PAIN MANAGEMENT A Practical Guide for Clinicians SIXTH EDITION Editor Richard S. Weiner AMERICAN ACADEMY OF PAIN MANAGEMENT €) CRC PRESS _ Boca Raton London New York Washington, D.C.60 Electromedicine: The Other Side of Physiology Daniel L. Kirsch, Ph.D., DA.A.PM. AA fresh look at physiology is needed to better understand the primary medical complaint of pain, Universities are still teaching their students that life is based on a chemical ‘model. Rather than view life processes on a chemical basis alone, itis more realistic to view them on an electrochem- ‘cat basis. All atoms are bonded electrically. This is a basic foundation necessary to understand electromedicine that is taught during the most elementary training in the basic sciences. Further in our rudimentary training we learned that there are voltage potentials across the membrane of all cells. All standard physiology textbooks define the ‘Nemst and Goldman Equations to determine membrane ‘and action potentials, They do not, however, speculate on the staggering significance of these facts. Irbatteries are placed in series, their voltage potentials are combined. A simple remote-control device may use three 1.5-V batteries to produce the 4.5 V needed to oper- ate a television. The human body has trillions of cells, ‘each having a 10- to 200-mV potential across their mem- branes, The overall electrical potential in humans is 2 x 10 V/mm (Kitchen & Bazin, 1996). All good scientists should ask themselves why we find electricity so prevalent in biological systems. It is already established that bioelectrcity plays & major role in physiology. Robert O. Becker, M.D. has ‘spent more than 30 years attempting to determine how tiftions of cells with hundreds of subtypes can function ‘harmoniously in the form we call human. The result of that inquiry is a complete revolution in our previous con- cepts of biology (Becker, 1983). Becker (1982) found that electromagnetic fields con- twol all living processes. The earliest concept of such field effects can be traced back to ancient China. Tradi- tional Oriental medicine is based on the controlling SRC pene power of ch’i (Qi) or ki energy: a concept that predates electricity but appears to be analogous (Kirsch, 1978), Chiropractic also developed based on a similar observa- tion termed innate intelligence by Daniel David Palmer in 1895 (Palmer, 1910). Indians use the term prana to represent the same concept, Allopathic practitioners are limited to the vague notion of homeostasis. In Wester civilization, the first documented use of clecrrcity to manage pain was by the physician Scribonius Largus in 46 A.D. (Tapio and Hymes, 1987). He claimed that just about everything from headaches to gout could be contoiled by standing on a wet beach near an electric cel, Not surprisingly, attempts at producing pharmaceuti- cal preparations from dead cels proved ineffective. In 1791, Luigi Galvani discovered that cfectical impulses could cause muscle contraction (Smith, 1981). By 1800, Carlo Matteucci showed that injured tissue generates an electric current (Becker and Marino, 1982). The discovery of alternating current by Michael Faraday in 1830 opened the door t0 the development of manmade devices a5 sources of electricity. Over 10,000 medical practitioners inthe United States tlone made use of electrotherspeutic ‘modalities unl publication of the 1910 Flexner report, Which stated that there was no scientific basis for electro- medicine at that time. Flexner’s report was originally pre- pared by the American Medical Association and sponsored by the Camegie Endowment for the Advancement of ‘Teaching (Walker, 1993). Since the Carnegie family was heavily invested in the young pharmaceutical industry, it is no wonder their report declared allopathic medicine superior Since then, arguably the gratest development in the fied of electromedicine was when Becker (1981) electr- cally induced limb regeneration in frogs and rats 38 & model 749750 Pain Management: A Practical Guide for Clinicians, Sixth Edition to study bioelectrical forces as a contoling momphogenetic field. Regeneration represents a return to embryonic control sysiems and cellular activites within a localized area. It can, therefore, be considered a more accessible and more observable form of morphogenesis. The complexity of instructions required to desigrate all of the details to ree- reate a finished exteity i impossible to wansmit by pre- viously understood biochemical processes alone. Becker (1983) proposed tha a primitive diect curent data transmission and conwol system exists in biological systems for the regulation of growth and healing. His studies of extrancuronal analog electrical morphogenetic fields have eliminated any rational arguments against che importance of bioelectricity forall