Research Report

Effectiveness of Interferential Current Therapy in the Management of Musculoskeletal Pain: A Systematic Review and Meta-Analysis
Jorge P. Fuentes, Susan Armijo Olivo, David ). Magee, Douglas P. Gross

Background, interferential current (IFC) is a common electrotherapeutic modality used to treat pain. Althotigh IFC is widely used, the available information regarding its clinical efficacy is debatable. Purpose. Ihe aim of this systematic review and meta-analysis was to analyze the available information regarding the efficacy of IFC in the management of msculo skeletal pain. Data Sources. Randomized controlled trials were obtained through a computerized search of bibliographic databases (ie, CINAHL, Cochrane Library, EMBASE, MEDLINE, PEDro, Scopus, and Web of Science) from 1950 to February 8, 2010. Data Extraction. Two independent reviewers screened the abstracts found in the databases. Methodological quality was assessed using a compilation of items included in different scales related to rehabilitation research. The mean difference, with 95% confidence interval, was used to quantify the pooled effect. A chi-square test for heterogeneity was performed. Data Synthesis, A total of 2,235 articles were found. Twenty studies fulfilled the incltision criteria. Seven articles assessed the use of IFC on joint pain; 9 articles evaluated the use of IFC on muscle pain; 3 articles evaluated its use on soft tissue shotilder pain; and 1 article examined its use on postoperative pain. Three of the 20 studies were cotisidered to be of high methodological quality, 14 studies were considered to be of moderate methodological quality, and 3 studies were considered to be of poor methodological quality. Fourteen studies were included in the meta-analysis. Conclusion, interferential current as a supplement to another intervention seems to be more effective for reducing pain than a control treatment at discharge and more effective than a placebo treatment at the 3-month follow-up. However, it is unknown whether the analgesic effect of IFC; is superior to that of the concomitant interventions. Interferential current alone was not significantly better than placebo or other therapy at discharge or follow-tip. Results mtist be considered with caution due to the low ntimber of studies that u.sed IFC alone. In addition, the heterogeneity across sttidies and methodological limitations prevent conclusive statements regarding analgesic efficacy.

).P. Fuentes, BPT, MSc, is a PhD student in the Faculty of Rehabilitation Medicine, University of Alberta, 3-50 Corbett Hall, Edmonton, Alberta, Canada T6C 2C4, and Department of Physical Therapy, Catholic University of Maule, Talca, Chile. Address all correspondence to Mr Fuentes at: jorgefis'ualberta.ca. S. Armijo Olivo, BScPT, MSc, PhD, is affiliated with the Faculty of Rehabilitation Medicine, University of Alberta. D.). Magee, BPT, PhD, is Professor, Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta. D.P. Cross, PT, PhD, is Associate Professor, Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta. [Fuentes |P, Armijo Olivo S, Magee D|, Gross DP. Effectiveness of interferential current therapy in the management of musculoskeletal pain: a systematic review and meta-analysis. Phys Ther. 2010,90: 1219-1238.] 2010 American Physical Therapy Association

Post a Rapid Response to this article at: ptjournal. apta, org September 2010 Volume 90 Number 9 Physical Therapy 1219

Interferential Current Therapy in Management of Musculoskeletal Pain

uccessful management of musculoskeletal pain is a major ehallenge in clinical practice. One of the electrotherapeutic teehniques used for managing musculoskeletal pain is interferential current therapy (IFC). The results of questionnaire surveys in England,' Canada,-^ and Australia^ * have shown that IFC is widely used by diverse clinicians throughout the world,

Interferential current therapy is the application of alternating mediumfrequency current (4,000 Hz) amplitude modulated at low frequeney (0-250 Hz),5-7 A claimed advantage of IFC over low-frecjuency ctirrents is its capacity to diminish the impedance offered by the skin,'' Another advantage speculated for IFC is its ability to generate an amplitudemodulated frequency (AMF) parameter, which is a low-frequency current generated deep within the treatment area,*^"'" Several theoretical physiological mechanisms such as the "gate control" theory," increased circtilation, descending pain suppression, block of nerve conduction, and placebo have been proposed in the literature to support the analgesic effects of IFC,5"'-2 Despite IFC's widespread use, information about it is limited. A review of the literature reveals incomplete and controversial documentation re-

garding the scientific support of IFC in the management of musculoskeletal pain. For example, a systematic review about the use of electrotherapy for neek disorders'^ excluded the analysis of IFC, Moreover, mtich of the IFC information is not written in English,'""-^^ and most artieles appear to be based on case reports,^^-^"^ clinical studies not including a randomization process,227 letters to the editor,^**-'^ clinical notes,* experimental settings,^'-^"' descriptive studies,**'^^**:*' or experienee in the field*'" instead of methodologically qualified studies. Thus, the objective of this systematic review and meta-analysis was to determine the analgesic effectiveness of IFC compared with control, placebo, or other treatment tnodalities for decreasing pain in patients with painful musculoskeletal conditions.

apta,org). The literature search procedure was complemented by mantially searching the bibliographies of the identified articles for key authors and journals.

Study Selection and Inclusion/Exclusion Criteria

Studies that met the following criteria were considered for inclusion: (1) randomized controlled trials (RCTs) from jotirnal ptiblications in the English language (because the clinical application of IFC; often is based on its coadjtitant effeet, studies in which IFC was used as a eointervention also were included); (2) studies of male and female htimans between 18 and 80 years of age; (3) sttidies of subjects clinically diagnosed with a painftil mtisctiloskeletitl condition, such as mii.scle (eg, low back pain, neck pain), soft tisstie (eg, tenilinosis/ tendinitis), or joint (eg, osteoarthritis) disorders; (4) regarding the type of interventions, all randomized comparisons of isolated orcoadjutant IFC applications verstis placebo, control, another phy,sical therapy intervention, or another type of intervention; and (5) studies in which the otitcome of interest was pain, as measured by the use of a visual analog scale (VAS) or numeric pain rating scale (NRS), Exclusion criteria for this study were: (1) studies based on animal data, (2) studies published in languages other than English, and (3) studies ineluding subjects who were healthy in experimental settings.

Method
Search Strategy
Relevant sttidies of IFC in musetiloskeletal pain management from 1950 to February 8, 2010, were obtained through an extensive computerized search of the following bibliographic databases; MEDLINE (1950 through week 4 of 2010), EMBASE (1988 through week 5 of 2010), CINAHL (1970 through February 8, 2010), Scopus (1970 through Febmary 8, 2010), Cochrane Ubrary (1991 tlinuigli the first quarter of 2010), ISI Web of Science (1970 through February 8, 2010), and PEDro (Physiotherapy Evidence Database) (1970 through Febrtiary 8, 2010), Tlie key words "interferential," "interferential therapy," "interferential current," "musculoskeletal pain," "electrotherapy," "electro analgesia," "muscle paiti," "low back pain," "shoulder pain," "hip pain," "knee pain," "neck pain," "osteoarthritis pain," and "joint pain" were used in the search, including combinations of these words. For details regarding the search terms and combinations, see eAppendix 1 (available at ptjoumal.

Available With This Article at ptjournal.apta.org

eAppendix 1 : Search Results From the Different Databases eAppendix 2: Critical Appraisal Sheet for Included Studies The Bottom Line Podcast Audio Abstracts Podcast This article was published ahead ot print on July 22, 2010, at ptjournal.apta.org.

