Electromedicine - The Textbook of the American Academy of Pain Management
Daniel L. Kirsch, Ph.D.
Fred N. Lerner, Ph.D.
Fred N. Lerner, Ph.D.
Sciences rarely evolve scientifically. At this junction in history economics play the major role in determining priorities. The pure pursuit of scientific knowledge has practically been abandoned from the list of factors influencing funding and reimbursement for scientific advancements. Science, and the scientific method, originally evolved to help us understand ourselves and the universe we live in. For government and insurance company bureaucrats who are not true scientists themselves, it has become an excuse to avoid bothering to understand new developments; even to deny obviously observable phenomena. Yet eventually science does seem to prevail, even if only by a complex and seemingly unrelated series of events. Experimental and experiential data in electromedicine is already accelerating independent of, and even in defiance of the standard means of support and controls. Perhaps more than any other therapeutic option, electromedicine is used by at least some of the practitioners from all of the health care professions, as well as by patients themselves.
A recent study examined the prevalence of so-called "unconventional medicine" in the United States. Eisenberg (1993) reported that Americans spent $13.7 billion for alternative treatments in 1990 of which $10.3 billion was out-of-pocket, non-reimbursable expenditures. This is comparable to the $12.8 billion spent out-of-pocket annually for hospital expenses. In addition, the study determined that in 1990 Americans made an estimated 425 million visits to these practitioners of unconventional medicine compared to 388 million visits to all primary care physicians.
One definition of conventional is "conforming to accepted standards." Another definition is "established by accepted usage; ordinary or usual" (Stein, 1980). The latter definition could be interpreted to mean that what is being called unconventional medicine has become conventional. This seems to be confirmed by the 37 million more visits to these practitioners. It is unlikely that patients would continue to spend their time along with such large sums of money if they were not getting results, or if safe and effective relief was more readily available in the more comprehensive context of conventional medicine.
Harvard Medical School is beginning to teach "alternative medicine" and the National Institutes of Health has set up an Office of Alternative Medicine to award grants to researchers in this emerging field. Many patients site the side-effects and short-term relief of drug therapy as the primary reason they seek alternative care. New developments in electromedical technology offers physicians safe, effective, and long-lasting treatment options for a wide variety of disorders for these patients. Unfortunately, most conventional physicians are slow to accept new developments.
It is ironic that change moves slowest in the one science most responsible for our very existence, biology, or more appropriately for our purposes; medicine as applied biological science. It is simply easier, safer and less time consuming for someone who struggled to become part of the status quo to maintain it. It is certainly a major shock to one's conception of reality to learn that it is incomplete or incorrect. Yet physiology was taught as a complete science 100 years ago, again today, and most likely it shall be taught that way 100 years from now.
A classic and often cited example of medicine's reluctance to change occurred last century when Lord Joseph Lister advised surgeons to wash their hands before operating (Lister, 1979). Even well after Louis Pasteur's discovery of bacteria, surgeons were still not willing to believe and accept the need to be clean into the early part of this century (Lyons & Petrucelli, 1987). In fact, Pasteur could have been considered an unconventional practitioner when he insisted surgeons wash their hands before operating on his daughter. The Johnson brothers were the real driving force behind the widespread use of sterilization which resulted from their starting a company to manufacture antiseptic bandages. It was only after industry took the initiative that doctors came to accept the reality and consequences of our microbacterial cohabitants.
Dr. Lawrence D. Wilson (1993) suggested that "drug medicine" is able to maintain a virtual monopoly in America due to the following reasons:
a. Medical practice acts restrict competition and limit innovation. State licensing boards not only police their members, but police the entire population.
b. Prescription laws prevent public access to medical products.
c. Laboratory regulations prevent public access to medical laboratories.
d. Hospital regulations block the establishment of alternative hospitals and clinics.
e. Insurance mandates block innovation and limit competition in the insurance industry.
f. Subsidies to allopathic schools stifle the ability of other healing schools to compete fairly.
g. Subsidies for drug research amount to billions. Taxpayer dollars flow to dozens of government institutes such as NIH, HIMH, and NHI. Patent agreements often tie these labs to drug companies. Federal research agencies frequently ridicule alternative therapies. By stifling 'the competition', NCI and other agencies often have a counterproductive effect.
h. Medicare and Medicaid powerfully support the monopoly. They are infiltrated by private interest groups, and only reimburse for allopathic treatment.
i. A bloated and powerful FDA, in the name of protecting the public, prohibits public access to many harmless health care products. Manufacturers and retailers are terrorized by a regulatory agency that does not have to follow due process of law.
On August 31, 1993, the U.S. Food and Drug Administration published a proposed ruling in the Federal Register for reclassification of cranial electrotherapy stimulators. The FDA exhibited extreme bias in their appraisal against this effective and harmless modality. Unless the CES industry can quickly raise millions of dollars for pre-market approval for a technology that has been on the market in the U.S. for well over 20 years, CES will no longer be available in the United States 90 days after the FDA publishes their final ruling.
The FDA and American drug medicine are not as opposed to diagnostic developments in electromedicine due to of several factors. Bentall (1990) reasoned that diagnostic technology is more easily introduced because it enhances the capability and reputation of the practitioner within an acceptable risk/reward equation, without jeopardy or the need to understand its physics. Electromedical imaging systems succeeds on its instantaneous merits. Electrocardiology, electroencephalography, electromyography and magnetic resonance imaging are just a few examples of relatively recent innovations that have dramatically improved the abilities of health practitioners to arrive at more precise diagnoses. However, allopathic practitioners would like to have the physiology of therapy explained within the satisfaction of their domain of chemical knowledge, rather than venture into a new physiological paradigm.
Within the framework of the established and acceptable therapeutic practice based on chemistry, it does not seem so urgent to understand the physiology of new developments quite as clearly. For once one acknowledges the core philosophy, it is human nature to accept the whole concept, and with it, its newest additions. As a result, there is an ever increasing supply of new patented drugs.
Although the search for new pain controlling drugs continues, none appear to be much of an improvement over morphine, codeine, opium and heroin. The latter was hailed as a nonaddictive wonder drug in 1898 when the Bayer Co. of Germany named it from the German word "heroish" meaning powerful or heroic. Of course, heroin turned out to be three times more addictive than morphine and eventually banned as a therapeutic agent in the United States. Only about a decade ago Johnson & Johnson announced its breakthrough of a new drug that was to have been stronger than morphine and no more addictive than aspirin. Unfortunately their product, Zomax, turned out to be fatal in an unacceptable number of users.
The pain, or at least concern about the pain is relieved with drugs, but there are the concerns of side-effects, addiction and worse of all, tolerance. Binding sites being what they are, systemic pharmaceutical solutions do not seem very promising for the long term management of chronic pain.
Chemistry, both physiological and for therapeutic intervention, can be viewed as the existence of matter at the level of elements or compounds. Electromedicine is a means of diagnosis and treatment at the next level of matter. For every thought and action creates, or is created by electrical signals along the fibers of the nervous system.
A fresh look at physiology is needed to solve the primary medical complaint of pain. Although "fresh" is only appropriate to those who are uninformed of the plethora of information on electromedicine amassed over the last three or four decades. The answer is apparent on a smaller scale than we were able to define previously. In fact, even today, subatomic structure goes beyond the eyes fully assisted ability to squint.
Atoms are bonded electrically. This is a basic foundation necessary to understand electromedicine that was taught during the most elementary training in the basic sciences. Further in our rudimentary training we learned that there are voltage potentials across the membrane of all cells. All standard physiology textbooks define the Nernst and Goldman Equations to determine membrane and action potentials. They do not, however, speculate on the staggering significance of these facts.
If batteries are placed in series their voltage potentials are combined. A simple remote control unit may use three 1.5 volt batteries to produce the 4.5 volts needed to operate a television. The human body has trillions of cells each having a millivolt potential across their membranes. All good scientists should ask themselves why we find electricity so prevalent in biological systems.
It is already established that bioelectricity plays a major role in the control of all life's processes. Robert O. Becker, M.D. has spent more than 30 years attempting to determine how trillions of cells with hundreds of subtypes can function harmoniously in the form we call human. The result of that inquiry is a complete revolution in our previous concepts of biology (Becker, 1983).
Becker (1982) has reasoned that an electromagnetic field exists that controls all of life's processes. The original concept of such field effects can be traced back to ancient China. Traditional oriental medicine is based on the controlling power of ch'i or ki energy; a concept that predates electricity but appears to be analogous (Kirsch, 1978). Chiropractic also developed based on a similar observation termed innate intelligence by Daniel David Palmer in 1895 (Palmer, 1910). Indians use the term prana to represent the same concept. Allopathic practitioners are limited to a vague notion they call homeostasis.
In western civilization, the first documented use of electricity to manage pain was by the physician, Scribonius Largus, in 46 A.D. He claimed that just about everything headaches to gout could be cured by standing on a wet beach near an electric eel. Not surprisingly, attempts at producing pharmaceutical preparations from dead eels proved ineffective. In 1791, Luigi Galvani discovered that electrical impulses could cause muscle contraction. By 1800, Carlo Matteucci showed that injured tissue generates an electric current. The discovery of alternating current by Faraday in 1830 opened the door to the development of man-made devices as sources of electricity. Over 10,000 medical practitioners in the United States alone made use of electrotherapeutic modalities until publication of the 1910 Flexnor report which stated that there was no scientific basis for electromedicine at that time. Dr. Flexnor's report was sponsored by the American Medical Association so it is no wonder why it declared allopathic medicine superior.
Since then, arguably the greatest development in the field of electromedicine was when Becker (1981) electrically induced limb regeneration in frogs and rats as a model to study bioelectrical forces as a controlling morphogenetic field. Regeneration represents a return to embryonal control systems and cellular activities within a localized area. It can therefore be considered a more accessible and more observable form of morphogenesis. The complexity of instructions required to designate all of the details to recreate a finished extremity is impossible to transmit by previously understood biochemical processes alone.
Becker (1983) has proposed that a primitive direct current data transmission and control system exists in biological systems for the regulation of growth and healing. His studies of extraneuronal analog electrical morphogenetic fields have eliminated any rational arguments against the importance of bioelectricity for all the basic life processes. Becker has laid the groundwork for the medical professions to start to evolve towards a more reasonable integrated view of biology incorporating our understanding of both biochemistry and biophysics.
Björn Nordenström, M.D. (1983), former Chairman of the Nobel Assembly, has also proposed a model of bioelectrical control systems he calls Biologically Closed Electric Circuits. The principle is analogous to closed circuits in electronic technology. Nordenström's theory is that the mechanical blood circulation system is closely integrated morphologically and functionally with a bioelectrical system. Nordenström hypothesized that ionic and nonionic compounds interact in a way that makes selective distribution and modulation of energy possible throughout the body, even over long distances. The biological circuits are switched on by both the normal electrical activity of the organs and pathological changes, such as a tumor, injury or infection. Like Becker, Nordenström views bioelectricity as the primary catalyst of the healing process. Using the vascular interstitial system as an example, Nordenström postulated two branches of this system. The first branch, the intravascular system, proposes that walls of blood vessels act as insulators to carry energy, much like cables in a battery system. The electrical resistance of the walls of the veins and arteries is at least 200 times greater than the blood within. The intravascular plasma acts as a conductor, where ions such as sodium, calcium and chloride supply immediately available energy to the system, primarily by electrophoresis. Nordenström called these ions ionars. According to Nordenström, delayed available energy, or potential energy, is carried by blood cells which bind oxygen, as well as other chemicals such as glucose, neutral fat, nonpolar amino acids, etc. These are all noncharged packages of energy that arrive at specific sites and are released primarily by reduction/oxidation. Nordenström termed these ergonars.
The second branch addresses the interstitial system. The tissue matrix acts as an insulator while the interstitial fluid acts as a conductor. The main component that "closes" the system is the capillary membrane. These membranes act as junctions between the interstitial and vascular fluids allowing exchange of ionars and ergonars along gradients of electric potential. This theory represents a comprehensive attempt to relate anatomical components in terms of electromagnetic forces, rather than limiting them to their chemical interactions. Nordenström further theorized that similar closed circuit systems exist in urinary and gastrointestinal systems. Using electrical intervention, Dr. Björn Nordenström reversed terminal cancer in most of his patients as clinical proof of his theories. Several other researchers are presently attempting to relate organ parts as electronic components in terms of their electrophysical functions. The medical community has barely taken notice of these remarkable theories. Few practitioners are even aware of the works of Becker or Nordenström. At least Nordenström has experience with this. He pioneered a series of remarkable innovations in clinical radiology (including percutaneous needle biopsy) in the 1950s that were considered radical then, but are routinely employed by every major hospital in the world today.
Lack of education of the health care professional is the main stumbling block to acceptance of the theories and practice of electromedicine. The other problem is the wide variety of technologies available. At present, there are well over 100 different models of transcutaneous electrical nerve stimulators (TENS) devices in the marketplace and an increasing number of other electrical devices. Most health care practitioners who want to utilize such technology have received little or no background training in electrobiology or electrical technology. Hence when it comes to making an educated decision on what type of instrument to choose for a practice or a particular patient, practitioners are often overwhelmed when meeting an electromedical sales representative. Purchase decisions are frequently made based on lack of knowledge, misinformation, unsubstantiated claims, and worse of all, price.
BASIC PRINCIPLES
The basic unit of energy is referred to as the electron. The term elektron came from the Greeks, from amber, a fossilized resin material. When amber is rubbed, it attracts non-metallic fibrous objects such as feathers and paper. In 1600, William Gilbert suggested that all such phenomena be called electrics and the word electricity was coined. Using sulfur and friction to generate electricity, Guericke found that it had several common properties with magnetic forces, such as repulsion/attraction, transference of properties and opposite poles. Faraday termed the positive pole the anode, meaning "upper route" and the cathode, or "lower route," the negative pole. It was first thought that electrons flowed from anode to cathode. This was later found to be opposite; electrons flow from negative to positive, or cathode to anode.
