Tara Jo Manal PT, OCS, SCS: Director of Clinical Services Orthopedic Residency Director
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Slide 1 Electrical Stimulation to Electrical Stimulation to Augment Muscle Strengthening: Augment Muscle Strengthening: Guidelines for Surgical Guidelines for Surgical Procedures, Diagnosis and Co- Procedures, Diagnosis and Co- Morbidities Morbidities Tara Jo Manal PT, OCS, SCS: Tara Jo Manal PT, OCS, SCS: Director of Clinical Services Director of Clinical Services Orthopedic Residency Director Orthopedic Residency Director University of Delaware Physical University of Delaware Physical Therapy Department Therapy Department [email protected][email protected]302-831-8893 302-831-8893
Tara Jo Manal PT, OCS, SCS: Director of Clinical Services Orthopedic Residency Director
Electrical Stimulation to Augment Muscle Strengthening: Guidelines for Surgical Procedures, Diagnosis and Co-Morbidities. Tara Jo Manal PT, OCS, SCS: Director of Clinical Services Orthopedic Residency Director University of Delaware Physical Therapy Department [email protected] 302-831-8893. - PowerPoint PPT Presentation
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EVIDENCE BASED PRACTICE FOR THE USE OF ELECTRICAL STIMULATION FOR
PAIN CONTROL AND STRENGTHING IN PHYSICAL THERAPY Tara Jo Manal PT,
OCS, SCS:
Director of Clinical Services
University of Delaware
Voltage
Voltage represents the driving force that repels like charges and
attracts opposite charges
Current
Current is the movement of charged particles in response to
voltage
Ampere represents an amount of charge moving per unit time
The higher the voltage, the higher the current
Slide *
Conductance
Relative ease of movement of charged particles in a charged
medium
If the ease of movement is high, the resistance to movement is
low
Resistance
Lower resistance provides greater comfort/tolerance by patient for
higher intensity stimulation since less charge is needed to
penetrate the skin
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I = V/R
Current increases as the driving force (V) is increased or as the
Resistance (R) to movement is decreased
As the skin resistance decreases, more of the current can flow,
increasing the response
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Properties
Impedance
Higher frequency stimulation can pass with greater ease
Impedance is the best word to describe resistance to flow in human
tissue since it is comprised of the tissue resistance and the
insulator (subcutaneous fat) effects of tissue
Greater the impedance, greater the intensity required to achieve
therapeutic goal
High frequency stimulation is more comfortable because impedance is
lower
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At fixed voltage
smaller the electrode the greater the intensity of the stimulation
compared to larger electrode
Caution in setting intensity level with smaller electrodes or
damaged electrodes
Very high current density can be related to biological damage or
burns
Large electrodes
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Train
a continuous, repetitive series of pulses at a fixed
frequency
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Pulse duration is 1/f
To increase pulse duration to improve muscle force output you would
decrease the train frequency
2000Hz = 1/2000 or 500second pulse duration
1000Hz = 1/1000 or 1000second (1 millisecond) pulse duration
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The duration is 1/5 or 20milliseconds
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Improves the muscle contraction
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Drive the motor units more quickly (Rate coding)
The main goal of using NMES is as an intervention to specifically
get the muscle to contract. The quantity of this contraction is
determined by the amount of force generated by the muscle.
There are 2 primary means of maximizing the force generated
1 - Increasing recruitment by activating more motor units
2 - Increase the rate at which the impulses are delivered. This
will cause summation and help to achieve tetany.
Slide *
Increase recruitment via
Increase amplitude
Or BOTH
Phase Charge
Mixed Nerve
When considering how to increase recruitment phase charge comes
into play which will allow for the chance of getting more motor
units stimulated. Recruitment of motor units can be increased by
increasing the phase charge (area under the curve).
Phase charge can be increased by either increasing the amplitude or
the intensity that the electrical stimulation is delivered or
increasing the pulse duration.
Certainly, combining the 2 would also result in greater increase in
recruitment.
Slide *
Frequency
Increasing frequency
Tetanic contraction
Force production reaches a plateau maximum between 50-80 pulses per
second
For muscle strengthening you want 50-80 pulses/second or 50-80
bursts/second
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Usually labeled “Rate or Pulse Rate”
Set the number of pulses (or AC cycles) delivered through each
channel per second
As frequency is increased, impedance is decreased
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Rate Coding
Increase the frequency of stimulation
But… increased frequency increased fatigue
One way of increasing force production is by increasing recruitment
and another way is by increasing frequency the stimulation is
delivered.
