Current electrotherapy concept Micro Current MET in Physiotherapy

Current electrotherapy concept

Micro Current (MET) in Physiotherapy Dj. TANIGAISELVANE. PT, MICP. , MISCP. PMR Hospital

Goals • • • To know what is Microcurrent? The physiological effects Therapeutic effects Clinical evidence Decision

Materials • • www. ovid. com www. coherence. com www. nhl. lib. org www. pubmed. com www. medline. com www. ptjournal. org www. jama. com www. electrotherapy. org

Definition “low-intensity direct current that delivers monophasic or biphasic pulsed microamperage currents across the intact surface of the skin’’ MET uses currents that are 1/1000 th of an ampere smaller than those delivered by standard TENS devices (milliamperes) American Physical Therapy Association. Electrotherapeutic terminology in physical therapy: Report by the Electrotherapy Standards Committee of the Section on Clinical Electrophysiology of The American Physical Therapy Association (APTA). Alexandria, VA: APTA, 1990.

Terminologies • • Microcurrent electrical nerve stimulation Microamperage stimulation Low-intensity direct current and Pulsed low intensity direct current

History Carlos Matteucci(1830) Dubois Reymond(1843) injured tissue 1 microamp Wolcott et. al 1960 200 -800 microamps. on variety of wounds 200 -350% faster healing rates in exp. group Gault and Gatens 1975 -76 Q. plegia, CVA, Brain Tumor, PVD, Burns, DM, TB, Fracture and Amputation

History contd. . Illingsworth and Barker (1980) stump of a finger tip 10 -30 micro amperes Borgens et al 1980 Barker, Jaffe, and Vanable 1982 Healing of wounds and union of bones

History contd. . Bio stimulation and Bio electric therapy Cheng et al (1982) effect of current on various intensities At 500 microamps level At milliamps level ATP generation 500% Amino acid uptake 30 -40% Protein synthesis ATP generation Amino acid uptake 20 -73% Protein synthesis 50%

Arnold-Shulz Law (Dorland 1985) Weak stimuli increase physiologic activity and very strong stimuli inhibit or abolish activity.

Dermatron • The first commercial device • Dr. Reinhold Voll of Germany in 1960 • Primarily used for electro-diagnostic testing and also therapeutically

• Pulse frequencies between 0. 5 pps and 150 pps with periodic reversals in polarity • Delivered using probe electrodes(sometimes in the form of a pen) or pad electrodes • Applied to acupuncture points, trigger points or over the site of pain. • MET can also be administered on ear lobes and transcranially, where it is claimed that it will relieve migraine, headache, insomnia and stress Heffernan MS. Comparative effects of microcurrent stimulation on EEG spectrum and correlation dimension. Integrative Physiol Behav Sci 1996; 31: 202– 209. • Some MET devices have a point finder to detect areas of the skin with low resistance, which are believed to correspond to acupuncture points Du. Pont JS, Graham R, Tidwell JB. Trigger point identification and treatment with microcurrent. Cranio 1999; 17: 293– 96.

• MET developed from the claim that tissue health is maintained by a direct current electrical system in the human body and that a shift in this‘normal current flow’ occurs when tissue is Damaged Watson T. Electrical stimulation for wound healing: a review of current knowledge. In: Kitchen S ed. Electrotherapy: evidence-based practice, eleventhedition. Edinburgh: Churchill Livingstone, 2002: 313– 34 • This direct current shift described as the ‘current of injury’, with a magnitude in the microampere range • Advocates claim that MET simulates this current of injury to assist tissue growth and healing, and that milliampere currents delivered by standard TENS devices are detrimental to this process of repair Cheng N, Hoof HV, Bockx E. The effects of electric current on ATP generation, protein synthesis, and membrane transport in rat skin. Clin Orthop Rel Res 1982; 171: 264– 72. Seegers JC, Engelbrecht CA, van Papendorp DH. Activation of signal-transduction mechanisms may underlie therapeutic effects of an appliedelectric field. Med Hypotheses 2001; 57: 224– 30

Becker’s theory • Polarity reversal sets up a current of injury • Initiates and signals beginning of tissue repair and regeneration

