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

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.

“low-intensity direct current that delivers monophasic or biphasic pulsed microamperage currents across the intact surface of the skin’’

MET uses currents that are 1/1000th of an ampere

smaller than those delivered by standard

TENS devices (milliamperes)

Terminologies

• Microcurrent electrical nerve stimulation

• Microamperage stimulation

• Low-intensity direct current and

• Pulsed low intensity direct current

HistoryCarlos Matteucci(1830) injured tissueDubois Reymond(1843) 1 microamp

Wolcott et.al 1960200-800 microamps.on variety of wounds200-350% faster healing rates in exp.group

Gault and Gatens 1975-76Q.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..

At milliamps level

ATP generation

Amino acid uptake 20-73%

Protein synthesis 50%

At 500 microamps level

ATP generation 500%

Amino acid uptake 30-40%

Protein synthesis

Bio stimulation and Bio electric therapyCheng et al (1982) effect of current on

various intensities

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 in1960

• Primarily used for electro-diagnostic testing and also therapeutically

• Pulse frequencies between 0.5pps 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 microcurrentstimulation 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 theskin with low resistance, which are believed tocorrespond to acupuncture points

DuPont JS, Graham R, Tidwell JB. Trigger pointidentification 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, proteinsynthesis, 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 mayunderlie the 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 injurythrough 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 injurythrough 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 injurythrough 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 injurythrough 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 diffusion-osmotic equilibrium.

5) Restoration of polarization to the nerves. 6) Stimulus of ATP function in freshly injured striated

muscle.

Usage in PTAnti nociceptive? (primary)

• Pain relief (not percieved)Tissue healing (secondary)

Protein synthesis

• Tissue healingAntimicrobial

effects

MET and pain relief

Weber et al- No significant differences

Massage, UBC , MET and NO treatmentOn induced DOMS of 40 healthy adults.

Weber MD, Servedio FJ, Woodall WR. The effects of three modalities on delayed onset musclesoreness. J Orthop Sports Phys Ther 1994; 20: 236–42.

Lambert et al- Reduction of painDouble blind,Placebo controlled conditionson induced DOMS over 30 adults.

Lambert MI, Marcus P, Burgess T, Noakes TD. Electro-membrane microcurrent therapy reducessigns and symptoms of muscle damage. Med Sci Sports Exerc 2002; 34: 602–607

Clinical trials

Lerner et al- Significant reduction of painDouble blind, placebo controlled trialOn 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 trialsRelieves pain in combination with low level laser and other alternative therapies.36 carpal tunnel cases3 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 – anopen protocol study. J Altern Complement Med 1999; 5: 5–26

not possible to determine the exact contribution of MET

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. Acomparison 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-laserand placebo treatment in degenerative joint disease of the temporomandibular joint. Cranio 1995; 13: 116–20

Clinical trials

Specific Frequency Microcurrent for Fibromyalgia and Myofascial PainJanuary 2006Carolyn McMakin ,Portland

McMakin CR, Gregory WM, Phillips TM 2005. Cytokine changes with microcurrent treatment offibromyalgia associated with cervical spine trauma. J Bodywork Move Ther 9:169-176

McMakin CR 2004. Microcurrent therapy: A novel treatment method for chronic low backmyofascial pain. J Bodywork Move Ther 8:143-153

McMakin C. 1998. Microcurrent treatment of myofascial pain in the head, neck and face. TopClin 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 healingExperiments in vitro suggested thatMET 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 orCheng 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 the therapeutic effects of an appliedelectric field. Med Hypotheses 2001; 57: 224–30

Seegers JC, Lottering ML, Joubert AM et al. A pulsed DC electric field affects P2-purinergic receptor functions by altering the ATP levels in invitro and in vivo systems. Med Hypotheses 2002; 58: 171–76

through antimicrobal effectsRowley BA. Electrical current effects on E. coli growth rates. Proc Soc Exp Biol Med 1972; 139: 929–34

Rowley BA, McKenna 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, McKenna JM, Wolcott LE. Proceedings: The use of low level electrical current for enhancement of tissue healing. Biomed SciInstrum 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 ofwound healing in rats. A histological study. Phys Ther 1994; 74: 195–200

Byl NN, McKenzie AL, West JM et al. Pulsed microamperage stimulation: a controlled study ofhealing of surgically induced wounds in Yucatan pigs. Phys Ther 1994; 74: 201–13

Clinical trials

Carley and Wainapel et al.- 30 patients2 hours twice a day for 6 weeksMET 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 byelectrotherapy. 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 skinwounds.] 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 head-and-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 : Train• Pulse mode : Unipolar• Shape : Rectangular• Pulse frequency : 200-5000 Hz• Pulse duration : 50–250 μs• Amplitude : 1–300 μA• Type of Electrode : Probe

