BTL BTL-5000 User manual

BTL-5000

Electrotherapy

U S E R ‘ S G U I D E

v 1 1 0 z 3 A M 1 7 / 1 1 / 2 0 0 4

E L E C T R O T H E R A P Y – U S E R ‘ S G U I D E

CONTENTS
1	GENERAL EFFECTS OF ELECTROTHERAPY .................................................................................................		4
2	CLASSIFICATION OF ELECTROTHERAPEUTIC CURRENTS.........................................................................		5
2.1		Galvanic Current...............................................................................................................................................	5
2.2		Pulse Direct Current .........................................................................................................................................	5
2.3		Alternating Current............................................................................................................................................	5
2.3.1		TENS.........................................................................................................................................................	5
2.3.2		Classic (Four-pole) Interference ................................................................................................................	6
2.3.3		Two-pole Interference................................................................................................................................	6
2.3.4		Isoplanar Interference................................................................................................................................	6
2.3.5		Dipole Vector Field ....................................................................................................................................	6
3	EFFECTS OF ELECTROTHERAPY....................................................................................................................		7
3.1		Analgesic Effect................................................................................................................................................	7
3.2		Myorelaxation and Spasmolytic Effect ..............................................................................................................	8
3.3		Trophic Effect ...................................................................................................................................................	8
3.4		Antiedematous Effect........................................................................................................................................	8
3.5		Placebo Effect ..................................................................................................................................................	8
3.6		Deferring Effect.................................................................................................................................................	9
3.7		Contraindications for Electrotherapy.................................................................................................................	9
3.8		Symbols of Effects A-E-T-R-S ..........................................................................................................................	9
4	SETUP AND CONTROL OF ELECTROTHERAPY...........................................................................................		10
4.1		Common Parameters......................................................................................................................................	10
4.1.1		Output Mode............................................................................................................................................	10
4.1.2		Polarity ....................................................................................................................................................	10
4.1.3		Therapy Time ..........................................................................................................................................	10
4.1.4		Physiological Effects................................................................................................................................	10
4.2		TENS ..............................................................................................................................................................	11
4.2.1		Type ........................................................................................................................................................	11
4.2.2		Pulse, Frequency, Pause ........................................................................................................................	11
4.2.3		Electro Parameters..................................................................................................................................	11
4.3		2–pole, 4–pole, Isoplanar and Dipole Interference .........................................................................................	11
4.3.1		Carrier Frequency....................................................................................................................................	11
4.3.2		Electro Parameters..................................................................................................................................	11
4.3.2.1		Isoplanar Interference – "Field Rotation"............................................................................................	11
4.3.2.2		Dipole Interference – Dipole Rotation ................................................................................................	12
4.4		Russian Stimulation ........................................................................................................................................	12
4.4.1		Carrier Frequency....................................................................................................................................	12
4.4.2		Pulse Frequency, DF...............................................................................................................................	12
4.4.3		Pulse Length (Electro Parameters)..........................................................................................................	12
4.5		Mid-frequency Surges.....................................................................................................................................	12
4.5.1		Carrier Frequency....................................................................................................................................	12
4.5.2		Pulse, Frequency, Pause ........................................................................................................................	12
4.5.3		Electro Parameters..................................................................................................................................	12
4.6		Diadynamic Currents ......................................................................................................................................	13
4.6.1		Type ........................................................................................................................................................	13
4.6.2		Base ........................................................................................................................................................	13
4.6.3		Electro Parameters..................................................................................................................................	13
4.6.3.1		Basic Frequency ................................................................................................................................	13
4.6.3.2		Interruption.........................................................................................................................................	13
4.7		Pulses: Rectangular, Triangular, Exponential and with Exponential Rise, Combined, Interrupted .................	14
4.7.1		Type ........................................................................................................................................................	14
4.7.2		Pulse, Frequency, Pause ........................................................................................................................	14
4.7.3		Electro Parameters..................................................................................................................................	14
4.8		Stimulation Pulses ..........................................................................................................................................	14
4.8.1		Type ........................................................................................................................................................	14
4.8.2		Pulse, Pause ...........................................................................................................................................	14
4.8.3		Electro Parameters..................................................................................................................................	14
4.8.3.1		Sound Signal......................................................................................................................................	14
4.9		Träbert Current, Leduc Current, Faradic Current, Neofaradic Current, H-waves............................................	15
4.10		Galvanic Current ..........................................................................................................................................	15
4.10.1		Type .......................................................................................................................................................	15

