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Physiotherapy and cardiac rhythm devices: a review of the current scope of practice

Geneviève C. Digby, Marguerite E. Daubney, Jim Baggs, Debra Campbell, Christopher S. Simpson, Damian P. Redfearn, F. James Brennan, Hoshiar Abdollah, Adrian Baranchuk
DOI: http://dx.doi.org/10.1093/europace/eup102 850-859 First published online: 2 May 2009

Abstract

Aims Several case reports have demonstrated negative interactions between various physiotherapy modalities and cardiac rhythm devices (CRD). Fear of these potential interactions may lead to suboptimal utilization of physiotherapy treatments in CRD patients. No prior review of available guidelines, or management strategies, on the interaction between physiotherapy modalities and CRD patients has been reported. To review existing guidelines regarding the use of physiotherapy modalities in patients with pacemakers and/or implantable cardioverter-defibrillators (ICDs). To retrospectively analyse CRD patient encounters at a local physiotherapy facility during a period of 2 years.

Methods and results A review of the literature regarding the potential interactions between physiotherapy modalities and CRDs was performed. Next, a 2 year retrospective analysis of patient encounters at a physiotherapy facility was conducted. In addition, seven international physiotherapy societies and four CRD manufacturers were surveyed with respect to recommendations regarding physiotherapy treatments in device patients. The local physiotherapy facility treated 25 patients with CRD (22 pacemaker and 3 ICD patients) for a total of 230 visits (9.2 visits/patient). Five patients received transcutaneous electrical nerve stimulation (TENS) and all 25 were administered additional treatment in the form of ultrasound (15), acupuncture (19), Laser (7), traction/manual therapy (12), exercise (8), education (18), taping (5), and/or moist heat (5). No complications occurred. Meanwhile, international societies and device manufacturers offered few specific or consistent recommendations.

Conclusion There are no specific international policies regarding the administration of physiotherapy modalities in CRD patients and, thus, there are no specific guidelines to be implemented at the local level. Review of the literature and of recommendations from CRD manufacturers suggests that TENS, Diathermy, and Interferential Electrical Current Therapy are best avoided in patients with CRDs. However, there is no consensus and it may be possible to safely deliver these modalities in a proper setting with device and patient monitoring. Although further research is required in this regard, active collaboration between physiotherapists and CRD clinic physicians should allow for the safe application of most physiotherapy modalities.

Introduction

The interactions between cardiac rhythm devices (CRD) and physical therapy procedures using sources of possible electromagnetic interference (EMI) have been reported for decades.13 Even so, the extent to which physical therapy procedures are safe in patients with CRD, namely permanent pacemakers and implantable cardioverter-defibrillators (ICDs), is still unclear. Given that these devices have been shown to prolong survival in well-defined patient populations47 and that implant rates are increasing, it is anticipated that an increasing number of CRD patients will be presenting to physiotherapy centres requiring treatment with physiotherapy modalities.

There is a concern that patients with CRD may be less likely to receive optimal care as a result of the preconception that some physical therapy modalities are potentially harmful to this patient population. Given the paucity of good data on safety, it is understandable that physiotherapists tend to adopt a conservative approach to decision making in this patient population,8 and this often leads to a decision to forego treatment in a patient who would otherwise be expected to derive benefit. In fact, it is not uncommon to see a patient with a pacemaker or ICD who may have benefited from electrical pain treatment or the use of another physiotherapy modality—but who has been denied this treatment on the basis of the fact that they have a CRD.9

In this paper, we review the current standards that exist at the local and international levels regarding the use of various physical therapy modalities in patients with pacemakers or ICDs. In order to assess safety issues and to develop recommendations, it is important to understand the indications for and the technical considerations of each modality, as well as to review the current evidence regarding potential interactions of the various treatment modalities with pacemakers or ICDs. Thus, we begin with a brief review of the literature regarding these potential interactions. Then, at the local level, we review the policy of care of a physiotherapy centre in a city of 150 000 inhabitants (Kingston, Ontario, Canada). Finally, at the international level, we investigate the standards that are used throughout the world, including the recommendations from cardiac device manufacturers and international physiotherapy societies.