Data Extraction and Quality Assessment

Two independent reviewers screened the abstracts of the publications found in the databases. The reviewers analyzed all articles initially selected by the abstract or title for the inclusion and exclusion criteria. Each criterion was graded on a yes/no basis. In case of diserepancies between reviewers regarding whether a particular article met a criterion, the ratings were compared and the
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criterion forms were discussed until a consensus was reached. A critical appraisal was condticted to determine the methodological quality of the final selected studies. We ased 7 scales (ie, Delphi List, PEDro, Maastricht, Maastricht-Amsterdam Ust, Bi/./ini, van Tulder, and Jadad) commonly tised in the physical therapy held to evaluate the methodological quality of the incltided studies, compiled in a set of .^9 items.'- These items were grouped itito S categcv ries: patient selection, blinding, intervention, outcomes, and statistics. Based on a recent systematic review,*'^ no one scale effectively determines the overall methodological cjuality ol' indivickial sttidies. I'or this reason, we used all of them in a compiled fashion. The articles were evaluated on the basis of only the information available in the articles using the critical appraisal sheet (eAppendix 2; available at ptjoiirnal.apta.org). Eor each item listed on the critical appraisal sheet, a score of 1 was given when the item was incltided in the article, and a score of 0 was given when the item was not included or the information provided by the authors was not sufficient to make a clear statement. In cases where the study did not consider a particular item, the item was marked as not applicable on the critical appraisal sheet. The scoring for each study was calculated by dividing the number of items included by the number of applicable items. Finally, each study was graded as having low, moderate, or high methodok)gical quality' based on how many items from the critical appraisal were met. The cutoff was determined as follows: 0-0.40=low methodological c|uality, 0.41-0.70= moderate methodological quality, and 0.71-1.00 = high methodological quality. This criterion was determinetl a priori to the quality assessment. Similar criteria for cutoffs have been used in correlational studies to determine reference values for quality of association or agreement.^^" The critical appraisal was independently completed by the 2 reviewers, and the results were compared. At this stage, the intraclass correlation coefficient (JCC) was calculated using SPSS version 17 software* in order to determine the agreement between the reviewers for article grading. Any discrepancies were settled throtigh discussion. Data Synthesis and Analysis Studies investigating similar outcomes and interventions and those providing clear quantitative data were grouped, evaluated for heterogeneity, and pooled, if possible. Wlien combining outcome data was not possible, narrative, descriptive, and qualitative summaries were completed. In the present study, a metaanalysis was performed to quantily the pooled effect of IFC alone or as an adjunct treatment on pain intensity' when compared with placebo, control group, or compari.son intervention. Because the pooled effect was based on the results of the VAS or NRS, the tnean difference was used to quantify the pooled effect. RevMan 5.0 software^ was used to summarize the effects (ie, pooled mean differences) and construct the
* Copenhagen, Denmark: The Nordic c:ochrane Centre, The Cxichrane Collaboration, 2008.

SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

The Bottom Line What do we already know about this topic?

Despite the widespread use of interferential current (IFC), information about its clinical effectiveness is limited and controversial. The painreducing effect of IFC, when applied alone or as part of a multimodal treatment plan to treat musculoskeletal pain, has not been determined.

What new information does this study offer?

The application of IFC as part of a multimodal treatment plan appears to produce a modest pain-relieving effect in a broad spectnim of actite and chronic musculoskeletal conditions when compared with tio treatment or placebo. In addition, the potential long-term effects of IFC; versus placebo observed at 3-month follow-up are of interest. Interferential current alone was not significantly better than placebo and other interventions (ie, manual therapy, traction, or massage). However, heterogeneity across the included studies, along with methodological limitations identified in these studies, prevents conclusive statements regarding the analgesic efficacy of IFC.

If you're a patient, what might these findings mean for you?

If you are seeking pain treatment, IFC could be potentially effective in redticing musculoskeletal pain; however, its application should be included as part of a multimodal treatment plan.

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ies not published in the English language"" -^^; (4) the absence of pain outcomes'^^-'"*; (5) randomized trial not used^"-^~ ""'-'"; (6) use of a ctirrent other than IFC'"*^""; (7) tise of animal data'"; and (8) unavailability of the ftill text of the article. " -- " ' At the end of the critical appraisal stage,
there was an agreement of K = . 8 3
2,235 articles screened 2,081 articles excluded on the basis of the title and abstract

2,231 articles identified through database search (CINAHL, Cochrane Library, EMBASE, MEDLINE, PEDro, Scopus, Web of Science)

4 articles identified through manual search

between the 2 raters. This ICC valtie is ct)nsidered as "excellent" agreement according to the approach described by McDowell."''

77 articles excluded: 154 full-text articles assessed for eligibility (57 repeated): 97 finally selected

Characteristics of the Studies

23 24 10 9 5 3 2 1 Not clinical studies Descriptive studies Not written in English No pain outcome included Not a randomized trial No full text available Did not truly assess IFC Animal data

20 studies included in the qualitative synthesis

14 studies included in the quantitative synthesis (meta-analysis)

4 5 2 1 1 1

Knee osteoarthritis pain Low back pain Fibromyalgia/myofascial pain Jaw pain Frozen shoulder pain Bicipital tendinitis pain

Figure 1.
Study screening process. IFC=interferential current therapy.

All 20 studies reviewed in detail were RCHs that examined the pain-reducing effectiveness of IFC. These studies analyzed the effects of IFC for several diagnoses considered to be either acute or chronic painful conditions. Only 6 articles (30%)'"^' ''"''"" ">^ examined the cUnical analgesic effectiveness of IFC as a single thenipetitic modality. 'Pie rest of the articles incltided the application of IFC as a cointervention along with other therapeutic alternatives such as exercise,"''''*'*''"-'""'^f''-'<' shortwave diatliermy,^''^'' hot ice,"*" myolascial release,^^ netironiiiscular electrical stimtilation,'*- infrared radiation,"*' and tiltra.sotind.'"<^''''^ Details of the sttidies' characteristics are shown in Table 1.

forest plots for all comparisons. For this analysis, the 95% confidence interval (CI) was used. A chi-square test for heterogeneity was performed (P<. lO).*"* In the presence of clinical heterogeneity in the study population or intervention, the DerSimonian and Laird random-effects model of pooling was used based on the assumption of the presence of intersttidy variability to provide a more conservative estimate of the trtie effect.'*"'*"' If there was relative homogeneity, a fixed-effects model was used to pool

were selected as potential studies of interest ba.sed on abstract review (Fig. 1). After full article review, only 20 studies were deemed to ftilfiU the initial selection criteria.^^-^'*' The kappa agreement between the reviewers in selecting articles after applying the inclusion and exclusion
criteria was perfect at K = 1 . 0 .

Methodological Quality of the Studies

The results of the critical appraisal for the selected studies are presented in Table 2. Three of the 20 studies were considered to be of high methodological quality. 14 studies were considered to be of moderate quality, and 3 studies were considered to be of poor quality. Even though the quality of most of the studies was rated as acceptable (17 studies were rated as being of moderate or high qtiality), there are some points regarding quality that need to be highlighted. Study fiaws regarding patient selection were mainly related to description and appropriateness

Results
A total of 2,235 articles were found in the database search. Of these, 154
1222 Physical Therapy

Seventy-seven studies were rejected after applying the inclusion and exclusion criteria. The primary reasons for exclusion from the sttidy were: (1) the tuse of subjects who were healthy Ln an experimental setting^'-"''^^-^; (2) descriptive studies in the form of case reports, dissertations, or clinical '; (3) sttid-

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of tbe randomization procedure and concealment of allocation, witb only 9 and 5 of tbe studies meeting tbese criteria, respectively. Items related to blinding were not acbieved by tbe majority of tbe studies. Only 3 of tbe studies used a double-blinded design. Testing subjects' adberence to intervention or baving adequate adberence was anotber issue tbat was not accomplisbed by many studies (only 8 and 6 studies, respectively). Furtbermore, adverse effects were reported in only 3 of tbe studies, and none of tbe studies provided details of tbe follow-up period. Despite tbe fact tbat tbe adequate bandling of dropouts is considered an important metbod used to prevent bias in data analysis, only 11 of tbe analyzed studies included information regarding tbe rate of witbdrawals/dropouts. Tbe outcome measures were not described well in terms of validity, reliability, or responsiveness.

