NMES

for bigger muscles, electrode placement should include

large electrodes, far apart, 2 channels and 4 pads (if pads are large, 1 channel is ok)

for smaller muscles, electrode placement should include

small electrodes, far apart, 1 channel

electrodes placed farther apart allows for

greater motor unti recruitment

if the negative phase duration has a long rise time

there might not be enough negative charge to activate a nerve

amplitude measures

peak to peak of phases - can vary day to day but we want a strong contraction

NMES for re-education parameters

200-300msec, 35-50pps, amplitude to a muscle contraction

charge =

amplitude x phase duration

motor nerves take more

charge/pulse duration to open/depolarize than sensory nerves do

NMES for re-education can be used for

any strengthening

NMES for abs

activate very few motor units, and have an unbalanced waveform - common to irritate the skin (1hr of use is equal to 3 situps)

normal AFO for LE orthosis/foot drop

keeps foot/ankle in neutral dorsiflexion, toes dont drag, muscles are not encouraged to activate

NMES for LE orthosis/drop foot

triggers cortical plasticity with thousands of reps of dorsiflexion activation to reduce foot drop

set up for drop foot

electrode on anterior tib (DF, inversion) and fibularis longus/brevis (PF, eversion) to achieve midline dorsiflexion, or electrode on common fibular n and anterior tib (to complete circuit)

drop foot parameters

200-300msec, 35-50pps, 0msec ramp time, on/off is controlled by hand switch or heel switch

when to activate NMES for functionality with drop foot

during swing phase of gait, NWB - to dorsiflex and lift toe

a flaccid stroke could cause

shoulder subluxation with flaccid rotator cuff - humeral heads moves inferior and anterior

setup for NMES shoulder subluxation

supraspinatus to elevate HH and posterior deltoid to move HH posteriorly - symmetric, biphasic waveform

parameters for NMES shoulder subluxation

200-300msec, 25pps (to reduce fatigue), ramo 1-2sec to avoid joint jamming, on 10sec, off ramp 1-2sec, off 5 sec

for NMES with shoulder subluxation to be effective

wear 7-8hours/day - ideally start right after flaccid stroke - studies found the patient returned to subluxed following use and had no increase in function

NMES for shoulder subluxation may be beneficial if

patient is in significant pain (could also tape or sling)

scoliosis NMES

various channels at intercostals at night to potentially pulls ribs together and encourage spine to be more straight (must be done before pt reaches skeletal maturity, caution at intercostals)

shoulder post-op phase 2

it is now okay to activated the repaired muscle - the estim on external rotators in this case

phase 2 shoulder post op NMES parameters

small electrodes, typical parameters

when you feel the stim

help it (start with gentle isometrics)

stimulation activates

fast twitch fibers

volitional contraction activates

slow twitch fibers

concurrent estim with volitional muscle activation will

gets lots of activation and provide lots of feedback from spindles

VMO firing

use a small electrode with a higher current density at VMO, and a large pad on the quad - the best way to selectively activate this muscle

VMO action

pulls patella slightly medially (important for patellar tracking) (preferentially activates post injury or post surgically)

post ACL repair co-contraction

activate hamstrings and quads at the same time to get strengthening while preventing anterior translation of the tibia (could activate just the quads with knee in extension)

NMES assisted lumbar stabilization

one channel on abs, one on back extensors - coactivation increases spinal stability

wrist ROM with NMES

2 channels - one on extensors and one on flexors, alternating activation of each side to get range, have pt activate when they feel it (typical parameters)

pt that would benefit from ROM co-stimulation

stroke, post splint or post cast patients to improve ROM

spasticity/tone with NMES

can either fatigue the agonist or activate the antagonist

fatiguing the agonist/spastic muscle acts by

depleting Ca+ supply from sarcoplasmic reticulum to decrease tone - decreases tone for 2-4 hours (when you should therapize)

activating the antagonist of a spastic muscle acts by

reciprocal inhibition shutting off the agonist with antagonist stimulation (typical NMES parameters), combine with functional activities - decreases tone for 2-4 hours

botox for spastic muscles

injections into high tone muscles to interfere with reuptake of ACh and shut down the spastic muscle, 2-4weeks to activate, then decreases tone for 3-5 months

can combine NMES and botox

apply NMES on botox day 1-2 to fatigue injected muscles and then stimulate antagonist after a few days to optimize effects of botox (still decreases for 3-5 months)

can also combine botox with

seriel casting

long term effects for NMES with tone if

performed daily for weeks/months

contraindications to estim

demand type pacemaker, malignancy, thrombus, transcranial, transthoracic, areas prone to hemorrhage, when motion is contraindicated, anterior cervical area, pregnancy, at eyes or testies