Fluid-based biological systems are conductive mediums. Blood, water and lymph all conduct electricity. Various ions, such as calcium, sodium and chlorides are molecules that carry current. When current is carried by ions, secondary effects of electrolysis occur. In this process, electricity breaks the conducting fluid down into its components. In the case of water, electricity breaks the H2O molecule down into its components of two hydrogen and one oxygen atom. This process occurs within all types of tissue (e.g., nerves, muscle, bone, etc.) throughout the body. Many interactions of this nature are highly complex and not yet thoroughly understood. Most neurotransmitters have been shown to be modified by electrical stimulation. Some are even considered to be frequency specific, but there is still a lot to learn before we can specify the effect of individual facets of a waveform.
Waves and Pulses
In fluids, such as water, the sinusoidal wave is the only basic waveform. However, with electrical technology, different shaped waveforms can be built. These are often referred to as square, rectangular, triangular, sawtooth, etc. In actuality, they are composed of thousands of waves known as harmonics. This collection of harmonics is called a pulse.
Frequencies and Pulse Repetition Rates
Pulses are measured in cycles, or frequencies moving through a medium per second. One cycle per second is also called a Hertz (Hz). In electrical devices, the pulses have their own frequencies. Just as the collection of harmonics is called a pulse, the total frequencies (built by the resonance of harmonic frequencies) is referred to as the pulse repetition rate (PRR). It is the speed at which the pulse moves. For example, a 1 Hz pulse will have harmonic frequencies that build the pulse ranging from 1 Hz to hundreds of thousands of Hz and beyond theoretically to infinity. This is often a source of confusion, not only among practitioners, but among manufacturers of devices as well. In engineering terms, the term "frequency" should only be used with a pure sine wave. In this one case, frequency is the same as the pulse repetition rate. With any other waveform (i.e., square, rectangular, triangular, etc.) there are an infinite number of harmonic frequencies generated in each pulse. The interplay of harmonics identify a musical instrument as a specific aural experience. While some people would prefer the sound of a specific note on a piano, others would rather hear the same note played on a violin. Although the note is the same in each case, the harmonics vary. The interplay of these harmonics in electromedicine are essential to the results of a given treatment. With this in mind, we can begin to understand why one electromedical device may work on one patient, yet provide poor results on another. If we could predict what harmonics each tissue needed at a given time, we could design devices that would provide more consistent results in pain management, healing and regulating biological processes. The body accepts frequencies and pulse repetition rates in a non-linear, differential manner. For example, low frequencies penetrate greater depths of tissue than high frequencies. Higher frequencies are auto-shielding; that is, they are limited in penetration because the resistance of tissue acts like a faraday cage, forming eddy-repulsion. This eddy current produces a back electromotive force and blocks the penetration. The reflection in any conductor (in this case the body) of input signals is a mirror-image of the opposite phase. The higher the frequency, the greater the rejection and shallower the penetration. Complex frequencies interact in the body causing a non-linear spread of current. A prime example of a non-linear electrical device is a diode. A diode conducts current of one polarity far greater than the opposite polarity. Most living tissue exhibits non-linear characteristics, functioning somewhat like diodes. With square and rectangular waves, a "shotgun" of thousands of frequencies occur simultaneously within each pulse, similar to buckshot scattering over a wide area. A sine wave resembles the rifle concept, where one "bullet" must strike a target accurately to be of use. Our present knowledge of electromedicine is not sufficient to determine the optimum frequency for a specific tissue response so the use of sine waves is not recommended.
Pulse Width
The length of time the pulse lasts is called the width. This is usually measured in microseconds. It may seem odd to measure a width in time intervals rather than millimeters or other measure of length, until one understands that pulse width really refers to the time the wave is active. This is important with respect to how a given tissue may be affected and is part of a hypothetical "window" of optimal electric stimulation. The body responds to the peak of electrical signals and to the number of electrons in that signal. The maximum charge per pulse is measured in microcoulombs and gives the total energy of each pulse. Using bullets as an analogy, we can see that a .22 bullet has less energy than a .45 bullet because it is lighter. The .22 might go faster, but with its increased energy, the .45 can knock down a bigger target. Consider each spike a bullet and the pulse width the energy carried by the bullet. In this case, the velocity of the bullet is the voltage, while the mass of the bullet is the energy, in
Biphasic Signals
Because ions dissociate by electrolysis in the presence of electrical current, living tissue can become polarized in a direct current field. This can be disastrous in neuronal tissue. Therefore, modern stimulators usually provide alternating or biphasic current. That is, current that reverses polarity each half cycle so that the electrolytes factor sum to zero. If the current continued to flow in the same direction, polarity stress could result in irreversible tissue damage. As an analogy, picture a group of soldiers marching across a bridge. Before they get to one side, an about face order is given and they return. Before they reach the opposite side, another about face order is given, and so on, so that they never actually reach a side. By going back and forth, biphasically, there is no net electron flow across the bridge and no soldiers are added or subtracted. They never get across the bridge to cause an irreversible balance in the status quo.
Since the first edition of this book a few engineers have commented that biphasic is incorrect and should be replaced with bipolar. Technically, this is true but the designation of biphasic has already become the usual and customary term in electromedicine, so we have maintained it.
Amperage, Voltage and Resistance
Electricity travels in a circuit. The number of electrons moving per unit of time is called amperage. This is a measure of the amount of current. Voltage is a measure of the pressure in the circuit. Resistance to the electron flow in the circuit is measured in Ohms. A classic analogy of this is a garden hose setup. The amount of water in the hose would correspond to the amperage. The water pressure would correspond to the voltage. The hose could only take so much water pressure at a given time. Any more pressure or water would be met by more resistance from the hose. This concept has been mathematically related by Ohm's law of E = IR, where E is the voltage, I is the current and R is the resistance. One can increase the current and decrease the voltage by decreasing resistance, just as more water could pass with a lower pressure through a fire hose instead of a garden hose. Similarly, more current can pass through a larger diameter wire or through a highly conductive metal such as copper. In both cases, the thicker wire and more conductive metal have lower resistance. In the case of a human body, resistance is determined by factors such as fluid content, general health, skin thickness, amount of oil on the skin, humidity in the air, etc. If a person has a higher resistance, less current will flow through. The voltage can be raised to maintain the desired level of current. The better electromedical devices deliver a constant current by self-adjusting the voltage as the skin resistance changes.
CLINICAL ASPECTS OF ELECTROMEDICINE
The correct form of electromedicine will have a profound and usually immediate effect on pain. Although caution is advised during pregnancy and electrical stimulation should not be used on patients with demand type cardiac pacemakers, there are no known significant adverse side effects to therapeutic electromedical technology.
A recent study examined the prevalence of so-called "unconventional medicine" in the United States. Eisenberg (1993) reported that Americans spent $13.7 billion for alternative treatments in 1990 of which $10.3 billion was out-of-pocket, non-reimbursable expenditures. This is comparable to the $12.8 billion spent out-of-pocket annually for hospital expenses. In addition, the study determined that in 1990 Americans made an estimated 425 million visits to these practitioners of unconventional medicine compared to 388 million visits to all primary care physicians.
One definition of conventional is "conforming to accepted standards." Another definition is "established by accepted usage; ordinary or usual" (Stein, 1980). The latter definition could be interpreted to mean that what is being called unconventional medicine has become conventional. This seems to be confirmed by the 37 million more visits to these practitioners. It is unlikely that patients would continue to spend their time along with such large sums of money if they were not getting results, or if safe and effective relief was more readily available in the more comprehensive context of conventional medicine.
Harvard Medical School is beginning to teach "alternative medicine" and the National Institutes of Health has set up an Office of Alternative Medicine to award grants to researchers in this emerging field. Many patients site the side-effects and short-term relief of drug therapy as the primary reason they seek alternative care. New developments in electromedical technology offers physicians safe, effective, and long-lasting treatment options for a wide variety of disorders for these patients. Unfortunately, most conventional physicians are slow to accept new developments.
It is ironic that change moves slowest in the one science most responsible for our very existence, biology, or more appropriately for our purposes; medicine as applied biological science. It is simply easier, safer and less time consuming for someone who struggled to become part of the status quo to maintain it. It is certainly a major shock to one's conception of reality to learn that it is incomplete or incorrect. Yet physiology was taught as a complete science 100 years ago, again today, and most likely it shall be taught that way 100 years from now.
A classic and often cited example of medicine's reluctance to change occurred last century when Lord Joseph Lister advised surgeons to wash their hands before operating (Lister, 1979). Even well after Louis Pasteur's discovery of bacteria, surgeons were still not willing to believe and accept the need to be clean into the early part of this century (Lyons & Petrucelli, 1987). In fact, Pasteur could have been considered an unconventional practitioner when he insisted surgeons wash their hands before operating on his daughter. The Johnson brothers were the real driving force behind the widespread use of sterilization which resulted from their starting a company to manufacture antiseptic bandages. It was only after industry took the initiative that doctors came to accept the reality and consequences of our microbacterial cohabitants.
Dr. Lawrence D. Wilson (1993) suggested that "drug medicine" is able to maintain a virtual monopoly in America due to the following reasons:
a. Medical practice acts restrict competition and limit innovation. State licensing boards not only police their members, but police the entire population.
b. Prescription laws prevent public access to medical products.
c. Laboratory regulations prevent public access to medical laboratories.
d. Hospital regulations block the establishment of alternative hospitals and clinics.
e. Insurance mandates block innovation and limit competition in the insurance industry.
f. Subsidies to allopathic schools stifle the ability of other healing schools to compete fairly.
g. Subsidies for drug research amount to billions. Taxpayer dollars flow to dozens of government institutes such as NIH, HIMH, and NHI. Patent agreements often tie these labs to drug companies. Federal research agencies frequently ridicule alternative therapies. By stifling 'the competition', NCI and other agencies often have a counterproductive effect.
h. Medicare and Medicaid powerfully support the monopoly. They are infiltrated by private interest groups, and only reimburse for allopathic treatment.
i. A bloated and powerful FDA, in the name of protecting the public, prohibits public access to many harmless health care products. Manufacturers and retailers are terrorized by a regulatory agency that does not have to follow due process of law.
On August 31, 1993, the U.S. Food and Drug Administration published a proposed ruling in the Federal Register for reclassification of cranial electrotherapy stimulators. The FDA exhibited extreme bias in their appraisal against this effective and harmless modality. Unless the CES industry can quickly raise millions of dollars for pre-market approval for a technology that has been on the market in the U.S. for well over 20 years, CES will no longer be available in the United States 90 days after the FDA publishes their final ruling.
The FDA and American drug medicine are not as opposed to diagnostic developments in electromedicine due to of several factors. Bentall (1990) reasoned that diagnostic technology is more easily introduced because it enhances the capability and reputation of the practitioner within an acceptable risk/reward equation, without jeopardy or the need to understand its physics. Electromedical imaging systems succeeds on its instantaneous merits. Electrocardiology, electroencephalography, electromyography and magnetic resonance imaging are just a few examples of relatively recent innovations that have dramatically improved the abilities of health practitioners to arrive at more precise diagnoses. However, allopathic practitioners would like to have the physiology of therapy explained within the satisfaction of their domain of chemical knowledge, rather than venture into a new physiological paradigm.
Within the framework of the established and acceptable therapeutic practice based on chemistry, it does not seem so urgent to understand the physiology of new developments quite as clearly. For once one acknowledges the core philosophy, it is human nature to accept the whole concept, and with it, its newest additions. As a result, there is an ever increasing supply of new patented drugs.
Although the search for new pain controlling drugs continues, none appear to be much of an improvement over morphine, codeine, opium and heroin. The latter was hailed as a nonaddictive wonder drug in 1898 when the Bayer Co. of Germany named it from the German word "heroish" meaning powerful or heroic. Of course, heroin turned out to be three times more addictive than morphine and eventually banned as a therapeutic agent in the United States. Only about a decade ago Johnson & Johnson announced its breakthrough of a new drug that was to have been stronger than morphine and no more addictive than aspirin. Unfortunately their product, Zomax, turned out to be fatal in an unacceptable number of users.
The pain, or at least concern about the pain is relieved with drugs, but there are the concerns of side-effects, addiction and worse of all, tolerance. Binding sites being what they are, systemic pharmaceutical solutions do not seem very promising for the long term management of chronic pain.
Chemistry, both physiological and for therapeutic intervention, can be viewed as the existence of matter at the level of elements or compounds. Electromedicine is a means of diagnosis and treatment at the next level of matter. For every thought and action creates, or is created by electrical signals along the fibers of the nervous system.
A fresh look at physiology is needed to solve the primary medical complaint of pain. Although "fresh" is only appropriate to those who are uninformed of the plethora of information on electromedicine amassed over the last three or four decades. The answer is apparent on a smaller scale than we were able to define previously. In fact, even today, subatomic structure goes beyond the eyes fully assisted ability to squint.
Atoms are bonded electrically. This is a basic foundation necessary to understand electromedicine that was taught during the most elementary training in the basic sciences. Further in our rudimentary training we learned that there are voltage potentials across the membrane of all cells. All standard physiology textbooks define the Nernst and Goldman Equations to determine membrane and action potentials. They do not, however, speculate on the staggering significance of these facts.
If batteries are placed in series their voltage potentials are combined. A simple remote control unit may use three 1.5 volt batteries to produce the 4.5 volts needed to operate a television. The human body has trillions of cells each having a millivolt potential across their membranes. All good scientists should ask themselves why we find electricity so prevalent in biological systems.
It is already established that bioelectricity plays a major role in the control of all life's processes. Robert O. Becker, M.D. has spent more than 30 years attempting to determine how trillions of cells with hundreds of subtypes can function harmoniously in the form we call human. The result of that inquiry is a complete revolution in our previous concepts of biology (Becker, 1983).
Becker (1982) has reasoned that an electromagnetic field exists that controls all of life's processes. The original concept of such field effects can be traced back to ancient China. Traditional oriental medicine is based on the controlling power of ch'i or ki energy; a concept that predates electricity but appears to be analogous (Kirsch, 1978). Chiropractic also developed based on a similar observation termed innate intelligence by Daniel David Palmer in 1895 (Palmer, 1910). Indians use the term prana to represent the same concept. Allopathic practitioners are limited to a vague notion they call homeostasis.