This is an actual tracing of the force generated at different
frequencies. The intensity of the stimulation was kept constant. As
you will see a single twitch generates approx 100 N and as the
frequency alone increases, the force generated also increases.
There is however a limit to the maximum amount of force that can be
produced.
Slide *
This slide illustrates this ceiling effect.
In order to get a strong tetanic contraction which is the goal of
NMES, the frequency needs to be 50-80 pulses per second. Beyond the
80 pps your force gains are not as great.
In addition to frequency of 50-80 pps to achieve a strong tetanic
contraction pulse duration 200-600 microsec. Pulse amplitude to
achieve >50%.
Slide *
AC: generally have a maximum of 100 – 200mA
Independent vs. Shared amplitude control for multiple
channels
Waveform Selection: Use evidence based decision making on the
choice, most comfortable may not be the appropriate choice
Balance Control: A balance control allows for higher intensity on
one channel and lower intensity on the other channel. Can be a
problem in the desired intensity is achieved on one channel but not
the other
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Rest time dependent on goal of treatment
Strengthening- Adequate rest to avoid fatigue
Ramp Controls: various names – slope time, surge time, ramp up, or
simply ramp
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Controls the rate the amplitude increases
Provide for more comfortable onset and cessation of stimulus when
very high levels of stimulation are required
Can adjust if contraction is coming on too quickly or stopping too
quickly
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Ramp time
Now let’s look at what can be changed or manipulated within the
machine to improve tolerance. Specifically we want to look at [read
slide]
Keep in mind that how you manipulate these parameters may vary
machine to machine
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Found on various stimulation devices, mostly
Can be limiting, if user is unable to program stimulation patterns
for a specific application
Output Channel Selection
it is called the EMPI 300PV
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Maximal tolerable current and device dependent- MVIC above blue
line
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Proper storage
Improves conductivity
The proper storage of electrodes will maximize the effective
lifespan of the electrodes. Electrodes have a defined amount of
treatments that they are good for and this amount of time will
differ between brands. By practicing consistent attention to proper
storage techniques you will be able to keep the electrodes in play
longer. The goal is to improve conductivity. This can be done by
maintaining moisture. Moisture can be added by applying water
either prior to their use or after their use. This can also be done
by storing them correctly on the plastic. [explain slide]
Slide *
With another brand electrode and the same placement
Note the difference in the force output at a greater
intensity
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With another brand electrode and the same placement
Note the difference in the force output at a greater
intensity
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Electrodes
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Monitor
Blunter
(Delitto et al PT 1992)
It is sometimes a challenge to get the patients to tolerate the
intensity of electrical stimulation we are presenting. This
stimulation is not comfortable and it requires therapists to know
their patient’s coping strategies as well as motivational
factors.
In cases in which a patient is having difficulty achieving the
minimum intensity of NMES to have an effective treatment. Our
therapists will call over a Senior therapist to basically talk with
the patient and distract them, and will adjust parameters if
needed.
Slide *
Explain to the patient the value of the modality
Another means to attempt to increase tolerance is to afford the
patient the opportunity to feel more in control of what is
happening.
This can be accomplished by [read slide]
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General
Specific
Only if you see them fatiguing drastically
Typically we start with trying to determine what exactly is the
source of the patient’s limitation
comfort, don’t like the feeling, don’t like how quickly it comes
on, etc
We can look from a general sense
As well as specifically
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Evidence to support the clinical use of electrical stimulation for
muscle strengthening
To provide quality physical therapy intervention we make the effort
to base our decision making on evidence based practice
In the use of electrical stimulation you there is an exhaustive
list of research throughout the last three decades.
