Transcript Kein Folientitel

H. U. MAY
High Ton Frequency Power Therapie
with HiToP®
in general and particularly in
cases of painful conditions
of the musculo-skeletal system
with special consideration of low back pain
including a part of the
results of a clinical study
carried out and evaluated by
E. RHADES and B. SCHNEIDER
Authors:
Dr. med. Hans-Ulrich May
Facharzt für Neurologie und Psychiatrie Neurologist & Psychiatrist
Albert-Einstein-Straße 1
D - 75015 Bretten
Dr. med. Eckhard Rhades
Facharzt für Orthopädie
Königstraße 3-7
D - 32545 Bad Oeynhausen
Prof. Dr. Berthold Schneider
Institut für Biometrie
Medizinische Hochschule Hannover
Carl-Neuberg-Straße 1
D - 30625 Hannover
Orthopedist
Institute for Biometry
Medical University
Hannover
0.
0.1.
Summary
Background
In this presentation I will begin with the explanation of the reasons
for the decision for the development of a new sophisticated
method within the physical therapy, described as “electrical high
tone frequency alternating field therapy”, abbreviated in German
“Hochtontherapie”, in English “high tone therapy”, in Polish
“terapia energotonowa”, that means “energy tone therapy”.
The new method has been realised in Germany by gbo.
The result is the equipment HiToP® (High Tone Power Therapy).
The study of RHADES & SCHNEIDER were carried out to
examine the efficacy of HiToP® in patients with painful conditions
of the musculo-skeletal system.
0.2. Material and methods of the clinical study
In 48 patients 94 “organs” or parts of the body respectively
had been treated, 9 vertebral columns in general, 18
patients with low back pain, 12 shoulder- joints, 22 hipjoints and 33 knee-joints.
All patients received local and whole-body treatments
simultaneously.
All patients received10 treatments.
The duration of one treatment was one hour.
Parameters for the judgement were the scaled estimation of
pain, range of motion, measurements of circumferences and
results of joint-specific tests.
Measurements and judgements were carried out by the
doctor and/or the patients and statistically evaluated.
0.3 Results and valuation
The evidence for the efficacy
of HiToP-treatments
can be exposed as
in many cases
statistically high significant.
1. Introduction and Questions
High tone therapy is a purposeful new development in the field of
electrotherapy.
It appears with the pretension to realise all effects known and
expected from the traditional low and middle frequency therapy
with higher efficacy. Including ranges of frequencies never used
until now and introducing the simultaneous modulation of
frequency and amplitude a completely novel method of
electrotherapy has been created. Important aspects of this
innovative creation were to optimise the therapeutically width and
to take more into account the very interesting non-stimulatory
effects.
Several clinical investigations published recently (2002, 2003
and 2004) in Poland confirm the expectations concerning the
efficiency of high tone therapy in various injuries and/or
diseases.
To understand correctly and completely the position
of the high tone therapy within the electrotherapy it
is required to be well acquainted with some terms of
the fields of physiology, related disciplines and
physical therapy.
However, neither all medical doctors nor all physical
therapists have been sufficiently educated during
their specific education's in both disciplines, or may
be they have forgotten some details.
Therefore I will try to repeat, to explain and to
comment some of the most important terms and
facts.
1.1. Terms:
1.1.1. The term “High tone therapy”
This term, abbreviated from “electrical high
tone frequency alternating field therapy”
was proposed by medical doctors just after
the introduction of the first generation of
high tone therapy units
1.1.2. High tone therapy
High tone therapy is a purposeful new development
in the field of electrotherapy, basing on the principles
of the electric differential therapy (HANSJÜRGENS
& MAY, 1990).
By means of simultaneous modulation of frequency and
amplitude (SimulFAM®),
either
a) along the threshold graph after it’s individual
determination (SimulFAMi) or
b) with crossing of this threshold graph with adjustable
crossing angles (SimulFAMx)
it is possible to generate alternatively either
a) selectively non-stimulatory effects or
b) non-stimulatory effects in combination with
stimulatory effects.
The modulation of frequency happens between two corner
frequencies, 212 Hz and 215 Hz.
The duration of one period of the “slow” threshold-adapted
modulation of frequency and amplitude, SimulFAMi, is 144 s
(2 min 24 s). Frequency and amplitude will be changed all
the time stepwise periodically in the same direction, either
both upstairs or both downstairs.
