Preface
There is no doubt electrotherapy belongs to the long-established therapeutic methods of physical medicine. The origin of this method of treatment goes back as far as to the 18th century. But at the present time it is considered to be a new topical alternative due to the tremendous progress in the field of electronics. The application of long-established types of currents has been improved and simplified, and old wishes e.g. of therapy for paralysis are now fulfilled.
The uncomplicated style and simplified presentation of the various problems will make it easy for the reader to transform the contents of this brochure directly into
practice.

1.  Electrotherapy
The different types of electrical current used in electrotherapy are divided into two groups according to their effects:

DIRECT (DC OR GALVANIC)
and
ALTERNATING (AC) CURRENTS

The noticeable effects for the patient will be the characteristic sensation of current flow or of occurring muscle contractions.

The stimulation currents furthermore are grouped into currents of low frequencies (LF) and medium frequencies (M F).

LOW-FREQUENCY (LF) STIMULATION CURRENTS:
When using frequencies in a range below 1000 Hz, nerves and muscle fibres are able to follow this rhythm and respond to each single current pulse.
Example: TENS, Faradic, Pulsed Galvanic, Diadynamic Currents.

MEDIUM FREQUENCY (MF) STIMULATION CURRENTS:
When using frequencies in the range of approximately 1000 Hz up to 100,000 Hz it becomes impossible for excitable structures to react to every single pulse. Only the summation of a number of pulses achieves a single depolarization response (Gildemeister Summation Effect).

2. Types of Low Frequency Currents
A great number of stimulation current variants can be produced with the techniques existing in modern electrotherapy.

A new type of stimulation current should only be used in daily practice when reliable information, concerning effect (indication, contra-indication) and application (electrode technique, dosage etc.) exists.

Types of low frequency currents which fulfill these requirements are:
-  The Galvanic Current
-  The Diadynamic Current
-  The Frequency-Modulated Current "FM"
-  The Impulse Galvanization "IG 30" and "IG 50"
-  The Ultra-Stimulation Current
-  The Surging Currents "aS" and "cC" as well as the variable triangular- and rectangular impulse currents.

3.  Effects from Low Frequency Current Types
Stimulation currents release a multitude of reactions in the body, which are functionally connected.

When using low frequency type currents to stimulate nerves of the autonomic, central and voluntary nervous systems the following effects are observed:

HYPERAEMIA 
- Together with increased metabolism, higher absorption, increased antiphlogistic and bactericidal condition of the permeated tissue.

ANALGESIA 
- Which is partially attributed to hyperaraemia, but especially to the superimposing effect of stimulation (gate-control theory)

INFLUENCE ON MUSCLES 
- Either in the sense of relaxing tension in muscles or stimulating atonic or paralysed muscles, in the course of which contractions with the desired rhythm and exact dosing of intensity, can be produced.

IONTOPHORESIS 
- Due to the voltage, across the potentials (electrodes), medicine can be passed into the body.

INFLUENCE ON INTERNAL ORGANS 
- With the appropriate electrode technique by direct stimulation of the organ concerned or over reflex tracts.

INFLUENCE ON THE CENTRAL NERVOUS SYSTEM
- e.g. by passing electrical currents through the brain or spinal cord.

4.  Impulse galvanization "IG 30" and "IG 50"


IG 30 is a "triangular pulse" (t 30 ms, H = 50 ms) with a frequency of approx. 12 cps (cps = pulses/sec.)


IG 50 is a neofaradic current of approx. 8 surges/sec. (surge duration 50 ms, surge interval 70 ms)

The impulse-galvanization according to Prof. Jantsch (Vienna) belongs to the group of vibrating frequency currents. Due to the low stimulation frequency of approx. 12 cps at "IG 30" and approx. 8 cps at "IG 50" no lasting contraction is produced, but an evident vibration or shaking is noticeable
The advantage of this type of current, in comparison to other modulations, lies in the fact, that at the same dosage a minimum of sensitive irritation is felt.

Main fields of application of "IG 30" and "IG 50":
Hyperaemia
Tests and measurements have shown that stimulation currents in the field of vibration frequencies cause a maximum expansion of the blood-vessels without exposing the organism to a high current load.

Analgesia
The soothing effect together with "electrical self massage" (vibrating, shaking) is preferably used when painful sensations in the locomotor system are experienced.

5.  Diadynamic Types of Current



"DF" is a 100 cps impulse current (t 10 ms)


"MF" is a 50 cps impulse current (t = 10 ms, R 10 ms)


"CP" is a 50/100 cps frequency modulation (1 sec. of 50 cps, 1 sec. of 100 cps)


"LP" is a 50/100 cps frequency modulation (10 sec. of 50 cps, 5 sec. of l00 cps)

The modulations named "diadynamic currents" (after its originator Dr. Bernard, France) have been successfully used since 1950. The frequencies of these types of currents are especially suited to affect a pain blocking (gate-control-effect). That is the reason why the "diadynamic currents" are preferably used where analgesia is desired.

