JNM

J Neurogastroenterol Motil, Vol. 24 No. 1 January, 2018

pISSN: 2093-0879 eISSN: 2093-0887
https://doi.org/10.5056/jnm17071
Journal of Neurogastroenterology and Motility Review

Neuromodulation via Interferential Electrical

Stimulation as a Novel Therapy in Gastrointestinal
Motility Disorders

Judith S Moore,* Peter R Gibson and Rebecca E Burgell

Department of Gastroenterology, Central Clinical School, Monash University and Alfred Hospital, Melbourne, Victoria, Australia

The concept of therapeutic percutaneous neuromodulation has, until recently, been limited by the ability to penetrate deeply enough
to stimulate internal organs. By utilizing 2 medium frequency, slightly out of phase electrical currents passing diagonally through the
abdomen, a third, low frequency current is created at the point of bisection. This interferential current appears to stimulate nerve
fibers in the target organs and may have a therapeutic action. The aim of the study is to review the use of transcutaneous interferential
electrical stimulation with a focus on its application in gastroenterology, particularly in motility disorders. Studies involving use of
interferential current therapy were searched from Medline, PubMed, and Scopus databases, and articles pertaining to history, its
application and all those treating abdominal and gastrointestinal disorders were retrieved. Seventeen studies were identified, 13
involved children only. Eleven of these were randomised controlled trials (3 in adults). Four trials were from the one center, where each
paper reported on different outcomes such as soiling, defecation frequency, quality of life, and colon transit studies from the one pool
of children. All studies found statistically significant improvement in symptom reduction. However, weaknesses in study design were
apparent in some. In particular, finding an adequate placebo to interferential current therapy has been difficult. Interferential current
therapy shows potential as a novel, non-pharmacological and economical means of treating gastrointestinal dysfunction such as
constipation. More studies are needed particularly in the adult population. However, the design of a suitable placebo is challenging.
(J Neurogastroenterol Motil 2018;24:19-29)

Key Words
Constipation; Electrical stimulation; Gastroenterology

nantly treating pain, tremor, or spasticity. Its use has now grown and
neuromodulation has been employed in many novel applications
Introduction across cardiology, neurology, psychiatry, urology, and not least,
Since the discovery of electricity, it has been known that nerve gastroenterology. Given the proposed pathogenic mechanisms for
fibers can be stimulated by an electrical current.1 Electrical therapy functional gastrointestinal disorders (alteration of efferent or afferent
was first utilized in Europe for neurological stimulation in the 19th function of the enteric and extrinsic nervous system), neuromodula-
century and possibly earlier in the Orient. More recently, neuro- tion has increasingly gained traction for treating functional gastro-
modulation has been in use clinically for the last 20 years, predomi- intestinal symptoms resistant to conservative treatments. The best

Received: June 9, 2017 Revised: November 1, 2017 Accepted: December 2, 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work
is properly cited.
*Correspondence: Judith S Moore, RN MN
Department of Gastroenterology, Alfred Hospital, Level 6, The Alfred Centre, 99 Commercial Rd, Melbourne, Victoria 3004, Australia
Tel: +61-3-9903-0233, Fax: +61-3-9903-0556, E-mail: [email protected]

ⓒ 2018 The Korean Society of Neurogastroenterology and Motility

J Neurogastroenterol Motil, Vol. 24 No. 1 January, 2018
www.jnmjournal.org
19
Judith S Moore, et al