The frequency of the “fast” simultaneous modulation of
frequency and amplitude (SimulFAMx) can be varied
between 0,1 Hz and 200 Hz. In this case frequency and
amplitude can be changed periodically quickly either in the
opposite direction or in the same direction (upstairs or
downstairs).
Opposite changes lead to more or less brusque stimulation,
corresponding changes lead to softer stimulation
(paradoxical stimulation).
1.1.2.1. The aim of the development of the
high tone therapy
The aim of this development was, to intensify and to
combine already known effects of the especially well
tolerable currents, the so called middle frequency currents.
Moreover, the equipment should indicate not only the
current intensity (amperage) in mA as a singular
quantitative parameter of the applied electricity: Now
additionally will be indicated the voltage in V, the power in
mW, the impedance in W and the sum of the applied
electrical energy in mWh.
Until now no other electrotherapy equipment offers such
completeness of indication of important electric
parameters.
The most important fundamental facts for the purposeful
development of the high tone therapy equipment are
originated from the publications of the physiologists Martin
GILDEMEISTER (Straßburg, Leipzig), Friedrich SCHWARZ
(Leipzig, Posen, Jena), Oscar A. M. WYSS (Zürich), and of
a pioneer of physical medicine, Siegfried KOEPPEN (Halle,
Wolfsburg), furthermore from the electrotoxicological
investigations of GEDDES and co-workers (1969).
KOEPPEN already 1935 introduced the term
“Tonfrequenzströme”, English “tone frequency currents”,
GILDEMEISTER 1944 the term “Mittelfrequenzströme”,
English “middle frequency currents, defined as alternating
currents with frequencies between ca. 1000 Hz and 100
kHz .
Monographs of WYSS (1975) and of his pupil SENN (1980)
contain comprehensive descriptions of the history and the
peculiarities of the middle frequency currents.
However, the descriptions of the pain relieving effects of
unmodulated and modulated middle frequency currents are
incomplete. The possibilities to use either the blocking or
pseudo-blocking effects of unmodulated middle frequency
currents or the counter-irritation principle (GAMMON & STARR
1941), caused by the low frequency effects of modulated middle
frequency currents have not been mentioned. On the other
hand, just the pain relieving effect by means of unmodulated
middle frequency currents can be easily explained by the results
of neurophysiological investigations of WYSS and his pupils, for
instance the “reversible reactive partial depolarisation”, with
other words the “plateau effect” (KUMAZAWA & WYSS 1966).
These results, gained by means of intracellular recordings, could
be confirmed later by extracellular recordings (BOWMAN 1981).
The cited publications reveal
1.) that the local and systemic tolerability of
alternating currents above 50 Hz is increasing
with increasing frequencies and accordingly the
possibility of incoupling of electric power into the
body is increasing too with increasing frequencies
– without any local discomfort and without any
risks for the heart,
2.) that these currents, named “(high) tone
frequency currents” or “middle frequency
currents” have particular advantageous qualities
in comparison to the traditional low frequency
currents and direct current.
The frequency-correlated increase of the threshold of afferent
fibres of the sensory nervous system is also valid for the motor
fibres innervating the striated muscles (DALZIEL, 1941-1973), and
we can assume for the sympathetic fibres responsible for the
smooth muscles of the vasculature as well.
Originally, interferential therapy was introduced by Hans NEMEC
(1947/1950-1960) with the aim to make the stimulating
(stimulatory) effects of traditional electrotherapy more comfortable:
two unmodulated middle frequency currents with slightly different
frequencies should be superimposed within the tissue to generate
interferential beats, a special kind of amplitude modulation. The
low frequency of beat generation or amplitude modulation
respectively determines the frequency of the neuronal responses,
that means the frequency of action potentials. Therefore, the
differences between the two middle frequencies have to be within
the low frequency range, that means mostly between > 0 Hz and
100 Hz.
In comparison to the interferential therapy and later introduced
other modifications of middle frequency therapy for the
development of high tone therapy (MAY, 2002) higher
frequencies and greater frequency ranges are included:
Interferential therapy mostly is using middle frequencies
around 4000 Hz, in some equipment moderately higher
frequencies but below 10000 Hz.
