PHYSICAL AGENTS &

ELECTROTHERAPY-1

Dr. Waqas Fayyaz PT

DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]

Lecture 1
 COURSE DETAILS

Physical agents & Doctor of Physical

Electrotherapy-1 Therapy

COURSE
PROGRAM
TITLE

03 (2:1)
5th • Two Lectures/week
• One Lab/week

SEMESTER CREDIT
HOURS
 COURSE FACULTY

Course Work
Dr. Waqas Fayyaz PT

Lab Work
Dr. Bazel Bukari PT
Dr. Waqas Fayyaz PT
COURSE OBJECTIVES

Physiological & therapeutic uses,

risks, preventions, indications &
contraindications on the type of electric
current

Demonstrate fundamental skills used

to train in electrotherapy
modalities
ASSESSMENT CRITERIA

üMidterm examination = 20 marks

üFinal Examination = 25 marks
üViva = 25 marks
üAssignment /Test/Attendance/Presentation = 30 marks
ASSESSMENT CRITERIA

Marks Distribution Scheme

25% Quiz
25% Assignments
10% Attendance
30% Final MCQs
10% Viva
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists.

UK: Faber; 1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy.
9th ed. USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th
ed. Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from
research to practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India:
Jaypee; 2012
 Today Lecture Learning
Objectives
vElectrotherapy Definition
vPhysical agents Definition
vCurrents Basics
vCurrents Classification
PHYSICAL AGENTS &
ELECTROTHERAPY-1
Introduction
ELECTROTHERAPY

Medical therapy using electric currents.

Also called electrotherapeutics

The use of electric currents passed through the

body to stimulate nerves and muscles, chiefly in
the treatment of various forms of diseases.
COURSE OBJECTIVES
ELECTROTHERAPY

Modalities
PHYSICAL AGENTS

“There are some physical agents

that can be used by the patient/client on themselves
with instruction and training such as superficial
heating agents or hot packs.”

Categories

Thermal (deep-heating agents, superficial heating

agents, cooling agents)
Mechanical (traction, compression )
PHYSICAL AGENTS
Thermal
PHYSICAL AGENTS
Mechanical
PHYSICAL AGENTS
Mechanical
 CURRENTS
Electric current

“The movement or flow of charged particles

through a conductor in response to an applied
electric field.”

Current is noted as I
Measured in Amperes( A).
 CURRENTS
Conventional Current

“Current flows out of the positive terminal, through

the circuit and into the negative terminal of the
source. This was the convention chosen during the
discovery of electricity.”
 CURRENTS
Conventional Current
They were wrong!
Electron Flow is what actually happens and
electrons flow out of the negative terminal, through
the circuit and into the positive terminal of the
source.
 CURRENTS
Charge
One of the basic properties of matter, which either
has no charge( is electrically neutral),
or may be negatively (-)
or positively (+) charged

Charge Is noted as Q and is measured in

Coulombs( C).
 CURRENTS
Polarity
The property of having two oppositely charged
conductors, with the positive called the anode, and
the negative called the cathode.
 CURRENTS
Voltage
The electrical force capable of moving charged
particles through a conductor between two regions
or points.
Voltage is also known as the "potential difference”
Voltage is noted as V and is Measured in volts (V)
 CURRENTS
FREQUENCY
Frequency is the number of complete cycles per
second in alternating current direction. The
standard unit of frequency is the hertz, abbreviated
Hz.
If a current completes one cycle per second, then
the frequency is 1 Hz.
60 cycles per second
equals 60 Hz
 CURRENTS
FREQUENCY
Larger units of frequency includes

Kilohertz (kHz)
Megahertz (MHz)
Gigahertz (GHz)
Terahertz (THz)
 CURRENTS
Direct Current (DC)

“A continuous unidirectional flow of charged

particles is known as direct current (DC).”

Direct current is used to for iontophoresis and for

stimulating contraction of denervated muscle and
also occasionally to facilitate wound healing
 CURRENTS
Direct Current (DC)
 CURRENTS
Alternating Current (AC)
“A continuous bidirectional flow of charged
particles is known as alternating current (A C)”
CURRENTS
DC VS AC
 CURRENTS
Pulsed Current
“Electrical current can be delivered
discontinuously in a series of pulses separated by
periods when no current flows.”
This is known as pulsed or pulsatile current.
 CURRENTS
Classification

A review on the differences…

1. High Frequency Currents
2. Medium Frequency Currents
3. Low Frequency Currents
 CURRENTS
Classification
1. HIGH FREQUENCY CURRENTS
ØFrequency is >6000 HZ
ØShort wavelengths (<10 mm)
ØEffects occur only at superficial structures
ØGeneral effect = HEATING
ØSample modalities:
US, MWD, SWD, IRR, UVR, LASER
 CURRENTS
Classification
2 & 3. MEDIUM and LOW FREQUENCY
CURRENTS
ØFrequency ranges from 1 to 6000 Hz
ØLonger wavelengths (>10 mm)
ØEffects occur at deeper structures
ØGeneral effects:
MFC: blocks pain
LFC: nerve stimulation
 CURRENTS
Classification
2 & 3. MEDIUM and LOW FREQUENCY
CURRENTS

ØSample modalities:
Electrical stimulators, Diadynamics, Biofeedback,
Iontophoresis, TENS, IF, Faradic.
 CURRENTS
Classification
LOW FREQUENCY MEDIUM FREQUENCY
CURRENT CURRENTS

Superimposed currents
TENS Interfrential current
Dia-dynamic current
 Learning Outcome

qBasic of Electrotherapy
qBasic of Current and its types
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists.

UK: Faber; 1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy.
9th ed. USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th
ed. Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from
research to practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India:
Jaypee; 2012
 Physical agents &
Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]

Lecture 2
 Today Lecture Learning Objectives

vFaradic Current
vModified Faradic Current
LOW FREQUENCY CURRENT
It includes;
• Faradic current
• Sinusoidal current
• TENS
• Galvanic current / IDC
• Dia-dynamic currents
• Superimposed currents
 FARADIC CURRENT

“Faradic current is a short-duration interrupted

current, with a pulse duration ranging from 0.1
and 1 msec and a frequency of 50 to 100 Hz,
used for the stimulation of innervated muscles.”
 FARADIC CURRENT
It is unevenly alternating with each cycle consisting
of two unequal phases.
1. Low intensity long duration current
2. High intensity short duration
 FARADIC CURRENT
Frequency 50 Hz duration 1ms.
(Effective one in 2nd phase)

Form of original FC
 FARADIC CURRENT

Faradic coils have now been replaced by modern

Electronic stimulator which have the same
physiological effects but different in wave form.
 FARADIC CURRENT

The waveform of faradic-type current may be

unidirectional or biphasic (asymmetrical)
 FARADIC CURRENT

Electronic stimulator works on same principles as

interrupted D.C, but resistance controlling
duration of impulses and intervals between them
have a very low value to give required duration
and repetition rate.
 FARADIC CURRENT

FC from modern Electronic stimulator

 Modified Faradic current

• For better treatment, FC is always surged to

produce a near normal tetanic-like contraction
and relaxation of the muscle.
 Modified Faradic current

• Current surging means the gradual increase

and decrease of the peak intensity.
 Modified Faradic current

• The Apparatus should have sufficient control

to surge the current so that the intensity of
successive impulses increase gradually with
surge varying in the waveform to produce
satisfactory muscle contraction and relaxation.
Modified Faradic current
Modified Faradic current
 Modified Faradic current

• Varies form of FC with respect to Wave form

1. Saw Tooth
2. Triangular
3. Trapezoidal
 Modified Faradic current

• Varies form of FC with respect to Wave form

1. Saw Tooth
 Modified Faradic current

• Varies form of FC with respect to Wave form

2. Triangular
 Modified Faradic current

• Varies form of FC with respect to Wave form

3. Trapezoidal
 Learning Outcome

qBasic of Faradic currents and

Modified Faradic Current
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists.

UK: Faber; 1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy.
9th ed. USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th
ed. Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from
research to practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India:
Jaypee; 2012
 Physical agents &
Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 3
 Today Lecture Learning Objectives

vPhysiological effects of faradic current

 Physiological effects of
Faradic Current
1. Stimulation of sensory nerves
2. Stimulation of the motor nerves
3.Stimulation of the nerve (Muscle contraction)
4. Faradic currents will not stimulate denervated
muscle
5. Reduction of swelling and pain
Physiological effects of
Faradic Current
 Physiological effects of
Faradic Current

1. Stimulation of sensory nerves:

Mild prickling sensation but it is not very marked

because of the short duration.
 Physiological effects of
Faradic Current
1. Stimulation of sensory nerves:

It causes reflex vasodilatation of the superficial

blood vessels leading to slight erythema.

The vasodilatation occurs only in the superficial

tissues.
 Physiological effects of
Faradic Current
2. Stimulation of the motor nerves

• It occurs if the current is of a sufficient intensity,

causing contraction of the muscles supplied by
the nerve distal to the point of stimulus. A
suitable faradic current applied to the muscle
elicits a contraction of the muscle itself and may
also spread to the neighboring muscles.
 Physiological effects of
Faradic Current
2. Stimulation of the motor nerves

• The character of the response varies with the

nature and strength of the stimulus employed
and the normal or pathological state of muscle
and nerve….
 Physiological effects of
Faradic Current
2. Stimulation of the motor nerves

• The contraction is tetanic in type because the

stimulus is repeated 50 times or more / sec, if
this type is maintained for more than a short
time, muscle fatigue occurs. So, the current is
commonly surged to allow for muscle relaxation.
 Physiological effects of
Faradic Current
2. Stimulation of the motor nerves

• “when the current is surged, the contraction

gradually increases and decreases in strength in
a manner similar to voluntary contraction”.
Physiological effects of
Faradic Current
MOTOR POINTS OF MUSCLES
 Physiological effects of
Faradic Current

3. Stimulation of the nerve

 Physiological effects of
Faradic Current

3. Stimulation of the nerve

Stimulation of the nerve is due to producing a

change in the semi-permeability of the cell
membrane.
 Physiological effects of
Faradic Current

3. Stimulation of the nerve

• This is achieved by altering the resting

membrane potential. When it reaches a critical
excitatory level, the muscle supplied by this
nerve is activated to contract.
 Physiological effects of
Faradic Current

4. Stimulation of denervated muscle

 Physiological effects of
Faradic Current

4. Stimulation of denervated muscle

• Faradic currents will not stimulate denervated

muscle.
 Physiological effects of
Faradic Current

4. Stimulation of denervated muscle

• The nerve supply to the muscle being treated

must be intact because the intensity of current
needed to contract the muscle membrane is too
great (1ms) to be comfortably tolerated by the
patient in the absence of the nerve.
 Physiological effects of
Faradic Current

5. Reduction of swelling and pain:

 Physiological effects of
Faradic Current

5. Reduction of swelling and pain:

• It occurs due to alteration of the permeability of

the cell membrane, leading to acceleration of
fluid movement in the swollen tissue and arterial
dilatation.
• Moreover, it leads to increase metabolism and
get rid of waste products.
 Learning Outcome

qBasic of Faradic currents and

its Physiological effects
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists.