studied of these is the application of sacral neuromodulation (com- are needed to stimulated nerves, result in high skin resistance. To
monly known as sacral nerve stimulation) for fecal incontinence.2 overcome this, a higher current is needed, which can cause pain. In
Sacral nerve stimulation is delivered via a percutaneous transfo- contrast, high frequency currents results in low skin resistance and
raminal approach, with the electrical current delivered directly to the passes through without pain.15 Unfortunately, these currents are not
sacral nerve roots known to control the pelvic viscera.3 Sacral nerve suitable to stimulate nerves. Interferential current therapy hopes to
stimulation has been shown to reduce episodes of fecal incontinence overcome this dilemma. An interferential current is produced when
and improve quality of life.4 It has also been trialled as a treatment 2 medium-frequency alternating currents that are slightly out of
for constipation with less impressive outcomes.5 However, this phase are crossed.16 This new modulated current is believed to be
method is expensive and invasive, and requires surgical procedures produced at the site of bisection of the 2 diagonally opposed cur-
under general anesthetic.6 Given this, sacral nerve stimulation is rents by their interference with each other.17 The use of interferential
not recommended as a first-line management strategy. Other non- current therapy dates back to the 1950s where it was found that the
invasive and more economical neuromodulatory techniques have use of an interferential current overcame or bypassed skin imped-
thus been explored, such as pudendal nerve stimulation,7 posterior ance that is usually experienced with low frequency currents, but
tibial nerve stimulation,8,9 and magnetic stimulation of the sacral allowed the benefits of a low frequency current to occur due to the
nerves.10 This review will address the latest technique, transcutane- development of an amplitude-modulated current within the target
ous interferential current therapy. of interest.18,19
It has been demonstrated that an interferential current can
reach targeted deeper tissue if the target tissue lies on a diagonal
Search Method path between the circuits outside the electrode border.17 However,
A search of Medline, PubMed, and Scopus databases for in reality, interferential stimulation is likely more complex. Inter-
information on electrical interferential current and its applica- estingly, despite the growing popularity of interferential current
tion using search words such as “electrical interferential current,” therapy in various clinical settings, there have been few studies on
“transcutaneous,” “therapeutics or uses,” “mechanisms of action,” its efficacy or its dispersion through body tissues.
and “gastrointestinal” was performed. Articles that were available in The situation is further complicated by the fact there are 2 types
English were included. This review focuses on the use of transcuta- of interferential currents: the “true” interferential current that is
neous interferential current therapy in the treatment of gastrointesti- generated by the use of 4 electrodes and the “premodulated” inter-
nal symptoms. ferential current that is generated within a device that delivers the
currents and transmits via 2 electrodes only.17 As would be expect-
ed, the true interferential current as opposed to the premodulated
The Nature of Interferential interferential current had the greater voltage recording at depth,
Current Therapy showing superiority in efficiency of stimulation at deeper levels.17,20
Interferential current therapy has been used in a variety of set- With the “true” interferential current, the orientation and location
tings including low back pain11 and neurological disorders such of nerve fibers in relation to the electrodes affects whether the nerve
as carpal tunnel syndrome.12 More recently, interferential current fibers experience unmodulated or continuous, fully modulated, or
therapy has been found to be effective in small studies in managing partially modulated stimuli.21 Orientation of the fibers along a cur-
conditions such as fecal incontinence and constipation. It has the rent pathway results in zero modulation. More efficient modulation
benefit of being completely non-invasive, cost effective and conve- occurs in contrast, if fibers are oriented at the point of bisection of
nient, as it can be self-administered at home.13 the stimulation axes.20 How this translates to the stimulation of fre-
Despite increased convenience to the patient, doctor and payer, quently mobile intra-abdominal structures is unknown. “True” in-
the use of transcutaneously-delivered current can be problematic. terferential current therapy is believed to have its maximal stimula-
To stimulate the nerve of interest, the current has to pass through tion deep at the intersection of the 2 currents whereas premodulated
the skin and surrounding muscle to reach its target. This causes is thought to act superficially near the electrodes. Consequently, it is
resistance to flow, requiring the use of a higher current to achieve the “true” interferential current that is recommended for abdominal
the desired result. Skin impedance is inversely proportional to or deep tissue use.19
the frequency of the current.14 Low frequency currents, which A 4 kHz carrier frequency for the 2 currents has been found to