In western civilization, the first documented use of electricity to manage pain was by the physician, Scribonius Largus, in 46 A.D. He claimed that just about everything headaches to gout could be cured by standing on a wet beach near an electric eel. Not surprisingly, attempts at producing pharmaceutical preparations from dead eels proved ineffective. In 1791, Luigi Galvani discovered that electrical impulses could cause muscle contraction. By 1800, Carlo Matteucci showed that injured tissue generates an electric current. The discovery of alternating current by Faraday in 1830 opened the door to the development of man-made devices as sources of electricity. Over 10,000 medical practitioners in the United States alone made use of electrotherapeutic modalities until publication of the 1910 Flexnor report which stated that there was no scientific basis for electromedicine at that time. Dr. Flexnor's report was sponsored by the American Medical Association so it is no wonder why it declared allopathic medicine superior.
Since then, arguably the greatest development in the field of electromedicine was when Becker (1981) electrically induced limb regeneration in frogs and rats as a model to study bioelectrical forces as a controlling morphogenetic field. Regeneration represents a return to embryonal control systems and cellular activities within a localized area. It can therefore be considered a more accessible and more observable form of morphogenesis. The complexity of instructions required to designate all of the details to recreate a finished extremity is impossible to transmit by previously understood biochemical processes alone.
Becker (1983) has proposed that a primitive direct current data transmission and control system exists in biological systems for the regulation of growth and healing. His studies of extraneuronal analog electrical morphogenetic fields have eliminated any rational arguments against the importance of bioelectricity for all the basic life processes. Becker has laid the groundwork for the medical professions to start to evolve towards a more reasonable integrated view of biology incorporating our understanding of both biochemistry and biophysics.
Björn Nordenström, M.D. (1983), former Chairman of the Nobel Assembly, has also proposed a model of bioelectrical control systems he calls Biologically Closed Electric Circuits. The principle is analogous to closed circuits in electronic technology. Nordenström's theory is that the mechanical blood circulation system is closely integrated morphologically and functionally with a bioelectrical system. Nordenström hypothesized that ionic and nonionic compounds interact in a way that makes selective distribution and modulation of energy possible throughout the body, even over long distances. The biological circuits are switched on by both the normal electrical activity of the organs and pathological changes, such as a tumor, injury or infection. Like Becker, Nordenström views bioelectricity as the primary catalyst of the healing process. Using the vascular interstitial system as an example, Nordenström postulated two branches of this system. The first branch, the intravascular system, proposes that walls of blood vessels act as insulators to carry energy, much like cables in a battery system. The electrical resistance of the walls of the veins and arteries is at least 200 times greater than the blood within. The intravascular plasma acts as a conductor, where ions such as sodium, calcium and chloride supply immediately available energy to the system, primarily by electrophoresis. Nordenström called these ions ionars. According to Nordenström, delayed available energy, or potential energy, is carried by blood cells which bind oxygen, as well as other chemicals such as glucose, neutral fat, nonpolar amino acids, etc. These are all noncharged packages of energy that arrive at specific sites and are released primarily by reduction/oxidation. Nordenström termed these ergonars.
The second branch addresses the interstitial system. The tissue matrix acts as an insulator while the interstitial fluid acts as a conductor. The main component that "closes" the system is the capillary membrane. These membranes act as junctions between the interstitial and vascular fluids allowing exchange of ionars and ergonars along gradients of electric potential. This theory represents a comprehensive attempt to relate anatomical components in terms of electromagnetic forces, rather than limiting them to their chemical interactions. Nordenström further theorized that similar closed circuit systems exist in urinary and gastrointestinal systems. Using electrical intervention, Dr. Björn Nordenström reversed terminal cancer in most of his patients as clinical proof of his theories. Several other researchers are presently attempting to relate organ parts as electronic components in terms of their electrophysical functions. The medical community has barely taken notice of these remarkable theories. Few practitioners are even aware of the works of Becker or Nordenström. At least Nordenström has experience with this. He pioneered a series of remarkable innovations in clinical radiology (including percutaneous needle biopsy) in the 1950s that were considered radical then, but are routinely employed by every major hospital in the world today.
Lack of education of the health care professional is the main stumbling block to acceptance of the theories and practice of electromedicine. The other problem is the wide variety of technologies available. At present, there are well over 100 different models of transcutaneous electrical nerve stimulators (TENS) devices in the marketplace and an increasing number of other electrical devices. Most health care practitioners who want to utilize such technology have received little or no background training in electrobiology or electrical technology. Hence when it comes to making an educated decision on what type of instrument to choose for a practice or a particular patient, practitioners are often overwhelmed when meeting an electromedical sales representative. Purchase decisions are frequently made based on lack of knowledge, misinformation, unsubstantiated claims, and worse of all, price.
BASIC PRINCIPLES
The basic unit of energy is referred to as the electron. The term elektron came from the Greeks, from amber, a fossilized resin material. When amber is rubbed, it attracts non-metallic fibrous objects such as feathers and paper. In 1600, William Gilbert suggested that all such phenomena be called electrics and the word electricity was coined. Using sulfur and friction to generate electricity, Guericke found that it had several common properties with magnetic forces, such as repulsion/attraction, transference of properties and opposite poles. Faraday termed the positive pole the anode, meaning "upper route" and the cathode, or "lower route," the negative pole. It was first thought that electrons flowed from anode to cathode. This was later found to be opposite; electrons flow from negative to positive, or cathode to anode.
Fluid-based biological systems are conductive mediums. Blood, water and lymph all conduct electricity. Various ions, such as calcium, sodium and chlorides are molecules that carry current. When current is carried by ions, secondary effects of electrolysis occur. In this process, electricity breaks the conducting fluid down into its components. In the case of water, electricity breaks the H2O molecule down into its components of two hydrogen and one oxygen atom. This process occurs within all types of tissue (e.g., nerves, muscle, bone, etc.) throughout the body. Many interactions of this nature are highly complex and not yet thoroughly understood. Most neurotransmitters have been shown to be modified by electrical stimulation. Some are even considered to be frequency specific, but there is still a lot to learn before we can specify the effect of individual facets of a waveform.
Waves and Pulses
In fluids, such as water, the sinusoidal wave is the only basic waveform. However, with electrical technology, different shaped waveforms can be built. These are often referred to as square, rectangular, triangular, sawtooth, etc. In actuality, they are composed of thousands of waves known as harmonics. This collection of harmonics is called a pulse.
Frequencies and Pulse Repetition Rates
Pulses are measured in cycles, or frequencies moving through a medium per second. One cycle per second is also called a Hertz (Hz). In electrical devices, the pulses have their own frequencies. Just as the collection of harmonics is called a pulse, the total frequencies (built by the resonance of harmonic frequencies) is referred to as the pulse repetition rate (PRR). It is the speed at which the pulse moves. For example, a 1 Hz pulse will have harmonic frequencies that build the pulse ranging from 1 Hz to hundreds of thousands of Hz and beyond theoretically to infinity. This is often a source of confusion, not only among practitioners, but among manufacturers of devices as well. In engineering terms, the term "frequency" should only be used with a pure sine wave. In this one case, frequency is the same as the pulse repetition rate. With any other waveform (i.e., square, rectangular, triangular, etc.) there are an infinite number of harmonic frequencies generated in each pulse. The interplay of harmonics identify a musical instrument as a specific aural experience. While some people would prefer the sound of a specific note on a piano, others would rather hear the same note played on a violin. Although the note is the same in each case, the harmonics vary. The interplay of these harmonics in electromedicine are essential to the results of a given treatment. With this in mind, we can begin to understand why one electromedical device may work on one patient, yet provide poor results on another. If we could predict what harmonics each tissue needed at a given time, we could design devices that would provide more consistent results in pain management, healing and regulating biological processes. The body accepts frequencies and pulse repetition rates in a non-linear, differential manner. For example, low frequencies penetrate greater depths of tissue than high frequencies. Higher frequencies are auto-shielding; that is, they are limited in penetration because the resistance of tissue acts like a faraday cage, forming eddy-repulsion. This eddy current produces a back electromotive force and blocks the penetration. The reflection in any conductor (in this case the body) of input signals is a mirror-image of the opposite phase. The higher the frequency, the greater the rejection and shallower the penetration. Complex frequencies interact in the body causing a non-linear spread of current. A prime example of a non-linear electrical device is a diode. A diode conducts current of one polarity far greater than the opposite polarity. Most living tissue exhibits non-linear characteristics, functioning somewhat like diodes. With square and rectangular waves, a "shotgun" of thousands of frequencies occur simultaneously within each pulse, similar to buckshot scattering over a wide area. A sine wave resembles the rifle concept, where one "bullet" must strike a target accurately to be of use. Our present knowledge of electromedicine is not sufficient to determine the optimum frequency for a specific tissue response so the use of sine waves is not recommended.
Pulse Width
The length of time the pulse lasts is called the width. This is usually measured in microseconds. It may seem odd to measure a width in time intervals rather than millimeters or other measure of length, until one understands that pulse width really refers to the time the wave is active. This is important with respect to how a given tissue may be affected and is part of a hypothetical "window" of optimal electric stimulation. The body responds to the peak of electrical signals and to the number of electrons in that signal. The maximum charge per pulse is measured in microcoulombs and gives the total energy of each pulse. Using bullets as an analogy, we can see that a .22 bullet has less energy than a .45 bullet because it is lighter. The .22 might go faster, but with its increased energy, the .45 can knock down a bigger target. Consider each spike a bullet and the pulse width the energy carried by the bullet. In this case, the velocity of the bullet is the voltage, while the mass of the bullet is the energy, in
Biphasic Signals
Because ions dissociate by electrolysis in the presence of electrical current, living tissue can become polarized in a direct current field. This can be disastrous in neuronal tissue. Therefore, modern stimulators usually provide alternating or biphasic current. That is, current that reverses polarity each half cycle so that the electrolytes factor sum to zero. If the current continued to flow in the same direction, polarity stress could result in irreversible tissue damage. As an analogy, picture a group of soldiers marching across a bridge. Before they get to one side, an about face order is given and they return. Before they reach the opposite side, another about face order is given, and so on, so that they never actually reach a side. By going back and forth, biphasically, there is no net electron flow across the bridge and no soldiers are added or subtracted. They never get across the bridge to cause an irreversible balance in the status quo.
Since the first edition of this book a few engineers have commented that biphasic is incorrect and should be replaced with bipolar. Technically, this is true but the designation of biphasic has already become the usual and customary term in electromedicine, so we have maintained it.
Amperage, Voltage and Resistance
Electricity travels in a circuit. The number of electrons moving per unit of time is called amperage. This is a measure of the amount of current. Voltage is a measure of the pressure in the circuit. Resistance to the electron flow in the circuit is measured in Ohms. A classic analogy of this is a garden hose setup. The amount of water in the hose would correspond to the amperage. The water pressure would correspond to the voltage. The hose could only take so much water pressure at a given time. Any more pressure or water would be met by more resistance from the hose. This concept has been mathematically related by Ohm's law of E = IR, where E is the voltage, I is the current and R is the resistance. One can increase the current and decrease the voltage by decreasing resistance, just as more water could pass with a lower pressure through a fire hose instead of a garden hose. Similarly, more current can pass through a larger diameter wire or through a highly conductive metal such as copper. In both cases, the thicker wire and more conductive metal have lower resistance. In the case of a human body, resistance is determined by factors such as fluid content, general health, skin thickness, amount of oil on the skin, humidity in the air, etc. If a person has a higher resistance, less current will flow through. The voltage can be raised to maintain the desired level of current. The better electromedical devices deliver a constant current by self-adjusting the voltage as the skin resistance changes.
CLINICAL ASPECTS OF ELECTROMEDICINE
The correct form of electromedicine will have a profound and usually immediate effect on pain. Although caution is advised during pregnancy and electrical stimulation should not be used on patients with demand type cardiac pacemakers, there are no known significant adverse side effects to therapeutic electromedical technology.
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION
Our understanding of pain mechanisms and how pain is perceived has undergone significant changes. Initially, pain was viewed as an emotion rather than a sensation. It was said to be the opposite of pleasure. This theory dated back to the time of Aristotle. The traditional theory, described as the specificity theory by Descartes in 1664, conceived of a pain system as a direct channel from the skin to the brain (Melzack & Wall, 1982). This concept was supported and expanded on by Von Frey, who argued that there were specific pain receptors (Sinclair, 1953). As scientific experimentation grew towards the later part of the last century, Goldscheider developed the pattern theory, which stated that sensation was based on spatial and temporal patterns of a number of impulses (Nafe, 1929; Geldard, 1953). Zotterman (1936) discerned A-Delta and C afferent nerve fibers. Later research stated that A-delta fibers carried fast, but short-lived, well-defined pain impulses while C fibers carried slow, diffuse, long-duration pain.
The modern basis for the widespread use of transcutaneous electrical nerve stimulation (TENS) for pain control is the gate control theory proposed by Dr. Ronald Melzack and Dr. Patrick Wall (1965). This theory suggests that hypothetical "gates" in lamina V of the substantia gelatinosa could be "closed" to block pain stimuli traveling from A-delta and C fibers in the peripheral nervous system where they synapse into the central nervous system. Although this theory was later modified, it created much notoriety at the time and revolutionized the way most practitioners viewed and treated chronic pain.
In 1967, C. Norman Shealy, M.D., a neurosurgeon who had been implanting dorsal column stimulators (DCS), discovered that devices that transmitted electricity transcutaneously were just as effective without the risks associated with surgery (Shealy, Mortimer, & Reswich, 1967). With the Melzack-Wall theory behind him, Shealy's work renewed interest in electromedicine and resulted in the beginning of the modern day TENS devices.