life processes. Becker has laid the groundwork for the medical professions t0 start to evolve toward a more reasonable integrated view of biology incorporating our understanding of both bio- chemistry and biophysics ‘Bj Nordenstrim, M.D. (1983, 1998), forme: Cair- ‘man of the Nobel Assembly, also has proposed a model of bioelectrical control systems he calls biologically closed electric circuits (BCEC), The principle is anale- ous 10 closed circuits in electonic technology: Norden- stSm's theory is that the mechanical blood circulation system is closely integrated anatomically and physiolog- ically with 2 bioelectrical system. Nordenstrim hypothesizes that ionic and nonionic ‘compounds interact in a way that makes selective distri bution and modulation of electrical and other forms of ‘energy possible throughout the body. even over long dis- tances. The biological circuits are switched on by both normal electrical activities of the organs and pathofogical changes, uch as tumor, injury, or infection, Like Becker, Nordenstrom views bioelectricity as the primary catalyst Of the healing process. Using the vascular interstitial system ax an example, Nordenstrém postulates two branches of this system, The fist branch, the intravascular system, proposes that walls Of blood vessels act as insulators. much lke cables in a battery system, The electrical resistance of the walls of the arteries and veins is 200 to 300 times greater thar the blood within Delayed available energy, or potential enemy is car- ried by blood ces that bind oxygen, as well «s other chemicals such as glucose, neutral fat, nonpolar amino acids, ete. These are all noncharged packages of energy that arrive at specific sites and are released primarily by reduetion/oxidation. Nordenstim terms these ergonars. The intravascular plasma acts as the conductor, whee ions such as sodium, calcium, and chloride supply immedistely available energy othe system, primarily by electrophore- sis, Nordenstrém cals these fone ‘The second branch addresses the interstitial system, ‘The tissue matrix acts a8 an insulator while the interstitial ‘uid acts as a conductor. Capillary membranes are the main components that close the system, These membranes act as junctions ‘between the interstitial and vascular fluids allowing exchange of ionars and ergonars along gradients of elec- trical potential This theory represents a comprehensive attempt to describe functions of anatomical components in terms of electromagnetic forces, rather than limiting them to chem- ical interactions. Nordenstrim further theorizes that sim- ilar closed circuit systems exist in the urinary and gas trointestinal systems, Using electrical intervention, Nordenstrom (1984, 1989) reversed terminal cancer in most of his patients as clinical proof of his theories, Sev- eral other researchers are confirming the value of electro- ‘medicine for the treatment of cancer (Pallares, 1998; Lyte, etal. 1991; Morris, et al., 1992; Sersa, et al. 1992; and Belehradek, et al, 1981). ‘The medical community has bare!y taken notice of these remarkable theories, Few practitioners are even aware of the works of Becker or Nordenstrém. Norden- strom is familiar with this type of ignorance. In the 1950s he pioneered a series of remarkable innovations in clinical radiology (including percutancous needle biopsy) that were considered radical at the time, but are routinely employed by every major hospital in the world today. Lack of updated education of healthcare professionals is the main stumbling block to asceptance of the modern theories and practice of electromedicine. The other prob- lem is the wide variety of technologies available. At present, there are well over 100 different models of tran- cutaneous electrical nerve stimulation (TENS) devices in the marketplace and an increasing number of other clec~ trical devices. Most healthcare practitioners who want to utilize such technology have received little or no training in electrobiology or electrical technology, Hence, when it ‘comes to making an educated decision on what type of instrument to choose for a practice or a particular patient, practitioners are often overwhelmed When meeting: with anelectromedical sales representative. Purchase decisions are frequently made based on lack of knowledge, misi formation, unsubstantiated claims such as testimonials not backed by solid research, or price. If a device is effective in only 2% of the population, treatment of 1000 patients ccan result in 20 testimonials. The plural of anecdote is not data. Accordingly, healthcare professionals should rely only on evidence-based technofogies supported by double- blind research, BASIC PRINCIPLES The basic unit of energy is the electron. In 1600, William Gilbert coined the word electricity (Baver, 1983). Using