20 Journal of Neurogastroenterology and Motility

 Interferential Electrical Stimulation and the Gut

more effective than 8 or 10 kHz in producing a hypoalgesic effect stimulated production of endorphins or enkephalins and that the
in back pain, and it is this setting that is frequently used in a variety additive effect of tramadol triggered this response. However, these
of scenarios for interferential current therapy.19,22 At this frequency, theories have yet to be confirmed and indeed a placebo response has
it is claimed that there is better penetration through to deeper tissue not been adequately excluded.
while overcoming the problem of skin impedance. The placebo effect associated with the therapeutic alliance that
develops with some practitioners is frequently a confounder in as-
sessing the therapeutic effect of such an intervention. In a study of
Potential Actions of Interferential Current patients with chronic lower back pain, active and sham interferential
Therapy on Various Systems current therapy were compared in conjunction with either a limited
The mechanism of action of interferential current therapy (minimal interaction with the therapist administering the treatment)
in gastrointestinal disorders is not understood. Whether it is via or an enhanced therapeutic interaction with participants (active
stimulation of the interstitial cells of Cajal, of the pacemaker cells listening, demonstrating concerns) to examine the placebo effect.11
of the gut, or of the enteric or extrinsic autonomic nerves is still to The strongly positive response to active therapy with enhanced
be defined. However, as the given effects of stimulation are not im- interaction was encouraging however the greater benefit of sham
mediate and last for some months after stimulation had ceased, they interferential current therapy with enhanced interaction over the real
are more likely to be driven by alteration of neuronal function rather interferential current therapy and limited interaction was also en-
than by directly causing myogenic contractions.23 It is postulated lightening. Certainly, a powerful influence of the therapeutic alliance
that an interferential current may influence the neuroplasticity of was demonstrated11 and future studies of this technique must con-
the enteric nerves, inducing structural, intrinsic or synaptic changes sider the role of placebo. For instance, in a randomised controlled
leading to altered neuronal function. Certainly neuroplasticity has study of children with juvenile arthritis, half of the study group had
been associated with motility disturbances in inflammatory bowel combined interferential current therapy and resistive underwater
disease and irritable bowel syndrome.24 exercises where the other half, as the control group, received tra-
Interferential current causes increased propagating sequences ditional physical therapy alone and no underwater therapy.28 The
and increased colonic activity,23 but evidence has yet to be found to authors suggested that improvements in muscle strength and pain
determine the precise mechanism of action. One hypothesis is that reduction was due to interferential current therapy theorised to be
interferential stimulation exerts its effects via electrically stimulating due to its actions on the local blood supply and suppression of pain-
excitable cells such as the interstitial cells of Cajal, which produce inducing chemicals. However, there is no direct evidence of this and
slow wave activity in the bowel responsible for peristalsis, or that it it is entirely possible that the underwater therapy alone could have
directly stimulates the nerves of the enteric nervous system.22 Al- produced the same results; it was after all a novel therapy for these
ternatively, because the placement of electrodes is in close proximity children, water being both less painful in which to move and more
to the spinal cord, it is also suggested that its effects may be exerted fun. Hence, this positive outcome may also have been secondary to
directly to the spinal cord, influencing the autonomic (or extrinsic) the placebo response.
nervous system either through the afferent or efferent pathways. It Interferential current therapy has been tested against placebo
is feasible that, when used for bladder dysfunction, the sinusoidal in studies examining the pain response in healthy subjects29 where
current created by the interferential currents acted on the spinal interferential current therapy is known to significantly increase the
cord around T12-L1.25 pain threshold. It has been reported as a safe therapeutic option for
There is also the possibility that hormonal systems are affected a number of conditions with a variety of actions including analgesia,
to explain the lingering effects after treatment. Increased endog- vasodilatation, and anti-inflammatory and sympatholytic effects. In
enous levels of gamma-aminobutyric acid and opioid agonists may addition it may also stimulate circulation and promotes a decrease in
also be induced by interferential current stimulation promoting anti- interstitial edema as suggested by a study examining its use in carpal
spastic effects for a short time.26 This is supported by a case report tunnel syndrome.12,30 However, only 2 studies included robust ob-
of a patient taking concurrent tramadol who displayed the effects of jective measures such as electroneurophysiological indicators (sen-
opioid use such as drowsiness, decreased alertness and inability to sory nerve conduction velocity) in carpal tunnel syndrome,12 passive
concentrate for several hours after treatment by interferential cur- range of movement in hemiplegic shoulders,30 and improved bal-
rent therapy.27 It was hypothesized that interferential current therapy ance and gait in stroke victims.20

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Judith S Moore, et al

The application of interferential current therapy for urological Posterior

conditions has been studied in both adult and pediatric settings.31,32

B2
Several studies have explored the effects of interferential current A2

therapy on urodynamic measures and continence in children with

myelomeningocele and detrusor overactivity, and in non-neuro-
pathic underactive bladder. These studies showed normalization
of bladder function. Interestingly, in these studies it was noted that
diarrhea was a side effect sometimes being reported the day after
commencing therapy. It was this finding that led to interest in inter-
ferential current therapy as a treatment for bowel dysfunction.33
A1
Gastrointestinal Application B1

