The Textbook of the American Academy of Pain Management
Daniel L. Kirsch, Ph.D.
Fred N. Lerner, Ph.D.

Sciences rarely evolve scientifically. At this junction in history economics play the major role in determining priorities. The pure pursuit of scientific knowledge has practically been abandoned from the list of factors influencing funding and reimbursement for scientific advancements. Science, and the scientific method, originally evolved to help us understand ourselves and the universe we live in. For government and insurance company bureaucrats who are not true scientists themselves, it has become an excuse to avoid bothering to understand new developments; even to deny obviously observable phenomena. Yet eventually science does seem to prevail, even if only by a complex and seemingly unrelated series of events. Experimental and experiential data in electromedicine is already accelerating independent of, and even in defiance of the standard means of support and controls. Perhaps more than any other therapeutic option, electromedicine is used by at least some of the practitioners from all of the health care professions, as well as by patients themselves.

A recent study examined the prevalence of so-called "unconventional medicine" in the United States. Eisenberg (1993) reported that Americans spent $13.7 billion for alternative treatments in 1990 of which $10.3 billion was out-of-pocket, non-reimbursable expenditures. This is comparable to the $12.8 billion spent out-of-pocket annually for hospital expenses. In addition, the study determined that in 1990 Americans made an estimated 425 million visits to these practitioners of unconventional medicine compared to 388 million visits to all primary care physicians.

One definition of conventional is "conforming to accepted standards." Another definition is "established by accepted usage; ordinary or usual" (Stein, 1980). The latter definition could be interpreted to mean that what is being called unconventional medicine has become conventional. This seems to be confirmed by the 37 million more visits to these practitioners. It is unlikely that patients would continue to spend their time along with such large sums of money if they were not getting results, or if safe and effective relief was more readily available in the more comprehensive context of conventional medicine.

Harvard Medical School is beginning to teach "alternative medicine" and the National Institutes of Health has set up an Office of Alternative Medicine to award grants to researchers in this emerging field. Many patients site the side-effects and short-term relief of drug therapy as the primary reason they seek alternative care. New developments in electromedical technology offers physicians safe, effective, and long-lasting treatment options for a wide variety of disorders for these patients. Unfortunately, most conventional physicians are slow to accept new developments.

It is ironic that change moves slowest in the one science most responsible for our very existence, biology, or more appropriately for our purposes; medicine as applied biological science. It is simply easier, safer and less time consuming for someone who struggled to become part of the status quo to maintain it. It is certainly a major shock to one's conception of reality to learn that it is incomplete or incorrect. Yet physiology was taught as a complete science 100 years ago, again today, and most likely it shall be taught that way 100 years from now.

A classic and often cited example of medicine's reluctance to change occurred last century when Lord Joseph Lister advised surgeons to wash their hands before operating (Lister, 1979). Even well after Louis Pasteur's discovery of bacteria, surgeons were still not willing to believe and accept the need to be clean into the early part of this century (Lyons & Petrucelli, 1987). In fact, Pasteur could have been considered an unconventional practitioner when he insisted surgeons wash their hands before operating on his daughter. The Johnson brothers were the real driving force behind the widespread use of sterilization which resulted from their starting a company to manufacture antiseptic bandages. It was only after industry took the initiative that doctors came to accept the reality and consequences of our microbacterial cohabitants.

Dr. Lawrence D. Wilson (1993) suggested that "drug medicine" is able to maintain a virtual monopoly in America due to the following reasons:

On August 31, 1993, the U.S. Food and Drug Administration published a proposed ruling in the Federal Register for reclassification of cranial electrotherapy stimulators. The FDA exhibited extreme bias in their appraisal against this effective and harmless modality. Unless the CES industry can quickly raise millions of dollars for pre-market approval for a technology that has been on the market in the U.S. for well over 20 years, CES will no longer be available in the United States 90 days after the FDA publishes their final ruling.