Regarding statistical issues, it was uncertain wbetber sample size was adecjuate in 15 of tbe studies. Intentionto-treat analysis was used only in 11 of tbe studies. Finally, it also was imclear wbetber extraneous factors sucb as equipment calibration or medications during tbe study could affect tbe treatment responsiveness for IFC. For example, only 2 studies (10%) reported tbat tbe IFC equipment was calibrated during tbe study procedure. ies49.52.5i.55.5(,.6().63 compared IFC witb anotber intervention sucb as manual IFC and Type of Pain tberapy or exercise.
Management

week of tberapy. One triaP' studied tbe effect of IFC on knee osteoartbritis, and tbe otber trial''' studied tbe effect of IFC on temporomandibular joint pain. One study"*' was rated of moderate metbodological quality, and tbe otber study*'' was rated of Meta-analysis Results poor quality.''' In tbis comparison, Fourteen studies were included in tbe botb studies bad opposite results remeta-analysis (Fig. 1);-.')-^MM.M.(,-M, garding tbe effectiveness of IFC witb an overall sample size of 1,114 wben compared witb a placebo patients. Six studies were excluded group (Fig. 2). Tbe pooled mean diffor tbe following reasons: informa- ference (MD) obtained for tbis analtion regarding data variability (ie, ysis was 1.17 (95% CI= 1.70-4.05). mean and standard deviation) was Tbese results indicate tliat IFC alone not present,^^'' tbe unit of variabil- was not significantly better tban plaity included was different tban tbe cebo at discbarge. standard deviation (ie, interquartile range, median),^^*^-^ tbe comparison Comparison 2: IFC Alone Versus included in tbe trial was not relevant Comparison Group on Pain for tbe study's purpose,'" and tbe Intensity at Discharge interventions included in tbe trial Two studies'*''''^ were included in were too beterogeneous^ ' (ie, IFC, this comparison. One study*'^ meainfrared radiation, sbortwave dia- sured outc(jmes at discbarge after 2 tbermy, and 2 drugs [sodium byal- to 3 weeks of treatment, and tbe uronate and bylan G-F 20]). otber study'^'' measured outcomes after 8 weeks. One triaP'' studied tbe Tbe 14 selected studies were cbosen effect of IFC on acute low back pain, because tbey provided complete in- and tbe otber trial*'^ studied tbe efformation on tbe outcomes evalu- fect of IFC on cbronic low back pain. ated and bomogeneity regarding out- Botb studies were of moderate metbcome measures. Of tbese studies, 4 odological quality. In tbis comparistudies^'<-^''>M addressed tbe anal- son, botb studies agreed tbat IFC was gesic effect of IFC alone and 10 not significantly better tban manual studies47-49.5.52.53.55,6o,64 - 66 e v a l u a t e d tberapy or traction and massage tbe effect of IFC applied as adjunct (Fig. 3). Tbe pooled MD obtained for in a multimodal treatment protocol. tbis analysis was -0.16 (95% In addition, of tbese 14 studies, 3 CI=-0.62, 0.31). Tbese results indistudies^''^''66 compared tbe effective- cate tbat IFC alone was not signifiness of IFC witb a control group, cantly better tban any of tbe compar6 studies"'^'"-'*'^''^''' investigated isons at discbarge from tberapy. IFC against placebo, and 7 studComparison 3: IFC as a Supplement to Another Treatment Versus Control Group on Pain Intensity at Discharge

jaw pain,^'' and myofascial syndrome pain.^"^ In contrast, tbe analysis of IFC in acute pain included just 4 articles, 3 of tbem related to acute low back pain and 1 to postoperative knee pain.

Tbe effect of IFC bas been studied predominantly in patients witb cbronic painful conditions (16 of 20 trials examined). Tbese conditions included knee osteoartbri,M,s9 clironic low back 5 sboulder soft tissue pain,^s.6o.62 fibromyalgia,^" cbronic
1228 Physical Therapy

Tbree studies'*^ '^*'''' were included in tbis comparison. Two studies"*^'^^ used a 4-week discbarge period, and Two studies^*''' were included in one study*'*' used a one-day discbarge tbis comparison. One study'^ mea- period. One triaP^ studied tbe effect sured outcomes at discbarge after 4 of IFC on knee osteoartbritis, anweeks of tberapy, and tbe otber otber triaP^ studied tbe effect of IFC study*'' measured outcomes after 1 on frozen sboulder, and tbe tbird triSeptember 2010

Comparison 1 : IFC Alone Versus Placebo Group on Pain Intensity at Discharge

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study or Subgroup Defrin et al,^" 2005 Taylor et al,'^ 1987 Total (95% CI) IFC Alone Mean 2.1 1.75 SD 0.5 1.96 Total 12 20 32 Mean -0.5 2.08 Placeb> SD 0.7 1.53

Total Weight
9 20 29 51.4% 48.6% 100.0%

Mean Difference IV, Random, 95% CI 2.60(2.06, 3.14) -0.33 (-1.42, 0.76) 1.17(-1.70,4.05)
1

Mean Difference IV, Random, 95% CI

Heterogeneity: tau^= 4.10, )(^ = 22.i3, df=-\ (P <.OOOO1), i^ = 96% Test for overall effect ^=0.80 (P=.42)

1 1 10 5 0 Favors Placebo

1 1 5 10 Favors IFC

Figure 2.
Forest plot of comparison: interferential current therapy (IFC) alone versus placebo treatment on pain intensity at 1 week and 4 weeks (data presented as change scores). IV=inverse variance, 95% C l = 9 5 % confidence interval.

aK'f' studied the effect of IFC on acute iow back pain. Two studies included in this comparison were of moderate methodological quality,'^'^'' and one study was considered to be of high quality.''^' In this comparison, the 3 studies tended to significantly favor IFC applied as a cointervention when compared with the control group (Fig, 4), The pooled MD obtained for this analysis was 2,45 (95% CI=1.69, 3.22). Thus, IFC applied as a cointervention was more than 2 points better, as measured with the VAS, in reducing pain intensity when compared with a control group in these conditions.
Comparison 4: IFC as a Supplement to Another Treatment Versus Placebo on Pain Intensity at Discharge

Five studies'*^''"'^'*,64,65 were included in this comparison. Different times of discharge were used in the
IFC Alone study or Subgroup Hurley et at^" 2004 Werners et al,<^^ 1999 Total (95% CI) Mean 2.13 0.42 SD 2.49 1.35 Total 65 50 115

studies, ranging from 2 weeks'''*'''' to 4 weeks,**^ '^" " ^ ^ Mean difference to pool the data was used. In addition, 95% CI and the random-effects model were chosen. In this comparison, 3 studies^^^"'^* of moderate quality tended to significantly favor IFC as a cointervention when compared with placebo. One study^'^ of moderate methodological quality tended to significantly favor the placebo group. One study of moderate quality did not favor either IFC as a cointervention or placebo (Fig. 5, upper part),^''^ The pooled MD obtained for this analysis was 1,60 (95% CI=-0,13, 3.34). This finding indicates that although IFC as a cointervention was statistically significantly better than a placebo at decreasing pain intensity at discharge in conditions such as osteoarthritis, chronic low back pain, and fibromyalgia, IFC tended to reduce pain in these conditions when compared with a
Comparison

placebo condition. In addition, the heterogeneity among studies was 1^ = 96%, which is considered substantial according to Cjchrane group guidelines.^"* Therefore, these results should be interpreted with caution. In this comparison, 2 studies''''''"* provided follow-up data (3 months). Thus, an analysis at the 3-month follow-up was performed (Fig, 5, lower part). The pooled MD obtained for this analysis was 1.85 (95% CI=1.47, 2.23). The 2 studies significantly favored IFC when compared with the placebo. This finding indicates that IFC as a cointervention was better than a placebo at tleereasing pain intensity at the 3-month follow-up.