Anterior
Studies in children
Figure 1. Pathway of interferential currents showing the positioning
The majority of studies on the application of transcutaneous of electrodes on the abdomen and the creation of a third current at
interferential current therapy for constipation have arisen from point of bisection inside the abdomen.
Melbourne, Australia where several studies on children with slow-
transit constipation have been conducted.13 Chronic constipation
remains a difficult condition to treat and children refractory to tradi- lie in the normal range.13,33 Nuclear transit studies in some of these
tional treatments face surgical procedures such as appendicostomy same children showed an improvement in transit time. However,
or colectomy. those with concurrent upper gastrointestinal dysmotility did not re-
Results from the first pilot study on interferential current ther- spond as well to interferential current therapy compared with those
apy in children were published in 20059 with findings supporting a participants with slow transit colon and normal upper gastrointes-
“proof-of-concept” that neuromodulation via interferential therapy tinal motility.34 As a response gradually appeared over time rather
improved colonic function. Eight children with severe constipa- than instantly, it is possible that the improvement in colonic transit
tion, of whom 7 had significant soiling problems, were treated via a times and increased propagating sequences reflect induction in
physiotherapist. Three children had appendicostomies. The appli- changes to the neuronal circuits rather than causing direct contrac-
cation of interferential current therapy to the lower gastrointestinal tions of intestinal muscle during stimulation.33
tract was via placement of 2 electrodes on the abdomen lateral to Subsequent to these early studies, and with the advent of small,
the umbilicus and 2 on the back at the level of T9-L2. Leads were hand-held interferential devices (Fig. 2), parents and children could
connected from the right front to the left back and vice versa so that be taught how to use the device at home. As a result, studies with
the currents crossed (Fig. 1).13 Participants received between 9 and larger groups of children, randomized to a longer, more frequent
12 stimulation sessions over a 4-week period.9 Soiling disappeared placebo or real stimulation (such as an hour a day daily for 3 to 6
in the first 2 weeks after interferential current therapy in 6 of the 7, months) were conducted.35,36 Outcome measures over these differ-
although long-term effects were less impressive. Constipation was ent studies included soiling, defaecation frequency, urge to defae-
considered resolved in 7 of the 8 children. cate, quality of life and objective transit studies. Again there was a
The success of this pilot study led to other studies over the significant improvement in varying degrees to all, though quality
next few years with children randomised to receive actual or pla- of life indicators showed a modest, but statistically significant im-
cebo treatment. Three studies involving children from this larger provement as reported by the children, but not by their respective
randomized controlled study reported on different outcome mea- parents.37
sures. The effects of interferential current therapy on propagating There are some concerns with the quality of the single institu-
sequences was reported on a sub-group of 7 children who had an tion studies discussed above. The main concern is that the reporting
appendicostomy and were able to undergo 24-hour colonic manom- of different outcomes on the same group of children across several
etry. These children had an increase in the frequency of antegrade different studies creates an artificial impression that the number of
propagating contractions with manometric patterns improving to studies conducted is higher than it is, and it is difficult to tease out

22 Journal of Neurogastroenterology and Motility

 Interferential Electrical Stimulation and the Gut

A B

Figure 2. Position of electrodes on the abdomen and back with the hand held device for home stimulation. (A) Anterior electrodes: between costal
margin and umbilicus. (B) Posterior electrodes: paraspinal between T9-L2.