sulfur and friction to generate electricity, Guericke found that it had several properties in common with magneticElectromedicine: The Other Side of Physiology forces, such as epulsiow/atraction, transference of prop erties, and opposite poles. Faraday termed the postive pole the anode, meaning “upper rovte” and the negative pole cathode, or “lower route.” Electrons flow from neg- Alive 0 positive, or cathode to anode: Fluid-based biological systems are conductive media. Blood, water, and lymph all conduct electricity Various molecular ions, such as calcium, sodium, and chlorides, carry current. When current is carried by ions, electrolysis occurs. In this process, electricity breaks the conducting fluid down into its components. In the case of water, electricity reduces the H,0 molecule into its components of two atoms of hydrogen and one of oxy gen. The half-eaction for the formation of water is °LO, + 2H" + 2e- HO. The resultant voltage released al a pli of 7.0 is 0816 V (egel, 1975). This process cccurs within all ypes of tissue (eg, nerves, muscle, bone, etc.) throughout the body. Many interactions of this nature are highly complex and not yet thoroughly understood. Certain types of elec- trical stimulation have caused neurotransmitters to be manufactured and released. Some of these treatments are even considered 1 be frequency specific, but there is still 1 Tot to Tearn before we can specify the biochemical effects of frequencies, or any other individual aspect of a waveform. Waves ano Purses In fluids, such as water, the sinusoids! wave is the only basic waveform. However, with electrical technology, di ferent shaped waveforms can be built. These are often referred to as square, rectangular, triangular, sawtooth, cic. In actuality, they are composed of thousands of waves known as harmonics, A collection of harmonics within a single electrical activity is called a pulse. Frequencies (H2) and Pulse Repetition Rates (PRR) Pulses are measured in cycles moving through a medium. in 1 second. One cycle per second is also called a Herts (Hz). In electrical devices, pulses have frequencies. Just 4s the collection of harmonics is called a pulse, total frequencies (built by the resonance of harmonics) is referred to as the pulse repetition rate (PRR). Itis the speed at which the pulse moves. For example, a1 Hz pulse will have harmonic frequencies that build the pulse, ranging from 1 Hz to hundreds of thousands of Hz and beyond, theoretically to infinity. This is often a source of confusion, not only among practitioners, but also among manufacturers of devices as well. In en neering terms, the term frequency should only be used with a pure sinewave. Only in this one case, frequency is the same as the pulse repetition rate. With any other 751 waveform (e.g., square, rectangular, triangular, ete) there isan infinite numberof harmonic frequencies gen- crated within each pulse “The interplay of harmonics identifies a given musical instrument as a particular aural experience. Some people prefer the sound ofa specific note ona piano, while others would rather hear the same note played on a violin Although the noe isthe sam in each cae, the harmonics vary. The interplay of harmonics in electromedicine is «essential in affecting the results oF given treatment With this in mind, we can begin te understand why one elec- tromedical device may work for one patient, yet provi poor resus for another. we could predict what harmon- ies each tissue needed aa given time, we could design devices that would provide more consistent results in pain management healing, altering consciousness. and regu- lating biological processes in general The body accepts frequencies and pulse repetition rates in nonlinear, differential manner For example, low frequencies penetrate greater depths of tissue than high frequencies. Higher frequencies are autoshielding; that is, they are limited in penetration because the resistance of tissue act ike a Faraday cage, forming eddy-repulsion ‘This eddy current produces aback electromotive fore and blocks the penetration. The reflection of input signals in any conductor (inthis ease the body) isa mirror image of the opposite phase. The higher the frequency, the greater the rejection and the shallower the penetration. Complex frequencies interact in the body causing a diffuse spread of current. ‘Anonlinear electrical device is called a diode. diode conducts current of one polarity far greater than the oppo- site polarity. Most living tissue exhibits nonlinear charac- teristics, funetioning somewhat like diodes With square and rectangular waves, a shotgun-like distribution of thousands of frequencies occurs simulta neously within each pulse, like buckshot scattering over a wide area. sinewave, on the other hand, is more ike a