Therapeutic Direct Current Direct current refers to a current passing continuously in the same direction.

T herapeutic direct current (d.c.) has been considered to pass for more than 1 sec ond, and is sometimes called constant current or galvanism. Interrupted Direct C urrent (IDC): This is also known as galvanic current. It is produced by modifica tion in the form of interruption in direct current where current is made to flow and seized at regular intervals. Production of Interrupted Direct Current: Production of interrupted direct current involves following: Source of IDC Trans istors Potential divider Timer circuit (Timer device) All that is needed to prov ide therapeutic d.c. is a steady unidirectional voltage, a means of regulating t he voltage applied to the tissues via terminals marked positive and negative and a means of measuring the current flow. The mains voltage is rectified and reduc ed and a potential divider is placed in parallel with the patient. Moving the co ntrol can alter this divider. With the potential divider at zero no voltage is a pplied so that no current will flow. The milliammeter in series with the patient will indicate zero current flow. Suppose 50V is applied across the resistance a nd the control is turned to make contact one-fifth of the way along the resistan ce, then 10V is applied to the tissues. If the total resistance of the patient a nd the meter were 5000 ohms then 2mA would pass through the tissues and be shown on the meter (10 / 5000 = 0.02; Ohm s Law). Similarly, if the connection is moved t o halfway and 25V is applied than 5mA will flow. Thus the current to the patient can by regulated from zero. The current in the patient depends not only on the voltage but also on the patient s resistance, so if skin resistance falls current wi ll rise. Duration & Frequency of IDC: The duration and frequency of the impulses can be adjusted, a duration of 100ms being commonly used, although it is often an advantage to increase this to 300 t o 600ms. 1

Frequency of the current reduces with increase in the pulse duration. Pulse dura tion of 100ms will have frequency of 30 cycles/minute. The interval between the impulses should never be shorter duration than the impulses themselves and is us ually appreciably longer. Types of IDC: Currents produced for therapeutic purposes may have sudden or gradual fall, henc e depending on this there are several types, which are as follows: 1) Rectangula r I t 2) Trapezoidal I t 3) Triangular I t 4) Saw-tooth I t 5) Depolarized I t Rec tangular pulses have sudden rise whereas others like trapezoidal, triangular and saw-tooth have gradual rise. The impulses in which current rises gradually are often termed selective , because a contraction of denervated muscle can often be produc ed with an intensity of current that is insufficient to stimulate the motor nerv es because accommodation occurs. 2

Some equipment allows for low-intensity reversed current between the impulses gi ving so-called depolarized impulses. Here the chances of electrolyte burns are v ery less. The reverse wave of current between the impulses reduces the chemical formation, and if the quantity of electricity passed in the reversed current is equal to that in the forward one any chemicals formed are neutralized and the da nger of burns eliminated. There is a consequent reduction in irritation of skin, so making the treatment more comfortable for the patient. Selection of impulses: Rectangular impulse is capable of producing muscle contraction but selective imp ulse is always satisfactory. With rectangular impulses rise is sudden whereas wi th trapezoidal it is slow, with triangular even slower and with saw-tooth still slower. A low intensity and gradual rise in current is often best for stimulatio n of denervated muscle as it brings about satisfactory contraction with less sen sory stimulation than with the rectangular impulses. Proper selection of current leads to elimination of unwanted contraction of innervated muscles present in t he closed proximity. In long-standing denervation a muscle contraction may be ob tained with a slowly rising current when there is no longer any response to a re ctangular impulse. When various types of impulses are available it is advisable to attempt stimulation with each in order to ascertain which produces the most s atisfactory contraction. It is often found that the more long-standing the dener vation the slower the rise in intensity of current that is required. Physiological & Therapeutic Effects of IDC: Low-density currents have been used for the effects they cause in the skin and f or iontophoresis, usually for periods of 10-30 minutes. The current density is k ept to a level that does not cause tissue damage or patient discomfort. Traditio nally this is said to be below about 0.33 mA/cm2. Following are the physiologica l and therapeutic effects of the interrupted direct current: Sensory Stimulation : During the passage of direct currents the patient is aware of a mild tingling or prickling sensation, which may merge into a mild irritation or itching. If su fficient current has passed for long enough an erythema of the skin will be evid ent under both electrodes, and is more marked under the negative (cathode). This erythema is confined to the area of the applied electrode. 3

