University of the Pacific University of the Pacific

Scholarly Commons Scholarly Commons

University of the Pacific Theses and Dissertations Graduate School

1986

A comparative study of positive versus negative polarity in the A comparative study of positive versus negative polarity in the

treatment of acute ankle sprains utilizing high voltage treatment of acute ankle sprains utilizing high voltage

electrogalvanic stimulation electrogalvanic stimulation

Lauren Michelle Wells University of the Pacific

Follow this and additional works at: https://scholarlycommons.pacific.edu/uop_etds

Part of the Medicine and Health Sciences Commons

Recommended Citation Recommended Citation Wells, Lauren Michelle. (1986). A comparative study of positive versus negative polarity in the treatment of acute ankle sprains utilizing high voltage electrogalvanic stimulation. University of the Pacific, Thesis. https://scholarlycommons.pacific.edu/uop_etds/2122

This Thesis is brought to you for free and open access by the Graduate School at Scholarly Commons. It has been accepted for inclusion in University of the Pacific Theses and Dissertations by an authorized administrator of Scholarly Commons. For more information, please contact mgibney@pacific.edu.

A Comparative Study of Positive Versus Negative Polarity

in the Treatment of Acute Ankle Sprains '--'-'---

~----

Utilizing High Voltage Electrogalvanic Stimulation ~--

A Thesis

Presented to

the Graduate Faculty

of the

University of the Pacific

In Partial Fulfillment

of the Requirements for the Degree

Master of Science H-----

by

Lauren Michelle Wells

January 1986

.---;;

This thesis, written and submitted by

Lauren M. Wells

is approved for recommendation to the Committee

on Graduate Studies, University of the Pacific.

Department Chairman or Dean:

Thesis Committee:

Chairman

Dated --------~--------------~------------

TABLE OF CONTENTS

PAGE ~----

H----~-

Acknlowledgments iv

List of tables ....................................... v

List of figures ...................................... vi

Introduction ......................................... 1

Materials and methods ................................ 13

Results .............................................. 18

Discussion ........................................... 19

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Literature cited ..................................... 26

iii

ACKNOWLEDGEMENTS ~--

I would like to thank Stockton Orthopaedic Medical M---

Group for referring patients for treatment. Without their

support, proper medical care and follow-up, the study would

not have been possible. Also, I would like to thank Gerry

Solberg for his assistance in developing the treatment pro-

tocol. My thesis committee has also been helpful in

completing this study. In particular, I would like to thank !o-l-----

Dr. Funkhouser for her support and understanding of some-

times difficult situations and circumstances. Last, but not

least, I would like to thank my parents for the opportunity

and encouragement necessary for me to complete this degree.

;--,-- ------ ---

i n

g

iv

TABLE

1.

2.

LIST OF TA.BLES

Ankle-Foot Volume and Range of Motion measurements of patients treated with negative polarity of high voltage electrogalvanic stimulation. Data presented as volume (ml), dorsiflexion­plantorflexion (degrees of movement) •..........

Ankle-Foot Volume and Range of Motion measurements of patients treated with positive polarity of high voltage electrogalvanic stimulation. Data presented as volume (ml), dorsiflexion-plantarflexion (degrees of movement) .......... .

iv

PAGE

29

==-- -- ---c r-.; -

30

;:;:;- ----- ----

LIST OF FIGURES ,-=

FIGURE PAGE --------

p--

1 DLagram of High Voltage Electrogalvanic Waveform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

2 Range of Motion versus Time' of all Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

[2---------

----------

3 Volume change versus Time of all Subjects ......................... _............. 32

4-11 Volume versus Time and ROM versus Time for negative polarity group subjects .......... 33

12-19 Volume versus Time and ROM versus Time for positive polarity group ................... 42

~--

~-------

v

Introduction

Electrical stimulation has long been used in the

treatment of a variety of ailments. Its current uses range

from muscle re-education and orthotic substitute to

scoliosis management and edema control. I chose to study

the effect of electrode polarity in high voltage

electrogalvanic stimulation in the treatment of edema for

several reasons. I had access to subjects because I was the

only physical therapist at the Stockton Orthopedic Medical

Group. High voltage electrogalvanic stimulation is a

commonly used modality in treating edema (Brown, 1981).

High voltage generators have a polarity switch, and the

direction manual which accompanies the Electro-Med generator

used by the Stockton Orthopedic Medical Group states that

the negative pole should be used for edema reduction.

(Instruction manual for high voltage Electrogalvanic

Stimulator, 1977). However, the effect of electrode

polarity on edema reduction has not been demonstrated, nor

documented in the literature.

In rilinical practice electrical stimulation can be

provided by a variety of generators. Low voltage

stimulation (using less than 150 volts) has been used for

many years and the effects are well understood (Osborne and

Holmquest, 1944). More recently, high voltage electro~

""" ,~ ~

~-~--

--------

r-" = -- -------

- - ---<=;=~~

~--~~-~~

- -- ----

2

galvanic stimulation (using greater than 150 volts) has been

introduced for clinical use (Instruction Manual for High

Voltage Electrogalvanic Stimulator, 1977).

The major effects of low voltage electrical current

include:

1) Iontophoresis, which is electrode and cellular

polarization due to ion transfer. Clinically this technique

can be used to drive compounds through the skin.

2) Electrophoresis, which is the movement of charged

cells or particles. This technique is not used in the

clinic; it can lead to caustic anion and cation accumulation

at the electrode interface.

3) Electro-osmosis, which is a shift in cellular water

content. This effect can be utilized in edema control.

4) A change in nerve sensitivity, which can be

effective in controlling pain and spasm.

5) A mild heating effect in tissue between electrodes

due to the conduction of current.

6) A slight increase in circulation due to the mild

heating effect and the increase in 02 and nutrient demand of

contracting muscle (Wolf, 1981).

In most instances, the current form (AC or DC) as well

as its magnitude and frequency determine the extent of these

effects in low voltage electrical stimulation. The effects

0---~-------------

~----------

~

~=----

~~-~-

-~----~-~-----~--------------------------~------- -------------------- -

I

3

of high voltage electrical stimulation are not as clear, but ,_...,- -----------

it is known that iontophoresis and electrophoresis do not

occur, nor does temperature change (Killian, 1985).

Electro-osmosis may or may not occur. There does appear to

be a change in nerve sensitivity and a slight increase in

circulation resulting from high voltage electro-galvanic

stimulation (Sohn, et al. 1982).

Treatment techniques can be either monopolar or

bipolar. In monopolar treatment one electrode (positive or

negative) is placed on the treated area and the other

electrode is placed in a remote location. In bipolar

treatment both the positive and negative electrodes are

placed on the treated area and in relative proximity to each

other (Killian, 1985).