Transcutaneous electrical nerve stimulation is an established modality with over 250,000 TENS units prescribed annually in the United States alone. Accordingly, much information is available on standard TENS applications, precautions, contraindications, side effects and results (Mannheimer & Lampe, 1984; Tapio & Hymes, 1987). Mixed results have occurred due to several factors, such as waveform, frequency, pulse repetition rate, intensity, alternating vs. direct current, electrode placement and treatment time. Perhaps the single largest variable is the education, or lack thereof, provided to health care practitioners recommending these devices and instructing patients in their use. Many professionals simply give the unit to a patient with the factory settings and never alter them, leaving each device as a hit or miss item. TENS devices must be tried at a variety of settings to achieve optimal pain relief for a given patient. In principle, TENS applies an electrical force that stimulates pain-suppressing A-beta afferent nerve fibers which compete against pain-carrying afferent nerve fibers. The same stimulation would occur if one lightly tapped the painful body part repeatedly with a pen, spoon, or other blunt object. Ice, massage, heat, manipulation and other long-standing therapy techniques have relieved pain this way for centuries.
Energy Source
Most TENS units work with currents in the milliampere range delivered for about 250 microseconds. The most common output is biphasic to avoid the side effects of polarization. They are powered either by alkaline or nickel cadmium batteries. In general, alkaline batteries are preferred for constant stimulation because they have a relatively slow, linear power decay. Rechargeable batteries have a series of peaks or near-peaks in their discharge rate because each cell discharges in series. Accordingly, rechargeable batteries should be avoided, especially in the cheaply made Taiwanese devices.
Electrodes
Initially, dry pads were provided that required the use of a gel. This was messy, provided uneven conductivity and caused minor skin burns at a high current. At present, self-adhesive electrodes are available that are semi-disposable and generally affordable. In this day and age of concern over deadly infectious diseases, it has become common practice for clinicians to keep a separate set of electrodes for the exclusive use of each patient.
Pulse Repetition Rate (PRR)
The reader will often see this listed as "frequency" on a typical TENS unit. According to the previous discussion in this chapter, the lower the PRR setting, the greater number of frequencies the patient will be exposed to; hence, the greater potential for pain relief. For the average pain patient, we recommend setting the PRR to the lowest setting for initial trials. Pomerantz (1981) has also shown by naloxone blocking studies that endorphins are only released at PRR settings of 8 Hertz or less.
Pulse Width
Wider pulses spread the current over greater distances. The maximum parameters in most TENS units ranges from 50 to 400 microseconds. The further apart the electrodes are, the wider the pulse width should be.
Electrode Placement
Electrode placement is perhaps the greatest variable in eliciting successful results with TENS. Electrodes can be placed "between the pain and the brain," along nerve roots, dermatomes of the respective nerve levels, following the referred pain pathway, or on trigger points. Janet Travell, M.D. started researching trigger points in 1957 (Travell & Simons, 1983). Trigger points are named such because they trigger pain when pressed. They are areas of localized tenderness that usually form with a persistent muscle spasm. For the purpose of this discussion, they can be measured as having higher conductivity than normal tissue. In most cases, electrical treatment directly on the point is indicated. Sometimes, this will increase the pain (as explained by the pattern theory of pain). If this occurs, treating across the area with microcurrent stimulation at 0.5 Hz will almost always alleviate it.
With the parameters discussed, it is apparent that several combinations of PRR, pulse width, intensity, electrode placement, time and frequency of stimulation may have to be attempted before desirable results are obtained. Perhaps this is the reason why most major medical insurance companies prefer to rent a TENS device to a patient for the first month before approving it for purchase.
Indications
Several studies have documented the desirable effects of TENS. Loeser and his coworkers (1975) examined TENS-induced relief of pain for headaches, cervical arthritis, low back, phantom limb, arthritis and acute post-operative pain. Tapio and Hymes (1987) reviewed the efficacy of TENS on low-back pain, cancer pain, post-herpetic neuralgia, phantom limb pain, rheumatoid arthritis, angina pectoris, various acute conditions, dysmenorrhea, visceral pain and several other disorders. Andersson (1976) found TENS could raise the threshold for dental pain. By using low-frequency, high-intensity stimulation (the so-called "acupuncture-like TENS") he was able to increase his success rate in pain reduction from 40 to 60%.
Contraindications
There are very few contraindications with TENS. All electrical modalities are contraindicated for pregnant women and patients with demand-type pacemakers. In general it is advisable that patients not drive or operate heavy machinery while TENS is being applied. Also, it is essential that electrodes from milliampere TENS units are not placed on the head or neck. This is especially true regarding the carotid sinuses as stimulation of the baroreceptors may result in a vaso-vagal syncopé.
TENS Summary
TENS is now a widely used modality for the treatment of general acute and chronic pain syndromes. When effective, the ease of use, general safety and portability make it a treatment over the long term use of medications and nerve blocks for chronic pain. Modern drug practitioners would do well to recall Aesculapius' motto regarding healing; primo non nocere (first, do no harm).
A disadvantage is the tinkering required for the average pain patient to find the best combination of variables for effective relief. Even after repeated attempts at different parameter combinations, TENS devices may not alter pain results. Although effective to some extent, they are simply an application of force, a counter-irritant produced analgesia. They provide no significant residual effect and as with drugs, tolerance is a significant problem.
MICROCURRENT ELECTRICAL THERAPY
Becker and Nordenström have provided a rational basis for a new and vastly more effective form of electromedical intervention for which Joseph M. Mercola, D.O. and Daniel L. Kirsch, Ph.D. (1994) coined the term "microcurrent electrical therapy" (MET). A growing body of research shows the effectiveness of MET to accelerate, and even induce healing. Eaglstein and Mertz (1978) have shown moist wounds to resurface up to 40% faster than air-exposed wounds. Falanga (1988) found that certain type of occlusive dressings, like Duoderm, accelerate the healing of wounds. It is probable that these dressings achieve their effects by promoting a moist environment (Kulig, Jarski, & Drewek, 1991). When a wound is dry, its current flow is shut off. The moisture may allow the endogenously produced current of injury to flow and promote wound healing. Electrical stimulation of the wound also tends to increase the amount of growth factor receptors which increases the amount of collagen formation (Falanga, 1987). Electricity was first used to treat surface wounds over 300 years ago with charged gold leaf to prevent smallpox scars (Robinson, 1925). There are several recent studies supporting the beneficial effects of treating wounds with an artificial current of injury (Goldin, 1981; Jeran, 1987; Ieran, 1990; Mulder, 1991). Experimental animal wound models in the 1960's demonstrated that electrical intervention can result in accelerated healing with skin wounds resurfacing faster, and with stronger scar tissue formation (Carey & Lepley, 1962; Assimacopoulos, 1968). Assimacopoulos (1968) published the first human study using direct electrical current for healing. He documented complete healing of chronic venous stasis leg ulcers in three patients with six weeks of electrical therapy. One year later the most frequently cited work in the history of electrical wound healing was published by Wolcott and Wheeler (1969). They used direct currents of 200-1,000 microamperes for 67 patients. Gault and Gatesn (1976) repeated the Wolcott and Wheeler protocol for 76 additional patients with 106 ischemic skin ulcers. Carey and Wainapel (1985) performed one of the only studies on this subject published with equal and randomized control and study groups. All of these studies documented significant accelerated healing with electrical stimulation. Working with Wolcott and others, Rowley et al. (1974) updated their initial experience with another group of patients having 250 ischemic ulcers of various types. These included 14 symmetrical control ulcers. The stimulated ulcers had a fourfold acceleration in healing response compared to the controls. One additional consistent observation in these studies was that there was a reversal of contamination in the wounds. Wounds that were initially contaminated with Pseudomonas and/or Proteus were usually sterile after several days of MET. Other investigators have also noticed similar improvements and encourage the use of this therapy as the preferred treatment for indolent ulcers (Kaada, Flatheim, & Woie, 1991; Barron, Jacobson, 1985; Lundeberg, Eriksson, & Malm, 1992; Alvarez et al., 1983). Additionally, no significant adverse effects resulting from electrotherapy have been documented (Weiss, 1990). A review of the literature by Dayton and Palladino (1989) shows that microcurrent electrical therapy is clearly an effective and safe supplement to the non-surgical management of recalcitrant leg ulcers.
Some of these studies used unipolar currents that were alternated between negative and positive based on various criteria. Some researchers initially used negative current to inhibit bacterial growth and then switched to positive current to promote healing. To date no study has compared this variable of MET. However, there is some compelling basic science research, and one animal study suggesting that a bipolar current, which provides both negative and positive phases, may be better for wound healing (Stromberg, 1988; Windsor, Lester, & Herring, 1993).
As mentioned previously, in the 1960s Dr. Becker demonstrated that an electrical current is the trigger that stimulates healing, growth and regeneration in all living organisms. He found that repair occurs after an injury in response to signals that come from an electrical control system and suggested that this system became less efficient with time. Dr. Becker (1985) developed his theory of biological control systems based on concepts derived from physics, electronics, and biology. He postulated that the first living organisms must have been capable of self-repair, otherwise they never would have survived. The self-repair process requires a closed-loop system. A specific signal is generated which causes another signal to start repair. The injury signal gradually decreases over time with the repair process until it finally stops when the repair is complete. Such a primitive system does not require demonstrable consciousness or intelligence. Therefore, many animals actually have a greater capacity for self-healing than do humans. Science has amassed a vast amount of information on how the brain and nervous system work. Most of this research involves the action potential as the sole mechanism of the nerve impulse. This is a very sophisticated and complex system for the transfer of information. It is helpful to compare this currently accepted process of the nervous system to a computer. The fundamental signal in both the computer and the nervous system is a digital one. Both systems transfer information represented by the number of pulses per unit of time. Information is also coded according to where the pulses go and whether or not there are more than one channel of pulses feeding into an area. All our senses (e.g., smell, taste, hearing, sight and touch) are based on this type of pulse system. Like a computer, the nervous system operates remarkably fast and can transfer large amounts of information as digital "on and off" data. It is unlikely that the first living organisms had such a sophisticated system. Becker believes they must have had a much simpler mechanism for communicating information because they did not need to transmit large amounts of sophisticated data. Accordingly, they probably used a much simpler analog system. An analog system works by means of simple DC currents. Information in an analog system is represented by the strength of the current, its direction of flow, and slow wavelength variations in its strength. This is a much slower system when compared to the digital model. However, the analog system is extremely precise and works well for its intended purpose. Becker theorizes that the first living organisms used this analog type of data-transmission and control system for injury repair. He postulates that we still have this primitive nervous system in the perineural cells of the central nervous system. These cells comprise 90% of the nervous system. The perineural cells have semiconductor properties that allow them to produce and transmit non-propagating DC signals. This analog system senses injury and controls repair. It controls the activity of cells by producing specific DC electrical environments in their vicinity. It also appears to be the primary primitive system in the brain, controlling the actions of the neurons in their generation and receipt of nerve impulses. This allows it to regulate our consciousness and decision-making processes. Given this understanding, the application of the correct form of electrical intervention is a powerful tool for treating pain, initiating the endogenous mechanisms of self-repair, and altering states of consciousness.
Clinical Applications
Clinically, we can use a point finder (ohmmeter) to measure pathological tissue because it exhibits a reduction in conductivity. This seems to be true in every case except in inflammatory conditions where the hot fluids conduct extracellularly causing a false-positive readings. The less conductive tissue sets up an electrical difference, or potential, on either side of the injury that controls pain and signals the healing process. This is known as the current of injury (COI). Since some tissues conduct electricity better than others, it is possible to calibrate a measurement device to an area near the injury before treating. Once a low conductive area is found, a microampere current with an effective waveform can augment the current of injury to effectively control pain as well as initiate or increase the rate of healing. Lerner and Kirsch (1981) developed this system and called it bioconductive therapy. The same meter can read a post treatment response (PTR) measurement. Generally up to four, six to ten second applications of stimulation with two small diameter probes is adequate per electrode placement. Several varying placements in an area may be needed to obtain an improved PTR. Once the area is adequately treated the PTR will exhibit a higher value with a slower decay time (Ullis, 1983). When using an effective device the improved PTR will almost always be associated with the patient's subjective feeling of improvement.The devices used for bioconductive therapy have come to be known as microcurrent stimulators. They deliver a much weaker signal about 2,500 times longer per pulse than TENS. The full spectrum ("shotgun") of frequencies within each pulse at this wavelength provide a phenomenally effective therapy. It is believed that cells within a specific organ or tissue system communicate through specific frequencies in the microampere range. The right frequency activates the COI causing the system to tend towards homeostasis. Caution is advised against purchasing devices claiming to be "cybernetic", or able to measure and automatically deliver the correct frequency for a given patient. Although at least one manufacturer makes such a claim, there is no such technology or scientific support material to design such a thing at this time. Originally, bioconductive therapy devices were large, expensive, metered units designed for clinical use only. A good microcurrent device requires more than ten times the circuitry of a standard TENS. However, in 1982, what is now Electromedical Products International, Inc. (EPII) of Mineral Wells, Texas introduced the first homecare microcurrent stimulator to the market. Their product, called the Alpha-Stim 350 weighed six pounds and was about half the size of a shoe box. Using surface mount technology manufactured by robotics EPII has been able to manufacture scaled down versions since 1990 at a cost competitive with TENS. Since then a number of imitations have flooded the market, primarily from Taiwan. Most of these products do not produce reproducible results because the design engineers know nothing about the underlying electrophysiology and they use cheap parts with tolerances as high as 35%. Alpha-Stim technology is actually produced by using two waveforms for each channel to create a full bioelectrical frequency range and introduce random factors into the waveform preventing the nervous system from recognizing it, and therefore habituating to it. The biggest mistake practitioners make with microcurrent devices is to use them the same way they would use a TENS device. As an example, TENS is often applied on either side of and close to the spine for back pain. This will not work with microcurrent technology because the current, following the path of least resistance, is too weak to actually reach the spine.
