ELECTRICAL

STIMULATION

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 ELECTRICAL STIMULATION

MAIN PROJECT REPORT

Submitted in partial fulfillment of the requirement for the award of degree

of

Bachelor of Technology

in

Mechanical Engineering

Submitted by

AMIT JAISWAL (5808614)

Under the esteemed guidance of

DR. .........................,B.Tech, M.Tech.,Ph.D

Head of Department

Of

Mechanical Engineering

.................................. ENGINEERING COLLEGE

(Affiliated to ...................................... University)

2015-2016

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 TABLE OF CONTENTS
S.NO. TOPIC PAGE NO.
1 CANDIDATE’S DECLARTION 4
2 CERTIFICATE 5
3 ACKNOWLEDGEMENT 6
4 ROLE AND RESPONSIBILITIES 7
5 PERSONAL ENGINEERING ACTIVITY 8
6 OVERVIEW 9

7 INTRODUCTION 12

8 LITERATURE REVIEW 13
9 RELATED TERMS 24
10 APPLICATIONS 46
11 HOW APPLY 47
12 CONCLUSION 53
13 REFERENCES 54

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 CANDIDATE’S DECLARTION

I hereby certify that the work which is being presented by Amit Jaiswal, Ajay
Singh Chauhan, Rajeev Kumar, Raman Kumar, Vijay Kumar in partial fulfillment
of requirement for the award of degree of B.Tech. in MECHANICAL ENGINEERING
submitted at KALPI INSTITUTE OF TECHNOLOGY under KURUKSHETRA
UNIVERSITY, KURUKSHETRA is an authentic record of my own work carried out
under the supervision of Er. Harish Kumar Sharma (HOD) and Er. Vikas Kunnar.

Project Member:

Amit Jaiswal [5808614]

Ajay Singh Chauhan [5808615]
Rajeev Kumar [5808608]
Raman Kumar [5808606]
Vijay Kumar [5808613]

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 CERTIFICATE

This is certify that the dissertation entitled “ ELECTRICAL STIMULATION ” by

RAJEEV KUSHWAHA, AMIT JAISWAL, SANDEEP ANAND SHARMA, MANISH KUMAR
TRIVEDI, PERVEZ KHAN,& DIVYANSH submitted to the Department of
mechanical engineering, Kalpi Institute Of Technology, Ambala in the partial
fulfillment of requirement for the award of Degree of Bachelor of Technology in
mechanical engineering is a record of bonafide work done by him under my
supervision and guidance during the session 2014-15. This work has not been
submitted to any other university or institute for the award of any degree or
diploma.

Head of department & project Guide

Mr.........................

Department of mechanical engineering

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 ACKNOWLEDGEMENT

First of all we would like to thank our project guide Mr. ......................
Assistant Professor, Mechanical engineering Department, Kurukshetra
University who has given valuable support during the course of our
project by clarifying our doubts and guiding us with her novel ideas.

We would like to thank Prof. .........................., Head of department,

mechanical engineering, Kurukshetra University.

We extend our sincere thanks to our Dean ....................................

Department of mechanical engineering for giving us this wonderful
opportunity to work in desired area of interest.

We extend our sincere thanks to all teaching staff of mechanical

engineering department, those who helped us in completing this
project successfully.

Lastly we also thank the people who directly or indirectly gave us

encouragement and support throughout the project.

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Role and Responsibilities

My roles and responsibilities includes:

 Prepare a requirement document to reach expectations of project and to

come up with functionalities which are needed to be implemented.
 Documentation of expected output for various aspects with accepted
margin error was also documented.
 To design overall system based on workflow requirements.
 Discussion with the project guide and Head of Department on ways to
improve the design and to optimize performance.
 Choosing suitable components and methods based on the configurations
availability and requirements.
 Testing and remedies.
 Recommendations

As a trainee mechanical engineer, I wanted to work on a project work

that would showcase my engineering knowledge. I got the opportunity
to work on ELECTRICAL STIMULATION. This project was very important
as it evaluated my skills and talents in my company.

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PERSONAL ENGINEERING ACTIVITY

As a mechanical engineer, before undertaking any task I checked the

feasibility of the project. In this project, my role is as team members.
This report provides an insight into the design and fabrication of a
ELECTRICAL STIMULATION.

I wanted to know more details of the project before commencing;

hence, I researched the topic thoroughly by referring to journals and
articles online. Additionally, I obtained more information by taking
references about the topic.

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OVERVIEW
Electrical Stimulation Overview
What is electrical stimulation?
Electrical stimulation is electrical current applied to the human body
transdermally by the use of an electrode and a transmission medium that creates
a physiological response.
Why do we use electrical stimulation?
 Creates muscle contraction through nerve or muscle stimulation
 Stimulate sensory nerves to modulate pain
 Stimulate or alter the healing process
 Create a electrical field to drive ions through the skin to enhance the healing
process
What physiological effects does electrical stimulation have?
Changes in the physiologic functioning can occur at various levels and can be
direct or indirect. Direct effects occur along lines of current flow and under
electrodes. Indirect effects occur remote to area of current flow and are usually
the result of stimulating a natural physiologic event to occur.

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Physiological Changes as a Result of Electrical Stimulation (Prentice, 2005, p. 105-
106)

Cellular Effects:

• Excitation of nerve cells

• Changes in cell membrane permeability
• Protein synthesis
• Stimulation of fibrobloasts, osteoblast s
• Modification of microcirculation

Tissue Effects:

• Skeletal muscle contraction

• Smooth muscle contraction
• Tissue regeneration
• Nerve Depolarization

Segmental Effects:

• Modification of joint mobility

• Muscle pumping action to change circulation and lymphatic activity
• Alteration of the microvascular system not associated with muscle pumping
• Increased movement of charged proteins into the lymphatic channels

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System Effects:

 Analgesic effects as endongenous pain suppressors are released and act at

different levels to control pain
 Analgesic effects from the stimulation of certain neurotransmitters to control
neural activity in the presence of pain stimuli

Evidence For Electrical Stimulation

E-Stim Indications:
• Pain
• Edema Management
• Wound Care/Tissue Healing
• Muscle Re-education
Manage tone
Manage decreased strength

The Research Cycle By Cameron Neylon (Slide 30 of this presentation.)

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INTRODUCTION
Electrical stimulation of human tissues is an old procedure dating from the
attempts of the early Greeks to use electric eels for therapeutic purposes. The
modern rediscovery of electricity and its uses in physical medicine dates from the
early eighteenth century, when again, electrical stimulation generated by electric
eels was applied therapeutically to relieve headaches and to affect neuromuscular
paralysis.

Therapeutically applied electrical stimulation has had a checkered history,

enjoying long periods of popularity and respectable use interspersed with periods
of widespread misuse by medical charlatans who treated everything from
psychiatric conditions to cancerous tumors. One must suppose that the simplicity
of electricity producing equipment (especially that utilizing static or direct
current) coupled with the seemingly magical effects that electrical currents have
on human tissues, unavoidably led to its exploitation by unscrupulous
"practitioners" at the expense of the unsophisticated and gullible.

Often billed as a near panacea for the cure of most human physical ills, over time
the therapeutic use of electrical stimulation, in the minds of many, gradually
became associated with quackery and therefore considered beneath the use of
scrupulous and sophisticated practitioners. This state of affairs was (and is)
unfortunate, since there are many physical ills that humans are afflicted with that
may be improved or corrected by appropriately applied electrical stimulation.