bullet from a rifle, which most strike a target accurately to be of use. Our present knowledge of electtopysiology is not sufficient to determine the optimum frequencies for specific tissue responses: therefore, the ws of sinewaves is not recommended Pulse Width ‘The length of time a pulse lasts is called the width. This is usually measured in microseconds, Pulse width really rofers to the time the wave is active. This is important with respect to how a given tissue may be affected, and is part of a hypothetica! window of optimal electric stimulation. ‘The body responds to the peak of electrical signals and to the number of electrons in that signal. The max~ imum charge per pulse is measured in microcoulombs, which is the total energy of each pulse. The definition752 Pain Management: Practical Guide for Clinicians, Sith Edition ‘of a coulomb is the quantity of electric charge carried by 6.25 x 20"electcons. Returning to our bullet analogy, we can see that a .22 bullet has less energy than a 45 tulle because iis lighter. While the .22 might go faster, the 45 can knock down a bigger target with its increased energy. Consider each spike bullet ané the pulse width the energy carried by that bullet. faking our analogy a step further, the velocity of the bullet is the voltage, While the mass of the bullet isthe energy, measured in ricrocoulombs Biphasic Signals Because ions dissociate by electrolysis inthe presence of electrical curent, living tissue can become polarized in a direct current field. This can cause conflict in neural tis- sues. Therefore, modern stimulators usually provide alter nating or biphasic (also known as bipolar) current. That ‘current that reverses polarity each half cycle. This is alled a zero net current. If the current continued to flow the same direction, polarity stress could result in ire- versible tissue damage, ‘As an analogy, picture a group of soldiers marching across a bridge. Before they get fo one side, an about face onder is given and they return. Before they reach the opposite side. another about-face order is given, and S0 On, so that they never actually reach a side. By going back and forth, biphasically, there is no net electron flow across the bridge and no soldiers are added or subtracted ‘They never get across the bridge to cause an ireversible balance in the status quo. Accordingly, a biphasic current {does not add electrons tothe boxy; it simply moves them back and forth. ‘Amperage, Voltage, and Resistance Blectrcity travels in a circuit. The number of electrons moving per unit of time is called amperage. Amperage is a measure of the amount of current. Voltage is a measure Of the pressure in the circuit. Resistance 0 the electron flow in the circuit is measured in ohms. A classic analogy of this is water flowing through a garden hose. The amount ‘of water in the hose corresponds to the amperage. The ‘water pressure corresponds to the voltage. The hose can take only so much water pressure at a given time, Any more pressure or water will be met by more resistance from the hose. This concept is mathematically stazct by ‘Olim’s faw of E = IR, where E (electromotive force) isthe voltage, I is the current, and R is the resistance. One can increase the current and decrease the voltage by decreas- ing resistance, just as more water can pass with a lower pressure through a fire hose than through a garden hose, ‘Similarly, more current can pass through a larger diameter ‘or through 2 highly conductive metal such as copper. In both cases, the thicker wire and more conductive metal have lower resistance. In the case of a human body, resistance is determined by factors such as fluid content, general health, skin thick- ness, amount of oil on the skin, temperature and humidity in the air, etc. If a person has a higher resistance, less current will flow through. However, voltage can be increased to maintain the desired level of current. The Detter electromedical devices deliver a constant current by self-adjusting voltage as skin resistance changes. ‘Conductivity Skin resistance is several thousand ohms (us high as 100,000 2 when dry). Wet skin can be as Jow as 1000 . Resistance between the hand and foot excluding skin resis- tance js as low as 500. Overall, tissue conductivity is proportional to its water content ax can be seen Table 60.1, TABLE 60.1 ‘Water Content of Various Tissues Tse Water Content skin S16 Bone 516% Fat 11s Brain Muscle CLINICAL ASPECTS OF ELECTROMEDICINE ‘The correct form of electromedical intervention will often have a profound and usually immediate effect on pain. ‘Although caution is advised during pregnancy for liability purposes and the possibility of inducing 2 miscarriage, and clectrical stimulation should not be used on patients with demand-type cardiac pacemakers manufactured