UK: Faber; 1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy.
9th ed. USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th
ed. Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from
research to practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India:
Jaypee; 2012
 Physical agents &
Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]

Lecture 4
 Today Lecture Learning Objectives

vIndications of faradic current

vContraindications of faradic current
 INDICATIONS of faradic current

1. Facilitation of muscle contraction inhibited by pain

2. Muscle re-education or relearning
3. Training a new muscle action
4. When a nerve is severed
5. Improvement of venous and lymphatic drainage
6. Prevention and loosening of adhesions
7. Replacing Orthosis
8. Inhibition of quadriceps contraction by pain
 INDICATIONS of faradic current

1. Facilitation of muscle contraction inhibited by

pain:
 INDICATIONS of faradic current

1. Facilitation of muscle contraction inhibited by

pain:
• When a patient is unable to produce muscle
contraction or find it difficult to do so, electrical
stimulation may be required in assisting to produce
voluntary contraction.
 INDICATIONS of faradic current

1. Facilitation of muscle contraction inhibited by

pain:

• Stimulation must be stopped when good voluntary

contraction is obtained.
 INDICATIONS of faradic current
2. Muscle re-education or relearning:
 INDICATIONS of faradic current
2. Muscle re-education or relearning:
 INDICATIONS of faradic current

2. Muscle re-education or relearning:

• Muscle contraction is needed to restore the sense

of movement in cases of prolonged disuse or
incorrect use and in muscle transplantation.
 INDICATIONS of faradic current

2. Muscle re-education or relearning:

• The brain appreciates movement not muscle

actions, so the current should be applied to cause
the movement that the patient is unable to
perform voluntarily.
 INDICATIONS of faradic current

3. Training a new muscle

action:
 INDICATIONS of faradic current

3. Training a new muscle action:

• After tendon transplantation, muscle may be

required to perform a different action from that
previously carried out.
 INDICATIONS of faradic current

3. Training a new muscle action:

• With stimulation by faradic current, the patient

must concentrate with the new action and assist
with voluntary contraction.
 INDICATIONS of faradic current
4. When a nerve is
severed:
 INDICATIONS of faradic current

4. When a nerve is severed:

 INDICATIONS of faradic current

4. When a nerve is severed:

• Degeneration of the axons takes place after

several days. So, for a few days after the injury,
the muscle contraction may be obtained with
faradic current.
 INDICATIONS of faradic current

4. When a nerve is severed:

• It should be used to exercise the muscle as long

as a good response is present but must be
replaced by modified direct current as soon as
the response begins to weaken.
 INDICATIONS of faradic current
5. Improvement of venous and lymphatic drainage:
 INDICATIONS of faradic current

5. Improvement of venous and lymphatic

drainage:

• In edema and gravitational ulcers, the venous and

lymphatic return should be encouraged by the
pumping action of the alternate muscle contraction
and relaxation.
 INDICATIONS of faradic current
6. Prevention and loosening of adhesions:
 INDICATIONS of faradic current

6. Prevention and loosening of adhesions:

• After effusion, adhesions are liable to form,

which can be prevented by keeping structures
moving with respect to each other.
• Formed adhesions may be stretched and loosened
by muscle contraction.
 INDICATIONS of faradic current

7.Replacing Orthosis:
 INDICATIONS of faradic current

• Prosthesis can’t be
replaced
INDICATIONS of faradic current

7.Replacing Orthosis:

• Low frequency stimulation may be used to

enhance the function of paralyzed or weak
muscles thus eliminating the need for a splint,
brace or orthosis.
 INDICATIONS of faradic current

8. Inhibition of quadriceps contraction by pain:

 INDICATIONS of faradic current
8. Inhibition of quadriceps contraction by pain:

• As in rheumatoid arthritis, subluxation of patella,

chondromalacia patellae and chronic effusion of
the knee.
 CONTRAINDICATIONS
of faradic current
ØSkin lesions
ØUnstable fracture
ØImpaired cognitive ability
ØPregnancy (1st trimester)
ØOver Carotid sinus*
ØLoss of sensation
ØCancer
Ø Cardiac pacemakers
Ø Superficial metals
 Learning Outcome

qIndications and
contraindications of Faradic
currents
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists.

UK: Faber; 1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy.
9th ed. USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th
ed. Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from
research to practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India:
Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 5
Today Lecture Learning Objectives

Ø Techniques of the treatment with

Faradic Type Current
 Techniques of the treatment with Faradic Type Current :
• By various methods, faradic current can be applied according to
requirement.
1. Apparatus preparation
2. Patient preparation
3. Techniques of Applications
 Preparation of Apparatus:
• Select low frequency electronic stimulator with automatic
surge.
• Operator should test the apparatus.
• Turning up the current until mild prickling sensation is
experienced & contraction produce.
• Educate the patient about sensation.
• Frequency should be tested by operator.
• Apparatus should be far away from pt. almost 2m.
• Prevent short wave therapy machine by output disturbance
ØActive electrodes may be:

i. Disc electrodes (for small muscles)

ii. Flat plate electrodes (for large muscles)
• Electrodes should be wet with 1% saline.
• Electrodes 1cm smaller all round than pads.
 Preparation of the Patient
• Clothing remove which area is treated.
• Pt should feel comfortable, fully supported.
• Proper lights.
• Pt should be warned.
• The part under treatment should be supported so that
muscle remain in shortened position.
• If there is pain, movement should be avoided.
• Skin show high resistance if it is dry.
• Skin should be washed with water & soap to remove natural
oil.
• Before electrodes applying, skin should be moist with saline.
• Break skin reduce the resistance of the skin cause discomfort
to the pt.
• Broken skin is protected by petroleum jelly, covered by
non absorbable cotton or wool under the electrode.
• Electrodes can be hold by bandage, rubber strap or body
weight to hold the position of electrode/pad , so that max
contact can be achieved.
 Technique of Application
1. Stimulation of motor points
2. Stimulation of muscle group
i. Quadriceps muscles
ii. Small muscles of foot
iii.Lumbrical muscles & interossei
iv.Abductor hallucis
v. Muscles of pelvic floor
 Technique of Application

Stimulation of motor points

 Stimulation of Motor Points

• The action of each muscles can be obtained by

stimulation of its own motor point.
• The electrodes applied in a suitable area at motor points.
• Contact should be firm to ensure minimum discomfort.
• A suitable duration & frequency should be selected.
 Stimulation of Motor Points
• Intensity of current gradually increase until a good
contraction is obtained. (Surged)
• Appropriate position of some motor points.
• Motor points are present frequently at the junction of
upper & middle one third of the fleshy belly muscles.
(almost mid point of fleshy belly of muscle)
Motor Points of Muscles Supplied by Facial Nerve
Motor Points of Anterior of Right Arm
Posterior Upper Extremity
Motor Points of Back
Anterior Lower Extremity
Posterior Lower Extremity
 Technique of Application

Stimulation of muscle group

Stimulation of muscle group
i. Quadriceps muscles
Stimulation of muscle group
ii. Small muscles of foot
Stimulation of muscle group
iii.Lumbrical muscles & Interossei
Stimulation of muscle group
iv.Abductor hallucis
 Stimulation of muscle group
v. Muscles of pelvic floor
Electrical stimulation assist
in reeducation in case of
§ Prolapse of pelvic organs
§ Stress incontinence
Stimulation of muscle group
v. Muscles of pelvic floor
ØElectrical stimulation assist in reeducation in case of
§Prolapse of pelvic organs
§Stress incontinence
Stimulation of muscle group
v. Muscles of pelvic floor
Prepare patient & apparatus:
Side lying with pillow between lower leg
 Stimulation of muscle group
v. Muscles of pelvic floor
Method to apply electrode:
a. Indifferent electrode
Lumbosacral region
 Stimulation of muscle group
v. Muscles of pelvic floor
Method to apply electrode:
b. Active electrode
• Vaginal electrode (female)
• Rectal electrode (male) (Incontinence after
Prostatectomy)
OR
Urogenital region/Anal region
 Stimulation of muscle group
v. Muscles of pelvic floor
Suitable duration and frequency:
Surge to gain good contraction of muscle then increase intensity
to gain strong contraction.
 Stimulation of muscle group
v. Muscles of pelvic floor
Suitable duration and frequency:

Muscles of pelvic floor are thin and fatigue rapidly.

Duration of treatment should be short.

 Learning Outcome

ØTechniques of the treatment with

Faradic Type Current
 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
 Physical agents & Electrotherapy-1

Dr. Waqas Fayyaz PT

DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 6
Today Lecture Learning Objectives
ØElectrical Activity of Nerves
oNerve Transmission
oElectrical Stimulation of Nerves
oAccommodation
oEffects of Nerve Stimulation
oEffects of frequency of stimulation
oStrength of Contraction
Nerve Transmission
 Nerve Transmission

Difference in conc. of ions inside & outside plasma membrane

Difference in PD inside & outside of nerve.