Long standing experience in the application has shown that it is practical to start the treatment with the current "DF" and to switch after a few minutes to the modulation "CP" or "LP". It is also advisable to select the types of current "IG 30" or "IG 50" after starting with "DF".
Besides the strong analgesic effect a good hyperaemia is noticed. That is the reason why diadynamic currents are successfully applied in sports-physiotherapy.

6. Ultra-stimulation current
The ultra-stimulation current has a stimulation frequency of 143 cps and is composed of rectangular pulses with a pulse duration of 2 ms and an interval duration of 5 ms.

This type of current was introduced by Träbert (first-named 1957) and produces a characteristic wave or kneading of the muscle on account of its frequency, which is appropriately named "electro stimulation massage". As with the diadynamic currents and pulse-galvanization, analgesia and hyperaemia are also in the foreground. That is why the indication fields are similar.

Träbert suggests using ultra-stimulation current, specifically for treating degenerative diseases of the spinal column.

7. Frequency modulated current ("FM")

At an appropriate intensity, muscle convulsions occur which alternate constantly with tremors, whereby an undesired permanent tension is avoided. Because of the continually changing frequency accommodation is avoided. This has been positively observed when treating pain (Sternek).

The FM-current belongs to the types of current, which cause extremely little unpleasantness. Therefore it is especially suited for sensitive patients.

The frequency modulated current ("FM") is a type of current which has very short "triangular pulses" with a duration of 1 ms. The relatively long and steadily changing pauses in the range between 70 and 150 ms cause a constant change of frequency between 7-74 cps.

From the effects of the types of current mentioned so far, it is obvious that the individual types of current are basically similar.

The therapist will know from his daily practice which type of current he prefers or if the selection of current is of only minor importance.

8.  Paralysis therapy
8.1 Application Technique
8.2 Types of Current

Defective or missing innervation of the muscle cause inactivity atrophy or even degeneration. The effects from lack of mobility do not occur, resp. are less pronounced if the muscle is regularly stimulated electrically until normal innervation is recovered.

The success of this treatment depends mainly on:
-  Application Technique
-  Type of Current
-  Dosage

8.1 Application Technique
There are basically two different ways of setting the electrodes:
1. Monopolar technique
A small electrode is placed on the object of stimulation (nerve or muscle) and a large (indifferent) electrode is usually attached to the trunk.
A small button electrode is often used. The indifferent electrode should be big enough not to irritate. When small areas are to be stimulated e.g. nerve- and muscle stimulation spots, or hand- and face muscles, preference is given to the monopolar technique.

2. Bipolar technique
Both electrodes - usually of the same size - are placed on the stimulation area. It is used when the greatest part of the muscle substance should be stimulated, for instance, if there is an absence of the motor stimulation point (muscle stimulation point). The size of the electrodes must be adjusted to the anatomic pro-portions. The muscle contraction must not be prevented by the size or the application of the electrodes. (Flexible electrodes should be used which do not constrict in any way.) Contractions are facilitated if the muscle is positioned in a way to bring origin and insertion close together.

8.2 Types of Current
The stimulation parameter PULSE DURATION, INTENSITY and
INTERVAL DURATION have to be adjusted in a way to enable the
injured muscle to contract sufficiently.

There are two possibilities:
1. Types of current with standardized data
Pulse duration, impulse and interval duration are already set in the right relationship through these types of current.
Only the intensity of the current has to be regulated.
There is a sufficient number of types of current with various pulse durations and co-ordinated interval duration, for example, the exponential impulses E 100, E 200 and E 500 and the surging currents "aS and cS'~.
The therapist selects the current (by test), which produces the strongest muscle contraction causing the least possible sense of unpleasantness.
Select a triangular pulse with a sufficiently slow rise time to avoid stimulating surrounding innervated muscle.

2. Types of current with adjustable parameters.
The free choice of each stimulation parameter makes it possible to compose a type of current, which applies exactly to the degree of damage done to the nerve or muscle.

Suggestion of procedure:
a. Select triangular type of pulse
b. Adjust "best pulse duration" (found out by TIC)
c. Adjust interval duration (approx. 7-10 times the pulse duration, see dosage)
d. Increase intensity slowly until the muscles contract vigorously.
e. Check at the same intensity if a stronger muscle contraction can be obtained, without the reaction of other muscles, by diminishing and extending the pulse duration.

DOSAGE
Number and intensity of muscle contraction as well as the intervals between should be adjusted in a way in order to obtain a strong stimulation training. The muscle must be prevented from being overcharged, it might cause injury.
The intensity must not be increased if the contractions became weaker and the muscle shows signs of fatigue!
The treatment should be brought to an end and if necessary the interval duration should be extended at the next treatment.

9. The Surging Currents "as"


The "automatic surging current ("as") is a neofaradic current (pulse duration 1 ms, pulse form, interval duration 20 ms), whose intensity increases and decreases.