Step One: History and Brief Exam
It is extremely important to take a comprehensive history before beginning MET. One should determine when the pain first presented, its frequency, duration, intensity, limitations-of-motion, positions which exacerbate the pain and any precipitating factors. Ask about the specifics of previous treatments. Microcurrent electrical therapy is a holistic procedure. It may be necessary to clear the body of any and all electrical "blocks" in order to achieve the best results (more on this later). Immediately before each treatment determine the patient's current pain level and the positions that exacerbate the pain. Ask the patient to rate their present pain on a scale of 0 (no pain) to 10, with 10 being excruciating, debilitating pain. Tell the patient to consider 10 as "the worst this condition has been". Also note any immediate limitations-of-motion, positive orthopedic and neurologic test findings, and psychological distress. This therapy usually produces instantaneous results so these indicators are necessary reference parameters to determine effectiveness throughout a single treatment session.
Adjust the Settings
Use a low frequency, preferably 0.5 Hz most of the time. It is unusual to ever need to use other frequency settings. However, if 0.5 Hz doesn't work, and everything else described herein has been tried, use a higher setting. In MET, this usually means 80 to 100 Hz. These higher frequencies are sometimes best for the first few minutes of treatment for inflammatory articular problems. Set the current intensity level at the highest comfortable position which is usually 500 to 600 microamperes (A) for probes, although it is sometimes slightly less for the silver-silver/chloride (Ag-AgCl) electrodes. Do not use any other type of self-adhesive electrodes for MET. Probes must be applied using a firm pressure, but less than the amount of pressure that would cause pain.
Treatment Strategy
There are several principles one must remember when treating patients with MET. The patient should be in a relaxed position to receive maximum beneficial effects. The most important variable is the position of the probes, or pads. Position them in such a way that if a line was drawn between them that line would transect the problem area. Keep in mind that the body is three dimensional. Therefore, there will be many possible ways to draw a line through the problem. Some lines will work much better than others! Sometimes it is helpful to imagine the problem area of the body as being transparent. As mentioned above, do not place the electrodes on each side of the spine for back pain as is done with TENS. With this placement the current will travel just under the skin and never reach the problem. A better way is to place one electrode next to the spine and the other on the contralateral side, anteriolaterally (front and opposite side). A line drawn between those will go right through the spinal nerves. Treat head, neck, and back (axial skeleton) problems bilaterally. If the other side is ignored, there is a good chance the problem will have been missed because pain often exhibits on the tense side which may just be compensating for muscular weakness on the other side. So after a few 10 second approaches with small diameter probes, or about 10 minutes with self-adhesive electrode pads, reverse sides.
Quick Probe Treatments
When using probes treat for 10 seconds per site. First treat in an "X" manner over an area wider than the problem. An example of this would be to treat the whole back for back pain. This can be done by placing one probe on the right shoulder and the other on the left hip, and then one on the left shoulder connected to the right hip. One treatment "set" is about five or six of these ten second stimulations, each at a different angle of approach (e.g., two obliques, two medial-lateral, and two anterior-posterior, etc.). Often the pain will migrate as a response to therapy. Follow it. Use the same treatment strategy described above for the pain's new location.
When to Stop
Reevaluate the patient after a few treatment sets. For some simple problems, it is preferable to reevaluate after each set. Use the original criteria. It is not enough to ask if the patient feels better, ask for a specific percentage of how much better. Also reexamine for objective signs like range-of-motion increases, etc. Stop when the pain is completely gone or when the improvement has reached a plateau after several sets of treatment. Continuing to treat the area at this time may cause the pain to return! If the pain is gone stop treatment for that day even if the patient only had one minute of treatment. If the patient can no longer identify any pain, but complains of stiffness, this is also a good indication that it is time to stop. Although most people will achieve immediate results, some will have a delayed effect and others will have a combined effect, continuing to improve over a day or two after the treatment.
Follow-up
The average patient should be given at least three treatments to evaluate their response to microcurrent electrical therapy. It helps to explain to the patient that the effects are cumulative. Like antibiotics, one must take several doses over a period of time to get results. Although results will often be seen during or subsequent to the first treatment, the longevity of the results can only be evaluated over the course of a few treatments. In some cases the results will plateau to a similar time period regardless of treatment. For example, a patient may only get two days of relief no matter what combination of treatment strategies are employed. For these and in cases of severe pathology, the effectiveness may only be short-lived so a MET device should be prescribed for home care. After an initial series of up to ten treatments, a good rule of thumb is to prescribe a unit to anyone with a chronic condition who requires more than one palliative treatment per month, and to those who have progressive pathologies.
Tips for Limited or Poor Results
Microcurrent electrical therapy will not work for everybody. However, as originally reported in an earlier version of this text, in nearly all cases of failure the common denominator is that the patient has had a significant exposure to a strong electrical current. This means that they have either been held by electrical current at some time in their life, or that they have been treated with milliampere TENS or similar modalities for a prolonged period of time (e.g., years). As yet, there is still no known effective method for treating people so afflicted.
The most commonly seen reversible reason patients fail to respond to treatment is that they have surgical or traumatic scars. Identify all scars by taking a very thorough, persistent history, and examining the patient completely. All scars are important no matter how old or how far they are from the chief complaint. Scar tissue impedes the systemic flow of endogenous bioelectricity because it is a poor conductor of electricity. Accordingly, scar tissue may interfere with the patient's entire bioelectrical system. If scars are present they should be treated with silver/silver-chloride (Ag/AgCl) electrodes for ten minutes per scar, at least four times. Simply cover the scars with the electrodes or, for large scars, place the electrodes on the ends of the scars. This may be done four days in a row or there can be a short interval of up to a few days between the scar treatments. When treating scars the person may experience a significant surge of energy. It can be viewed as if an electrical bioresistor is broken down. Patients will often report feeling half their age, or 20 years younger after scar therapy. Since people have nothing to compare their life experience with, they usually attribute the subtle effects of scars on their electrical system as normal aging. Be aware that this treatment will more often than not also increase the pain because the whole body and mind "wakes up", including the painful part. However, when this happens in nearly all cases, the painful area can then be successfully treated. Always schedule enough time to treat the pain after the scar treatment so the patient will not need to endure even a temporary increase in pain. If all the scars are treated and there is still no or poor results there are a few other options. Question the patient about old injuries that may not have healed properly. These could also be electrical blocks and should be approached in the same way as scars. To relieve pain in some patients a lower current setting of no more than 100 A with the Ag/AgCl electrodes for one or more hours at a time is necessary. Higher pulse repetition rates may produce results in some people when the 0.5 Hz fails, but this is rare.
CRANIAL ELECTROTHERAPY STIMULATION
Cranial electrotherapy stimulation (CES) is the application of low-level pulsed electrical currents (usually less than one milliampere) applied to the head for medical and/or psychological purposes. Cranial electrotherapy stimulation has also been known by many other names. Transcranial electrotherapy (TCET), neuroelectric therapy (NET), alphasleep, electroanalgesia, electronarcosis and the original electrosleep are just a few of the more common terms that have referred to the same therapy. Cranial electrotherapy stimulation was first called electrosleep because it was thought to induce sleep. Rabinovich, a Russian, is given credit for making the first claim for electrical treatment of insomnia in 1914 (Achte, Kauko, & Seppala, 1968). In 1957, in the U.S.S.R., Anan'ev et al. published the first work on CES and the first book, simply titled Electrosleep, was published a year later by Gilyarovski. This generated a high degree of interest in the then-known Eastern Block countries and CES was soon adopted as a treatment modality. Obrosow (1959) reviewed the CES literature and published the first American paper on CES. By 1966 the first International Symposium on Electrotherapeutic Sleep and Electroanesthesia was held in Austria. Cranial electrotherapy stimulation use had spread worldwide by the late 1960's when animal studies of CES began in the U.S. at the University of Tennessee, and at what is now the University of Wisconsin Medical School. These were soon followed by human clinical trials at the University of Texas Medical School in San Antonio, the University of Mississippi Student Counseling Center and the University of Wisconsin Medical School. There are well over 100 published reports on CES in the U.S. and several times that amount in the European literature. The most comprehensive research review published to date on CES is a chapter in a textbook by Ray B. Smith, Ph.D. (1985). Dr. Smith has been researching CES since 1972. He concluded, "There are 40 studies of CES readily available in the U.S., in which the dependent variable is reliable. When these are examined alone it becomes apparent that CES is effective in alleviating symptoms of anxiety, depression, and insomnia...CES appears effective as a treatment for withdrawal in the chemically dependent person...Other promising areas of treatment are in hypergastric acidity and migraine headaches." Dr. Smith adds, "CES appears to be safe, with no harm or negative side effects having been reported to date in controlled studies...Finally, while one usually assumes some placebo effect from a treatment as dramatic as this, none has been reported in studies controlled for this effect." Sidney Klawansky, M.D., Ph.D. (1993) has recently concluded a meta-analysis of CES at Harvard and has also found it to be efficacious. Open marketing of CES devices began in the 1970's in the U.S. for the treatment of anxiety, depression and insomnia. To date, several thousand Americans are treated with CES annually, and more than 50,000 people own CES devices which have been prescribed for home use. From a broad reading of the published literature, no negative effects or contraindications have been found from the use of CES, either in the U.S. or in other parts of the world. Regardless of these facts, CES is in jeopardy of being removed from the market in the United States due to a recent FDA action.
Our understanding of pain mechanisms and how pain is perceived has undergone significant changes. Initially, pain was viewed as an emotion rather than a sensation. It was said to be the opposite of pleasure. This theory dated back to the time of Aristotle. The traditional theory, described as the specificity theory by Descartes in 1664, conceived of a pain system as a direct channel from the skin to the brain (Melzack & Wall, 1982). This concept was supported and expanded on by Von Frey, who argued that there were specific pain receptors (Sinclair, 1953). As scientific experimentation grew towards the later part of the last century, Goldscheider developed the pattern theory, which stated that sensation was based on spatial and temporal patterns of a number of impulses (Nafe, 1929; Geldard, 1953). Zotterman (1936) discerned A-Delta and C afferent nerve fibers. Later research stated that A-delta fibers carried fast, but short-lived, well-defined pain impulses while C fibers carried slow, diffuse, long-duration pain.
The modern basis for the widespread use of transcutaneous electrical nerve stimulation (TENS) for pain control is the gate control theory proposed by Dr. Ronald Melzack and Dr. Patrick Wall (1965). This theory suggests that hypothetical "gates" in lamina V of the substantia gelatinosa could be "closed" to block pain stimuli traveling from A-delta and C fibers in the peripheral nervous system where they synapse into the central nervous system. Although this theory was later modified, it created much notoriety at the time and revolutionized the way most practitioners viewed and treated chronic pain.
In 1967, C. Norman Shealy, M.D., a neurosurgeon who had been implanting dorsal column stimulators (DCS), discovered that devices that transmitted electricity transcutaneously were just as effective without the risks associated with surgery (Shealy, Mortimer, & Reswich, 1967). With the Melzack-Wall theory behind him, Shealy's work renewed interest in electromedicine and resulted in the beginning of the modern day TENS devices.
Transcutaneous electrical nerve stimulation is an established modality with over 250,000 TENS units prescribed annually in the United States alone. Accordingly, much information is available on standard TENS applications, precautions, contraindications, side effects and results (Mannheimer & Lampe, 1984; Tapio & Hymes, 1987). Mixed results have occurred due to several factors, such as waveform, frequency, pulse repetition rate, intensity, alternating vs. direct current, electrode placement and treatment time. Perhaps the single largest variable is the education, or lack thereof, provided to health care practitioners recommending these devices and instructing patients in their use. Many professionals simply give the unit to a patient with the factory settings and never alter them, leaving each device as a hit or miss item. TENS devices must be tried at a variety of settings to achieve optimal pain relief for a given patient. In principle, TENS applies an electrical force that stimulates pain-suppressing A-beta afferent nerve fibers which compete against pain-carrying afferent nerve fibers. The same stimulation would occur if one lightly tapped the painful body part repeatedly with a pen, spoon, or other blunt object. Ice, massage, heat, manipulation and other long-standing therapy techniques have relieved pain this way for centuries.
Energy Source
Most TENS units work with currents in the milliampere range delivered for about 250 microseconds. The most common output is biphasic to avoid the side effects of polarization. They are powered either by alkaline or nickel cadmium batteries. In general, alkaline batteries are preferred for constant stimulation because they have a relatively slow, linear power decay. Rechargeable batteries have a series of peaks or near-peaks in their discharge rate because each cell discharges in series. Accordingly, rechargeable batteries should be avoided, especially in the cheaply made Taiwanese devices.
Electrodes
Initially, dry pads were provided that required the use of a gel. This was messy, provided uneven conductivity and caused minor skin burns at a high current. At present, self-adhesive electrodes are available that are semi-disposable and generally affordable. In this day and age of concern over deadly infectious diseases, it has become common practice for clinicians to keep a separate set of electrodes for the exclusive use of each patient.
Pulse Repetition Rate (PRR)
The reader will often see this listed as "frequency" on a typical TENS unit. According to the previous discussion in this chapter, the lower the PRR setting, the greater number of frequencies the patient will be exposed to; hence, the greater potential for pain relief. For the average pain patient, we recommend setting the PRR to the lowest setting for initial trials. Pomerantz (1981) has also shown by naloxone blocking studies that endorphins are only released at PRR settings of 8 Hertz or less.
Pulse Width
Wider pulses spread the current over greater distances. The maximum parameters in most TENS units ranges from 50 to 400 microseconds. The further apart the electrodes are, the wider the pulse width should be.
Electrode Placement
Electrode placement is perhaps the greatest variable in eliciting successful results with TENS. Electrodes can be placed "between the pain and the brain," along nerve roots, dermatomes of the respective nerve levels, following the referred pain pathway, or on trigger points. Janet Travell, M.D. started researching trigger points in 1957 (Travell & Simons, 1983). Trigger points are named such because they trigger pain when pressed. They are areas of localized tenderness that usually form with a persistent muscle spasm. For the purpose of this discussion, they can be measured as having higher conductivity than normal tissue. In most cases, electrical treatment directly on the point is indicated. Sometimes, this will increase the pain (as explained by the pattern theory of pain). If this occurs, treating across the area with microcurrent stimulation at 0.5 Hz will almost always alleviate it.