 Nerve Transmission

Resting Nerve:
ØOutside: Positive
ØInside: Negative

Plasma membrane is not permeable to Sodium ions (Polarized

stage of membrane).
 Nerve Transmission

Nerve is stimulated:
Causes a fall in PD
When fall to a critical level
Alteration in permeability of membrane to sodium ions
• Reversal of polarity occurs Now,
ØInside: Positive
ØOutside: Negative
 Nerve Transmission

Local electron flow

• Sodium ions are pumped out again
• Nerve return to its resting state
• Difference of potential b/w active & resting part of nerve
causes local electron flow
• Current flows in opposite direction to PD across the fiber
Nerve Transmission
 Nerve Transmission

• Fiber acts as a resistance, current flow lowers the PD thus making

the membrane permeable to sodium ions.
• Thus PD reverses.
• It constitutes the passage of an impulse along the nerve.
Nerve Transmission
Nerve Transmission
 Electrical Stimulation of Nerves

• Nerve Impulse initiates: electrical stimulus

• Plasma membrane of nerve fiber forms resistance : lies in series with other
tissues
• Across it , PD is set up as current flows
 Electrical Stimulation of Nerves

• Surface of membrane near to Cathode:

üMore negative
üReduces PD

• Surface near to Anode:

üPositive
üIncreases PD
Fig: 3.7 Electrical stimulation of a nerve fiber
 Electrical Stimulation of Nerves

• If PD falls below the level then these ions enter the axon & initiate the series
of events So that the nerve impulse is generated
• Impulse is initiated: PD falls sufficiently across any part of plasma
membrane of nerve cell or fiber
 Accommodation

“When the constant current flows the nerve adapts itself to the
altered conditions. This effect is known as Accommodation.”
 Accommodation
Current rises, impulse is initiated.
But fall in current also initiates an impulse.

While current flows at constant level.

Accommodation of nerve takes place.

PD no longer affects the excitability.

 Accommodation

• Current ceases, PD across plasma membrane suddenly

disappears.
• It alters the total PD.
• Nerve nearer to the anode ,the applied PD was augmenting
that across the resting membrane & its sudden loss causes a
fall in PD.
 Accommodation

• If this fall goes as far at the level where membrane becomes

permeable to sodium ions, an impulse is initiated.
• Fall in current is less effective than a rise in current.
• Anode produces a greater stimulation than cathode.
 Accommodation

How to break accommodation?

• As nerve has power of accommodation, current which varies
suddenly is more effective than that which changes slowly.
• If variation is gradual: accommodation takes place.
• If variation is sudden: current is more effective
• A current that changes slowly doesn’t initiate a nerve impulse.
Effects of Nerve Stimulation
 Effects
Effectsof
ofNerve
NerveStimulation
Stimulation

§ Nerve impulse is initiated at nerve cell or

end organ: it travels along the axon i.e.
only in one direction.

§ If it is initiated at some point on nerve fiber:

it is transmitted in both directions from point of stimulation.
 Effects of Nerve Stimulation
Sensory Nerve
• Sensory nerve is stimulated , downward-travelling impulse
has no effect.

• Upward-travelling impulse is appreciated when it reaches at

conscious levels of the brain.

• Impulses of long duration produce an uncomfortable, stabbing

sensation but when it is reduced (1ms or less) only mild
prickling sensation is experienced.
 Effects of Nerve Stimulation
Motor Nerve

• Motor nerve is stimulated, upward-travelling impulse is

unable to pass the first synapse (wrong direction)

• But downward-travelling impulse passes to the muscles

causing them to contract.

• Stimulus is when applied to motor nerve trunk, impulses pas

to muscles (stimulation point) causing contraction.
 Effects of Nerve Stimulation

• When current is applied on innervated muscle,

nerve fibers are stimulated.

• Maximum response is obtained either from:

1) Stimulation at motor point (point at which main nerve
enters the muscle)
2) Deeply placed muscles, at the point where the muscle
emerges from under cover of the more superficial ones.
Effects of Nerve Stimulation
 Effects of frequency of stimulation

When single stimulus is applied, impulses pass simultaneously to a

number of motor units then there is:

Sudden Brisk Contraction,

Immediate Relaxation
 Effects
Effectsofoffrequency
frequencyofofstimulation
stimulation

If multiple of stimuli are applied at rather long intervals

One stimulus per second , each produces an isolated muscle

contraction & there is complete relaxation b/w impulses.
 Effects of frequency of stimulation

• Partial Tetany: (Until frequency exceeding 20 Hz )

Increasing the frequency of the stimulus shortens the period of

relaxation, then there is no time for complete relaxation
between the contractions.
 Effects of frequency of stimulation

• Complete Tetany: (Frequency over 60 Hz )

Further Increase in frequency reduces the amount of relaxation

there is no perceptible relaxation & the contraction is fully
tetanic.
 Strength of Contraction

Depends on:
Ø No. of motor units activated (Intensity of current)
Ø Rate of change of current
 Strength of Contraction

• If intensity of current rises suddenly, there is no time for

accommodation & muscle contraction results.

• If current rises more slowly (as with trapezoidal, triangular

& saw-tooth impulses) , there is some accommodation &
greater intensity of current is needed to produce a contraction.
 Learning Outcome

ØDifferent electrical Activity of Nerves

 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 7
 Today Lecture Learning
Objectives
Sinusoidal Current
Ø Introduction
Ø Production
Ø Characteristics
Ø Advantages
Ø Applications
Ø Effects of SC
Ø Indications
Ø Contraindications
 “Sinusoidal currents are evenly sine wave
alternating currents with a frequency (LFC) of 50
Hz”
Rarely used nowadays in modern Physiotherapy.
• The sine wave or sinusoid is a mathematical
curve that describes a smooth repetitive
oscillations.
 PRODUCTION

• This is the form of UK main current.

• The UK mains supply is about 230 volts AC.

• It is produced from the mains by reducing the

voltage to 60 to 80 volts with a step down
transformer.
 PRODUCTION

• This gives 100 pulses or phases in each second,

50 in one direction and 50 in other.

• It is usually surged to cause rhythmical muscle

contractions.
 CHARACTERISTICS

Because of its marked sensory stimulation this

current is often used over large areas and rarely used
for local muscle stimulation.
 CHARACTERISTICS

Ø Similar to faradic current.

Ø Alternating current that produces mechanical

contractions that tone the muscles.
 CHARACTERISTICS

Ø It relieves pain and reduces edema.

 ADVANTAGES

Ø Supplies greater stimulation & deeper

penetration.
Ø Soothes the nerves & penetrates into deeper
muscle tissue
Ø Is best suited for the nervous client
 APPLICATION

Ø Sinusoidal currents can be applied in the same

way as other low frequency currents by means of
Electrodes and pads.

Ø This current is applied to large areas due to

marked sensory stimulation.
 APPLICATION

Ø It is rarely used for local muscle stimulation.

Ø Thus it is applied either through large pads or

water bath or both.
 EFFECTS

1. STIMULATION

Ø When it is applied continuously, it causes a tetanic

muscle contraction and tingling sensation due to
stimulation of motor and sensory nerves.

Ø It is usually surged to cause a rhythmical muscle

contraction.
 EFFECTS

1. STIMULATION

Ø The sensory stimulation help for pain relief by

the mechanism, same as that of TENS and the
rhythmic muscle contraction help in relief of
edema.
 EFFECTS

2. Metabolism:-
It also helps for enhancing blood flow and
intramuscular metabolism.
 EFFECTS

3. Reduction of edema:

The unsurged sinusoidal

current also helps for
reduction of edema
inflammatory exudates.
 INDICATIONS

1. Pain:-
For pain control continuous sinusoidal current is
applied at intensity close to patient tolerance and
applied for approx.. 5 min and repeat if there is
insufficient immediate side effects.
 INDICATIONS

2. Edema:-
For reduction of edema and to
increase the limb circulation
surged sinusoidal current is
suggested; causing rhythmical
muscle pumping action.
 INDICATIONS

3. Used during scalp & facial manipulations

 INDICATIONS

4. Other same as Faradic Current.

 CONTRAINDICATIONS

• Skin lesions
• Unstable fracture
• Impaired cognitive ability
• Pregnancy
• Over Carotid sinus
• Cancer
• Cardiac pacemakers
• Superficial metals
Electrical Stimulation of Nerves

• Nerve Impulse initiates: electrical stimulus

• Plasma membrane of nerve fiber forms
resistance : lies in series with other tissues
• Across it , PD is set up as current flows
 Electrical Stimulation of Nerves
• Surface of membrane near to Cathode:
üMore negative
üReduces PD

• Surface near to Anode:

üPositive
üIncreases PD
Fig: 3.7 Electrical stimulation of a nerve fiber
 Electrical Stimulation of Nerves

• If PD falls below the level then these ions

enter the axon & initiate the series of events
So that the nerve impulse is generated
• Impulse is initiated: PD falls sufficiently
across any part of plasma membrane of nerve
cell or fiber
Learning Outcome

qBasic and advance of

Sinusoidal currents
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists.

UK: Faber; 1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy.
9th ed. USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th
ed. Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from
research to practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India:
Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 8
 Today Lecture Learning Objectives

Transcutaneous Electrical Nerve Stimulation

Ø Pain Relief Methods
Ø Parameters of TENS
Ø Types of TENS
Ø Methods of treatment
Ø Indications
Ø Dangers and Contraindication
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Transcutaneous Electrical Nerve Stimulation (TENS)

“TENS is the application of low

frequency current in the form of
pulsed rectangular current through
surface electrode on the patient's
skin to reduce pain”
Pain Relief Methods

Analgesics VS TENS
 Pain Relief Methods

• Pain can be managed in short term using analgesics, but long term
use can be detrimental to the patient’s health.

• Side effects of long use of analgesics may effect may effect on liver,
kidney or stomach.
 Pain Relief Methods

• In many cases where pain is constant, PHYSIOTHERAPISTS may

recommend the use of TENS unit, because it is safe, effective and
virtually with no side effects.
Parameters of TENS
Parameters of TENS

1. Pulse width ----- 100 − 200 𝜇s or 50-300 𝜇s

2. Pulse shape------ Usually rectangular

Parameters of TENS

3. Frequency -------- 2Hz – 600 Hz

Commonly used 150 Hz

4. Intensity----------- 0-60mA OR upto pt. comfort level

Parameters of TENS
Types of TENS
Types of TENS

1. High TENS
2. Low TENS
3. Burst TENS
1. High TENS
• In this High frequency and low intensity electrical stimulation
is applied.

• The stimulation will cause impulse to be carried along with the

large diameter afferent fibers and produce presynaptic
inhibition of transmission of nociceptive A-delta and C-fibers
at substantia gelatinosa of the pain gate.
1. High TENS

ü Frequency --- 100-150Hz

ü Pulse width---- 100- 500𝜇s
ü Intensity---- 12- 30 mA
2. Low TENS

• In this low frequency and high intensity electrical pulses are

applied, it gives a sharp stimulus and like a muscle twitch.