Mean 1.99 0.7

SD 2.5 1.49

Total
63 51 114

Weight
29.1% 70.9% 100.0%

Mean Difference IV, Random 95% CI 0.14 (-0.72, 1.00) -0.28 (-0.83, 0.27) -0.16 (-0.62, 0.31)

Mean Difference IV, Random, 95% CI

Heterogeneity: tau-'-O.OO, ; ^ - 0 . 6 4 , d = 1 (P=.42), 1^-0% Test for overall effect: z=0.66 (P=.51)

10 5 0 Favors Comparison

5 10 Favors IFC

Figure 3.
Forest plot of comparison: interferential current therapy (IFC) alone versus comparison treatment on pain intensity at 3 weeks and 8 weeks (data presented as change scores). IV=inverse variance, 95% CI=95% confidence interval.

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Interferential Current Therapy in Management of Musculoskeletal Pain

IFC Therapy as Supplement study or Subgroup Cheing et al,^' 2008 Defrin et al,*" 2005 Lau et a l , " 2008 Total (95% Cl) Heterogeneity: tau^=O 31; ; ^ - 6 . 7 6 , df-2 Test for overall effect; !=6.28(P<.00001) Mean 3.02 2.1 2.2 SD 1,94 0.5 1.65 Total 23 12 55 90 (P- 03), l^ = 70%

Control Croup Mean 0.08 -0.7 0.4 SD 2.13 0.7 1.5

Mean Difference IV, Weight

23.0% 38.9% 38.1% 100.0% Random, 9 5 % CI 2.94(1.78,4.10) 2.80(2.24, 3.36) 1.80(1.21,2.39) 2.45(1.69, 3.22) Mean Difference iV, Random, 9 5 % CI

Total
24 8 55 87

1 1
10 5 () Favors Control

5 10 Favors IFC

Figure 4.
Forest plot of comparison: interferential current therapy (IFC) as a supplemental treatment versus control treatment on pain intensity at 1 day and 4 weeks (data presented as change scores). IV=inverse variance, 95% CI = 95% confidence interval.

Comparison 5: IFC as a Supplement to Another Treatment Versus Comparison on Pain Intensity at Discharge live studies'''"*-^''^''''''" were included in this comparison (Fig. 6). Different times of discharge were used, ranging from 1 day"*"* to 4
IFC Therapy as Supplement study or Subgroup Mean SD Total

weeks''^^^^'" to 2 months. "'^ Two studies''''^- evaltiated the effectiveness of IFC as a cointervention for knee osteoarthritis, 2 studies'"^"' evaluated the effectiveness of IFC as a cointervention for shoulder pain, and 1 study^^ evaluated the effective-

ness of IFC as a cointervention for myofascial pain. One study'''* compared IFC plus hot packs, active range of motion, and myofascial release with 5 different treatment modalities; thus, different analyses were nin in order to deter-

Placebo Mean SD Total Weight Mean Difference IV, Random, 9 5 % CI Mean Difference IV, Random, 9 5 % CI

3,1,1 Pifi dl diiclidrge (1 week, 2 weeks, 4 weeks) Zambito et a l , " 2007 Zambito et al,'* 2006 Adedoyin et al,'" 2002 Defrin et al,** 200S Almeida et a l , " 2003 Subtotal (9S% Cl) 1.9 1.8 6,87 2.1 4,2 0.78 1.27 1,2 0.5 2 35 45 15 12 9 116 2.6 1.7 4.5 -O.S 0 1 1,65 2,79 0.7 1,82 35 30 15 9 8 97 21,5% 21,0% 18,6% 21.3% 17,6% 100,0% 0 . 7 0 ( - l , 1 2 , -0,28) 0,10 (-0,60, 0,80) 2.37(0,83, 3,91) 2,60(2.06, 3.14) 4.20(2.38,6.02) 1.60 (-0.1 3, 3,34)

- .

Heterogeneity: tau' = 3.59, ^^=112.03, df=4 (P<.00001), 1^=96% Test for overall effect: 7=1.81 (P=.O7) 3,1.2 Pain up to 3-month follow-up Zambito et a l , " 2007 Zambito et al,'* 2006 Subtotal (9S% CI) 3,8 3.2 1,1 1,64 35 45 80 2 1,2 0,71 1,7 35 30 65 76,1% 23,9% 100.0% 1.80(1.37,2.23) 2.00(1.23,2,77) 1,85(1,47,2.23)

I I
1

Heterogeneity: tau^=O.OI3, ;^=0.02, df=\ (P=.66), 1^= 0% Test for overall effect: z ' 9 . 5 7 (P<,00001)

I I

in S 0 Favors Placebo

5 10 Favors IFC

Figure 5.
Forest piot of comparison: interferential current therapy (IFC) as a supplemental treatment versus piacebo treatment on pain intensity at 1-week, 2-week, 4-week, and 3-month follow-ups (data presented as change scores). IV=inverse variance, 95% C l = 9 5 % confidence interval. Volume 90 Number 9 Physical Therapy 1231

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Interferential Current Therapy in Management of Musculoskeletal Pain

IFC as Supplement Mean 5.07 SD 1.39 Total 16 Comparison Mean 4.74 SD 1.14 Total 15 Weight 20.1%

study or Subgroup Adedoyin et al,"*" 2005 urch et a l , " 2008 Cheing et al,^' 2008 Hou et a l , " 2002 (Bl) Taskaynatan et al,'" 2007 Total (95% CI)

Mean Difference iV, Random, 9S<>/o CI 0.33 (-0.56, 1.22)

Mean Difference 1)/ , Random, 95<>/o CI

1-

2.79 3.17

1.32 1.94

53 23

2.32 3.04

1.54 1.97

53 24

23.1% 18.0%

0.47 (-0.08, 1.02) 0.13 (-0.99, 1.25)

r
r

3.34

1.14

0.77

1.8

21

18.5%

2.57(1.50, 3.64)

0.8

1.49

21

1.4

1.59

26

20.2%

-0.60 (-1.48, 0.28)

122

139

100.0%

0.55 (-0.33, 1.44)

>

Heterogeneity: tau^ = 0.80, x"-= 20.86 df-A (P -.0003) 1^-81% Test for overall effect: 2=1.22 (P=.22)

-10-5 0 Favors Comparison

5 10 Favors IFC

Figure 6.
Forest plot of comparison: interferential current therapy (IFC) as a supplemental treatment versus comparison treatment on pain intensity at 1 day, 2 weeks, 4 weeks, and 2 months (data presented as change scores). IV=inverse variance, 95% CI = 95% confidence interval. Bl = h o t pack + active range of motion.