With the parameters discussed, it is apparent that several combinations of PRR, pulse width, intensity, electrode placement, time and frequency of stimulation may have to be attempted before desirable results are obtained. Perhaps this is the reason why most major medical insurance companies prefer to rent a TENS device to a patient for the first month before approving it for purchase.
Indications
Several studies have documented the desirable effects of TENS. Loeser and his coworkers (1975) examined TENS-induced relief of pain for headaches, cervical arthritis, low back, phantom limb, arthritis and acute post-operative pain. Tapio and Hymes (1987) reviewed the efficacy of TENS on low-back pain, cancer pain, post-herpetic neuralgia, phantom limb pain, rheumatoid arthritis, angina pectoris, various acute conditions, dysmenorrhea, visceral pain and several other disorders. Andersson (1976) found TENS could raise the threshold for dental pain. By using low-frequency, high-intensity stimulation (the so-called "acupuncture-like TENS") he was able to increase his success rate in pain reduction from 40 to 60%.
Contraindications
There are very few contraindications with TENS. All electrical modalities are contraindicated for pregnant women and patients with demand-type pacemakers. In general it is advisable that patients not drive or operate heavy machinery while TENS is being applied. Also, it is essential that electrodes from milliampere TENS units are not placed on the head or neck. This is especially true regarding the carotid sinuses as stimulation of the baroreceptors may result in a vaso-vagal syncopé.
TENS Summary
TENS is now a widely used modality for the treatment of general acute and chronic pain syndromes. When effective, the ease of use, general safety and portability make it a treatment over the long term use of medications and nerve blocks for chronic pain. Modern drug practitioners would do well to recall Aesculapius' motto regarding healing; primo non nocere (first, do no harm).
A disadvantage is the tinkering required for the average pain patient to find the best combination of variables for effective relief. Even after repeated attempts at different parameter combinations, TENS devices may not alter pain results. Although effective to some extent, they are simply an application of force, a counter-irritant produced analgesia. They provide no significant residual effect and as with drugs, tolerance is a significant problem.
MICROCURRENT ELECTRICAL THERAPY
Becker and Nordenström have provided a rational basis for a new and vastly more effective form of electromedical intervention for which Joseph M. Mercola, D.O. and Daniel L. Kirsch, Ph.D. (1994) coined the term "microcurrent electrical therapy" (MET). A growing body of research shows the effectiveness of MET to accelerate, and even induce healing. Eaglstein and Mertz (1978) have shown moist wounds to resurface up to 40% faster than air-exposed wounds. Falanga (1988) found that certain type of occlusive dressings, like Duoderm, accelerate the healing of wounds. It is probable that these dressings achieve their effects by promoting a moist environment (Kulig, Jarski, & Drewek, 1991). When a wound is dry, its current flow is shut off. The moisture may allow the endogenously produced current of injury to flow and promote wound healing. Electrical stimulation of the wound also tends to increase the amount of growth factor receptors which increases the amount of collagen formation (Falanga, 1987). Electricity was first used to treat surface wounds over 300 years ago with charged gold leaf to prevent smallpox scars (Robinson, 1925). There are several recent studies supporting the beneficial effects of treating wounds with an artificial current of injury (Goldin, 1981; Jeran, 1987; Ieran, 1990; Mulder, 1991). Experimental animal wound models in the 1960's demonstrated that electrical intervention can result in accelerated healing with skin wounds resurfacing faster, and with stronger scar tissue formation (Carey & Lepley, 1962; Assimacopoulos, 1968). Assimacopoulos (1968) published the first human study using direct electrical current for healing. He documented complete healing of chronic venous stasis leg ulcers in three patients with six weeks of electrical therapy. One year later the most frequently cited work in the history of electrical wound healing was published by Wolcott and Wheeler (1969). They used direct currents of 200-1,000 microamperes for 67 patients. Gault and Gatesn (1976) repeated the Wolcott and Wheeler protocol for 76 additional patients with 106 ischemic skin ulcers. Carey and Wainapel (1985) performed one of the only studies on this subject published with equal and randomized control and study groups. All of these studies documented significant accelerated healing with electrical stimulation. Working with Wolcott and others, Rowley et al. (1974) updated their initial experience with another group of patients having 250 ischemic ulcers of various types. These included 14 symmetrical control ulcers. The stimulated ulcers had a fourfold acceleration in healing response compared to the controls. One additional consistent observation in these studies was that there was a reversal of contamination in the wounds. Wounds that were initially contaminated with Pseudomonas and/or Proteus were usually sterile after several days of MET. Other investigators have also noticed similar improvements and encourage the use of this therapy as the preferred treatment for indolent ulcers (Kaada, Flatheim, & Woie, 1991; Barron, Jacobson, 1985; Lundeberg, Eriksson, & Malm, 1992; Alvarez et al., 1983). Additionally, no significant adverse effects resulting from electrotherapy have been documented (Weiss, 1990). A review of the literature by Dayton and Palladino (1989) shows that microcurrent electrical therapy is clearly an effective and safe supplement to the non-surgical management of recalcitrant leg ulcers.
Some of these studies used unipolar currents that were alternated between negative and positive based on various criteria. Some researchers initially used negative current to inhibit bacterial growth and then switched to positive current to promote healing. To date no study has compared this variable of MET. However, there is some compelling basic science research, and one animal study suggesting that a bipolar current, which provides both negative and positive phases, may be better for wound healing (Stromberg, 1988; Windsor, Lester, & Herring, 1993).
As mentioned previously, in the 1960s Dr. Becker demonstrated that an electrical current is the trigger that stimulates healing, growth and regeneration in all living organisms. He found that repair occurs after an injury in response to signals that come from an electrical control system and suggested that this system became less efficient with time. Dr. Becker (1985) developed his theory of biological control systems based on concepts derived from physics, electronics, and biology. He postulated that the first living organisms must have been capable of self-repair, otherwise they never would have survived. The self-repair process requires a closed-loop system. A specific signal is generated which causes another signal to start repair. The injury signal gradually decreases over time with the repair process until it finally stops when the repair is complete. Such a primitive system does not require demonstrable consciousness or intelligence. Therefore, many animals actually have a greater capacity for self-healing than do humans. Science has amassed a vast amount of information on how the brain and nervous system work. Most of this research involves the action potential as the sole mechanism of the nerve impulse. This is a very sophisticated and complex system for the transfer of information. It is helpful to compare this currently accepted process of the nervous system to a computer. The fundamental signal in both the computer and the nervous system is a digital one. Both systems transfer information represented by the number of pulses per unit of time. Information is also coded according to where the pulses go and whether or not there are more than one channel of pulses feeding into an area. All our senses (e.g., smell, taste, hearing, sight and touch) are based on this type of pulse system. Like a computer, the nervous system operates remarkably fast and can transfer large amounts of information as digital "on and off" data. It is unlikely that the first living organisms had such a sophisticated system. Becker believes they must have had a much simpler mechanism for communicating information because they did not need to transmit large amounts of sophisticated data. Accordingly, they probably used a much simpler analog system. An analog system works by means of simple DC currents. Information in an analog system is represented by the strength of the current, its direction of flow, and slow wavelength variations in its strength. This is a much slower system when compared to the digital model. However, the analog system is extremely precise and works well for its intended purpose. Becker theorizes that the first living organisms used this analog type of data-transmission and control system for injury repair. He postulates that we still have this primitive nervous system in the perineural cells of the central nervous system. These cells comprise 90% of the nervous system. The perineural cells have semiconductor properties that allow them to produce and transmit non-propagating DC signals. This analog system senses injury and controls repair. It controls the activity of cells by producing specific DC electrical environments in their vicinity. It also appears to be the primary primitive system in the brain, controlling the actions of the neurons in their generation and receipt of nerve impulses. This allows it to regulate our consciousness and decision-making processes. Given this understanding, the application of the correct form of electrical intervention is a powerful tool for treating pain, initiating the endogenous mechanisms of self-repair, and altering states of consciousness.
Clinical Applications
Clinically, we can use a point finder (ohmmeter) to measure pathological tissue because it exhibits a reduction in conductivity. This seems to be true in every case except in inflammatory conditions where the hot fluids conduct extracellularly causing a false-positive readings. The less conductive tissue sets up an electrical difference, or potential, on either side of the injury that controls pain and signals the healing process. This is known as the current of injury (COI). Since some tissues conduct electricity better than others, it is possible to calibrate a measurement device to an area near the injury before treating. Once a low conductive area is found, a microampere current with an effective waveform can augment the current of injury to effectively control pain as well as initiate or increase the rate of healing. Lerner and Kirsch (1981) developed this system and called it bioconductive therapy. The same meter can read a post treatment response (PTR) measurement. Generally up to four, six to ten second applications of stimulation with two small diameter probes is adequate per electrode placement. Several varying placements in an area may be needed to obtain an improved PTR. Once the area is adequately treated the PTR will exhibit a higher value with a slower decay time (Ullis, 1983). When using an effective device the improved PTR will almost always be associated with the patient's subjective feeling of improvement.The devices used for bioconductive therapy have come to be known as microcurrent stimulators. They deliver a much weaker signal about 2,500 times longer per pulse than TENS. The full spectrum ("shotgun") of frequencies within each pulse at this wavelength provide a phenomenally effective therapy. It is believed that cells within a specific organ or tissue system communicate through specific frequencies in the microampere range. The right frequency activates the COI causing the system to tend towards homeostasis. Caution is advised against purchasing devices claiming to be "cybernetic", or able to measure and automatically deliver the correct frequency for a given patient. Although at least one manufacturer makes such a claim, there is no such technology or scientific support material to design such a thing at this time. Originally, bioconductive therapy devices were large, expensive, metered units designed for clinical use only. A good microcurrent device requires more than ten times the circuitry of a standard TENS. However, in 1982, what is now Electromedical Products International, Inc. (EPII) of Mineral Wells, Texas introduced the first homecare microcurrent stimulator to the market. Their product, called the Alpha-Stim 350 weighed six pounds and was about half the size of a shoe box. Using surface mount technology manufactured by robotics EPII has been able to manufacture scaled down versions since 1990 at a cost competitive with TENS. Since then a number of imitations have flooded the market, primarily from Taiwan. Most of these products do not produce reproducible results because the design engineers know nothing about the underlying electrophysiology and they use cheap parts with tolerances as high as 35%. Alpha-Stim technology is actually produced by using two waveforms for each channel to create a full bioelectrical frequency range and introduce random factors into the waveform preventing the nervous system from recognizing it, and therefore habituating to it. The biggest mistake practitioners make with microcurrent devices is to use them the same way they would use a TENS device. As an example, TENS is often applied on either side of and close to the spine for back pain. This will not work with microcurrent technology because the current, following the path of least resistance, is too weak to actually reach the spine.
Step One: History and Brief Exam
It is extremely important to take a comprehensive history before beginning MET. One should determine when the pain first presented, its frequency, duration, intensity, limitations-of-motion, positions which exacerbate the pain and any precipitating factors. Ask about the specifics of previous treatments. Microcurrent electrical therapy is a holistic procedure. It may be necessary to clear the body of any and all electrical "blocks" in order to achieve the best results (more on this later). Immediately before each treatment determine the patient's current pain level and the positions that exacerbate the pain. Ask the patient to rate their present pain on a scale of 0 (no pain) to 10, with 10 being excruciating, debilitating pain. Tell the patient to consider 10 as "the worst this condition has been". Also note any immediate limitations-of-motion, positive orthopedic and neurologic test findings, and psychological distress. This therapy usually produces instantaneous results so these indicators are necessary reference parameters to determine effectiveness throughout a single treatment session.
Adjust the Settings
Use a low frequency, preferably 0.5 Hz most of the time. It is unusual to ever need to use other frequency settings. However, if 0.5 Hz doesn't work, and everything else described herein has been tried, use a higher setting. In MET, this usually means 80 to 100 Hz. These higher frequencies are sometimes best for the first few minutes of treatment for inflammatory articular problems. Set the current intensity level at the highest comfortable position which is usually 500 to 600 microamperes (A) for probes, although it is sometimes slightly less for the silver-silver/chloride (Ag-AgCl) electrodes. Do not use any other type of self-adhesive electrodes for MET. Probes must be applied using a firm pressure, but less than the amount of pressure that would cause pain.
Treatment Strategy
There are several principles one must remember when treating patients with MET. The patient should be in a relaxed position to receive maximum beneficial effects. The most important variable is the position of the probes, or pads. Position them in such a way that if a line was drawn between them that line would transect the problem area. Keep in mind that the body is three dimensional. Therefore, there will be many possible ways to draw a line through the problem. Some lines will work much better than others! Sometimes it is helpful to imagine the problem area of the body as being transparent. As mentioned above, do not place the electrodes on each side of the spine for back pain as is done with TENS. With this placement the current will travel just under the skin and never reach the problem. A better way is to place one electrode next to the spine and the other on the contralateral side, anteriolaterally (front and opposite side). A line drawn between those will go right through the spinal nerves. Treat head, neck, and back (axial skeleton) problems bilaterally. If the other side is ignored, there is a good chance the problem will have been missed because pain often exhibits on the tense side which may just be compensating for muscular weakness on the other side. So after a few 10 second approaches with small diameter probes, or about 10 minutes with self-adhesive electrode pads, reverse sides.
Quick Probe Treatments
When using probes treat for 10 seconds per site. First treat in an "X" manner over an area wider than the problem. An example of this would be to treat the whole back for back pain. This can be done by placing one probe on the right shoulder and the other on the left hip, and then one on the left shoulder connected to the right hip. One treatment "set" is about five or six of these ten second stimulations, each at a different angle of approach (e.g., two obliques, two medial-lateral, and two anterior-posterior, etc.). Often the pain will migrate as a response to therapy. Follow it. Use the same treatment strategy described above for the pain's new location.