Methods

Current standard of practice for patients with cardiac rhythm devices at a local physiotherapy facility

In order to assess the current standard of practice in a local physiotherapy centre, we conducted a retrospective analysis of all patient encounters that occurred within a 2 years period. The number of individual patients seen by this centre as well as the total number of patient encounters was recorded. A specific analysis was conducted on patients who presented with a CRD. All of these patients were analysed by retrospective chart review in order to determine the nature of the treatment recommended by the clinic staff and the clinical outcomes.

Recommendations from international physiotherapy societies

To assess the existing international policies and recommendations regarding the use of physiotherapy modalities in CRD patients, we contacted the national physiotherapy societies or associations governing physiotherapists in the English-speaking world, namely: the American Physical Therapy Association (APTA), the Australian Physiotherapy Association (APA), the Canadian Physiotherapy Association (CPA), the Chartered Society of Physiotherapists (CSP), and the Irish Society of Chartered Physiotherapists (ISCP). We also contacted the Ontario Physiotherapy Association (OPA) as well as the International Society of Education in Physiotherapy (ISEP) to obtain more local and international guidelines. Societies were initially contacted by email using addresses acquired from their websites. An inquiry was posed as to whether the society had implemented any policy or regulation regarding the administration of various physiotherapy modalities in patients with pacemakers or ICDs. If a response had not been obtained, a contact by telephone was attempted until all societies had been contacted.

Recommendations from cardiac rhythm device manufacturers

Cardiac rhythm device manufacturers were contacted to obtain their current international recommendations regarding the administration of various physical therapy modalities in patients implanted with their devices. The Canadian representative of each company was contacted by email (Medtronic, Boston Scientific, St Jude Medical and Sorin Group–ELA). Electronic copies of the manufacturer-specific recommendations were obtained from each company.

Commonly used physiotherapy modalities and documented interactions with cardiac rhythm devices

The following is a summary of the more frequently used physical therapy modalities and documented interactions between physical therapy modalities and CRD.

Acupuncture

Acupuncture involves the insertion of needles into the skin at specific points in order to relieve pain. This therapeutic modality is generally considered to have a low risk of interfering with pacemakers or ICDs because of the lack of electrical current being used.10 However, case reports suggest possible adverse reactions to acupuncture in patients with CRD. Apaloo11 reported a case of a patient with a pacemaker experiencing an episode of syncope during acupuncture treatment. Notably, this patient also experienced several episodes of syncope during electro-acupuncture treatment, which involves electrical stimulation of the acupuncture needles by various frequencies and voltages to provide a longer-lasting pain blocking effect. The author did not report abnormal findings on pacemaker interrogation.

Acupuncture-related syncope may have a different aetiological origin than pacemaker interference, given several reports of syncope during acupuncture in patients with no cardiac devices.12

Overall, it seems as though acupuncture may be a relatively benign treatment in CRD patients, but the extent to which adverse effects are likely to occur, especially in the case of electro-acupuncture, needs to be further investigated.

Diathermy

Diathermy refers to the deep heating of tissues by either ultrasound (US) or electrical means in order to relieve pain. Short-wave diathermy (SWD) specifically refers to the therapeutic application of radiofrequency electromagnetic radiation in order to achieve deep tissue heating.8 Treatment may be applied as either a continuous beam of energy (CSWD) or pulses of energy (PSWD). Because of the nature of this treatment, it is potentially dangerous to use it in patients with CRD. The generated heat can cause burning to surrounding tissues and damage the circuitry of the pacemaker, but also, the electromagnetic fields generated may directly interfere with the performance of the device.8

