. NMES can act like the brain by sending similar electrical signals through the skin to the muscles telling them to contract.The client must have an intact or partially intact peripheral nerve.
- 31. IndicationsCVA, TIA, TBIMuscular DisordersNeurological degenerative diseases/syndromesContracturesDecreased ROMEdemaDecreased blood flow“ Functional electrical stimulation (FES) is a type of NMES that is used to enhance the ability to walk in patients with spinal cord injuries or stroke. FES attempts to replace stimuli from destroyed nerve pathways with computer-controlled sequential electrical stimulation of muscles, (NMES PDF, 2006).”
- 32. TOOLSA stimulator transcends an electrical signal that flows through leads to electrodes placed on motor points over a targeted muscle or muscle group. This causes an electrical reaction in the specified motor nerves and results in muscle contraction.Stimulus parameters include:Pulse rate/frequency- Tension of mm. Pulse amplitude- The amplitude is increased until strong maximal contraction is obtained, upon tolerance of the client. Pulse waveform:Symmetrical- allows both electrodes to be active, and results in a hard and fast contraction of the muscle or muscle groupAsymmetrical- allows the selective recruitment of smaller muscle fibers
- 33. Evaluation GuidelinesElectrodes are attached over a muscle that needs help to contract. Bipolar placement tends to be used most often in NMES, because for a given intensity of stimulation, more current reaches the muscle to be stimulated.For optimal bipolar positioning, the clinician should place the muscle at resting length or in a slightly lengthened range, avoiding any close-packed positions of the limb or joint. A rest cycle that is 5 to 6 times as long as the hold cycle allows the muscle adequate time to recover between contractions and produces same amount tension on each subsequent contraction.Treatment should be provided daily, or at least every other day, for approximately 15 minutes, total time.
- 34. PrecautionsMuscle fatiguePeripheral n. pathologyPatient tolerancePatients with severe dementia, inability to follow directions and verbalizationAllergic reactionsDecreased skin sensationOpen woundsThe patient must have a non-neurological reason for disuse atrophy
- 35. ContraindicationsCardiac pacemakers, metal implantsPregnancyNeuromuscular or neurological disorders in which fatigue has a negative impact on the disorderSevere ObesityActive bleeding
- 36. Russian Electrical StimulationSimilar concept as the NMES, but with medium frequency waveforms. Russian Stimulation is a specific type of electrical muscle stimulation utilizing a higher carrier frequency of 2500 Hz. The system is designed to stimulate motor nerves, resulting in muscle contraction.Originally used for strength training, but currently being used for muscle strengthening, and reduction in muscle spasms and reducing edema.
- 37. IndicationsScoliosisCVA, TIATBIMuscular DisordersNeurological degenerative diseases/syndromes (Ex. Parkinson’s Disease- to increase muscle strength to help reduce fatigue and atrophy).EdemaDecreased blood flow
- 38. TOOLS(May look just like an NMES or other MES systems, and can also be an option on a general MES system)Similarly, the makeup is the same as the described NMES, but the grading options are much higher.
- 39. Evaluation GuidelinesThe "10/50/10" Treatment Regimen “Russian electrical stimulation is applied for a 10-second "on" period followed by a 50-second "off" period, with a recommended treatment time of 10 minutes per stimulation session. The objective is to increase a muscle's ability to generate force”, (Russian, 2009)
- 40. PrecautionsMuscle fatiguePatient toleranceThe nerve supply to the muscle must be intact
- 41. ContraindicationsCardiac pacemakersPrevious casting or splinting of the limbContracture from a burnHip replacement surgeryPatients with severe dementia, inability to follow directions and verbalizationDO NOT use on smaller muscles or muscle groups, such as:Muscles of the throat and faceMm. of the hands and feetNeuromuscular or neurological disorders in which fatigue has a negative impact on the disorder
- 42. IontophoresisA non-invasive, pain free method of delivering medication into the body using a low electrical currentIontophoresisis able to transcend drug ions through the skin and underlying tissue through a low-level electrical current, (Empi, 2010).
- 43. General PurposeProvides option for patients reluctant or unable to receive injectionsDecreases risk or infectionMedication is delivered directly to treatment siteDecreases tissue damageDelivers medication much quicker, and effects can be felt within minutes, (Empi, 2010).Can be, and is often used in conjunction with other modalities.Often used before therapy to reduce inflammation and pain.
- 44. TOOLSThe majority of units consist of a compact phoresor that operates with a 9-volt battery and two wire leads, each connected to an electrode.One electrode is the drug-delivery electrode, the other is used as a dispersive electrode charged opposite to the first one.When the electrodes contain solutions of ions, negatively charged anions are repelled from the cathode into the body
- 45. Evaluation GuidelinesThe inflammation must be near the body surface (Ex. a superficial muscle or tendon rather than a deep muscle tendon bursa).The medication must carry a charge to work with the iontophoresis.Transient erythmia often occurs, but is normal and the patient should be informed prior to treatment.Be sure to start with a mild sensation, so that the client feels only a tingling sensation and is not uncomfortable.Place the negative end of the electric charge on a part of the client’s body, away from the intended area. Apply the medication on the client’s affected area.Put another pad on it for the positive electrical charge.Turn on the electrical source and the charges of the medicine and electricity will push the medicine into the intended area.