prior to the electromagnetic compatibility standards that went into effect in 1998, there are no known significant lasting adverse side effects to therapeutic electromedical technol- ogy. There are, however, a number of contraindications as listed below. Geverat, OvERviEW OF BENEFITS Low incidence of adverse effects. Relatively easy to learn, Can be administered by paramedical personnel. Expands the practitioner's clinical capability. Enhances the total efficacy of clinical efforts. An alternative therapy in cases refractive to ‘conventional methods, 7. Eliminates or reduces the need for addictive ‘medications in chronic pain syndromes. oueepeElectromedicine: The Other Side of Physiology 8. May be applied on a scheduled basis or PRN. 9. Some modalities produce cumulative effects. 10. May be self-administered by patients for pal- Tiative care 11, Noninvasive therapies are less liable 0 result in malpractice claims than many conventional procedures. 12, Highly cost effective. GeneRat. OvERviEW oF CONTRAINDICATIONS, PRecauTions, AND Avense Errects 1, Possible interference with pre-1998 demand- type pacemakers, Also, other implanted devices such as defibrillator, morphine pumps, ar cial joints, joint screws, ete 2. Strong stimulation or pressure from probes placed directly on the carotid sinus could result in vaso-vagal syncope. 3. Some modalities may cause skin eaction (ed- ness through actual bums) due t excessive stimulation, prolonged use of direct current (or polarity imbalance), or simply sensitive skin 4, Direct currents can cause electrochemical dam- age (ie. chemical burn). 5. Contact dermatitis or disease transmission duc to unclean electrodes. 6. Electric shock hazard due to device maifunction ‘or improper use. 7. Many modalities contraindicated for use around heart Most modalities contraindicated for use on head 9. Excessive stimulation may produce muscular Soreness oF spasm, or exceptionally vigorous ‘muscle stimulation can cause muscle oF joint damage. 10. Some modalities can cause cardiac fibrillation 21 Shock azard from sudden interruption of cur- rent in some modalities. 12 The use of most modalities has not been researched in pregnancy (possible physio cal implications, such as miscarriage: and unsubstantiated egal arguments in case of developmental defects. 13. Masking of pain that may serve as protective ‘mechanism, 14. Masking of pain that may hinder or delay diag oss, 15, Some devices can raise or lower blood pressure 16. Patients may not be able 10 drive or operate heavy machinery during or after use. 17. Some devices may cause headaches, vertigo, or 18, Sensations experienced by the patient can cause anxiety, or panic atacks due wo fear of electecity 753 19, Some devices may cause vasodilation which ‘would be contraindicated in some people due to hemophilia or thrombosis (may detach thrombus), 20. Spreading of acute inflammation due to muscle pumping action 21, Some devices may increase injury if used for recent traumatic injuries. 22. Some modalities must not be used over the spine. 23, Some devices may be contraindicated in malignancy (while others are designed to treat cancer). 24, As in drugs, tolerance i the biggest problem of most modalities, such as TENS, 25, Metal electrodes may be toxic. Electrode mate- rials may be driven through the skin through iontophoresis. 26, Electricity passing through any substance pro- duces heat. For human skin 1 mA/em? is just below the level at which cell damage due to heat is produced, Higher currents may damage cells (Becker, 1990), INDICATIONS AND CONTRAINDICATIONS For Seeciric Etecrrotuerapy MODALITIES ‘The following tables may be used as general guides to determine which modality might be preseribed for a given diagnosis. However this information i fr from complete, and cerainly will not, in icf, suffice as complete ‘course in electromedicine. The reader should keep in mind the above list of general contraindications, precautions, and adverse effects, and that quality, consistency of the outputs, and other factors vary widely among products ‘This information is culled from the author's 3 docades of. training and experience in electromedicine as well as that of several other leading authorities (Becker, 1990; Benton, Baker, Bowmen, & Waters, 1981; Jaskoviak & Schater, 1993; Kirsch, 1999; Kitchen & Bazin, 1996; Low & Reed, 1994; Nelson & Currier, 1991; Thuile & Kirsch, 2000) Auriculotherapy ‘Treatmen of ear acupuncture points for pain management and systemic disorders (all acupuncuure applications. Uses low frequency 0.5-320 Hz, < 2 $, < 500 mA. Cranial Electrotherapy Stimulation (CES) ‘Treatment of the brain for pain, stress, anxiety, depression, insomnia, and addictions when (reated at lower oF mid brain levels (car iobes). Also may be useful to treat organic brain