There is very little evidence-based literature that addresses the issue of potential interference between SWD and CRD. In fact, as pointed out by Shields et al.,8 electrotherapy textbooks provide only broad contraindications to SWD and the literature available is not sufficiently comprehensive to substantiate all the suggested contraindications to electrotherapeutic agents. The few studies that exist are largely outdated, and may no longer be applicable to modern CRD. One review13 noted interference in pacemakers due to CSWD application and found that patients wearing demand pacemakers were more vulnerable to interference than asynchronous ones. Valtonen et al.14 found that CSWD caused pacemaker output to decrease and pulse rate to increase. These induced changes were dependent on applied power, electrode-pacemaker distance, and orientation of the pacemaker and leads relative to the electrical field. Although the effects of SWD on pacemakers have been investigated in the laboratory, very little evidence exists regarding these interactions in the human body. Thus, in order to err on the side of caution, it has generally been accepted that SWD of any form should be contraindicated in patients with both dependent and non-dependent pacemakers.8 In our service, dependency is defined as an absence of intrinsic signals when the pacemaker is programmed at 40 b.p.m. Another study15 found no disruption in eight pacemaker patients being treated with SWD, a finding that was believed to reflect modern developments in pacemaker shielding. It has also been suggested that treatment of extremities in patients with pacemakers is permissible given the remoteness of the treatment site from the device.16 The review from Shields et al.8 compiles the contraindications as advocated by textbooks, published articles, and device manufacturers’ literature into a list to be used by physiotherapists in clinical practice. On the basis of the evidence listed above, they included pacemakers among their list of contraindicated devices. Implantable cardioverter-defibrillators are not specifically mentioned, but as the review contraindicates implanted metal devices as well, it is likely that ICDs would fall into the contraindicated category along with their pacing counterparts. In fact, even the US Food and Drug Association (FDA) has broadcasted a warning against the use of diathermy in a patient with any implanted metallic lead in the body, including cardiac pacemakers and implantable defibrillators, after two patients with implanted devices (neurostimulators) died as a result of diathermy treatment.17 Even so, Shields et al.8 point out that this is a complex and poorly evidenced area, and while limited (largely anecdotal) evidence is available, some of the information presented is deductive and therefore contraindications are typically based on consensus rather than evidence.

Interferential electrical current therapy

Interferential current therapy is a treatment to aid the relief of pain and promotion of soft-tissue healing. It is similar to a transcutaneous electrical nerve stimulation (TENS) unit, but provides deeper penetration and less patient discomfort. Case reports specifically relating to this form of treatment are not available, but deductive reasoning has led one device manufacturer (Medtronic) to advise that the electrical current applied to the body in this form of treatment may affect implanted devices.10

Light amplification stimulated emission of radiation

Light amplification stimulated emission of radiation (Laser) therapy is the application of red and near infra-red light to improve tissue healing and relieve pain. It has become a popular modality to treat musculoskeletal and skin disorders with an athermic effect and has been reported to have a substantial therapeutic role in rheumatoid arthritis, post-traumatic joint disorders and myofascial pain.18 However, little has been reported with regards to the safety of Laser therapy in patients with CRD. A review by Volkman et al.19 suggests that Laser application poses no risks to the pacemaker patient and that its relative safety is comparable to that of US, direct currents, thermotherapy, and phototherapy.

Manual therapy/traction

Manual therapy and traction involve the mobilization of the soft tissues and joints of the body in order to relieve pain and promote healing. No specific recommendations exist surrounding the safety of various massage therapy and traction procedures in patients with CRD. This is likely a result of the lack of electrical current being used and the lack of deep tissue heating involved in this form of physiotherapy—a putative mechanism for device interference has not been postulated.

Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation is a commonly used treatment for the relief of acute and chronic musculoskeletal pain. It involves placing electrodes on the skin, through which TENS is applied at varying frequencies, intensities, and pulse durations of stimulation in order to maximize pain relief.20 Pinski and Trohman21 reviewed the evidence indicating adverse interactions between TENS and CRD. They concluded that TENS could be used safely in patients with modern implanted bipolar pacemakers and in patients with unipolar pacemakers if sensitivity were reduced. Eriksson et al.1 reported inhibition by TENS in four patients with non-programmable unipolar pacemakers, whereas other studies found that inhibition by a TENS machine could be eliminated by making the pacing device less sensitive.22 However, the risk associated with reducing the sensitivity of the device is that if the native signals are smaller than the EMI signals, this may predispose to undersensing and competition with the intrinsic rhythm. Meanwhile, other authors have been unable to confirm the observation that TENS may lead to interference of pacing devices; they found no interference, inhibition, or automatic reprogramming.2