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4.11		Microcurrents ...............................................................................................................................................	15
4.11.1		Type .......................................................................................................................................................	15
4.11.2		Pulse, Frequency, Pause .......................................................................................................................	15
4.11.3		Electro Parameters.................................................................................................................................	15
4.12		Spastic Stimulation.......................................................................................................................................	15
4.12.1		Pulse, Delay, (Frequency) ......................................................................................................................	15
4.13		Pulse Modulation .........................................................................................................................................	16
4.13.1		Constant Frequency ...............................................................................................................................	16
4.13.2		Random Frequency................................................................................................................................	16
4.13.3		Burst .......................................................................................................................................................	16
4.13.4		Sine Surges............................................................................................................................................	16
4.13.5		Trapezoid Surges ...................................................................................................................................	16
4.13.6		Symmetric Surges ..................................................................................................................................	16
4.14		Interference – parameters............................................................................................................................	17
4.14.1		AMF and Spectrum.................................................................................................................................	17
4.14.2		Frequency Sweep ..................................................................................................................................	17
4.15		Electrodiagnostics........................................................................................................................................	18
4.15.1		Motor Point Detection .............................................................................................................................	18
4.15.2		Rheobase – Chronaxie...........................................................................................................................	18
4.15.3		Accommodation Coefficient....................................................................................................................	18
4.15.4		I/t Curve..................................................................................................................................................	18
4.15.4.1		I/t Curve – Options............................................................................................................................	18
4.15.4.2		I/t Curve – Properties........................................................................................................................	19
4.15.4.3		I/t Curve – Measuring .......................................................................................................................	19
4.16		Combined Therapies....................................................................................................................................	19
4.16.1		Polarity of Ultrasound Head....................................................................................................................	19
4.16.2		Setting of Parameters of Combined Therapy .........................................................................................	19
4.16.2.1		BTL-5000 Combi Devices .................................................................................................................	19
4.16.2.2		Connected Devices BTL-5000 Pulse and BTL-5000 Sono ...............................................................	20
4.17		Specific Electrotherapy Settings ..................................................................................................................	20
4.17.1		Check of Contact of Electrodes ..............................................................................................................	20
4.17.2		Measuring of Electrodes.........................................................................................................................	20
5	RECOMMENDATIONS FOR ELECTROTHERAPY ..........................................................................................		21
5.1		Use of Plate Electrodes ..................................................................................................................................	21
6	TECHNICAL PARAMETERS OF ELECTROTHERAPY ...................................................................................		22
6.1		Parameters of Particular Therapies – Currents ..............................................................................................	22
6.1.1		TENS.......................................................................................................................................................	22
6.1.2		4-pole Interference ..................................................................................................................................	22
6.1.3		2-pole Interference ..................................................................................................................................	22
6.1.4		Isoplanar Interference..............................................................................................................................	22
6.1.5		Interference - Dipole Vector.....................................................................................................................	22
6.1.6		Russian Stimulation.................................................................................................................................	23
6.1.7		Mid-frequency Surges (Amplitude-modulated) ........................................................................................	23
6.1.8		Rectangular Pulses .................................................................................................................................	23
6.1.9		Triangular Pulses.....................................................................................................................................	23
6.1.10		Exponential Pulses, Pulses with Exponential Rise .................................................................................	23
6.1.11		Combined Pulses ...................................................................................................................................	24
6.1.12		Stimulation Pulses (for Stimulations according to Electrodiagnostics).................................................	24
6.1.13		Interrupted Pulses ..................................................................................................................................	24
6.1.14		Träbert, Ultra-Reiz 2-5............................................................................................................................	24
6.1.15		Leduc......................................................................................................................................................	24
6.1.16		Faradic, Neofaradic ................................................................................................................................	25
6.1.17		H-wave ...................................................................................................................................................	25
6.1.18		Diadynamics...........................................................................................................................................	25
6.1.19		Galvanic Current (Iontophoretic) ............................................................................................................	26
6.1.20		Microcurrents..........................................................................................................................................	26
6.1.21		Spastic Stimulations (according to Hufschmidt) .....................................................................................	26
6.1.22		High-voltage Therapy (HVT)...................................................................................................................	26
6.2		Modulation of Currents ...................................................................................................................................	27
6.3		Frequency Sweep (Interference) ....................................................................................................................	27
6.4		Steps of Setting of Parameters.......................................................................................................................	27
6.5		Maximum Intensity Values..............................................................................................................................	28