The FDA and American drug medicine are not as opposed to diagnostic developments in electromedicine due to of several factors. Bentall (1990) reasoned that diagnostic technology is more easily introduced because it enhances the capability and reputation of the practitioner within an acceptable risk/reward equation, without jeopardy or the need to understand its physics. Electromedical imaging systems succeeds on its instantaneous merits. Electrocardiology, electroencephalography, electromyography and magnetic resonance imaging are just a few examples of relatively recent innovations that have dramatically improved the abilities of health practitioners to arrive at more precise diagnoses. However, allopathic practitioners would like to have the physiology of therapy explained within the satisfaction of their domain of chemical knowledge, rather than venture into a new physiological paradigm.

Within the framework of the established and acceptable therapeutic practice based on chemistry, it does not seem so urgent to understand the physiology of new developments quite as clearly. For once one acknowledges the core philosophy, it is human nature to accept the whole concept, and with it, its newest additions. As a result, there is an ever increasing supply of new patented drugs.

Although the search for new pain controlling drugs continues, none appear to be much of an improvement over morphine, codeine, opium and heroin. The latter was hailed as a nonaddictive wonder drug in 1898 when the Bayer Co. of Germany named it from the German word "heroish" meaning powerful or heroic. Of course, heroin turned out to be three times more addictive than morphine and eventually banned as a therapeutic agent in the United States. Only about a decade ago Johnson & Johnson announced its breakthrough of a new drug that was to have been stronger than morphine and no more addictive than aspirin. Unfortunately their product, Zomax, turned out to be fatal in an unacceptable number of users.

The pain, or at least concern about the pain is relieved with drugs, but there are the concerns of side-effects, addiction and worse of all, tolerance. Binding sites being what they are, systemic pharmaceutical solutions do not seem very promising for the long term management of chronic pain.

Chemistry, both physiological and for therapeutic intervention, can be viewed as the existence of matter at the level of elements or compounds. Electromedicine is a means of diagnosis and treatment at the next level of matter. For every thought and action creates, or is created by electrical signals along the fibers of the nervous system.

A fresh look at physiology is needed to solve the primary medical complaint of pain. Although "fresh" is only appropriate to those who are uninformed of the plethora of information on electromedicine amassed over the last three or four decades. The answer is apparent on a smaller scale than we were able to define previously. In fact, even today, subatomic structure goes beyond the eyes fully assisted ability to squint.

Atoms are bonded electrically. This is a basic foundation necessary to understand electromedicine that was taught during the most elementary training in the basic sciences. Further in our rudimentary training we learned that there are voltage potentials across the membrane of all cells. All standard physiology textbooks define the Nernst and Goldman Equations to determine membrane and action potentials. They do not, however, speculate on the staggering significance of these facts.

If batteries are placed in series their voltage potentials are combined. A simple remote control unit may use three 1.5 volt batteries to produce the 4.5 volts needed to operate a television. The human body has trillions of cells each having a millivolt potential across their membranes. All good scientists should ask themselves why we find electricity so prevalent in biological systems.

It is already established that bioelectricity plays a major role in the control of all life's processes. Robert O. Becker, M.D. has spent more than 30 years attempting to determine how trillions of cells with hundreds of subtypes can function harmoniously in the form we call human. The result of that inquiry is a complete revolution in our previous concepts of biology (Becker, 1983).

Becker (1982) has reasoned that an electromagnetic field exists that controls all of life's processes. The original concept of such field effects can be traced back to ancient China. Traditional oriental medicine is based on the controlling power of ch'i or ki energy; a concept that predates electricity but appears to be analogous (Kirsch, 1978). Chiropractic also developed based on a similar observation termed innate intelligence by Daniel David Palmer in 1895 (Palmer, 1910). Indians use the term prana to represent the same concept. Allopathic practitioners are limited to a vague notion they call homeostasis.

