ElectrotherapyElectrotherapy (aka. clinical (aka. clinical

electrophysiological intervention) electrophysiological intervention) is the safe is the safe and competent use of electrical current and competent use of electrical current for a therapeutic purpose.for a therapeutic purpose.

APTA HOUSE OF DELEGATES APTA HOUSE OF DELEGATES POLICYPOLICY

APTA website: APTA Leadership; Policies & Bylaws, Section IAPTA website: APTA Leadership; Policies & Bylaws, Section I POSITION ON EXCLUSIVE USE OF PHYSICAL AGENTS POSITION ON EXCLUSIVE USE OF PHYSICAL AGENTS

/ MODALITIES - HOD 06-95-29-18/ MODALITIES - HOD 06-95-29-18

It is the position of the American Physical Therapy It is the position of the American Physical Therapy Association (APTA) that physical agents/modalities Association (APTA) that physical agents/modalities should be utilized only as a component of patient should be utilized only as a component of patient management. management.

Without documentation which justifies the necessity of Without documentation which justifies the necessity of the exclusive use of physical agents/modalitiesthe exclusive use of physical agents/modalities, the , the use of physical agents/modalities, in the absence of use of physical agents/modalities, in the absence of other skilled therapeutic or educational other skilled therapeutic or educational interventions, should not be considered physical interventions, should not be considered physical therapy. therapy.

Electricity Knowledge MapElectricity Knowledge Map

Identifying type, form, and Identifying type, form, and descriptive characteristicsdescriptive characteristics

• Phases:Phases: number of; number of; applies to Pulsed applies to Pulsed Current Current onlyonly

• Symmetry:Symmetry: are the are the phases mirror images? phases mirror images? (size and shape)(size and shape)

• Balance:Balance: is the area is the area under each (+) and (-) under each (+) and (-) phase equal? phase equal? (eg. (eg. amount of charge)amount of charge)

Practice Practice using the using the

Descriptive Descriptive CharacteristicCharacteristics of Electrical s of Electrical

PulsesPulses

Quantitative Characteristics of Quantitative Characteristics of Pulsed CurrentsPulsed Currents

Effects of changing Amplitude, Effects of changing Amplitude, Width, and RateWidth, and Rate

Electrical Stimulation of TissuesElectrical Stimulation of Tissues

• Conductivity of tissuesConductivity of tissues

• Directional flow of current in tissuesDirectional flow of current in tissues

• Excitable tissues in the body and Excitable tissues in the body and comparable thresholdscomparable thresholds

More . . Classification of peripheral nerve fibersMore . . Classification of peripheral nerve fibers

Strength (amplitude) and Duration Strength (amplitude) and Duration (width)(width)

Electrode Electrode Arrangement Arrangement Terminology:Terminology: Monopolar PlacementMonopolar PlacementBipoloar PlacementBipoloar Placement

Quadpolar PlacementQuadpolar Placement

Current Density IssuesCurrent Density Issuesvisualize the 3-D electrical field and how the field-density visualize the 3-D electrical field and how the field-density changes based on these factors: amplitude, width, Hz, changes based on these factors: amplitude, width, Hz,

electrode size, distance btwn electrodes, electrode electrode size, distance btwn electrodes, electrode contact (pressure)contact (pressure)

Depth of Current PenetrationDepth of Current PenetrationAll else being equal, depth of penetration is Increased by: All else being equal, depth of penetration is Increased by:

Increasing the amplitude, Increasing distance between electrodes, Increasing the amplitude, Increasing distance between electrodes, or Decreasing pulse duration. or Decreasing pulse duration.

What’s the target with What’s the target with NMES?NMES?

Classic Responses all applyClassic Responses all apply

Motor Responses are KEYMotor Responses are KEY

Electrode Size & Electrode Size & Placement :Placement :

Electrode Placement Electrode Placement

20

Figure 12-05. Electrodes placed over the proximal and distal ends of the quadriceps muscles for maximum efficacy.

Voluntary vs. Electrically Voluntary vs. Electrically Induced Muscle ContractionsInduced Muscle Contractions

• 2 main differences related to recruitment:2 main differences related to recruitment:– Order of recruitment Order of recruitment of motor nerve fibers and of motor nerve fibers and

muscle fiber types. SIZE PRINCIPLEmuscle fiber types. SIZE PRINCIPLE– Pattern of recruitment Pattern of recruitment of motor nerve fibers of motor nerve fibers

Physiologically initiated contraction

Electrically stimulated contraction

Muscle fiber type Slow twitch type I first Fast twitch type II first

Contraction force Low High

Speed of contraction Slow Fast

Fatigue Fatigue resistant Fatigues quickly

Atrophy Atrophy resistant Atrophies quickly

Recruitment Asynchronous Synchronous

Clinical Implication & Application Clinical Implication & Application of Order or Recruitment of Order or Recruitment

DifferencesDifferences• NMES can be more effective at specifically NMES can be more effective at specifically

strengthening muscle fibers weakened by strengthening muscle fibers weakened by disuse. Why?disuse. Why?

