List of Tablespage 2

Index

Contents

List of TablesPage 2

List of FiguresPage 2

List of AbbreviationsPage 3

Chapter 1: Introduction and backgroundPage 4

1.1The pain problemPage 5

1.2Electrotherapy as a possible solution in pain controlPage 7

1.3Apparatus availablePage 7

1.4The body’s natural ability to cope with painPage 8

1.5Mechanisms of action of analgesic electrotherapyPage 9

1.6Indication for the use of analgesic electrotherapyPage 10

1.7A comparison of conventional medicinal analgesic treatment with

analgesic electrotherapyPage 12

1.8Side effects, contra-indications and special warningsPage 14

1.9Purpose of this investigative studyPage 15

Chapter 2: EquipmentPage 16

2.1Selection of apparatusPage 17

2.2APS Compact Mk1 specificationsPage 18

2.3Skin electrodesPage 19

2.4Skin cleanser and disinfectantPage 19

Chapter 3: MethodPage 20

3.1ClinicsPage 21

3.2CandidatesPage 21

3.3Types of pain and injury treatedPage 21

3.4MethodologyPage 21

Chapter 4: Results and discussionPage 24

4.1Categories of pain treatedPage 25

4.2Head and neck painsPage 27

4.3Torso painsPage 29

4.4Arm, wrist and hand painsPage 31

4.5Leg, ankle and foot painsPage 33

4.6Pain in special casesPage 35

4.7SummaryPage 37

4.8Standard deviationsPage 37

4.9Quantitative expressions of pain relief Page 38

ConclusionPage 41

ReferencesPage 45

List of Tables

Table 1.A comparison of conventional medicinal substances with

electro-analgesic apparatusPage 13

Table 2.Pains of the head and neck before and after treatment with

APS CompactPage 27

Table 3.Pains of torso before and after treatment with

APS CompactPage 29

Table 4.Pains of the arm, wrist and hand before and after treatment with

APS CompactPage 31

Table 5.Pains of the leg, ankle and foot before and after treatment with

APS CompactPage 33

Table 6.Pains in special cases before and after treatment with

APS CompactPage 35

Table 7.Summary of pain levels before and after treatment with

APS CompactPage 37

Table 8.Average pain levels and their standard deviations after

treatment with APS CompactPage 38

Table 9.Average pain relief as a percentage after treatment with

APS CompactPage 40

List of Figures

Figure 1.Catagories of pain treated with APS CompactPage 26

Figure 2.Pains of the head and neck before and after treatment with

APS CompactPage 28

Figure 3.Pains of torso before and after treatment with

APS CompactPage 30

Figure 4.Pains of the arm, wrist and hand before and after treatment with

APS CompactPage 32

Figure 5.Pains of the leg, ankle and foot before and after treatment with

APS CompactPage 34

Figure 6.Pains in special cases before and after treatment with

APS CompactPage 36

Figure 7.Percentage cases whose pain level dropped to “mild” and lower

after treatment with APS CompactPage 39

ABBREVIATIONS

Standard deviation

ACAlternating current

ADPAdenosine diphosphate

ATPAdenosine triphosphate

DCDirect current

EMSElectrical muscle stimulation

mAMilli-ampere

METMicrocurrent electrical stimulation

nNumber

OTC Over-the-counter

PETSPill for every thrill syndrome

TENSTranscutaneous electrical nerve stimulation

xAverage

APS COMPACTAPS Compact

This study was originally performed on the Neuro Stim 200 Mk1, which was later re-branded the APS Compact.