Injury currents(DC) The body does have a means of activating its own semiconductor bioelectric circuits to send endogenous biological electricity where it is needed for healing • the classical description of acupuncture meridians are actually maps of this glial cell network which parallel the peripheral nervous system • these electrical signals are conducted through the Schwann cell and glial cell perineural sheath • injury currents conducted through this system are the naturally occurring bioelectric signals for tissue repair and regeneration acupuncture points are maximally conductive windows into this bioelectric system serving as amplifiers to compensate for downstream damping of signal strength • • the insulation properties of the arterial microcapillaries can be adjusted by the body to shunt bioelectricity into the area of injury through the blood stream Robert O. Becker, M. D. (Becker 1985); Bjorn Nordenstrom, M. D. of Sweden; and Richard Borgens, Ph. D. at Purdue University

Injury currents(DC) • The body does have a means of activating its own semiconductor bioelectric circuits to send endogenous biological electricity where it is needed for healing These electrical signals are conducted through the Schwann cell and glial cell perineural sheath • • the classical description of acupuncture meridians are actually maps of this glial cell network which parallel the peripheral nervous system injury currents conducted through this system are the naturally occurring bioelectric signals for tissue repair and regeneration acupuncture points are maximally conductive windows into this bioelectric system serving as amplifiers to compensate for downstream damping of signal strength the insulation properties of the arterial microcapillaries can be adjusted by the body to shunt bioelectricity into the area of injury through the blood stream

Injury currents(DC) • • The body does have a means of activating its own semiconductor bioelectric circuits to send endogenous biological electricity where it is needed for healing these electrical signals are conducted through the Schwann cell and glial cell perineural sheath The classical description of acupuncture meridians are actually maps of this glial cell network which parallel the peripheral nervous system • • • injury currents conducted through this system are the naturally occurring bioelectric signals for tissue repair and regeneration acupuncture points are maximally conductive windows into this bioelectric system serving as amplifiers to compensate for downstream damping of signal strength the insulation properties of the arterial microcapillaries can be adjusted by the body to shunt bioelectricity into the area of injury through the blood stream

Injury currents(DC) • • The body does have a means of activating its own semiconductor bioelectric circuits to send endogenous biological electricity where it is needed for healing These electrical signals are conducted through the Schwann cell and glial cell perineural sheath the classical description of acupuncture meridians are actually maps of this glial cell network which parallel the peripheral nervous system injury currents conducted through this system are the naturally occurring bioelectric signals for tissue repair and regeneration Acupuncture points are maximally conductive windows into this bioelectric system serving as amplifiers to compensate for downstream damping of signal strength • the insulation properties of the arterial microcapillaries can be adjusted by the body to shunt bioelectricity into the area of injury through the blood stream

Injury currents(DC) • • • The body does have a means of activating its own semiconductor bioelectric circuits to send endogenous biological electricity where it is needed for healing These electrical signals are conducted through the Schwann cell and glial cell perineural sheath the classical description of acupuncture meridians are actually maps of this glial cell network which parallel the peripheral nervous system injury currents conducted through this system are the naturally occurring bioelectric signals for tissue repair and regeneration acupuncture points are maximally conductive windows into this bioelectric system serving as amplifiers to compensate for downstream damping of signal strength The insulation properties of the arterial microcapillaries can be adjusted by the body to shunt bioelectricity into the area of injury through the blood stream and there is an intracellular influx of calcium

Injury currents(DC) • • • The body does have a means of activating its own semiconductor bioelectric circuits to send endogenous biological electricity where it is needed for healing These electrical signals are conducted through the Schwann cell and glial cell perineural sheath the classical description of acupuncture meridians are actually maps of this glial cell network which parallel the peripheral nervous system injury currents conducted through this system are the naturally occurring bioelectric signals for tissue repair and regeneration acupuncture points are maximally conductive windows into this bioelectric system serving as amplifiers to compensate for downstream damping of signal strength the insulation properties of the arterial microcapillaries can be adjusted by the body to shunt bioelectricity into the area of injury through the blood stream and there is an intracellular influx of calcium Uncapping of insulin receptors on the cell membrane and enhancement of protien and DNA synthesis

Acupuncture and Microcurrent Becker and Nordenstrom et al. • Needle generates measurable electric charges when twirled in the skin • Needles left in tend to drain excess electric charge from tense or inflamed tissue • Play to balance the charge between.