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LITERATURE REVIEW

What does the research literature say about each of these indications?
Note: This summary is not all-inclusive
• Pain
TENS used for pain management has been shown to have benefit in phantom
pain, dental pain, peripheral neuropathies, migraine, postoperative pain, low
back pain, chronic pain syndromes, osteoarthritis, trigeminal neuralgia, reflex
sympathetic dystrophy, post traumatic pain, painful shoulder, whiplash and other
disorders. (Belanger, 2002, p. 288-292)
Interferential e-stim has good evidence for osteoarthritis pain and low back pain
(Belanger, 2002, p. 367)
Microcurrent has poor evidence for pain management (Belanger, 2002, p. 313)
High Volt Pulsed Current has benefit for back pain, hand and wrist pain, and bell's
palsy (Belanger, 2002, p. 328)
• Edema Management
High Volt Pulsed Current has some benefit for post traumatic edema (Belanger,
2002, p. 328)
• Wound Care/Tissue Healing
Microcurrent has good evidence for treating dermal wounds (Belanger, 2002, p.
313);
High Volt Pulsed Current has fair to good evidence for dermal wounds (Belanger,
2002, p. 327);
• Muscle Re-education

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Contraindications to Electrical Stimulation

Stop Sign by Arlette on Flickr

1. DO NOT apply to the thoracic area (or transthoracically) of a patient with

arrhythmia, congestive heart failure, recent myocardial infarction, and other
heart conditions
2. DO NOT apply anywhere on the body of a patient with a demand-type
implanted cardiac pacemaker or defibrillator or deep brain stimulator
3. DO NOT apply through the carotid sinus area (at the bifurcation of the
common carotid artery); it may cause a rise in blood pressure, reflex
vasodilatation and slow the heart rate.
4. DO NOT apply transcerebrally (thru the head) at a milliamp level because it
may cause changes in brainwave patterns. EXCEPTION Microcurrent can be
applied transcerebrally.
5. DO NOT apply through cancerous (malignant) tissue.
6. DO NOT apply through areas of broken or irritated skin. The current flows
through breaks in the skin, causing discomfort. Exception: (This is different
from using electrical stimulation for wound healing.)
7. DO NOT apply near or touching protruding metal such as surgical surface
staples or external pins because they are excellent conductors of electricity.

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8. DO NOT use on any patient who reacts very negatively to the experience or to
the sensation of stimulation.
9. DO NOT apply to a patient with undiagnosed pain.
10.DO NOT apply to patients who cannot provide adequate feedback concerning
the level of stimulation (infants, individuals with mental disorders)."

Precautions to Electrical Stimulation

Yield by My Own Worst Nightmare on Flickr

1. USE CAUTION in applying at high amplitude directly over areas where bone is
superficial. Periosteal pain can result.
2. USE CAUTION when applying in areas of excessive adipose tissue since the high
levels of stimulation necessary to activate underlying structures may cause
pain or autonomic reactions
3. USE CAUTION in applying within 3 feet of a transmitting cellular phone or two-
way radio. This may cause electrotherapy equipment malfunction.
4. USE CAUTION in applying near the uterus during pregnancy and delivery. (The
possible effects on a fetus are not known.)
5. USE CAUTION in applying within 10 feet of Group 2 ISM equipment that
generates high frequency or high energy electromagnetic radiation. Such

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 equipment includes welding or cutting equipment, diathermy units & surgical
electrocautery units. This may cause electrotherapy equipment malfunction.
6. USE CAUTION when applying in the region of the urinary bladder because the
current may interfere with normal function
7. USE CAUTION when applying over scar tissue because the scar will have an
increased electrical resistance. The current will preferentially travel around the
scar causing increased current density at the edges of the scar with possible
burning.
8. USE CAUTION in applying to a patient with history of metastatic disease.
9. USE CAUTION in a patient with poor sensation."

Physics Behind Electrical Stimulation

Electricity Defined
Electricity is the force created by an imbalance in the number of electrons at two
points
–Negative pole an area of high electron concentration
–Positive pole an area of low electron concentration
When talking about electrical stimulation of nerves, the cathode is usually is the
site of depolarization (negative), whereas the anode (positive) makes the nerve
cell membrane potential higher making depolarization harder. (Prentice, 2005, p.
107)

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 Electrical Generator
Basic Physical Terminology

Electrons—negatively charged particles; movement of electrons is the electrical

current, and always moves from higher potential to lower potential
Ions—positively and negatively charged components of atoms; possess electrical
energy and tend to move from an area from higher concentration to an area of
lower concentration, which establishes electrical potential; more ions, more
electrical potential
Ampere—the rate at which current flows; for e-stim, usually described with
therapeutic modalities in milliamperes
Voltage--electromotive force; difference in electron population between two
points; force resulting from accumulation of electrons at one point in an electrical
circuit (we use either high voltage or low voltage stimulators)
• Hi Volt: greater than 100-150 V
• Lo Volt: less than 100-150 V

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Conductance—ability of electrons to move freely through a pathway; high
conductance=easy for current to move; number of amps flowing in a conductor is
dependent on the voltage applied and the conduction characteristics of the
material
Insulators--materials with poorer conductance; offer resistance to current flow
Resistance—opposition to electron flow, measured in ohms, higher resistance will
have less amps; current flow=voltage/resistance (ohm’s law);
• Factors affecting resistance: Material composition
• Length (greater length yields greater resistance)
• Temperature (increased temperature, increase resistance)

Watts--electrical power; watts=volts x amperes; indicates the rate at which

electrical power is being used
Charge--An imbalance in energy. The charge of a solution has significance when
attempting to “drive” medicinal drugs topically via inotophoresis and in
attempting to artificially fires a denervated muscle
Pulse Charge--total amount of electricity being delivered to the patient during
each pulse; may be no net charge if the waveform is symmetrical and biphasic
Average current--(also called Root Mean Square) the “average” intensity, Factors
affecting: pulse amplitude, pulse duration, waveform (Direct current (DC) that is
monophasic has more net charge over time thus causing a thermal effect.
Alternating Current(AC) has a zero net charge (ZNC). The DC may have long term
physiological effects and/or adverse effects; Current (AC or DC) that
issymmetrically biphasic will develop no pulse charge; Asymmetrically biphasic
(AC or DC) current will develop a pulse charge)

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Capacitance--The ability of tissue (or other material) to store electricity. For a
given current intensity and pulse duration
The higher the capacitance the longer before a response. Body tissues have
different capacitance. From least to most:
1. Nerve (will fire first, if healthy)
2. Muscle fiber
3. Muscle tissue
Increased intensity (if pulse duration decreased) is needed to stimulate tissues
with a higher capacitance.
Muscle membrane has 10x the capacitance of nerve
Frequency--number of cycles occurring in a period of time; normally measured in
cycles/second or Hertz (Hz), pulses per second (pps), or cycles per second (cps)
(Prentice, 2005, p. 86)
One additional current...Interferential

Interference pattern (summed wave); public domain via Wikimedia commons

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Interferential current is biphasic alternating current that has two different
frequencies in the two different channels...usually 4000 and 4100 Hz. These
summate to form a desired beat frequency. At points the currents will be totally
in phase and summate (constructive interference), and at points they will be in
total opposite phase and will cancel each other out (destructive interference)

Current Modulation
Modulation—alteration in magnitude or duration of pulses; helps prevent the
body accommodating to stimulation
Continuous—amplitude of current flow remains the same for seconds or minutes;
creates an acidic or alkaline environment (medical galvanism); used to elicit
muscle contraction; iontophoresis uses medical galvanism to move medication
particles by the flow of current from pos to neg or vice versa
Interrupted—current flows for some period of time, and is turned off; used with
monophasic or biphasic currents; used with sine, rectangular, or triangular shaped
waveforms; used for muscle re-ed and improved ROM
Burst—pulsed current flows for a short period and turned off in a short period;
repetitive cycle; aka pulse trains; muscle effect is negligible due to the short
nature of the pulse break; used with monophasic, biphasic, or pulsatile current
(ifc)
Hey...wait one minute...isn't burst interrupted? Burst is interrupted but for
microseconds and milliseconds, the fact is that that there is a break in the current,
however, it is not significant enough to change the physiologic effect; true
interrupted current is off for seconds at a time and on for seconds at a time and
the break is significant enough to change the physiologic effect

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Ramped—current builds gradually to a max amplitude; makes for more
comfortable muscle re-ed

Types of Electrical Generators

Transcutaneous Electrical Stimulators or Transcutaneous
Electrical Nerve Stimulators (TENS)--generators that deliver AC, DC, or pulsatile
current through electrodes attached to the skin
Neuromuscular Electrical Stimulators (NMES)--stimulators that stimulate muscle
directly
Microcurrent Electrical Nerve Stimulators (MENS)--stimulator that generates a
low intensity stimulus that is too low to stimulate peripheral nerves
There is no relationship between the type of current delivered to the patient and
the type of current used to drive the electrical generator. (Prentice, 2005, p. 86).