Despite several cases demonstrating EMI between TENS and pacemakers, fewer cases have been reported on the interactions between TENS and ICDs. One report describes a patient in whom a TENS unit created an electrical artefact that was interpreted by a transvenous ICD as ventricular fibrillation, leading to spurious shock treatment.23 A safety study24 showed that neuromuscular electrical stimulation could cause EMI leading to interference in atrial and ventricular sensing or intermittent ventricular undersensing due to post-sense blanking. Although EMI did not trigger an inappropriate ICD therapy in this study, interference was seen when stimulation was applied close to the ICD and during leg muscle therapy, regardless of interelectrode spacing or sensing mode. The authors suggested that not only could EMI affect ventricular pacemaker or ICD tachycardia detection algorithms, but could also trigger atrial mode switch episodes or inappropriate atrial therapies. Siu et al.25 published another case in which TENS therapy applied to the mid-back resulted in two consecutive shocks to a patient with an ICD. The shocks were attributed to EMI simulating a series of low-voltage-ventricular signals that were interpreted as ventricular fibrillation, resulting in shock delivery. Several other cases have confirmed interference of ICD function with TENS treatment, including interference with pacemaker function in patients with biventricular ICDs,26 as well as several cases of inappropriate shocks with exposure to TENS.27

More recently, a study on EMI in 30 patients with ICDs was conducted.9 In this study, it was found that TENS produced EMI triggering inappropriate detection of VT/VF. Interference was found more frequently in systems with integrated vs. dedicated bipolar leads. Interference was also more likely to occur when TENS treatment occurred at the mammilla than at the hip, and at a frequency of 80 Hz as opposed to 2 Hz. Because of the potentially serious consequences of interference, they concluded that TENS should not be recommended for patients with ICDs.

Transcutaneous electrical nerve stimulation is perhaps the best-studied physiotherapy modality in terms of its interactions with CRD. Nonetheless, the clinical evidence is limited and, consequently, the medical community acts conservatively by contraindicating the use of this device in CRD patients. Overall, the risk of TENS interference seems to be lower when electrode placement is further away from the device and when a lower frequency is used. Perhaps under such situations of controlled distance and frequency, and by sub-selecting populations with lower risk—such as bipolar systems in non-dependent patients—TENS may be safe enough to be used. Finally, one could perhaps envision the delivery of TENS in a monitored setting, with ICD therapies temporarily turned off, to facilitate the treatment required.

Ultrasound

Ultrasound therapy uses high-energy sound waves to help relieve musculoskeletal pain. Although no evidence-based literature specifically refers to the safety of US therapy in patients with CRD, the manufacturers of these devices report few EMI concerns in this regard. Medtronic suggests maintaining a distance of 15 cm (5.9 in.) between the US transducer head and the implanted device to minimize mechanical damage to internal circuitry of pacemaker or ICD.10

Results

Current standard of practice regarding patients with cardiac rhythm devices at a local physiotherapy facility

The retrospective data collected from the local physiotherapy facility analysed all patient encounters that occurred within the 2 years period from 1 June 2006 to 1 June 2008. During this time period, 2780 patients presented to this physiotherapy centre a total of 31 918 times, with an average number of patient visits of 11.5 (range 1–27). Of these patients, 25 had an implanted CRD and accounted for 230 of the visits to this clinic, (average of 9.2 visits per patient). The patients with implanted devices included 22 patients with pacemakers and 3 patients with ICD (single chamber 13 patients, dual chamber 10 patients, biventricular 2 patients).

Of the 25 device patients, five presented on two separate occasions for treatment of different clinical problems. Thus, there were a total of 30 occasions in which a CRD patient presented to the physiotherapy clinic for treatment. None of the patients that presented to the physiotherapy clinic with a CRD were denied care. In five cases (occurring in five different patients), TENS was administered despite the presence of a CRD. Alternative forms of treatment commonly believed to be associated with a lower risk of interference with CRD were administered to the remaining 25 cases, as well as to the five patients receiving TENS therapy. This care occurred in the form of US (15 cases), acupuncture (19 cases), Laser (7 cases), traction or manual therapy (12 cases), exercise (8 cases), education (18 cases), taping (5 cases), or moist heat (5 cases). The body parts being treated in all the CRD patients included lower back (18), neck (8), shoulder (4), hip (4), arm/hand (2), leg/foot (5), or other (2). With regards to the five patients who received TENS therapy, the body parts being treatment included lower back (1), neck (1), arm/hand (1), and leg/foot (2). In one of the 30 CRD patient cases, the Arrhythmia Service at the local tertiary care centre was consulted regarding the care of the patient. The consult occurred to discuss the relative safety of administering TENS to the patient which was later applied with no adverse outcome.