Physiological effects 1) Spasmolysis of smooth muscles of the circulatory, lymphatic and hollow organ systems. 2) Tonification of elastic fibers, for example, increasing lung capacity in emphysema patients. 3) Reduction of inflammatory processes through reducing infiltrative, proliferative, and exudative processes. 4) Reduction of degenerative process by restoring diffusionosmotic equilibrium. 5) Restoration of polarization to the nerves. 6) Stimulus of ATP function in freshly injured striated muscle.

Usage in PT • Pain relief Anti nociceptive? (primary) (not percieved) Tissue healing (secondary) Protein synthesis • Tissue healing Antimicrobial effects

MET and pain relief Weber et al- No significant differences Massage, UBC , MET and NO treatment On induced DOMS of 40 healthy adults. Weber MD, Servedio FJ, Woodall WR. The effects of three modalities on delayed onset muscle soreness. J Orthop Sports Phys Ther 1994; 20: 236– 42. Lambert et al- Reduction of pain Double blind, Placebo controlled conditions on induced DOMS over 30 adults. Lambert MI, Marcus P, Burgess T, Noakes TD. Electro-membrane microcurrent therapy reduces signs and symptoms of muscle damage. Med Sci Sports Exerc 2002; 34: 602– 607

Clinical trials Lerner et al- Significant reduction of pain Double blind, placebo controlled trial On 40 chronic low back pain patients MET administered for two 6 secs period to 16 points on low back, 3 times /week for 2 weeks. Lerner F, Kirsch D. A double blind comparative study of micro-stimulation and placebo effect In short term treatment of the chronic back pain patient. J Chiropract 1981; 15: 101– 106 No physiological rationale given to such a prescriptive treatment regimen

Other clinical trials Relieves pain in combination with low level laser and other alternative therapies. 36 carpal tunnel cases 3 treatments/week for 4 -5 weeks Branco K, Naeser MA. Carpal tunnel syndrome: clinical outcome after low-level laser acupuncture, microamps transcutaneous electrical nerve stimulation, and other alternative therapies – an open protocol study. J Altern Complement Med 1999; 5: 5– 26 not possible to determine the exact contribution of MET effects are comparable to TENS for patients with migraine and chronic head aches Annal N, Soundappan S, Palaniappan K, Chandrasekar S. Introduction of transcutaneous, low voltage, non-pulsatile direct current (DC) therapy for migrane and chronic headaches. A comparison with transcutaneous electrical nerve stimulation (TENS). Headache Q 1992; 3: 434– 37 Less effective than LASER for improving mobility and relieving pain in patients with degenerative joint diseases. Bertolucci LE, Grey T. Clinical comparative study of microcurrent electrical stimulation to mid-laser and placebo treatment in degenerative joint disease of the temporomandibular joint. Cranio 1995; 13: 116– 20

Clinical trials Specific Frequency Microcurrent for Fibromyalgia and Myofascial Pain January 2006 Carolyn Mc. Makin , Portland Mc. Makin CR, Gregory WM, Phillips TM 2005. Cytokine changes with microcurrent treatment of fibromyalgia associated with cervical spine trauma. J Bodywork Move Ther 9: 169 -176 Mc. Makin CR 2004. Microcurrent therapy: A novel treatment method for chronic low back myofascial pain. J Bodywork Move Ther 8: 143 -153 Mc. Makin C. 1998. Microcurrent treatment of myofascial pain in the head, neck and face. Top Clin Chiro 5(1): 29 -35

Relieves pain? • Contradictory results • Inconclusive evidences from clinical trials • Clinical trials lack methodological rigor “Putative pain relief may be a by-product of the accelerated healing process’’