Image public domain via Wikimedia Commons

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Electrical Circuits

image public domain via Wikimedia Commons

Stimulators are set in series or parallel circuits; parallel circuits have less
resistance and higher current flow; series; decrease in voltage at each
component, so serial currents have higher resistance and lower current flow.
Electrical modalities act in both parallel and series currents due to the tissue
resistance offered by the body.
Components of Generators of Electrical Currents--AKA How do I turn
AC to DC current?
Transformers—steps down or reduces the amount of voltage from the power
supply
Rectifier—converts AC current to pulsating DC current
Filter—changes pulsating DC to smooth DC
Regulator—produces a specific controlled voltage output

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Output amplifier—magnifies or increases the ammplitude of the voltage output
and controls it at a specific level, adjusting for impedance
Oscillator—produces a specific waveform

Components of generators and biological tissuses act in several ways:

• As insulators: materials and tissues which deter the passage of energy

• As semiconductors: both insulators and conductors. These materials will
conduct better in one direction than the other
Control rate of flow: How fast the energy travels. This depends on two factors:
the voltage (the driving force) and the resistance.

Electrical Stimulation Waveforms

This unit will cover the different waveforms and parameters to utilize for different
conditions. Please proceed to the next section to learn how to apply electrodes
to the body. Subsequent sections will cover specific applications for specific
conditions.

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RELATED TERMS
Electrical Stimulation Related Terms
Modern instrumentation used to apply electricity to the body is designed for
users who are without detailed knowledge of the instrument's internal circuitry or
the physics responsible for the production of electricity. However, some
knowledge of the basic principles that govern electrical stimulation is useful for an
understanding of the variable results that come from the necessary “trial and
error” that is a regular feature of its therapeutic use. A few terms are defined
below to help those of us who have little or no education in this area.
Ampere: the unit of flowing charge (current). Most therapeutic electrical
stimulators have a low average current of less than 1.5 milliamperes (mA) and
relatively high peak currents of between 60 and 100 mA. (Amps =
coulomb/second).
Bipolar Electrode Placement: both cathode (negative) and anode (positive)
electrodes are placed on the treatment area in relative proximity to each other.
This arrangement provides for rather specific stimulation of structures with few
variations in responses.
Burst frequency: the number of trains of impulses produced per second; it is
dependent on the “stimulation on and stimulation off” duty cycle selected.
Coulomb: a basic unit of charge theoretically produced by 6.28 x 1018 electrons.
Most therapeutic electrical stimulators have a low pulse charge, expressed in
micro‐coulombs (10‐6 coulombs).

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Current density: the amount of current per unit area; i.e., the smaller the
electrode, the greater the current density, making the stimulus perceptually
stronger to the recipient.
Monopolar electrode placement: one electrode is placed on the treatment area
and the other is placed on a remote location on the body. This arrangement
provides a rather general stimulation pattern because of the multiple parallel
pathways the current that may be taken from one electrode to the other. One
may also expect variations in the responses produced by the electrical stimulation
applied this way because of the number of nerves and other structures the
current may pass through.
Ohm: a unit expressing the amount of resistance offered by a current conductor
(the recipient’s soft tissues).
Ohm's Law: “The current (amps) is directly proportional to potential (volts) and
inversely proportional to resistance (ohms). Current = potential/resistance.” Amps
(amperes) = volts/ohms.
Pulse duration: the amount of time the current flows in one direction. Pulse
duration is measured when the current level is at 50% of its peak, usually
expressed in microseconds.
Pulse frequency: the number of pulses produced per second, hertz (Hz) or cycles
per second (c/s).
Resistance to current: The body is made up of tissues and fluids that vary in their
electrical conductivity and, conversely, their resistance to the passage of
electricity. Tissue conductivity is proportionally related to the tissue's water
content; the higher the water content the greater the conductivity and the lower
the tissue's resistance. The water content of muscle is 72 to 75%, the brain is 68%,

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fat is 14 to 15%, and of the peripheral nerve, skin, and bone is five to 16%.
Resistance varies in direct proportion to the distance between electrodes. The
resistance increases, as the distance the electrical stimulus must travel increases.
Volt: A volt is a unit of measure that indicates the amount of potential energy
(Joule) each unit of charge (coulomb) contains (Voltage = Joule/coulomb).

Electrotherapeutic currents are generally derived from the commercial lighting

circuit (alternating current in the United States or direct current in some other
parts of the world) or from the direct current (d/c) provided by batteries.
Transformers, electromagnetic or thermionic devices, or complex circuitry
(beyond our scope here) modify these basic currents to produce various
therapeutic current forms. The therapeutic current forms include galvanic (square
wave), interrupted galvanic, surged interrupted galvanic, sinusoidal, alternating,
surged alternating, faradic, surged faradic and other hybrid waveforms (generally
produced by combining two or more waveforms). The variables manipulated to
produce the various waveforms include: voltage, amperage, mode flow
(direction), pulse frequency, and pulse duration (pulse width).
Applying Electrical Stimulation to Soft Tissues: Electrical stimulation is applied
through a pair of electrodes placed on the body. The electricity is passed from the
cathode (negative) pole electrode, over and through the soft tissues, to the anode
(positive) pole electrode (sometimes called the dispersive), thus completing an
electrical circuit with the recipient’s body.

Electrical currents passed through muscle or nervous tissue from an external

source (electrical stimulator) will be partially depolarized in the region of the

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negative and hyperpolarized in the region of the positive. If the current is
sufficiently strong, the degree of depolarization will reach or exceed the critical
level necessary to produce a muscle contraction or the firing of the nerve. At the
anode, as the circuit is completed. The body overcompensates for electrical
changes induced by the current, so that some degree of irritability is present at
the anode. If sufficiently great, the irritability will also cause a muscle contraction
or nerve firing under the anode. The current level required to produce a single
neuron impulse or single muscle fiber contraction is called a minimal stimulus. If a
stronger stimulus is required to excite all of a group of nerve fibers or denervated
muscle fibers, it is called a maximal stimulus. A stimulus higher than that is called
a supramaximal stimulus.
The factors that determine the adequacy of a stimulus to either elicit a muscle
contraction or provoke the firing of nervous tissue include pulse frequency, pulse
duration, and the amplitude of the current. The minimal duration of an effective
electrical stimulus (sufficient to provoke a muscle contraction or nerve firing) is
1.0 microsecond for a normal innervated muscle fiber and 0.03 microseconds for
a normal nerve fiber. The strength of an electrically induced muscle contraction is
related to the intensity and pulse duration of the stimulus: the greater the
intensity and pulse duration, the greater the strength of contraction.

Equipment Utilized in Electrical Stimulation

Electrical units currently used for the stimulation of muscle or other deep tissues
can be generally classified into six categories:

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High Frequency (Medium Frequency) Stimulators:

These units, by definition, generate more than 1000 c/s, with popular models
producing 2500 c/s. The 2500 c/s units usually employ a duty cycle of 10
milliseconds (msec) on and 10 msec off. In this case, the 2500 c/s is interrupted at
1/100 of a second on and 1/100 of a second off with a 50% duty cycle producing
50 bursts per second with 25 cycles per burst. The 2500 c/s unit generally has a
peak current of 130 mA with an average current level of from 80 to 100 mA root
mean square (RMS). These units provide a variety of duty cycles, ramps, and peak
currents from which to choose. They can create a muscle contraction that is 60%
(or greater) of that produced by a maximal isometric contraction.