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1 G E N E R A L E F F E C T S O F E L E C T R O T H E R A P Y

Electrotherapy is one of widespread types of physical therapy (PT). When correctly indicated and applied it is very effective. However, it cannot be lifted out of the context of comprehensive therapy, neither regarded as a cure-all. Most of the physical procedures have similar effects and, depending on the parameters, some of them may be dominant. The main effects are:

•analgesic,

•myorelaxation, trophic and antiedematous.

By selection of a procedure and its parameters you can select one of the above stated effects or their combination.

P.S. An important note about continuing education

Continuing education is a very important aspect of healthcare delivery. Many excellent resources are today available to expand a user's knowledge about many aspects of electrical stimulation therapy. BTL recommends a thorough review of this guide prior to operating the equipment and a search of educational reading material on the internet.

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2 C L A S S I F I C A T I O N O F

E L E C T R O T H E R A P E U T I C C U R R E N T S

2 . 1 G A L V A N I C C U R R E N T

Galvanic current (or “continuous”) is current of constant intensity. It is always DC. It is used mostly for iontophoresis, or its trophic stimulative (hyperaemic) effect is utilized. A big disadvantage of the galvanic current is the risk of chemical damage of the tissue under the electrodes. The damage may be caused by the hydrochloric acid which originates under the anode or by the soda lye which originates under the cathode. Similar danger of the tissue damage can occur also at any direct current (e.g. diadynamic). Direct currents must not be used for the patients with metallic implants!

At present this current is often substituted by galvanic intermittent current. This current has the same effects (galvanic component is 95 %) but thanks to interrupting of the originally continuous intensity by the frequency 8 kHz it is better tolerated by the patients. It is suitable especially for iontophoresis.

2 . 2 P U L S E D I R E C T C U R R E N T

The pulse direct current is current of variable intensity but only one polarity. The basic pulse shape may vary. It includes e.g. diadynamics (combination of pulse DC – "dosis" and galvanic current – "basis"), rectangular (e.g. Träbert current), triangular and exponential pulses of one polarity.

Depending on the used frequency and intensity it has the stimulation, trophic and analgesic effects. Generally, direct current with variable intensity implies the same risks as galvanic current (corrosion of the skin surface) and therefore it requires careful observance of correct procedure, especially the correlation between the applied intensity and the length of application.

The main effect is the stimulation which is important especially below the cathode (green negative electrode).

2 . 3 A L T E R N A T I N G C U R R E N T

In comparison with DC, alternating current is safer and better subjectively tolerated by the patient. The basic pulse shape again may be various – rectangular, triangular, harmonic sinusoidal, exponential or combined. It can be alternating, symmetric or asymmetric. The DC component is always zero, which prevents from chemical damage of the skin under the electrodes.

Therefore this current enables also long-lasting applications, even for the patients with metal implants. Implanted electronic stimulators such as pacemakers etc. are indeed absolutely contraindicated. Nowadays the low-power pulses – TENS (Transcutaneous Electrical Nerve Stimulation) and interference – gain ground among the alternating currents. Use of alternating currents in the contact electrotherapy implies much lower stress on the tissue under the electrode.

For these types of current the capacitive component of skin resistance is involved, and also thanks to it these currents are very well tolerated by the patients.

In general:

•short duration of the pulse improves the subjective perception,

•the zero average value (DC component) prevents from chemical damage of the tissue,

•frequency and amplitude are responsible for the required therapeutic effect.

2 . 3 . 1

T E N S

TENS = transcutaneous electrical nerve stimulation

Nowadays very prevalent group of currents which substitutes the standard applications of diadynamic currents, Russian stimulation, etc. TENS pulses are low-power and have zero DC component. Therefore, besides suppression of chemical damage of the tissue, the risk of electric damage of the tissue is also minimized.