When to Stop
Reevaluate the patient after a few treatment sets. For some simple problems, it is preferable to reevaluate after each set. Use the original criteria. It is not enough to ask if the patient feels better, ask for a specific percentage of how much better. Also reexamine for objective signs like range-of-motion increases, etc. Stop when the pain is completely gone or when the improvement has reached a plateau after several sets of treatment. Continuing to treat the area at this time may cause the pain to return! If the pain is gone stop treatment for that day even if the patient only had one minute of treatment. If the patient can no longer identify any pain, but complains of stiffness, this is also a good indication that it is time to stop. Although most people will achieve immediate results, some will have a delayed effect and others will have a combined effect, continuing to improve over a day or two after the treatment.
Follow-up
The average patient should be given at least three treatments to evaluate their response to microcurrent electrical therapy. It helps to explain to the patient that the effects are cumulative. Like antibiotics, one must take several doses over a period of time to get results. Although results will often be seen during or subsequent to the first treatment, the longevity of the results can only be evaluated over the course of a few treatments. In some cases the results will plateau to a similar time period regardless of treatment. For example, a patient may only get two days of relief no matter what combination of treatment strategies are employed. For these and in cases of severe pathology, the effectiveness may only be short-lived so a MET device should be prescribed for home care. After an initial series of up to ten treatments, a good rule of thumb is to prescribe a unit to anyone with a chronic condition who requires more than one palliative treatment per month, and to those who have progressive pathologies.
Tips for Limited or Poor Results
Microcurrent electrical therapy will not work for everybody. However, as originally reported in an earlier version of this text, in nearly all cases of failure the common denominator is that the patient has had a significant exposure to a strong electrical current. This means that they have either been held by electrical current at some time in their life, or that they have been treated with milliampere TENS or similar modalities for a prolonged period of time (e.g., years). As yet, there is still no known effective method for treating people so afflicted.
The most commonly seen reversible reason patients fail to respond to treatment is that they have surgical or traumatic scars. Identify all scars by taking a very thorough, persistent history, and examining the patient completely. All scars are important no matter how old or how far they are from the chief complaint. Scar tissue impedes the systemic flow of endogenous bioelectricity because it is a poor conductor of electricity. Accordingly, scar tissue may interfere with the patient's entire bioelectrical system. If scars are present they should be treated with silver/silver-chloride (Ag/AgCl) electrodes for ten minutes per scar, at least four times. Simply cover the scars with the electrodes or, for large scars, place the electrodes on the ends of the scars. This may be done four days in a row or there can be a short interval of up to a few days between the scar treatments. When treating scars the person may experience a significant surge of energy. It can be viewed as if an electrical bioresistor is broken down. Patients will often report feeling half their age, or 20 years younger after scar therapy. Since people have nothing to compare their life experience with, they usually attribute the subtle effects of scars on their electrical system as normal aging. Be aware that this treatment will more often than not also increase the pain because the whole body and mind "wakes up", including the painful part. However, when this happens in nearly all cases, the painful area can then be successfully treated. Always schedule enough time to treat the pain after the scar treatment so the patient will not need to endure even a temporary increase in pain. If all the scars are treated and there is still no or poor results there are a few other options. Question the patient about old injuries that may not have healed properly. These could also be electrical blocks and should be approached in the same way as scars. To relieve pain in some patients a lower current setting of no more than 100 A with the Ag/AgCl electrodes for one or more hours at a time is necessary. Higher pulse repetition rates may produce results in some people when the 0.5 Hz fails, but this is rare.
CRANIAL ELECTROTHERAPY STIMULATION
Cranial electrotherapy stimulation (CES) is the application of low-level pulsed electrical currents (usually less than one milliampere) applied to the head for medical and/or psychological purposes. Cranial electrotherapy stimulation has also been known by many other names. Transcranial electrotherapy (TCET), neuroelectric therapy (NET), alphasleep, electroanalgesia, electronarcosis and the original electrosleep are just a few of the more common terms that have referred to the same therapy. Cranial electrotherapy stimulation was first called electrosleep because it was thought to induce sleep. Rabinovich, a Russian, is given credit for making the first claim for electrical treatment of insomnia in 1914 (Achte, Kauko, & Seppala, 1968). In 1957, in the U.S.S.R., Anan'ev et al. published the first work on CES and the first book, simply titled Electrosleep, was published a year later by Gilyarovski. This generated a high degree of interest in the then-known Eastern Block countries and CES was soon adopted as a treatment modality. Obrosow (1959) reviewed the CES literature and published the first American paper on CES. By 1966 the first International Symposium on Electrotherapeutic Sleep and Electroanesthesia was held in Austria. Cranial electrotherapy stimulation use had spread worldwide by the late 1960's when animal studies of CES began in the U.S. at the University of Tennessee, and at what is now the University of Wisconsin Medical School. These were soon followed by human clinical trials at the University of Texas Medical School in San Antonio, the University of Mississippi Student Counseling Center and the University of Wisconsin Medical School. There are well over 100 published reports on CES in the U.S. and several times that amount in the European literature. The most comprehensive research review published to date on CES is a chapter in a textbook by Ray B. Smith, Ph.D. (1985). Dr. Smith has been researching CES since 1972. He concluded, "There are 40 studies of CES readily available in the U.S., in which the dependent variable is reliable. When these are examined alone it becomes apparent that CES is effective in alleviating symptoms of anxiety, depression, and insomnia...CES appears effective as a treatment for withdrawal in the chemically dependent person...Other promising areas of treatment are in hypergastric acidity and migraine headaches." Dr. Smith adds, "CES appears to be safe, with no harm or negative side effects having been reported to date in controlled studies...Finally, while one usually assumes some placebo effect from a treatment as dramatic as this, none has been reported in studies controlled for this effect." Sidney Klawansky, M.D., Ph.D. (1993) has recently concluded a meta-analysis of CES at Harvard and has also found it to be efficacious. Open marketing of CES devices began in the 1970's in the U.S. for the treatment of anxiety, depression and insomnia. To date, several thousand Americans are treated with CES annually, and more than 50,000 people own CES devices which have been prescribed for home use. From a broad reading of the published literature, no negative effects or contraindications have been found from the use of CES, either in the U.S. or in other parts of the world. Regardless of these facts, CES is in jeopardy of being removed from the market in the United States due to a recent FDA action.
Although CES treatment is indicated for insomnia, because of the increased alertness some patients find it difficult to fall asleep immediately after a treatment. Accordingly, it is recommended that CES be done at least three hours before going to bed. Also, in most cases after the first week or so of CES, treating every other day is usually more effective than every day.
Results
The end result of a successful CES session is that the patient will feel more relaxed and more alert; as if they have a type A mind in a type B body. Immediately after a CES treatment, patients usually report feeling relaxed and somewhat inebriated for the first few minutes. This is a pleasant and very comfortable sensation. After several minutes to hours, the light-headed feelings usually disappear, the relaxed state remains and a profound sense of alertness is achieved. This relaxed/alert state will usually remain for an average of 12 to 72 hours after the first few treatments. With regular use it is possible for the patient to habituate to this preferred state of consciousness. Following CES, many patients relate feeling better, less distressed, and more focused on mental tasks. They generally sleep better and report improved concentration, increased learning abilities, enhanced recall and heightened states of well-being. These general feelings were first described by psychologists during the 1970's as an alpha state of consciousness. Such states are also produced by meditation, biofeedback training, relaxation instructions, chanting, hypnotherapy and certain religious rituals. This is not the same as the alpha brain wave frequency of three to eight Hz. Often, practitioners are confused by device representatives who claim that their particular device will output and entrain a brain to the alpha frequency. There is no evidence to support that any devices work on an entrainment principle.
Contraindications
As mentioned earlier, there have been no harmful side effects reported in any of the research literature since CES was begun in the 1950's. As with all electrical devices, caution is advised during pregnancy and on patients with a demand-type pacemaker. In addition, we recommend that patients not operate complex machinery or drive automobiles during and shortly after a CES treatment.
Summary
CES is an electrical transcranial therapy that employs devices which do not exceed 1.5 milliamperes and usually work in the microampere current range. Beneficial effects have been reported for a wide variety of pain, distress and addiction disorders.
Pain is a central nervous system event. To achieve optimal results through electromedical intervention, the brain should also be treated. Cranial electrotherapy stimulation produces a relaxed, alert state. It is effective in controlling the anxiety, depression, insomnia and generalized stress associated with pain patients and as a primary modality for these disorders. In addition, there is mounting evidence that CES can enhance various cognitive functions. Because of its safety and effectiveness, CES is highly recommended for a broad range of pain-related disorders.
AURICULAR MEDICINE
Auricular medicine is an interesting and highly effective system of treating the entire body from the external ear. It originated in China but has been redeveloped in Europe, primarily France and Germany, over the past 40 years. Prior to that, Egyptians used earrings to treat eye and fertility problems. Through Mediterranean trading routes, the Romans learned this technique and would use it to cauterize specific points on ears for sciatica.
In 1957, Paul Nogier, M.D., a French neurologist noticed several of his patients had scars on the same spot on their ears (Nogier, 1972). They each related their scars to a prior treatment for sciatic pain by a local unconventional practitioner. Nogier confirmed that treatment of specific points on the external ear alleviated specific problems of the body. He proposed and proved a somatotopic relationship exists between different anatomical areas of the body and specific points on the ear. He then began mapping auricular points based on an embryological model and found somatic correlations with mesoderm, ectoderm and endodermal auricular structures. Under Chairman Mao's direction, The Nanking army ear acupuncture team studied over 2,000 patients confirming Nogier's findings (Huang, 1974). In the U.S., Oleson, Kroening and Bresler (1980) completed a conclusive study to determine the validity of auricular points. Using a double-blind model they examined 40 patient's ears to diagnose "problem present" or "problem absent" at specific somatic sites. They achieved a 75.2% correlation between auricular diagnostic measurements and problem areas. In 1983, Ercolani, Zucchini and Poli (1983) had encouraging results with functional amblyopia in children. Zanini (1983) studied 724 various pain conditions with auricular medicine and Electro-Acutherapy compared to traditional acupuncture. He obtained superior results with auricular medicine. This technique was discredited by the American Medical Association when Melzack and Katz (1984) published a placebo study on 36 pain patients. They did not see a significant difference between the treated and placebo groups. It is interesting how this study did not use a device made for auricular medicine, nor was it done by practitioners trained and experienced in this modality.
Very brief, six to ten second stimulation at about 100 microamperes on auricular points can often produce profound, and immediate results. The key is to treat the exact point on the front and directly behind it on the back of the ear associated with the regional area of pathology. These areas are called corresponding points. They will measure highly conductive and be sensitive to pressure, sometimes long after the pathology is considered healed. The points Shen-men (literally, "heaven's gate"), Adrenal and Subcortex (thalamus) must also be treated on the front of the ear for neuromusculoskeletal pain disorders. Auricular medicine charts are available from most acupuncture supply companies.
CASE HISTORIES
Three case histories are given to illustrate the effectiveness of electromedical procedures. Although they may seem rather amazing to those inexperienced with MET, they actually somewhat representative of the results seem with the better instrumentation available today.
Case one: This was published by William Bauer, M.D. (1983). At the time of publication, Dr. Bauer was from the Division of Otolaryngology, Case Western Reserve University School of Medicine and Chief, Department of Otolaryngology at the Veterans Administration Medical Center in Cleveland.
"A 58-year-old man had squamous cell carcinoma of the laryngopharynx diagnosed in 1980. It was staged at T4N2MO. The patient received full-course radiation therapy to the primary tumor in the piriform sinus and to the ipsilateral neck mode. He had recurrence in the larynx after one year and underwent a laryngectomy and radical neck dissection. Four months later, a metastatic mass was discovered in the area of the neck that had been operated on. Further radiation treatment was given and provided temporary palliation of growth and pain. Pain became the most notable problem, requiring at least 7 mg of morphine every four hours along with various sedatives. This failed to give complete relief. At this point, electrical stimulation to the neck was given. Treatment was given directly across the area of the tumor with a current of 500 microamperes at 0.5 Hz for ten minutes. The pain disappeared. The treatment was repeated the following two consecutive days, and the patient remained pain free for one week without further treatment. At the end of one week, pain returned and he was again treated. The patient again remained pain free, but began having symptoms of withdrawal from the morphine. He was then placed on a regimen of methadone hydrochloride. He is presently pain free with electrical treatments every three days for one minute."
Case two: This is a letter written by a retired dentist to an electromedical manufacturing company (Chudzinski, 1990). In this case, the patient purchased a small unit for home care.
"I am a retired 69 year old dentist trained in oral surgery. I purchased the Alpha-Stim CS to treat a recurring pain and spasticity in both sternocleidomastoid muscles which did not respond very well to the traditional treatment. By placing one electro pad on the muscle origin and its mate toward the muscle insertion and the other set of pads in the contra-position, I gave the most painful left muscle two twenty minute 0.5 Hz treatments. There was a very noticeable relief of pain. I treated the less painful right muscle in the same manner and the pain was almost fully relieved. It took four days of treatment to relieve all of the pain and stiffness. In addition to the above results and a bonus which I cannot explain, a left sub-deltoid bursitis which had been bothering me for about four months completely disappeared the morning after the first muscle treatment. I have been bothered with an intermittent tinnitus since about 1950. It became continuous in about 1965. I was unaware that there was any successful treatment of this annoying complaint. The noise in my left ear was a constant loud whistling and the right ear a less noisy ringing. By placing the ear clip electrodes on my earlobes and the pads at the level of my upper posterior teeth and using 0.5 Hz for two 20 minute treatments for about a week, the ringing noise disappeared completely and the whistling noise was reduced about 85%. Thank you for developing this new instrument. It certainly has made my life more enjoyable."
