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Electrical stimulation on metal implant

According to Canadian Guidelines in 2010, all forms of electrical stimulation can be applied on the body parts with intact skin overlying implants containing metal, plastic or cement. The Guidelines explained that the conduction of electrical current produced by electrical stimulation is unlikely affected by most metal components, including surgical metal implants.

Nevertheless, there is still one or two reported burnt cases when the electrical stimulation was applied directly on the metal implant.

May I ask whether there is any update on this aspect and whether there is any evidence whether the electrical current will affect the union and healing process of those metal implants?

Thanks a lot.

Alexander WOO

9 months ago

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Dr Sandy Rennie
Dr Sandy Rennie

To the question raised about studies examining current density and biphasic currents... unfortunately am I unaware with any such studies.

leomassabki114
leomassabki114

Dr Sandy Rennie said:

Thank you Dr. Bellew. Your reference to the Contraindications Special Issue of Physiotherapy Canada (2010) is most likely the guidelines document Alexander was referring to in his post. And I agree with you re your comments about monophasic waveforms potentially being a culprit in an electrical skin burn/irritation. I have also seen in my EPA teaching labs that IFC used with electrodes smaller than 5 X 5 cm may cause skin irritation due to the increased amount of current density.

Dr Sandy Rennie, do you have/know any study about the relationship of current density and vascular effects of biphasical currents? Thank you.

Alexander WOO
Alexander WOO

Dear all,

Thanks a lot for the input and discussion. I try to summarize what we have discussed.

Metal implant is no longer a contraindication for electrical stimulation, but it is still a precaution for all forms of electrical stimulation. In order to avoid any potential risk, the following procedures must be followed:

  1. Electrodes should be placed away from the proximity of the metal implant, skin staples, skin with reduced sensation or tissues treated with dressings or topical agents containing metal ions.
  2. Avoid using too small electrodes which create high current density and may lead to a heat burnt.
  3. No evidence revealed a bad effect on the healing process of the metal implant.

Thanks a lot again. Alex

Dr Sandy Rennie
Dr Sandy Rennie

I hope everyone on this topic reads Dr. Ethne Nussbaum's entry to this discussion, particularly her comment on combining cryotherapy with TENS or IFC. So may physiotherapists believe that combining ice and TENS or IFC is more beneficial than doing the treatments separately. There is no evidence to support the combination of the two treatments at the same time, and more importantly, as Dr. Nussbaum has so correctly stated: " Besides burn risk what is the point - all routes to pain reduction using TENS or IFC are blocked if the peripheral nerves are numbed!"

Dr Ethne Nussbaum
Dr Ethne Nussbaum

I have followed this interesting discussion - I'm joining in rather late. Kerry et al provided a photo of their electrode set-up. Noteworthy that the electrodes are small - in my opinion too small for the purpose of pain reduction involving a large joint - might as well apply TENS. Difference between TENS & IFC really comes down to depth and area of effect. But importantly, risk of a heat burn from too high current density is very real with IFC (as already mentioned by Sandy Rennie). Satter EK. Third deg burns incurred as a result of IFC therapy. Am J Dermatopathol 2008; 30, 3,281-2 also makes for interesting reading. The author notes the risk of applying electrical currents with decreased skin sensation but does not comment on the patient's concomitant use of cryotherapy and TENS. It is unclear whether IFC was also applied in conjunction with ice. Besides burn risk what is the point - all routes to pain reduction using TENS or IFC are blocked if the peripheral nerves are numbed!

Alexander WOO
Alexander WOO

Thanks Dr. Rennie, Will try to invite one of my friend to join regarding the union issue. Alex

Alexander WOO
Alexander WOO

Thanks all. I think I do agree we still need to be cautious on putting directly on the metal implant especially we still have so many choices on the placement. Why do we need to take this risk?

For monophasic current, I do agree we should avoid because of the risk of accumulating of charges leading to burn.

Thanks a lot again.

Do you usually use the interferential current to reduce the swelling of those cases like total knee replacement or post surgical cases with metal implants?

Dinesh Verma
Dinesh Verma

Hi
I do agree that it matters with the type of current we use. Direct currents / Monophasic may have More Charge accumulation... and hence need to be Cautious in using over metallic implants etc .. Hence its more of PRECAUTION in those cases.

Dr Sandy Rennie
Dr Sandy Rennie

Hi again Alexander. I am unaware of any literature than indicates problems with healing around metal implants when using electrical stimulation.

Cliff Eaton
Cliff Eaton

I agree with previous posts Monophasic impulses can result in heating effect and worse case scenarios a physiological burn. Biphasic alternating impulses fully compensate for all the positive ions therefore there is no heating affect. Therefore they are not contraindicated for any metal work inc pins, screws, plates wires staples etc It is not recommended or indeed warranted to stim directly over a superficial plate

Alexander WOO
Alexander WOO

Thanks a lot, Dr. Rennie and Prof. Bellew. These are the articles I referred to.

  1. Pamela E.H., et al. (2010). Electrophysical Agents – Contraindications and Precautions: An Evidence-Based Approach to Clinical Decision Making in Physical Therapy. Physiotherapy (Canada). 62(5).
  2. Kerry S. F., et al. (2005). Full-thickness Burn Formation after the Use of Electrical Stimulation for Rehabilitation of Unicompartmental Knee Arthroplasty. The Journal of Arthroplasty. 20: pp. 950 - 953

Moreover, is there any evidence showing it will affect the union and healing of those metal implants, e.g. Total knee replacement.

Really thanks a lot to carry on the discussion. Alex

Dr Sandy Rennie
Dr Sandy Rennie

Thank you Dr. Bellew. Your reference to the Contraindications Special Issue of Physiotherapy Canada (2010) is most likely the guidelines document Alexander was referring to in his post. And I agree with you re your comments about monophasic waveforms potentially being a culprit in an electrical skin burn/irritation. I have also seen in my EPA teaching labs that IFC used with electrodes smaller than 5 X 5 cm may cause skin irritation due to the increased amount of current density.

Prof James Bellew
Prof James Bellew

Alexander, I believe the reference you refer to is from ELECTROPHYSICAL AGENTS Contraindications and Precautions: An Evidence-Based Approach to Clinical Decision Making in Physical Therapy. Physiotherapy Canada VOLUME 62 NUMBER 5 SPECIAL ISSUE 2010 ISSN-0300-0508 E-ISSN-1708-8313.

I agree with Dr. Rennie and also have not seen these 1 or 2 reports you write of. I expect that the currents used were monophasic and thus potentially (although still unlikely with modern stimulators) capable of resulting in electrothermal and electrochemical adverse effects (i.e. burns). However, biphasic pulsed currents and burst or amplitude modulated currents (i.e. Russian/Aussie or IFC), as more commonly used would likely not result in a burn. I would like to read these reports because I believe the answer will be found in the methodology.

Dr Sandy Rennie
Dr Sandy Rennie

Hi Alexander. Can you tell me more about these Canadian Guidelines and where I might find them? In answer to your question, I believe the literature is clear that metal implant and plastic implants (other than those that are electrical implanted such as indwelling cardiac, phrenic or urinary stimulators) are not contraindications for the use of electrical stimulation. If the electrical stimulation is directly over a metal implant, it is prudent for the physiotherapist to use caution and make sure the patient feels nothing unusual or untoward.

A also have not heard of the one or two burn cases with electrical stimulation over metal implants. Can you give me more information? Thanks.

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