THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

Therapeutic Direct Current (Notes)

Sagar Naik, PT

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Direct current refers to a current passing continuously in the same
direction. Therapeutic direct current (d.c.) has been considered to pass for more than 1

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second, and is sometimes called constant current or galvanism.

Ö Interrupted Direct Current (IDC):

This is also known as galvanic current. It is produced by modification in
the form of interruption in direct current where current is made to flow and seized
at regular intervals.

4a
• Production of Interrupted Direct Current:
 Production of interrupted direct current involves following:
y Source of IDC
y Transistors
y Potential divider
y Timer circuit (Timer device)
 All that is needed to provide therapeutic d.c. is a steady unidirectional
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voltage, a means of regulating the 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 reduced and a potential divider is placed
in parallel with the patient. Moving the control can alter this divider.
 With the potential divider at zero no voltage is applied so that no current will
flow. The milliammeter in series with the patient will indicate zero current
flow.
y

 Suppose 50V is applied across the resistance and the control is turned to make
contact one-fifth of the way along the resistance, then 10V is applied to the
tissues.
ph

 If the total resistance of the patient and 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 to 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 will rise.
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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

• 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 to 600ms.

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 Frequency of the current reduces with increase in the pulse duration. Pulse
duration of 100ms will have frequency of 30 cycles/minute.

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 The interval between the impulses should never be shorter duration than the
impulses themselves and is usually appreciably longer.

• Types of IDC:
Currents produced for therapeutic purposes may have sudden or gradual
fall, hence depending on this there are several types, which are as follows:
1) Rectangular
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I

2) Trapezoidal
t

I
sio
t
3) Triangular

t
y

4) Saw-tooth

I
ph

t
5) Depolarized

I
t

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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

 Rectangular 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 produced with an
intensity of current that is insufficient to stimulate the motor nerves because

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accommodation occurs.
 Some equipment allows for low-intensity reversed current between the

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impulses giving so-called depolarized impulses. Here the chances of
electrolyte burns are very 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 danger of burns eliminated. There
is a consequent reduction in irritation of skin, so making the treatment more
comfortable for the patient.
4a
• Selection of impulses:
 Rectangular impulse is capable of producing muscle contraction but selective
impulse is always satisfactory.
 With rectangular impulses rise is sudden whereas with 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 stimulation of
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denervated muscle as it brings about satisfactory contraction with less
sensory stimulation than with the rectangular impulses.
 Proper selection of current leads to elimination of unwanted contraction of
innervated muscles present in the closed proximity.
 In long-standing denervation a muscle contraction may be obtained with a
slowly rising current when there is no longer any response to a rectangular
impulse.
y

 When various types of impulses are available it is advisable to attempt

stimulation with each in order to ascertain which produces the most
satisfactory contraction. It is often found that the more long-standing the
ph

denervation 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 for iontophoresis, usually for periods of 10-30 minutes. The current
density is kept to a level that does not cause tissue damage or patient
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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

discomfort. Traditionally this is said to be below about 0.33 mA/cm2. Following

are the physiological and therapeutic effects of the interrupted direct current:
D 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.

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 If sufficient current has passed for long enough an erythema of the skin
will be evident under both electrodes, and is more marked under the

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negative (cathode). This erythema is confined to the area of the applied
electrode.
D Hyperaemia:
 Since this erythema is confined it indicates a capillary hyperaemia, unlike
that due to heat in which arteriolar dilatation occurs.
 The erythema causes vasomotor stimulation and increased circulation
may promote improved nutrition of the area and speed up the resolution
4a
of inflammatory products.
D Electrotonus:
 Subthreshold nerve stimuli do not cause an action potential but they do
affect the membrane potential. This phenomenon is known as
electrotonus.
 The cathode produces a local depolarizing potential that rises rapidly but
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falls exponentially with time making the outer nerve membrane surface less
positive lowers the threshold, which increases the nerve’s excitability
known as catelectrotonus.
 The anode produces hyperpolarization making the outer membrane surface
more positive, which has the reverse effect is known as anelectrotonus.
D Relief of Pain:
 Strong sensory stimulation blocks the pain transmission at the level of
y

spinal cord by pain gate theory.

 The hyperaemia occurring may help to remove the nociceptive substances
and thus reducing pain.
ph

 The repulsion of H+ and K+ ions from the region of anode also helps in
pain relief.
D Acceleration of Healing:
 Electrical stimulation by direct current enhances healing process.
 It leads to increase bone formation and accelerate healing when current
is applied through implanted electrodes.
 It has also got effects on healing of superficial and open wounds.
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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

D Iontophoresis:
 Iontophoresis involves the movement of ions across biological
membranes by means of a direct current for therapeutic purposes. It is
also called ion transfer.
 Physiological and therapeutic effects of iontophoresis are as follows:

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y Local anaesthesia
y Relief of idiopathic hyperhidrosis