As can be seen from their name, these currents are intended for stimulation of nerve stems or nerve fibres. Their major utilization is in alleviation of pain, inhibition of itching, etc. The mechanism of their effect is most often explained by the so-called gate theory of pain. Besides treating of pain, these currents can be also effectively utilized in electrogymnastics (stimulation of non-denervated muscles).

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2 . 3 . 2

C l a s s i c ( F o u r - p o l e ) I n t e r f e r e n c e

Four electrodes are located crosswise. Two frequency signals with different frequencies fA and fB are brought to the tissue. Their interference in the tissue induces a low-frequency surge in the centre of the cross; its frequency is:

AMF = fA - fB.

This surge of the frequency AMF has therapeutic effect, both basic currents of the frequency fA and fB are used only for "transport" of the AMF surges to the tissue. The fA frequency is constant, changes of the fB frequency by the value of so-called Spectrum serve for change of the resulting frequency AMF to the frequency AMF + Spectrum. Interference has similar effects as the low-frequency currents although it is carried by current of higher frequency and does not stress the tissue under the electrode so much. The carrier frequency of channels ranges from 3.5 to 10 kHz. The higher this frequency, the better is it tolerated by the patient. The advantage of the four-pole interference is the indepth aiming of the treated area and lower stress on the superficial skin. Therefore there can be set higher intensity values than for the two-pole application.

2 . 3 . 3

T w o - p o l e I n t e r f e r e n c e

According to the new recommended terminology, these groups should be called "bipolar-applied amplitude-modulated mid-frequency currents"; however, owing to the length of this name we are keeping to the original one.

The resulting low-frequency current of the frequency AMF (or AMF + Spectrum) is created by the equipment. Therefore two electrodes are sufficient for its application. The absolute intensity values that can be reached are lower than for the classic interference (this current is worse tolerated by the patient than the classic interference) and at the same time the stress on the skin surface is higher than for the classic interference.

Its advantage is that it can be applied by the point electrode and thus it can be effectively used in combination with therapeutic ultrasound.

2 . 3 . 4

I s o p l a n a r I n t e r f e r e n c e

A special form of the four-pole interference where the additional modulation of both channels enables to distribute the treated area to the whole space of the current circuits’ interlacement. It implies that placing of individual electrodes is much easier – those do not need to form a perfect cross anymore. The effect of these currents is very diffuse, in-depth and delicate.

2 . 3 . 5

D i p o l e V e c t o r F i e l d

Additional phase and amplitude modulation of basic signals of the four-pole interference enables to achieve the only one direction of the electric field’s acting (so-called dipole is created in the tissue). In the direction of this dipole, the modulation of the field reaches up to 100 %, in the other directions it is almost zero. You can either rotate this dipole (abscissa) manually, and thus precisely aim the required effect of the therapy at the treated tissue, or let it rotate automatically.

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3 E F F E C T S O F E L E C T R O T H E R A P Y

3 . 1 A N A L G E S I C E F F E C T

Pain is a multi-factor phenomenon and the practice positively shows that various types of pain respond more or less well to various physiotherapeutic, i.e. also electrotherapeutic procedures. There are several mechanisms of the analgesic effect of electrotherapy – besides the well-known gate theory of pain there is also proven increase of production of endogenous opiates. The analgesic effect is also supported by trophic effects of the flowing current. Timely myorelaxation removes the muscular hypertone and thus also pain of myofascial origin. Since the analgesic effect of electrotherapy is fundamental and most utilized it shall be described in a little more details.

Pain is usually simply defined as an unpleasant sensuous and emotional experience connected with actual or potential damage of the tissue. We usually distinguish between acute and chronic pain. Acute pain is short-lasting (maximum several days or weeks). It is caused by mechanical damage of the tissue or by a disease, comes immediately after the painful stimulus and subsides after its ending; the intensity of pain depends on the intensity of stimulation. On the other hand, chronic pain is long-lasting (more than 3 months) or it recurs; its intensity does not depend on the intensity of stimulation; emotions particularly play a leading role.