manual therapy, traction, massage) at discharge from physical therapy treatment. However, few included studies (27%) examined the clinical analgesic effectiveness of IFC as a single therapeutic modality, and most did not focus on a specific musIn this comparison, no clear trend culoskeletal disorder. We also obfavoring either IFC as a cointerven- served differences in length of treattion or the comparison treatments ment (ie, 1, 2, 3, and 8 weeks) and was observed for any of the analyses type of pain (ie, acute or chronic), performed (Fig. 6). The pooled MD indicating no consensus on optimal obtained for the various analyses was treatment parameters, which poten0.55 (95% CI=-0.33, 1.44). The tially contributed to the nonsignifimean difference indicated that IFC as cance of the results. a cointervention was no better than other conventional interventions Analysis of the Analgesic Effect of such as exercise, transcutaneous IFC as Part of a Multimodal electrical nerve stimulation, or ultra- Protocol (Cointerventions) sound plus hot packs at decreasing An important factor in this metapain intensity at discharge. analysis was the inclusion and analysis of studies including the applicaDiscussion tion of IFC as a cointervention in a Analysis of the Analgesic multimodal treatment protocol. This Effect of IFC Alone decision was clinically sound beThe results of this meta-analysis indi- cause IFC is used mainly as an adcate that IFC applied alone as an in- junct treatment. The results of this tervention for musculoskeletal pain study indicate that IFC as a cointeris not significantly better than pla- vention is significantly better than cebo or comparison therapy (ie. control and placebo for reducing
1232 Physical Therapy Volume 90 Number 9

mine the effect of IFC as a cointervention when compared with all of these modalities (sensitivity analysis). We used the MD to pool the data. In addition, 95% CI and the random-effects model were chosen.

chronic musculoskeletal pain at discharge and at 3 months posttreatment, respectively. The pooled effect for IFC as a cointervention versus control was 2.45 on the VAS (95% CI=1.69, 3.22). According to some authors, this change is considered a clinically meaningful effect for acute painful conditions.'""-"'^ However, in chronic pain, a more stringent criterion seems to operate because a relative pain reduction of 50% or at least 3 cm on a VAS has been recommended for detecting a clinically successful pain reduction.'^" 1^' In addition, when IFC as a cointervention was compared with placebo at discharge, there was no statistically significant difference between the groups. At 3-month follow-up, IFC as a cointervention obtained a better effect on the VAS, although less pronounced than when compared witli a control group (pooled effect=1.85, 95% CI=1.47, 2.23). Thus, it seems that although IFC applied as a cointervention may have a modest analgesic effect, the magniSeptember 2010

Interferential Current Therapy in Management of Musculoskeletal Pain

tude of the effect is not large enough to be considered clinically relevant wben compared witb placebo or comparison interventions. Because tbis is tbe first meta-analysis looking at tbe analgesic effect of IFC, direct comparisons cannot be made. In a previous study, Jobnson and Martinson'-- concluded tbat transcutaneous electrical nerve stimulation, used mainh' as an isolated intervention, provided significant pain relief wben compared witb a placebo intervention in a variety of chronic mu.sculoskeletal conditions. Althougli metbodological differences are present between botb metaanalyses, some similarities sucb as tbe final sample sizes included, tbe focus on cbronic musculoskeletal conditions, and clinical beterogeneity make tbe compadst^n between these 2 meta-analyses worth considering. on IFC; effectiveness, especially in cbronic pain. Additionally, IFC bas not been applied using a consistent treatment protocol. For example, similar AMF settings (>80 Hz) were considered for treating either acute'*''"*" or chronic'"'"'"'^'''*''*'''* conditions. Moreover, under the same condition (eg, osteoarthritis), the authors inconsistently applied fixed AMF frecjuencies (ie, 80 Hz) ''' or sweep AMF frequencies (ie, 1-150 Hz, 30-60 Hz, 0-100 Hz)."*^"*'"*'^ Althougb experimental evidence bas challenged the role of AMF as the main analgesic component of IFC;,^*'-^"""*'-" inconsistency in tbe use of tbis parameter in clinical settings warrants consideration. Based on tbe current evidence, recommendations for optimal dosage wben using IFC are not clear. It .seems, bowever, tbat clinical evidence supports tbe fact tbat AMF should not be the most important parameter for clinical decision making. This fact has been corroborated by recent experimental evidence as well."" Instead, tbe use of a sensory level of intensity appears to be a consistent factor for tbe majority of the studies. Altbougb some variations in tbe number of treatments and tbe treatment time exist, it seems tbat 10 to 20 minutes of application for 2 to 4 weeks witb a total of 12 sessions is tbe most common treatment protocol for IFC 17-51.Si.S4.S9.60.62.6..65 Adverse Effects An important .safety feature wben applying electrotherap) modalities is the report of adverse effects. Although IFC; is con.sidered a safe modality, its application has been associated witb local adverse effects sucb as blisters, burns, bruising, and swelling.'-' '-" Interestingly, only 3 studies"*-^ '"'"" included reports of adverse effects as a re.sult of IFC treatment. Two studies'*'' '"" reported no complications, and one study"^-^ reported tbe presence of muscle soreness in one subject. Reporting adverse effects must be mandator>, not only for tbe safety' of patients, but also for tbe professional integrity of tberapists.

Methodological Elements Affecting Observed Effect

Even thougb the c|uality of tbe trials appraised generally was moderate, tbere are some metbodological biases common to these studies that could have bad an impact on the Some factors regarding IFC treatresults. Selection bias could have exment may have accounted for tbe isted, as only 9 trials reported appromodest effect size observed. For expriate randomization and only 5 triample, althougb the stimulation of als reported concealment of small-diameter fibers bas been demallocation. Anotber potentially imonstrated to produce a more positive portant bias was tbe lack of blinding, effect for cbronic pain wben comespecially of tbe patients (9 studies) pared witb tbe stimulation of largeand assessors ( 11 studies). I be outdiameter fibers (A),"*' the included come measure for tbis meta-analysis studies, regardless of the type of was pain, which is a subjective outpain, used stimulation parameters come and dependent on the subthat were related mainly to the stimject's report. Trials without approulation of A fibers and the pain gate priate randomization, concealment mechanism." '"'-'*"^^''^''-'^'"f'^ Alof allocation, and blinding tend to thougb tbe stimulation of largereport an inaccurate treatment effect diameter fibers is acknowledged to In tbis systematic review, 16 out of compared witb trials that include produce a fast onset of analgesia, an 20 studies evaluated tbe role of IFC; tbese features.'-'' '^' important sbortcoming is its brief an- in cbronic ratber tban acute pain. algesic effect.'^*-'^'* Thus, it is plau- Based on tbis fact, it seems tbat IFC sible tbat in chronic pain, which was bas been applied more often in tbe (^tber potential biases that could the dominant condition in tbis re- management of cbronic painful con- have affected tbe observed effects view, tbe effectiveness of IFC under ditions. Interestingly, and apparently were tbe lack of an appropriate samtbese stimulation parameters may in contrast to current clinical prac- ple size (only 5 of tbe trials reported bave been attenuated, resulting in a tice in wbicb IFC; is used mostly for adequate sample size) and tbe inapsmall effect in reported pain reduc- sbort-term pain relief, this meta- propriate bandling of witbdrawals tion. Furtber researcb is needed to analysis provided information re- and dropouts (only 11 trials used evaluate tbe effect of noxious stim- garding potential positive long-term intention-to-treat analysis). Reportulation (eg, small-diameter fibers) benefits from IFC.""'^ ing clinical significance of results has become a relevant issue to demVolume 90 Number 9 Physical Therapy 1233