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High Voltage Stimulators: These units have a high peak current of 500 mA or
greater with a low average current of less than one mA. They are constant voltage
generators with a pulse charge of approximately four micro coulombs, and their
pulse durations usually range from five to eight microseconds. They generally
provide a variety of duty cycles and pulse‐frequencies from which to choose.
Interferential Stimulators: These units are constant current generators that
create a pulse frequency of 4000 to 5000 c/s. The interferential units generally
employ two electrical sine wave circuits, one of which has a fixed frequency while
the other varies its frequency; when the two waveforms intersect, an
interferential frequency is said to result. The interferential unit usually has a peak
current of 60 mA.
Low Voltage Electrical Stimulators: These units have low peak currents, low
voltage driving forces that can be alternate or direct currents, and their pulse
duration’s are usually large, measured in msec or seconds. If using a direct
current, they can produce thermal and chemical effects and can be used to
produce iontophoresis.
Portable Neuromuscular Stimulators: These units generally employ a constant
current, which generally has a peak of 100 mA with a driving force of from 50 to
100 volts. They generally provide a choice of duty cycles, pulse frequencies, peak
currents, and ramps (the time it takes for the current level to rise from zero to its
peak).
Electrodes: The electrical energy from electrical stimulators is conveyed to the
recipient by conducting cables. The cables are plastic or rubber insulated flexible
copper or silver wires. The thickness of the cable depends on the amount of
current to be carried by the conductor (the greater the current, the thicker the

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cable needs to be). These cables may be a uniform color or color‐coded according
to function. If color‐coded, the wire to the negative (cathode) electrode is
conventionally black, and that to the positive (anode) electrode is red. An
electrode is a medium that intervenes between the cable from the electrical
stimulator and the recipient's body (only surface electrodes will be discussed
here). It generally consists of a good conducting material whose shape and form
can be adapted to conform to contours of the body. Electrode mediums include
water, metal foil (usually made from an alloy of lead, tin, and zinc), moist‐ pads, or
flexible carbon or “silicone” pads.

Flexible electrode pads

Electrode pads are usually employed in pairs, often of equal size. Between two
electrode pads of equal size, the current density beneath each of them is equal. If
one is twice as large as the other is, the current density under the smaller one will
be twice as great as that under the larger. As the current spreads between two
electrode pads, across the body, its density must gradually decrease so that
midway between them the density is the least. The closer the electrodes are to

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one another, the greater the density of the current that passes between them.
The higher the current density, the greater the effect on the tissues stimulated.
The electric current carried along the cable length eventually leads to some
crystallization and to breaks in the conducting wires at the sites where the most
bending or movement of the cable occurs, usually close to the electrode
connections at both ends.
Application:
If low frequency sponge pad electrodes are being used, they must be well
moistened with a saline solution (or water) and placed over the chosen treatment
sites. If carbon or “silicone” pads are used, take care that the skin between the
electrodes remains dry to avoid an “electrode bridge” that would decrease or
preclude effective electrical stimulation (the electricity would pass through the
water to complete the circuit, having no effect on the body).
Generally, place a negative electrode on the muscle's motor point (where the
motor nerve is most superficial as it innervates the muscle) so that when
stimulated the greatest muscle contraction is provoked. Once the best sites for
electrode placement have been determined, elastic strapping, weighting, or
taping may be applied to ensure good continued electrode contact.
Set a watch or timer for the length of treatment. Turn the electrical stimulator on
and increase the amplitude (intensity) until a visible contraction takes place,
always staying within the recipient’s range of tolerance.
Allow the recipient to become accustomed to the current before additional
intensity increases are slowly made. Continue this process until the desired
degree of contraction is reached. Closely monitor the recipient for excessive

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muscle spasm, cramping, joint compression, or pain. Never leave the recipient out
of hearing range once the treatment has been started.
At the end of the session (if not automatically shut off) gradually decrease the
intensity until it is switched off. Return all controls to zero. Remove all electrodes
from the recipient. Have the recipient rest for several minutes before being
allowed to exercise.
Precautions:
Electrical burns may occur if continuous uninterrupted galvanic current is used
and an excess of current density applied to the skin or mucous membrane. If an
electrical burn results, the tissue damage produced occurs in a roughly conical
area, extending from the apex on the skin's surface (where the original electrical
contact occurred) and fanning out into the deeper layers. Just following the
injury, the burn site appears rather small and inconsequential but becomes more
alarming as the damaged tissues are subsequently sloughed off and ulceration
occurs. Electrical burns are slow to heal, prone to infection, and (if sufficiently
deep) may be followed by extensive unsightly scarring.

Electric shock may be caused if the recipient touches a grounded object (a water
pipe, radiator, or electric circuit) while being stimulated. This is especially serious
if a large area is subjected to the shock. Electric shock may also occur if the
electrical stimulator suffers transformer breakdown (which is unlikely with
modern units). If this happens the high‐tension, low frequency current may jump
to the recipient and produce an electrical burn as well as a shock.

32 | P a g e
Take care to avoid over‐fatigue of the muscles stimulated. Stimulation should stop
when the muscle begins to respond with less vigor.
Generally, do not place electrodes over scar tissue, skin irritations or open skin
lesions (unless used to help fight infection). If increased sweating, salivation or
signs of nausea occur discontinue stimulation.
Do not let electrical current flow across a pregnant uterus or a cardiac pacemaker.
When applying electrodes, take care to avoid overlapping negative and positive
electrodes, and avoid having conductive materials (electrode cream, water or gel)
form a conductive “electrode” bridge between the two. Either situation will cause
a completion of the circuit without involving or affecting the recipient’s tissues.
When applying electrical stimulation, a gradual increase of intensity is preferred
because of the tendency of natural skin resistance to suddenly break down after
being exposed to an electric current for several minutes. If the apparent lack of
tissue response persuades the practitioner to increase the intensity to a relatively
high level before skin resistance breaks down, the recipient may pay for the
practitioner's lack of patience by experiencing additional pain or discomfort.
Future treatment may be put in jeopardy because of the recipient’s acquired fear.

33 | P a g e
CIRCULATION ENHANCEMENT
It has long been accepted that electrical stimulation of muscle tissue to provoke
muscle contractions to rhythmically squeeze associated blood vessels may be
used to therapeutically improve circulation. This process induces the muscles to
artificially provide the pumping action required by nature to facilitate venous
blood flow and to add impetus to lymphatic circulation.

Less known or appreciated is the effect that electrical stimulation may have on
capillary development. Research undertaken in the late 1970's demonstrated that
continuous low frequency electrical stimulation could increase capillary to muscle
fiber ratio and thus the number of capillaries present in a cross‐sectional area.
The formation of new capillaries may be accompanied by an increase in the total
capillary surface area and the “sprouting” of large capillaries (making new
branches). Increases in capillary density (20% after 4 days of stimulation, 50%
after 14, and 100% after 28 days) are apparently not a consequence of the action
of the electrical current itself. They result from the muscular need for additional
blood supply to support the demand of electrically induced muscular
contractions. Similar changes accompany hypoxia in humans and animals
(non‐primates) when engaging in aerobic exercise (repetitive isotonic
contractions, like running). It should be noted that high frequency electrical
stimulation (30 Hz and above) and isometric exercise have both failed to
demonstrate the ability to increase capillary density.

34 | P a g e
 Electrode placement for electrical stimulation of the calf

Because of the ability to increase capillary density, low frequency electrical

stimulation may be used to good effect when treating conditions stemming from
impaired or decreased blood circulation.
Application:
 To increase capillary density, the electrodes may be placed in bipolar fashion
over a large muscle or muscle group in the involved extremity or associated
with the involved area.
 Preset the electrical stimulator to deliver a pulsed square wave or faradic
current flow at a pulse frequency of between four and 14 Hz (7 to 10 Hz would
be ideal), for a 20‐ minute period.
 Turn the stimulator on, and slowly increase the intensity until a visible
contraction of the muscle or muscle group develops.
 As the patient gets used to the sensation of electrical stimulation, gradually
increase the current until the contractions are quite brisk.
 Daily treatments provide the best results.