The effects of current passed through tissues and the

magnitude of the reaction depend on the tissue type, pulse

duration, the type of waveform, current density through a

specified area, and the frequency of the current used

(Killian, 1985).

The perception of pain that many people anticipate

prior to being stimulated is motivated by fear of high -------

voltage generating a high average current of long pulse ~-~~

duration. Adjusting pulse duration and voltage so that

there is a low average current and therefore a less painful

stimulus is the basis of both high voltage electrogalvanic

stimulation (EGS) and low-voltage electrical stimulation

(Benton, et al, 1981). If patients are to tolerate the

treatment, they must not be stimulated with a higher

amplitude (higher current) than their pain threshold.

Therefore, high voltage electrogalvanic stimulation uses a

short pulse duration (measured in micro-seconds) and high

voltages to deliver an average current at non-painful

levels; low voltage uses a longer pulse duration and lower

voltages to deliver an average current at non-painful

levels. The pulse duration on a high voltage stimulator

range from 50-75 microseconds and may be delivered at 20-80

4

pps, while low voltage pulse durations last 300 microseconds

and are usually delivered at a frequency of 35 pps (Killian,

1985; Benton, et al, 1981).

The waveform of the pulse is also important in how

stimulation is perceived and how it functions in treatment.

Most low voltage generators are battery operated and convert

continuous direct current into rectangular pulsed direct

current. The high voltage generator used in this study

changes 120 volt, 60 cycle household current into dual

spiked pulsed direct current. The interval between the

pulses is much longer than the duration of the pulse. The

current is off more than it is on. This allows for the low

,.._..,_ ----------­R- --- ------

-- --- --

5

average current (approximately 1.5 milliamps in typical ~ ------.=-::---::..:__-:__-= ~---

treatment) delivered by high voltage generators despite peak

currents between 300-400 milliamperes (Killian, 1985).

The short pulse duration of high voltage direct current

stimulation permits selective stimulation of predominantly

sensory and motor axons and much less stimulation of pain

conducting fibers. Consequently, such stimulation is more

tolerable.

The short pulse duration does not seem to cause the

chemical and thermal effects seen with low volt, long pulse

duration direct current stimulation. Therefore, high

voltage electrogalvanic stimulation may be used for extended

treatment periods with no apparent side effects. Because

pulse duration cannot be shortened, any increase in pulse

frequency rate will increase average current. Such an

increase will cause a stronger contraction of the stimulated

muscle and will increase the patient's perception of the

current, but it will not increase the depth of penetration

of the current.

However, increasing the amplitude of the peak current

--- - -- ---

will increase the depth of penetration of current into ----

------

tissues. Some electrogalvanic stimulators have maximum peak

currents of approximately 300-400 milliamperes, compared

to the 80 milliampere current of low voltage stimulators.

6

Even though the peak currents in electrogalvanic stimulation

are 4-5 times that of low voltage electrical stimulation,

they are safe because the average current is low (Smith,

1981). Because of the greater penetration of current with -------

electrogalvanic stimulation, deep nerves and muscles can be

stimulated effectively. As a result, muscle contraction is

effective and can be achieved even without placement of the

electrode on a nerve or muscle motor point. -----

The deep penetration obtained from high voltage

electrogalvanic stimulation is not limited to peripheral

nerves and skeletal muscles. It may be possible to

stimulate sympathetic nerves and the smooth muscles of

blood vessels directly or indirectly (Alon, 1981).

The current physiological theory concerning pain

reduction through electrical stimulation is that stimulation

can release endorphins and enkephalins from several sites in

the central nervous system (Killian, 1985). However, the

supposed release of endorphin/enkephalins is theoretical.

This has not been demonstrated in humans, and the mechanism

by which electrical stimulation of a peripheral body part

can stimulate release of a substance from the central ner-

vous system is not clear at present. Two different methods

are presumed to achieve endorphin and enkephalin release E--

(Francis, 1983).

.-..,---------

7

-~

===--------

One method is to use a supra-painful stimulus to a very ==----=---'--'=--=---

narrow area at a trigger point, acupuncture point, or motor --- ------ --

point. Trigger, acupuncture and motor points are often the

same points, but they are defined differently. A trigger

point is one where pain, numbness or tingling radiate from

the point while being palpated. The name trigger describes

the use of the index finger to press the point and "trigger"

the radiation. An acupuncture point lies along the meri---~--

. ~

~---

dians of the body (Tappan, 1978). A motor point is where a

nerve to a muscle lies close to the skin (Brobeck, 1979).

The Western use of acupuncture points has been used for many

years without realizing it, because many trigger, acupunc-

ture and motor points are the same (Paris, et al, 1983).

The other method is to deliver non-painful stimuli to

larger areas (usually to a painful area where a trigger

point cannot be isolated, or to an injured area) in which

pain fiber stimulation is minimized and sensory fiber

activation is maximized. High voltage electrogalvanic

stimulation can be used to deliver either a supra-painful

stimulus or a non-painful stimulus (Killian, 1985).

By using larger electrodes, controlling intensity, and

having very short pulse durations, selective non-painful

sensory fiber stimulation can prevail. Both treatment ' methods appear to function equally well in most patients

(Killian, 1985). =- ---- ---e

8

The mechanism by which high voltage electrical stimula-

tion functions physiologically in increasing joint mobility

is unclear. The use of long pulse duration, low voltage

direct current is known to cause softening of some tissues

under the negative electrode due to "liquification" of the

protein (Osborne & Holmquest, 1944, p. 38). This softening

is attributed to an increase in alkalinity due to the chemi-

cal effect of the stimulation (Alon, 1981). What tissues

are affected by the current depends on the depth of penetra-

tion and tissue type. Current will flow more easily through

substances with low impedance than through substances with

high impedance. The relative conductivity of tissues is

approximately equal to their content of water and available

ions. Skin and bone are not softened by electrical stimula-

tion because of their high impedence (5-16% water and ion

content compared to 75% water and ion in muscle) (Benton, et

al, 1981). In high voltage electrogalvanic stimulation such

effects are practically non-existent, thus such a mechanism

is unlikely to explain the result (Newton and Karselis,

19 83) .

With low voltage electrical stimulation peripheral

circulation can be increased to the skin, muscles, core and

any combination of these. High voltage pulsed direct

current does not seem to increase the core circulation of

normal subjects (Alon, 1981).

~----

~----- -----

~---

i""'""': -·---------

;;;;---==-----

b'--

--~:-- -

9

It may, however, have a electrical effect on blood

vessels to increase blood circulation (clinical obser-~-~·---

vation). When electrical stimulation is used to increase ~-----

peripheral blood circulation the results that occur could

be attributed to either a direct or an indirect effect on

the circulatory system (Alon, 1981).

