User:Gregory O'Kelly/Sandbox

ELECTROTHERAPY

Because electrotherapy involves the introduction of electric energy to the body, a brief discussion of the nature of this energy is in order so that electrotherapy may be better understood in its variety of forms. "Electric energy is the potential energy associated with the conservative Coulomb forces between charge particles with a system.". "Electrical Energy is the movement of electrical charges. Everything is made of tiny particles called atoms. Atoms are made of even smaller particles called electrons, protons, and neutrons. Applying a force can make some of the electrons move. Electrical charges moving through a wire [carried by electrons, since protons don't move through wires] is called electricity. Lightning is another example of electrical energy." 

The rate of movement of coulombs carried by electrons from a battery or in a lightning bolt is termed an ampere (coulomb/sec). "The ampere is a base unit.  Because it is a base unit, the definition of the ampere is not tied to any other electrical unit -  it is defined without reference to the quantity of electric charge. The unit of charge, the coulomb, is defined, as a derived unit, to be the amount of charge displaced by a one ampere current in the time of one second - The ampere is...maintained via Ohm's Law from the units of EMF and resistance, the volt and the ohm, since the latter two can be tied to physical phenomena that are relatively easy to reproduce..." A volt is the force or pressure driving the coulomb, and an ohm is an electrical characteristic of a conductor or path along which coulombs move that consists of impedance and conductance. Ohm's Law is then V=IR where V is for volts, I is for amperes, and R is for Ohms.

"Chemical energy is the energy due to associations of atoms in molecules and various other kinds of aggregates of matter. It may be defined as a work done by electric forces during re-arrangement of electric charges, electrons and protons, in the process of aggregation." "Chemical energy is the greatest source of energy used by man. From flashlight batteries to commercial airlines, it is the energy released from chemical reactions..." "Chemical Energy is energy stored in the bonds of atoms and molecules. It is the energy that holds these particles together. Biomass, petroleum, natural gas, and propane are examples of stored chemical energy." 

"A battery is a device that converts chemical energy directly to electrical energy. It consists of one or more voltaic cells. Each voltaic cell consists of two half cells connected in series by a conductive electrolyte. One half-cell is the positive electrode, and the other is the negative electrode. The electrodes do not touch each other but are electrically connected by the electrolyte, which can be either solid or liquid. In many cells the materials are enclosed in a container, and a separator, which is porous to the electrolyte, prevents the electrodes from coming into contact."

"There are two types of batteries, primary (disposable) and secondary (rechargeable), both of which convert chemical energy to electrical energy. Primary batteries can only be used once because they use up their chemicals in an irreversible reaction. Secondary batteries can be recharged because the chemical reactions they use are reversible..." To the extent that biological cells are batteries, and to the extent their chemical functioning is reversible (e.g., the synthesis of NADH in the mitochondrion, which hydrolizes to form ATP in the mitochondrial matrix as it breaks down to NAD and H+, the biological cell is a secondary cell susceptible to recharge from amperage introduced from an extracellular source.

Rechargeable or secondary batteries are recharged by reintroducing amperes to reverse the chemical reactions in the battery that gave off the electrons to begin with. The biological cell has a long association with the battery, and is in fact a sort of secondary voltaic cell, immersed in a liquid electrolyte and containing electrolytic fluids. Otherwise cell proliferation would violate the conservation of energy. The electrolytic fluids contain salts; pure water would otherwise act as an insulator. The movement of positively charged ions (cations) of hydrogen, calcium, potassium, sodium, etc., in the electrolyte, when amperes pass because of a voltage from one chemical site to another, is R in Ohm's Law.

Electrotherapy is then about how we introduce an electric field as amperes to the body and its cells, using a battery or source of electrochemical energy. A battery has two poles: the positive pole or cathode, and the negative pole or anode. When a battery gives off energy it comes from the anode, also called the ground electrode, for where the energy goes. The biological cell is traditionally considered to be a primary cell whose contents must constantly be replenished to enable the reactions that will keep it charged. This appears in the standard measurement techniques for cell membrane voltages, in which the ground electrode is placed externally to the cell. To the extent that the biological cell is rechargeable, however, the ground is considered to be within the cell. In terms of electrical energy delivery to the cell or the muscle, therefore, the electrical field must be introduced by the anode of the battery. Though the cell or muscle must be in contact with both anode and cathode for there to be flow of electricity, if that flow is driven by chemical reactions in a battery resulting in the flow of amperes, the battery's potential chemical energy is changed into kinetic electrical energy for transmission.