In western civilization, the first documented use of electricity to manage pain was by the physician, Scribonius Largus, in 46 A.D. He claimed that just about everything headaches to gout could be cured by standing on a wet beach near an electric eel. Not surprisingly, attempts at producing pharmaceutical preparations from dead eels proved ineffective. In 1791, Luigi Galvani discovered that electrical impulses could cause muscle contraction. By 1800, Carlo Matteucci showed that injured tissue generates an electric current. The discovery of alternating current by Faraday in 1830 opened the door to the development of man-made devices as sources of electricity. Over 10,000 medical practitioners in the United States alone made use of electrotherapeutic modalities until publication of the 1910 Flexnor report which stated that there was no scientific basis for electromedicine at that time. Dr. Flexnor's report was sponsored by the American Medical Association so it is no wonder why it declared allopathic medicine superior.

Since then, arguably the greatest development in the field of electromedicine was when Becker (1981) electrically induced limb regeneration in frogs and rats as a model to study bioelectrical forces as a controlling morphogenetic field. Regeneration represents a return to embryonal control systems and cellular activities within a localized area. It can therefore be considered a more accessible and more observable form of morphogenesis. The complexity of instructions required to designate all of the details to recreate a finished extremity is impossible to transmit by previously understood biochemical processes alone.

Becker (1983) has proposed that a primitive direct current data transmission and control system exists in biological systems for the regulation of growth and healing. His studies of extraneuronal analog electrical morphogenetic fields have eliminated any rational arguments against the importance of bioelectricity for all the basic life processes. Becker has laid the groundwork for the medical professions to start to evolve towards a more reasonable integrated view of biology incorporating our understanding of both biochemistry and biophysics.

Bjrn Nordenstrm, M.D. (1983), former Chairman of the Nobel Assembly, has also proposed a model of bioelectrical control systems he calls Biologically Closed Electric Circuits. The principle is analogous to closed circuits in electronic technology. Nordenstrm's theory is that the mechanical blood circulation system is closely integrated morphologically and functionally with a bioelectrical system. Nordenstrm hypothesized that ionic and nonionic compounds interact in a way that makes selective distribution and modulation of energy possible throughout the body, even over long distances. The biological circuits are switched on by both the normal electrical activity of the organs and pathological changes, such as a tumor, injury or infection. Like Becker, Nordenstrm views bioelectricity as the primary catalyst of the healing process. Using the vascular interstitial system as an example, Nordenstrm postulated two branches of this system. The first branch, the intravascular system, proposes that walls of blood vessels act as insulators to carry energy, much like cables in a battery system. The electrical resistance of the walls of the veins and arteries is at least 200 times greater than the blood within. The intravascular plasma acts as a conductor, where ions such as sodium, calcium and chloride supply immediately available energy to the system, primarily by electrophoresis. Nordenstrm called these ions ionars. According to Nordenstrm, delayed available energy, or potential energy, is carried by blood cells which bind oxygen, as well as other chemicals such as glucose, neutral fat, nonpolar amino acids, etc. These are all noncharged packages of energy that arrive at specific sites and are released primarily by reduction/oxidation. Nordenstrm termed these ergonars.

The second branch addresses the interstitial system. The tissue matrix acts as an insulator while the interstitial fluid acts as a conductor. The main component that "closes" the system is the capillary membrane. These membranes act as junctions between the interstitial and vascular fluids allowing exchange of ionars and ergonars along gradients of electric potential. This theory represents a comprehensive attempt to relate anatomical components in terms of electromagnetic forces, rather than limiting them to their chemical interactions. Nordenstrm further theorized that similar closed circuit systems exist in urinary and gastrointestinal systems. Using electrical intervention, Dr. Bjrn Nordenstrm reversed terminal cancer in most of his patients as clinical proof of his theories. Several other researchers are presently attempting to relate organ parts as electronic components in terms of their electrophysical functions. The medical community has barely taken notice of these remarkable theories. Few practitioners are even aware of the works of Becker or Nordenstrm. At least Nordenstrm has experience with this. He pioneered a series of remarkable innovations in clinical radiology (including percutaneous needle biopsy) in the 1950s that were considered radical then, but are routinely employed by every major hospital in the world today.

