Lecture 1 - Introduction To The Use of EPA

1.
Introduction to Electrophysical
Agents (EPA)
Steve Milanese
B.App.Sc. (Physio), Grad.Cert (Sports Physio),
M.App.Sc. (Manipulative Physio)
Grad.Dip (Ergonomics)
PhD
MCSP
Specific Learning goals
• Understand the role of endogenous currents
within living tissue.
• Describe the mechanism underpinning the use
of high energy and low energy therapies
• Understand the notion of therapeutic windows
with the application of EPA modalities.
• Understand the general guidelines for the
application of EPA modalities.
Readings
• Watson T. (2010): Key concepts with electrophysical agents.
Physical Therapy Reviews 15 : 4: 351-359
• Watson T. (2008): Chapter 1: Introduction: current concepts

and clinical decision making in electrotherapy. In Watson T
(ed) Electrotherapy: Evidence-Based Practice, 12th Edition.
Churchill Livingstone: Edinburgh.
• Robertson V, Ward A, Low J, Reed A (2006): Electrotherapy
Explained: Principles and Practice 4th Edition, Butterworth
Heinman: Edinburgh, Chapter 2: Background biophysics and
physiology.
What are EPAs?
Electrical or physical agents applied to the human

body for assessment or treatment purposes.
Classification of EPAs
Therapeutic Assessment
Superficial Heat (Hot packs/wax baths etc)
Thermal Superficial cold
Contrast baths
Mechanical Therapeutic Ultrasound Diagnostic Ultrasound
Transcutaneous Nerve Stimulation (TENS)

Functional Electrical Stimulation (FES)
Faradic/Galvanic/High Voltage Galvanic
Electrical Stimulation (HVGS)
Interferential therapy (IFT)/Modulated
Medium Frequency (MMF)
Russian Current
Short Wave Diathermy (SWD)

Ultraviolet
Electromagnetic Low Level Laser
Magnetic field therapy
Infra-red
History of EPA use
Scribonius
Largus 43AD
Duchenne de Bologne 1800’s Luigi Galvani

1771
Mary Shelley
1900s 1950’s 2000’s
Why are they used therapeutically?
• Underlying premise = external application of
energy can beneficially alter physiological
processes.
Endogenous current
All cells have an electrical current associated

with them.
Cell membranes control the movement of ions

from the outside to the inside of the cell
through three main mechanisms.
Endogenous current
This means that there is a difference in ionic
concentration across the cell membrane.
This results in a drop in charge from one side of the
cell membrane to the other (ie. a potential
difference)
A potential difference is what drives an electric
current
Endogenous current
These endogenous currents have been found
across a wide range of tissue.
Interestingly when a wound occurs there is a

change in the measured electric current (both
strength and polarity) (in the order of 10 –
30µA/cm2), which returns to normal when the
injury heals.
High Energy EPA
The delivery of an energy form that will overcome
the electrical activity of the cell membrane, forcing
the cell to change its ‘excitement levels’ and hence
its activity.
 Examples
 Electrical Stimulation
(motor and sensory)
 Heat/cold for pain control
(sensory)
Low Energy EPA
The delivery of an energy form that will bring
about an increase in cell membrane/
mitochondrial activity (usually by influencing a
variety of ion gates or channels) bringing about
a change in cell state without overt effects.
• Examples
– Electrical Stimulation
– Pulsed ultrasound for healing
– Microcurrents
Therapeutic windows
Therapeutic windows are a popular concept in
medical practice. This concept is based on the
observation that there is an optimal ‘amount’ of
treatment.
The Arndt-Schulz Law
The concept of therapeutic windows were described
as early as 1854 (Virchow), and formed one of the
earliest principles of pharmacology – the Arndt-
Schulz law (1888)
Therapeutic window
The healing process is a cascade, an ever-
changing cell mediated response.
Textbook Reality
www.electrotherapy.org
Therapeutic windows
If we superimpose the Arndt-Schulz law over the
healing process, maybe there is an optimal level
of stimulus for EPA that will fits this therapeutic
window.
Therapeutic windows
This therapeutic window may move as the
pathophysiological processes underpinning healing
progresses.
We would assume the therapeutic window moves to the
right.
Therapeutic windows
There are three phases in the A-S law
1. Sub-stimulation
2. Bio-stimulation
3. Bio-inhibition
2
3
1
As the cascade processes
the tissue requires more
energy for bio-stimulation.
Sub-stimulation
A dosage of any modality that has no effect on
the pathophysiological process.
Any effect based on the ‘placebo’ effects.

Bio-Stimulation
A dosage of any modality that has the effect of
promoting the pathophysiological inflammatory
cascade.
It does not increase the reaction, but facilitates the

cascade process.
It shortens the phase, hence promoting the repair

process
Bio-inhibition
A dosage of any modality that has the effect of
decreasing the cellular activity in the bodies
tissue.
Could have +ve or –ve therapeutic effects
If excessive may lead to aggravation

Clinical Expertise
Patient values, Research

circumstances etc Evidence
Information from Practice

context
When to use EPA?
• Little good quality research evidence to
guide clinical practice – keep looking!
• Remember a ‘lack of evidence of effect’
is not the same as ‘evidence of a lack of
effect’
• Rely on expert opinion and your own
clinical reasoning ability.
When to use EPA?
• In order to choose, for each modality you
require a good understanding of
– Physics
– Biophysics
– Physiology
– Contraindications/precautions
Consider
•What therapeutic effect is intended.
•Is this modality safe?
• Is it the best method of treatment to achieve

this effect? What can you combine it with?
Safety Considerations
1. Contraindications and precautions

2. Informed Consent
3. Patient Sensation Testing
4. Electrical safety
5. Occupational health and safety
6. Infection control
Contraindications and Precautions
• You must be aware of the precautions and the
contra-indications for each modality.
Safety
• Assess patient
• Select modality
• Prepare Patient
• Get equipment
• Check equipment
• Set up equipment/patient
• Treat
• Check patient
• Pack up equipment
• Record
Guidelines for the safe application
of EPA
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1.

• Watson T. (2008): Chapter 1: Introduction: current concepts

Electrical or physical agents applied to the human

Mechanical Therapeutic Ultrasound Diagnostic Ultrasound

Transcutaneous Nerve Stimulation (TENS)

Short Wave Diathermy (SWD)

Duchenne de Bologne 1800’s Luigi Galvani

All cells have an electrical current associated

Cell membranes control the movement of ions

Interestingly when a wound occurs there is a

Any effect based on the ‘placebo’ effects.

It does not increase the reaction, but facilitates the

It shortens the phase, hence promoting the repair

Could have +ve or –ve therapeutic effects

If excessive may lead to aggravation

Patient values, Research

Information from Practice

•Is this modality safe?

• Is it the best method of treatment to achieve

1. Contraindications and precautions

You must have a copy (and

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