Recommendations from international physiotherapy societies

The responses acquired from surveying the designated international physiotherapy societies and associations are summarized in Table 1. The majority of these societies had no specific recommendations regarding the use of various physiotherapy modalities in patients with CRD. The APA as well as the International Society of Educators in Physiotherapy, based out of Australia, both referred us to the Guidelines for the Clinical Use of Electrophysical Agents as developed by Robertson et al.28 in 2001 for the APA. This document states that the provided guidelines err on the conservative side and that some historically accepted contraindications and precautions are repeated due to the absence of adequate research findings to exclude them. These guidelines suggest that deep heating in the form of SWD should be contraindicated in patients with inbuilt stimulators (such as pacemakers) within 3 m of the device, whereas microwave diathermy and US therapy (with or without heat) should be contraindicated directly over the pulse generator device. The use of electrical stimulators (e.g. TENS) with transthoracic application or long duration direct current is also contraindicated. No precautions are listed for Laser therapy or for superficial heating in the form of infra-red or moist heat.

View this table:
Table 1

Summary of international physiotherapy societies recommendations

SocietyRecommendation
APTA (American Physical Therapy Association)aNo comment
APA (Australian Physiotherapy Association)Refer to Robertson et al.28
• Deep heating: SWD C/I within 3 m of inbuilt pulse generator (e.g. pacemaker); MW and US C/I over pulse generator
• Superficial heating or cold: no C/I
• EStims (electrical stimulation e.g. TENS)—C/I over stimulator
• US (no/low heat)—C/I over pulse generator
• UV/Laser—no C/I
CPA (Canadian Physiotherapy Association)bNo specific recommendations are implemented. A document is in preparation at the time of writing.
OPA (Ontario Physiotherapy Association)cNo specific recommendations are implemented.
International Society of Educators in Physiotherapy (Australia)Refer to Robertson et al.28
Chartered Society of Physiotherapists (UK)dNo comment
Irish Society of Chartered PhysiotherapistseNo comment
  • C/I, contraindicated; SWD, short-wave diathermy; MW, microwave diathermy; US, ultrasound.

  • a800/999-APTA (2782) (personal communication, 3 July 2008).

  • binformation{at}physiotherapy.ca (personal communication, 30 June 2008).

  • cphysiomail{at}opa.on.ca (personal communication, 30 June 2008).

  • denquiries{at}csp.org.uk (personal communication 02 July 2008, 24 July 2008), sarah.bazin{at}heartofengland.nhs.uk (personal communication, 29 July 2008), +44 (0)20 7306 6666 (personal communication, 29 July 2008).

  • ek.cradock{at}st-vincents.ie (personal communications, 2 July 2008, 9 July 2008, and 24 July 2008).

Recommendations from cardiac rhythm device manufacturers

Electronic copies of recommendations regarding the use of physical therapy modalities in patients with CRD were obtained from four CRD manufacturers. These data are summarized in Table 2. The following physical therapy modalities are reported to be associated with a risk of affecting implanted pacemaker or ICD function and are advised against being administered to patients with CRD by the device manufacturers listed in parentheses: Interferential Electrical Current Therapy (Medtronic),10 Microcurrent Electrical Therapy (Medtronic),10 TENS (Medtronic, Guidant–Boston Scientific, St Jude Medical)10 (Hospital EMI and the Pacemaker/Implantable Cardioverter Defibrillator (ICD) Patient, personal communication; Diathermy Warning from User’s Manual & TENS Therapy and ICD, personal communication), Diathermy (Guidant–Boston Scientific, St Jude Medical, Sorin Group–ELA) (Hospital EMI and the Pacemaker/Implantable Cardioverter Defibrillator (ICD) Patient, personal communication; Diathermy Warning from User’s Manual & TENS Therapy and ICD, personal communication; Sorin Group, personal communication), Ultrasound (Sorin Group–ELA) (Sorin Group, personal communication). The following physical therapy modalities are reported to have a low risk of interfering with CRD by the manufacturers listed in parentheses: Acupuncture (Medtronic),10 Magnetic Therapy (Medtronic),10 Pulse Radiation Therapy (Medtronic),10 Ultrasound (Medtronic, Guidant–Boston Scientific)10 (Hospital EMI and the Pacemaker/Implantable Cardioverter Defibrillator (ICD) Patient, personal communication), as well as TENS (Sorin Group–ELA) (Sorin Group, personal communication).