35 | P a g e
EDEMA REDUCTION
It has long been accepted that electrical stimulation of muscle tissue to provoke
muscle contractions to rhythmically squeeze associated blood vessels may be
used to therapeutically improve circulation. This induces the muscles to artificially
provide the pumping action required by nature to facilitate venous blood flow
and to add impetus to lymphatic circulation. Consequently, electrical stimulation
may be used to good effect when the patient has lost the ability or is unable to
voluntarily contract the necessary muscles (as when splinted or when closely
confined for therapeutic reasons). This provides a way of reducing lymph edema
that is often a consequence of syndromes in which the muscles are kept from
contracting or "working out".
Apart from the mechanical pumping action that electrically induced muscle
contractions can provide, pulsed direct (galvanic) current has the observable and
apparent ability to carry or drive fluid out of edematous tissue, possibly because
of electrical ionic transfer.
To facilitate lymph circulation or decrease edema, in the most effective manner,
place the largest possible electrodes over the largest possible areas. For example,
place the patient’s swollen ankle in a basin of water (the water above the level of
the malleoli) with the positive electrode. Place the negative electrode on the low
back. This set‐up will affect the greatest number of muscles possible and may
additionally facilitate the flow of the edematous fluid out of the swollen
extremity. To treat a single swollen joint, place a wet cloth (wet wrap) over and
around the swollen joint, and the positive electrode over the area most swollen. If
a dual positive is available, place each positive electrode on either side of the

36 | P a g e
joint; place the negative electrode in an area distant from the swollen joint (in the
midback area, for example).

Application:
 Preset the electrical stimulator to deliver a pulsed square wave current flow at
a pulse frequency of 28 Hz for a 20‐minute period.
 Turn the stimulator on and slowly increase the intensity until the patient’s
muscles just begin to involuntarily tighten.

 Ideally, daily treatment is best but suitable outcomes have resulted from
treatments every other day, or even two to three times a week.

Electrical stimulation for the reduction of edema is remarkable for its ability to
immediately reduce the swelling associated with strained, sprained, or
immobilized joints. Consequently, when appropriate, following electrical
stimulation the involved joint should be taped or fitted with a pressure‐splint
(usually an inflated sleeve) to prevent swelling from redeveloping and to help
stabilize the involved joint, thus preventing further joint trauma.

37 | P a g e
MUSCLE TONING
Research has confirmed that electrical stimulation, if appropriately applied, may
be used to effectively increase tone, strengthen muscle, improve endurance, and
increase the size of innervated muscle. Electrical stimulation has not been shown
to be superior to traditional forms of voluntary exercise, for building tone and
strength. Nevertheless, several studies have shown electrical stimulation to be
nearly as effective. In fact, some research has demonstrated that high voltage
pulsed electrical stimulation of at least 30 Hz may be used to cause involuntary
isometric muscular (tetanic) contraction against resistance without causing the
stress to the cardiovascular system. Both isometric and isotonic exercise cause
increases in heart rate and blood pressures as a normal consequence of voluntary
exertion.
Review of the literature suggests that more study is needed to establish which
types of electrical stimulation are most effective for increasing muscle tone and
strength and which methods of application are most efficient. In addition, more
study is necessary to establish which types of muscle fibers (fast or slow twitch)
will respond best to electrical stimulation. Muscle toning with electrical
stimulation seems to be most effectively accomplished by electrical stimulation
units capable of producing currents strong enough to produce tetany (or near
tetany) while being fairly comfortable for the patient. Such stimulation units
generally provide a duty cycle of 10 to 15‐seconds on and 10 to 50‐seconds off.
Such stimulation is usually best provided by a high voltage, high frequency
(medium frequency) unit.

38 | P a g e
Application:
 To tone muscle with electrical stimulation, the best results seem to come from
putting the muscle or muscle group on stretch and fixing the involved joint in
place to prohibit them from moving in response to provoked contractions (i.e.,
an isometric contraction). Place the electrodes over the muscle or muscle
group to be stimulated in a bipolar fashion. Place the cathode (negative)
electrode over the dominant muscle's motor point, and the anode (positive)
electrode elsewhere on the same muscle or muscle group.
 Turn the electrical stimulator on and slowly increase the intensity until a visible
contraction develops. As the patient gets used to the stimulation (shows signs
of relaxing), gradually increase the current until tetany or near tetany occurs.
 Continue stimulation for 10 to 15 minutes. Use a duty cycle of 10‐seconds on
and 10‐ seconds off to produce maximum toning, if that option is available.
Treatment may occur daily, but suitable results have come from treatments
every other day or twice a week.

Muscle toning with electrical stimulation has been shown to be remarkably

effective for retrieving muscle tone lost as a secondary effect of long term
inflammatory conditions (chronic tennis elbow or debilitating knee or ankle
ailments) or disuse from prolonged bed rest. If the electrical stimulation is applied
correctly and appropriately, muscle strength can be improved without any risk of
reinflaming the previously involved soft tissues through strain, which is often a
consequence of voluntary exercise.

39 | P a g e
MUSCLE LENGTHENING
Chronically “tight” muscles, muscles spasm, and trigger points may be treated by
relengthening the muscles involved through the judicious use of electrical
stimulation.

Application:

 Put the involved muscle(s) on stretch and (if possible) place both the negative
and positive electrode pads over either the muscle involved or its most active
antagonist. If medium frequency is used, place the pads over the involved
muscle. If wide‐pulsed electrical stimulation at 7 Hz is used, place the pads
over the antagonist(s) of the involved muscle.
 Preset the electrical stimulation machine to deliver either the medium
frequency current, in a duty cycle of 10‐seconds on 10‐ seconds off, or a
wide‐pulse frequency of five to 7 Hz.
 Turn the electrical stimulation on and set it (if possible) to turn off after
10‐minutes of stimulation.

 Slowly turn the electrical amplitude up until the desired level of muscle
contraction is produced; a firm maintained contraction if medium frequency is
used or a brisk, brief visible contraction if wide‐pulse stimulation is used.
 Turn the machine off after 10 minutes of stimulation.
 If the medium frequency current was used, encourage the patient not to move
and to maintain the “stretched‐out” position for five minutes. If the
wide‐pulsed current was used, vibrate the “tight” muscle’s antagonist(s) for

40 | P a g e
 one minute (each site), and then have the patient maintain the “stretch‐out”
position for five minutes.
 Remove the pads and any remaining electrode cream or gel from the patient’s
skin.
A variation of the above technique may be used to enhance the effects of both
cervical and lumbar traction, by itself or in combination with vibration (refer to
Vertebral Traction, Electrical Stimulation Enhancement, and Electrical Stimulation
and Vibration Enhancement in Combination).
TISSUE AND BONE REPAIR
Clinical research and experience have confirmed that low intensity, low
frequency, electrical stimulation may facilitate the healing processes of damaged
soft and bony tissues, increasing the quality and rate of repair. Electrical
stimulation has been shown to be remarkably effective for precipitating the
healing of long‐term nonunion fractures and the closure of healing‐resistant
incisions and pressure sores (decubiti).
Not only has electrical stimulation been shown to facilitate tissue growth, but also
research has shown monophasic (one direction) electrical stimulation to have a
bacteriostatic or antibiotic effect on some types of bacteria commonly associated
with dermal lesions, including pseudomonas aeruginosus (in vivo).
Many types of electrical instrumentation provide current forms with the requisite
amplitudes (0 to 100 mA or up to 90 volts), frequencies (1 to 10 Hz), and pulse
width duration (100 to 200 msec) necessary to inhibit bacterial infection and
facilitate soft tissue or bone healing. Of all the current forms, the pulsed square
wave has been shown to be the most effective and safest.