MET and wound healing Experiments in vitro suggested that MET accelerates the healing of damaged tissue Wolcott L, Wheeler P, Hardwicke H, Rowley B. Accelerated healing of skin ulcers by electrotherapy. South Med J 1969; 62: 795– 801 Nessler J, Mass D. Direct-current electrical stimulation of tendon healing in vitro. Clin Orthop Rel Res 1987; 217: 303– 12 Oweye I, Spielholz N, Fetto J, Nelson J. Lowintensity pulsed galvanic current and the healing of tenotomized rat achilles tendons: preliminary report using load-to-breaking measurements. Arch Phys Med Rehabil 1987; 68: 415– 18 Richez J, Chamay A, Bieler L. Bone changes due to pulses of direct electric microcurrent. Virchows Arch A Pathol Anat 1972; 357: 11– 18 possibly through increased protein synthesis or Cheng N, Hoof HV, Bockx E. The effects of electric current on ATP generation, protein synthesis, and membrane transport in rat skin. Clin Orthop Rel Res 1982; 171: 264– 72 Seegers JC, Engelbrecht CA, van Papendorp DH. Activation of signal-transduction mechanisms may underlie therapeutic effects of an applied electric field. Med Hypotheses 2001; 57: 224– 30 Seegers JC, Lottering ML, Joubert AM et al. A pulsed DC electric field affects P 2 -purinergic receptor functions by altering the ATP levels in in vitro and in vivo systems. Med Hypotheses 2002; 58: 171– 76 through antimicrobal effects Rowley BA. Electrical current effects on E. coli growth rates. Proc Soc Exp Biol Med 1972; 139: 929– 34 Rowley BA, Mc. Kenna JM, Chase GR, Wolcott LE. The influence of electrical current on an infecting microorganism in wounds. Ann N Y Acad Sci 1974; 238: 543– 51 Rowley BA, Mc. Kenna JM, Wolcott LE. Proceedings: The use of low level electrical current for enhancement of tissue healing. Biomed Sci Instrum 1974; 10: 111– 14

Clinical trials 2 well controlled animal studies MET not accelerating induced wound healing in rats and Yucatan pigs. Leffmann D, Arnall D, Holmgren P, Cornwall M. Effect of microamperage stimulation on the rate of wound healing in rats. A histological study. Phys Ther 1994; 74: 195– 200 Byl NN, Mc. Kenzie AL, West JM et al. Pulsed microamperage stimulation: a controlled study of healing of surgically induced wounds in Yucatan pigs. Phys Ther 1994; 74: 201– 13

Clinical trials Carley and Wainapel et al. - 30 patients 2 hours twice a day for 6 weeks MET accelerated healing against conventional wound dressing Carley P, Wainapel S. Electrotherapy for acceleration of wound healing: low intensity Direct current. Arch Phys Med Rehabil 1985; 66: 443– 46 Absence of placebo control group Healing of wounds and ulcers are undermined by lack of appropriate control groups Wolcott L, Wheeler P, Hardwicke H, Rowley B. Accelerated healing of skin ulcers by electrotherapy. South Med J 1969; 62: 795– 801 Assimacopoulos D. Low intensity negative electric current in the treatment of ulcers of the leg due to chronic venous insufficiency. Preliminary report of three cases. Am J Surg 1968; 115: 683– 87 Sinitsyn L, Razvozva E. [Effects of electrical microcurrents on regeneration processes in skin wounds. ] Ortop Travmatol Protez 1986; Feb (2): 25– 28 (Rus)

MET in sports injuries William Stanish, M. D. , physician for the Canadian Olympic team, found that implanted electrodes delivering 10 -20 microamps of electrical current hastened recovery from ruptured ligaments and tendons. Using microcurrent stimulation, Stanish shortened the normal 18 -month recovery period to only 6 months. (Stanish 1984).

Clinical trial -ROM • Pilot study of impedance-controlled microcurrent therapy for managing radiation-induced fibrosis in headand-neck cancer patients. • 26 patients -treatment sequelae in head and neck cancer patients impedance-controlled microcurrent therapy for 1 week • 92% exhibited improved cervical rotation, 85% had improved cervical extension/flexion, and 81% had improved cervical lateral flexion • Some patients also reported symptom improvement for tongue mobility, facial asymmetry, xerostomia, cervical/facial muscle spasms, trismus, and soft tissue tenderness ennox AJ, Shafer JP, Hatcher M, . Int J Radiat Oncol Biol Phys. 2002 Sep 1; 54(1): 23 -34

Indications Alleviation of • Pain • Inflammation • Spasm Promotion of • Healing • • • Osteoarthrotis Osteoporosis Sports injuries Fractures Wounds and Ulcers

Precautions and Contraindications • Cardiac pacemakers • Near eyes and carotid sinus • Transcerebral stimilation • Pregnancy • Pain of central origin