Hyperaemia: Since this erythema is confined it indicates a capillary hyperaemia, unlike that due to heat in which arteriolar dilatation occurs. The erythema cau ses vasomotor stimulation and increased circulation may promote improved nutriti on of the area and speed up the resolution of inflammatory products. Electrotonu s: Subthreshold nerve stimuli do not cause an action potential but they do affec t the membrane potential. This phenomenon is known as electrotonus. The cathode produces a local depolarizing potential that rises rapidly but falls exponential ly with time making the outer nerve membrane surface less positive lowers the th reshold, which increases the nerve s excitability known as catelectrotonus. The anod e produces hyperpolarization making the outer membrane surface more positive, wh ich has the reverse effect is known as anelectrotonus. Relief of Pain: Strong se nsory stimulation blocks the pain transmission at the level of spinal cord by pa in gate theory. The hyperaemia occurring may help to remove the nociceptive subs tances and thus reducing pain. The repulsion of H+ and K+ ions from the region o f anode also helps in pain relief. Acceleration of Healing: Electrical stimulati on by direct current enhances healing process. It leads to increase bone formati on and accelerate healing when current is applied through implanted electrodes. It has also got effects on healing of superficial and open wounds. Iontophoresis : Iontophoresis involves the movement of ions across biological membranes by mea ns of a direct current for therapeutic purposes. It is also called ion transfer. Physiological and therapeutic effects of iontophoresis are as follows: Local an aesthesia Relief of idiopathic hyperhidrosis Application of antibiotics Applicat ion of anti-inflammatory drugs Neurogenic pain Chronic wound healing Increase ex tensibility of scar tissues 4

Fungal skin infections Relief of pain Techniques of Treatment: Among the several indications of IDC, muscle stimulation is most important one. Here, treatment should be given in such a way that all muscle fibres get stimula ted properly. There are several methods to achieve this: 1) Labile Technique: He re one electrode is fixed over the origin of muscle group and other electrode, w hich is preferably disc or pen electrode is held over the lower end of the muscl e belly to be stimulated or is stroke down it. This is known as labile technique . The movement of the electrode ensures proper contraction or stimulation of all the muscle fibres. Also there is less skin irritation by this technique. Only d isadvantage with this technique is that if there are many muscles to be stimulat ed, then this procedure becomes time consuming. 2) Stabile Technique: In this me thod two disc electrodes or pen electrodes are placed over the muscle to be stim ulated. But procedure becomes difficult from therapist point of view, so both el ectrodes (disc electrodes) are fixed over muscle belly. This is known as stable technique. The disadvantage with this technique is that it causes skin irritatio n more than the labile technique but has advantage that it permits large number of contractions. 3) Group Stimulation: In this technique active electrode is pla ced over the muscle group to be stimulated (Eg:- extensor muscles of wrist in ca se of radial nerve palsy) and large indifferent electrode is placed over conveni ent site to complete the circuit. This is known as group stimulation technique. Contraindications to electrical stimulation: Metal implants in closed vicinity should be avoided to avoid concentration of el ectrical charges because it can pass electrical currents more than the tissues. Strong muscle contraction might cause joint or muscle damage; detachment of a th rombus; spread of infection; and hemorrhage. Stimulation of autonomic nerves mig ht cause altered cardiac rhythm or other autonomic effects. Currents might provo ke undesirable metabolic activity in neoplasms or in healed tuberculous infectio ns. 5