41 | P a g e
BACTERIAL INFECTION
To utilize electrical stimulation to help fight bacterial infection the following steps
should be taken:
 If necessary, undress the dermal lesion and cleanse it of any exudates or loose
debris, following sanitary debridement guidelines.
 Place a sterilized sponge electrode, moistened with pure saline solution, over
the dermal lesion. Attach this electrode to the electrical stimulation device as
the negative electrode. Place the positive or dispersive electrode some
distance away from the lesion.
 Preset the electrical stimulator unit at zero amplitude, at a minimum
frequency of 28 Hz, and at the longest pulse width possible (from 100 to 200
msec).
 Turn the electrical stimulator on and slowly increase the intensity until the
patient reports feeling the stimulation, which usually occurs at 20 mA or
slightly less.
 Higher currents are not thought to be advisable, so don’t allow any involuntary
muscle contraction or increased in muscle tonus to occur.
 Stimulate for from 20 to 60 minutes.
 Ideally, apply this treatment three or four times a day, at equally spaced
intervals. Successful treatment has been noted to occur if stimulation is
provided only once a day, or even as little as three times a week. However, the
speed of healing seems directly related to the number and frequency of
treatment sessions.
 Following treatment, remove the electrodes. If necessary, redress the dermal
lesion according to hygienic guidelines.

42 | P a g e
 Sanitize the electrodes according to institutional hygienic guidelines (i.e.,
soaked in a bactericide solution or sterilized) before reuse.

OSTEOGENESIS
To promote osteogenesis with electrical stimulation, go through the following
steps:
 Place surface electrodes above and below the fracture site, so that the current
flow is parallel with the long axis of the bone. If the electrical stimulation unit
is monophasic, place the negative electrode(s) as close to the fracture site as is
possible, even over the site (since osteogenesis is promoted right under it).
 Preset the electrical stimulation unit at zero amplitude, at a minimum
frequency of 28 Hz, and at the longest pulse width possible (from 100 to 200
msec).
 Turn the electrical stimulation unit on and slowly increase the intensity until
the patient shows signs of being aware of the stimulation, usually occurring at
the 20 mA level or slightly less. Higher currents are not thought to be
advisable, so allow no involuntary muscle contraction or increased muscle
tonus to occur.
 Stimulate for 20 to 60 minutes.
 Ideally, apply this treatment three or four times a day, at equally spaced
intervals. However, successful treatment has been noted to occur if
stimulation is provided only once a day.
 Following treatment, remove the surface electrodes and thoroughly cleanse
the skin under the electrodes.

43 | P a g e
WOUND HEALING
To promote wound healing (without the presence of infection) with electrical
stimulation go through the following steps:
 Place surface electrodes in opposition on either side of the open wound. If
four electrodes are available, arrange the electrodes a crisscross pattern
(negative‐ positive, positive‐negative) to allow the current flow to intersect
over the surface of the wound.
 Preset the electrical stimulation unit at zero amplitude, at a minimum
frequency of 28 Hz, and at the longest possible pulse width (from 100 to 200
msec).
 Turn the electrical stimulation unit on and the slowly increase the intensity
until the patient reports feeling the stimulation, usually at 20 mA or slightly
less. Higher currents are not thought to be advisable, so do not allow an
involuntary muscle contraction or increased muscle tonus to occur.
 Stimulate for 30 to 60 minutes.
 Ideally, apply this treatment three or four times a day, at equally spaced
intervals. Successful treatment has been noted to occur if stimulation is
provided once a day, or as little as three times a week. However, the speed of
healing seems directly related to the number and frequency of treatment
sessions.
 Following treatment, remove the surface electrodes and cleanse the skin
formerly under the electrodes.

44 | P a g e
Precautions:
As mentioned above, the selection of the electrode site and electrode polarity
may be critical to the healing process it facilitates. Osteogenesis is facilitated by
the presence of the negative electrode and inhibited by the presence of the
positive electrode. Additionally, research has demonstrated that if the electrodes
are placed in opposition to one another across the fracture site, perpendicular to
the long axis of the bone, it will cause osteogenesis to occur in a manner that
creates bone cells at right angles to the long axis of the bone. This will produce a
relatively weak union and a weakened bone. A stronger union is produced if the
electrodes are placed in opposition across the fracture site, parallel to the long
axis of the bone; this facilitates osteogenesis of bone cells parallel with the long
axis of the bone more closely imitating original bone formation.
If osteogenesis (calcific deposit) is not desired, the positive electrode should be
placed over the treatment site and the negative electrode placed in a relatively
distant site, and the protocol described above for osteogenesis should be
followed in all other particulars. This technique may be useful in discouraging
calcium deposit in joints, muscles or along tendons.

45 | P a g e
APPLICATION OF ELECTRICAL STIMULATION
Electrical Stimulation Safety

• Ensure proper grounding is present

• Ensure that the power cord is intact

• Remove defective equipment from the clinic immediately

• Do not use extension cords

• Have electrical modalities evaluated yearly for safety

• Watch for water present in the treatment area

Current Flow Through the Body

Bodily tissues will either resist or conduct electricity. The skin offers resistance to
current flow, and will increase the voltage needed for stimulating muscle and or
nerve. (Prentice, 2005, p. 96) Since direct current causes changes in the chemical
composition of the skin, skin resistance is generally higher with DC than AC.

Below the biological tissues are organized in conductance from least to most.

1. Blood--best conductor of all tissues

2. Nerve--six times that of muscle

3. Muscle--requires movement of ions for contraction; propagates better

longitudinally than transversely

4. Dry Skin

5. Fat

6. Tendon

7. Bone--poorest biologic conductor of all tissues

46 | P a g e
How do I apply electrical stimulation?

Use electrodes and a transmission medium (if not pre-gelled, use gel, if pre-
gelled, the gel on the electrode serves as the conductive medium) to decrease
skin impedance:
1. Prepare the skin
Inspect the skin for breaks, cleanse the skin with mild soap and water to cleanse
and hydrate; if the area is very hairy shave it; do not use alcohol wipes to prep the
skin, due to drying effect and increased tissue resistance
2. Place the electrode Place the electrode according to the goal of treatment3.
Prepare the stimulator
Turn on the stimulator, select the protocol, and connect the lead wires to the
electrodes

47 | P a g e
Place the lead wire in a position to minimize the stress on the electrode
connection; preferably, the patient should not lie on the electrodes or leads
3. Adjust the stimulator
4. Check the treatment area For evidence of irritation or patient complaint of
pain, adjust the output downward; with continued complaint pain, discontinue
the treatment; if treatment needs to be discontinued, what do we do? Alter
treatment parameters on the next treatment session, use alternate electrode
placement
5. Complete the treatment
6. Remove the electrode Disconnect the lead wires from the electrode
Turn off the stimulator
Grasp the electrode and slowly peel of the electrode, walking your fingers under
the electrode to prevent skin tearing as you peel back
Mark each use on the electrode pouch and store the electrodes on the film that is
inside the pouch and place into the pouch
Seal the pouch
Re-usable electrodes can be used approximately 5-8 times
Care of Electrodes
General use:
• Use a different pack of electrodes for each individual patient
• Test the area to be stimulated for decreased sensation
• Use the largest electrodes possible
• Place the electrodes a minimum of 1 inch apart
• Do not use small electrodes (less than 2x2) when treating with MFAC or IFC
• Inspect the electrode surface prior to application

48 | P a g e
• Store in sealed bag in cool place
• When applying, firmly and uniformly attach the electrode to the skin
• Moisten the electrode with a few drops of water if the electrode gel
appears to be getting dry
• Clip hair if a good interface is not achieved (Belanger, 2002)
Electrode Safety
Effective Interface—current distribution should be even across the interface—if
area of lower resistance exists in the tissue or electrode the current naturally
travels to that location and current density increases dramatically; can cause pain,
tissue damage, or inappropriate stimulation of the tissue; patients with loss of
sensation are susceptible to this; when does this occur: as electrodes are re-used
they dry out, dry skin and hair adheres to the conductive gel; so: Minimize air-
electrode interface, Keep electrode clean of oils, etc., Clean the skin of oils, etc.
How do we address having an effective interface? using the electrode fewer
times, and rehydrating the gel on the electrode surface with tap water
Current density: type, size, and placement influences current density
 Type, size, and placement of electrodes affects sensation and muscle
recruitment
 Power density in milliwatts/cm2 determines the potential for tissue damage
 As tissue and electrode resistance increases, more voltage is required to push
the current through the tissue