The now generally accepted theory of perception of pain is based on the assumption of existence of a specific sensory system which transfers information from receptors of pain (nociceptors) to the central nervous system by preformed special nerve paths. However, the process is in fact much more complicated and persons interested can learn about it from the available specialized literature.

To understand the effects of electrotherapy it is important to understand especially the modulation factors which can influence the perception and transfer of the painful stimulus:

•First crucial modulation factor is described by the so-called gate theory of pain which is based on the presumption that the nervous mechanism in posterior medullary horns act as a small gate which lets through only limited flow of nervous impulses from the peripheral afferent fibres to the central nervous system, depending on how much it is opened. Stimulation of some particular fibres can modulate the extent of the gate’s opening or closing for pain and thus also increase or decrease transfer of the nociceptive information. A similar gate system is supposed to exist also on the level of thalamus.

•The other important modulation factor is described by the neuromodulation theory which is based on the analgesic effect of some substances belonging to the group of so-called neuromodulators, especially endorphins

and encephalins. These substances are produced in the central nervous system and according to the mentioned theory they have crucial importance especially for subjective perception of pain.

Anyway, the analgesic effect of electrotherapy is used most often. To make PT a real benefit for the patient, it is necessary to observe the following principles:

•Do not suppress the signalling and protective function of pain (which is especially important for acute pain!), i.e. at first decrypt the information being signalled by the pain, properly determine the diagnosis or at least a preliminary hypothesis and only then intervene against the pain. Pain modified by PT or analgesics can loose its specificity insomuch that later it cannot be decrypted.

•Together with application of analgesic PT it is necessary to considerably reduce administering of analgesics. This rule is very important, owing to the possibility of relatively precise aiming of the analgesic effect of PT (in contrast to the unaimed effect of medicaments) and possible undesired interaction between PT and the medicaments.

•When choosing the type of PT consider the expected effect (gate theory, endorphins).

•For chronic or recurrent complaints do not obstinately apply various types of PT, but examine the locomotive system (or get it examined by a specialist) – very often the source of these complaints is far from the place of

projection of pain (catenation-generalization).

For stimulation of thick, myelinized nerve fibres of A beta and delta types (gate theory) it is suitable to use lowfrequency currents of the frequency 50 - 150 Hz (optimum 100 Hz) and intensity at or above threshold sensitivity. This method is effective especially for acute and segmentally localised pains. For chronic painful syndromes it is most suitable to use low frequencies 2 - 8 Hz and intensity at the highest tolerable level (up to the threshold of pain); thus thin fibres of C type are stimulated (creation of endorphins). For achievement of combination of both above-stated mechanisms of easing of pain use the "burst modulation". The carrier frequency should be about 100 Hz, burst frequency up to 10 Hz (even frequencies lower than 1 Hz are not exceptional). Currents with burst modulation bring the cumulated analgesic effect. By the depth of the required effect the procedures can be ordered as follows (from the most superficial to the deepest ones):

•analgesic effect of anelectrotonus (galvanic current)

•diadynamic currents LP and CP-ISO

•Träbert current

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•TENS

•2-pole interference (amplitude-modulated mid-frequency currents),

•4-pole interference, isoplanar interference and vector fields

3 . 2 M Y O R E L A X A T I O N A N D S P A S M O L Y T I C E F F E C T

Especially after the posturographic examination had proved that overall administering of so-called myorelaxancies has a negative long-term influence on the body posture, the possibility of exact aiming at the hypertonic muscle has been regarded as an especially valuable advantage of myorelaxation procedures. At overall application of myorelaxancies there are first affected the phasic muscles which have been already weakened due to the layer syndrome. Later, or when stronger dose is applied, there are also affected the tonic muscles and only at the end, at the strongest dosage, also hypertonic muscles are positively affected. This effect lasts for several weeks and affects the static of the spine very negatively even after the acute complaints have subsided.

Procedures with myorelaxation effect include therapeutic ultrasound, 2-pole interference with contour frequency 100 – 200 Hz, 4-pole interference currents and high-voltage therapy in the same frequency modulation band. For small superficial muscles especially on hands also paraffin can be used.

A favourable side effect of myorelaxation is also the analgesic effect.