However, the newest version of high tone therapy equipment,
more exactly “high tone power therapy” equipment, HiToP®, are
able to generate frequencies up to 215 Hz (32768 Hz), and
between 212 Hz (4096 Hz) and 215 Hz 73 different frequencies
are available.
In comparison to NEMEC’s interferential therapy the highest
frequency in HiToP® equipment is more than eight times higher,
and the range of frequency modulation is more than 286 times
higher: 28672 Hz in comparison to 100 Hz.
For therapeutic purposes mostly the mentioned 73
frequencies in logarithmic steps between 212 Hz and 215 Hz
are used. The factor is 2-24 corresponding a little bit less
than 1,03. Because of the great distance between the lower
and the upper corner frequency linear steps were not
suitable.
The “distances” between the neighbouring frequencies of
tones in our music are defined too as logarithmic steps. The
factor for the elevation in half tone steps is 2-12.
The decision for the term “high tone frequency therapy”,
abbreviated “high tone therapy”, derived from relations to
tones or music respectively, resulted from the following
considerations:
1.) The term “high tone frequency” is more concrete than “middle
frequency”. The high tone frequency range (~ 1000 - 20 000 Hz)
covers the low middle frequency range.
2.) The frequencies of the first generation of equipment varied in
the high tone frequency range only. The new generation, HiToP®,
includes even frequencies of the ultrasound range. Nevertheless,
the introduced term has not been changed besides in Poland;
there the term “energy tone therapy” is preferred.
Both terms are ingenious: “high” characterises the means, namely
the high tone frequencies as the agens for the possibility for an
easier application of more energy, “energy” this purpose itself.
3.) The distances between the frequency steps correspond to
distances of quarter tone steps in music.
4.)
By means of frequency scanning the probability of
resonance phenomena within structures of the treated
tissue should be increased. Resonance plays an important part in music too.
5.)
The new term should emphasise the great difference to
traditional middle frequency units.
6.)
It is possible and useful to explain the modes of action of
HiToP® by an loud-speaker. It facilitates the
understanding of the physical realisation of the various
“programs”, SimulFAMi and the variations of SimulFAMx
using modulation frequencies between 0.1 and 200 Hz.
The demonstration of hearing emphasises the relation to
tones and the absence of similarity to a “current” as a
great river.”
1.1.2.2. Main differences between traditional
electrotherapy and high tone power therapy (HiToP®)
1. Main differences in comparison to direct current (DC) and
low frequency currents with DC-components:
HiToP is without any risks of DC as chemical burning caused
by electrolysis.
Vasodilatation and acceleration of reabsorption of topically
applied substances in the treatment area, known as DCiontophoresis, can be achieved by HiToP too, but by other
mechanisms: vasodilatation via fatiguing stimulatory effects
upon sympathetic fibres, and the acceleration of resorption via
an electrochemical shaking effect resulting in facilitation of
diffusion.
2. Main differences in comparison to low frequency
currents:
HiToP has important advantages:
Great superiority concerning local and systemic tolerance,
very much greater spectrum of effects by additional
sophisticated utilisation of non-stimulatory effects.
3. Main differences in comparison to traditional middle
frequency equipment:
The most important difference or advantage respectively is
basing on the ability of HiToP to generate very much (up to
circa 50 times) more power without any discomfort or
systemic risks for the patient in comparison to traditional
middle frequency equipment. HiToP offers 5000 mW as
maximum output per channel; this limit of the output is
prescribed by law.
Additional advantageous differences:
The greater frequency range increases the probability of
resonance.
SimulFAMx, used for stimulation of nerves including
motor and sympathetic fibres, can be adjusted as more
brusque (“combined” or “parallel” stimulation) or more soft
(“paradoxical” stimulation) according the slope of the
graph representing the simultaneous modulation of
frequency and amplitude.
SimulFAMi can be used to minimise or avoid stimulatory
effects
Threshold current mA (eff)
Threshold graph of the current
sensation
Threshold curve
Frequency in Hz
Intensity
Intensität
Threshold Curve
lle
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hw
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Horizontal
stimulation.
Vertical
stimulation.
Threshold threshould
Sensation
curve as a function
beim
Menschen
of
frequency
in Abhängigkeit
der frequency
Frequency
Frequenz
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Threshold Curve
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Frequency
Threshold Curve
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Intensity
3 octaves in 72
steps of 1/4 tones
SimulFAM i
1 second each
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Balanced relation between the
phases above threshold and
below threshold
fmin
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Now Ifmax can be adjusted
via the modification knob
as x% of Ifmin.