Rebox devices 1970 • • Pulse type Pulse mode Shape Pulse frequency Pulse duration Amplitude Type of Electrode : Train : Unipolar : Rectangular : 200 -5000 Hz : 50– 250 μs : 1– 300 μA : Probe Low J, Reed A. Electrical stimulation of nerve and muscle. In: Low J, Reed A eds. Electrotherapy explained: principles and practice. Oxford: Butterworth-Heinemann, 1994: 39– 116. Bjordal JM. Electrical currents. In: Bjordal JM, Johnson MI, Couppe C eds. Clinical electrotherapy. Your guide to optimal treatment. Kristians and. Hoyskole. Forlaget Norwegian Academic Press, 2001: 102– 16

Cell. Stim® 400 T INDICATIONS • • • • chronic and acute pain inflammation - edema synovitis musculoskeletal dysfunctions sports injuries - sprains, strains and contusions arthritic conditions - osteoarthritis sciatica neuropathies temporalmandibular joint dysfunction TMJ fibromyalgia FMS plantar fasciitis tennis elbow carpal tunnel syndrome CTS fractures - bone reunion wound healing - ischemic ulcers CONTRAINDICATIONS • • • on pain syndromes where the etiology has not been established pregnancy demand type cardiac pacemakers wound infections through malignant or benign tumors through the eyeball through carotid sinus osteomyelitis over laryngeal musculature over the thorax intersecting the heart presence of topical substances containing metal ion

Microcurrent 850 Specifications Channels Power Source Output Voltage Timer Frequency : Dual : 9 V alkaline battery : 12 volts : 20, 40 min and constant : 0. 3, 8 and 80 Hz

Patches

Occular & Dental MET • Macular Degeneration and Micro. Current therapy • Evaluation of microcurrent electrical nerve stimulation (MENS) effectiveness on muscle pain in temporomandibular disorders patients Journal of Applied Oral Science Print ISSN 1678 -7757 J. Appl. Oral Sci. vol. 14 no. 1 Bauru Jan. /Feb. 2006 doi: 10. 1590/S 1678 -7757200600012

MC in cosmetic therapy

Conclusion

Clinical Decision Making?

Can it be used to relieve pain ?

Can it be used for Soft Tissue healing?

For improving ROM ?

Analyse and Decide

HAVE FUN

Discussion

References 1. Picker R, Micro electrical neuromuscular stimulation. Network-Electrix 1987; (March): S 72–S 74. Efficacy of TENS and TENS-like devices in pain relief 41 Pain Reviews 2001; 8: 00– 00 stimulation parts 1 and 2. Clin Man Phys Ther 1988; 9: 10– 33. 2. Mercola JM, Kirsch DL. The basis for microcurrent electrical therapy in conventional medical practice. J Adv Med 1995; 8(2). Available from: URL: http: //www. harborside. com/naspenmed/page 8. htm [Accessed 15 -Jan-03] 3. Kirsch DL, Lerner FN. Electromedicine: The other side of physiology. In: Weiner R ed. The Textbook of the America Academy of Pain Management, Innovations in pain management: a practical guide for clinicians, vol. 4 update. Winter Park, FL: GR Press, 1995. Available from: URL: http: //www. alternatives. com/raven/cpain/chap 230. html [Accessed 15 -Jan-03] 4. Du. Pont JS, Graham R, Tidwell JB. Trigger point identification and treatment with microcurrent. Cranio 1999; 17: 293– 96. 5. Heffernan MS. Comparative effects of microcurrent stimulation on EEG spectrum and correlation dimension. Integrative Physiol Behav Sci 1996; 31: 202– 209. 6. Becker R, Selden G. The body electric. New York: Morrow, 1985. 7. Becker R, Murray D. Method for producing cellular dedifferentiation by means of very small electrical currents. Trans N Y Acad Sci 1967; 29: 606– 15. 8. Watson T. Electrical stimulation for wound healing: a review of current knowledge. In: Kitchen S ed. Electrotherapy: evidence-based practice, eleventh edition. Edinburgh: Churchill Livingstone, 2002: 313– 34. 9. Cheng N, Hoof HV, Bockx E. The effects of electric current on ATP generation, protein synthesis, and membrane transport in rat skin. Clin Orthop Rel Res 1982; 171: 264– 72.