Slide *
Increased Functional Load
For muscle to hypertrophy and/or gain strength the overload
principle of high weight at low repetitions is necessary
Currier and Mann
Looked at healthy male college students
Utilized an intensity of at least 60% MVIC paralleling voluntary
exercise protocols for functional overload
Conclusion: NMES and volitional exercise were equivalent training
stimuli
(Delitto,Snyder-Mackler, 1990)
Clinical relevance: These were healthy subjects with no strength
deficits
Slide *
Intensity was 10-30% greater than MVC
Strength gains of 30-40%
(Delitto,Snyder-Mackler, 1990)
Clinical Relevance: Intensity on healthy subjects needed to be
excessively high, and was extremely uncomfortable
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Increased Functional Load
Conclusions on Overload
Significant strength gains can be achieved in healthy muscle with
an electrically augmented training program
The intensity however needs to be extremely high
(>100%MVIC)
Electrical stimulation offers equivalent muscle strengthening
effects to voluntary exercise in healthy subjects
If intensity level parallels volitional exercise intensities
(Delitto,Snyder-Mackler, 1990)
Intensity for NMES was from 33% - 91% MVIC, whereas it was 78% to
119% for volitional exercise
studies of NMES have strength gains from intensities as low as
25%
studies of volitional exercise do not show gains with training
intensities as low as 50%
In other types of subjects, NMES is more effective
Slide *
Lower loads may still help in muscle recovering from
injury/surgery
Most studies using subjects other than healthy male college
students demonstrated greater strength gains in subjects training
with NMES compared to volitional exercise alone
(Delitto,Snyder-Mackler, 1990)
Electrical Stimulation for Strength
Snyder-Mackler et al., 1991
Purpose: To ascertain the effects of electrically elicited
co-contraction of the thigh muscles on several parameters of gait
and on isokinetic performance of muscles in patients who had
reconstruction of the ACL
2 groups: NMES + volitional exercise
Volitional exercise only
Slide *
Results:
Significantly greater average and peak torque of the quadriceps
femoris at both 90°/sec and 120°/sec in the NMES group
No significant difference in performance of the hamstring muscles
between groups
Torque produced in the involved hamstrings averaged 80% of the
strength in the uninvolved leg
Clinical Relevance: Strength gains in the early postoperative phase
can be significantly improved with the use of electrical
stimulation
Slide *
Conclusions:
The quadriceps muscles of these patients were stronger in the
eighth post-operative week than reported averages for similar
patients even years after surgery
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Electrical Stimulation for Strength
Snyder-Mackler et al., 1995
Purpose: To assess the effectiveness of common regimens of
electrical stimulation as an adjunct to ongoing intensive
rehabilitation in the early postoperative phase after
reconstructions of the anterior cruciate ligament
Slide *
High level volitional exercise
Combined high & low intensity NMES + volitional exercise
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2500Hz triangular AC current
Burst rate of 75bps
Amplitude to maximal tolerance
Frequency of 55pps
15 minutes 4 times/day
Intensity was maximum effort for 8 seconds
Visual Feedback provided
All groups followed a standard volitional exercise protocol beyond
the experimental treatment interventions
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Electrical Stimulation for Strength
Snyder-Mackler et al., 1995
At least 70% recovery of the quadriceps by 6 weeks after the
operation, vs. 51% in the groups that did not include high
intensity stimulation
High intensity electrical stimulation leads to more normal
excursions of the knee joint during stance
-at heel strike and sustain this position after heel strike
Slide *
Conclusion: For quadriceps weakness, high-level NMES with
volitional exercise is more successful than volitional exercise
alone
Electrical Stimulation for Strength
Fitzgerald et. al., 2003
Subjects receiving the modified NMES treatment combined with
exercise demonstrated greater quadriceps strength and higher ADLS
scores than the comparison group
Unfortunately, the use of a force dynamometer is not always
available to us or it is too time consuming to change the unit from
1 body part to another, and for many clinicians they may not have
one at their access. Therefore, to assess MVIC’s and assure we are
achieving 50% or greater dose is not always feasible.
This does not stop us from attempting to utilize this adjunct
intervention in the care of our patients. A recent study by
Fitzgerald and colleagues provides evidence in the effectiveness in
performing a modified NMES protocol to the quadriceps in patients
who have undergone ACL reconstruction. The amplitude of the
stimulus was set to an intensity that was high enough to produce a
full tetanic contraction of the quadriceps (no fasciculations
observed on visual inspection) with visual and/or palpable evidence
of superior glide of the patella. Then the stimulus intensity was
increased further to maximum subject tolerance. Their results
comparing a NMES + exercise group to an exercise only group
concluded ….
Slide *
Fitzgerald et. al., 2003
Their data support the modified NMES protocol in clinics without
access to a dynamometer
Option of using a dynamometer
Authors choose the high intensity NMES protocol
It is important to note their strength gains were not as great as
those seen in Snyder-Mackler et al. 1995 study, however their
results do demonstrate that some stim is better than none.
The authors concede that if….