whether the overall outcome measures are met. affecting the pattern of current flow,19 the effects on the autonomic
Nevertheless, the technique has been investigated further nervous system overall or mediated via enteroenteric reflexes. In
in other centers with some success. Thirty Iranian children with children post-surgery for Hirschsprung disease, interferential treat-
neuronal bowel dysfunction from myelomeningocele participated ment plus behavioural therapy was more successful in normalizing
in a randomized controlled trial.38 Constipation, as determined by stool form, reducing incidences of fecal incontinence and increasing
stool form, decreased and the neurogenic bowel dysfunction scores frequency of defecation than behavioural therapy alone.41 Neverthe-
improved from ‘moderate’ to ‘mild’ in the interferential current less, success may well be attributed to the placebo effect. Use of the
therapy group. These results were noted at 6 months after receiving device with a sham current would be ideal, but a true sham stimula-
treatment with an overall improvement in 73% of the children in tion has yet to be described.
the interferential current therapy group. In this group, it was sug- Very little has been done in exploring the use of interferential
gested that the therapeutic action maybe more than just improved stimulation in the treatment of other gut dysmotility disorders in
colonic transit time, and it was postulated that pelvic floor muscle children. As discussed before, children with slow-transit constipa-
fibers may be strengthened or that there may be neuromodula- tion and normal upper gut transit responded to interferential cur-
tion of the sacral reflexes as seen in patients with urinary and fecal rent therapy, whereas those with concurrent upper gastrointestinal
incontinence.38 Anorectal manometric indices also improved with a dysmotility did not. More recently, delayed gastric emptying was
significant reduction in both sphincter pressure and the recto-anal improved in 2 children with delayed gastric emptying and consti-
inhibitory reflex, although it is not clear what the clinical signifi- pation associated with rectal or colonic distension rather than slow
cance of this is, as normal reference ranges are still debated.39 transit.45 Formal randomized controlled trials studies have yet to be
Two recent studies have explored the efficacy of interferential conducted.
stimulation in conditions related to anal sphincter function. One Concurrent bladder and bowel dysfunction in children im-
study hypothesized that placement of electrodes over the lower proved with additional interferential current therapy compared
abdomen and sacral nerves would better assist with outlet obstruc- to education, diaphragmatic breathing exercises and behavioural
tion or defecatory dysfunction. Intriguingly, not only was there an modification alone.42 This observation supports the notion that
increase in defecation frequency and reduction in fecal incontinence electrical stimulation enhances the function of both sympathetic
in the majority of children, but the 2 with delayed gastric emptying and parasympathetic nerve fibers including the sacral nerves, since
had a demonstrated decrease in gastric emptying time.40 This would bowel and bladder are similarly innervated.41
suggest an effect in an organ that lies outside the area of stimula-
tion. This may be because of the heterogeneity of biological tissue

Vol. 24, No. 1 January, 2018 (19-29) 23

Judith S Moore, et al

Studies in adults Unfortunately, neither study had physiological outcome measures,