10. Seegers JC, Engelbrecht CA, van Papendorp DH. Activation of signal-transduction mechanisms may underlie therapeutic effects of an applied electric field. Med Hypotheses 2001; 57: 224– 30. 11. Weber MD, Servedio FJ, Woodall WR. The effects of three modalities on delayed onset muscle soreness. J Orthop Sports Phys Ther 1994; 20: 236– 42. 12. Lambert MI, Marcus P, Burgess T, Noakes TD. Electro-membrane microcurrent therapy reduces signs and symptoms of muscle damage. Med Sci Sports Exerc 2002; 34: 602– 607. 13. Johnson MI, Penny P, Sajawal MA. An examination of the analgesic effects of microcurrent stimulation (MES) on cold-induced pain in healthy subjects. Physiother Theory Pract 1997; 13: 293– 301. 14. Lerner F, Kirsch D. A double blind comparative study of micro-stimulation and placebo effect in short term treatment of the chronic back pain patient. J Chiropract 1981; 15: 101– 106. 15. Branco K, Naeser MA. Carpal tunnel syndrome: clinical outcome after low-level laser acupuncture, microamps transcutaneous electrical nerve stimulation, and other alternative therapies – an open protocol study. J Altern Complement Med 1999; 5: 5– 26. 16. Annal N, Soundappan S, Palaniappan K, Chandrasekar S. Introduction of transcutaneous, low voltage, non-pulsatile direct current (DC) therapy for migrane and chronic headaches. A comparison with transcutaneous electrical nerve stimulation (TENS). Headache Q 1992; 3: 434– 37. 17. Bertolucci LE, Grey T. Clinical comparative study of microcurrent electrical stimulation to mid-laser and placebo treatment in degenerative joint disease of the temporomandibular joint. Cranio 1995; 13: 116– 20. 18. Wolcott L, Wheeler P, Hardwicke H, Rowley B. Accelerated healing of skin ulcers by electrotherapy. South Med J 1969; 62: 795– 801. 19. Nessler J, Mass D. Direct-current electrical stimulation of tendon healing in vitro. Clin Orthop Rel Res 1987; 217: 303– 12. 20. Oweye I, Spielholz N, Fetto J, Nelson J. Lowintensity pulsed galvanic current and the healing of tenotomized rat achilles tendons: preliminary report using load-to-breaking measurements. Arch Phys Med Rehabil 1987; 68: 415– 18. 21. Richez J, Chamay A, Bieler L. Bone changes due to pulses of direct electric microcurrent. Virchows Arch A Pathol Anat 1972; 357: 11– 18.

22. Seegers JC, Lottering ML, Joubert AM et al. A pulsed DC electric field affects P 2 -purinergic receptor functions by altering the ATP levels in in vitro and in vivo systems. Med Hypotheses 2002; 58: 171– 76. 23. Rowley BA. Electrical current effects on E. coli growth rates. Proc Soc Exp Biol Med 1972; 139: 929– 34. 24. Rowley BA, Mc. Kenna JM, Chase GR, Wolcott LE. The influence of electrical current on an infecting microorganism in wounds. Ann N Y Acad Sci 1974; 238: 543– 51. 25. Rowley BA, Mc. Kenna JM, Wolcott LE. Proceedings: The use of low level electrical current for enhancement of tissue healing. Biomed Sci Instrum 1974; 10: 111– 14. 26. Leffmann D, Arnall D, Holmgren P, Cornwall M. Effect of microamperage stimulation on the rate of wound healing in rats. A histological study. Phys Ther 1994; 74: 195– 200. 27. Byl NN, Mc. Kenzie AL, West JM et al. Pulsed microamperage stimulation: a controlled study of healing of surgically induced wounds in Yucatan pigs. Phys Ther 1994; 74: 201– 13. 28. Rothstein J. Microamperage: a lesson to be learned [editors note]. Phys Ther 1994; 74: 194 29. Assimacopoulos D. Low intensity negative electric current in the treatment of ulcers of the leg due to chronic venous insufficiency. Preliminary report of three cases. Am J Surg 1968; 115: 683– 87. 30. Gault W, Gatens P. Use of low intensity direct current in management of ischemic skin ulcers. Phys Ther 1976; 56: 265– 69. 31. Sinitsyn L, Razvozva E. [Effects of electrical microcurrents on regeneration processes in skin wounds. ] Ortop Travmatol Protez 1986; Feb (2): 25– 28 (Rus). 32. Carley P, Wainapel S. Electrotherapy for acceleration of wound healing: low intensity direct current. Arch Phys Med Rehabil 1985; 66: 443– 46. 33. Mulder G. Treatment of open-skin wounds with electric stimulation. Arch Phys Med Rehabil 1991; 72: 375– 77. 34. Feedar JA, Kloth LC, Gentzkow GD. Chronic dermal ulcer healing enhanced with monophasic pulsed electrical stimulation. Phys Ther 1991; 71: 639– 49. 35. Gardner SE, Frantz RA, Schmidt FL. Effect of electrical stimulation on chronic wound healing: a meta-analysis. Wound Repair Regen 1999; 7: 495– 503.