View this table:
Table 2

Cardiac rhythm device manufacturers’ recommendations for use of physical therapy modalities in cardiac rhythm device patients

Physical therapy modalityRecommendations
Medtronic10
Acupuncture—no electrical stimulusLow risk of affecting pacemaker or ICD
Interferential Electrical Current TherapyPotential pacemaker reversion or magnet rate
Potential ICD shock
Recommend magnet application for ICD and pacemakers
Magnetic TherapyLow risk when following safety precautions
Potential pacemaker reversion or magnet rate
Potential disable of ICD detection circuit
Maintain a 6 in. (15 cm) distance between all therapy magnets and an implanted device
MET (Microcurrent Electrical Therapy) Alpha-Stim 100®Potential pacemaker reversion or magnet rate
Potential pacemaker inhibition
Potential ICD shock
Pulse Radiation TherapyLow risk when following safety precautions
Potential pacemaker reversion or magnet rate
Potential pacemaker inhibition
Potential ICD shock
Magnet application recommended for pacemaker and ICD. Nerve ablation can damage pacemaker and ICD circuitry, if it is administered within 6 in. (15 cm) of the device. If the ablation is farther than 6 in. (15 cm), there is the potential for pacemaker reversion or ICD shock.
TENS Unit (Transcutaneous Electrical Nerve Stimulation)Potential pacemaker reversion or magnet rate
Potential pacemaker inhibition
Potential ICD shock
There is a lower risk of the pacemaker or ICD detecting TENS when used on extremities
Ultrasound diagnostics/therapeuticsLow risk when following safety precautions
Maintain a 6 in. (15 cm) distance between the transducer head and the implanted device
Guidant–Boston Scientific28
DiathermyDirect current interference
Possible inhibition of pacing or asynchronous pacing
Possible device reset
Risk of inappropriate shock
Possible device damage due to heating effects
Recommendations: temporarily deactivate ICD, no direct contact, monitor patient and watch for interactions, confirm normal device operation and programmed parameters
TENS (Trancutaneous electrical nerve stimulation)Direct current interference
Possible inhibition of pacing or asynchronous pacing
Risk of inappropriate shock
Generally contraindicated for patients
Recommendations: place TENS electrodes as close together as possible, place TENS electrodes as far from device/lead system as possible, test TENS settings in clinic before home use (test at maximum output and high/low frequencies, use lowest clinically effective setting, instruct patient not to change any settings)
UltrasoundNo EMI concerns
St. Jude Medical (Hospital EMI and the Pacemaker/Implantable Cardioverter Defibrillator (ICD) Patient, personal communication)
DiathermyAvoid, even if the device is programmed off
TENSPlace a magnet over the device, positioned off-centre, to suspend arrhythmia detection. A magnet reversion will not affect the bradycardia pacing function of the device; therefore, the need for asynchronous pacing must be evaluated OR program the device to non-tachyarrhythmia configuration, e.g. ‘Defic Off’, ‘All Functions Off’ or ‘Brady Pacing Only’.
Programming the pacer to the bipolar mode of sensing and decreasing the sensitivity level will minimize the potential for interaction with TENS stimulation.
Burst mode is contraindicated
Recommendations: (i) monitor the patient’s heart rate during the procedure, (ii) electrode placement should be left to right (lateral not anterior, posterior), (iii) place electrode pads in close proximity to each other, (iv) maintain a high frequency (>30 Hz) at all times, (v) pacemakers utilizing impedance based sensors (like minute ventilation or stroke volume) for rate responsive pacing should be programmed to a non-rate responsive mode to prevent increased pacing rates during TENS therapy, (vi) following the procedure, evaluate the pacing system by determining the capture and sensing thresholds.
Sorin Group–ELA (Diathermy Warning from User’s Manual & TENS Therapy and ICD, personal communication)
TENSWill not interfere with pacemaker or ICD with proper precautions.
Place the TENS electrodes as close to each other as possible.
Place the TENS electrodes as far from the pulse generator/lead system as possible and monitor cardiac activity during TENS use.
DiathermyNot recommended. If necessary, the following precautions must be used: keep the current path and ground plate as far away from the device and the leads as possible (a minimum of 15 cm/6 in.); before the procedure, deactivate ATP and shock therapies; during the procedure, keep the diathermy device as far as possible from the cardiac defibrillator, set it at minimum intensity, and use it briefly; after the procedure, check for proper implant function. The device should never be exposed directly to the diathermy source.
Therapeutic UltrasoundNot recommended

