NMES - Neuromuscular Electrical Stimulation
What is the procedure or NMES?
Bypass the CNS to create muscular contractions.
Similar to Acupuncture-like TENS
Effecting the Alpha Motor Neuron
What are the specifics of NMES waveform?
Pulsed, Biphasic (both + and -) wave
Current amplitude in motor range for a motor response.
Use motor points - high concentration of myoneural junctions
Need surge (on:off) times
Do not need modulation(motor nerves do not accomodate)
What is the pulse frequency for NMES?
35-80pps (Hz) - has to be greater than 35 for tenany (sufficient overlap of twitches)
Less than 100 is not so fatiguing to muscle
What's the pulse duration for NMES?
How long it lasts.
150-200 microseconds for small muscles
200-350 microseconds for large muscles (need more total average current to produce a muscle contraction)
What are clinical indications for NMES?
Muscle Strengthening 35-80 pps 6-10 sec on 1:5 ratio on average 10 seconds on/50 seconds off
Muscle re-education (FES) 35-50 pps # of seconds on/off depends on functional activity
Muscle spasm reduction 35-50 pps frequency 2-5 sec on 1:1 ratio - fatigues muscle
Subacute Edema Reduction 35-50 microsec frequency 2-5 sec on 1:1 on/off ratio skeletal muscle pump
What is Russian Stimulation and what are the details?
Soviet wrestling team in 1976 olympics
Sinusoidal wave using 2500Hz carrier frequency
Delivering pulse bursts at 50Hz
10-15 sec on time/50 sec off time
10 strong Isometric contractions (block)
What fibers are triggered with NMES?
Type II fast twitch muscle fibers
How does NMES differ from regular muscular contraction?
Voluntary contraction recruits Type I slow twitch muscle fibers
Assynchronous recruitment - less fatigue
In weak, deconditioned (or post surgical) patients, early use of NMES can result in _____________ (greater/smaller) strength gains than exercise alone?
Because NMES recruits fast twitch (Glycolytic, Type 2, white) fibers first and more
With disuse, Type 2 muscle fibers atrophy before Type 1.
In human subjects, adding electrical stimulation with a voluntary exercise regimen _____________ (has;has not) been shown to produce greater strength gains than exercise alone if same force of contraction is produced?
In healthy individuals, combining electrical stimulation with voluntary exercise produces NO greater strengthening than either intervention alone.
What's the overload principle of muscle strengthening?
Greater the load - greater the force contraction produced - greater strength gain
Physiological exercise: PRE's (progressive resistance exercise)
E-stim - increasing total amount of current (amplitude)
What's the specificity principle of muscle strengthening?
Recruit specific type of muscle fibers that you want to strengthen
Physiological exercise - Type 1 (slow twitch); fatigue & atrophy resistant) recruited first
E-stim - Type 2 (fast twitch) recruited first
An electrically stimulated muscle contraction can ______________ (increase;decrease;have no effect) blood flow in healthy individuals and in patients with poor circulation.
Inccrease because skeletal muscle pump increases circulation, increases tissue healing and decreases risk of DVT formation.
What other areas of research are there for NMES?
Orthopedic; joint surgery
Dysphagia (swallowing issues)
FES (foot drop, sh. subluxation spacticity)
Research studies ____________ (do;do not) recommend stimulation of contractions in denervated (no nerves) muscles in DC.
Because final rehab outcome is NOT improved (and may be worse) with denervated muscle stimulation
Partially innervated muscles can be helped with AC current stimulation.
Card #1 scenario
Pt. Dx - Medial epicondylitis on R side
Wound (in phase 2 healing) on her R forearm
Stg#1: decrease inflammation and pain in her R medial epicondyle
Stg#2: Closure of woundon her right forearm
Pt. Treatment: Iontophoresis, using dexamethasone, to her right medial epicodyle.
HVPC, monopolar technique, to wound on her right forearm (2 electrodes, one small, one dispersive) healing wound - so positive at wound site, dispersive (larger) more proximal. 120 pps/60 min/buzzing (sensory)
Card #2 scenario
Pt. Dx - acute contusion to his right olecranon Deconditioned state (due to bed rest)
Stg#1: prevent further acute edema formation on right olecranon
Stg#2: increase muscle strength in his biceps to at least a 3+/5 for functional swivel bar transfers
Pt treatment: HVPC treatment, using underwater bipolar technique, to his right olecranon (polarity = negative) use a bucket - put negative wire on right olecranon side (closer, not touching) 60 min/buzzing (sensory)
EMG - for strengthening his left biceps muscle
Card #3 scenario
Pt. Dx - acute ankle inversion sprain on the R side
Inflammation in his right patellar tendon
Traumatic event - slipping on ice in the parking lot yesterday (acute)
Stg#1: prevent accumulation of new edema and decrease pain in his right ankle
Stg#2: decrease inflammation and pain in his right patellar tendon
Pt treatment: HVPC, using monopolar technique, to reduce pain and edema in his right ankle (negative polarity at edema area) other electrode (dispersive/larger) s/b proximal. 120 pps/buzzing(sensory)/30 minutes - repels proteins & hold to stay inside vessel)
Iontophoresis, using dexamethosone, to decrease inflammation in his right patellar tendon
Card #4 scenario
Pt. Dx - Dog bite on the right posterior calf - 1 day old wound. Trigger points in thoracic paravertebral muscles
Participating event: patient was bit by a dog near the end of a stressful 30 mile bike race involving uphill conditions yesterday.
