Combination Therapy
Original Editor - Professor Tim Watson
Top Contributors - Admin, Rachael Lowe, Nehal Shah, Kim Jackson, WikiSysop and Sai Kripa
Introduction[edit | edit source]
In general terms, combination therapy involves the simultaneous application of ultrasound (US) with an electrical stimulation therapy.Most commonly used applications are US with TENS, US with IFT and US with Electrical stimulation of any form including Iontophoresis In Europe, Diadynamic Currents are frequently utilised, but in the UK, US is most often combined with bipolar Interferential Therapy (IF).
There is a significant lack of published material in this area. And much of the information herein is anecdotal or based on the experience of those who use the modality frequently. Broadly, the effects of the combined treatment are those of the individual modalities. There is no evidence at present for any additional effects which can only be achieved when the modalities are used in this particular way.[1]
Therapeutic Ultrasound is the high frequency modality which produces thermal and nonthermal effects. Thermal effects include increase tissue metabolism, collagen elasticity, and capillary blood flow and reduce skeletal muscle spasm[2] and nonthermal effects include acoustic streaming and cavitation enhancing inflammatory response, , increase in protein synthesis, membrane alterations and tissue repair. It is well absorbed in tissues rich in collagen content[3]
Various electrical stimulation approaches like Transcutaneous Electrical Stimulation (TENS) - High TENS and Low TENS, Neuromuscular Electrical Stimulation (NMES), Interferential current therapy (IFT), Pulsed Electrical Stimulation, noninvasive interactive neurostimulation, etc are used for pain relief in musculoskeletal conditions like OA etc[4]
Combination therapy is simultaneous application of two different modalities at the same site where production, application and therapeutic effects of both modalities can be achieved at the same time. During such an application, enhancing effect of one over the other modality is seen. Few studies have concluded that combination therapy is more effective than application of individual modality in relieving pain[5]
Technique of application[edit | edit source]
Combination therapy units are specialised units which can give US and any form of Electric current simultaneously where both the modalities become the part of one circuit.
US transducer is one of the two electrodes which acts as the stimulating electrode and it is applied over the painful area
Second electrode is that of a stimulator or IFT or iontophoresis or TENS and is placed little away from the US head
US is administered simultaneously along with the stimulation and current stops if the US application is stopped suggesting US as one of the electrodes for completing circuit in Electrical Stimulation
US head is slowly moved over the skin overlying the target tissue
DOSAGE - Doses of individual modality is chosen depending upon the condition under treatment.
US with Electrical Stimulation[edit | edit source]
Various forms of stimulating currents are used. For eg. monophasic, biphasic, AC, direct, continuous, surged, pulsed currents.
Due to the simultaneous application of US, and increased cell membrane permeability, there will be decreased resistance to current flow. Hence even with low amperage ES, there will be an increased ATP activity within the cells which in turn increase their ability to repair. Increased phagocytosis and increased circulation would assist in collection and removal of cellular wastes from the treatment area.
US with Iontophoresis[edit | edit source]
Active electrode is US head. Hence Ion source / medication is used under US head. Polarity of the electrode of the stimulator depends on the ion used. So it becomes more or less like phonophoresis
US with IFT[edit | edit source]
Bipolar IFT is used where US head is applied over the painful area and IFT electrode is put over some nearby area. This application reduces accommodation which is usually caused when IFT is applied as a sole modality.
Practical Considerations[edit | edit source]
The problem with Combination therapy is that the treatment duration of US is less compared to that of ES or IFT
Once the US stops, current also stops
Hence for the remaining time remove the US head and keep the other electrode of ES or IFT and complete the treatment
Advantages[edit | edit source]
It is suggested that:
- by combining US with IF, the advantages/effects of each treatment modality can be realised, but lower intensities are used to achieve the effect.
- the accommodation effects that accompany IF treatment are reduced (or even eliminated)
The main advantages on such a combination are said to be:
- in localising lesions (especially chronic) i.e.diagnostic use
- in ensuring accurate localisation of US treatment- to provide increased accuracy/effectiveness in treating deeper lesions
- in treating trigger points
Possible Explanation[edit | edit source]
Exposure of a peripheral nerve to US reduces the membrane resting potential by increasing its permeability to various ions (especially Sodium (Na+) and Calcium (Ca++). By virtue of this adjusted permeability, the nerve membrane is taken closer to its threshold (the point where it depolarises, though doesn’t usually make the nerve fire. The simultaneous application of the Interferential current through the nerve induces the depolarisation potential, though it will take a smaller current than usual to achieve this due to the potentiation effect of the ultrasound.
This can easily be demonstrated. If both the US and IF are applied, and during the application, the US is turned down to zero, the sensation produced by the IF will diminish even though the IF intensity has not been changed. The intensity of the IF sensation returns when the US is turned up again.
The combination of US with IF appears to give rise to less adverse treatment effects than are associated with the combination of US with Diadynamic Currents, or other electrical stimulations. It has also been suggested that a greater effective treatment depth can be achieved with the US - IF combination though there is no direct evidence for such a claim..
In summary, it would appear that by combining the two treatment modalities, none of the individual effects of the treatments are lost, but the benefit is that lower treatment intensities can be used to achieve the same results, & there are additional benefits in terms of diagnosis & treatment times.
Read more about combination therapy here .....
References[edit | edit source]
- ↑ Pope GD, Mockett SP, Wright JP. A survey of electrotherapeutic modalities: ownership and use in the NHS in England. Physiotherapy. 1995 Feb 1;81(2):82-91.
- ↑ Kapidzic S. Measurement of therapeutic effect of ultrasound on knee osteoarthritis; double blind study. Annals of Physical and Rehabilitation Medicine. 2011(54):e181.
- ↑ Johns LD. Nonthermal effects of therapeutic ultrasound: the frequency resonance hypothesis. Journal of athletic training. 2002 Jul;37(3):293.
- ↑ Zeng C, Yang T, Deng ZH, Yang Y, Zhang Y, Lei GH. Electrical stimulation for pain relief in knee osteoarthritis: systematic review and network meta-analysis. Osteoarthritis and cartilage. 2015 Feb 1;23(2):189-202.
- ↑ Usman Z, Maharaj SS, Kaka B. Effects of combination therapy and infrared radiation on pain, physical function, and quality of life in subjects with knee osteoarthritis: A randomized controlled study. Hong Kong Physiotherapy Journal. 2019 Dec 4;39(02):133-42.