49 | P a g e
How do we address current density ?
 selecting a lower intensity waveform (MFAC and IFC most intense waveform,
must take care when applying to patients with poor sensation and use TENS,
or patterened MFAC; do sensation testing to determine amount of impairment
 Skin preparation and hydration—inspect the skin prior to application
 Selecting a larger electrode will decrease current density—size and location of
the muscle or tissue to be treated determines the electrode size and
configuration; should be as large as possible for the muscle to be treated
without targeting adjacent muscle/tissue
 Larger, low resistance electrodes will produce a more comfortable stimulation
 Larger space between electrodes decreases current density—if are in close
proximity (<1 inch) conduction may occur toward electrode edges and increase
potential for burns
 Resistance of electrodes (select appropriate electrode resistance for
waveform; higher frequency of current, the lower resistance of tissue to the
current, greater tissue conductivity and greater depth of penetration, so want
to make the electrode resistance less than that of the tissue—why?), lower
resistance the lower the voltage needed to achieve the same therapeutic
effect
 Not using a uneven conductive surface: the further the distance from the lead
entry point the higher the resistance of some electrodes
 Not using dried out electrodes: if surface is dried out or skin/hair is adhered to
the electrode power density increases dramatically how can we tell?
Decreased comfort, difficulty in achieving satisfactory levels of sensation or
muscle activation

50 | P a g e
Conductive gels
 Skin tearing is a significant issue in electrode removal in the frail elderly, with
RSD, diabetes, or compromised skin—avoid aggressive tacky gels
 Gels should be made primarily of hydrogel to decrease tack of the electrode
 Should not introduce chemical irritants or change in structure under high
current application
 Gel should provide hydration and adhesion during muscle contraction, but
easy to remove
 Gel should not dissolve in salt
 Should not delaminate from the electrode or leave a residue

Heat with Electrical Stimulation

Preheating the treatment area may increase the comfort of the treatment but
also increases resistance and need for higher output intensities

51 | P a g e
Principles of Electrodes: Summary

 Electrodes used in clinical application of current: At least two electrodes are

required to complete the circuit
 The body becomes the conductor
 Monophasic application requires one negative electrode and one positive
electrode
 The strongest stimulation is where the current exists in the body
 Electrodes placed close together will give a superficial stimulation and be of
high density
 Electrodes spaced far apart will penetrate more deeply with less current
density
 Generally the larger the electrode the less density. If a large “dispersive” pad
is creating muscle contractions there may be areas of high current
concentration and other areas relatively inactive, thus functionally reducing
the total size of the electrode
 A multitude of placement techniques may be used to create the clinical and
physiological effects you desire

52 | P a g e
CONCLUSIONS
We believe that reporting of EM stimulation dose should be guided by the
principle of reproducibility: sufficient information about the stimulation
parameters should be provided so that the dose can be replicated.

53 | P a g e
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Formation Following Impact Injury," Physical Therapy, 70:4, April 1990. Pp. 219‐224

56 | P a g e
K.A. Cosgrove, G. Alon, S.F. Bell, S.R. Fischer, N.R. Fowler, T.L. Jones, J.C. Myaing, T.M. Crouse,
L.J. Seaman, "The Electrical Effect of Two Commonly Used Clinical Stimulators on Traumatic
Edema in Rats," Physical Therapy, 72:3, March 1992. Pp. 227‐233

D.R. Fish, F.C. Mendel, A.M. Schultz, L.M. Gottstein‐Yerke, "Effect of Anodal High Voltage Pulsed
Current on Edema Formation in Frog Hind Limbs," Physical Therapy, 71:10, October 1991. Pp.
724‐733

A.C. Guyton, Textbook of Medical Physiology, W.B. Saunders Co., Philadelphia, Pa., 1971. Pp.
242‐248

C.B. Killian, "Electrical Stimulation Overview Introduction to High Frequency Stimulation,"

Presented at a Combined Section Meeting in Orlando, Florida, February 1985. [Reprint available
from Mr. Clyde Killian, Department of Physical Therapy, 1400 East Hanna Avenue, Indianapolis,
In., 46227.]

J. Owens and T. Malone, "Treatment Parameters of High Frequency Electrical Stimulation as

Established on the Electro‐Stim 180," JOSPT, 4:3, winter 1983. Pp. 162‐168

B.V. Reed, "Effect of High Voltage Pulsed Electrical Stimulation on Microvascular Permeability to
Plasma Proteins," Physical Therapy, 68:4, April 1988. Pp. 491‐495

W.J. Shriber, A Manual of Electrotherapy, Lea & Febiger, Philadelphia, Pa., 1975. Pp. 110‐123,
139‐147

G.K. Stillwell, Therapeutic Electricity and Ultraviolet Radiation, The Williams & Wilkins Co.,
Baltimore, Md., 1983. p. 151

K. Taylor, D.R. Fish, F.C. Mendel, H.W. Burton, "Effect of a Single 30‐Minute Treatment of High
Voltage Pulsed Current on Edema Formation in Frog Hind Limbs," Physical Therapy, 72:1,
January 1992. Pp. 63‐68

K. Taylor, D.R. Fish, F.C. Mendel, H.W. Burton, "Effect of Electrically Induced Muscle
Contractions on Posttraumatic Edema Formation in Frog Hind Limbs," Physical Therapy, 72:2,
February 1992. Pp. 127‐132

R.A. Wong, "High Voltage Versus Low Voltage Electrical Stimulation," Physical Therapy, 66:8,
August 1986. Pp. 1209‐1214

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Muscle Toning

G. Alon, "High Voltage Stimulation," Physical Therapy, 65:6, June 1985. Pp. 890‐895

L.L. Baker, K. Parker and D. Sanderson, "Neuromuscular Electrical Stimulation for the
Head‐Injured Patient," Physical Therapy, 63:12, December 1983. Pp. 1967‐1974

L.L. Baker, C. Yeh, D. Wilson and R.L. Waters, "Electrical Stimulation of Wrist and Fingers for
Hemiplegic Patients," Physical Therapy, 59:12, December 1979. Pp. 1495‐1506

U. Bogataj, N. Gros, M. Malezic, B. Kelih, M. Kljajic, R. Acimovic, "Restoration of Gait During Two
to Three Weeks of Therapy with Multichannel Electrical Stimulation," Physical Therapy, 69:5,
May 1989. Pp. 319‐327

D.P. Currier, J. Lehman and P. Lightfoot, "Electrical Stimulation in Exercise of the Quadriceps
Femoris Muscle," Physical Therapy, 59:12, December 1979. Pp. 1508‐1512

D.P. Currier and R. Mann, "Pain Complaint: Comparison of Electrical Stimulation with
Conventional Isometric Exercise," The Journal of Orthopaedic and Sports Physical Therapy, 5:6,
1984. Pp. 318‐323

D.P. Currier and R. Mann, "Muscular Strength Development by Electrical Stimulation in Healthy
Individuals," Physical Therapy, 63:6, June 1983. Pp. 915‐921

A. Delitto, J.M. McKowen, J.A. McCarthy, R.A. Shively and S.J. Rose, "Electrically Elicited
Co‐contraction of Thigh Musculature After Anterior Cruciate Ligament Surgery," Physical
Therapy, 68:1, January 1988. Pp. 45‐50

A. Delitto, J.M. McKowen, J.A. McCarthy, R.A. Shively, S.J. Rose, "Electrically Elicited
Co‐Contraction of Thigh Musculature After Anterior Cruciate Ligament Surgery," Physical
Therapy, 68:1, January 1988. Pp. 45‐50

A. Delitto, S.J. Rose, J.M. McKowen, R.C. Lehman, J.A. Thomas, R.A. Shively, "Electrical
Stimulation Versus Voluntary Exercise in Strengthening Thigh Musculature After Anterior
Cruciate Ligament Surgery," Physical Therapy, 68:5, May 1988. Pp. 660‐663

A. Delitto, L. Snyder‐Mackler, "Two Theories of Muscle Strength Augmentation Using

Percutaneous Electrical Stimulation," Physical Therapy, 70:3, March 1990. Pp. 158‐164

58 | P a g e
A. Delitto and S.J. Rose, "Comparative Comfort of Three Waveforms Used in Electrically
Eliciting Quadriceps Femoris Muscle Contractions," Physical Therapy, 66:11, November 1986.
Pp. 1704‐1707

L.F. Eckerson and J. Axelgaard, "Lateral Electrical Surface Stimulation as an Alternative To

Bracing in the Treatment of Idiopathic Scoliosis," Physical Therapy, 64:4, April 1984. Pp.
483‐490

C.B. Killian, "Electrical Stimulation Overview Introduction to High Frequency Stimulation,"

Presented at a Combined Section Meeting in Orlando, Florida, February 1985. [Reprint available
from Mr. Clyde Killian, Department of Physical Therapy, 1400 East Hanna Avenue, Indianapolis,
In., 46227.]