Ifmax
fmin
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Intensität
Advantages of
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SimulFAM
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Now Ifmax can be adjusted
via the modification knob
as x% of Ifmin.
fmin
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Frequenz
Intensität
“Paradoxical” Stimulation via
®
lle
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SimulFAM X Schw
Now Ifmax can be adjusted
via the modification knob
as x% of Ifmin.
fmin
fmax
Frequenz
Intensität
“Paradoxical” Stimulation via
®
lle
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SimulFAM X Schw
Now Ifmax can be adjusted
via the modification knob
as x% of Ifmin until the
patient has the maximum
comfort
fmin
fmax
Frequenz
The recommended whole body treatment carried out
besides the topic application has not only general effects
upon the mood and the general condition of the patient;
moreover, the superposition of the alternating electric fields
of the general treatment and the topical treatment causes
periodical changes of the directions of the vectors of the
local electric fields responsible for the electrochemical
shaking effect. This kind of interference is used for the
support of non-stimulatory effects and not for the
generation of stimulatory effects, realised in traditional
interferential current units, invented by NEMEC.
HiToP allows the use of more than two electrodes per
channel. The purpose is to compensate the different
sensitivities of different body regions or to concentrate the
effects in particular areas respectively. Moreover, it is
possible to treat two different body regions in the same time
using only one channel
1.1.3. Electric differential therapy
Electric differential therapy (MAY & HANSJÜRGENS, 1988;
HANSJÜRGENS & MAY, 1990) can be considered
as a principle to classify currents used in electrotherapy and
as a principle to select the most suitable kind of current for the
pathological condition or symptom just to be treated.
For the selection of the best suitable current is decisive – like in
pharmacology – the best relation between efficacy and
tolerability, in other words: the therapeutic width.
1.1.4. Tolerance
We have to distinguish between local and systemic tolerance
for currents.
1.1.4.1. Local tolerance
The local tolerance is correlated with or described by
respectively
a) the value of the (“direct”) pain threshold,
b) the risk of chemical burning,
c) the risk of burning by heat,
d) the value of the (“indirect”) pain threshold caused by
intensive muscle contraction, measured as functions of
frequency and intensity,
for b and c additionally as functions of time.
1.1.4.2. Systemic tolerance
The systemic tolerance can be defined mainly by means of
the
a) the value of the threshold for ventricular fibrillation or
b) the value of the threshold for cardiac arrest.
In cases of current applications including head and brain
thresholds for undesired sensations and/or generalised
epileptic seizures are important.
In cases of treatments of the trunk with high current
intensities above the motor threshold the thresholds of the
muscles responsible for respiration are important.
1.1.5. Effects
The electric differential therapy distinguishes between
stimulatory and non-stimulatory effects.
1.1.5.1. Stimulatory effects
Stimulatory effects are caused by generation of action
potentials in excitable structures (nerves, muscles,
receptors). The frequency of the triggered action potentials
ranges between > 0 and – for very short periods – 1000 Hz,
defined in physiology and physical medicine as the “low
frequency range. The application of stimulatory effects can
be realised either according the functional imitation principle
or according the functional fatiguing principle, depending on
the values of the frequencies of stimulation in relation to the
fatiguing frequency of the just stimulated excitable structure.
1.1.5.1.1. Important frequencies for therapeutically
desired special effects, basing on well known physiological
investigations regarding the discharge behaviour of excitable
structures - usable as border line frequencies between the
functional imitation principle and the functional fatiguing principle
Efferent nerve fibres
Sympathetic nerve fibres
Lipolysis
3 Hz
This frequency of 3 Hz is not a border line frequency between
imitation and fatiguing frequencies. The lipolytic effect of a
stimulation of sympathetic nerve fibres innervating fatty tissue is
decreased in case of using higher frequencies than 3 Hz because of
the simultaneously increasing vasoconstriction (ROSELL, 1966).