• The encephalin and endorphins have the effect of blocking

forward transmission in the pain circuit.
2. Low TENS

ü Frequency --- 1-5Hz

ü Pulse width---- 100- 150𝜇s
ü Intensity---- 30 mA or more
3. Burst TENS
• In this high frequency, short pulse, high intensity electrical
current is used.

• Burst TENS is a series of impulse repeated for 1-5 time per

second.
• Each train (burst) lasts for about 70 ms.
3. Burst TENS

• The benefits for the burst TENS are that it combines both the
conventional and acupuncture like TENS and thus provide pain
relief by the both routes.
Methods of Treatment
Methods of treatment

Electrode placement: TENS electrodes can be placed over

1. Area of greater intensity of pain

2. Superficial nerve proximal to the site of pain
3. The appropriate dermatome.
4. To the nerve trunk trigger point.
Methods of treatment

A number of treatment methods may be used depending upon the

severity of problem.

1. TENS can be used for a single daily treatment of 10-15 minutes

(40mins max) duration
2. Portable TENS can be used continuously for 24 hours.
Methods of treatment

A number of treatment methods may be used depending upon the

severity of problem.

3. TENS can be used in night, e.g. for treatment of Phantom limb

pain.
Indications
 INDICATIONS

TENS can be used for the treatment of:

1. Chronic pain syndrome

2. Phantom limb pain
3. Reflex sympathetic dystrophy
4. Post operative pain
Dangers and Contraindications
Dangers and Contraindications

1. Continuous application of high TENS may result in some

electrolytic reaction below the skin surface.

2. TENS is contraindicated in patients having cardiac

pacemakers may be because of possible interference with
the frequency of pacemaker.
Dangers and Contraindications

3. TENS should be avoided in first Trimester.

4. TENS should be avoided in hemorrhagic conditions.

5. TENS should be avoided over upon open wounds, carotid

sinus, over the mouth, near the eyes, etc.
Learning Outcome

Ø TENS Basic and advance

 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 9
 Today Lecture Learning Objectives

ØIONTOPHEROSIS

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IONTOPHEROSIS

“This term is used to describe the technique in which medically

useful ions are driven through the patient’s skin into the tissues.”
IONTOPHEROSIS
PRINCIPLE
• Place the ions under an electrode with same charge e.g.
negative ions placed under cathode. This electrode is known as
Active Electrode.
• Constant (DC) current is applied & ion is electrically propelled
into the patient.
PRINCIPLE
PRINCIPLE
PRINCIPLE
GRICE 1980:

• Constant DC current is seldom (rare) used in treatment of

hyperhidrosis (excessive sweating)

• Extremely common condition & reacts well to this treatment.

MORGAN 1980:
• The use of tap water for this treatment purpose.

• Ions may not inhibit sweating, so use of anticholinergic

compound in distilled water is recommended.

• Glyco-pyrronium bromide under the anode has long lasting

effects.
APPARATUS

a) A source of constant current of low voltage & low amperage

b) A shallow plastic tray for anode
c) A foot or arm bath for cathode
APPARATUS

a) Two large electrodes & leads

b) Two large lint pads to cover
electrodes
APPARATUS

a) Solution of anticholinergic
compound
b) Distilled water
APPARATUS
METHOD OF TREATMENT
HANDS:
METHOD OF TREATMENT

HANDS:
• Shallow plastic tray is placed on an arm bath table.
• Patient sits alongside
• Active electrode (anode) is placed in tray

• Covered with: lint pads

• Pads : 8 layer thick so it makes good contact with tissues &
electrode
METHOD OF TREATMENT

HANDS:
• Tray contains: 0.05% of anticholinergic compound &
glycopyrronium bromide to cover the palm.

• Hand is now placed in tray & connected to positive terminal of

treatment unit.
METHOD OF TREATMENT

HANDS:
• Feet is placed in few cm of warm water in foot bath,

• Lint pads connected to negative terminal

• Current is now switched on & slowly increased to the desired

amount for the desired time.
• Glycopyrronium becomes positive ion when salt is
dissolved in distilled water, so patient having completed
circuit, positive ions will be:

Repelled by: ANODE

Attracted to: CATHODE
METHOD OF TREATMENT

FEET:

• For treatment of feet, arrangements should be reversed.

• Place the shallow tray with anode on floor.
• Arm bath with cathode, for the arm to complete the circuit.
 METHOD OF TREATMENT

FEET:
DOSAGE

ØFirst treatment is based on size of Pt. and modified by skin

tolerance.

ØFor average adult 12 mA for 12 mints

ØFor child half than adult amount.
DOSAGE

ØNeed to repeat treatment varies with each Pt.:

– Some have relief for months after one treatment
– Few require a repeat in less than four to six weeks.
PRECAUTIONS
ØSkin abrasions

ØRemove Pt. rings.

ØWarn Pt to still during treatment

ØEnsure correct thickness of pads.

SIDE EFFECTS

ØAnticholinergic compounds have an atropine like action so…

§ Drying of mouth and throat

§ Restricted general body sweating
§ Pt advised not to do strenuous activities.
CONTRAINDICATIONS

ØPregnancy
ØOpen wound or Burn
ØCardiac Pacemakers
ØAllergy to medication
ØLoss of sensation
ØDirty skin
ØSole of foot (Hard for the ions to pass inside)
CONTRAINDICATIONS

ØCondition where there is congestion of lungs and respiratory

system.
Learning Outcome

Ø IONTOPHEROSIS Basic and

advance
 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 10
 Today Lecture Learning Objectives

ØGalvanic Current
GALVANIC CURRENT

• It is a steady direct current.

• Long duration current having pulse duration more than 1 ms up
to 300 ms or 600 ms.
• But the commonly used duration is 100 ms duration.
• It requires a frequency of 30 pulses/ min.

• If the duration increases the frequency must be reduced.

Types of Galvanic current

Two types of Galvanic current

1) CONSTANT GALVANIC CURRENT

. An electric current that moves in one direction with constant
strength
Types of Galvanic current
Two types of Galvanic current

2) MODIFIED GALVANIC CURRENT/ IDC

. It is Interrupted Direct current. Interruption is the most
common modification of direct current.
MODIFIED GALVANIC CURRENT
OR
INTERRUPTED DC
INTERRUPTED DC

ØInterruption is most common modification of DC.

ØRise and fall of intensity may be
– Sudden (Rectangular)
– Gradual (Trapezoidal, Triangular, Saw Tooth)
INTERRUPTED DC
 Selective Impulse
OF
INTERRUPTED DC
INTERRUPTED DC
ØSelective Impulse

Impulse in which current rises gradually termed as Selective,

because a contraction of denervated muscle can often be
produced with an intensity of current that is insufficient to
stimulate motor nerves because accommodation occurs.
Wave form Characteristics
Of
Interrupted DC
Wave form Characteristics of IDC
Duration
 Wave form
INTERRUPTED DC Characteristics of IDC
Frequency

• It requires a frequency of 30 pulses/ min.

• If the duration increases the frequency must be reduced.

 Wave form Characteristics of IDC
Depolarized impulses

• Low intensity reversed current is used between D.C, to reduced

chemical formation and skin burn.
 Wave form Characteristics of IDC
Depolarized impulses

• D.C ----------- Chemical formation and burn as in Iontophoresis.

• Reversed wave of current-------- reduced Chemical formation

and burn
• Neutralized effect, less irritation, more comfortable.
 Production
Of
Interrupted DC
 Production of IDC

üModern apparatus have transistors and timing devices.

üLength of pulse of electricity produced can be varied by altering

parts of circuit through which current flows.
 Production of IDC

üSelector switch provides

üFrequency
üpulses buttons
 Production of IDC

üPotentiometer -------

This allows the intensity of current to be turned up from zero.

Physiological effects
Of
Interrupted DC
 Physiological effects of IDC

1. Muscle Contraction (Denervated)

The intensity and duration of impulses in galvanic current is

adequate so that it can cause a sluggish like contraction.
 Physiological effects of IDC

2. Sensory Nerve Stimulation:-

When current is applied it produces sensory stimulation resulting

in the feeling stabbing or burning sensation.
 Physiological effects of IDC

3. Stimulation of motor nerve:-

Current produces contraction of the muscle supplied by that nerve.

Stimuli are frequently repeated, so each one produces a brisk

muscle twitch followed by relaxation.
Therefore little benefit effect on muscles.
 Physiological effects of IDC

4. Blood flow:-

Reflex dilation of superficial b.v and it increases blood circulation

causing erythema (redness) of the skin.
 Learning Outcome

Ø Galvanic Current Basic and advance

 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 11
Today Lecture Learning Objectives

ØMODIFIED GALVANIC CURRENT

INTERRUPTED DC
GALVANIC CURRENT

• It is a steady direct current.

• Long duration current having pulse duration more than 1 ms up
to 300 ms or 600 ms.
• But the commonly used duration is 100 ms duration.
• It requires a frequency of 30 pulses/ min.

• If the duration increases the frequency must be reduced.

Types of Galvanic current
Two types of Galvanic current

1) CONSTANT GALVANIC CURRENT

. An electric current that moves in one direction with constant
strength
Types of Galvanic current
Two types of Galvanic current

2) MODIFIED GALVANIC CURRENT/ IDC

. It is Interrupted Direct current. Interruption is the most
common modification of direct current.
Indications of MODIFIED GALVANIC
CURRENT / INTERRUPTED DC
Indications of MODIFIED GALVANIC CURRENT / INTERRUPTED DC

1. Contraction of denervated muscle:-

The main value of I.D.C lies its ability to produce contraction of

denervated muscle.
Indications of MODIFIED GALVANIC CURRENT / INTERRUPTED DC

1. Contraction of denervated muscle:-

When a muscle is deprived of its nerve supply, changes in its

structure and properties tend to occur.
Indications of MODIFIED GALVANIC CURRENT / INTERRUPTED DC

1. Contraction of denervated muscle:-

⇣ Changes in its structure and properties

⇣ Marked muscle fiber wasting
⇣ If degeneration is of long standing----- muscle tend to-----
fibrosed and lose their properties.
Indications of MODIFIED GALVANIC CURRENT / INTERRUPTED DC

1. Contraction of denervated muscle:-

⇣ By electrical stimulation
⇣ May be or may be not restore muscle bulk or muscle properties.
⇣ Once re-innervation take place----- lost muscle bulk can be
restored by Exercise.
Indications of MODIFIED GALVANIC CURRENT / INTERRUPTED DC

2. Muscle fatigue:-

300 contraction required at each treatment but resulting muscle

fatigue
so,
90 contraction for the treatment to be consider as effective
treatment
Indications of MODIFIED GALVANIC CURRENT / INTERRUPTED DC

3. Reeducation (Re-innervation):-

In early stage of reinnervation, electrical stimulation may be useful

for re-education.
Indications of MODIFIED GALVANIC CURRENT / INTERRUPTED DC

3. Reeducation (Re-innervation):-

Use pulse duration current which is comfortable for patients.