• If possible, patients should perform both If possible, patients should perform both stimulated and voluntary exercises to stimulated and voluntary exercises to optimize functional integration of strength optimize functional integration of strength gains. Why?gains. Why?

• Since NMES contractions are more fatiguing Since NMES contractions are more fatiguing than voluntary contractions, long rest times than voluntary contractions, long rest times should be provided between contractions.should be provided between contractions.

Russian Pulsed Current: a strong polyphasic pulse that is balanced & symmetrical. internal frequency of each pulse is 2500 Hz, which only gives one nerve depolarization; It is totally different than Burst on a TENS unit.

Types of pulsed currents approp for NMESTypes of pulsed currents approp for NMES

Biphasic Pulsed CurrentBiphasic Pulsed Current: same as what : same as what we used with TENS; now we will increase we used with TENS; now we will increase the pulse width to 250the pulse width to 250uus and greater. s and greater.

Common current used on battery Common current used on battery operated NMES units operated NMES units

Types of pulsed currents approp for NMESTypes of pulsed currents approp for NMES

Timing Modes for NMES Timing Modes for NMES parametersparameters

Ramp-Surge Mode: Ramp-Surge Mode: ParametersParameters

Ramp-Surge Mode: Ramp-Surge Mode: ParametersParameters

Physiologic Effects of NMESPhysiologic Effects of NMES• Increasing vascular flow via ms. pumpIncreasing vascular flow via ms. pump• Decreasing painful muscle spasm / guarding Decreasing painful muscle spasm / guarding • Muscle re-education (facilitating innervated ms with Muscle re-education (facilitating innervated ms with

impaired motor control); improve motor controlimpaired motor control); improve motor control• Muscle strengthening or to slow the rate of muscle Muscle strengthening or to slow the rate of muscle

atrophy atrophy • Maintain or increase joint range of motion Maintain or increase joint range of motion • Temporarily reduce muscle spasticity / hypertonicityTemporarily reduce muscle spasticity / hypertonicity• Act as an orthotic device to improve function at a Act as an orthotic device to improve function at a

moveable area. (Functional Electrical Stimulation moveable area. (Functional Electrical Stimulation [FES] )[FES] )

– State the impairment and treatment goalState the impairment and treatment goal

Example NMES setupsExample NMES setups

Example NMES setupsExample NMES setups

Example NMES setupsExample NMES setups

Example NMES setupsExample NMES setups

Example NMES setupsExample NMES setups

Relating Muscle Fatigue and Relating Muscle Fatigue and NMES ParametersNMES Parameters

NMES summary Rx chartNMES summary Rx chart

Cameron’s NMES summary Rx chartCameron’s NMES summary Rx chart

Discussion of NMESDiscussion of NMES

• Strengthening muscle with NMES • NMES for Muscle Facilitation / Re-education.

– To Strengthen or Re-educate, that is often the Question.

• NMES for Temporary reduction/fatigue of muscle spasticity (hypertonicity) due to upper motor neuron lesion

•  Additional advanced uses of NMES

US / E-stim ComboUS / E-stim Combo

CASE: Patient is a 36 yo male with thoracic & lumbar back pain bilaterally (rated 3/10); worse with movement (rated 6/10). Onset 4 days ago from a MVA. Erector spinae muscle spasms are tender to palpation bilaterally from ~T8 to L4 and trunk motion is limited. There is some pain also thru the right buttock and down the right proximal posterior thigh. Score on the Modified Oswestry is 22/50 (44/100).

Rx: NMES??

CASE: Patient is a 22 yo male who was in a motorcycle accident 3 days ago which severely damaged the soft tissue of the R foot (from malleoli down) and fractured ribs and wrist on the left. No fractures of the foot appeared on plain film radiographs; foot lacerations were sutured and severe abrasions are bandaged. Motions of the toes and ankle are limited and painful. The foot and ankle region is significantly swollen. Patient is brought to OP PT for wound care and Rx for all impairments. VAS rating of the foot pain is 8/10. He says the entire foot hurts.

Rx: NMES ??