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Haug et al., 1988
Purpose: Efficacy of NMES of the quadriceps femoris during CPM
following total knee arthroplasty
CPM/NMES group
Pulse width: 300 microseconds
Frequency: 35pps
On 15sec off 20 seconds at 40° setting and 65sec at 90°
setting
Ramp time: 2 seconds up and 1 second down
CPM group
Haug et al., 1988
Results: Stimulation group had significant reduction of extension
lag, and spent fewer days in the hospital
Intensity level was low compared to the other studies
mentioned
Conclusion: Electrical stimulation combined with CPM in the
treatment of patients with total knee arthroplasty is a worthwhile
adjunctive therapy
The low intensity of the stimulation still lead to positive gains,
which may support the idea of a window of opportunity for the
greatest strength gains.
Slide *
Role of Strength in Physical Therapy Management
Strength losses can result in loss of the ability to perform
activities of daily living
Strength recovery following surgery is often incomplete
Strength deficits can place patients at risk of further
injury
(Snyder-Mackler, 1991)
Strength also plays a significant role in our care for our
patients.
It has been reported that Strength recovery from arthroscopic to
total knee replacements are often incomplete
Patients deficits can create significant disabilities such as
inability to travel between floors of their home more than once a
day, or ambulate the long distances required in many of the major
shopping centers and result in compromise to patients participation
at home and the community.
These types of strength deficits can place patients at a
significant risk for falls and further injury.
Slide *
<80%MVIC
At this time lets look at the indication for choosing NMES as an
intervention for your patients plan of care.
The patients who will benefit from NMES are the individuals who
demonstrate strength deficits …
Once the patient is over 80%, we are talking about the range of
side to side differences in relatively healthy muscle
In order to make significant gains in this population, we would
need to use excessively high intensities as were proposed by
Kotz.
Slide *
50-75 bursts per second
Amplitude to maximal tolerance of patient
With dynamometer feedback
Minimum of 30% MVIC for TKA
50% for PFS, Patellar Subluxations
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Procedure Modified Rehabilitation
Now we are going to take a look at how we utilize NMES in various
patient populations
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Single Channel two electrode placement
Below the AIIS
Minimum Intensity
Another area in which persistent weakness is an issue is in ACL
reconstruction.
This position is one in which anterior translation forces on the
graft are the least and relatively negligible
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Bone-Tendon-Bone Autograft
flexion position > 40°
Due to patellofemoral issues the bone-tendon-bone graft, the angle
of knee flexion can be adjusted to the most comfortable angle but
no less than 40 degrees.
To prevent undo stress on the graft
Slide *
Patient encouraged to increase the intensity to maximum
tolerated
Dose-response curve demonstrates greater intensities lead to
greater strength gains
(Snyder-Mackler et al., 1994)
Minimum of 50% should achieve 80% recovery over the course of
treatment.
Slide *
Off time- sufficient for rest/recovery before next contraction
30-90 seconds
Ramp time- as needed for comfort
Dose- maximal tolerable (no less than that needed for strength
gains to be seen)
Frequency 2-3 times/week until strength recovers
Average 18 visits
NMES for Quadriceps Strengthening
Following injury or surgery to the knee, quadriceps weakness can be
major impairment
We utilize electrical stimulation on all patients who demonstrate
quadriceps weakness of 80% involved/uninvolved ratio or less
After ROM is, quadriceps strengthening is most important.
Potential for long term problems if strength issues are not
addressed and resolved.
Quadriceps weakness may or may not be accompanied by inhibition. It
may be a result simply of muscle atrophy. Just weakness.
Slide *
Post Operative Modification to ACL Protocol for Other Knee
Problems
PCL 30° Knee Flexion
Meniscal Excision/ Repair None
Chondroplasty None
Post surgical intervention- follow soft tissue healing 8wks to
protect surgical site or 12 weeks for bony healing
Slide *
If Pain if limiting toleration – use most comfortable angle
If Range of motion is limiting toleration – use most comfortable
angle
As long as modification does not risk surgical procedure
Perform with support from the referring physician
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Identify “true” maximal force generating capability
Identify presence or absence of “inhibition”
Central activation deficit
NMES is performed at the most comfortable knee joint angle
Tape is often applied for pain control
When necessary, treatments to calm irritated structures are
added
Slide *
Determined by volitional contraction
Greater than 70°
Patella taped medially
As for the non-operative cases quadriceps weakness is sometimes
seen in PFS
In patellofemoral syndrome the angle of knee flexion is based on
area of least contact stress and will tend to be any angle greater
than or equal to 40 degrees.