September 2010

Interferential Current Therapy in Management of Musculoskeletal Pain onstrate the effectiveness of an in- mation about the selected studies. tervention. Clinical significance pro- The 20 RCT articles included in this vides the clinician with adequate review covered a broad spectrum of information regarding the clinical im- acute and chronic musculoskeletal pact of an intervention because it can conditions. Interferential current identify when a meaningftil change is therapy was analyzed as isolated inproduced.'*2 Despite this message, tervention, as well as part of a multhe report of clinically meaningftil timodal treatment plan. In addition, changes in the present study was the study provided multiple analylargely neglected, with only 3 studies ses, including the comparison beincluding this c tween IFC and placebo, the comparison between IFC and control, and The present study used a compila- IFC contrasted to different types of tion of items from all of the scales interventions. used in the studies in the physical therapy literature. Although some of Limitations the scales used in physical therapy Outcome level. A main limitation (ie, PEDro, Jadad) have been vali- of this meta-analysis is the presence dated in some way, our recent anal- of clinical heterogeneity in the study ysis of health scales used to evaluate population in most of the comparimethodological quality determined sons, casting some doubt on the vathat none of these scales are ade- lidity of our results. quate for that use alone.^^ Therefore, it was decided that all of these scales Study and review level. A potenwould be used to assess methodolog- tial limitation is the omission of ical quality, and we used a compila- non-English-language publications; tion of items to provide a compre- however, English is considered the hensive and sensitive evaluation of primary scientific language. It also the quality of individual trials. How- has been reported that languageever, further research investigating restricted meta-analyses only minimethodological predictors for deter- mally overestimate treatment efects mining trial quality in physical ther- (~2% on average) compared with apy is needed. language-inclusive meta-analyses. ' ' ^ Therefore, language-restricted metaanalyses do not appear to lead to Summary of Evidence As an isolated treatment, IFC was not biased estimates of intervention efsignificantly better than placebo or fectiveness.'^^ '^' Applicability of reother interventions. Conversely, sults about the isolated effect of IFC when included in a multimodal treat- on musculoskeletal pain also is limment plan, IFC displayed a pain- ited, as only 4 studies addressed this relieving effect (VAS reduction of issue. Another important limitation over 2 points) compared with a con- is that this study included only pain as an outcome measure. It would be trol condition. important to know whether outcomes such as disability or ftmction Strengths This meta-analysis is the first system- could have been modified by the apatic investigation regarding the pain- plication of IFC. reducing effectiveness of IFC on musculoskeletal pain. A comprehen- Conclusions sive search was made of all the pub- Implications for Practice lished research in this area over a Interferential current therapy inwide range of years (1950-2010). In cluded in a multimodal treatment addition, authors were contacted in plan seems to produce a painan attempt to have complete infor- relieving effect in acute and chronic
1234 Physical Therapy Volume 90 Number 9

musculoskeletal painful conditions compared with no treatment or placebo. Interferential current therapy combined with other interventions was shown to be more effective than placebo application at the 3-month follow-up in subjects with chronic low back pain. However, it is evident that under this scenario, the unic|ue effect of IFC is confounded by the impact of other therapeutic interventions. Moreover, it is .still unknown whether the analgesic effect of IFX ; is superior to that of these concomitant interventions. When IFC is applied alone, its effect does not differ from placebo or other interventions (ie, manual therapy, traction, or massage). However, the small number of trials evaluating the isolated effect of IFC:, heterogeneity across studies, and methodological limitations identified in these studies prevent conclusive statements regarding its analgesic efficacy. Implications for Research Because only 4 studies that evaluated the isolated effect of IFC were identified, and these studies had mixed results, further research examining this issue is needed, ideally in homogeneous clinical samples. Further research also is needed to study the effect of IFC on acute painful conditions. Also of interest would be the study of the effect of IFC in chronic conditions using a theoretical framework for the selection of parameters associated with suprasegmental analgesic mechanisms (ie, noxious stimulus) instead of sensory stimulation.
Mr Fuentes, Dr Armijo Olivo, and Dr Cross provided concept/idea/research design and writing. Mr Fuentes and Dr Armijo Olivo provided data collection and analysis. Mr Fuentes provided project management. Dr Magee and Dr Cross provided consultation (including review of manuscript before submission). This study was supported by the Alberta Provincial CIHR Training Program in Bone and

September 2010

Interferential Current Therapy in Management of Musculoskeletal Pain

joint Health, an Izaak Walton Killam scholarship to Dr Armijo Olivo from the University of Alberta, the Provost Doctoral Entrance Award to Mr Fuentes from the University of Alberta, the Canadian Institutes of Health Research, the government of Chile (MECESUP Program), the University Catholic of Maule, Chile, and the Physiotherapy Foundation of Canada through an Ann Collins Whitmore Memorial Award to Dr Armijo Olivo. This article was received October 13, 2009, and was accepted May 14, 2010. 13 Kroeling P, Gross A, Houghton PE, Cervical Overview Group. Electrotherapy for neck disorders. Cochrane Diitahase of Systematic Keriews. 2OO5;2: CDOO4251. 14 Checchia GA, Halboni M, Franchi F, et al. The use of vector field interference currents in the treatment of low back pain associated with muscle tension |in Italian]. Kiabititazione. 1991;24:43-49. 15 Checchia GA, Pezzoli R, Gorini L, etal. Flectrotherap)' in the treatment of shotilder pain |in Italian]. Kiabilitazione. 1991;24:121-127. 16 Gelecek N, Akyol S, Algun C. The comparison of the effect of interferential current and magnetotherapy applications on pain in the patients with ostearthritis of the knee. Eizyoterapy Rehabititas)'on. 2000; 11:30-.37. 17 Kuppardt H, Borgmann II, Kanzler I, et al. Experiences of the application of a stimulation current of medium frequency in chronic low back pain ]in German]. Z Physiother. 1991 ;43:151 -154. 18 Mucha C. Results of a controlled trial to physical therapy of the epicondylopathia hunieri ]in Slovak]. Rehahititacia. 2002; 35:28-37. 19 Mucha C, Wannske M. Results of a controlled trial to physical therapy of the epicondylopathia liumeri ]in Ciermanl. Zeitschrift fur Physikatische Medizin Batneoiogie Med Klimntoltigie. 1989; 18: 1.-7-147. 20 Raimundo A, Brandal) D, Lucena K. Comparative study of the analgesic effect between frequencies of interferential current in the fibromyalgia ]in Portuguese]. fisioterapia em .Moriinenla. 2()()4;17: 65-72. 21 Tauchmannova H. Treatment of inflamniatoiy rheumatic di.seases with interferential currents. Fysiatricky a Reumatotogicky Vestnik. 1974:52:93-96. 22 lian Y, Kang Lti. Rehabilitation unit therapy for lumbar di.sc protrtision: evaluation of short- and long-term clinical effect and patient compliance, /o//;/;/ ofCtiniciil Rehiibititatire Tissue Engineering Research. 2007; 11:9902-9905. 23 Gerber JM, Herrin SO. (Conservative treatment of calcine trochanteric bursitis. J Maniputatire Physiot 77)t'/.1994;17: 250-252. 24 Moore MK. 1 Ipper crossed syndrome and its relationship to cervicogenic headache. / Maniputatire Physiot Tf.ier. 2OO4;27;4l4-42O. 25 lruscott B. Interferential therapy as a treatment for classical migraine: case reports. AustJ Physiotiu-r. 1984:30:33-35. 26 Al Abduhvahab SS, lkatti AM The effect of prone position and interferential therapy on lumbosacral radiculopathy. Adrances in Physiotherapy. 20()6;8:82-87. 27 Ni Chiosoig F, Hendriks O, Malone J. A pilot study of the therapeutic effects of bipolar and quadripolar interferential therapy, using bilateral osteoarthritis as a model. Physiother Ire. 1994;15:3-7. 28 Van 1 wider M. Randomized trial loniparing interferential therapy with motorized lunib;ir traction anil massage in the management of low hack pain in a primary care setting Ipoini of view]. Spine (Phila Pa 1976). 1999:24:1584. 29 Embcrson W. Interferential therapy is safe. Physiotherapy Fronttine. 1995; 1:10. 30 Cianne |M. Interlerential therapy. .Aust / 19"'6;22:101 - 110 31 Cheing GL, Hui-Chan CW. Analge.sie effects of transcutaneous electrical nerve stimtilation anil interferential currents on heat pain in healthy subjects / Rehabit Med. 2()O3;35:I5-19. 32 Johnson MI, Tabasam G. A single-blind placebo-controlled investigation into the analgesic effects ol intcrtcrential currents on experimentally induced ischaeniic pain in healthy subjects. Ciin Physiot Funct tmaging. im2;2i. 187-196. 33 Johnson Ml, Tabasam (i. An investigation into the analgesic effects of different frequencies of the amplitude-modulated wave of interferenlial current ilunipy on cold-induced pain in normal subjects. Arch Phys MedRehabil. 2003;84:13871394. 34 Johnson Ml, Tabasam G. An investigation into the analgesic effects of inlerfcrential curretils and transcutaneous electrical nerve .stimulation on experinuiitally induced ischmie pain in otherwi.se painfree volunteers. Phys IJter. 2()O3;83: 208-223. 35 Johnson MI, Tabasam G. A single-blind investigation into the Inpoalgcsic effects of different swing patterns of interferential currents on cold-induced pain in healthy voltinteers. Arch Phys Med Rehabit. 20b3;84:350-357. 36 Palmer ST, Manin DJ, Steedman WM, Ravey J. Alteration of interferenlial current and transcutaneous elect dial nerve stimtilation fieqticncy: effecis on nerve excitation. .4/C/J Phys Med Rehabit. 1999;80:1065-l()71. 37 Palmer ST, Martin DJ, Steedman WM, RaveyJ. Effects of eleclric slimulalion on C and A delta liber-mcdialeil Ihermal perception thresholds. Arch Phys Med Rehabit. 2OO4;85:l 19-128. 38 Hansjuergens A. Interferential current clarihcalion. t'hys Ti.ier 198(i:66:1002. .39 John.son ML Tran.scutaneous electrical nerve stimulation (Tl-NS) and lF.NS-like devices: do they provide pain relief? Pain Ret'iews. 2001:8:121-158. 40 Noble JG. Current tl.se of interferentiat nwrapy in Physiotherapy Outpatient Departments for Treatment of l.ow Back Pain |dissertation]. Jordanstown, Northern Ireland: University of ULster; 1998. 41 Watson T. The role of electrotherapy in contemporary physiotherapy practice. Man her. 2(H)O;5:132-I41. ' 42 Arniijo-Olivo SA, Macedo LG, Gadotti IC, et al. Scales to assess the quality of randomi/ed controlled trials: a systematic review. Phys Iher. 2()08;88:156-175.