Future directions: communication between physiotherapists and cardiac rhythm device clinics

Clinical guidelines and recommendations regarding the use of various physical therapy treatment modalities in patients with CRD are often lacking, inconsistent, and/or inexplicit. Certainly, device patients being considered to receive physical therapy treatment involving various sources of EMI require careful consideration to ensure their safety. To avoid unnecessary complications to the CRD patient, many factors need to be considered including the patient’s dependence on the device, the type of device, the device manufacturer, as well as the treatment method and location. As previously recommended, when in doubt regarding diagnostic or therapeutic procedures that may result in cardiac device interference, a consultation ought to be performed to the device centre. A collaborative consultation process would ensure an individualized approach to treatment involving physiotherapists, arrhythmia physicians, device manufacturers, and CRD clinic (CRDC) staff. This individualized approach to treatment would expedite the transfer of pertinent patient information between the Physiotherapy Clinic and the Cardiac Rhythm Device team. A collaborative and consultative process would identify patients who might truly be at risk of negative consequences with a particular therapy and would ensure proper follow-up for these patients.

Such a collaborative consultative process is being developed for CRD patients at our centre based on our previous successful experience with device patients receiving radiation therapy.29 It has culminated in the creation of two forms. The first form (Appendix 1) is to be completed and faxed to the CRDC by the Physiotherapist who is consulting the Arrhythmia Service. Once the Pre-Physiotherapy Screening Pacemaker/Implantable Cardioverter Defibrillator (ICD) Assessment Request Form is received in the CRDC, the information will be reviewed by the arrhythmia physician. The second form (Appendix 2) will be completed by the arrhythmia physician outlining their recommendations. The device manufacturer will be contacted at the discretion of the arrhythmia physician. Once the Arrhythmia Service Response to Physiotherapy Clinic Form is completed, it is faxed back to the Physiotherapy Clinic.

Given the logistical difficulties that would be involved in attempting to arrange for the arrhythmia service and physiotherapy clinic to meet to assess these patients together, we suggest using these forms as a mean of providing an exchange of pertinent patient information between the two treatment facilities. This collaborative process ensures that patients are individually assessed, provided optimal care and are adequately followed.

Discussion and conclusion

Despite years of research, there is no comprehensive policy that addresses the extent to which physical therapy modalities are safe to be used in patients with CRD. The majority of international societies offer no specific recommendations regarding the use of safety of physical therapy modalities in patients with CRD, whereas the device manufacturers themselves are not always consistent with regards to their recommendations. In terms of the local experience, it was found that there was no comprehensive policy that allowed physiotherapists to determine whether a CRD patient would be best treated with regular care or by alternative means, although communication between physiotherapists and arrhythmia services regarding appropriate treatment was found to be practically non-existent.

Review of the literature and of the recommendations from CRD manufacturers lead us to believe that, at the moment, the physical therapy modalities of TENS, Diathermy, and Interferential Electrical Current Therapy are best avoided in patients with CRD. However, there is no consensus, and, furthermore, it may be possible to safely deliver these modalities in a proper setting with device and patient monitoring, and with specific arrhythmia physician supervision. Further research regarding distance of electrode placement from CRD, frequencies of stimulation, and sub-selecting populations of patients with lower risk, such as non-dependent patients with bipolar systems, may allow for these modalities to be safely used in CRD patients. Meanwhile, acupuncture, Laser therapy, manual therapy/traction, and US therapy appear to pose no significant risk to patients with CRD and should be considered as safe treatment in this patient population. Active collaboration between physiotherapy clinics and Cardiac Rhythm Device Clinic physicians and staff should allow the safe application of most physiotherapy modalities.

Conflict of interest: C.S.S., D.P.R. and A.B. have received honorarium to deliver talks and conferences from Medtronic, St Jude Medical, Boston Scientific and ELA SORIN group. A.B. has received unrestricted grants from Boston Scientific and Medtronic. D.P.R. has received unrestricted grants from St Jude Medical.

Appendix 1

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Appendix 2

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References

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