Chapter 1

Introduction and Background

1.1The pain problemPage 5

1.2Electrotherapy as a possible solution in pain controlPage 7

1.3Apparatus availablePage 7

1.4The body’s natural ability to cope with painPage 8

1.5Mechanisms of action of analgesic electrotherapyPage 9

1.6Indication for the use of analgesic electrotherapyPage 10

1.7A comparison of conventional medicinal analgesic treatment with

analgesic electrotherapyPage 12

1.8Side effects, contra-indications and special warningsPage 14

1.9Purpose of this investigative studyPage 15

1.1 The pain problem

During the past few years, most likely because of very aggressive advertising campaigns, there has been a tremendous increase in the number of people taking medicinal substances for a wide spectrum of ailments. Society has become so aware of ‘a pill for every thrill’ that South Africans are visiting doctors and pharmacists for ailments which do not really require such intervention. Nature has provided man with a well functioning coping mechanism. However, we appear to be losing this natural ability to cope. Not only have we lost our ability to cope, but we have also seen a discomforting increase in the number of ‘legal drug addicts’. These are people who have become addicted to medicines such as analgesics, sedatives, hypnosis, etc. which they have obtained legally from doctors and/or pharmacists. In the USA the ‘Pill for Every Thrill Syndrome’ (PETS) has been evident for many years. It apparently does not matter what is wrong with you, but all you have to do to overcome your problem is to “take an aspirin and go to bed”. In Europe people are rapidly becoming aware of the serious side effects of the modern powerful synthetic drugs and are changing over to less harmful homeopathic medicines. Whether one takes an aspirin or whether one takes a homeopathic remedy, the fact remains that one is taking a foreign substance (i.e. drug) which may be relatively harmless, but which is not completely harmless at all. The following section will clarify this statement in somewhat more detail.

Taking medicines for some or other ailment has become socially acceptable to the extent that it is almost impossible to find someone who is not taking at least one form of medication. One condition most commonly treated, sometimes with very potent drugs, is pain. Although not a disease as such (and it can be in some individuals!), pain is probably the most common reason why people visit doctors, pharmacists, clinics etc. But what is pain? Pain is a complex phenomenon involving physiological and emotional interactions. Being a symptom of a great variety of medical conditions, it is nature’s way of telling an individual that something is wrong somewhere. It is therefore not ideal to simply mask pain in an indiscriminate manner. However, when someone is suffering because of a diagnosed pain, i.e. when the cause is known is treated if possible, and the pain is truly intolerable, then that person becomes a candidate for treatment with analgesic substances. Persistent long-lasting (chronic) pain, if properly diagnosed, serves no purpose.

Of the most commonly prescribed and purchased medicines in modern society is the analgesic. Analgesics are, however, not at all without dangers:

1. All analgesics have unwanted or side effects, some very serious. These include, amongst others, gastric ulceration, nephritis, hepatotoxicity, dyspepsia, nausea, vomiting, angio-edema, rhinitis, blood dyscrasias, bronchospasms and several additional conditions.
2. Some of these agents lead to emotional or physical dependence or even both, irrespective of whether they are prescription or over-the-counter (OTC) drugs.

1. Certain analgesics can interact with other necessary medication and produce serious untoward effects.
2. Another problem is that the regular taking of analgesics could lead to a tendency to abuse various other types of drugs. Many people who can be classified as ‘legal addicts’ will inform you that it all started with pain killers or appetite suppressant drugs. The difficulties encountered in breaking an addiction to analgesics can be compared with the same situation encountered in persons who wish to stop smoking. One of the difficulties experienced when attempting to stop smoking is not just the craving for nicotine, but also the actual act of bringing the flame of a lighter or match to a cigarette, lighting it and then inhaling the smoke. This type of emotional dependence can be as difficult to break as a physical dependence on nicotine. In the same way people addicted to medicinal agents find it soothing simply to know that something (i.e. a drug) was taken or administered to him or her. This motion can lead to addiction because of the PETS mentioned earlier. It can also make it difficult to stop taking drugs once already addicted, be it of an emotional or physical nature.

1. Probably the most popular type of drug prescribed in today’s society is the anti-inflammatory agent. These drugs are truly wonderful in treating pain and inflammation associated with a great variety of ailments. They do, however, have some very serious side effects and that is also exactly why one needs a prescription for them. A commonly encountered problem is that patients who take them have their pain or inflammation taken care of, but then they develop gastric ulcers because of the medication. These agents can also not be taken for long periods of time and are therefore not indicated for chronic pain like in arthritis. This is really a pity, as they are one of a very few drugs which do work in relieving pain in these case. Patients who suffer from arthritic pains become so desperate that they ignore these warnings and keep on taking the steroidal anti-inflammatory drugs until they suddenly discover that they have now developed serious blood dyscrasias. Lastly, such drugs are also very expensive.