The direct effect could be direct activation of the

sympathetic fibers of the autonomic nervous system. The """---

indirect effect could be achieved by three different _c:-

mechanisms. The first would be the circulatory response to

the chemical changes of acid and alkaline under the positive

and negative electrodes respectively. Such an effect would

be unlikely to occur when high voltage pulsed direct current

is used because the pulse characteristics eliminate the

chemical changes under the electrodes (Newton and Karselis,

1983). ------

The second possible indirect effect is through the

somatic sympathetic reflex. Such a response has been

demonstrated on the sympathetics innervating a dog's

kidneys. Whether such an influence affects the autonomic

innervation of the peripheral arteries is still unclear

(Alon, 1981).

The third possible indirect effect is from the pumping

action of muscles. Effective venous return requires strong

10

intermittent contractions. High voltage pulsed direct - ----- ---

current, because of its depth of penetration and relatively

comfortable stimulation, can elicit such contractions (Alon,

1983).

Acute ankle sprains, strains and fractures develop

post-traumatic edema which seriously limits recovery due to

abnormal adhesion formation (Cyriax, 1978). The primary

goals of treatment are to decrease pain and swelling and

increase mobility. If range of motion limitation is asso-

ciated with pain, then reduction of such pain should improve

joint mobility (Nirschl and Sobel, 198li Grava and Schelberg-

Karness, 1983). Edema reduction would be a secondary gain

because the patient would be more willing to move the

affected part thus reducing adhesions.

Post-traumatic edema has traditionally been treated

with compression, elevation and ice (Lehman, et al, 1974i ~---=--- -- ----

Quillen and Rouillien, 1982). This treatment is currently

being supplemented with high voltage electrogalvanic stimu-

lation. The literature which accompanies the Electro

Galvanic Stimulator (Electro-Med Health Industries, Miami,

FL) used by the Stockton Orthopedic Medical Group suggests

that negative polarity be used to treat edema. There is no

literature available to verify that negative polarity is

more effective than positive polarity. - ------ ----

- ----------

~---

11

The object of this study is to test the use of both ~-

positive and negative polarity of high voltage ;;--

electrogalvanic stimulation in the treatment of edema in

acute ankle sprains. The null hypothesis of this study is

that polarity has no effect on edema reduction.

12

~-----

Figure l.

(a) "High voltage" paired spikes are most frequently

monophasic, resulting in ion flow in one direction.

Because of their short duration, spikes are paired

and required high amplitude to generate neural

excitation (Benton, et al, "1981).

-------

~

13

Materials and Methods

Patients participating in this study were seen

initially by one of the physicians of the Stockton

Orthopedic Medical Group, Stockton, California. These

patients were then referred to Physical Therapy with a

diagnosis of second degree ankle sprain. (In a second

degree ankle sprain, the ligament is weakened, but there is

no instability. Weight bearing is painful and range of

motion is limited. Tenderness is marked over the anterior

talofibular ligament. Swelling and ecchymosis are signifi-

cant. X-rays are normal. Ice, elevation, taping and non-

weight bearing are the immediate treatment (Floriani,

1976.)) All patients were treated according to the protocol

shown below. The information from those who attended 75% of

scheduled appointments was used as data in this study.

Subjects whose information was included signed a release of

information form after discharge.

Protocol:

Once a patient is referred to the clinic the stability

of the ankle is re-evaluated according to the method of

Hoppenfeld. The anterior talofibular ligament is checked

for a positive drawer sign (when the talus slides anteriorly

from under the cover of the ankle mortise). If the patient

has a positive drawer sign, they are not a candidate for the

R __ .::-_ ~--------~:___-:_:_.::­E:

'---"----

14

study. Only those patients with ecchymosis and swelling,

without ligamentous instability may participate.

Once the stability of the ankle is verified, range of

motion is evaluated. Dorisiflexion and plantarflexion are

measured with a goniometer. (When the angle between the

tibia and 5th metatarsal is at 90° the ankle is in neutral

position and is re-defined as 0° for dorsiflexion-

plantarflexion measurement. Normal dorsiflexion range is

considered 0° - 20° and normal plantarflexion is considered

0°- 50°. Many individuals do not have "normal 11 range of

motion, (ROM), therefore the injured ankle is compared to

the non-injured ankle (Esch & Lepley, 1974). The goal of

treatment is equal ROM for both ankles.

Volumetric displacement measurements are taken to

quantify the amount of edema. A plexiglass tank (30 x 45 x

15 em) with a side spout was built for the study. The tank

is filled to the base of the spout. The patient places

their non-injured foot in the tank with the foot resting on

the bottom. The water run-off is collected in a graduated

cylinder and the volume of water is recorded. The same

procedure is repeated with the injured ankle. The

difference between the two measurements is the volume due to

edema. The normal slight size or shape difference between

left and right feet does not result in a significant volume

difference (Paris, et al, 1983).

~----

-----,_,. _________ _

15

Following initial evaluation, treatment is begun. The

patient begins by icing the injured ankle. When the ankle H~:_ ---- --

appears red the icing is stopped and patients begin the

exercise program. The exercises consist of active

plantarflexion and dorsiflexion with resistance added to

patient tolerance, toe flexion and extension and toe

abduction and adduction.

The ankle is then stretched by the patient with a

towel, by the therapist, then again by the patient in a

weight-bearing position.

Following stretching, patients are treated with high

voltage electrogalvanic stimulation (Electro Galvanic

Stimulator, Electro-Med Health Industries, Miami, FL). The

dispersive pad (ground) is placed over the lower back and

held in contact with an elastic belt. The toes are covered

with a neoprene bootie and the injured ankle submerged in a

bucket of cold water. The two active electrodes are

submerged on the medial and lateral sides of the ankle (not

in contact with the ankle) (Roy, 1983).

Treatment is delivered for 20 minutes. Switching rate

is set on constant and the frequency at 80 pulses per

second. The patient dorsiflexes and plantarflexes the foot

during treatment. Ice cubes are added to the water 10

minutes into stimulation. Following stimulation, the ankle

16

is taped (Johnson & Johnson, 1983). The tape is to be kept

on until the next clinic visit unless complications occur

secondary to decreased circulation. Each patient is sche-

duled to be seen daily Monday through Friday.

Follow-up measurements for ROM and volume are taken,

when possible during clinic visits.

The first group of patients were treated with negative

pole, and the second group were treated with positive pole.