DOI: 10.2522/ptj.20090335

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The effects of home interferential therapy on post-operative pain, edema, and range of motion of the knee. Clin I Sport Med. 2003:13:16-20. 59 Quirk AS, Newman RJ, Newman KJ. An evaluation of interferential therapy, shortwave diathermy and exercise in the treatment of osteoarthrosis of the knee. Physiotherapy. 1985:71:55-57. 60 Taskaynatan MA. Ozgul A, zdemir A, Tan AK. Kalyon TA. Effects of steroid iontophoresis and electrotherapy on bicipital tendonitis. Journal of Musculoskeletal Pain. 2007:15:47-54. 61 Taylor K, Newton RA, Personius WJ, Bush FM. Effects of interferential current stimulation for treatment of subjects with recurrent jaw pain. Phys TIjer. 1987:67:346-350. 62 Van Der Heijden GJ, Leffers P. Wolters PJ. et al. No effect of bipolar interferential electrotherapy and pulsed ultrascnmd for soft tissue shoulder disorders: a randomised controlled trial. Ann Rheum Dis. 1999:58:530-540. 63 Werners R, Pynsent PB, Bulstrode CJ. Randomized trial comparing interferential therapy with motorized lumbar traction and massage in the management of low back pain in a primary care setting. Spine (Phila Pa 1976). 1999:24:15791584, 64 Zambito A, Bianchini D, Gatti D, et al, Interferential and horizontal therapies in chronic low back pain due to multiple vertebral fractures: a randomized, double blind, clinical study. Osteoporosis Int. 2007:18:1541-1545, 65 Zambito A. Bianchini D, Gatti D, et al, Interferential and horizontal therapies in chronic low hack pain: a randomized, double blind, clinical sttidy. Clin Exp Rheumatol. 2006:24:534 -539, 66 Lau PM, Chow DH, Pope MH. Early physiotherapy intervention in an accident and emergency department reduces pain and improves satisfaction for patients with acute low back pain: a randomised trial. AustJ Physiother. 2008:54:243-249. 67 Alves-Guerreiro J, Noble JG, Lowe AS, Walsh DM. The effect of three electrotherapeutic modalities upon peripheral nerve conduction and mechanical pain threshold. Clin Physit)t. 2001:21: 704-711. 68 Cramp FL, Noble G, Lowe AS, et al. A controlled .study on the effects of transcutaneous electrical nerve stimulation and interferential therapy tipon the RIII nociceptive and H-reflexes in humans. Arch Phys Med Rehabil. 2000:81:324333. 69 Johnson MI. labasam G. A double blind placebo controlled inve.stigation into the analgesic effects of inferential currents (IFC) and transcutaneous electrical ner\e stimulation (TENS) on cold-intlucetl pain in healthy subjects. Physiother theor Pract. 1999:15:217-233. 70 John.son MI, Wilson H. The analgesic effects of different swing patterns of interferential currents on cold-indticed pain. Physiotherapy. 1997:83:461-467. 71 Martin DJ. Palmer .ST. The effect of beat frequency on perceived comfort during stimulation of healthy suhjects with interferential current. Physiotherapy. 1996:82:639. 72 Minder PM, Noble JG, Alves-Guerreiro J, et al. Interferential therapy: lack of effect upon experimentally induced delayed onset muscle soreness. Ciin Physiol Funct Imaging. 2002:22:339-347. 73 Ozcan J. Ward AR, Robertson VJ. A comparison of true and premotlulated interferential currents. Arch Phys Med Rehabil. 2004:85:409-415. 74 Salsburj' L, Johnson M, The analgesic effect of interferenlial therapy compared with TENS on experimental cold induced pain in healthy suhjects. Physit)therapy. 1995:81:741. 75 Schmitz RJ, Martin DE, Perrin DH, et al. Effect of interterential ctirrent on perceived pain and serum cortisol associated with delayed onset mu.scle soreness. J Sport Rehabil. 1997:6:.3()-37. 76 Stephenson R.Johnson M, The analge.sic effects of interferential therap\' on coldinduced pain in health)' subjects: a preliminar)' report, Physiother Theory Pract. 1995:11:89 -95,' 77 Stephen.son R, Walker EM, The analgesic effects of interferential (IF) ctirrent on cold-pressor pain in healthy suhjects: a single blind trial of three IF currents against sham IF and control, Physiother Theoiy Pract. 2003:19:99-107, " 78 Tabasam G, Johnson Ml, Electrotherapy for pain relief, does it work: a laboratoryhased study to examine the analgesic effects of electrotherapy on cokl-induced pain in healthy individuals. Clin EffNurs. 1999:3:14-24. 79 Ward AR, Robertson VJ, Sensor), motor, and pain thresholds for stimulation with meditim frequency alternating current. Arch Phys Med Rehat?il. 1998:79:273278, 80 Ftientes C J, Armijo-Olivo S. Magee I)J. 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82 Ward AR. l.ucas-Tounibourou S. Lowering ol scns()r\\ motor, and pativtolcrancc ihrcsholds with burst diinition using kiliihcrt/Irciiucncy alternating current ikctric Minuilalion. .{rch I'hys Mett Rehiihit 20()7;KH: 1036-1041. 8. llnrlty DA. Baxter GD. McDonoiigh SM, Walsh DM. An investigation of two interlerential Iherapy eleclroile placement sites lor treatment of low back pain: hypoalgesie and functional disability effects. In: Proceeditigs of the 1.3th International (.ongres.s of the World ( Confederation for Physical Therapy. 1999:66. 84 Hurley DA. MeDonough SM. Baxter (il), et al. A deseriptive study of the usage of spinal manipulative therapy techniques within a randomized clinical trial iti acute low back pain. Man Ihcr 2()()S: 10:616". 85 Kitinunen M, Alasaarela U Registeritig the response of tissties exposed to an interferential electric current stinitilation. Acupunct lUcctrother Res. 2()04;29: J13-226. 86 Ltmbert HI.. Vanderstraeten (ic;, De Cuyper IIj, et al. HIectric current distribution during interferential therapy. Eur I I'hys Rehahit Mod. 1993:3:6-10,' 87 Nelson H. Interferential therapy. Au.-it / I'hysiolher. m81;27:'i3-'i6. 88 Noble J, Lowe A, Walsh D. Interferential therapy review: mechanisms of analgesic action anil clinical tisage. Phys Ther Rev. 20O0:'i:2.39-24'S. 89 Schwan/ KC. Electric sympathetic block: a review of electrotherapy physics. Advances in Therapy. 1991;8:l-5. 