- 46. PrecautionsBurning of the skin! Electrical discharges (sparks) may occurDo not use in the presence of flammable anestheticsDo not apply over an area where the hair has been shaved in the past 24 hours.Known skin allergies
- 47. ContraindicationsAllergic reaction to medicationHigher fat contentCardiac pacemakersKnown sensitivity to ionic solutionsDamaged skin, wounds or recent scar tissue
- 48. American Occupational Therapy Association. (2004). Roles and responsibilities of the occupational therapist and occupational therapy assistant during the delivery of occupational therapy services. American Journal of Occupational Therapy, 58, 663-667. Bracciano, A.G. (2008). Physical agent modalities: Theory and application for the occupational therapist (2nd ed.). Thorofare, NJ: Slack. eMedicine, Clinical Knowledge Base. (2007). Transcutaneous electrical nerve stimulation. Retrieved January 16, 2010 from http://www.emedicine.com/pmr/topic206.htm#section~introduction Empi: Health care professionals. (2009). DJO, Inc. Retrieved January 15, 2010 from http://www.empi.com/healthcare_professionals/detail.aspx?id=106 Iontophoresis drug delivery electrode insert. (2009). Pain Management. Life Tech, Inc. Retrieved January 17, 2010 from http://www.life-tech.com/pm/meditrodeindications.shtml Larson, J. (2007). Electrical stimulation therapy. Wild Irish Medical Education, Inc. Retrieved January, 15 2010 from http://www.nursingceu.com/courses/211/index_nceu.html McPhee, S.D. (2008). “Physical Agent Modalities: A Position Paper”. American Journal of Occupational Therapy, The. FindArticles.com. Retrieved January 12, 2010 from http://findarticles.com/p/articles/mi_hb5914/is_n32312314/ Modalities. (2009). Occupational Therapy: University Hospitals. Retrieved January 13, 2010 from http://www.uhhospitals.org/tabid/3728/Default.aspx “Neuromuscular electrical stimulation. Fallon Community Health Plan. (2006). Retrieved January 15, 2010 from http://www.fchp.org/NR/rdonlyres/50B823A6-3A65-44C3-A7AE-6C31A7B11A3E/0/NeuromuscularStimulation.pdf Pendleton, H.M. & Krohn, W.S. (2006). Pedretti’s occupational therapy: Practice skills for physical dysfunction (6th ed.). St. Louis, MI: Mosby, Inc. Russian electrical stimulation. (2009). Equinew, LLC. Retrieved January 18, 2010 from http://www.equinew.com/russian.htm
Editor's Notes
- #5: “The unique perspective of the OT is seeing the potential for performance and using modalities that lead incrementally to performance relevant to the lives clients wish to lead” (Pendleton, 2006).
- #6: Therefore, using electrical modalities alone cannot be considered treatment, but must be used with the purpose of improving one’s occupational performance.
- #7: Furthermore, to be supervised in the use of electrical modalities, the supervisor must be officially documented as having the same competency as described previously (AOTA, 2004).
- #8: (note: unless you are trained and certified to do so)
- #10: Bullet 3: -Cut hair, rather than shaveBegin each modality with this process, and modify the remaining steps according to the different modalities.
- #11: This is done through an electrical stimulator and electrodes connected by lead wires,
- #12: Ex. After injury, pain is a signal that warns the individual not to use the affected structure. Therefore, the muscles begin to weaken from disuse and cause potential spasms of the surrounding musculature. As this cycle persists, it exacerbates the initial pain response, into an even more painful and prolonged experience. Therefore, the therapist can use the TENS unit to stop the cycle, and speed up the healing process indirectly through pain reduction.Chronic- Essentially, to keep it from getting worse and causing further damage to the surrounding joints and muscles.
- #13: Bullet 1: The therapist presets the phase duration and pulse rate. Both are often battery operated (9-V), but the Therapist’s version is generally larger and less “user friendly”.
- #14: The current stimulated unto the patient is controlled and modulated by the therapist. The features that should be modulated include (bullet 1, 2, 3)Bullet 4, 5: Low Fire is more often used with acute pain, and high frequency with chronic pain
- #15: Bullet: If any muscles begin to contract, turn down the intensity slightly.
- #16: Bullet 1: (hypoallergenic electrodes can then be used)Bullet 2:(ex. Scar)Bullet 3:(avoid putting electrodes on them)Bullet 4:Example: Someone with tendonitis may greatly benefit from pain reduction, but must also be educated on the proper guidelines of tendon protection and rest. If not, the tissues can become overworked and overstressed, and become even more inflamed and/or stiff. Thus, causing an even more painful and debilitating situation in the long run.Bullet 5: is another condition that the OT should be concerned with when utilizing TENS, and should educate the client on proper nerve protection and rest, (Pendleton, 2006).Clients who present with conditions that may further become exacerbated without a pain sensation may need to undergo other techniques that may not stop the pain, but simply reduce it to a more tolerable level.
- #17: Bullet 1: , as the currents could cause a seizure.Bullet 2:, as the currents can disrupt the device and cause cardiac arrest.Bullet 3: muscle, with its high content of water, is more conductive than fat. Thus muscle tends to transmit the current, while fat impedes it. /the higher the resistance (ie: skin, fat..), the more heat is generated by the electrodes, causing potential for burn.