During a year and a half only sixteen patients met the

criteria of the study. The group treated with (-) polarity

had an age range of 14 to 56 years, with 50% of the patients

under 25. The group treated with (+) polarity had an age

range of 18 to 45 years, with 25% under 25. Patient Cr, age

18, sprained both ankles at different times and was a

subject in both groups.

In each group the younger patients (age 14-20) incurred

their injuries in sports-related activities associated with

competition for their high schools. They accounted for 6 of

the 16 subjects participating in the study.

The other 10 patients sustained their injuries by

tripping, and presented under a variety of circumstances:

three CGu, An and Do) were seen within 24 hours of injury,

four (Sm, Fl, Ga, Br) were seen within 72 hours of injury,

one (Bi) had circulatory insufficiency so could not ice or

"--"-----

;:;;; -=------=--=-=-===-­'-"

17

exercise, one (Va) had been injured in New York, seen in the ;____;_ _____ _

emergency room there and was not seen in the clinic until P-- - ---

two weeks post-injury, and one (Th) sustained a fracture

that required further follow-up.

Despite this difference in prior histories, all

patients were begun on the same protocol.

" ,.---,-- -- ------

[j_ ______ _ :=:---------

m:··-p-~ ---~

b

18

Results c: ---

Range of motion (ROM) and volume data were analyzed for c __

both groups. A total of 58 observations for ROM and volume

were made for both groups. Thirty four observations were

made on the negative group: 32 of these observations were

made though the first 10 days, 1 at 20 days and 1 at 22

days. The other 24 observations were made on the positive

group: 23 of these observations were made through the first

10 days and 1 at 14 days.

ROM versus time and volume versus time for both groups

were considered separately and then together. ROM values

were obtained by adding dorsiflexion and plantarflexion

ranges together. The slope of the regression line for each

subject was derived (Tables 1 and 2) then the average slopes

for both groups were determined. The average slopes of both

groups were compared using a t-test and found not to be

significant at the 5% level.

19

Discussion

The ankle is one of the primary weight bearing joints.

It must be both mobile and stable. Inversion or eversion

sprains can tear the joint's supporting ligaments and pro-

duce instability. Excessive inversion stress is the most

common cause of ankle sprains. There are two anatomical

reasons for inversion ankle injuries: The medial malleolous

is shorter than the lateral malleolous, and the talus can

thus be forced to invert farther than it can evert and the

ligamentous thickening on the lateral side of the joint are

separate, and therefore not as strong as the massive deltoid

ligament on the medial side (Hoppenfeld, 1976). The

anterior talofibular ligament is the ligament most often

involved in ankle sprains. The anterior talofibular and the

calcaneofibular ligaments must both be torn to produce gross

lateral ankle instability. All of the subjects participating

in the study suffered from inversion sprains and Lu may also

have had some stress applied to the deltoid ligament on the

medial side. Th also had an associated fracture.

Each individual participating in the study suffered

from various degrees of disability from their injury. Each

had visible ecchimosis with swelling resulting in pain and

stiffness, but the amount varied considerably between sub-

'----------

"""' ;----':------ --

-----

----­=---- ---

n

20

jects. The more severe the injury the more swelling present

at the time of initial evaluation. The patient with the

greatest amount of swelling was also the patient who suf-

fered from an associated fracture.

The amount of post-traumatic edema is also influenced

by the length of time between injury and initial treatment,

the age of the individual and the number of complicating

factors (i.e., fractures, tendon rupture, vascular compro-

mise, other systemic disease). These factors acting in con-

junction may lead to higher original volumes. For example,

the second largest initial volume measured was that of a

patient who had venous insufficiency and suffered from

swollen ankles independant of trauma (Bi).

An acute injury is more likely to respond to treatment

than a chronic injury because secondary damages caused by

excessive bleeding, adhesion formation and weakness have not

developed. The longer the tissues remain edematous the more

stretched the tissues and associated vessels become. The

accumulation of extracellular fluid is therefore greater in

regions which are loose in texture and where the skin is

readily stretched. In persons with firm resistant skin,

edema makes its appearance later and is less pronounced. If

edema can be prevented from forming and stretching the

tissues, the initial volume is lower and there is less to

'---'-------

-- -- -- ---

21

reduce. Those patients in the study who were seen imrne-

diately post-injury were those who participated in high

school atheletics (Cr, Me, Ha, Lu, De, Cr), one seen in the

emergency room (An) and two in the office (Gu, Do). In

general younger patients have more elastic and resilient

tissues than older patients.

There are some significant muscle changes that occur

with aging that may affect an individual's recovery from

injury. These include: "Gross muscular atrophy secondary to

the loss of both number and size of muscle fibers" (Payton

and Poland, 1983:43). This "muscular atrophy may be

differentially attributed to a decrease in the number of red

fibers" (McCarter, 1978:17). Muscle atrophy is always

associated with weakness.

In the lower extremities, venous return is aided by the

muscular pump. The stronger the contraction the more effi-

ciently the muscular pump works to return blood to the heart

(against gravity). When an i'ndividual becomes less active

because of weakness they do not "pump" as effectively as an

individual without weakness.

Weakness may also result from an increasing proportion

of skeletal muscle free fat being replaced by fibrous

tissue. Nevertheless, the primary cause of loss of strength

appears to be a change in lifestyle and decreased use of the

=----=-~:__ __ ~ __ ~

EO :=:;--

=== i---=i

E ~ --- --

~----

22

----

neuromuscular system. Osteoarthrosis is a result of an Fi-- ---- -- --

imbalance between the stress a joint receives and the abi- :==.-~~- -=-=----~-

;___;;

lity of the physiological shock absorbers in that joint to

absorb the stress (Radin, 1976). This is accompanied by a

marked decrease in tensile stiffness and fracture strength

with increasing age. On the average, strength begins to

decline around age 40 (Raven & Mitchel, 1980).

These musculoskeletal changes which occur with aging

are accompanied by cardiovascular changes. Both the heart

and the smooth muscle of vascular tissue decrease in sym-

pathetic responsiveness in people of advanced age (Lakotta,

1980). Associated with the aging cardiovascular system is a

decline in lipid catabolism, which generates lipid accumula-

tion; this process may underlie the development of ------

atherosclerosis (Kritchevsky, 1980).

These changes associated with aging coupled with the

degree of injury account for some differences in recovery

time and initial volumes. When these factors are considered

in conjunction with the time between injury and first treat-

ment, the test subjects are further divided into the

following subgroups: young subjects with acute injuries;

young subjects with chronic injuries; old subjects with d- -

acute injuries; old subjects with chronic injuries; patients

with complicating factors. The sample size of each subgroup

23

is so small it is difficult to draw conclusions about the

effect of the polarity of treatment.