disorders (e.., stroke, Parkinson's disease, multiple sclerosis, ete.) when treated on top ar above ears. Remove cearrings and hearing aids754 Pain Management: A Practical Guide for Clinicians, Sith Edition Uses low-frequency biphasic currents of 0.5~-100 Hz, <25,<10mA Indications Contrandications Addictions Learsing disorders Patents proe 9 (aleobotism, Mottin sclerosis vertigo cigarete Muncletone/move- —Presnancy swith smentemor cxcsine, heroin, Obsessive smarijuans, compulsive metiadone, disorders opiates, Pain (system polysubsance lori, base, witbdrawal) —dehsionry or Ansty alcinteryy ‘Altenian deficit obs disorder Patkinsons nese Bronchial astims Phantom ind Cerebral palsy syndrome Chronic fatigue Raynaud’ disease syndrome Reseton time, (Closed head njrins vigilance Cognitive efix sympathetic ‘ysfoncton dysogy Dena analgesia Rebabilaton Depression (oystemic ating disorders diverter) Fibonyalgia Suess syndrome Soke Aeadactes “Temporal Insomnia joi isoeder Cryotherapy lee, cold packs, vapocoolant sprays, cold therapy, cold jimmersions, and eryokinetics. This is included here in ‘opposition to hyperthermia treatment that is a given ther- peutic factor of some electromedical modalities. It takes about 15 minutes for ice to reduce skin temperature from 84 to 43°F, 60 minutes to decrease subcutaneous tissue from 94 10 70°F, and about 2 hours to decrease intramuscular temperature from 98 t0 79°F. Use of cold for more than 30 minutes may cause tem- porary nerve palsy. Tdications Contrandications Inhibits bleeding Anglomas Raynaud’ dense alter cite trauma ols ad Coma ‘Reduces pain and carbs Rheumatoid reduces the Fee states atrts and gout fsccompanying Herpes listers —_Cresthesia eg. reflex muscle —Spains and strains tooth decay) spasm in acute Tumors Paroxysmal old ruscoloseltal_ Varicose ulcers hemoglobinuria injuries Was Dress blood flow o ates of cue nfamaation Spasiity Bons Closed pressure Reduces adverse tissue charges and relieyespain inthe firs treatment finer and smake wes Hlectroacupuncture Pain management, vasodilation, nausea, healing (all acu- puncture applications) Uses low frequency 05-100 Hr, 0.2 mS, at microeur- rent to TENS-like amplitudes. Faradic Functional electrical stimulation (FES) provides tetanic contractions of denervated muscles, Used for impaired ‘movernent, muscle sizengchening. Uses low frequency 30-100 Hz, 0.11 mS, biphasic currents applied to motor points. ‘Contvaindlcations Areas of diminished sensation Beyond the flexibility of implaned prosthesis Mersstatc carcinoma ‘dications Brachial plexus injury Dicky in voluntary movement (poststroke or head vrauma Filton of voluntary motor Over metalic implants funecon Over open wounds Gailian- Bare syaome (Over o through ear Mainining or increasing ange Pactaers ‘of motion Pregnaney Muscle spasticity ‘Tansvznially Muscle sengtening ‘Onto ting Rehabilitation of masls (post conhopedic suey, pial inj) Galvanic Neuralgia, circulation disorders, myalgia (denervated muscle), alleviates pain, promotes healing. Used for fore- ing chemicals through the skin via iontophoresis, Negative electrode (cathode) is generally thought to promote healing: however, recent evidence indicates that the driving electric force of the degrading, energy- liberating, catabolic process of injury fluctuates from anodic into cathodic phases, attenuating toward a stateHiectromedicine: The Other Side of Physiology of equilibrium (“healing”) as is the case with atl spon- taneous reactions (Nordenstrom, 1983). Biphasic devices are safer and may actually be better for promot- ing healing, Galvanic currents are continuous direct currents of <033 mAlemt, Primary Effect of Direct Currents ‘Type of kifect Anode (+) Cathode Prysiochemical Atrats aide Atwacis alkaloids Repels alkaloids Repels ace Awacts oxygen Ales hyarogen Condes metals by Does ot corrode metals ‘oxidation Physiological Hardens sr tisue Softens ses Decreases nerve ‘Increases nerve ibility italy Detydates tissue Congest Uses Predvees Produces vasodilation vasoconstriction Enhances bleeding Retads bleeding Proues hyperemia Produces ischemia Tendetoinrease paint Tends tobe analgesic ow intensities Germicidal eters Indications Conteaindications ‘Ace waume Carotid situs area Adhesions Innuired euaeous sensation An New the heart Tecervetebral dis syrromes Over any metalic implant Soin pain (jos, pins, or LUD) Neurts (Ove Sears and adhesions Male Pacemakers Sciatica Pregnancy Sprains and stains ‘ranscraviay “Treatment on 2 mete table High Voltage Pulsed Galvanic ‘Vasodilation, healing of superficial wounds, reduction of ‘edema, pain management, muscle stimulation. Uses low frequency 2-200 Hz typical (<1 KHz}, = 500 V, 12-15 mA, 1-600 mS. Trdications Cantvaindications —_— Adbesions Areas of dimisisbed sensation Cirulatery sss Meu impents