Vasoconstriction
10 Hz
Motor nerve fibres
20 Hz
Afferent nerve fibres
100 Hz, however, not valid for
all groups of afferent fibres
1.1.5.1.1.1. instructions regarding the meaning of
the principles of functional imitation and
functional fatiguing related to the stimulation of
the mentioned groups of nerve fibres
The principle of imitation can be used therapeutically for all
of the mentioned groups, the principle of fatiguing mainly for
sympathetic fibres, in few cases for motor nerves as well.
To avoid undesired fatiguing effects during the initial phase of
a treatment in cases of applications of various (low)
modulation frequencies, please start every time with the
lowest frequency!
Stimulation of sympathetic nerve fibres:
Frequencies up to
3 Hz: activation of the lipolysis within the
innervated area
Frequencies up to 10 Hz: mainly vasoconstriction increasing with
frequency
reduced lipolysis caused by
vasoconstriction and product inhibition
Frequencies
for example
> 10 Hz,
100 Hz: vasodilatation after initial
vasoconstriction
Stimulation of motor nerve fibres:
Frequencies up to 20 Hz:
muscle exercise, re-education, strengthening with
individually designed and adjusted periods
consisting in phases of stimulation interrupted by
pauses.
Physiological tetanising frequency, i. e. maximum discharge
frequency in the efferent neurones of the motor units during
voluntarily initiated maximum isometric contraction
(HENNEMAN 1957; HENNEMAN et al. 1965; SOMJEN et al
1965; MILNER-BROWN et al. 1973; FREUND, BÜDINGEN &
DIETZ 1975; BÜDINGEN & FREUND 1976)
Frequencies > 20 Hz:
muscle relaxation caused by fatiguing stimulation
Stimulation of afferent (somato-sensory) nerve fibres:
This group of nerve fibres is not homogeneous.
Therefore a frequency limit valid for all fibres does not exist.
Furthermore, there is no indication for purposeful fatiguing
stimulation of this group of fibres.
Nevertheless, 100 Hz can be accepted as the most useful
frequency to cause central pain relief according the imitation
principle by means of counter-irritation.
1.1.5.2. Non-stimulatory effects
These effects are defined as effects caused independently from
the generation of action potentials.
1.1.5.2.1. Non-stimulatory effects at the physical and
chemical levels of efficacy
Such effects are for instance movements
of freely movable charged particles, ions as carriers of the
electrical currents,
of water molecules (dipoles) and
of charges fixed in molecules as constituents of the tissue.
Results of these primary effects are
facilitation and acceleration of diffusion, that means
equilibration of concentration differences, and
the enhancement of the ability of water to act as an solvent.
1.1.5.2.2.
Non-stimulatory effects at the
biochemical level of efficacy
1.1.5.2.2.1. Increase of the probability of “meetings” and
contacts between enzymes and substrates
Enzymes are biocatalysts.
The mediated biochemical reactions are in all cases
electrical events too,
facilitated by means of alternating electrical fields.
1.1.5.2.2.2. Conformation changes of signal molecules as a
a reason for the activation of the adenylatcyclase
In several papers changes of the intracellular formation of
cAMP (cyclic Adenosinemonophosphate, one of the most
important second messengers) caused by middle frequency
currents have been published (KORENSTEIN 1984;
BRIGHTON & TOWNSEND 1986; NOSZVAY-NAGY 19881994).
Beneficial influences upon the trophism of the tissues, antiasthmatic, generally activating and antidepressive effects within the therapeutic level of efficacy – could be explained by
this electro-biochemical effect.
1.1.5.2.3.
Non-stimulatory effects
at the neurophysiological level of efficacy
Intensities of unmodulated middle frequency currents
distinctly above the threshold cause
in nerves and muscles partial depolarisation,
in nerves correlated with a block,
in muscles additionally with a physiological contracture.
Below of these relatively high intensities a range of
intensities exists which is characterised by some
particularities:
1. The principle of apolar “stimulation” is valid:
Using two electrodes (of the same size) under both electrodes are
generated the same effects at the same time.
Anodic or cathodic effects do not exist.
2. The law of “Alles oder nichts” (everything or nothing) is not valid.
.With repetitions of tests of the thresholds the values increase.
3. There are no relations between the single phases of the middle
frequency current and the begin of the triggered action potentials.
4. Around the threshold single action potentials are triggered irregularly,
but this kind of ongoing activity disappears after a while
5. Intensities above the threshold trigger a “transient excitatory activity”,
abbreviated “tea”: immediately after the start of the establishment of the
alternating electrical field the firing rate has it’s highest values, followed
by decreasing discharge frequencies.