The other major complicating factor is the amount of

home follow-up. Each patient was instructed in a home exer-

cise and icing program to be done three times per day. The

amount of compliance cannot be verified. Each patient

reported about their compliance level, which was frequently

less than the amount prescribed. Standardizing and quan-

tifying the amount of home follow-up is difficult. One

patient may have overdone his home program in an attempt to

get back to the football field faster, while another patient

may have underdone her home program because the exercises

may be painful and she does not tolerate pain well (by

admission of patient). In essence, data from each patient

can only be considered as an individual case study making it

impossible to arrive at any significant conclusions from

this study.

To help eliminate the variability which prevented

conclusions from being drawn from this study, the following

suggestions are offered.

It is essential to have (1) a large number of patients,

(2) of similar age. The investigator should (3) adopt a set

of standards related to the degree of injury (for example,

decide on limits of talar-tilt), (4) obtain patients with

~--~--

F~

~~~-

..... ____ ------------------

f§-

24

---

comparable injuries who are (5) seen no later than 24 hours

post injury (6) before initial treatment. ~-

One way to achieve most of these goals would be to per-

form the study out of an emergency room rather than from a

private practice. The number of acute patients is greater

during a given time period in an emergency room and they are

less likely to have received previous treatment. They may

then be referred to a physical therapist directly. A larger ---

------

initial number of patients would facilitate selection for

age and comparable degree of injury.

There is probably no reasonable way of insuring that

patients keep their appointments and perform the home

follow-up treatment and exercises. However, a large enough,

initial sample might provide enough data to eliminate some

of the individual differences.

~'---

25

Summary t ____ _

The goal of this study was to determine whether one [___, --

pole of high voltage electrical stimulation is more effec-

tive than the other in edema reduction of acute ankle

sprains.

Patients were seen initially by a physician of the

Stockton Orthopedic Medical Group and referred to Physical

Therapy for treatment. Range of motion and volume of the

affected ankle were measured during initial treatment, and

follow-up measurements were taken until time of discharge.

The first eight patients who attended 75% of their scheduled

appointments were treated with negative pole and the second

eight patients with positive pole.

Range of motion and volume data from each subject and

from each group were analyzed by linear regression and

t-tests. No significant difference was found between the

range of motion and volume of individuals in the two treat-

ments. The small sample size prohibits any conclusions

being drawn regarding the relationship between polarity and

edema reduction.

-

~

Literature Cited

Alon, G., Synopsis and High Voltage Stimulation, Chattanooga, TN, Chattanooga Corporation, 1981.

26

Benton, Laurel A., Baker, Lucinda L., Bowman, Bruce R., and Waters,'Robert L., Functional Electrical Stimulation A Practical Clinical Guide. The Professional Staff Association of the Rancho Los Amigos Hospital, Inc., Downey, California, 1981

Brobeck, John R., Best and Taylor's Physiological Basis of Medical Practice. Williams & Wilkins, Baltimore/ London, Tenth Edition, 1979, pg. 9-9.

Brown, Sam C.P.T., "Ankle Edema and Galvanic Muscle Stimulation," The Physician and Sports Medicine, Vol. 9, No. 11, November 1981, pg. 137.

Cyriax, James, Textbook of Orthopaedic Medicine, Vol. 1, Diagnosis of Soft Tissue Lesions, Baillere Tindall, London, 1978.

Esch, Dortha, Lepley, Marvin, Evaluation of Joint Motion: Methods of Measuring and Recording. University of Minnesota Press, Minneapolis, Minnesota, 1974.

Floriani, Lawrence P., MD, "Ankle Injury Mechanism and Treatment Guides," The Physician and Sports Medicine, September 1976, pg. 72-78.

Francis, Kennon T., "The Role of Endorphins in Exercise: A Review of Current Knowledge," Vol. 4, No. 3, JOSPT, Winter 1983, pp. 169-173.

Grava, William A., MD, Schelberg-Karness, Eileen, RPT, "How I Manage Deep Muscle Bruises," The Physician and Sports Medicine, Vol. 11, No. 6, June 1983, pp. 123-127.

Hoppenfeld, Stanley, Physical Examination of the Spine and Extremities, Appleton-Century-Crofts, New York, 1976.

Instruction Manual for High Voltage Electrogalvanic Stimulator. Electro-Med Health Industries, Miami, FL, 1977

Johnson & Johnson, Athletic Uses of Adhesive Tape, 1983.

~ ------

=---

Killian, Clyde, Seminar on High Voltage Electrogalvanic Stimulation, Ralph K. Danes Hosp., San Francisco, CA 1985.

27

Kritchevsky, D.: "Age-related Changes in Lipid Metabolism," Proc. Soc. Exp. Biol. Med. 165: 193-199, 1980.

Lakotta, E. G., "Age-related Alterations in the Cardiovascular Response to Adrenergic Mediated Stress," Fed Proc. 39: 3173-3175, 1980.

Lehmann, Justus F., MD, Warren, Gerald C., MTA, and Steward, Scham, M., MD, "Therapeutic Heat and Cold," No. 99, Vol. 3-4, Clinical Orthopaedics and Related Research 1974, pp. 207-245.

McCarter, R., "Effects of age on Contraction of Mammalian Skeletal Muscle." In Kalkor, G., DiBattista, W. J. (Eds.): r Aging in Muscle. New York, NY, Raven Press, 19 7 8, pp. 1-2 2 .

Newton, Roberta A., Karselis, Terence c., "Skin pH Following High Voltage Pulsed Galvanic Stimulation," Vol. 63, No. 10, Physical Therapy, October 1983, pp. 1593-1595.

Nirschl, Robert P., MS, MD, Sobel, Janet, BS, RPT, "Conservative Treatment of Tennis Elbow," The Physician in Sports Medicine, Vol. 9, No. 6, 42-54, June 1981.

Osborne, S.L., Holmquest, H.J. Technic of Electrotherapy and Its Physical and Physiological Basis, Bannerstone House Springfield, Illinois. Second Edition, 1944, pg. 38.

Paris, David L., Baynes, Frank, Grucker, Barbara, "Effects of the Neuroprobe on the Treatment of Second-Degree

·Ankle Inversion Sprains," Physical Therapy, Vol. 63, No. 1, January 1983, pp. 35-40.

Payton, Otto D., Poland, James L., "Aging Process Implications for Clinical Practice," Physical Therapy, Vol. 63, No. 1, January 1983, pp. 41-47.

Quillen, Williams, Rouillier, Leon H., "Initial Management of Acute Ankle Sprains with Rapid Pulsed Pneumatic Compression and Cold," Vol. 4, No. 1, JOSPT, Summer 1982, pp. 39-43.

~----

28

Radin, E., "Aetiology of Osteoarthrosis," Clin. Rheum. Dis., 2: 509-522, 1976.

Raven, P. B., Mitchell, J., "The Effects of Aging on the Cardiovascular Response to Dynamic and Static Exercise," In Weisfelt, M. L. (Ed.), The Aging Heart, New York, NY, Raven Press, 1980, pp. 269-296.

Roy, Steven, MD, "How I Manage Planta Fascilitis," The Physician and Sports Medicine, Vol. 11, No. 10, October 1983, pp. 127-131.

Smith, Wayne, ATL, RPT, "A Case Report: High Galvanic Therapy in the Symptomatic Management of Acute Tibial Fracture," Athletic Training, Spring 1981, reprint.