A handful of studies have explored interferential current ther- but were restricted to symptom and quality of life scales. A strong
apy in adults with constipation, but there are no reports for gastro- placebo response was noted in both studies with no clear difference
paresis. In a French pilot study, 11 patients with proven slow transit between the significant improvements from baseline in the real
constipation used interferential current therapy at home for an hour or placebo arms.47 There was also a moderate participant dropout
a day for 3 months.43 Primary outcome measures were the number rate, possibly related to the exclusion of rescue medication. In addi-
of bowel motions a week and validated constipation questionnaires tion, each study was at risk of responder bias as the questionnaires
completed before and after the 3-month period. Colon transit stud- were administered by the study physiotherapists. Furthermore, the
ies were repeated at the end of the 3 months. Seven of the eleven method of applying the electrodes in a quadripolar method on the
significantly improved in all scores and there was a slight improve- back, rather than the abdomen and back for those with functional
ment in colonic transit times. Pre-stimulation, the majority had a dyspepsia, does not fit with the suggestion that the area for treat-
median number of stools per week of 0.33 or 0.66, and the highest ment should be on a diagonal path where the currents cross at
post-stimulation frequency was 1.66 stools per week. Though clini- right angles.19 In this study, their leads were all on the one plane,
cally significant, these results might be regarded as sub-optimal. which contrasts to previous reports of the transabdominal approach
In addition, as there was no control group, it is possible that the where 2 electrodes are on the abdomen and 2 on the back, and the
improvement could be attributed to the placebo effect, particularly currents cross diagonally through the abdomen.9,13 This may have
since the greatest improvement was in quality of life, a subjective affected the outcomes. As the results were presented as the number
outcome measure. As there was a quantitatively small, though sta- of patients who reported improvement, not as individual scores,
tistically significant, improvement in colonic transit time, it was sug- the overall effect size is not clear. A further recent study on the ap-
gested that parasympathetic nerve fibers were being stimulated.43 plication of transcutaneous electrical stimulation to the sacral nerves
It is noted that this group have a protocol published for a future for constipation also applied electrodes on the same plane but over
randomized control study44 to follow on from this preliminary study. the sacral region.49 It is entirely possible that their failure to achieve
The results will be awaited with interest. significant effects also related to the lack of intra-abdominal cross
The second study was a randomized control trial in 28 women currents. A summary of all studies on interferential current therapy
who met at least 2 of the 6 Rome II criteria for constipation.45 All and the gastrointestinal system are in the Table.
treatments were performed by a therapist for 20 minutes a day, 3
times a week for 4 weeks. The placebo intervention (n = 14) ap-
Discussion
peared to receive the same treatment as the therapeutic arm (n =
14) with the exception that the stimulator was not actually switched The majority of studies into interferential therapy for fecal in-
on (ie, they received no current). Overall, the average number of continence and constipation have been conducted at a single center
defecations per week improved from 3.7 to 5.6 in the treatment only and, while results from the Melbourne group appear as though
arm, but not in the placebo group. Stool form or the number of many children have been studied, a number of reports are from the
complete defecations per week was not captured.46 There tended same group of children.23,33,34 It is plausible that this could also be
to be greater improvement in the constipation assessment scale and the same for studies arising from Iran32,38 as it is unclear whether the
pain scores, which improved in both groups consistent with a place- same group of children were the subjects of at least 2 of the papers.
bo response. The authors do note the lack of objective measures as a There were some differences in study design such as home stimula-
limitation, as well as the small sample size.45 Another 2 studies were tion for some children or physiotherapist-administered stimulation
reported by a Turkish research group exploring the use of vacuum in hospital, or a variety of outcome measures. While this did not
interferential current therapy in both adults with irritable bowel appear to impact on results of the various studies, it is clear that an
syndrome or functional dyspepsia. Both were randomized, blinded, evolutionary pattern in the use of interferential current therapy in
placebo-controlled trials. Sham stimulation was the absence of any children is observed as it is becoming more accepted in practice.
current, but suction cups were placed according to the study design, Overall, it was noted that the benefits lasted from between 6 months
and still connected to the stimulating machine in the same way as and 2 years,50 and children who have since relapsed have gone on to
active therapy, but not switched on.47,48 In both studies, treatment continue home stimulation with ongoing benefit. A previous review
was administered by a physiotherapist 3 times a week for 4 weeks. of studies on children in Melbourne suggested that more placebo-

24 Journal of Neurogastroenterology and Motility

 Table. Studies on Interferential Current Therapy and the Gastrointestinal System

Author and year Study purpose Study design Participants Outcome measures Intervention, frequency, duration Results
Children
Chase et al,9 Effect on constipation Pilot study 8 children with slow Bowel diary pre, during, 1 and 3 Physiotherapist given IFC 3/wk, Soiling ceased, spontaneous
2005 and soiling open label transit constipation mo after – Soiling, number of for 3-4 wk defecation increased, need
washouts, medications for washouts ceased

Clarke et al,23 Effect on transit time Placebo 26 slow transit children Nuclear transit study pre, 2 Physiotherapist given IFC 3/wk Colon transit time significantly
2009 controlled of a larger study group months after RCT, and after for 4 wk, either placebo or real faster following real IFC.
RCT open phase stimulation. All received active No significant change in
IFC for further 4 wk placebo
Clarke et al,37 QOL after IFC Placebo 33 children QOL scores Physiotherapist given IFC 3/wk Child score improved after
2009 controlled Parent and child before, and 6 for 4 wk, either placebo or real real IFC but not placebo
RCT weeks after treatment stimulation No difference in parental score

Ismail et al,35 Viability of Pilot study 11 children who Bowel diary daily 1 mo prior and Home stimulation IFC 1 hr/day Significant increase in
2009 self-managed previously failed earlier after 2 mo of stimulation for 2 months defecation
home stimulation study
Leong et al,50 Long term effects Follow up 39 children Questionnaire via interview up to Physiotherapist given IFCa 3/wk 1/3 had improvement for
2011 from RCT 4.7 yr post for 4 wk, either placebo or real > 2 yr
stimulation
Yik et al,34 Effect in children Subgroup in 17 children in Nuclear transit study results as Physiotherapist given IFCa 3/wk Transit time did not improve
2011 with slow transit larger RCT prior study for other studies for 4 wk, either placebo or real in those with concurrent
constipation and stimulation upper gut dysfunction.