“Tea” is correlated at the psychophysical level of efficacy with a fading
tingling sensation.
“Tea” leads to fatigue of the involved excitable structures.
1.1.5.2.4.
Non-stimulatory effects at the therapeutic level
of efficacy
1.) Pain relief
a) symptomatic, immediate, transient
via distribution and thinning of mediators of pain and
inflammation
via blocking of afferent fibres involved in coding of pain
information
b) causal, longer lasting
by facilitation and/or activation of metabolic processes,
acceleration and abbreviation of healing processes
c) indirect
by anti-oedematous effects
via reversible physiological contractures
of the smooth muscles of the vessels including lymphatic
vessels
3.) Acceleration and abbreviation of healing processes,
which are not accompanied by pain (s. 1 b)
4.) Local anti-oedematous effects (explained under 1 c)
and diuretic effects
Results of the study of RHADES and SCHNEIDER
concerning low back pain
18 patients had been treated.
The range of motion could be improved by 5.3° (
statistically significant.
4.7°),
The distance of the fingers to the ground could be diminished by
3.7 cm ( 4.0) cm, (significant).
Pain relief after the end of the treatment series in 8 patients
(44%), later additionally in 3 patients (16.6%), together circa 60%.
Degree of pain relief:
Statistically high significant improvement from 6.25 (
3.44 ( 1.82) (NAS-Score).
1.73) to
Judgement of the efficiency
40%
30%
20%
10%
0%
very good
good
doctor
moderate
bad
patients
Fig.1 Judgement of the efficiency
Low back pain caused by problems of the lumbar part of the vertebral column
Mean value (°)
130
120
110
100
90
80
70
1st treatment
last treatment
bowing
follow-up examination
range of motion
Fig. 2 Effects upon bowing and range of motion
0. Summary
0.1. Background
In this presentation I will begin with the explanation of the
reasons for the decision for the development of a new
sophisticated method within the physical therapy, described as
„electrical high tone frequency alternating field therapy“,
abbreviated in German „Hochtontherapie“, in English „high
tone therapy“, in Polish „terapia energotonowa“, that means
„energy tone therapy“.
The new method has been realysed in Germany by gbo. The
result is the equipment HiToP® (High Tone Power Therapy).
The study of RHADES & SCHNEIDER were carried out to
examine the efficacy of HiToP® in patients with painful
conditions of the musculo-skeletal system.
0.2. Material and methods of the clinical study
In 48 patients 94 „organs“ or parts of the body respectively
had been treated, 9 vertebral columns in general, 18 patients
with low back pain, 12 shoulder- joints, 22 hip-joints and 33
knee-joints.
All patients received local and whole-body treatments
simultaneously.
All patients received10 treatments.
The duration of one treatment was one hour.
Parameters for the judgement were the scaled estimation of
pain, range of motion, measurements of circumferences and
results of joint-specific tests.
Measurements and judgements were carried out by the doctor
and/or the patients and statistically evaluated.
0.3 Results and valuation
The evidence for the efficacy of HiToP-treatments
can be exposed as in many cases
statistically high significant.
1. Introduction and Questions
High tone therapy is a purposeful new development in the field of
electrotherapy.
It appears with the pretension to realize all effects known and
expected from the traditional low and middle frequency therapy
with higher efficacy. Including ranges of frequencies never used
until
now
and
introducing
frequency
and
amplitude
electrotherapy
has
the
a
simultaneous
completely
been created.
modulation
novel
Important
method
aspects
of
of
of
this
innovative creation were to optimize the therape utical width and to
take
more into account the
very
interesting
non-stimulatory
effects.
Several clinical investigations published recently (2002, 2003 and
2004)
in
Poland
confirm
the
expectations
concerning
the
efficiency of high tone therapy in various injuries and/or diseases.
To understand correctly and completely the position
of the high tone therapy within the electrotherapy it
is required to be well acquainted with some terms of
the fields of physiology, related disciplines and
physical therapy. However, neither all medical
doctors nor all physical therapists have been
sufficiently educated during their specific education
in both disciplines, or may-be they have forgotten
some details. Therefore I will try to repeat, to explain
and to comment some of the most important terms
and facts.