90 Draper DO, Knight KL. Interferential curtent therapy: often used bul tnisunderstood. Athtelic Therapy Today. 2006:11: 29-31. 91 I laman K. Fenety A. lloens A. et al. Physiotherapy anil low back p;iin in the injuR-d worker: ati examination ot current practice iluring the sulv.iciue phase ol healing. Pijysiother Can. 2(K)9;61 :H -1 (K). 92 Helmers KM. Irwin KE. Physical therapy as conservative management for cervical pain anil heailaches in an ailolescent with neurofibromatosis type 1: a case study. J Neural Phys Ther. 2(K)9;33:212223. 93 buiiben I, Tebbs SK. Hill 1), et al. Interferential therapy machines as possible vehicles for cross-infection. J Hosp Infect. 2OO();44:59-64. 94 Petrofsky J. l.aym()n M, Prowse M, et al. The transfer of current through skin and muscle lUiring electrical stitnulation with sine, square, Kussiati and interferential waveforms.y;Werfn^ Technol. 2OO9;33: 170-181. 95 Poitras S, Brosseau L. Evidence-inlbrnied management of chronic low back pain with ttanscutaneous electrical tier\'e .stimulation, interterential cunx-nt. electrical muscle stimulation, ultni.sotinil. and theniiother.ipy .SpineJ. 2(M):H:226-233. 96 Satter EK. I hird-ilegree burns incurred as a result of interferential current therapy. AmJ Dermatoputhot. 2OO8;3O:281-283. 97 Baltaci G. Ergun N, Bayrakci V. Nonoperative treatment of anterior cruciate ligament injuries. Sports Exercise und Injury. 1997:3:160-163. 98 Christie AD, Willoughby (il.. The effect of interferential therapy on swelling following open reduction and internal fixation of ankle fractures. I'hysiother Iheory Pract. 1990:6:3-7, 99 I'ouiie JA. Bowerbank P. Stimulation of bone healing in new fractures of the tibial shaft using interferential currents. Physiother Kes Int. 1997;2:255-268. 100 Indergand HJ, Morgan BJ Effect of interference current on forearm vascular resistanee in a.symptomatic humans. Phys liter. 1995:75:306-312. 101 Nu.ssbaum E, Rush P, Disetihaus 1.. The effects of interferential therapy on petipheral blood flow. Physiotherapy. 1990:^6:803-807. 102 Savery F, Ortiz AA, May HU. C:linical applications and effects ot' Endosan therapy and Interferential therapy on diabetic neuropathy with gangrene of the toe. Advances in Tlterapy. 1990:7:283-288. 103 C;hase J, Robertson V), Southwell B. et al. Pilot sttiily using transeutaiieous electrical .stimulation (interferential current) to treat chronic treatment-resistant constipation and .soiling in children./ Gastroenterot llepatot. 2005:20:1054-1(K)1. 104 Demirturk E. Akbayrak T, Karakaya 1. et al. Interferentialeurrent versusbiofeedback results in urinary stR'ss incontinenee. Swiss Med Wkty. 2(X)8;138:317-321. 105 Noble JG, Henderson G. Gramp AE, et al. The effect of interferential thet~apy upon cutaneous blood How in humans. Clin Physiot. 2000:20:2-7. 106 Esniat N. Treatment of arthrosis deformans by simultaneous application of interferential current and ultt-asonic waves. / Egypt Med Assoc. 1975:58:328-333. 107 Shafshak TS, El-Sheshai AM. Soltan HE. Personality traits in the mechanisms of interferential therapy for osteoarthritie knee pain. Arch I'hys Med Rehahil. 1991 ; 72:579-581. 108 Walker f IA. Uhl M. Weiner SM, et al. Analgesic and disease modifying effeets of interferential eurrent in p.soriatic arthritis. Rheumtitot hit 2006:26:904 -907. 109 lx-e JG, Lin DT, Hong C'/.. The effectiveness of simultaneous thermotherajiy with ultra,sound and electrotherapy with combineil AG and DC current on the immediate pain relief of tiiyofascial trigger points, /ournat of Musculoskeletal Pain. 1997;5:81-90. 110 Morris RH. Medial tibial syndrome: a treatment protocol using electric ctir112 Martin D. Palmer S. Interterential current as an adjunct to exereise and mobilisation in the treatment of proximal humerus fracture pain: lack of evidence of an aililitional effect. Physiotherapy. 2000:86:147-147. 113 Sidenco EL. Dragoi E. Scheau V. Efficiency of medium frequency' electroanalgesia in cervicogenic lieatlache. / Neurol Sei. 1997:150(suppl l):S2()l-S2b2. 114 Young SL. Woodbury MG, Fryday-Eield K. Efficacy of interferential current stimulation alone for pain reduction in patients with osteoarthritis ot the knee: a randomized placebo control trial. Phys Ther. 1991;71(.suppl):S252-S261. 115 McDowell I. The theoretical and technical foundations of health measurements. In: McDowell 1, eil. Metisuiiit^ llvalth. 3rd ed. New York. NY: Oxford lliiiversity Press; 2006:10-54. 116 (iallagher EJ, l.iebman M, Bljur PE Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med. 2()()I:38:633-6.S8. 117 Kelly AM. Does the clinically significant difference in visual analogue scale pain scores vary with gender, age, oi' cause of

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127 Partridge CJ, Kitchen SS. Adverse effects of electrotherapy used by physiotherapists. Physiotherapy. l999;S'^:29S-iOi. 128 Satter EK. Third<legree hums incurred as a result of interferential current therapy. AmJ Dermatopatijoi. 2()08;30:281-283. 17O Mnher n r n n W n i i:i,HriAR rt ji A<130 Chalmers TC. Celano P. Sacks HS, Smith H Jr. Bias in treatment a.ssignment in controlled clinical trials. TVin^Z/Af/. 1983; -^"9:1358-1361. ' 131 Schulz KF, Chalmers 1, Hayes RJ, Altman DG. Empirical evidence of bias: dimensions of methodological quality associ133 Moher D. Pham. Klassen IP. et al. What contrihutions do languages other than English make on Ihe results of nictaanalyses? / Clin iipidemiol. 2()()();S3: 134 Moher D. Pham B. biw.son ML. Klassen PP. The inclusion of reports of random-

' sensing 'thelity-'o/?5ortfof rLfdonv

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T ' T , ' '''* tn^ls. JAMA. 1995;273: 408-412. 132 Musselman KE. C:iinical significance testing in rehabilitation research: what, why. and how? Phys Ther Rev. 2007; 12:287296.

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than hnghsh m systematic revaws. Health Technol Asses.s. 2()()3;7:1-90.

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