Vol. 24, No. 1 January, 2018 (19-29)

upper gut dysfunction
Yik et al,36 Home stimulation Prospective 32 children Bowel diary and Peds QLd ques- Home stimulation IFCa 1 h/d for > BMs week improved in
2012 trained by surgeon tionnaire before and during 3 to 6 months soiling but not bowel action
< 3 BM week improved in
defecation frequency
Clarke et al,33 Effect on propagating Prospective 8 children with 24 hr colonic manometry before Physiotherapist delivered IFC Significant increase in
2012 sequences pilot study appendix stomas and 2 months after 3/wk for 4 wk propagating sequences.
Half ceased washouts
Yik et al,52 Effect on Retrospective Children requiring Retrospective review of operation IFC stimulation as per other Appendicostomy rates dropped
2012 appendicostomy rates appendicostomy and medical records studies from 5.4 cases per year to 1.2
Kajbafzadeh Impact on neurogenic Placebo 30 children with Bowel diary and anorectal IFC and placebo groups 3/wk, Significant improvement in
et al,43 2012 bowel dysfunction in controlled myelomeningocele manometry before and 6 20 min session for 15 sessions symptoms, sphincter
myelomeningocele RCT months after therapy pressure and recto-anal
inhibitory reflex, with IFC.
Persisted in 53% for 6 mo
Interferential Electrical Stimulation and the Gut

25
26
Table. Continued

Author and year Study purpose Study design Participants Outcome measures Intervention, frequency, duration Results
45
Judith S Moore, et al

Yik et al, Home IFC in children Pilot study 10 children with Number of defecations, episodes Home IFC an hour a day for 90% children had increased
2016 with anorectal anorectal retention of fecal incontinence per week, 3 mo defecation frequency,
retention stool consistency, PedsQL4.0, decreased fecal incontinence,
gut transit improved QOL. No change
in transit rate.
Zivkovic Efficacy of IFC and RCT 70 children with Number of day and night time Group A: education + Significant improvement in
et al,42 2016 DBEf in children dysfunctional voiding urinary incontinence episodes; behavioural training + all outcome measures in
with bladder and and chronic UTIs, voiding and defecation IFC 20 min, 5/wk for 2 wk children in group A only,
bowel dysfunction constipation difficulties, defecations and fe- Group B: education + except for uroflowmetry
cal incontinence episodes per behavioural training + DBE where no indices changed in
week, uroflowmetry Group C: education + training any children
only
Ladi-Seyedian Effectiveness in chil- RCT 30 children with Number of defecations per week, IFC + behavioural therapy Constipation symptoms
et al,41 2017 dren with post-oper- constipation and fecal soiling, stool consistency, (n = 15) vs behavioural improved and frequency
ative Hirschsprung’s Hirschsprung’s with pain and constipation scores, therapy alone (n = 15). of defecation significantly
disease no post-operative anorectal manometry Treatment 2/wk for 15 sessions increased in the group with
complications IFC
Adults
Koklu et al,48 Effect in functional Placebo 44 adults functional Questionnaires given pre, dur- Physiotherapist applied vacuum Statistically significant
2010 dyspepsia controlled dyspepsia ing, at end of treatment & 1 mo IFC 3/wk for 4 wk improvement in symptoms
RCT after scores at both 2 and 4 wk
Coban et al,47 Impact on IBSh Placebo 58 adults with IBS IBS-GAI, VAS measuring pain, Physician applied vacuum IFC Improvement in both IFC and