The push button control surging current is also a neofaradic current. By operating the key, the patient can regulate the intensity. By doing this, the so-called intention exercises (after FOERSTER) can be carried out, which lead to an optional innervation.

The muscle is "faradic not excitable" if it does not react to the surging current on account of its injury. Electro contraction must then be applied with pulses of longer duration. (next page)

10. The Triangular Pulse Currents E 100, E 200, E 500

The pulse duration is 100 msec., 200 msec. or 500 msec. depending on the instrument setting.
Rise and decay of the pulse are delayed (triangular pulse). The pause interval is fixed to 2000 msec.

Triangular or exponential pulses are preferred for stimulating severely damaged muscles.
Delaying the pulse rise allows diseased muscles to be stimulated without causing healthy (and easier excitable) surrounding muscles to react. This selectivity in muscle stimulation is possible due to the better ability of healthy musculature to adapt to triangular pulses. Furthermore, triangular pulses are better tolerable than square pulses.
The higher the degree of damage to the nervous muscular system the longer is the pulse duration required for an effective stimulation (f.e. 200 msec. or longer).

However, it can be considered a positive sign, if muscles show an increased response to short triangular pulses (for example 100 msec.) than to longer ones of the same amplitude, because it is an indication of the remaining ability to accommodate.

11. Indications and Contra-indications

Indications:
Treatment of a wide range of medical indications and conditions is possible because of the variety of effects produced by low frequency currents. Stimulations therapy is a well-proven treatment method for:

PAIN
Treatment of the cause and the referred pain pathway has marked analgesic effects for pain of sympathetic origin such as causalgia, reflex sympathetic dystrophy, migraine and neuralgia.

DISEASES OF THE LOCOMOTOR SYSTEM (boned, joints, capsules, ligaments, muscles, etc.)
a) trauma-induced:
Distortions, contusions, conditions following luxations and fractures, over stretched muscles.
b) degenerative
arthrosis, humeroscapular periathritis, chondrosis and osteochondrosis of the spine, myalgia like lumbago and torticollis, muscular atrophy, epicondylitis.

CIRCULATORY DISORDERS
a) Functional type:
Raynaud's disease, migraine, acrocyanosis.
b) Organictype:
arterial sclerosis, endo-angutis obliterans, varicosis, conditions following frostbites and burns.

DISTURBANCES OF THE NERVOUS SYSTEM
Neuralgia like ischialgia, trigeminal neuralgia, brachialgia, etc. neuritis, radiculopathy, herpes zoster and faradisable paralysis

DISORDERS OF INNER ORGANS
Obstipation or other functional disorders of inner organs.

PERIPHERAL PARALYSES
Strengthening of atrophic muscles, for example after long periods of immobilization of a limb
- Individual intentional training

Contra-indications:

Stimulation current therapy must not be used in cases of
- highly inflamed of feverish infections
- pregnancy
- patients with cardiac pacemakers
- malignant tumors
- spastic paralysis
- skin lesions in the area of treatment like skin injuries
- varicous and atrophic degenerated skin
- arterial disease, deep vein thrombosis, thrombo-phlebitis
- danger of hemorrhage

12. Dosage
Experience indicates that only high intensities guarantee the desired effect (gate-control-theory) for treating pain.
For muscle exercises, the intensity has to be selected high enough to obtain vigorous contractions of the muscular system. Ensure that the intensity of current does not go beyond the tolerance limit and that no muscle contractions occur at types of current of more than 20 cps (e.g. "DF"). Acid burns might occur if prolonged applications exceed a current density of 0,1 mA/cm2. Calculation of current density:



Example:
At an intensity of current of 10 mA and an electrode surface of
100 cm2 amounts the current density to 0,1 mNcm2 (10 mA:
100cm2--0,1 mA/cm2)

By using electrodes of 2 different sizes at the same time, the current density of the smaller electrode is the determining factor.

TREATMENT TIME
The duration of treatment depends on the state of the disease and the selected type of current.

For "galvanization" (e.g. treatment of disturbances in the blood circulation or for iontophoresis) a treatment duration of somewhere between 10-30 minutes is applicable.

In the course of which, even with several application techniques, a total time of 12-15 minutes is rarely exceeded.

On application of the electro gymnastics (paralysis therapy with as, cs, E 100, E 200, E 500) the treatment duration is determined by the number of contractions.

TREATMENT INTERVALS
As with all other physiotherapeutic methods, acute conditions are treated daily and often even twice a day, while chronic conditions are treated 2-3 times per week. Therapy for paralyzed muscles should be applied daily, or preferably twice a day.

It could be considered, that after a short training, the patient may be able to apply the therapy himself with the appropriate unit. Then the therapist only needs to control the therapy regularly and to give instructions (lit curve diagnostic).

NUMBER OF TREATMENTS
In acute cases, the desired result can often be achieved with a short treatment series (approx. 6) whereas chronic cases require a greater number of treatments (approx. 10 sessions).

NOTES:
If the patient's reaction is not known low dosages should be used even when treating chronic cases.

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