 Selection of Impulse for INTERRUPTED DC

Rectangular Impulse:
Use for good muscle contraction but selective impulses prove
more satisfactory.
 Selection of Impulse for INTERRUPTED DC

• It rise sudden with trapezoidal.

• Triangular (slower)
• Saw Tooth (more slower)
INTERRUPTED DC
Selection of Impulse for INTERRUPTED DC

All these are of same duration, intensity may be vary.

A slow rise in intensity has advantages to produce contraction

of denervated muscles then rectangular impulses are used.
Techniques of Treatment with INTERRUPTED DC

ØMethods of Application
ØPreparation of Equipment
ØPreparation of the Patient
ØApplications of IDC
Techniques of Treatment with INTERRUPTED DC

• By various methods, ID current can be applied according to

requirement.
1. Apparatus preparation
2. Patient preparation
3. Techniques of Applications
Techniques of Treatment with INTERRUPTED DC

Preparation of Apparatus:
• Select low frequency electronic stimulator with automatic
surge.
• Operator should test the apparatus.
• Turning up the current until mild prickling sensation is
experienced & contraction produce.
Techniques of Treatment with INTERRUPTED DC

• Educate the patient about sensation.

• Frequency should be tested by operator.
• Apparatus should be far away from pt. almost 2m.
• Prevent short wave therapy machine by output disturbance
Techniques of Treatment with INTERRUPTED DC

Preparation of the Patient

• Clothing remove which area is treated.
• Pt should feel comfortable, fully supported.
• Proper lights.
• Pt should be warned.
• The part under treatment should be supported so that muscle
remain in shortened position.
Techniques of Treatment with INTERRUPTED DC

• If there is pain, movement should be avoided.

• Skin show high resistance if it is dry.
• Skin should be washed with water & soap to remove natural
oil.
Techniques of Treatment with INTERRUPTED DC

• Before electrodes applying, skin should be moist with saline.

• Break skin reduce the resistance of the skin cause discomfort
to the pt.
Techniques of Treatment with INTERRUPTED DC

• Electrodes can be hold by bandage, rubber strap or body

weight to hold the position of electrode/pad , so that max
contact can be achieved.
Techniques of Treatment with INTERRUPTED DC

• Broken skin is protected by petroleum jelly, covered by

non absorbable cotton or wool under the electrode.
 Learning Outcome

Ø Galvanic Current advance techniques

 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 12
 Today Lecture Learning Objectives

By the end of this session you shall be able to

understand;
ØAbout Diadynamic current
• Defination
• Types of DDC
• Physiological Effects
• Indications
• Contraindications
Diadynamic currents

• Introduce by Pierre Bernard (a French Dentist)

nearly 70 years ago.

• Diadynamic currents also called Bernard

current.

• They are Sinusoidal, direct currents with

frequency of 50-100 Hz.
 DEFINITION

Dia-dynamic currents are mixed currents,

which use effects of the concurrent application
of galvanic and faradic, or other impulse-like
currents.
Types of Diadynamic Currents
u There are six different types of current, which
are each used for different purposes.
Types of Diadynamic Currents

1. Monophasic
2. Diphasic
3. Short Period
4. Long Period
5. Syncopated Rhythm
6. Modulated Monophasic
 Types of Diadynamic Currents

1. Monophasic:-
It is a half sinusoidal alternating current,
which is crated by one way DC-converter of
50 Hz, with an impulse length and interruption
of 10 ms each.
 Types of Diadynamic Currents

1. Monophasic:-
Indication:
u When there is pain but no muscle spasm.
(Pain spot)
u Use for muscle stimulation.
 Types of Diadynamic Currents

2. Diphasic:-

u It is crated by an alternating current of

50Hz by means of two way DC-converter,
so that a current of 100Hz is achieved.
 Types of Diadynamic Currents

2. Diphasic:-

u The patient feels a stabbing sensation in

the treated area.
u The stimulus is less than that of
monophasic.
 Types of Diadynamic Currents

2. Diphasic:-

Indication:
u Pain with muscle spasm
u Circulatory Disorder (Vasotropic application)
u It primarily effects the autonomic nervous
system in the sense of lowering the increased
sympathetic tone.
 Types of Diadynamic Currents

3. Short period:-

u It involves a sudden alternation of MF

and DF currents.
u The patient senses the abrupt change.
 Types of Diadynamic Currents

3. Short period:-

Indication:
u Traumatic Pain
 Types of Diadynamic Currents
4. Long period (LP):-
u The MF current is mixed with second
modulated MF.
u 10 sec MF followed by 5 sec DF in which
intensity and frequency rise then fall.
u The gradual rise and lowering in amplitude is
experienced by the patient as a more
pleasant sensation than that produced by
Short period.
 Types of Diadynamic Currents

4. Long period (LP):-

Indication:
u Myalgesia\Neuralgia
 Types of Diadynamic Currents

5. Syncopated Rhythm (SR):-

u The current is interrupted by a pause of 0.9

second after a current flow of 1.1 second.
 Types of Diadynamic Currents

5. Syncopated Rhythm (SR):-

Indication:
u This type is used by electrical stimulus of
muscles. (Motor nerve root)
 Types of Diadynamic Currents
6. Modulated Monophasic (MM):-
u In the MM the SR is gradually reduced in
a stepwise fashion.
u Like the SR, the MM is suited for the
treatment of muscular atrophies.
Physiological Effects
 Physiological Effects

u Pain Relief
u Vasodilatation and hyperemia
u Muscle fibers stimulation
u Stimulation of vibration sense
 Physiological Effects
Type Wave Physiological Indication Feeling
Effect
DF Full wave alternating Has strong Pain with muscle Itching or
current analgesic effect for spasm prickling
short duration sensation
MF Half wave alternating Stimulate muscle Pain without Strong vibration
current contraction muscle spasm sensation

CP Equal phase of DF and Stimulate Traumatic pain Rapid alternating

MF are alternating circulation and feeling between
without interval reduce pain DF and MF
pauses
LP 10 sec MF followed long lasting Myalgesia\Neural Strong vibration
by 5 sec DF in which analgesic effect gia to little pricking
intensity and
frequency rise then
fall
INDICATIONS
 INDICATIONS

Didynamic stimulation causes relief of pain

and edema in the following conditions:

1. Soft tissue injury

Sprains, Strain, Contusion and
Epicondylitis
 INDICATIONS

2. Joint disorders

Post-immobilization and Arthritis

 INDICATIONS

3. Circulatory disorders

Reynaud's disease and Migraine

 INDICATIONS

4. Peripheral nerve disorders

Neuralgia and Sciatic neuritis

CLINICAL APPLICATION
CLINICAL APPLICATION

u Pain spot application

The two electrodes are applied as a bipolar

technique with the anode applied over pain
spot and the cathode adjacent to it.
 CLINICAL APPLICATION

u Trans-regional application

To treat a joint, electrodes positioned on

opposite side of the joint.
CLINICAL APPLICATION

u Nerve Trunk application

The two electrodes are placed along the

course of the peripheral nerve where the
nerve is superficial.
CLINICAL APPLICATION

u Para-vertebral application

The electrodes may be applied on

both sides of the spine at the level
of the nerve root supplying the
painful area.
CLINICAL APPLICATION

u Vasotropic application

The electrodes are applied along the

vascular paths affected in the
circulatory disorders.
CONTRAINDICATIONS
 CONTRAINDICATIONS

u Open skin: The current tends to concentrate at

this point; small broken areas can be insulated by
Vaseline.

u Bony areas: It may produce burn.

u Loss of sensation: It can produce burn

 CONTRAINDICATIONS

u Skin lesions: Eczema fungi can be irritated and

made worse.

u Infections: It may cause spreading of infection.

u Thrombosis.
u Cardiac pace makers.
u Superficial metal.
Learning Outcome

Diadynamic current
 Learning Outcome

Ø Diadynamic Current basic

and advance techniques
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists.

UK: Faber; 1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy.
9th ed. USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th
ed. Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from
research to practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India:
Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 13
 Today Lecture Learning Objectives

By the end of this session you shall be able to

understand;
Ø About Pain Modulation
 PAIN MODULATION

• Many of electrical agents and physical treatments applied by

the PT are an attempt to reduce the level of pain perceived by
patients.
 PAIN MODULATION

• Important to know how nociceptive or pain impulses are

generated, transmitted and interpreted by nervous system.
 PAIN MODULATION

• Base of this knowledge PT may be able to explain in more

scientific manner how treatments affects modulation of patients
pain.
 PAIN MODULATION

• Pain is usually considered to be a pathological state in itself

by patients, who are often happy to have its level reduced (even
when the underlying pathology is unaffected)
 PAIN MODULATION
Pathway of Pain
Noxious physical or chemical agents (Stimulates)

Peripheral receptors

Peripheral Nerve Spinal Cord Brainstem

Cerebral Cortex (Pain)

PAIN MODULATION
 PAIN MODULATION
Pathway of Pain

This route involves a number of synapses and inhibition

of impulses.
Where pain can be modulated.
 PAIN MODULATION
Pathway of Pain

P.N >>> S.C >>> BS >>> CC (Pain)

 PAIN MODULATION
Pathway of Pain

For pain to perceived there is usually a chain whereby peripheral

receptors are stimulated by a noxious physical or chemical agents
and this stimulus is carried by peripheral nerves to spinal cord,
through the brainstem and so to cerebral cortex where the pain
is appreciated at conscious level.
 PAIN MODULATION
Nociceptive Nerve Endings

These nerve ending may be stimulated by chemical

released by tissue injury or as a result of metabolic
activity, thus creating an electrical potential.
 PAIN MODULATION
Nociceptive Nerve Endings
The degree of stimulation produced is governed by
amount of chemical present.