Sohn, Norman, MD, FACS, Weinstein, Michael A., MD, FACS, Robbins, Richard P., MD, FACS, "The Levator Syndrome and its Treatment with High-Voltage Electrogalvanic Stimulation," The American Journal of Surgery, Vol. 144, November 1982, pp. 580-582.

Tappan, Frances M., Healing Massage Techniques: A Study of Eastern and Western Methods. Reston Publishing Company, Inc., 1978.

Wolf, Steven L. (Ed.), "Applications of Low and High Voltage Electrotherapeutic Currents," Clinics in Physical Therapy: Electrotherapy, Chapter 1, Churchill, Livingston, New York, Edinburgh, London, and Melbourne, 1981.

~~---=-=--==-

~

ci_-

"

' ,..., _____ ~

i. I

0"\ N

' 1!111 I •II I I

.. , ! I'll I ij I

I ]"II ' , ~~I I I

I 1!,! I :1,

I I 'I i

I 'I ' .illillr:::d Jl! !II l,i

Table 1. Ankle-foot volume and range of motion measurements of patients treated with negative polarity of electrogalvanic stimulation. Data presented as volume (ml), dorsiflexion-plantarflexion (degrees of movement).

Patient/ TREATMENT DAYS diagnosis/

time post- Sex/ iniurv age Initial Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Gu/acute M/17 180 ml 100 ml 90 ml 24 hours 0-30° 50-300 lQD-300

An/acute M/53 180 ml 160 ml 110 ml 24 hours -30-300 -30-300 00-300

Cr/acute M/18 80 m1 80 m1 70 m1 24 hours lQD-450 10°-40° lQ0-400

SM/acute M/27 80 ml 60 ml 0 m1 30 ml 72 hours 00-300 00-300 00-450 00-450

fl/acute M/43 220 m1 140 m1 72 hours -15°-30 00-300

Me/acute M/14 200 ml 140 m1 20 m1 24 hours oo-450 0°-45° oo-450

Ha/acute M/18 60 m1 60 m1 24 hours 0° 45° 0°-45°

Lu/acute M/18 140 m1 140 ml 120 ml 90 m1 24 hours 00-300 00-300 00-300 00-350

I i

SloP.e b I I Dav 8 Dav 9 Dav 10 Volume ROM I

20 ml -18.71 1.8 '

lQ0-350 I 80 m1 80 ml -11.58 1.08

I 50-300 50-300

50 ml - 3.51 .058 10°-45

- 4.5 2.967

40 m1 -19.05 3.214 oo-450

-29.99 0

20 ml - 4.78 0 oo-450

60 m1 100 m1 20 days - 5.34 .8825 Q0-450 Q0-400 30 m1

OD-450 -12.182 1.25

22 days 20 ml 5°-45°

0 ("'')

I ! ! I

I

I

II:

Table 2. Ankle-foot volume and range of motion measurements of patients treated with positive polarity of e1ectrogalvanic stimulation. Data presented as volume (ml), dorsiflexion-plantarflexion (degrees of movement).

Patient/ TREATMENT DAYS diagnosis/

time post- Sex/ injury age Initial Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Ga/acute M/35 170 ml 160 ml 160 m1 72 hours 00-350 00-350 oo-350 Bi/chronic vascular in- f/37 260 ml 100 ml 80 ml sufficiency 00-400 00-450 00-450

Va/chronic f/62 130 ml 130 ml 90 m1 70 ml 50 ml 2 weeks -50-300 -50-300 -50-300 -50-350 00-350

Do/acute M/33 10 ml 24 hours 5°-50° Th/acute fracture M/42 270 ml 200 ml 24 hours -15°-30 00-300

Br/acute f/28 160 ml 80 ml 72 hours 00-300 00-350

De/acute M/18 60 ml 25 ml 24 hours 00-400 00-450

Cr/acute M/18 60 ml 50 ml 24 hours 10°-45° 10°-45°

... 1 I

Slof!e b Day 8 Day 9 Day 10 Volume ROM

100 ml - 6.9 .476 00-400

14 days .26581 0 ml - 16.50

00-450

80 ml - 5.93 1.8688 00-400

No Slope

100 ml - 21.12 2.3468 00-350

40 ml - 14.28 1.8877 00-450

- 8.75 1.25

- 3.33 0

- 10.97 l.?Q.4

r-1 ('")

!I !IIIII I' !:: :J.

til 41 (11 L 0\ (11

-o • ~

• 0

• ~

60

SCJ

4CJ

- 3~

20

10

B

X

0

0

B

~

B

X

~

B

X

0

:I

B

B

0

X

B

Ill 0

lilt' 1:::::"

B

X

0

X

X

X

I I I I

I I ·1· "l!ll·h

B

X

Ill

X

X

0

1 1 ~ l ~ ~ 1 ~ ~ lo TREATMENT DAIS ------->

FIGURE 2 - RANGE OF MOTION

Change in range of motion (R.O.M.) of all subjects during treatment with either negative (x) or positive (o) polarity following acute ankle sprain.

:lillll I I ! Ill I I

, I I I I

! ! I I

'HIIC!ill'--,1 , I ! !···p··1 ' ! I I

3~~

N 25CJ 8 (V)

,.... 2CJCJ

X

E X

--0

w X :a: 15CJ 8 :::l X 0 0 _J X 0 0 >

leJCJ

so I ~ ~ X X

~ X B 0 8 s X

X X 0 0 X

X X 0 0

0 ~ X

FI GORE 3 - VOLUME CHANGE

Change in ankle-foot volume (Volume - ml) of all subjects during treatment with either negative (x) or positive (o) polarity following acute ankle sprain.

, I I I

l , I

I ' ~ 1111 ~~ l

{V')

{V')

I

l: :I I ., !~ ~.~ [lll:':lil. . I I . !I ' I ~ i ,IJIII,Iil,

3eJeJ

,-.

25eJ X ,_..

- 2(1(1 E

w 5 . 15(1 -1 0 > leJeJ

10 ; I· I I I I I I I I I ·

1 2 3 4 ' 5 6 7 8 9 1~

TREATMENT DAYS ------~>

FIGURE 4- SUBJECT lGu

Change in ROM and volume of subject GU during treatment with negative polarity following acute ankle sprain. X = volume, o = ROM

'II , I r1::1•,

6CJ

Sel ;;u • 0

4eJ • ::3: •

3eJ n. ro c.O ,

2eJ tD Jl) lJl

leJ 0 .......

:I

i I

i I

l Iiiii

11!1"

3eJCl ~ ("")

X 2SeJ ......

!i 2eJeJ w :;E:

lSeJ => _J 0 > leleJ

scr

I I J I f f I I I f 1 2 3 4 5. 5 7 8 9 leJ

TREATMENT DAIS ------->

FIGURE 5- SUBJECT lAn

Change in ROM and volume of subject An during treatment with negative polarity following acute ankle sprain. x = volume, o = ROM

6~

SeJ ;:u • C)

4CJ • 3: •

3eJ a.. rt> \0 ,

2Cl ro (I) tJl .......

1~ 0 .._,.

II

~I I,, 'r"' 1.'1 '1:' II rr·1

5Cl 0 I

SeJ :::0

~--------------&--_ -•

4eJ 0 .. 3: •

3eJ . CL ro \0 "1

2CJ tD (I) tA

-¥ fD 0 ~

- X --------- ~~-~----~------------------------------------

i

[

I I 9 l(j

I I I I I I I I 1 2 3 4 5 6 7 8

i TREATMENT DAIS ------->

FIGURE 6 - SUBJECT lCr

Change in ROM and volume of subject Cr during treatment with negative polarity following acute ankle sprain. x = volume, o = ROM

1.0 CV)

! 'I

,, ' I I ',,. :•1 II

i I

'': ll"'i'lit·:ji-•111 l:l"l

3ClCl

25~ :<

.......

s 2eJCl tu ::E: 15CJ ::,) _J

....----~..e..------ ~-

. --------------------- --e

n~--~ 0 >

lCJCJ

~CJ ~-----------------x I f I f I I I I I --t 1 2 3 4 5 5 7 8 9 lei

TREATMENT DAYS -------~

FIGURE 7 - SUBJECT lSm

Change in ROM and volume of subject Sm during treatm~nt with negative polarity following acute ankle sprain. . x = volume, o = ROM

I

I :Ill"

6('J

SCJ

4eJ

3eJ

2~

lCJ

:;u a

0 • ""7 -'""' • 0.. fl)

tD ., tD tD til

0 .......

ill I ~ ,,

~ ! ! " .. I" llili '' :I

:!JL i ::i lllii!T l'i

!:; 3('1Cll oeJ

~ 25eJ 5(j ~ --- . ~ - 2(JCJ 4CJ E.

--------------w ------------- ----~ 3el =.J · lSCJ -----~ _J --~---- -x.., . 0 -------------- ~ > l(jeJ 2Cl ---- ~ ~

~ ll(j Sel I

I I I I I - - __ 1_ ______ --JL------..k.-------' · --r ------ I I I

1 2 3 4 5 5 7 8 9 lCJ

TREATMENT ORIS

FIGURE 8 - SUBJECT lFl

. --..... ------~

Change in ROM and volume Df subject Fl during treatment with negative polarity following acute ankle sprain. x = volume, o = ROM

;u • 0 w

~

-0.. ro

U) ..... I

:1) ro lll ...... 0

1\il II l,li,

I

1:. i ! 1'. '!I'll ··::1 '111 II 1 1" l"!!lll!r·

.- CH'I j - 6() 00 M

X 25(J

_.. Sl:l

;Q •

F. 206 0---------o----- --- -··~--·---0 0

4eJ • "7" _,.

LLJ ~

.. -L. 15() ::.J _J 0 >

l~[j

3L1 o_ fD

tiJ ..... I

26 fD (!)

5(J

.......................... -......., . .........__ -............ ..............

-...~

lfl

lCJ ~

0

·I I I I .l I 1··- I I I 1 2 3 4 5 6 7 8 9 lEI

TREATMENT DAYS ------->

FIGURE ~ - SUBJECT lMc

Change in ROM and volume of subject Me during treatment with negative polarity following acute ankle sprain. x =. Y<?lume, o = __ RQ~--

.1.1 ,: 1