Taped medially to resist lateral pull.
Follow the NMES parameters
Patella taped medially
Electrodes over the proximal quadriceps/ distal pad is moved
central and superior (avoiding the VMO)
The theme continues with respect to quadriceps weakness
post-operatively and the use of NMES
The angle is to protect the proximal reconstruction
Follow the NMES parameters
Precautions
Proximal/Distal Realignment
Dosage is maximal tolerable rather than % MVIC
Slide *
Quad weakness decreased by 60% following surgery
Impaired ability to perform ADL’s
Increased fall risk
Wolfson et al 1995 J Gerontol A: Biol Sci Med
Stevens et al JOR 2003
Studies looking at strength deficits following TKA have shown that
muscle strength can take several months (even years) to be
restored.
Stevens et al evaluated strength in patients with end-stage knee
OA. Their strength was evaluated 10 days before and then 26 days
after surgery. They found that quad strength decreased by 60% and
the central activation decreased 17%.
The profound weakness in addition to significant changes in the
patient’s ability to activate the quadriceps muscle lead to
considering NMES as a treatment intervention.
Slide *
Strength gains reflect intensity tolerated
Therefore …
Ultimate goal is to generate the greatest tolerable force
output
Slide *
Total Joint Arthroplasty
Amplitude targeted at a minimum of 30% MVIC (Snyder-Mackler et al.,
1994)
Ramp time, frequency adjusted to increase comfort and tolerance for
higher intensity stimulation
Modification of pulse duration by decreasing frequency to 2000Hz or
1500Hz (inc. pulse duration from 400 to 500 or 666
microseconds)
Persistent weakness after discharge from physical therapy is a
major problem in patients who undergo total knee arthroplasty. At
UD we are currently in our 2nd year of research, looking at the
recovery of the quadriceps post TKA
The intervention we are looking at is obviously NMES with..
30% is above the minimum threshold for generating significant
gains, and in early work with these patients, we were just unable
to get them to 50% consistently. Many time they would max out the
machine.
Mod. Pulse duration - can lead to greater contraction response with
the same level of intensity
Slide *
Weakness can lead to compensation strategies for daily
activities
COMPENSATIONS MUST BE PREVENTED!!!
After ROM is, quadriceps strengthening is most important.
Potential for long term problems if strength issues are not
addressed and resolved.
Quadriceps weakness may or may not be accompanied by inhibition. It
may be a result simply of muscle atrophy. Just weakness.
Slide *
Can be seen as
2. Putting involved leg out in front of her
These have to be pointed out to patient and drilled into them to
stop doing.
Patient won’t even know they are doing it.
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Done in all facets of life
Watch in clinic for patient to do this, they will
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Not utilizing full extension during stance phase of gait
At heel strike to mid-stance, pt must actively force knee into
terminal knee extension
Patient must consciously work on avoiding this pattern
Very common compensation pattern
Slide *
Patellar baja
Quad dysplasia
Functional Use of Quadriceps
Use of quadriceps during daily activities must be relearned in
order to eliminate compensation strategies.
If it gets to this point…you are in a hole!
Slide *
Composite overview of muscle performance
Functional Testing
Lack of progress with a strengthening program
Re-education in order to retain strength gains
The absolute strength of muscle is one way to assess the patients
muscles, however these measures may not correlate into functional
performance.
we look at their ability to squat, jump, ambulate, run, transfer to
standing to give us an overview of how they are using their
muscles
Then we look for compensatory patterns
seen in avoidance patterns
we try to catch early on to prevent
If you strengthen an individual and the rest of the day they are
not using that muscle, because of an avoidance pattern, more than
likely you will not be able to demonstrate appreciable strength
gains. Imperative to break patients of these avoidance
patterns
Slide *
17 y/o female soccer player 4 months s/p ACL reconstruction
Quad Index (involved/uninvolved)
Decrease in quadriceps strength originated from decreased use and
compensation strategies secondary to anterior knee pain at 3
months
Slide *
Severe pain at infrapatellar tendon and medial border of
patella
Compensations to avoid use of involved leg with functional
activities secondary to anterior knee pain
Slide *
No quadriceps inhibition with burst superimposition test
Decreased superior migration of patella with quad set and superior
patellar hypomobility
Patient also presented with patellar baja that we theorized was due
to decreased resting tone of the quadriceps from avoidance of
use.