It is postulated that removal of these chemicals from the

area may help reduce the level of nociceptive stimulation
and thus reduce pain.
 PAIN MODULATION
Nociceptive Nerve Endings

Physiotherapeutic agents affecting the circulation may help

to reduce pain and nociceptive stimulation

Physiotherapeutic agents may be ice and heat.

 PAIN MODULATION
Nociceptive stimulus Conduction

Nociceptive stimulus is entered/carried to cord via posture route.

• Slow conducting (non myelinated C fibers)

or
• Fast conducting (myelinated A delta fibers)
 PAIN MODULATION
Nociceptive stimulus Conduction
It is postulated that as both of these fibers have a maximum
frequency at which they conduct.
• C- 15 pulses per sec
• A delta- 40 pulses per sec
 PAIN MODULATION
Nociceptive stimulus Conduction
ü So if higher frequency of stimulation is applied, a pathological
block to conduction might occur.
 PAIN MODULATION
Nociceptive stimulus Conduction
ü TENS, Interferential or some other agents can produce this
required frequency so reduce pain and Nociceptive stimulus.
 Learning Outcome

PAIN MODULATION Mechanism and Pathway

 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 14
 Today Lecture Learning
Objectives

By the end of this session you shall be able to

understand;
Ø About Pain Gate Theory
PAIN Gate Theory
Afferent input mainly via the posterior root of spinal cord
and all afferent information must pass through synapses in
the substantia gelatinosa and nucleus proprius of
posterior horn. (Spinal cord level)
It is at this level that the pain gait first postulated by
Melzack and Wall in 1965.
PAIN Gate Theory
• This theory suggests that for pain to pass through the
gate there must be unopposed passage for nociceptive
information at the synapses in substantia gelatinosa.
• If gate is also concurrently receiving impulse
produced by stimulation of Thermoreceptors or
Mechanoreceptors (Transmitted via large myelinated
diameter fibers) then this traffic predominates (stronger)
with resultant pre-synaptic inhibition of small diameter
nociceptive information.
• Consequently for gate to be open to nociceptive traffic,
input has to be predominantly small diameter
nociceptive information.

• If large diameter afferent information is superimposed

then the gate is closed to nociceptive traffic.
üMany physiotherapeutic agents cause stimulation of
ending connected to large diameter nerves and the
use of manipulation, TENS, Interferential, Heat, Ice,
Massage, Vibration and movement can produced a
reduction of pain by closing pain gate.
PAIN Gate Theory
• If nociceptive information is allowed through the gate
then traffic will continue up the lateral spino-thalamic
tract of the spinal to the thalamus, and from here to the
cerebral cortex.
• As this stimulus passes through the brainstem it may
cause an interaction between the periaqueductal area of
grey matter ( PAG ) and the raphe nucleus in the mid
brain.
• These nuclei form part of the descending pain
suppression system and their descending neurons can
release an endogenous opiate substance into the substantia
gelatinosa at a spinal cord level.
PAIN Gate Theory
• The chemical nature of this endogenous opiate, which
may be Beta endorphin or enkephalin, is such as to
cause inhibition of transmission in the nociceptive
circuit synapses .
• This is achieved by blocking the release of the chemical
transmitter ( substance P ) in the pain circuit .
üThus if a cutaneous stimulus of a noxious type is
applied such as ice, low TENS, when UV counter-
irritation, ionization, transverse frictions, etc., then the
release of enkephalin or B endorphin could reduce pain
at a spinal level.
üPharmacological evidence supports this view, as when
patients experiencing pain relief from TENS are given
the anti-morphine agent naloxone, their pain returns .
üTherefore, it would appear that physiotherapists have a
valuable role to play in the modulation of pain levels
at peripheral, spinal and higher levels by the physical
treatments they apply.
Close Gate
Close Gate
Learning Outcome
 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 15
 Today Lecture Learning
Objectives
By the end of this session you shall be able to
understand;
• About electrodiagnosis Basic
• Test used for electrodiagnosis purpose

Scan for Video

Demonstration
 ???
What is ELECTRODIAGNOSIS
ELECTRODIAGNOSIS ???
ØStrength Duration Curve
ØNerve conduction tests
ØRheobase
ØChronaxie
ØFaradic & I.D.C Test
ØElectromyography
ØBiofeedback
 ELECTRODIAGNOSIS

Changes in Electrical Reactions

• When there is disease or injury of motor nerves or muscles,
alterations are liable to occur in response to electrical
stimulation.

• Altered electrical reactions may be of considerable assistance

in diagnosing the type & extent of the lesion.
 ELECTRODIAGNOSIS
ØReduction or loss of voluntary power of muscle is due to:

1. Lesion of Upper Motor Neuron

2. Lesion of Lower Motor Neuron
3. Damage of muscle itself
4. Fault at neuromuscular junction
5. Functional Disorder
 ELECTRODIAGNOSIS
1. Upper Motor Neuron Lesions

• Lesion at brain level.

• There are no changes in the lower motor neuron or
muscle (leads to altered electrical reactions)
• Normal type of response is obtained with electrical
stimulation although nerve and muscles are hyper
excitable & react to lower intensity of current.
 ELECTRODIAGNOSIS
2. Lower Motor Neuron Lesions
• It involves either Anterior horn cells or the fibers of nerve
roots or peripheral nerves.
• These are classified into three groups:
i. Neurapraxia
ii. Axonotmesis
iii. Neurotmesis
 ELECTRODIAGNOSIS
2. Lower Motor Neuron Lesions
 ELECTRODIAGNOSIS
2. Lower Motor Neuron Lesions
 ELECTRODIAGNOSIS
2. Lower Motor Neuron Lesions
i. Neurapraxia
• First Degree Injury.
• It is a condition in which bruising or pressure renders the
nerve incapable of conducting impulses past the site of the
lesion .
• But damage is not severe enough to cause degeneration of the
fibers.
• If electrical reactions are tested on affected muscles, normal
response is obtained
 ELECTRODIAGNOSIS
2. Lower Motor Neuron Lesions
ii. Axonotmesis
• 2nd Degree Injury.
• It is liable to occur if the lesion is more severe.
• Degeneration of axons takes place, the sheath of the nerve
remaining intact.
• Example: Radial Nerve Palsy along with fractured shaft of
humerus.
 ELECTRODIAGNOSIS
2. Lower Motor Neuron Lesions
iii. Neurotmesis
• 3rd Degree Injury.
• It is severing of the nerve sheath & fibers.
• Fiber degenerate below the site of the lesion, causing the
alterations.
• Condition is more serious.
• A lesion of this type would be observed if the ulnar nerve were
severed by a cut on the front of the wrist.
 ELECTRODIAGNOSIS
2. Lower Motor Neuron Lesions
Ø All these types of nerve lesion may be partial or complete or
there may be combination of both e.g. neurapraxia &
axonotmesis.
Ø If all nerve fibers degenerate, complete denervation are
observed.
Ø If only some fibers degenerate, partial denervation occurred.
 ELECTRODIAGNOSIS
3. Defects of Neuromuscular Junction

• In Myasthenia Gravis:
Reduction of voluntary power is
due to faulty conduction at the
neuromuscular junction.
 ELECTRODIAGNOSIS
4. Muscle Lesions
• If reduction of voluntary power is due to weakness or disease of
muscle & there is no degeneration of motor nerve, reactions to
stimulus are of normal type but are reduced in strength.

• Absence of response occurs in: Ischaemic Contracture,

Myopathies or fibrosis of muscles in longstanding denervation
 ELECTRODIAGNOSIS
5. Functional Disorders

• Loss of voluntary power may be due to hysterical paralysis, in

which there is no alteration in the electrical reactions.
 ELECTRODIAGNOSIS
Stage of Denervation
• Denervation is any loss of nerve supply regardless of the
cause.

• Wallerian degeneration is an active process

of degeneration that results when a nerve fiber is cut or
crushed and the part of the axon distal to the injury (i.e.
farther from the neuron's cell body) degenerates.
ELECTRODIAGNOSIS
Stage of Denervation
 ELECTRODIAGNOSIS
Stage of Denervation
• When nerve fiber is severed, Wallerian Degeneration takes
place below the site of lesion & above it as first Node of
Ranvier.
• Take 14 days to complete.
• If nerve is stimulated below the site, an impulse is initiated &
normal response produced.
 ELECTRODIAGNOSIS
Stage of Denervation

• If normal motor nerve trunk is stimulated with a current of

adequate intensity,
• there is contraction of all the muscles it supplies.
 ELECTRODIAGNOSIS
Stage of Denervation
• If there is degeneration, then response is reduced or lost & it
takes place 3 or 4 days after injury.
• Changes observed before the end of 1st week.
• If reaction of complete denervation is obtained, severity of
lesion is immediately apparent.
 Learning Outcome

ELECTRODIAGNOSIS Basic toward diagnosis

 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK:

Faber; 1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th
ed. USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
 Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 16
 Today Lecture Learning Objectives

By the end of this session you shall be able

to understand;
Scan for Video
Demonstration
 Strength Duration Curve (SDC)

“Strength duration OR Intensity duration curve

shows the relationship between the magnitude of
the change of the stimulus and the duration of the
stimulus.”