1. Because analgesics are understandably the most popular and most commonly used drugs in the world they have also become very expensive, bringing in billions of Rands to their manufacturers. As mentioned earlier, the anti-inflammatory drugs are notoriously expensive.

1. Analgesics are usually not long-acting drugs and they have to be taken at regular short intervals. It is inconvenient to have to carry medicines around in order to follow the prescribed dosage regimen. Taking them regularly disturbs the normal social life.

1. Analgesics have organoleptic problems e.g. almost all have a bitter taste.

1. Many people experience problems in taking large tablets. People with cancer of the throat

experience general discomfort in swallowing.

Having taken the above aspects in consideration, it becomes clear that an ideal analgesic agent should have the following properties:

1. Free of side and toxic effects.

1. Not be dependence producing.
2. Lasting effects.
3. Not unpleasant to take.
4. Affordable on the short and long run.
5. Easy to take or use.
6. Convenient to use and not disrupt the normal everyday life
7. Have a long-lasting effect.

1.2 Electrotherapy as a possible solution in pain control

Excluding pharmaceutical medication, a number of methods have been used in the past to manage pain. These included vibration, massage, the application of heat or cold, ultrasound, acupuncture, electrical muscle stimulation (EMS), transcutaneous electrical nerve stimulation (TENS), microcurrent electrical stimulation (MET) etc.

Electrotherapy has been receiving increasing attention during the past few years as a safe, effective and easy to use method of controlling pain, even those types which do not respond to potent pharmaceutical analgesic agents. It is not unknown that electricity is one of the most basic forms of energy found everywhere in nature, including all living organisms, monocellular to multicellular, simple to complex. It is indeed the driving force for many reactions within the human body, including beneficial and disadvantageous (Becker in 1982; Cheng et al. in 1982). The controlled use of electrical stimulation to manage a number of different physiological activities in the human body has therefore become the subject of serious investigative studies during recent years.

The first application of electricity to specifically manage pain goes back more than two millenia. In 46 AD Scribonius Largus (Kirsch and Lerner, 1995) claimed that almost everything from headaches to gout could be treated successfully by standing on a wet beach near an electrical eel. This loss of sensation (i.e. anaesthesia) was also described by Aristotle (Kirsch and Lerner, 1995) who claimed that swimming near electric ray fish produced a feeling of numbness. A very interesting finding by Carlo Matleucci (Kirsch and Lerner, 1995) in the 1800s was that injured tissue produced an electrical current. The question which should have been asked was indeed “Why?”. It is very likely that through evolution the human body learnt to produce a current which either attracted pain-soothing chemicals to the site of trauma, dispelled pain-inducing chemicals from the site or both. It was only in 1983 that Becker pro-posed that a current data transmission and control system exists in biological systems for the regulation of healing. Similarly Nordenström (1983) theorised that the mechanical blood circulation system is closely integrated, both morphologically and functionally, with some form of a bio-electrical system. He also regarded bio-electricity as the primary catalyst of the healing process, but it was already in 1981 that Becker electrically induced limb regeneration in frogs and rats as a model to study bio-electrical forces as a controlling morphogenetic field. This clearly illustrated the ability of electrotherapy to increase protein synthesis, increase cell growth and the formation of new tissues. The same effect was demonstrated even earlier by Nordenström in 1974 in higher plants.

1.3 Apparatus available

In recent years the study of clinical electrophysiology and its applications has resulted in a better understanding and acceptance of electromedicine. Pain being one of the most commonly encountered medical problems all over the world, it is not surprising that electrotherapy aimed at specifically alleviating pain were the first to truly become popular amongst health professionals as well as private individuals. Machines which utilise electrical currents to alleviate pain, reduce inflammation and promote healing have made their way onto the market and are now becoming every popular. For a period of time the TENS machines were the equipment of choice in the medical and health professions. Recently, however, two additional types became available viz. the Action Potential Stimulation (APS) and APS Compact (APS COMPACT). The major difference between the TENS apparatus and the APS COMPACT is that the latter generates unipolar pulses which cause a nett current to flow and this is claimed to have healing properties which the TENS apparatus does not have.