Lack of education of the health care professional is the main stumbling block to acceptance of the theories and practice of electromedicine. The other problem is the wide variety of technologies available. At present, there are well over 100 different models of transcutaneous electrical nerve stimulators (TENS) devices in the marketplace and an increasing number of other electrical devices. Most health care practitioners who want to utilize such technology have received little or no background training in electrobiology or electrical technology. Hence when it comes to making an educated decision on what type of instrument to choose for a practice or a particular patient, practitioners are often overwhelmed when meeting an electromedical sales representative. Purchase decisions are frequently made based on lack of knowledge, misinformation, unsubstantiated claims, and worse of all, price.

The basic unit of energy is referred to as the electron. The term elektron came from the Greeks, from amber, a fossilized resin material. When amber is rubbed, it attracts non-metallic fibrous objects such as feathers and paper. In 1600, William Gilbert suggested that all such phenomena be called electrics and the word electricity was coined. Using sulfur and friction to generate electricity, Guericke found that it had several common properties with magnetic forces, such as repulsion/attraction, transference of properties and opposite poles. Faraday termed the positive pole the anode, meaning "upper route" and the cathode, or "lower route," the negative pole. It was first thought that electrons flowed from anode to cathode. This was later found to be opposite; electrons flow from negative to positive, or cathode to anode.

Fluid-based biological systems are conductive mediums. Blood, water and lymph all conduct electricity. Various ions, such as calcium, sodium and chlorides are molecules that carry current. When current is carried by ions, secondary effects of electrolysis occur. In this process, electricity breaks the conducting fluid down into its components. In the case of water, electricity breaks the H2O molecule down into its components of two hydrogen and one oxygen atom. This process occurs within all types of tissue (e.g., nerves, muscle, bone, etc.) throughout the body. Many interactions of this nature are highly complex and not yet thoroughly understood. Most neurotransmitters have been shown to be modified by electrical stimulation. Some are even considered to be frequency specific, but there is still a lot to learn before we can specify the effect of individual facets of a waveform.

Waves and Pulses
In fluids, such as water, the sinusoidal wave is the only basic waveform. However, with electrical technology, different shaped waveforms can be built. These are often referred to as square, rectangular, triangular, sawtooth, etc. In actuality, they are composed of thousands of waves known as harmonics. This collection of harmonics is called a pulse.

Frequencies and Pulse Repetition Rates
Pulses are measured in cycles, or frequencies moving through a medium per second. One cycle per second is also called a Hertz (Hz). In electrical devices, the pulses have their own frequencies. Just as the collection of harmonics is called a pulse, the total frequencies (built by the resonance of harmonic frequencies) is referred to as the pulse repetition rate (PRR). It is the speed at which the pulse moves. For example, a 1 Hz pulse will have harmonic frequencies that build the pulse ranging from 1 Hz to hundreds of thousands of Hz and beyond theoretically to infinity. This is often a source of confusion, not only among practitioners, but among manufacturers of devices as well. In engineering terms, the term "frequency" should only be used with a pure sine wave. In this one case, frequency is the same as the pulse repetition rate. With any other waveform (i.e., square, rectangular, triangular, etc.) there are an infinite number of harmonic frequencies generated in each pulse. The interplay of harmonics identify a musical instrument as a specific aural experience. While some people would prefer the sound of a specific note on a piano, others would rather hear the same note played on a violin. Although the note is the same in each case, the harmonics vary. The interplay of these harmonics in electromedicine are essential to the results of a given treatment. With this in mind, we can begin to understand why one electromedical device may work on one patient, yet provide poor results on another. If we could predict what harmonics each tissue needed at a given time, we could design devices that would provide more consistent results in pain management, healing and regulating biological processes. The body accepts frequencies and pulse repetition rates in a non-linear, differential manner. For example, low frequencies penetrate greater depths of tissue than high frequencies. Higher frequencies are auto-shielding; that is, they are limited in penetration because the resistance of tissue acts like a faraday cage, forming eddy-repulsion. This eddy current produces a back electromotive force and blocks the penetration. The reflection in any conductor (in this case the body) of input signals is a mirror-image of the opposite phase. The higher the frequency, the greater the rejection and shallower the penetration. Complex frequencies interact in the body causing a non-linear spread of current. A prime example of a non-linear electrical device is a diode. A diode conducts current of one polarity far greater than the opposite polarity. Most living tissue exhibits non-linear characteristics, functioning somewhat like diodes. With square and rectangular waves, a "shotgun" of thousands of frequencies occur simultaneously within each pulse, similar to buckshot scattering over a wide area. A sine wave resembles the rifle concept, where one "bullet" must strike a target accurately to be of use. Our present knowledge of electromedicine is not sufficient to determine the optimum frequency for a specific tissue response so the use of sine waves is not recommended.