Journal of Neurogastroenterology and Motility

2011 controlled bloating, gas, incomplete relief 3/wk for 4 wk placebo groups but at 1 mo
RCT after defecation, IBS-QOL on improvement remained in
at baseline, end of therapy, a IFC group only
month after
Queralto Home IFC in adults Pilot study 11 adults with Bowel diary, KESS, CCCS Home stimulation IFC 1 hr/day Significant improvement in
et al,43 2012 with constipation constipation GIQLI scores and colon transit for 3 mo bowel action, and scores
time before and after from questionnaires
Yang et al,45 Effect on slow transit Placebo con- 28 women with slow Number of defecations per week, IFCa 20 min/day, 3/wk for 4 wk Increased defecation rate in
2016 constipation in women trolled RCT transit constipation Constipation assessment scale, administered by therapist treatment group, decrease in
VAS abdominal pain in both groups
IFC, interferential current therapy; RCT, randomized control trial; QOL, quality of life; Peds QL, pediatric quality of life; BM, bowel motion; DBE, diaphragmatic breathing exercises; UTI, urinary tract in-
fection; IBS, irritable bowel syndrome; IBS-GAI, irritable bowel syndrome global assessment of improvement; VAS, visual analogue scale; KESS, Knowles-Eccersley-Scott symptom; CCCS, Cleveland clinical
constipation score; GIQLI, Gastrointestinal quality of life index.
 Interferential Electrical Stimulation and the Gut

controlled studies are needed.51 While this is true, it unfortunately < 33 mA in adults. The beat frequency sweep varied in pediatric
means that children in the placebo arm face the prospect of lack of studies from 80-120 Hz to 80-150 Hz.9,33,35
effective therapy for some time, which potentially impacts on their To date, no serious adverse effects have been described. The
future well-being from the social and developmental ramifications only reported side effect is diarrhea, which was the trigger for
of constipation and fecal incontinence.37 It may be, therefore, prefer- investigating its application in constipation in the first place.9
able to keep the placebo-controlled studies confined to adults. However, the effect of an electrical current on a developing fetus
The theory that interferential current therapy works by creating is unknown, and as such it is recommended that pregnancy or the
a third therapeutic current at the point of bisection is appealing in desire to conceive be a contraindication. It should also not be used
that it targets places that have previously been relatively inaccessible. in the presence of a cardiac pacemaker,44 as it may interfere with the
However, exactly what happens is hotly debated.18 The heterogene- programed therapeutic electrical activity. Neither should it be used
ity of skin, muscle and other tissue means an uneven resistance to in the presence of metal implants within the abdomen nor spine
electrical currents reducing the predictability of penetration of the because of a potential risk of thermal injury.30 Caution should be ap-
interferential current.19 Nevertheless, numerous studies have found plied.
it to have benefit with several studies using a placebo-controlled
group. This is difficult to accomplish as sham stimulation so far has
been applied via no current passing between electrodes with the par-
Conclusion
ticipant being told that the current is subsensory.23,38 This may con- There is speculative evidence that interferential current therapy
vince children, but is less likely to do so in adults. These studies also is a viable alternative in reducing symptoms of constipation and
required participants to come in to the clinic for treatment, which fecal incontinence. While preliminary data in children is encourag-
also makes it easier for an investigator to create a realistic sham sce- ing, more adult studies are needed, particularly placebo-controlled
nario, whereas more recent devices are small enough for patients to studies. Furthermore, an effective means of delivering a placebo
take home and use.36 This also has implications for a sham control current still needs to be identified, as comprehension on the exact
by this means. The moving of electrodes away from the therapeutic distribution and effects on deeper tissue is still limited.19 Neverthe-
target and non-crossing of currents have been suggested as possible less interferential stimulation is an attractive therapy for chronic
sham, but, as the actual predictability of current behaviour in hu- gastrointestinal disorders as it appears effective, is relatively low cost,
man tissue is still unknown, it is possible some therapeutic benefit and is a non-invasive and non-pharmacological intervention.13
may occur.
Determining an appropriate sham is difficult as the exact
mechanism of action of interferential current therapy is not known. Financial support: None.
However, the fact propagating sequences increased in a small group Conflicts of interest: None.
of children after treatment does suggest it may impact on the enteric
nervous system potentially affecting overall neuronal health.37 This Author contributions: Judith S Moore wrote the manuscript;
theory was postulated by the fact that effects took some time to de- and Peter R Gibson and Rebecca E Burgell were involved in the
velop, and lasted long after therapy had been ceased. As mentioned revision and approval of its final form for publication.
earlier, it is possible interferential current therapy stimulates motor
and sensory spinal nerves, and/or the parasympathetic and sympa-
thetic nerves, the interstitial cells of Cajal and/or other enteric nerves
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