Currents might be unduly localized due to open wounds or skin lesions, Eg:eczema . (For such cases any break in skin or wound is carefully covered with Vaseline prior to the treatment.) Current is not evenly biphasic, leading to possible ski n damage or irritation, especially if there is loss of sensation. [Neoplasm: A t umour; an abnormal growth serving no function is known as neoplasm. Eczema: A su perficial inflammation affecting the epidermis, which manifests in redness, itch ing, weeping, oozing, and crusting is called eczema.] Iontophoresis: Iontophores is involves the movement of ions across biological membranes by means of an elec tric current for therapeutic purposes. It is also called ion transfer. Mechanism of Iontophoresis: If a voltage is applied to electrolyte convection current will flow. This consis ts of positively charged ions moving towards the negative pole and negatively ch arged ions moving to the positive pole. If a drug is in an ionic form, i.e., it has a charge, it can be made to travel in either direction depending on the pola rity applied. Atoms and molecules in an electrolyte are constantly gaining or lo sing electrons to become ions and then reverting to their non-ionized form. Ther e is also considerable random movement of particles. When an electric charge is applied it results in a steady drift of appropriately charged ions in each direc tion. If membranes divide the electrolyte, then many more ions are driven throug h the membranes than would pass through due to random particle (Brownian) motion . When iontophoresis is applied above mentioned mechanism occurs. The tissues ar e effectively a continuous electrolyte with the solution of the wet pad or spong e, which contains the ionized drug. Thus positively charged ions can be made to drift away from the positively charged pole towards the negative pole and will p ass through the skin and into the tissues, and vice versa for negatively charged ions. Some will lose their charge in the tissues and become chemically active. Hence some of the drugs have been locally introduced into the tissues. An additi onal mechanism involves the passage of a solvent, which can carry dissolved subs tances through the skin due to direct current. This form of electromosis has bee n called iontohydrokinesis. It is strongly dependent on the pH of the skin. 6

The actual passage of current, hence of ions, occurs mainly via the sweat gland ducts and to lesser extent via the hair follicles and sebaceous glands. The effe cts of any drug introduced by iontophoresis are likely to be either local in the skin under the active electrode or systemic because when the drug enters the ti ssue fluid it is disseminated throughout the body tissues. The number of ions en tering the tissues from any given area of active electrolyte is proportional to the cube root of the product of current density (current per unit area) and time of application. For practical purposes the current density is limited by the sk in tolerance, which usually allows between 0.1 and 0.3 mA/cm2. The concentration of ions in the solution used will obviously have an effect on the number of ion s available. Tissue penetration by ions used therapeutically is not a simple mat ter. Specific conductivity and pH of the solution used, as well as the presence of non-drug ions, which will compete with the drug, are all factors, which have an influence. Physiological & Therapeutic Effects of Iontophoresis: The physiological and therapeutic effects of iontophoresis depend on the nature of the drugs introduced into the tissues. Local Anaesthesia: Local cutaneous ana esthesia can be achieved by the iontophoresis of suitable agents such as lignoca ine or procaine. The time of anaesthesia can be increased considerably by the ad dition of adrenaline. This has been used therapeutically in the treatment of her pes zoster and trigeminal neuralgia. It is used sometimes for minor ear or eye s urgery in which hypodermic injection is especially painful. [Herpes Zoster: Shin gles (band-like involvement of neurocutaneous tissues) caused by varicellazoster virus. It involves posterior root ganglia and presents with severe continuous p ain in the distribution of the affected nerve. Trigeminal Neuralgia: Recurrent p aroxysmal, brief episodes of intense pain over one side of the face confined to one of the three divisions of trigeminal nerve.] Relief of Idiopathic Hyperhidro sis: Idiopathic hyperhidrosis is a condition in which there is increased sweatin g due to unknown reasons. 7

This distressing condition usually affects the palms, soles, and sometimes the a xillae. It can be sufficiently severe to interfere with the patient s work. Topical application of various antiperspirants may be ineffective so that surgical treat ment sympathectomy for hands and feet or skin removal for axillary hyperhidrosis ains the only other option. Glycopyrronium bromide iontophoresis is a simple, sa fe, and effective treatment particularly for hands and feet. Exocrine sweat glan ds in the palms and soles are innervated by the sympathetic system but stimulate d by acetylcholine so that the introduction of an anticholinergic agent (glycopy rronium bromide) into the skin will suppress sweating immediately. Other drug us ed with same effect is poldine methylsulphate. Using tap water iontophoresis wit h direct current (Anode is used as active electrode), sweat-reducing effect is d ue to obstruction of the sweat gland by the deposition of keratin. Application o f Antibiotics: The application of antibiotics to avascular areas by iontophoresi s is used therapeutically. Ear chondritis following burn injury has been success fully treated. Another method of dealing with chronic infection is metallic silv er iontophoresis. Chronic non-healing ulcers have been treated with xanthinol ni cotinate, a capillary dilator, and histamine diphosphate, which presumably acted similarly. [Ear chondritis: Inflammation of a cartilage of the ear usually caus ed by mechanical pressure, stress, or injury is known as ear chondritis.] Applic ation of Anti-Inflammatory Drugs: Anti-inflammatory drugs used to treat tendinit is and bursitis when delivered by iontophoresis. The advantages of this method o f delivery over conventional injection are the painlessness and sterility of the treatment: absolute sterility is clearly important for the introduction of anti -inflammatory agents. The disadvantages are that there is even less certainty of their efficacy and it is a time-consuming, hence expensive, method. The major d oubt is whether these drugs reach the inflamed tissues, particularly if they are relatively deeply placed structures such as ligaments. Various non-steroidal an ti-inflammatory drugs (NSAID) are used for the treatment of musculoskeletal pain . Treatment of epicondylitis can be done by the iontophoresis of sodium salicyla te and sodium diclofenac. 8