J. Kleinkort, Isoelectronic Rehabilitation Program, Dynatronics Research Corporation, Salt Lake

City, U., 1986.

J.F. Kramer, "Effect of Electrical Stimulation Current Frequencies on Isometric Knee Extension
Torque," Physical Therapy, 67:1, January 1987. Pp. 31‐38

J. Kramer, D. Lindsay, D. Magee, S. Mendryk, and T. Wall, "Comparison of Voluntary and

Electrical Stimulation Contraction Torques,” Journal of Orthopaedic and Sports Medicine
Physical Therapy, 5:6, May/June, 1984. Pp. 324‐331

R.K. Laughman, J.W. Youdas, T.R. Garrett, and E.Y.S. Chao, "Strength Changes in the Normal
Quadriceps Femoris Muscle as a Result of Electrical Stimulation," Physical Therapy, 63:4, April
1983. Pp. 494‐499

R.L. Lieber, M.J. Kelly, "Factors Influencing Quadriceps Femoris Muscle Torque Using
Transcutaneous Neuromuscular Electrical Stimulation," Physical Therapy, 71:10, October 1991.
Pp. 715‐723

T. Mohr, B. Carlson, C. Sulentic and R. Landry, "Comparison of Isometric Exercise and High Volt
Galvanic Stimulation on Quadriceps Femoris Muscle Strength," Physical Therapy, 65:5, May
1985. Pp. 606‐609

A.J. Nitz and J.J. Dobner, "High Intensity Electrical Stimulation Effect on Thigh Musculature
During Immobilization for Knee Sprain," Physical Therapy, 67‐2, February 1987. Pp. 219‐222

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J. Owens and T. Malone, "Treatment Parameters of High Frequency Electrical Stimulation as
Established on the Electro‐Stim 180," Journal of Orthopaedic and Sports Physical Therapy, 4:3,
1983. Pp. 162‐168

R. Packman‐Braun, "Relationship Between Functional Electrical Stimulation Duty Cycle and

Fatigue in Wrist Extensor Muscles of Patients with Hemiparesis," Physical Therapy, 68:1,
January 1988. Pp. 51‐56

C.A. Phillips, "Functional Electrical Stimulation and Lower Extremity Bracing for Ambulation
Exercise of the Spinal Cord Injured Individual: A Medically Prescribed System," Physical Therapy,
69:10, October 1989. Pp. 842‐849

D.M. Selkowitz, "Improvement in Isometric Strength of the Quadriceps Femoris Muscle After
Training with Electrical Stimulation," Physical Therapy, 65:2, February 1985. Pp. 186‐195

C‐L. Soo, D.P. Currier and A.J. Threlkeld, "Augmenting Voluntary Torque of Healthy Muscle by
Optimization of Electrical Stimulation," Physical Therapy, 68:3, March 1988. Pp. 333‐337

M.H. Trimble, R.M. Enoka, "Mechanisms Underlying the Training Effects Associated with
Neuromuscular Electrical Stimulation," Physical Therapy, 71:4, April 1991. Pp. 273‐282

D.J. Twist, "Acrocyanosis in a Spinal Cord Injured Patient‐Effects of Computer‐Controlled

Neuromuscular Electrical Stimulation: A Case Report," Physical Therapy, 70:1, January 1990. Pp.
45‐49

Y. Urabe, "Strengthening the Quadriceps Femoris by Electrical Stimulation," Physical Therapy,

66:2, February 1986. p. 283

D.C. Walker, D.P. Currier and A.J. Threlkeld, "Effects of High Voltage Pulsed Electrical
Stimulation on Blood Flow," Physical Therapy, 68:4, April 1988. Pp. 481‐485

R.P. Walmsey, G. Letts, and J. Vooys, "A Comparison of Torque Generated by Knee Extension
with a Maximal Voluntary Muscle Contraction vis‐ à‐vis Electrical Stimulation," Journal of
Orthopaedic and Sports Medicine Physical Therapy, 6:1, July/August, 1984. Pp. 10‐17

R.A. Wong, "High Voltage Versus Low Voltage Electrical Stimulation, Physical Therapy, 66:8,
August 1986. 1209‐1214

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Tissue and Bone Repair

H. Aro, J. Aho, K. Vaatoranta and T. Ekfors, "Asymmetric Biphasic Voltage Stimulation of the
Osteotomized Rabbit Bone," Acta Orthop. Scand., vol. 51, 1980. Pp. 711‐718

M. Brown, M.K. McDonnell, D.N. Menton, "Electrical Stimulation Effects on Cutaneous Wound
Healing in Rabbits," Physical Therapy, 68:6, June 1988. Pp. 955‐960
J.A. Feeder, L.C. Kloth, G.D. Gentzkow, "Chronic Dermal Ulcer Healing Enhanced with
Monophasic Pulsed Electrical Stimulation," Physical Therapy, 71:9, September 1991. Pp.
639‐649

J.W. Griffin, R.E. Tooms, R.A. Mendius, J.K. Clifft, R.V. Zwaag, F. El‐Zeky, "Efficacy of High
Voltage Pulsed Current for Healing of Pressure Ulcers in Patients with Spinal Cord Injury,"
Physical Therapy, 71:6, June 1991. Pp. 433‐444

D.B. Harrington and R. Meyer, "Effects of Small Amounts of Electric Current at the Cellular
Level," Annals of the N.Y. Academy of Science, vol. 238, October 11, 1974. Pp. 300‐305

M.J. Im, W.P.A. Lee, J.E. Hoopes, "Effect of Electrical Stimulation on Survival of Skin Flaps in
Pigs," Physical Therapy, 70:1, January 1990. Pp. 37‐ 40

J. Kahn, "Transcutaneous Electrical Nerve Stimulation for Nonunited Fractures," Physical

Therapy, 62:6, June 1982. Pp. 840‐844

C.B. Kincaid, K.H. Lavoie, "Inhibition of Bacterial Growth In Vitro Following Stimulation with
High Voltage, Monophasic, Pulsed Current, Physical Therapy, 69:8, August 1989. Pp. 651‐655

L.C. Kloth, J.A. Feedar, "Acceleration of Wound Healing with High Voltage, Monophasic, Pulsed
Current," Physical Therapy, 68:4, April 1988. Pp. 503‐508

K. Piekarski, O. Demetriades and A. Mackensie, "Osteogenetic Stimulation by Externally Applied

DC Current," Acta Orthop. Scand., vol. 49, 1978. Pp. 113‐120

B.A. Rowley, J.M. McKenna and G.R. Chase, "The Influence of Electrical Current on an Infecting
Microorganism in Wounds," Annals of the N.Y. Academy of Sciences, vol. 238, October 11,
1974. Pp. 543‐551

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I. Yasuda, "Mechanical and Electrical Callus," Annuls of the N.Y. Academy of Science, vol. 238,
October 11, 1974. Pp. 457‐465

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