Pulse Width
The length of time the pulse lasts is called the width. This is usually measured in microseconds. It may seem odd to measure a width in time intervals rather than millimeters or other measure of length, until one understands that pulse width really refers to the time the wave is active. This is important with respect to how a given tissue may be affected and is part of a hypothetical "window" of optimal electric stimulation. The body responds to the peak of electrical signals and to the number of electrons in that signal. The maximum charge per pulse is measured in microcoulombs and gives the total energy of each pulse. Using bullets as an analogy, we can see that a .22 bullet has less energy than a .45 bullet because it is lighter. The .22 might go faster, but with its increased energy, the .45 can knock down a bigger target. Consider each spike a bullet and the pulse width the energy carried by the bullet. In this case, the velocity of the bullet is the voltage, while the mass of the bullet is the energy, in

Biphasic Signals
Because ions dissociate by electrolysis in the presence of electrical current, living tissue can become polarized in a direct current field. This can be disastrous in neuronal tissue. Therefore, modern stimulators usually provide alternating or biphasic current. That is, current that reverses polarity each half cycle so that the electrolytes factor sum to zero. If the current continued to flow in the same direction, polarity stress could result in irreversible tissue damage. As an analogy, picture a group of soldiers marching across a bridge. Before they get to one side, an about face order is given and they return. Before they reach the opposite side, another about face order is given, and so on, so that they never actually reach a side. By going back and forth, biphasically, there is no net electron flow across the bridge and no soldiers are added or subtracted. They never get across the bridge to cause an irreversible balance in the status quo.

Since the first edition of this book a few engineers have commented that biphasic is incorrect and should be replaced with bipolar. Technically, this is true but the designation of biphasic has already become the usual and customary term in electromedicine, so we have maintained it.

Amperage, Voltage and Resistance
Electricity travels in a circuit. The number of electrons moving per unit of time is called amperage. This is a measure of the amount of current. Voltage is a measure of the pressure in the circuit. Resistance to the electron flow in the circuit is measured in Ohms. A classic analogy of this is a garden hose setup. The amount of water in the hose would correspond to the amperage. The water pressure would correspond to the voltage. The hose could only take so much water pressure at a given time. Any more pressure or water would be met by more resistance from the hose. This concept has been mathematically related by Ohm's law of E = IR, where E is the voltage, I is the current and R is the resistance. One can increase the current and decrease the voltage by decreasing resistance, just as more water could pass with a lower pressure through a fire hose instead of a garden hose. Similarly, more current can pass through a larger diameter wire or through a highly conductive metal such as copper. In both cases, the thicker wire and more conductive metal have lower resistance. In the case of a human body, resistance is determined by factors such as fluid content, general health, skin thickness, amount of oil on the skin, humidity in the air, etc. If a person has a higher resistance, less current will flow through. The voltage can be raised to maintain the desired level of current. The better electromedical devices deliver a constant current by self-adjusting the voltage as the skin resistance changes.

The correct form of electromedicine will have a profound and usually immediate effect on pain. Although caution is advised during pregnancy and electrical stimulation should not be used on patients with demand type cardiac pacemakers, there are no known significant adverse side effects to therapeutic electromedical technology.

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