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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 Orthopedist Königstraße 3-7 D -
32545 Bad Oeynhausen Prof. Dr. Berthold
Schneider Institut für Biometrie Institute for
Biometry Medizinische Hochschule Hannover Medical
University Carl-Neuberg-Straße 1 Hannover D -
30625 Hannover
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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 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.
4
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.
5
0.3 Results and valuation The evidence for
the efficacy of HiToP-treatments can be
exposed as in many cases
statistically high significant.
6
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.
7
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.
8
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
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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),eithera)
along the threshold graph after its 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.
10
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).
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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.
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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 .
13
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).
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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.
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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 gt 0 Hz and 100 Hz.
16
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 Interferent
ial 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
NEMECs 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.
17
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.
18
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.
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4.) By means of frequency scanning the
probability of resonance phenomena within
structures of the treated tissue should be
increased. Resonance plays an im- portant 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.
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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 DC-iontophoresis,
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.
21
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.

22
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
23
Threshold graph of the current sensation
Threshold current mA (eff)
Threshold curve
Frequency in Hz
24
Threshold Curve
Threshold
Intensity
Sensation threshould beim Menschen in
Abhängigkeit der frequency
Threshold curve as a function of frequency
Frequency
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
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Threshold CurveSimulFAM i
Intensity
SimulFAM
i
f
f
Frequency
min
max
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Threshold CurveSimulFAM i
3 octaves in 72 steps of 1/4 tones 1 second each
Intensity
SimulFAM
i
f
f
Frequency
min
max
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SimulFAM X
t
ä
t
i
s
n
e
t
n
I
SimulFAM X
f
f
Frequenz
max
min
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SimulFAM X
40
SimulFAM X
41
SimulFAM X
42
SimulFAM X
43
SimulFAM X
44
SimulFAM X
45
SimulFAM X
46
SimulFAM X
47
SimulFAM X
48
SimulFAM X
49
SimulFAM X
50
SimulFAM X
51
SimulFAM X
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SimulFAM X
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Advantages of SimulFAM X
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Advantages of SimulFAM X
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Advantages of SimulFAM X
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Advantages of SimulFAM X
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Advantages of SimulFAM X
Sensitive patient
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Advantages of SimulFAM X
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Advantages of SimulFAM X
Now Ifmax can be adjusted via the modification
knob as x of Ifmin.
Ifmax
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Advantages of SimulFAM X
Now Ifmax can be adjusted via the modification
knob as x of Ifmin.
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Paradoxical Stimulation via SimulFAM X
Now Ifmax can be adjusted via the modification
knob as x of Ifmin.
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Paradoxical Stimulation via SimulFAM X
Now Ifmax can be adjusted via the modification
knob as x of Ifmin until the patient has the
maximum comfort
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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
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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.
65
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.
66
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.
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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 gt 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.
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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
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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!
70
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 gt 10 Hz, for example
100 Hz vasodilatation after initial
vasoconstriction
71
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 gt 20 Hz muscle
relaxation caused by fatiguing stimulation
72
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.
73
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.
74
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.
75
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 1988-1994). Beneficial influences
upon the trophism of the tissues, anti-asthmatic,
generally activating and antidepressive effects -
within the therapeutic level of efficacy could
be explained by this electro-biochemical effect.

76
1.1.5.2.3. Non-stimulatory effects at the
neurophysiological level of efficacy
Intensities of unmodulated middle frequency
currents distinctly above the threshold causein
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
77
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 its 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.
78
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
informationb) 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
79
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
80
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 (? 4.7), statistically
significant. 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 reliefStatistically
high significant improvement from 6.25 (? 1.73)
to 3.44 (? 1.82) (NAS-Score).
81
Fig.1 Judgement of the efficiency
82
Fig. 2 Effects upon bowing and range of motion
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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.
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