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y Application of antibiotics
y Application of anti-inflammatory drugs
y Neurogenic pain
y Chronic wound healing
y Increase extensibility of scar tissues
y Fungal skin infections
y Relief of pain
4a
• 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 stimulated properly. There are several methods to achieve this:
1) Labile Technique:
 Here one electrode is fixed over the origin of muscle group and other
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electrode, which is preferably disc or pen electrode is held over the lower
end of the muscle 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 disadvantage with this technique is that if there are many muscles to
be stimulated, then this procedure becomes time consuming.
y

2) Stabile Technique:
 In this method two disc electrodes or pen electrodes are placed over the
muscle to be stimulated. But procedure becomes difficult from therapist
ph

point of view, so both electrodes (disc electrodes) are fixed over muscle
belly. This is known as stable technique.
 The disadvantage with this technique is that it causes skin irritation more
than the labile technique but has advantage that it permits large number of
contractions.

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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

3) Group Stimulation:
 In this technique active electrode is placed over the muscle group to be
stimulated (Eg:- extensor muscles of wrist in case of radial nerve palsy)
and large indifferent electrode is placed over convenient site to complete
the circuit. This is known as group stimulation technique.

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• Contraindications to electrical stimulation:

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 Metal implants in closed vicinity should be avoided to avoid concentration of
electrical charges because it can pass electrical currents more than the
tissues.
 Strong muscle contraction might cause joint or muscle damage; detachment
of a thrombus; spread of infection; and hemorrhage.
 Stimulation of autonomic nerves might cause altered cardiac rhythm or
other autonomic effects.
4a
 Currents might provoke undesirable metabolic activity in neoplasms or in
healed tuberculous infections.
 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 skin damage or irritation,
especially if there is loss of sensation.
sio
[Neoplasm: A tumour; an abnormal growth serving no function is known
as neoplasm.
Eczema: A superficial inflammation affecting the epidermis, which
manifests in redness, itching, weeping, oozing, and crusting is called
eczema.]

Ö Iontophoresis:
y

Iontophoresis involves the movement of ions across biological

membranes by means of an electric current for therapeutic purposes. It is also
called ion transfer.
ph

• Mechanism of Iontophoresis:
 If a voltage is applied to electrolyte convection current will flow. This consists
of positively charged ions moving towards the negative pole and negatively
charged 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 polarity applied.
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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

 Atoms and molecules in an electrolyte are constantly gaining or losing

electrons to become ions and then reverting to their non-ionized form. There 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 direction. If membranes divide the electrolyte, then

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many more ions are driven through the membranes than would pass
through due to random particle (Brownian) motion.

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 When iontophoresis is applied above mentioned mechanism occurs.
 The tissues are effectively a continuous electrolyte with the solution of the wet
pad or sponge, 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 pass 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.
4a
Hence some of the drugs have been locally introduced into the tissues.
 An additional mechanism involves the passage of a solvent, which can carry
dissolved substances through the skin due to direct current. This form of
electromosis has been called iontohydrokinesis. It is strongly dependent on
the pH of the skin.
 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 effects of any drug introduced by iontophoresis are likely to be either
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local in the skin under the active electrode or systemic because when the
drug enters the tissue fluid it is disseminated throughout the body tissues.
 The number of ions entering 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 skin tolerance,
which usually allows between 0.1 and 0.3 mA/cm2.
y

 The concentration of ions in the solution used will obviously have an effect on
the number of ions available.
ph

 Tissue penetration by ions used therapeutically is not a simple matter. 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.

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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

• Physiological & Therapeutic Effects of Iontophoresis:

The physiological and therapeutic effects of iontophoresis depend on the
nature of the drugs introduced into the tissues.
D Local Anaesthesia:
 Local cutaneous anaesthesia can be achieved by the iontophoresis of

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suitable agents such as lignocaine or procaine.
 The time of anaesthesia can be increased considerably by the addition of

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adrenaline.
 This has been used therapeutically in the treatment of herpes zoster and
trigeminal neuralgia.
 It is used sometimes for minor ear or eye surgery in which hypodermic
injection is especially painful.
[Herpes Zoster: Shingles (band-like involvement of neurocutaneous
tissues) caused by varicellazoster virus. It involves posterior root
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ganglia and presents with severe continuous pain in the distribution of
the affected nerve.
Trigeminal Neuralgia: Recurrent paroxysmal, brief episodes of
intense pain over one side of the face confined to one of the three
divisions of trigeminal nerve.]
D Relief of Idiopathic Hyperhidrosis:
 Idiopathic hyperhidrosis is a condition in which there is increased
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sweating due to unknown reasons.
 This distressing condition usually affects the palms, soles, and sometimes
the axillae. It can be sufficiently severe to interfere with the patient’s work.
 Topical application of various antiperspirants may be ineffective so that
surgical treatment – sympathectomy for hands and feet or skin removal for
axillary hyperhidrosis – remains the only other option.
 Glycopyrronium bromide iontophoresis is a simple, safe, and effective
y

treatment particularly for hands and feet.