The curve provides valuable information

regarding the state of excitability of nerve lesion.
 Strength Duration Curve (SDC)

q It shows the interdependence between stimulus

strength and the time required in activating the
muscles.
 Strength Duration Curve (SDC)

q It indicates the strength of impulses of various

durations required to produce muscle contraction by
joining the points that graphically represent the
threshold value along the ordinate for various
durations.
 Strength Duration Curve (SDC)

Advantages of SDC
o This is a simple, reliable and shows a proportion
of denervation.
 Strength Duration Curve (SDC)
Disadvantages of SDC
o In large muscles it can not shows the full pictures
but only a proportion of muscle fibers can be
stimulated.
o It can not show the site of lesion.
o It is Qualitative rather than Quantitative test.
 Strength Duration Curve (SDC)
Optimum timing of SDC:

u SDC test can be done 10 – 14 days after the lesion

has occurred (Maximum up to 21 days).

u SDC is used to identify denervation, partial

innervation, and compression.
Methods of SDC
 Methods of SDC

u Take a neuromuscular stimulator (TENS,

stimulator) having rectangular duration i.e. 0.3,
0.1, 1, 3, 10, 30, 100, 300 ms and constant current.
 Methods of SDC

u Put the passive electrode over the midline of the

body or near the origin of the muscle.

u Put the active electrode over the fleshy belly of

the muscle.
 Methods of SDC
u Alternately both the electrodes are placed on both
ends of the muscle.

u First apply current having longest duration and

look for minimum perceptible contraction,
gradually shorten the impulse duration and note
the corresponding increase in current strength.
 Methods of SDC

u The electrode placement should not

be changed through out the test.

u Plot a SD graph from the results of

the test.
Characteristics of SDC
For the stimulation of denervated fibers
impulses of longer duration are required

while for the stimulation of innervated fibers

impulses of shorter duration are required.
 Characteristics of SDC
1. Innervated muscles

u When all the nerve fibers supplying the muscles

are intact, the strength duration curve has a shape
characteristic of normally innervated muscles.(Next
Fig)
 Characteristics of SDC
1. Innervated muscles

u Longer duration >>

Same Intensity
u Shorter duration >>
Increase Intensity
 Characteristics of SDC
1. Innervated muscles

u The same strength of stimulus is required to produce

a response with all the impulses of longer duration,
while those of shorter duration require an increase
in strengths of the stimulus(Intensity) each time the
duration is reduced.
 Characteristics of SDC
1. Innervated muscles
 Characteristics of SDC
2. Denervated muscles

u When all the nerve fibers supplying a muscle have

degenerated, the strength duration produced is
characteristic of complete denervation. (Next Fig)
 Characteristics of SDC
2. Denervated muscles

u Longer duration (100 or

less) >> Increase Intensity
u Shorter duration >> No
response
 Characteristics of SDC
2. Denervated muscles

u For all impulses with duration of 100 ms or less the

strength of the stimulus must be increased each time the
duration is reduced and no response is obtained to impulses
of very short duration.

u The curve rises steeply and is shifted to the right than

that of normally innervated muscle.
 Characteristics of SDC
2. Denervated muscles
 Characteristics of SDC
3. Partial denervated muscles

u For the stimulation of denervated fibers impulses

of longer duration are required while for the
stimulation of innervated fibers impulses of
shorter duration are required.
 Characteristics of SDC
3. Partial denervated muscles

u Thekink produce show the partial denervation

which disappear after 10 -20 days or month.
 Characteristics of SDC
3. Partial denervated muscles
Learning Outcome
 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
Physical agents & Electrotherapy-1

Dr. Waqas Fayyaz PT

DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 17
 Today Lecture Learning
Objectives

By the end of this session you shall be able to

understand;
• Other tests of Electrical Reactions e.g:
ØRheobase
ØChronaxie
ØFaradic & I.D.C Test

Scan for Video

Demonstration
RHEOBASE

Rheo mean Minimum

Base mean Current
 RHEOBASE

“The rheobase is the smallest current that will

produce a muscle contraction if the stimulus is
of infinite duration; in practice an impulse of
100 ms (0.1 sec) is used.”
 RHEOBASE

ØIn denervation the rheobasc may be less

than that of innervated muscle, and it often
rises as re-innervation commences.
 RHEOBASE
Factors responsible for Rheobase

• These changes are not, however, sufficiently

predictable to be reliable guides.
The rheobase varies due to
Ø Different muscles
ØSkin resistance and temperature of the part
ØRise may be due to fibrosis of the muscle
CHRONAXIE
Minimum Duration
 CHRONAXIE
Minimum Duration

“The Chronaxie is the duration of the shortest

impulse that will produce a response with a
current of double the rheobase.”
Chronaxie is double the rheobase current.
 CHRONAXIE
Minimum Duration

The chronaxie of innervated muscle is

appreciably less than that of denervated muscle,
the former being lets and the latter more than 1 ms
if the constant voltage stimulator as used with the
constant current stimulator the values are higher,
but heal a similar relationship to each other.
 CHRONAXIE

Chronaxie is not a satisfactory method of testing

electrical reactions as partial denervation is not
clearly shown.

For example, the chronaxie of a muscle with 25

percent of its fibers innervated would be the same
as that of a completely denervated muscle
Faradic and I.D.C tests
Faradic Test
 Faradic and I.D.C tests

Testing with faradic type and interrupted direct

currents was widely used in the past, but it is very
inaccurate.
 Faradic and I.D.C tests
Faradic Test

The faradic type current provides impulses with a

duration of 0.1-1 ms and a frequency of 50-100
Hz.
 Faradic and I.D.C tests
Faradic Test

These cause a tetanic contraction of innervated

muscle, but with a faradic coil it is difficult or
impossible to elicit a response from denervated
muscle owing to the short duration of the stimulus.
 Faradic and I.D.C tests
Faradic Test

With modern stimulators, however, a response

can usually be obtained from denervated
muscle with impulses of this duration, owing to
the greater output and more tolerable forms of
current than that provided by the older equipment.
 Faradic and I.D.C tests
Faradic Test

Inaccuracies due to variations in the form and

duration of the impulses have also been
eliminated.
Faradic and I.D.C tests
Interrupted direct current
 Faradic and I.D.C tests
Interrupted direct current

Interrupted direct current was used in impulses

with a duration of approximately 100 ms repeated
30 times per minute.

These usually produce a brisk contraction of

innervated muscle fibers, but a sluggish
contraction of denervated fibers.
 Faradic and I.D.C tests
Interrupted direct current

Innervated muscles may, however, respond sluggishly if their

temperature is below normal, or in certain conditions such as
myxedema, while the contraction of denervated muscle
becomes brisker as its temperature rises.
Learning Outcome

Tests of Electrical Reactions

REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK:

Faber; 1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy.
9th ed. USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research
to practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee;
2012
Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 18
 Today Lecture Learning
Objectives
By the end of this session you shall be able
to understand;
About Nerve Conduction Study
• NCS
• USES/Indications
• Common Disorder Diagnosed
• Nerve conductivity
• Nerve Distribution
• Conduction speed
• Procedure
• Important Info
• Points for Placements
Scan for Video
Demonstration
 Nerve Conduction Study (NCS)

• NCS is a test commonly used to evaluate the

function of the motor and sensory nerves of the
human body.

• Nerve conduction velocity (NCV) is a

common measurement made during this test.
 Nerve Conductivity

• When a nerve fiber is degenerating,

conductivity is lost distal to the lesion
within a few days, and this give some
indication of state of lesion and possible
prognosis.
 Nerve Conductivity

• With lesion in which degeneration does

not occur, it may be possible to determine
the level at which impulses are blocked by
testing at different points on nerve trunk.
• Stimulation below the site of lesion should
elicit a response, but not above.
 Nerve Distribution

• Nerve Distribution can be determined

by stimulating the nerve trunk and
observing the resulting muscle
contractions.
 Conduction Speed

• The speed with which an impulse is

transmitted along a nerve fiber can be
measured with suitable equipment called
Electromyography.
Learning Outcome
 REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 19
 Today Lecture Learning
Objectives

By the end of this session you shall be able to understand;

About ELECTROMYOGRAPHY

Scan for Video

Demonstration
ELECTROMYOGRAPHY

‘Electro’ – electric
‘Myo’ – muscle
‘Graphy’ – to graph / to measure
 ELECTROMYOGRAPHY

“EMG is the recording of electrical activity of a

muscle at rest & during contraction which aids in
the diagnosis of neuromuscular disease.”
 ELECTROMYOGRAPHY

Types of Electromyography
1. Diagnostic or clinical electromyography
2. Kinesiological electromyography
 Types of Electromyography

1. Diagnostic or clinical electromyography:

It is used for the study of diseases of muscles,
neuromuscular junctions and nerves.
It is used for the purpose of electrodiagnosis.
 Types of Electromyography

2. Kinesiological electromyography:
It is used in the study of muscle activity and to
establish the role of various muscles in specific
activities.
How can we detect electrical signals?

ØDifferent types of electrodes

1. Surface electrodes
2. Fine – wire indwelling electrodes
3. Needle electrodes
How can we detect electrical signals?

ØRecording is made through a coaxial

needle electrode; diagnostic
electromyography (EMG) cannot be
carried out with surface electrodes.
How can we detect electrical signals?

ØElectrical activity is examined first with

the muscle at rest and then during
voluntary activity.
How can we detect electrical signals?
How can we detect electrical signals?

• A motor unit consists of an anterior horn cell,

the nerve and its divisions arising from that cell,
and the muscle fibers supplied by these
divisions.

• The fewer the fibers in a unit, the more precise

the voluntary control. (Inverse relation)
How can we detect electrical signals?

• Two types of activity observed….