VOLTAGE WAVE FORMS

The Food and Drug Administration's (FDA's) Part 890 - Physical Medicine Devices, Subpart F - Physical Medicine Therapeutic Devices, sec. 5850 Powered Muscle Stimulator, specifies three types of wave form for an electrical voltage to be used in a powered muscle stimulator. "A powered muscle stimulator is an electrically powered device intended for medical purposes that repeatedly contracts muscles by passing electrical currents through electrodes contacting the affected body area." The wave forms are biphasic symmetrical, biphasic asymmetrical, and monophasic.

Only asymmetrically biphasic and monophasic wave forms pass amperage, where amperage is defined as the total area between a voltage curve and the X axis, where X is time, and Y is voltage. If the same amount of area above the X axis (positive) also occurs below (negative), the wave form is considered biphasic symmetrical, and no amperage is passedsince one area cancels out the other. AC is the paradigm case of a symmetrically biphasic wave form that does not pass amperage, but DC can also be symmetrically biphasic if it is pulsed off and on, and the polarity changes back and forth with each pulse. To the extent that the area above the curve is greater than, or lesser than the area beneath the curve, the voltage wave form is asymmetrically biphasic, and some amperage is passed depending upon how great the asymmetry is. If the curve is always above or below the X axis, the wave form is monophasic, and is always passing amperage. The paradigm case of this wave form is DC in which the polarity remains the same with each pulse. Passing of amperage implies electrochemistry. Curiously, FDA regulations prohibit for sale to the public any electrically-powered stimulator that passes or 'leaks' more than one half of one milliampere. This rules out the use of monophasic and asymmetrically biphasic waveforms (i.e., all of electrochemistry) in the stimulation of muscle. This prohibition is allegedly for the safety of the user. The FDA makes clear that, lacking guidance from the medical community as to what sort of waveform is effective at building muscle, its main concern is the safety of the user. Consequently safety is considered more important than effectiveness since muscle building is dependent upon the passing of amperage.

In 1855 Guillaume DuChenne, the father of electrotherapy, announced that AC was superior to DC for electrotherapy involving the triggering of muscle contractions. DuChenne's choice was not informed by understanding of amperage and the nature of electrical energy, knowledge that would not be available until the 20th century. DuChenne was motivated by the attempt to avoid what he called the 'warming affect' of DC that irritated the skin. Amperage, at voltage strengths needed for muscle contractions, causes the skin quickly to blister and pit, with blistering at the anode and pitting at the cathode. Furthermore, with DC the muscle would contract upon initiation of current flow, and then relax, with each new contraction requiring the current to be stopped and restarted. This made working with DC to achieve muscle contractions cumbersome for the therapist.

With AC there was no warming affect, and the current could be allowed to run on, producing strong muscle contractions, regardless of the condition of the muscle. This contrasted with contractions produced by the amperage of DC. DC-induced contractions were strong if the muscle was strong, and weak if the muscle was weak. Since that time almost all rehabilitation involving muscle contraction has been done with a symmetrically biphasic wave form, and has not involved electrochemistry.

In the 1940s, however, the US War Department, in the interests of investigating the application of electrical stimulation to not just retard and prevent atrophy, but to restore muscle mass and strength, employed what was termed galvanic exercise, on the atrophied hands of those who had had an ulnar nerve lesion from a wound repaired surgically. Galvanic exercise employed a monophasic wave form, i.e., the passage of amperes - electrochemistry. The clinical findings reported favorably upon galvanic exercise to accomplish these very things, with those in the group receiving galvanic exercise and physical therapy recovering far faster than those in the control group that just engaged in physical therapy. These findings suggested that electrochemical therapy (ECT or EChT) was an important subset of electrotherapy.

ATROPHY, MUSCLE, AND ELECTRICITY

"The maintenance of adult skeletal muscle mass is ensured by physical exercise. Accordingly, physiological and pathological situations characterized by either impaired motor neuron activity, reduced gravity (microgravity during space flights), or reduced physical activity result in loss of muscle mass. Furthermore, a plethora of clinical conditions, including cancer, sepsis, diabetes, and AIDS, are associated with varying degrees of muscle atrophy. The cellular and molecular pathways responsible for maintaining the skeletal muscle mass are not well defined. Nonetheless, studies aimed at the understanding of the mechanisms underlying either muscular atrophy or hypertrophy have begun to identify the physiological determinants and clarify the molecular pathways responsible for the maintenance of muscle mass." 