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Concentrations of NSAIDs in the tissues have been found to be greatly increased by iontophoresis compared with their percutaneous absorption. [Tendinitis: Painf ul inflammation of a tendon caused by injury, overuse, or prolonged pressure is called tendinitis. Bursitis: Inflammation of the bursa is known as bursitis. Epi condylitis: Inflammation of the epicondyle is known as epicondylitis.] Neurogeni c Pain: Iontophoresis of vinca alkaloids (vincristine and vinblastine) has been used and recommended for the treatment of intractable, chronic pain syndromes, n otably for patients suffering from post-herpetic and other neuralgias, and chron ic pain in terminal cancer. The vinca alkaloids are cytotoxic drugs, which are m icrotubule inhibitors and have been used in the treatment of malignancy. Their a pplication to sensory nerve endings in the skin by iontophoresis allows them to act in an unusual way on these nerve endings to interfere with axoplasmic transp ort. Other Uses: Hyaluronidase has been used for the reduction of local oedema, but these remains considerable doubt about its stability and usefulness. Zinc io ntophoresis in the treatment of ischaemic ulcers and for allergic rhinitis has b een recommended and used. The dramatic skin erythema and weal produced by ehtylm orphine hydrochloride (Renotin) or histamine iontophoresis are rarely used at pr esent. Iodine and chlorine have been used to increase the extensibility of scar tissue in association with passive stretching. Copper iontophoresis has been use d for the treatment of fungal infections (tinea pedis). Salicylate is used for t he relief of pain in rheumatic diseases. [Oedema: Accumulation of fluid in subcu taneous tissue due to extracellular volume expansion is called oedema. Ulcer: A circumscribed depressed lesion on the skin or mucous membrane of any internal or gan following sloughing of necrotic inflammation is called ulcer. Allergic Rhini tis: Occurs as an immediate hypersensitivity reaction to allergens in the nasal mucosa. It is associated with nasal congestion, watery nasal discharge, and snee zing. Scar: Fibrous trace of destructive lesion of tissue is known as scar tissu e. 9

Tinea pedis: Fungal infection of the soles that appear as circumscribed areas of scaling and fissures in adults is called tinea pedis. Rheumatism: A painful con dition arising from articular or other elements of musculoskeletal system is cal led rheumatism.] Dangers of Iontophoresis: Chemical damage to the tissues, a chemical burn, can occur as a result of the cu rrent density becoming too high. Low skin resistance due to cuts or abrasions, u neven pressure or thickness of pads can cause chemical burns. There is also dang er of a burn if a bare piece of the metal lead or electrode inadvertently touche s the skin. A shock can occur if the circuit is broken so that the current is in terrupted, such as would happen if the current is switched off without being tur ned down slowly. This may happen in a number of ways such as a lead breaking durin g treatment or the patient removing a hand from the bath but with the relatively l ow currents employed there is no damage, except that the patient will suffer an alarming shock. Some patients experience a skin irritation caused by hypersensit ivity to the chemicals produced by the current. Washing the treated part after t reatment can usually prevent it. Systemic effects can occur, especially if large areas are treated by iontophoresis. With anticholinergic drugs these can take t he form of headaches, abdominal pains or mild dryness of the mouth. Patients sho uld be warned to avoid vigorous exercise immediately after treatment, and if the symptoms are severe the area of treatment should be reduced. Pregnancy is a con traindication of iontophoresis. During histamine iontophoresis therapy in cardio vascular responses there is appreciably altered blood pressure or heart rate of normal subjects. 10