~~~~.~ 1.

1

I i

1/1': 1 rl:illltll ·ri1· lj

' I

I I l•i/ I

I . '1, :·:n:l,;

0"1 ("') 3CJCJ t'

25~1 r6Q I

SCl X

.... ···---··--~----- e I Of---- "' '.__

. 4Cl r-- 2CJG £

tl.J

3eJ :£: lSCJ ::::> _J ("..)

> leJCJ 2LJ

1~ .. 5CJ x------x-*--- ---------------+, .j. .

I I r 1 1 I j s 9 1~ 1 I ~ 4 ·5 5

TREATMENT DAYS ------->

FIGURE 10 - SUBJECT lHa

Change in ROM and volume of subject Ha during treatment with negative polarity following acute ankle sprain._~ __ X; volume, o = RQ~---

;:u • CJ • 3: •

CL (D

u:1 1 IV !D VI

o·

I

i : !':. I l 1: '" ':' i ''T [

~ 3CHj

--- 25Ci >:

-$...__ . .. -- -....____ ·---- '=J --·----·· -------. -

,--

~ 2[j[J ---w ;.:: => _J 0 >

~

15Clf r-----~~--------/ l~Lll

SCJ I

I I I I - I I I l + 1 2 3 4 5 7 8 9 16 -.

TRERTHENT ORIS --·- ... ·--->-

FIGURE 11 - SUBJECT lLu

Change in·ROM and volume of subject Lu during treatment with negative polarity following acute ankle sprain. ___ ~-J<:. =_y9~uii1~ { _ o = ROM

iii ' 1::

5C'J

sa ;;o • 0

4Cl :::s: •

3LJ 0... ro

\.0 . .., I

2CJ f'j) rD 11'1

---lei 0 ......

i 1:11:11 "·; nJ ...

I 'I 11·1; 'I'

r--1 3CJO "<t

....... 25() X ......

.---E 26CJ

l.LJ -;::- 15~ 1 ~-5

- - .... - .. -----·· ·-----·-·=.::_._ ~__.a ~

_j 0 >

leJCJ ·}."

'_5CJ

I I I -1 . --t- I I 1 2 3 4 5 5 7 8 9 1~

TREATMENT DRYS ------->

FIGURE .12 - SUBJECT 2Ga

Change in ROM and volume of subject Ga during treatment with positive polarity following acute ankle sprain. X = volume, o = ROM

5eJ

5fJ

4fJ

3(J

2el

II !j

!I :1'1

;;o ~

CJ • 3: •

CL ro ~ I ro ro IJl

1 eJ 0 .....