Stg#1: decrease pain and spasm in his right thoracic paravetebral muscles by at least 3 levels on the VAS.
Stg#2: closure of wound on his right posterior calf
Pt treatment: EMG to reduce pain and spasm in his right paravertebral muscles at the thoracic level
HPVC, using monopolar technique (polarity - negative at wound bed - dispersive proximal/larger - 45-60 min - buzzing (sensory)
Card #5 scenario
Pt. Dx - spasm in right biceps muscle
Spasm in lumbar paravertebral muscle
Precipitating conditions: patient has excess abdominal fat, an increased lumbar lordosis and started a new factory job a month ago. Pt reports not being used to standing on cement floors for prolonged periods or having to do so much lifting of heavy boxes.
Stg#1: decrease pain and spasm in his right bicep muscle to 2/10 or lower on VAS.
Stg#2: decrease chronic pain and spasm in his lumbar paravertebral muscles to 2/10 or lower on VAS.
Pt treatment: NMES, using bipolar technique, to reduce muscle spasm in his right biceps muscle 50 pps, 150-200 microseconds for small muscle, visible contraction, 5 sec on, 1:1 ratio, 1 sec minimum ramp time, 10-30 min - every 2-3 hrs until spasm relieved.
IFC to his lumbar paravertebral muscles (note perform on right side only) 4 electrodes X, fixed, no vector, 10Hz Motor twitch, 20-30 min every 2 hrs.
Card #6 scenario
Pt. Dx - subacromial bursitis on the right
Flaccid paralysis in right upper extremity due to left CVA
Precpitating conditions: Pt is in a nursing home that has a weak therapy dept and poor training program for CNA's. the pt's hemiplegic upper extremity has been ranged improperly, positioned poorly and been allowed to jam (head of humerus & acromion) during ADL's
Stg#1: reduce edema in her hand
Stg#2: decrease pain in her right shoulder to at least a 2/10 on the VAS.
Pt treatment: NMES, using quadripolar technique, and alternating channels, for skeletal muscle pump edema reduction in her right hand and forearm.
portable machine - 30 min 50 Hz, 5 sec on 1:1 ratio, visible contraction, 35-50pps Cycling ALT, waveform Sym, width 300 microseconds.
IFC for acute pain in her right subacromial area - 100-150 Hz, sensory (tingling) vector scanning, 20 min to 24 hrs.
Card #7 scenario
Pt. Dx - Bell's Palsy, resulting in partial innervation on the right side of her face
Carpel tunnel syndrome on the right
Stg#1: Prevent muscle atrophy in the muscles innervated by the facial nerve (CN7) on the right side of her face
Stg#2: Decrease acute pain in her right wrist
Pt treatment: NMES, using the monopolar technique, to her right orbicularis oculi (for muscle strengthening)
IFC to her right wrist - 100-150Hz, sensory (tingling) vector scanning - 4 electrodes 20 min to 24 hrs.
Card #8 scenario
Pt. Dx - Traumatic damage to right ulnar nerve at the level just distal to the right elbow
Precipitating conditions: Pt is a professional athlete who works as a bouncer in a bar. He had his right ulnar nerve partially severed by a broken beer bottle while attempting to break up a fight in the bar two weeks ago.
Stg#1: Prevent muscle atrophy in the muscles innervated by the ulnar nerve (FCU/FDigiProfu/abductor digiti minimi)
Stg#2: Improve muscle strength in his right Quadricep muscles
Pt treatment: NMES, using monopolar technique, to atleast 3 muscles innervated by the right ulnar nerve. (haven't done yet)
Russian stimulation, using quadripolar technique to his right quadriceps. 50 pps, co-contraction - each channel on each side of quads - set one channel then the next - contraction is blocked for isometric contraction.
Card #9 scenario
Pt. Dx - left CVA with right hemiplegia
Stg#1: Pt will ambulate independently without any toe drag during swing phase at least 8/10 gait cycles.
Stg#2: Pt will ambulate with a stable R knee, at early mid-stance, atleast 8/10 gait cycles.
Pt treatment: NMES, using bipolar technique, to right tibialis anterior muscles - FES (use heel switch) (Haven't done yet)
NMES (using bipolar technique) for right quadriceps muscle weakness - 50-80 pps, 10 sec on 1:5 ratio - 50 sec off - 2 sec min. ramp time 10-20 min for 10-20 repititions (double check amplitude)
Card #10 scenario
Pt. Dx - right radial nerve injury at the level just distal to the elbow (lateral)
Precipitating conditions: the Pt. just started a new summer job in the kitchen of a chinese restaurant. She accidentally cut her right hand while cutting vegetables with a sharp knife. She is left hand dominant and liked fresh veggies before her accident.
Stg#1: improve muscles strength and prevent atrophy in her extensor carpi radialis muscle on her right side.
Pt treatment: NMES, using bipolar technique for strengthening her Right wrist/hand - ECR 50-80 pps, 10 sec on 1:5 ratio 2 sec minimum ramp time, 10-20 min every 2-3hrs.
NMES, using bipolar technique, to her extensor carpi radialis on the right side (FES) use hand switch (haven't done yet)