1. Spontaneous activity
2. Volitional activity
Some examples of spontaneous
activity
1. Spontaneous activity

ØAt rest normal muscle is electrically silent,

apart from occasional nerve discharges,
which are particularly noticeable if the
needle is near the motor point.
1. Spontaneous activity

• These discharges are initially negative in

deflection and of higher frequency than
fibrillation potentials.
• Small negative deflections due to end-plate
potentials may also be seen occasionally.
1. Spontaneous activity

ØAbnormal spontaneous activity may be

classified into
I. Fibrillation potentials,
II. Positive sharp waves,
III.Fasciculation potentials and
IV.High-frequency discharges.
1. Spontaneous activity

Each potential has a characteristic sound

which can only be learnt by hearing it or by
wave form.
1. Spontaneous activity

• Abnormal spontaneous activity can only

be properly observed when the needle is at
rest,
because activity due to irritation
by the needle occurs briefly after the needle is
Inserted into normal muscle.
 I. Spontaneous activity
Fibrillation potentials

• These are bi- or tri-phasic, of 1-2ms duration

and 50-300uV amplitude.
• They are due to spontaneous excitation of
individual muscle fibers and appear 10-20 days
after nerve degeneration.
• Fibrillation and positive sharp-waves both
Indicate denervation of muscle.
I. Spontaneous activity
Fibrillation potentials
 II. Spontaneous activity
Positive sharp waves

• It give a sharp initial positive deflection followed by

prolonged negative phase.
• The amplitude varies widely, being mostly between 50
and 2000uV.
• These potentials occur in denervated muscle, often
with fibrillation.
It must be distinguished from those from normal motor
units some distance from the needle tip; hence complete
relaxation of the muscle is essential.
II. Spontaneous activity
Positive sharp waves
 III. Spontaneous activity
Fasciculation potentials

ØThey are usually from 0.5 to 3mV in amplitude and 7 to

20 ms duration.
ØThey differ widely in size and shape from one to
another.
ØFasciculation potentials may be of three phases or may
be highly complex, and although a single one maintains
its own characteristic appearance on the screen.
III. Spontaneous activity
Fasciculation potentials
 III. Spontaneous activity
Fasciculation potentials

ØThese are spontaneous discharges from motor units not

under voluntary control.
ØConsist of potentials repeating at a lower rate than
fibrillations.
• Fasciculation occurs in benign myokymia, particularly
in the extensor muscles of the forearms or in eye.
• But it is usually an indication of pathology at spinal
cord or root level.
 IV. Spontaneous activity
High-frequency discharges

ØThey give a characteristic 'dive-bomber' sound on the

loudspeaker.
ØIt occur in myotonia, especially dystrophies and
occasionally with polymyositis.
How can we detect electrical signals?
• Two types of activity observed….
1. Spontaneous activity
2. Volitional activity
i. In Normal Muscle
ii. Denervation
iii. Re-innervation
iv. Peripheral Neuropathy
v. Myopathy
vi. Myositis
Learning Outcome
Spontaneous activity of EMG
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
Physical agents & Electrotherapy-1
Dr. Waqas Fayyaz PT
DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 20
 Today Lecture Learning
Objectives

By the end of this session you shall be able to understand;

About ELECTROMYOGRAPHY (Volitional activity)

Scan for Video

Demonstration
How can we detect electrical signals?

• Two types of activity observed….

1. Spontaneous activity
2. Volitional activity
How can we detect electrical signals?
• Two types of activity observed….
1. Spontaneous activity
2. Volitional activity
i. In Normal Muscle
ii. Denervation
iii. Re-innervation
iv. Peripheral Neuropathy
v. Myopathy
vi. Myositis
 ELECTROMYOGRAPHY
Volitional activity
i: In normal individual motor units

• Recordings are made first in minimal volition

and then with increasing strengths of muscle
contraction.
 ELECTROMYOGRAPHY
Volitional activity
i: In normal individual motor units

• The potentials recorded from normal

individual motor units vary in amplitude and
duration depending on the number of muscle
fibers composing the motor unit.
 ELECTROMYOGRAPHY
Volitional activity
In normal individual motor units
• The interference pattern of normal muscle. A
small number of polyphasic units (over four phases)
occur in normal muscle.
 ELECTROMYOGRAPHY
Volitional activity
In normal individual motor units
• The motor units in the face are much smaller than those in
the limb muscles and as a consequence the potentials
recorded from them are shorter in duration and smaller in
amplitude.
• Normal motor unit potentials have three or four phases
and at first repeat 10-15 times per second, other units then
firing to give the confused pattern of electrical activity
displayed on the screen.
 ELECTROMYOGRAPHY
Volitional activity
ii: Denervation

• Denervation causes a reduction to the number of motor

units acting with a consequent reduction in the interference
pattern.
• In cases of severe denervation parts of the baseline are
visible even at maximum volition — a so-called 'discrete'
interference pattern.
• With complete denervation no motor units are electrically
active.
 ELECTROMYOGRAPHY
Volitional activity
iii: Re-innervation

• Re-innervation after a nerve injury causes 'nascent'

polyphasic units to appear, at first of only a few hundred
microvolts amplitude.
 ELECTROMYOGRAPHY
Volitional activity
iv: Peripheral neuropathy

• Peripheral neuropathy may cause a reduced interference

pattern of motor units, with increased polyphasic units on
volition as well as abnormal spontaneous potentials.
 ELECTROMYOGRAPHY
Volitional activity
Peripheral neuropathy

• Similar changes occur in lesions of the anterior horn cell

such as motor-neurone disease, but then the polyphasic
potentials are usually much larger, up to 3 or 4 mV
amplitude; they are easily seen in the anterior tibial and
small hand muscles.
 ELECTROMYOGRAPHY
Volitional activity
Peripheral neuropathy

• When denervation is found in both arm and leg muscles, a

diffuse pathology is indicated.
• Nerve conduction studies combined with the EMG
findings make it possible to distinguish between peripheral
neuropathy and other pathology either near or in the spinal
cord.
 ELECTROMYOGRAPHY
Volitional activity
Peripheral neuropathy

• It is advisable to examine muscles in the distribution of

more than one nerve root or peripheral nerve, to avoid
confusion with a local nerve lesion.
• In the latter case nerve conduction studies will show a
local slowing of conduction in contrast to the diffuse
slowing in peripheral neuropathy.
• Lesions at or near cord level may cause slowing of
peripheral nerve conduction, but usually only at a stage in
the disease when the diagnosis is evident.
 ELECTROMYOGRAPHY
Volitional activity
V: Myopathy

• Myopathy causes a loss of individual muscle fibers.

• There is no reduction in the total number of motor units at

first, but a reduction of the interference pattern occurs later
in the disease.
• A few high-frequency discharges may be heard and seen in
many myopathies, but are mostly seen with myotonia.
 ELECTROMYOGRAPHY
Volitional activity
Myopathy

• The muscles show few, if any, fibrillation potentials at rest,

but motor unit discharges appear smaller and shorter than is
normal for the muscle under examination, with increased
numbers of polyphasic units. Then changes are substantially
the same whatever the cause of the myopathy, e.g. carcinoma,
thyrotoxicosis, muscular dystrophy or steroid treatment.
 ELECTROMYOGRAPHY
Volitional activity
Vi: Myositis

• Myositis, in which the muscle is inflamed, causes

changes to the volitional pattern.
• Spontaneous fibrillation potentials also occur in
about 50 per cent of cases.
ELECTROMYOGRAPHY
Summary Findings
Indications of Electromyography

Ø Muscular dystrophy
Ø Congenital myopathies
Ø Mitochondrial myopathies-energy making parts
Ø Metabolic myopathies
Ø Myotonias
Ø Peripheral neuropathies
Ø Radiculopathies
Ø Chronic Musculoskeletal Injury
Ø Pain
Ø Posture Control
Ø Balance and Mobility
Indications of Electromyography

Ø Nerve lesions
Ø Amyotrophic lateral sclerosis
Ø Polio
Ø Spinal muscular atrophy
Ø Guillain-Barré syndrome
Ø Ataxias
Ø Myasthenias
Ø Stroke
Ø Spinal Cord Injury
Ø Recovering and improving muscle action
Ø Trunk Muscle Reeducation
Ø Idiopathic Raynaud’s Disease
Learning Outcome
Volitional activity of EMG
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012
Physical agents & Electrotherapy-1

Dr. Waqas Fayyaz PT

DPT, MSPT(Neurology)
Lecturer at University of Lahore
[email protected]
[email protected]

Lecture 21
 Today Lecture Learning
Objectives

By the end of this session you

shall be able to understand;
• About BIOFEEDBACK

Scan for Video

Demonstration
 BIOFEEDBACK

The term 'biofeedback' refers to the procedure

by which information about a physiological
function is feedback to the individual by an
auditory or visual signal.
 BIOFEEDBACK

This information is usually from an internal

system which is inaccessible to the individual.
When presented with this visual or auditory
feedback the patient can attempt to modify the
activity of this system.
BIOFEEDBACK
 BIOFEEDBACK

Another use of electromyography (EMG) is in

the form of Biofeedback, which is becoming a
more widely used adjunct to physiotherapy (Dc
Wcerdt 1985).
BIOFEEDBACK
Principle

THE PRINCIPLE
 BIOFEEDBACK
Principle

The principle upon which the measure of activity is based is

that the signal produced by the EMG apparatus relates
directly to the level of contractile activity taking place in the
muscle, and that changes in activity will produce a
corresponding change in the EMG feedback.
BIOFEEDBACK
Electrodes
 BIOFEEDBACK
Electrodes

To ensure a degree of accuracy three surface

electrodes are often used.
 BIOFEEDBACK
Electrodes

Biofeedback training in physiotherapy may take

a number of forms, but one of the most
commonly used is to apply surface EMG
electrodes over particular muscles and present
the patient with an auditory or visual measure of
the muscles activity.
 BIOFEEDBACK
Feedback Form
The patient is presented with

either visual feedback using the needle on a

meter,
or
auditory feedback in the form of a series of
clacks (sharp sound).
 BIOFEEDBACK
Types

Several types of EMG biofeedback machines are

available, and here too the advances in
microcircuitry have allowed considerable
(Smaller) of the units to take place and hence
make them very portable.
 BIOFEEDBACK
Procedure
The therapist selects which muscles to train, places the
surface electrodes appropriately, and sets the sensitivity of the
apparatus.
As the patient learns to produce the required response the
sensitivity can be altered as a means of progression.
 BIOFEEDBACK
Example
In cases of increased muscle tone, the patient can attempt to
reduce the level of feedback by trying to gradually reduce the
tone.
Conversely, where muscle activity needs to be increased,
the patient attempts to increase the amount of feedback.
 BIOFEEDBACK

This form of training can be used with adults and is also

popular with children where it is possible to turn the
procedure into a game by linking the EMG machine to a
computer
BIOFEEDBACK
 BIOFEEDBACK
Future Goal

Biofeedback is very mush an adjunct to physiotherapy and

not treatment in its own right. However, in the correct
circumstances, with appropriate application and training, it
can be a very effective way of modifying motor function.
Learning Outcome
Basic and Advance Biofeedback
REFERENCE BOOKS

1. Savage B. Practical electrotherapy for physiotherapists. UK: Faber;

1960.
2. Scott PM. Clayton’s electrotherapy and actinotherapy. 9th ed.
USA: Williams & Wilkins: 1980.
3. Watson T. Electrotherapy: evidence-based practice. 12th ed.
Edinburgh: Churchill Livingstone; 2008
4. Cameron MH. Physical agents in rehabilitation: from research to
practice. 4th ed. St. Louis: Elsevier; 2013.
5. Singh J. Textbook of electrotherapy. 2nd ed. India: Jaypee; 2012