36. Low J, Reed A. Electrical stimulation of nerve and muscle. In: Low J, Reed A eds. Electrotherapy explained: principles and practice. Oxford: Butterworth-Heinemann, 1994: 39– 116. 37. Bjordal JM. Electrical currents. In: Bjordal JM, Johnson MI, Couppe C eds. Clinical electrotherapy. Your guide to optimal treatment. Kristiansand: Hoyskole. Forlaget Norwegian Academic Press, 2001: 102– 16. 38. Johannsen F, Gam A, Hauschild B, Mathiesen B, Jensen L. Rebox: an adjunct in physical medicine? Arch Phys Med Rehabil 1993; 74: 438– 40. 39. Hatten E, Hervik J, Kalheim T, Sundvor T. Pain treatment with Rebox. Fysioterapeuten 1990; 11: 8– 13. 40. Nussbaum EL, Gabison S. Rebox effect on exercise-induced acute inflammation in human muscle. Arch Phys Med Rehabil 1998; 79: 1258– 63. 41. Khan J. Electrical stimulation. In: Khan J ed. Principles and practice of electrotherapy. New York: Churchill Livingstone, 1987: 95– 125. 42. Kloth LC, Feedar JA. Acceleration of wound healing with high voltage, monophasic, pulsed current. Phys Ther 1988; 68: 503– 508. 43. Griffin JW, Tooms RE, Mendius RA, Clifft JK, Vander Zwaag R, el-Zeky F. Efficacy of high voltage pulsed current for healing of pressure ulcers in patients with spinal cord injury. Phys Ther 1991; 71: 433– 42. 44. Jette D. Effect of different forms of transcutaneous electrical nerve stimulation on experimental pain. Phys Ther 1986; 66: 187– 93. 45. Morris L, Newton RA. Use of high voltage pulsed galvanic stimulation for patients with levator ani syndrome. Phys Ther 1987; 67: 1522– 25. 46. Asbjorn O. Treatment of tennis elbow with transcutaneous nerve stimulation (TNS). Available from: URL: http: //www. paingone. com/ 2000 [Accessed 01 -Jul-02] 47. Ivanova-Stoilova T, Howells D. The usefulness of Pain. Gone pain killing pen for self-treatment of chronic musculoskeletal pain - a pilot study [Abstract]. In: The Pain Society of Great Britain Annual Scientific Meeting Abstracts; 2002 Apr 9– 12; Bournemouth, UK; abstr. 104. 48. Kirsch DL, Smith RB. The use of cranial electrotherapy stimulation in the management of chronic pain: a review. Neuro. Rehabilitation 2000; 14: 85– 94. 49. Limoge A, Robert C, Stanley TH. Transcutaneous cranial electrical stimulation (TCES): a review 1998. Neurosci Biobehav Rev 1999; 23: 529– 38. 50. Southworth S. A study of the effects of cranial electrical stimulation on attention and concentration. Integrative Physiol Behav Sci 1999; 34: 43– 53. 51. Taylor D, Lee C, Katims J. Effects of cranial transcutaneous electrical nerve stimulation in normal subjects at rest and during psychological stress. Acupunct Electrother Res 1991; 16: 65– 74.

WISH YOU A HAPPY FUTURE “Happiness & Success are Voyage, not Destination” MAY GOD BLESS YOU IN ALL YOUR FUTURE ENDEVOUR TO MR. SUNDARA S. BALAMURUGAN PHYSIOTHERAPIST AL SABAH GENERAL HOSPITAL