Edema Meuse cxeinoma Marcle spas ‘Over or though heat Masculararophy ver open wounds Phin Pacemakers Passive exercise Pregnancy Restricted joint movernem ———Transeranilly ‘Tiger poines 735 Interferential Pain due fo traumatic injuries, post-operative pain, joint con- ditions, myalgia and tendinitis, bursitis, edema, hematoma. Nerve blocks via Wedensky Inhibition oecar ven the fre- {quency of the stimatacon is faster than the frequency of the action potential (due to its shorter wavelength), because the nerve cannot recover. With continued stimulation, the nerve becomes partially insensitive. The maximum frequency of an action potential lasting 10 ms is 100 Hz. Generally uses medium frequency combination of 4000 and 4100 Hz = 100 He, at 4-15 mA. Teaications ‘Contraindiations Anterior whi] Myositis Abacess synicome Newalia Anxiety Bursts Newroma Carotid sius area Brophal estims Gussie Circulation block Capi Pa Hear area Caseig Peianis Hyperpyrexin Choleyetis Phantom fimb pain Menstruation (ctwonic) Postaraumatic Metastatic Eftsions edema ‘carina Fpicondyits Prestiis Pacomakers Facial ploy Pscassynfrome Pregnancy Fibosts Rheumatic ‘Thrombophlebiis Frozen shoulder iorders ranean Hematora Scinica ‘Tberulsis ciation ‘Shoaer-arm Varcosies Hemiplegis symirome Herpes zee Spasms Incontinence Spondylitis Interment, Sprains and sans ladication Spurs Inververeral ise Stee syndrome Sadeck's atrophy Ischia Synoniis Joint deformity Thoracodyia Low back pain THgger points Lympbedema Vasospaem Myalgia Laser ("Cold Laser”) Nanosecond pulse widths, usually 500-5000 Ha, 15-25 W (« 25 mW actual). Avoid eves. “Contraindieations Tedications Barskis New eyes Degenerative joins ‘Over thyeod gland Diseases of the eal cavity ‘Over pacemakers (mattis, pavexrction —_Preguancy problems, olers,herpeslbils) Tumors Postoperative nt iaumatic maseuloskeleta complaint Sears ‘lees (docabits an herpetic)756 Pain Management: A Practical Guide for Clinicians, Sixth Edition ‘Microcurrent Electrical Therapy (MET) Acute, chronic, and postoperative accelerating healing Often references Amdt's Law: Weak stimuli excite physiological activity, moderate stimuli favor it, stong ‘stimuli retard it, and very strong stimuli arrest physiolog- ical activity. At 500 WA adenosine triphosphate (ATP) increases by 500%, but drops below baseline above 5 mA (Chang, Van Hoff, Bockx, ct al, 1982). At 100-500 mA, amino acid transport rises 30 to 40% above contol. Uses low-frequency biphasic currents of <2 S, 03-100 Hz, <1 mA initiating and Indications Head and Neck systemic Pain Pain ‘Abdominal Pain Artis Cersicogeic Blade pain Borstis headache Bowel stasis Concer Custer headache Diverticulosis Coustgia DDenul disorders _Dysmesorstea Cholecystitis (periodontal and Labor (chronic) cerhodontic pain) Postoperative pain ecubtl ulcers Facial play Prostaits ffsions Mignine Fibrosis Sinusitis Hematoms Sprains and sins calefieaon Svboccisal Hemiplegia. eacaches Herpes zoster Tinie Ischialia Temporomandibular {ympoderma joint disorder Multi sclerosis Tension headache Myalgia Toricols Myositis Tigeminal Neuralgia euaigia ewroma Whiplash Oseoantsts Pain Gysteric and itiogatie) Panto lit syndrome Posttraumatic edema Raynes aiscase Rheumstoid antits Soars Syoovits ‘Teggerpoins Lower Extremity Upper Extremity Back Pain Pai Pain Coneyia Ankle pin Carpal cone! Failed back surgery Anterior bial, syndrome syndrome Bpicondylis oct pain Frozen shoulder Fracures Hand pa Low hack pain Lumbosacral pul Radicals Spasm Spetns and ssins ‘Thorscodyria Whole back pain Cat sins aren Joint moilzation Kose pain Passive seth pain Scion pening and susins Spurs Tendonitis ‘Thrombopblebiis Conteaingi Demind ype pacemakers Russian Stimulation Peripheral nerve ‘jury ‘Shoulder sm syndrome Sprains and suns Sobdeltoid bars Wrist pain Propraney Muscle stimulation primarily for post-operative reha- bilication Uses medium frequency 2500-4000 Hz, 50 Hz, 02-04 ms Increases elasticity in connective tissue (particulary skin), ruscles, ligaments, and joiat capsules. Generally used for vasodilation, wound healing (use only after 2 (0 4 days), artis, bursitis, sinusitis, tendonitis, contusion, rupture, fracture, hematoma, herpes zoster, neuropathy, deep mus- cle pain and spasm, Diathermy creates heat but does not depolarize nerves. Remove all metals 10 a distance of at least I m. Contraindicated if there is any implanted metal. Patients should be dressed in a gown with a towel under the electrodes. Uses high-frequency >300 kHz, short wavelengths 3-30:m. Typically, 27.12 MHz, 65-400 mS, 32 W average (< 200 W). Indications Amenonbes Brachial plnus| Bronchictais Bronchitis Bursts (subacute and chronic) cate Contusions Dislocations Divertcuias Dysmenortes Epicondyis Fibrosis ibrous fuatonankyosis ‘Absolute Contrainicatons Fractures (recent) Hoang