Electrotherapy (aka. clinical electrophysiological
intervention) is the safe and competent use of
electrical current for a therapeutic purpose.
APTA HOUSE OF DELEGATES POLICY
APTA website: APTA Leadership; Policies & Bylaws, Section I
POSITION ON EXCLUSIVE USE OF PHYSICAL AGENTS
/ MODALITIES - HOD 06-95-29-18
It is the position of the American Physical Therapy
Association (APTA) that physical agents/modalities
should be utilized only as a component of patient
management.
Without documentation which justifies the necessity of
the exclusive use of physical agents/modalities, the
use of physical agents/modalities, in the absence of
other skilled therapeutic or educational
interventions, should not be considered physical
therapy.
Electricity Knowledge Map
Identifying type, form, and
descriptive characteristics
• Phases: number of;
applies to Pulsed
Current only
• Symmetry: are the
phases mirror images?
(size and shape)
• Balance: is the area
under each (+) and (-)
phase equal? (eg.
amount of charge)
Practice using
the Descriptive
Characteristics
of Electrical
Pulses
Quantitative Characteristics of
Pulsed Currents
Effects of changing Amplitude,
Width, and Rate
Electrical Stimulation of Tissues
• Conductivity of tissues
• Directional flow of current in tissues
• Excitable tissues in the body and
comparable thresholds
More . . Classification of peripheral nerve fibers
Strength (amplitude) and Duration (width)
Electrode
Arrangement
Terminology:
Monopolar Placement
Bipoloar Placement
Quadpolar Placement
Current Density Issues
visualize the 3-D electrical field and how the field-density
changes based on these factors: amplitude, width, Hz, electrode
size, distance btwn electrodes, electrode contact (pressure)
Depth of Current Penetration
All else being equal, depth of penetration is Increased by:
Increasing the amplitude, Increasing distance between
electrodes, or Decreasing pulse duration.
What’s the target with NMES?
Classic Responses all apply
Motor Responses are KEY
Electrode Size &
Placement :
Electrode Placement
Figure 12-05. Electrodes placed over
the proximal and distal ends of the
quadriceps muscles20for maximum
efficacy.
Voluntary vs. Electrically Induced
Muscle Contractions
• 2 main differences related to recruitment:
– Order of recruitment of motor nerve fibers and
muscle fiber types. SIZE PRINCIPLE
– Pattern of recruitment 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 of
Order or Recruitment Differences
• NMES can be more effective at specifically
strengthening muscle fibers weakened by
disuse. Why?
• If possible, patients should perform both
stimulated and voluntary exercises to
optimize functional integration of strength
gains. Why?
• Since NMES contractions are more fatiguing
than voluntary contractions, long rest times
should be provided between contractions.
Types of pulsed currents approp for NMES
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 NMES
Biphasic Pulsed Current: same as what we
used with TENS; now we will increase the
pulse width to 250us and greater. Common
current used on battery operated NMES units
Timing Modes for NMES parameters
Ramp-Surge Mode: Parameters
Ramp-Surge Mode: Parameters
Physiologic Effects of NMES
• Increasing vascular flow via ms. pump
• Decreasing painful muscle spasm / guarding
• Muscle re-education (facilitating innervated ms with
impaired motor control); improve motor control
• Muscle strengthening or to slow the rate of muscle
atrophy
• Maintain or increase joint range of motion
• Temporarily reduce muscle spasticity / hypertonicity
• Act as an orthotic device to improve function at a
moveable area. (Functional Electrical Stimulation
[FES] )
– State the impairment and treatment goal
Example NMES setups
Example NMES setups
Example NMES setups
Example NMES setups
Example NMES setups
Relating Muscle Fatigue and
NMES Parameters
NMES summary Rx chart
Cameron’s NMES summary Rx chart
Discussion 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 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 ??