1.4 The body’s natural ability to cope with pain

In order to fully understand the mechanism whereby electrotherapy exhibits its beneficial affects it is also necessary to understand how the human body copes with pain. The body copes with pain by making use of its own natural chemical agents known as endogenous opiates or opioids. Examples of such endogenous opiates are endorphins (particularly beta-endorphin), dynorphins and enkephalins (met- and leu-enkephalins). These substances are polypeptides which can bind to neuroreceptors in the brain in order to bring about pain relief. When they bind to these specific receptors the release of polypeptide P is prevented. The latter is a carrier which transmits pain impulses from the site of trauma to the brain where recognition and awareness of the pain then take place. The endogenous opiates are very similar to pharmaceutical substances like codeine, heroine and morphine which are well known for their narcotic and potent analgesic effects. Thus when endorphine for example is administered exogenously the same effects are observed as when morphine is administered i.e. strong pain relief and sedation. The endor-phines are therefore also referred to as the body’s own morphine.

The enkephalins (Martindale, 1989) can be found in the brain and in those parts of the spinal cord which transmit pain signals. They can bind to and activate at least three types of receptors on brain neurons. Morphine and similar derivatives act on the same receptors.

The endorphins are opioid derivatives and they induce, like morphine, powerful analgesic effects (Mar-tindale, 1989). They are secreted mainly by the anterior pituitary gland in the brain. Endorphins are secreted with corticotrophin in response to injury.

Melatonin (Martindale, 1989) is a hormone which is secreted by the pineal gland in the centre of the brain. When released it increases serotonin levels in the system. It also enhances the activity of pyridoxal-kinase which is involved in the synthesis of serotonin. Serotonin has a sedatory effect on the brain. The release of melatonin depends on factors such as age and time of day. Melatonin levels are much lower in adults than in children. It is also higher during the night than during the day. Considering these effects of melatonin, it is proposed that it also plays a role in the sleep pattern. Children for example sleep much more than adults. During air travel melatonin release becomes desynchronised. and this leads to jet lag.

Seratonin(Martindale, 1989) is an endogenous antidepressant with sedatory effects at high levels. It is released by tryptaminergic neurones in the central nervous system and is found in the brain, intestines, mast cells and in blood. It is a very powerful vasoconstrictor and also acts as a neurotransmitter. It is found mainly in the brain and hypothallamus where changes in its concentration can lead to mood disorders. Low levels result in depression and antidepressant drugs act by inhibiting the body’s ability to inactivate serotonin thereby allowing an increase in serotonin concentration. Excessive quantities can lead to migraine and nausea.

All processes in living things need energy in order to take place. This energy comes from the foods we ingest. When the foods are oxidised, energy is released. The carrier of this energy to energy-requiring processes is adenosine triphosphate (ATP). The energy-requiring process converts the ATP to adenosine diphosphate (ADP) plus inorganic phosphates or to adenosine monophosphate (AMP) plus inorganic pyrophosphate. ATP plays an essential role in the building up of cell components and therefore regeneration of new tissues, the transmission of nerve impulses and muscle contraction (e.g. during walking, breathing etc.). High localised levels of ATP promote essential protein synthesis e.g. desoxy-ribonucleic acid (DNA) and collagen. This can speed up tissue regeneration by 150% to 350% (Cheng et al., 1982). ATP also stimulates Na+ pump activation. This leads to a decrease in effusion. Because ATP decreases the activation of T-lymphocytes, inflammation is reduced. ATP further reduces the intracellular uptake of Ca2+ ions. In order to be efficient in tissue repair and maintaining growth ATP must be replenished continuously. It was shown by Mitchell (1976) that a stream of H+ ions drives the formation of ATP.

1.5 The mechanism of action of analgesic electrotherapy

Mention has been made of the ability of a small DC current when passed through living tissue to cause a rapid localised cell-healing process characterised by -

1. reduced swelling

1. less inflammation
2. improved tissue regeneration, and
3. reduced pain levels.

This is due to the forced flow of H+ ions in the region which in turn drives the formation of ATP. The function of ATP is described in the previous section.