sds Hemopeysis, pits, lens, aed other hemocrhagic tendencies Matgnancy Meastration Meza dena appliances and Alings Mea implants On 8 metal ube Over adhesive strapping Relative ontraindcations Aas of decreed vecclaiy Anenoscerois (advanced) Hypothermesthesia Infant debited elderly Irorauerne device (neti Mozalie batons, inpers,halepis, buckles claps, keys, nes, Nondeaining cells OsteomyelitisElectromedicine: The Other Side of Physiology Forunclelewbuncle Over ess Oscoporois Hypeno ‘Over mais (advanced) Inecosta neuralgia dressings Over growing Iscinigia (chronic) Pacemakers piel plate Imerveiebrl diss epee ulcers Pens on syndrome Prrgaaney avicoagalans, Low back pein Pyreti states comsone, old Masts Rheumatoid therapy Myalg arts (ule) Peipberal vascular Myositis Septic arth ess (cclsive) Nears (acute) Poliomyelitis acute COsenartsits ‘Toberslosis stage) Pelvcialammatery (pulmonary or Poets with seas (subacie, jolt) impairs choc) ration Plerisy Suppurting Prowse intammatory yeti (subacute, Process roi) ‘Thrombosis Rheumatoid ‘Transeranally atts (ebacat, Varicose vein eteonic} Sprains ad stains Tenosynoviis ‘Transcutaneous Electrical Nerve Stimulation (TENS) ‘Acute, chronic, and post-operative pain, Uses low-frequency biphasic currents of 25-400 mS, 50-150 Hz, < 100 mA, Indications ‘Systemic Pain Abdominal Pain Back Pain Bursts Blader pain Coveydynia cancer Bowe sasis Iercostal neuralgia Couatgin Diverticulosis Inervertbra die Ischia Dysmenorriea ‘geome Nearalgia Labor Low back pain Oseoarhis Postoperative pia Lumbosacral pin Passive stretch pale Radiulits Ramat ata Sprains and seins Synovts ‘Thoracdynia Whole back pain Lower Extremity Upper Extremity Contraindicaticns Pain ain ‘Ankle pin Capa tuned Metalic implants Foot pain syndrome Meustatic Fractures pcondyliis acinoma Joi mobibeaion Frozan shoulder Near cri snus Kase pain and pain sea Sciatica Peripheral ceve Over or through Sprains and ssins injury heart Tendonitis Sprains and seins Pacemakers ‘Thrombophlebiis Subdelioid bursitis Preganey Writ pin ‘Transcranially| 787 Ultrasound Promotes blood circulation; improves metabolisra, mus- cle relaxation, pain control; increases clastcity of con- nective tissues. Used to treat tendon adhesions and scar Post-traumatic injuries, binding tissue contractions (cars), Dupuytren’s Contractare, bursitis. capsulitis, tendonitis, and chranic open wounds. Micromassage, microdestruction, and heat generation. May cause mechanical or thermal tissue damage. Overdose may decrease blood sugar levels, cause fatigue, nervousness, irritability, constipation, and a tendency t0 catch cold. Do not use over pregnant ulerus, hear, Sesi- les; spine, areas of thrombophlebitis, infections Nigh frequency mechanical vibrations using piezo- lectcity > 20 KHz (ypically between 0.8 and 3 Mhz} and 0,1-3 Wien Tadications Bursts (subacute, Spins and strains ‘Contraindications Acie infestion| chronic) ‘subacute chronic) Areas of CCalcfc nursis—-Sudeck’s awophy——_hermoyperthesia Cussalgia ‘Tendonitis Near heaving ad DDecubialwloes (subacute, chronic) Neae malignant Fibroste(subacute.—Thiger points Iesions chronic) Varicose ules Near meulle ibrotie (etronie) plans polymylosic Near pacemakers lees zoster Ocelusive vascular Joins contrerues aisewe Myalgia Over tony Neural prominences Oneoartits Over epiphyseal Pinfol neuroma plates of growing Periandiis shildee ‘oonseptc) Over nerve plexuses Radicl Over suspected ‘ubacut, chronic) embolus Rayna’ disease Over the eye Rheumatoid Over the heat anti (subacue, ‘Over pregnant krone) mers Over the reproctive orgene ponds Over spiral cord ahr laminectomy Rachcaits (ewe) Tendeny © femortage Transeranaly SUMMARY ‘One must stray from the routine procedures of today in ‘order to create the advances of tomorrow. There is sill & Tot to Tearn about bioelectrcity and electrommdicine, In758. Pain Management: 4 Practical Guide for Clinicians, Sixth Edition ‘order to do so, we must first acknowledge that there is| another side of physiology. Everyone concerned about health should demand widespread access to conservative, safe, alternative care, To lessen human suffering is a nota- ble goal. That we have not been able to achieve enough of this to date without causing undo harm is a good indi cation that the answers must lie elsewhere. Biophysics ust be better understood t0 realize the actual basis for the control of the regulatory processes of life. Even at its present state of evolution, electromedicine offers an unprecedented conservative, cost-effective, fast, safe, and powerful tool in the management of the pain patient. As such, it should be the fist priority om the list of treatment options. REFERENCES Baver, W. (1983). Neurosleciic medicine. Jounal of Bioelec tricity, 2,2-3. 199. 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