Physical exercise works only for muscles that can be used, but, as noted above, is aided with galvanic exercise. " Skeletal muscle atrophy in [haemodialysis] patients contributes to their poor exercise tolerance. The application of an exercise training rehabilitation programme improved muscle atrophy markedly, and therefore had beneficial effects in overall work performance." "Open muscle biopsies were taken from their vastus lateralis muscle before and after a 6 month exercise rehabilitation programme and examined by routine light- and transmission electron-microscopy. Histochemical stainings of frozen sections were performed and morphometric analysis was also applied to estimate the proportion of each fibre type and the muscle fibre area. Spiroergometric and neurophysiological testing and peak extension forces of the lower limbs were measured before and after exercise training. Results: All patients showed impaired exercise capacity, which was associated with marked muscular atrophy (mean area 2548±463 &mgr;m2) and reduction in muscle strength and nerve conduction velocity. All types of fibres were atrophied but type II were more affected."

The type II (a and b) fiber cross-sectional area has been related to muscle atrophy and loss of muscle mass for over a quarter century. "Biopsies of the rectus femoris muscle of 22 paraplegic patients with complete acute spinal cord transection due to trauma were taken for enzyme-histochemical and electron-microscopic studies in successive stages starting from the occurrence of the accident (1–17 months)....muscular atrophy was demonstrated with a progressive decrease in the fiber diameter and changes in the fiber type distribution with predominant type II atrophy in the first stage and type I atrophy in the later stage of the cord transection." The implication is that paralysis and muscle weakness following spinal cord injury, stroke, prolonged inactivity, could be a result of muscle deterioration. When the muscle can't be used, galvanic exercise may still provide restoration of muscle mass lost to atrophy.

Of powered muscle stimulators used to retard or prevent atrophy, the most widely used employs a symmetrically biphasic current, and is known as Functional Electrical Stimulation (FES). FES does not pass amperes or involve electrochemistry. Research involving the affect of FES on both type II (a and b) muscle fibers, and type I fibers, reveals "...sizes of the three types of fibres were not modified with the use of FES." What this means is that FES, and, by extrapolation, all electrotherapy that uses a symmetrically biphasic voltage wave form that does not pass amperage, has no affect on atrophy whatsoever. These findings are discussed in a 2000 report of the Dutch Health Council entitled: "Insufficient scientific evidence for efficacy of widely used electrotherapy, laser therapy, and ultrasound treatment in physiotherapy."

The subset of electrotherapy that does involve the passage of amperage, known as electrochemical therapy (ECT or EChT) has demonstrated effectiveness in a number of areas, most notably the destruction of tumors, and the healing of bone breaks. The literature available in the former area is voluminous, and quite encouraging. In the latter instance limb regeneration has also been investigated, with pulsed magnetic fields inducing a slight electrical field "...to circumvent the necessity for implantation of electrodes" that would otherwise pass DC. Success in healing breaks that would not heal otherwise, is between 80 and 85%.

In the past decade the investigation of what is called Transcranial Direct Current Stimulation, or Galvanic Stimulation, has been found to have positive affects on a number of chronic and mental conditions, from wound healing to depression. The ongoing research in all these areas is widespread and rapidly accumulating, pointing to not only the catabolic, destructive aspects of monophasic pulses, but also to their building aspects, to anabolism. In 2005 the use of monophasic pulses to build muscle by increasing muscle mass (type II (a & b) muscle fiber cross-sectional area) was patented (patent #6,856,837). This means there was no prior art, such art being any prior patents or procedures used to restore muscle mass using electrochemistry. The procedure is new and still not widely known or practiced, having been overshadowed by FES despite the latter's lack of supporting biopsies and substantiation based upon anecdote and computer tomagraphy incapable of verifying changes in type II cross-sectional area. The meager results for muscle restoration associated with FES could easily be the result of the arduous physical activity necessitated by or accompanying resort to this treatment modality. The future of electrotherapy, apparently, is tied to electrochemistry and amperage transmission, with its long history of clinical ineffectiveness being the result of adherence to the 1855 advice of DuChenne about the preferability of AC (symmetrically biphasic) to DC (monophasic) currents.