Case Three: This patient was seen by Dr. Fred Lerner in his private practice in Santa Monica, California. A twenty-six year old female was involved in a rear-end type automobile accident. She was not wearing a seat belt and on impact struck her chin against the steering wheel rendering her unconscious for several minutes. She sustained injuries to her temporomandibular joint, neck, low back and was also diagnosed with post-concussion syndrome. After almost two years of multiple therapies which included drugs, heat, ultrasound, massage, manipulation, electric muscle stimulation, a temporomandibular joint splint and various stretching exercises, as well as consulting several different practitioners in the process, she still complained of constant headaches that began suboccipitally and wrapped around to both temples. She graded the headaches as beginning at a level of three out of ten, ten being the worst, upon arising in the morning and proceeding to a level of eight out of ten by mid-afternoon, thus incapacitating her. Her low back pain had resolved although her neck pain radiated into the trapezius areas bilaterally and was fairly constant at a level of three to four out of ten. All of her symptoms were aggravated by "stress." Furthermore, she complained of difficulty concentrating, had trouble falling asleep and when she did, slept fitfully. She complained of occasional short-term memory lapses and various other mild dysfunctions of mental capacity consistent with the post-concussion syndrome. Extensive diagnostics procedures were done, including plain films, computerized tomography (CT) scan of the neck, a magnetic resonance image (MRI) of the brain and a complete neurological evaluation. The patient even had an overnight sleep laboratory electroencephalograph (EEG). None of these provided a structural finding that would account for her symptoms.
Although her case had been litigated, a settlement compromise had occurred six months before. Therapeutic trial was begun using CES with bioconductive therapy administered in the trapezius areas bilaterally. Treatment was provided three times per week for two weeks, at which time a re-evaluation was made. Her headache levels had decreased to a mid-afternoon peak of four out of ten, with no pain on arising. Her neck pain had subsided to a level of one to two out of ten and she had experienced two nights of uninterrupted sleep. She reported an increased ability to concentrate and stated that she was beginning to feel like her old self again.
The patient was instructed on the use of a prescribed home Alpha-Stim CES/bioconductive therapy device, including electrode placement, frequency of use and length of treatment. On six month's follow-up she presented with occasional minimal pain in her neck region, had one headache in the last two months that she graded at an intensity level of three and had fully resumed a normal lifestyle.
SUMMARY
The proposed theories do not yet fully account for the observable results. Accordingly, several questions remain: 1) what is the exact nature of the relationship between the specific harmonics of various tissues and these methods? 2) what is the mechanism responsible for electrogenesis when induced by various forms of electricity? 3) why doesn't a given tissue respond in the same way at different times? 4) why don't nonunion fractures with gaps larger than one-half the diameter of the bone, and synovial pseudoarthroses, respond to any form of electromedical intervention? 5) what are the exact parameters of stimulation that should be used in what type of clinical situation to give the best response? 6) Finally, if it is true that people who have been over-exposed to electricity fail to benefit from electromedical therapy, what has occurred physiologically and what can we do to reverse it? One must stray from the routine procedures of the day in order to create the advances of tomorrow. There is still a lot to learn about bioelectricity and electromedicine. In order to do so, we must first acknowledge that there is another side of physiology. We must take the time and spend the money to fight oppressive government bureaucracies such as the FDA who clearly support the drug industry monopoly. Everyone concerned about health should demand widespread access to conservative, non-damaging alternative care. To lessen human suffering is a notable goal. That we have not been able to achieve enough of this to date is a good indication that the answers must lay elsewhere. Biophysics must be better understood to realize the actual basis for the control of the regulatory processes of life. Even at its current state of evolution, electromedicine is an unprecedented conservative, cost-effective, safe and powerful tool in the management of the pain patient. As such, it should be the first priority on the list of treatment options.
REFERENCES
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Results
The end result of a successful CES session is that the patient will feel more relaxed and more alert; as if they have a type A mind in a type B body. Immediately after a CES treatment, patients usually report feeling relaxed and somewhat inebriated for the first few minutes. This is a pleasant and very comfortable sensation. After several minutes to hours, the light-headed feelings usually disappear, the relaxed state remains and a profound sense of alertness is achieved. This relaxed/alert state will usually remain for an average of 12 to 72 hours after the first few treatments. With regular use it is possible for the patient to habituate to this preferred state of consciousness. Following CES, many patients relate feeling better, less distressed, and more focused on mental tasks. They generally sleep better and report improved concentration, increased learning abilities, enhanced recall and heightened states of well-being. These general feelings were first described by psychologists during the 1970's as an alpha state of consciousness. Such states are also produced by meditation, biofeedback training, relaxation instructions, chanting, hypnotherapy and certain religious rituals. This is not the same as the alpha brain wave frequency of three to eight Hz. Often, practitioners are confused by device representatives who claim that their particular device will output and entrain a brain to the alpha frequency. There is no evidence to support that any devices work on an entrainment principle.
Contraindications
As mentioned earlier, there have been no harmful side effects reported in any of the research literature since CES was begun in the 1950's. As with all electrical devices, caution is advised during pregnancy and on patients with a demand-type pacemaker. In addition, we recommend that patients not operate complex machinery or drive automobiles during and shortly after a CES treatment.
Summary
CES is an electrical transcranial therapy that employs devices which do not exceed 1.5 milliamperes and usually work in the microampere current range. Beneficial effects have been reported for a wide variety of pain, distress and addiction disorders.
Pain is a central nervous system event. To achieve optimal results through electromedical intervention, the brain should also be treated. Cranial electrotherapy stimulation produces a relaxed, alert state. It is effective in controlling the anxiety, depression, insomnia and generalized stress associated with pain patients and as a primary modality for these disorders. In addition, there is mounting evidence that CES can enhance various cognitive functions. Because of its safety and effectiveness, CES is highly recommended for a broad range of pain-related disorders.
AURICULAR MEDICINE
Auricular medicine is an interesting and highly effective system of treating the entire body from the external ear. It originated in China but has been redeveloped in Europe, primarily France and Germany, over the past 40 years. Prior to that, Egyptians used earrings to treat eye and fertility problems. Through Mediterranean trading routes, the Romans learned this technique and would use it to cauterize specific points on ears for sciatica.
In 1957, Paul Nogier, M.D., a French neurologist noticed several of his patients had scars on the same spot on their ears (Nogier, 1972). They each related their scars to a prior treatment for sciatic pain by a local unconventional practitioner. Nogier confirmed that treatment of specific points on the external ear alleviated specific problems of the body. He proposed and proved a somatotopic relationship exists between different anatomical areas of the body and specific points on the ear. He then began mapping auricular points based on an embryological model and found somatic correlations with mesoderm, ectoderm and endodermal auricular structures. Under Chairman Mao's direction, The Nanking army ear acupuncture team studied over 2,000 patients confirming Nogier's findings (Huang, 1974). In the U.S., Oleson, Kroening and Bresler (1980) completed a conclusive study to determine the validity of auricular points. Using a double-blind model they examined 40 patient's ears to diagnose "problem present" or "problem absent" at specific somatic sites. They achieved a 75.2% correlation between auricular diagnostic measurements and problem areas. In 1983, Ercolani, Zucchini and Poli (1983) had encouraging results with functional amblyopia in children. Zanini (1983) studied 724 various pain conditions with auricular medicine and Electro-Acutherapy compared to traditional acupuncture. He obtained superior results with auricular medicine. This technique was discredited by the American Medical Association when Melzack and Katz (1984) published a placebo study on 36 pain patients. They did not see a significant difference between the treated and placebo groups. It is interesting how this study did not use a device made for auricular medicine, nor was it done by practitioners trained and experienced in this modality.
Very brief, six to ten second stimulation at about 100 microamperes on auricular points can often produce profound, and immediate results. The key is to treat the exact point on the front and directly behind it on the back of the ear associated with the regional area of pathology. These areas are called corresponding points. They will measure highly conductive and be sensitive to pressure, sometimes long after the pathology is considered healed. The points Shen-men (literally, "heaven's gate"), Adrenal and Subcortex (thalamus) must also be treated on the front of the ear for neuromusculoskeletal pain disorders. Auricular medicine charts are available from most acupuncture supply companies.
CASE HISTORIES
Three case histories are given to illustrate the effectiveness of electromedical procedures. Although they may seem rather amazing to those inexperienced with MET, they actually somewhat representative of the results seem with the better instrumentation available today.
Case one: This was published by William Bauer, M.D. (1983). At the time of publication, Dr. Bauer was from the Division of Otolaryngology, Case Western Reserve University School of Medicine and Chief, Department of Otolaryngology at the Veterans Administration Medical Center in Cleveland.
"A 58-year-old man had squamous cell carcinoma of the laryngopharynx diagnosed in 1980. It was staged at T4N2MO. The patient received full-course radiation therapy to the primary tumor in the piriform sinus and to the ipsilateral neck mode. He had recurrence in the larynx after one year and underwent a laryngectomy and radical neck dissection. Four months later, a metastatic mass was discovered in the area of the neck that had been operated on. Further radiation treatment was given and provided temporary palliation of growth and pain. Pain became the most notable problem, requiring at least 7 mg of morphine every four hours along with various sedatives. This failed to give complete relief. At this point, electrical stimulation to the neck was given. Treatment was given directly across the area of the tumor with a current of 500 microamperes at 0.5 Hz for ten minutes. The pain disappeared. The treatment was repeated the following two consecutive days, and the patient remained pain free for one week without further treatment. At the end of one week, pain returned and he was again treated. The patient again remained pain free, but began having symptoms of withdrawal from the morphine. He was then placed on a regimen of methadone hydrochloride. He is presently pain free with electrical treatments every three days for one minute."
Case two: This is a letter written by a retired dentist to an electromedical manufacturing company (Chudzinski, 1990). In this case, the patient purchased a small unit for home care.
"I am a retired 69 year old dentist trained in oral surgery. I purchased the Alpha-Stim CS to treat a recurring pain and spasticity in both sternocleidomastoid muscles which did not respond very well to the traditional treatment. By placing one electro pad on the muscle origin and its mate toward the muscle insertion and the other set of pads in the contra-position, I gave the most painful left muscle two twenty minute 0.5 Hz treatments. There was a very noticeable relief of pain. I treated the less painful right muscle in the same manner and the pain was almost fully relieved. It took four days of treatment to relieve all of the pain and stiffness. In addition to the above results and a bonus which I cannot explain, a left sub-deltoid bursitis which had been bothering me for about four months completely disappeared the morning after the first muscle treatment. I have been bothered with an intermittent tinnitus since about 1950. It became continuous in about 1965. I was unaware that there was any successful treatment of this annoying complaint. The noise in my left ear was a constant loud whistling and the right ear a less noisy ringing. By placing the ear clip electrodes on my earlobes and the pads at the level of my upper posterior teeth and using 0.5 Hz for two 20 minute treatments for about a week, the ringing noise disappeared completely and the whistling noise was reduced about 85%. Thank you for developing this new instrument. It certainly has made my life more enjoyable."
Case Three: This patient was seen by Dr. Fred Lerner in his private practice in Santa Monica, California. A twenty-six year old female was involved in a rear-end type automobile accident. She was not wearing a seat belt and on impact struck her chin against the steering wheel rendering her unconscious for several minutes. She sustained injuries to her temporomandibular joint, neck, low back and was also diagnosed with post-concussion syndrome. After almost two years of multiple therapies which included drugs, heat, ultrasound, massage, manipulation, electric muscle stimulation, a temporomandibular joint splint and various stretching exercises, as well as consulting several different practitioners in the process, she still complained of constant headaches that began suboccipitally and wrapped around to both temples. She graded the headaches as beginning at a level of three out of ten, ten being the worst, upon arising in the morning and proceeding to a level of eight out of ten by mid-afternoon, thus incapacitating her. Her low back pain had resolved although her neck pain radiated into the trapezius areas bilaterally and was fairly constant at a level of three to four out of ten. All of her symptoms were aggravated by "stress." Furthermore, she complained of difficulty concentrating, had trouble falling asleep and when she did, slept fitfully. She complained of occasional short-term memory lapses and various other mild dysfunctions of mental capacity consistent with the post-concussion syndrome. Extensive diagnostics procedures were done, including plain films, computerized tomography (CT) scan of the neck, a magnetic resonance image (MRI) of the brain and a complete neurological evaluation. The patient even had an overnight sleep laboratory electroencephalograph (EEG). None of these provided a structural finding that would account for her symptoms.
Although her case had been litigated, a settlement compromise had occurred six months before. Therapeutic trial was begun using CES with bioconductive therapy administered in the trapezius areas bilaterally. Treatment was provided three times per week for two weeks, at which time a re-evaluation was made. Her headache levels had decreased to a mid-afternoon peak of four out of ten, with no pain on arising. Her neck pain had subsided to a level of one to two out of ten and she had experienced two nights of uninterrupted sleep. She reported an increased ability to concentrate and stated that she was beginning to feel like her old self again.
The patient was instructed on the use of a prescribed home Alpha-Stim CES/bioconductive therapy device, including electrode placement, frequency of use and length of treatment. On six month's follow-up she presented with occasional minimal pain in her neck region, had one headache in the last two months that she graded at an intensity level of three and had fully resumed a normal lifestyle.
SUMMARY
The proposed theories do not yet fully account for the observable results. Accordingly, several questions remain: 1) what is the exact nature of the relationship between the specific harmonics of various tissues and these methods? 2) what is the mechanism responsible for electrogenesis when induced by various forms of electricity? 3) why doesn't a given tissue respond in the same way at different times? 4) why don't nonunion fractures with gaps larger than one-half the diameter of the bone, and synovial pseudoarthroses, respond to any form of electromedical intervention? 5) what are the exact parameters of stimulation that should be used in what type of clinical situation to give the best response? 6) Finally, if it is true that people who have been over-exposed to electricity fail to benefit from electromedical therapy, what has occurred physiologically and what can we do to reverse it? One must stray from the routine procedures of the day in order to create the advances of tomorrow. There is still a lot to learn about bioelectricity and electromedicine. In order to do so, we must first acknowledge that there is another side of physiology. We must take the time and spend the money to fight oppressive government bureaucracies such as the FDA who clearly support the drug industry monopoly. Everyone concerned about health should demand widespread access to conservative, non-damaging alternative care. To lessen human suffering is a notable goal. That we have not been able to achieve enough of this to date is a good indication that the answers must lay elsewhere. Biophysics must be better understood to realize the actual basis for the control of the regulatory processes of life. Even at its current state of evolution, electromedicine is an unprecedented conservative, cost-effective, safe and powerful tool in the management of the pain patient. As such, it should be the first priority on the list of treatment options.
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