Low J, Reed A. Electrical stimulation of nerve and muscle. In: Low J, Reed A eds. Electrotherapyexplained: 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 andHoyskoleForlaget Norwegian Academic Press, 2001:102–16

CellStim®400TINDICATIONS

• 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 850Specifications

Channels :Dual

Power Source :9V alkaline battery

Output Voltage :12 volts

Timer :20, 40 min and constant

Frequency :0.3, 8 and 80Hz

Patches

Occular & Dental MET

• Macular Degeneration and MicroCurrent therapy

• Evaluation of microcurrent electrical nerve stimulation (MENS) effectiveness on muscle pain in temporomandibular disorders patients

Journal of Applied Oral Science Print ISSN 1678-7757J. Appl. Oral Sci. vol.14 no.1  Bauru Jan./Feb. 2006doi: 10.1590/S1678-77572006000100012

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

References1.Picker R, Micro electrical neuromuscularstimulation. Network-Electrix 1987; (March):S72–S74. Efficacy of TENS and TENS-like devices in

pain relief 41Pain Reviews 2001; 8: 00–00stimulation parts 1 and 2. Clin Man Phys Ther 1988; 9:

10–33.2. Mercola JM, Kirsch DL. The basis for microcurrentelectrical therapy in conventional medical practice.J Adv Med 1995; 8(2). Available from: URL:http://www.harborside.com/naspenmed/page8.htm[Accessed 15-Jan-03]3.Kirsch DL, Lerner FN. Electromedicine: The otherside of physiology. In: Weiner R ed. The Textbookof the America Academy of Pain Management,Innovations in pain management: a practical guidefor clinicians, vol. 4 update. Winter Park, FL: GRPress, 1995. Available from: URL:http://www.alternatives.com/raven/cpain/chap23-0.html [Accessed 15-Jan-03]

4.DuPont JS, Graham R, Tidwell JB. Trigger pointidentification and treatment with microcurrent.Cranio 1999; 17: 293–96.5. Heffernan MS. Comparative effects of microcurrentstimulation on EEG spectrum and correlationdimension. 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 cellulardedifferentiation by means of very small electricalcurrents. 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, eleventhedition. Edinburgh: Churchill Livingstone, 2002:313–34.9. Cheng N, Hoof HV, Bockx E. The effects ofelectric current on ATP generation, proteinsynthesis, and membrane transport in rat skin. ClinOrthop Rel Res 1982; 171: 264–72.

10.Seegers JC, Engelbrecht CA, van Papendorp DH.Activation of signal-transduction mechanisms mayunderlie the therapeutic effects of an appliedelectric field. Med Hypotheses 2001; 57: 224–30.11. Weber MD, Servedio FJ, Woodall WR. The effectsof three modalities on delayed onset musclesoreness. J Orthop Sports Phys Ther 1994; 20:236–42.12. Lambert MI, Marcus P, Burgess T, Noakes TD.Electro-membrane microcurrent therapy reducessigns and symptoms of muscle damage. Med SciSports Exerc 2002; 34: 602–607.13. Johnson MI, Penny P, Sajawal MA. Anexamination of the analgesic effects of microcurrentstimulation (MES) on cold-induced pain in healthysubjects. Physiother Theory Pract 1997; 13: 293–301.14. Lerner F, Kirsch D. A double blind comparativestudy of micro-stimulation and placebo effect inshort term treatment of the chronic back painpatient. J Chiropract 1981; 15: 101–106.15. Branco K, Naeser MA. Carpal tunnel syndrome:clinical outcome after low-level laser acupuncture,microamps transcutaneous electrical nervestimulation, and other alternative therapies – anopen protocol study. J Altern Complement Med1999; 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. Acomparison with transcutaneous electrical nervestimulation (TENS). Headache Q 1992; 3: 434–37.17. Bertolucci LE, Grey T. Clinical comparative studyof microcurrent electrical stimulation to mid-laserand placebo treatment in degenerative joint diseaseof the temporomandibular joint. Cranio 1995; 13:116–20.18. Wolcott L, Wheeler P, Hardwicke H, Rowley B.Accelerated healing of skin ulcers byelectrotherapy. South Med J 1969; 62: 795–801.19. Nessler J, Mass D. Direct-current electricalstimulation of tendon healing in vitro. Clin OrthopRel Res 1987; 217: 303–12.20. Oweye I, Spielholz N, Fetto J, Nelson J. Lowintensitypulsed galvanic current and the healing oftenotomized rat achilles tendons: preliminary reportusing load-to-breaking measurements. Arch PhysMed Rehabil 1987; 68: 415–18.21. Richez J, Chamay A, Bieler L. Bone changes dueto pulses of direct electric microcurrent. VirchowsArch A Pathol Anat 1972; 357: 11–18.