Decreased superior patellar mobility
Superior patellar mobs for her patellar hypomobility and
baja.
Noxious done to infrapatellar tendon and lateral quadriceps tendon.
Parameters…Used on non-contractile tissues. Use small electrodes to
produce higher current density
Patient had trouble tolerating noxious stim, so we had to use ice
massage for pain control. Little burns.
Could not do NMES with patient because she couldn’t tolerate
it.
Slide *
Quadriceps Re-education
Two 4 x 6 inch pads over distal VMO and proximal bulk of quad
Intensity = maximum contraction patient can tolerate
Used 4 x 6 inch pads to decreased the current density to where pt
could tolerate it
Patient performs exercise during ON cycle
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Slide uninvolved foot out to place more demand on involved
Put ball under uninvolved foot
Unilateral
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Patient was able to do this painfree with Muscle Max
may have helped pull patella enough to reduce irritation
Done in pain free arc of 90-45 degrees for patellofemoral
considerations
Slide *
6 months post-op (16 visits) QI = 51%
7 months post-op (28 visits) QI = 72%
8 months post-op (37 visits) QI = 98%
6 months post-op (16 visits) QI = 51%
between 6 and 7 month strength check, no more muscle max
At 28 visits (7 months post-op) QI = 72%
between 7 and 8 month strength check, pt began return to soccer
progression
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By 9 months...
Completed soccer season, playing majority of games over the last
couple of weeks following strict minute regulations per game
Self-management
Coaching
Helped progression and kept pt happy
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Patient Position
Involved arm belted to the body with the elbow at 90° for isometric
contraction
Forearm is blocked to avoid rotation during the contraction
Stepping away from the quadriceps there are other muscle groups we
use NMES to improve the effectiveness of our treatment plan.
There is no dynamometer attached to the patient, however that could
be an option if it is kept in an isometric position.
Slide *
Current Intensity: Maximal tolerable with visible contraction
causing movement of the arm against the restraint
Once again we are using the same parameters as we use for the
quadriceps, but our intensity is based on …
Good communication with your patient will help to determine if the
contractions are at maximum tolerance. In this situation it is
common your patient will say that its their maximum, however when
you look at the muscle a solid tetanic contraction has not been
achieved yet.
Its imperative for success that you continue your communication
with them to achieve a visible tetanic contraction
Slide *
The patient was then setup in a chair with his arm strapped to his
trunk, and a pillow folded under his arm. This minimizes movement
during contraction, making it as close to isometric as
possible.
A single channel is then placed on the target muscle to be
treated.
Slide *
Modified surgical procedure (loop tightens under tension)
Patient prone, knee resting in >50° of flexion and ankle in full
plantar flexion
Single Channel on the medial/lateral gastroc
Current Intensity
Visible tendon gliding
Another area we utilize NMES is in the rehabilitation of Achilles
tendon repairs if a Modified surgical procedure is performed
extra loop that tightens under tension
reducing the risk of rupturing the repair site
Ankle is supposed to be in full plantar flexion, this picture does
not show that well
The therapist must heed caution here in the early phase to protect
the surgical repair. The only modification to the parameters is
intensity which is increased to the point of...
Slide *
Patient prone with knee extended and ankle in resting
position
Can increase to isometric against the wall
Whereas in the late phase at >10 weeks post-operatively, we are
looking for actual...
Slide *
Continue treatment until patient has full active plantar
flexion
At this point the repair sight has healed and the patient is
returning to an increased activity level.
Once again if you have the option of using a dynamometer in an
isometric mode and can set it up with ease, then the application of
minimum intensity of 50%MVIC help increase the overall
effectiveness of the treatment
Slide *
Pelvis strapped to the table in posterior pelvic tilt
Assess movement to active lumbar extension and tighten as
necessary
Finally, the use of NMES for the lumbar spine is a common procedure
in our clinic. Understanding that overloading the erector spinae
muscles is a difficult task with volitional exercise, especially
with deep rotators and multifidi.
The objective of this set-up is to prevent anterior pelvic
tilting
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High Intensity Electrical stimulation
A single channel is placed on the right and left side of the
spine
Slide *
Using the NMES parameters, we are once again …
electrode placement
For the average sized adult this technique will be isometric from
the position set-up
Ex: young figure skaters however can come right off the table and
isometric is achieved at the end of the motion
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Laura Schmitt PT, DPT, OCS, SCS, ATC
Airelle Hunter PT
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