' '"

I

N '<:!'

~ ---F.

l.L) :-:: =.J _J 0 >

Cllll

li,f' II,' II ,,

., 'Jll:ri:lr::l' · , :llr .,.

II I . i

::! I

IIi

3CIEI

25~1 X

2(jl'JI ~ --e-------~-· ·--·····--·---1 ~ --·--0

15l'll ~ '"" ...... lEleJ

Sll

+ J ~ 1. "-

'\. "X.--­ - -- ----?:

I I I I I I 3 4 ' 5 5 7 8

TREATMENT DAYS -------1

FIGURE ·13 - SUBJECT 2Bi

5Cl

5CJ

4!J

3!J

2(j

l(j

I I I -l-g lel

Change in ROM and volume of subject Bi during treatment with positive pol?rity following chronic ankle sprain with vascular insufficiency. x = volumer o = ROM

I I

'11'1

;;o • 0

3: ~

CL ro

\,{)

I ro ro 1.11 ,_ 0 ~

'Ill :I ,,

~~~ I

,, ,. ,, li ,i

1:1 i.i I I I 1:1 'I II i I

II I I,

1:1 II II I I!'

I '!, I I!' 1''11111'1 ilh,t·,iilu [! I, ; !i

1': 1[";1""! I I ~ Ill

('\")

""' 3()()

..,..._ ':'>5(] >< ~

r(3 5() . ;::o

I • . r--

2CiC1 E

llJ :E:

150 ::J _j 0 >

1 eJO.

so

--·--~ + 4(J 0 I

3: •

3D ;:)__ :i) l[) -.,

2el I

ro :ll

~: I trl

r~ 0

____ _.. ...... -------· .. ~ -----.....e------·

($ -~------~ '~

··~- ----·---------,-........

++- ') 3 1 L.

:t;----1

-t---+ 9 l(j

r---5

TREATMENT DRYS -------/

FIGURE 14 - SUBJECT 2Va

Change in ROM and volume of subject Va during treatment with positive polarity following chronic ankle sprain. x = volume, o = ROM

I i I

l;li::, ! :I IIi: '1:!

'<:!' 3~CJ '<:!'

le ,... 25~ ><·

:,_.

,--2eJCJ E

w :::L 15(j ::J _J 0 >. 1 CleJ

5rJ

f I I I I I I I I · 1-1 2 3 4 . 5 . 6 7 8 9 leJ

TREATNENT DAYS ----->

FIGURE _15~ SUBJECT 2Do

Change in ROM and volume of subject Do during treatment with positive polarity following acute ankle sprain. X = volume, o = ROM

5EJ

5Cl

4EJ

3CJ

2B

lei

::0 • 0 • 3: • 0... (t) \0 , tD (t) IJl ,... 0

Ul .q<

>:: ~

---E

w :L.: ::) _J 0 >

I I"

3CJ(Jr

25()

i I I

i ; I" I[ "'Til ...

2('J('Jr --

15(']+ ~----1 ('](') 1 __ __.---.a- - -· ___ -=:::::::_..,_

I 1: .,.

,,,

!'I

I

----x

1

111111

"·il'l1i:·:··

1:: t4('J

fCJ f20

. l ---------------------- =:::::..:-·--··--Sel a--- . --~~--

1

-~---- .. ___ _

I 1 I 3 I ·

I +lei I I

RERT ~1ENT PRYC I 9 -+ ! 5 T 6 ,

I l ,:) ---·- 1 (7J ---) u

FIGURE 16 - SUBJECT 2Th

Change in ROM and volume of subject Th during treatment with positive polarity following acute ankle sprain with an associated fracture. X = volume, o = ROM

;u . 0 • -~ •

0... fD

\.0 I (1J lD Ill

0 ~

------------------------------------------~==--~~~-=~~~--~--------------~----~----~--~------------~-------------------------------··

ll!ll.:.'.i .. 1':1111 ~:II' II '.1 I! II i• I • I ' •

llll,i I, I . '' I IIJilill[' I' I

I

I

I !: 1·111: 'i!ITI! 'lill·:ri I :Ill I: 'I

_L ____ 1 _______ L_ -~ _ .. L __ ___ L__ _ ____ I ____ _ __ L _ __ _ __ L_ ______ L_ ___ 1

l- ----- -r-- - --- -,~·----.---------,- ---r----~-,--------,

2 3 4 5 6· . 7 8 9 10

TREATMENT DAIS ~----->

FIGURE 17- SUBJECT 2Br

Change in ROM and volume. of subject Br during treatment with positive polarity

following acute ankle sprain. x = volume~ 0 = ROM -----·

I !

ill ')"" I !

:

!

,'lllJ: I!:: I IIIII i · ] i:l! I

II : I' IC:I " 1'1 " '

.I'

"""

3LJLI 5el

...... 25Cl X

5CJ ::::0

~

2CJCJ+ a .--E

- _____________ ...-----

tLl

• 0

4el • 3: •

---·€>

:!: 15el => _.J 0 > l(J(j

SCi IX-

3(} o_ ~ \0 "1

2CJ fD fD l"l ,.... 0

1Cl ~

I ---------------x -t I I I I. I~- __ l I I t--~----~r-------,

1 2 3 4. 5 5 7 8 9 lEI

TREATMENT DRYS -------> FIGURE 18 - SUBJECT 2De

Change in ROM and volume of subject De during treatment with positive polarity following acute ankle sprain. X = vo~~~~! · __ Q_ :::_:RQ!V!_~--

:1111

1

1 :/

II J;

II ii II !I I I " , I ···I il I 'II I !I I I i _ IIIII 'I ''' ''lll'llm···::IJJIItl!i[l lll I 'I

I '1111 .I Ji t•::.1JI·1 ::' n11:n Ill

00 3CJCJ "<f'

0 0

~ 25CJ

~

,..-2eJCJ s

'W ::::E:

15Cl ::J _J 0 > l(jeJ

S.Cl 1 ~ I I I I f I I I -1 I 1 2 3 4 5·- 6 7 8 9 lCJ

TREATMENT DAIS ------->

. FIGURE 19 - SUBJECT 2Cr

Change in ROM and volume of subject Cr during treatment with positive polarity following acute ankle spra{n. -X= volume o =ROM , . .

6eJ

SeJ

4eJ

3eJ

2CJ

leJ

II . II I :''II

;o • 0 • 3: • 0.. tD \0 ., (0 (0 11\ ~

0 ~