22. Seegers JC, Lottering ML, Joubert AM et al. Apulsed DC electric field affects P2-purinergicreceptor functions by altering the ATP levels in invitro and in vivo systems. Med Hypotheses 2002; 58:171–76.23. Rowley BA. Electrical current effects on E. coligrowth rates. Proc Soc Exp Biol Med 1972; 139:929–34.24. Rowley BA, McKenna JM, Chase GR, Wolcott LE.The influence of electrical current on an infectingmicroorganism in wounds. Ann N Y Acad Sci 1974;238: 543–51.25. Rowley BA, McKenna JM, Wolcott LE.Proceedings: The use of low level electrical currentfor enhancement of tissue healing. Biomed SciInstrum 1974; 10: 111–14.26. Leffmann D, Arnall D, Holmgren P, Cornwall M.Effect of microamperage stimulation on the rate ofwound healing in rats. A histological study. PhysTher 1994; 74: 195–200.27. Byl NN, McKenzie AL, West JM et al. Pulsedmicroamperage stimulation: a controlled study ofhealing of surgically induced wounds in Yucatanpigs. 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 electriccurrent in the treatment of ulcers of the leg due tochronic venous insufficiency. Preliminary report ofthree cases. Am J Surg 1968; 115: 683–87.30. Gault W, Gatens P. Use of low intensity directcurrent in management of ischemic skin ulcers.Phys Ther 1976; 56: 265–69.31. Sinitsyn L, Razvozva E. [Effects of electricalmicrocurrents on regeneration processes in skinwounds.] Ortop Travmatol Protez 1986; Feb (2):25–28 (Rus).32. Carley P, Wainapel S. Electrotherapy foracceleration of wound healing: low intensity directcurrent. Arch Phys Med Rehabil 1985; 66: 443–46.33. Mulder G. Treatment of open-skin wounds withelectric stimulation. Arch Phys Med Rehabil 1991;72: 375–77.34. Feedar JA, Kloth LC, Gentzkow GD. Chronicdermal ulcer healing enhanced with monophasicpulsed electrical stimulation. Phys Ther 1991; 71:639–49.35. Gardner SE, Frantz RA, Schmidt FL. Effect ofelectrical stimulation on chronic wound healing: ameta-analysis. Wound Repair Regen 1999; 7:495–503.

36.Low J, Reed A. Electrical stimulation of nerve andmuscle. In: Low J, Reed A eds. Electrotherapyexplained: 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:HoyskoleForlaget 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. Paintreatment with Rebox. Fysioterapeuten 1990; 11:8–13.40. Nussbaum EL, Gabison S. Rebox effect onexercise-induced acute inflammation in humanmuscle. 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 woundhealing with high voltage, monophasic, pulsedcurrent. Phys Ther 1988; 68: 503–508.43. Griffin JW, Tooms RE, Mendius RA, Clifft JK,Vander Zwaag R, el-Zeky F. Efficacy of highvoltage pulsed current for healing of pressure ulcersin patients with spinal cord injury. Phys Ther 1991;71: 433–42.

44.Jette D. Effect of different forms of transcutaneouselectrical nerve stimulation on experimental pain.Phys Ther 1986; 66: 187–93.45. Morris L, Newton RA. Use of high voltage pulsedgalvanic stimulation for patients with levator anisyndrome. Phys Ther 1987; 67: 1522–25.46. Asbjorn O. Treatment of tennis elbow withtranscutaneous nerve stimulation (TNS). Availablefrom: URL: http://www.paingone.com/ 2000[Accessed 01-Jul-02]47. Ivanova-Stoilova T, Howells D. The usefulness ofPainGone pain killing pen for self-treatment ofchronic musculoskeletal pain - a pilot study[Abstract]. In: The Pain Society of Great BritainAnnual Scientific Meeting Abstracts; 2002 Apr 9–12;Bournemouth, UK; abstr. 104.48. Kirsch DL, Smith RB. The use of cranialelectrotherapy stimulation in the management ofchronic pain: a review. NeuroRehabilitation 2000;14: 85–94.49. Limoge A, Robert C, Stanley TH. Transcutaneouscranial electrical stimulation (TCES): a review 1998.Neurosci Biobehav Rev 1999; 23: 529–38.50. Southworth S. A study of the effects of cranialelectrical stimulation on attention andconcentration. Integrative Physiol Behav Sci 1999;34: 43–53.51. Taylor D, Lee C, Katims J. Effects of cranialtranscutaneous electrical nerve stimulation innormal subjects at rest and during psychologicalstress. 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

TOMR. SUNDARA S. BALAMURUGANPHYSIOTHERAPISTAL SABAH GENERAL HOSPITAL