3 . 3 T R O P H I C E F F E C T

is caused by hyperaemia which occurs in almost all types of PT (except cryotherapy). Since the mechanism of hyperaemia in various types of PT is different, it is necessary to take these mechanisms into account so as to be able to select the particular PT. Generally, galvanization can be recommended, especially longitudinal (capillary hyperaemia, vessel eutonisation), low-frequency currents of the frequency 30 - 60 Hz and the intensity at or above the threshold motor activity level (muscle micropump) or ultrasound, laser, polarized specified achromatic light, vacuumoverpressure therapy, etc.

The trophic effect may be partly caused by the fact that most forms of PT, esp. laser, biolamp and magnetotherapy, bring energy into the organism, to be used by cells (or other structures) for their activity.

The trophic hyperaemic effect is also usually connected with the analgesic effect.

3 . 4 A N T I E D E M A T O U S E F F E C T

is practically connected with hyperaemia, vessel eutonisation and higher capillary permeability. Therefore the therapies referred to as trophic are also antiedematous (see the previous paragraph).

3 . 5 P L A C E B O E F F E C T

Opponents of the physical therapy tend to refer to its effects as placebo.

If PT is applied accidentally, without knowledge of its mechanism, accurate aiming and dosage (as it often happens), its effects can be called like this. Exact verification of the effects of PT faces many troubles.

•Owing to the fact that lege artis application of PT requires to take into account especially the patient's individuality and momentary functional status (including the limbic system status, mood, muscular tonus, season of the year, weather, motivation, attitude to the troubles, etc.) it is almost impossible to create a group for further statistical processing. Creation of a control group is practically out of question.

•The effect of PT lies almost only in affecting of the afferent system. The afferent system processes all data, including the visual, auditory, tactile and other analysers. Since very often a slight stimulus is sufficient to deviate the organism from the existing functional balance (even the pathological one) and, using its enormous selfreparation abilities, the organism helps itself, there cannot be carried out e.g. a blind experiment without at least minimum excitation of an afferent system and/or higher components of CNS.

•Functional defects of the locomotive organs which belong to the main positive effects of PT tend to self-repair, if they are not prevented from that (e.g. by inappropriate pharmacotherapy). If correctly indicated, PT both initiates and accelerates this self-reparation, which indeed can be hardly exactly proved.

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3 . 6 D E F E R R I N G E F F E C T

A "troublesome" patient is often invited for the check examination only after undergoing of usually ten procedures and "hopefully will be better then". This way of thinking is immoral, unethical and discreditable to a specialist, but nevertheless most of the existing prescriptions of PT unfortunately belong to this category. In some surgeries the patients are even told that the effect of the chosen PT will come only after several months (!), which means that the physician fully relies on the organism's self-reparation abilities.

Indication of PT then should not be based only on the diagnosis, especially if the diagnosis is confusing, e.g. periarthritis humeroscapularis etc.

The attending physician should know the answers to the following questions:

•What is the cause of the complaints, i.e. usually pain?

•Is the defect functional or organic?

•Where was the defect initiated – where is (are) the key area(s)?

•Which of the above-mentioned effects of PT is the most important for the patient at the moment?

•Is there not a risk of aggravation or organification of the functional defect after the chosen PT?

By these answers the physician should choose the type, location, intensity, frequency and total number of treatments, and, in relation to them, also the date of the check examination of the patient.

3 . 7 C O N T R A I N D I C A T I O N S F O R E L E C T R O T H E R A P Y

•active TB

•allergy to the solutions used for moistening of the electrode sponge covers

•application in the area of heart or eyes

•pacemaker

•cardiovascular diseases

•cochlear implants

•metal implants and/or malignancies in the current path

•skin defects and inflammations

•bleeding

•menstruation

•tumours

•defects of sensitivity in the point of location of the electrode

•psychopathological syndromes and organic psychosyndromes

•multiple sclerosis

•pregnancy

•inflammations of veins and lymphatic paths

3 . 8 S Y M B O L S O F E F F E C T S A - E - T - R - S

Symbols of effects of therapy used in the equipment have the following meaning:

A	-	analgesic
E	-	antiedematous
T	-	trophic
R	-	myorelaxation
S	-	myostimulation

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