 Exocrine sweat glands in the palms and soles are innervated by the
sympathetic system but stimulated by acetylcholine so that the introduction
ph

of an anticholinergic agent (glycopyrronium bromide) into the skin will

suppress sweating immediately.
 Other drug used with same effect is poldine methylsulphate.
 Using tap water iontophoresis with direct current (Anode is used as active
electrode), sweat-reducing effect is due to obstruction of the sweat gland
by the deposition of keratin.

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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

D Application of Antibiotics:
 The application of antibiotics to avascular areas by iontophoresis is used
therapeutically.
 Ear chondritis following burn injury has been successfully treated.
 Another method of dealing with chronic infection is metallic silver

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iontophoresis.
 Chronic non-healing ulcers have been treated with xanthinol nicotinate, a

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capillary dilator, and histamine diphosphate, which presumably acted
similarly.
[Ear chondritis: Inflammation of a cartilage of the ear usually caused
by mechanical pressure, stress, or injury is known as ear chondritis.]
D Application of Anti-Inflammatory Drugs:
 Anti-inflammatory drugs used to treat tendinitis and bursitis when
delivered by iontophoresis.
4a
 The advantages of this method of 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 doubt is whether these drugs reach the inflamed tissues,
particularly if they are relatively deeply placed structures such as ligaments.
sio
 Various non-steroidal anti-inflammatory drugs (NSAID) are used for the
treatment of musculoskeletal pain.
 Treatment of epicondylitis can be done by the iontophoresis of sodium
salicylate and sodium diclofenac.
 Concentrations of NSAIDs in the tissues have been found to be greatly
increased by iontophoresis compared with their percutaneous absorption.
[Tendinitis: Painful inflammation of a tendon caused by injury,
y

overuse, or prolonged pressure is called tendinitis.

Bursitis: Inflammation of the bursa is known as bursitis.
Epicondylitis: Inflammation of the epicondyle is known as
ph

epicondylitis.]
D Neurogenic Pain:
 Iontophoresis of vinca alkaloids (vincristine and vinblastine) has been
used and recommended for the treatment of intractable, chronic pain
syndromes, notably for patients suffering from post-herpetic and other
neuralgias, and chronic pain in terminal cancer.

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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

 The vinca alkaloids are cytotoxic drugs, which are microtubule inhibitors
and have been used in the treatment of malignancy.
 Their application 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 transport.

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D Other Uses:
 Hyaluronidase has been used for the reduction of local oedema, but these

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remains considerable doubt about its stability and usefulness.
 Zinc iontophoresis in the treatment of ischaemic ulcers and for allergic
rhinitis has been recommended and used.
 The dramatic skin erythema and weal produced by ehtylmorphine
hydrochloride (Renotin) or histamine iontophoresis are rarely used at
present.
 Iodine and chlorine have been used to increase the extensibility of scar
4a
tissue in association with passive stretching.
 Copper iontophoresis has been used for the treatment of fungal infections
(tinea pedis).
 Salicylate is used for the relief of pain in rheumatic diseases.
[Oedema: Accumulation of fluid in subcutaneous tissue due to
extracellular volume expansion is called oedema.
Ulcer: A circumscribed depressed lesion on the skin or mucous
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membrane of any internal organ following sloughing of necrotic
inflammation is called ulcer.
Allergic Rhinitis: Occurs as an immediate hypersensitivity reaction to
allergens in the nasal mucosa. It is associated with nasal congestion,
watery nasal discharge, and sneezing.
Scar: Fibrous trace of destructive lesion of tissue is known as scar
tissue.
y

Tinea pedis: Fungal infection of the soles that appear as

circumscribed areas of scaling and fissures in adults is called tinea
pedis.
ph

Rheumatism: A painful condition arising from articular or other

elements of musculoskeletal system is called rheumatism.]

• Dangers of Iontophoresis:
 Chemical damage to the tissues, a chemical burn, can occur as a result of
the current density becoming too high. Low skin resistance due to cuts or
abrasions, uneven pressure or thickness of pads can cause chemical burns.
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 THERAPEUTIC DIRECT CURRENT Sagar Naik, PT

There is also danger of a burn if a bare piece of the metal lead or electrode
inadvertently touches the skin.
 A shock can occur if the circuit is broken so that the current is interrupted,
such as would happen if the current is switched off without being turned
down slowly. This may happen in a number of ways – such as a lead breaking

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during treatment or the patient removing a hand from the bath – but with the
relatively low currents employed there is no damage, except that the patient

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will suffer an alarming shock.
 Some patients experience a skin irritation caused by hypersensitivity to the
chemicals produced by the current. Washing the treated part after treatment
can usually prevent it.
 Systemic effects can occur, especially if large areas are treated by
iontophoresis. With anticholinergic drugs these can take the form of
headaches, abdominal pains or mild dryness of the mouth. Patients should be
4a
warned to avoid vigorous exercise immediately after treatment, and if the
symptoms are severe the area of treatment should be reduced. Pregnancy is a
contraindication of iontophoresis. During histamine iontophoresis therapy
in cardiovascular responses there is appreciably altered blood pressure or
heart rate of normal subjects.
sio
y
ph

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