Neuromuscular electrical stimulation

neuro-muscular electrical stimulation is a very useful technique t regain lost functions..

1. Neuromuscular electrical stimulation Presented by : Dr. Hemangi Parmar 1 st MPT

2. contents Introduction How NMES works? Muscle responses to NMES Electrical waveforms used in NMES Stimulus parameters in NMES Precautions and contraindications of NMES Application of NMES References

3. introduction Neuromuscular Electrical Stimulation (NMES)  uses a device that sends electrical impulses to nerves. This input causes muscles to contract. The electrical stimulation can increase strength and range of motion, and offset the effects of disuse .

4. It is often used to “re-train” or “re-educate” a muscle to function and to build strength after a surgery or period of disuse. Therapeutic NMES – Use of repetitive stimulation of activation of paralyzed muscles to minimize specific impairments like limited ROM motor weakness spasticity cardiovascular de conditioning.

5. Functional NMES – Use of NMES to activate paralyzed muscle at a precised sequence to assist in the performance of ADLs or to provide stability to a joint or maintain biomechanical integrity and therefore function. Functional Electrical Stimulation or FES FES involves the use of NMES to activate muscles in a specific order and degree to complete a functional task.

6. How nmes works? An electric current is the directed flow of charged particles in some conducting medium. Electric currents also occur naturally in human body, and for that there are two conducting mediums : 1. ionic fluids 2. nerves

7. Nerves are specialized , excitable tissues , designed to carry waves of ion fluxes in the form of action potentials, action potentials carry the impulses transmitted within the central and peripheral nervous system. Skeletal muscles are innervated by peripheral motor nerves organized in a functional units known as Motor units.

8. The electrical current activates the motor units by inducing action potentials in the motor nerve. Activation always takes place through the motor nerves because the nerves are much more excitable . Intact motor nerve is a pre-requisite for activating a muscle with NMES.

9. Muscle response to NMES 3 types of muscle fibers, Slow oxidative Fast Oxidative- Glycolytic Fast Glycolytic

10. Electrical waveforms used in NMES Mono- phasic {one polarity only} Biphasic {alternating polarity} Pulsed {isolated pulses of current between which there is no current flow} Bursted {bursts of currents between which there is no current flow}

11. Any of these waveforms can work well , but there are relative advantages depending upon the application. Examples : Pulsed current , are especially useful for activating small muscles. When there is a requirement of strong contractions of lower extremities , biphasic waveforms will be more effective.

12. Stimulus parameters in nmes Pulse amplitude and duration control Both together regulates the charge of each pulse and so determine the number of peripheral nerve fibers recruited with each stimulus. Amplitude control accompanies by balance control which effectively shifts between the channels. As the balance control is adjusted , the output amplitude on one channel rises while of the other channel falls.

13. optimal pulse duration likely lies between 50 and 1000 microseconds. 2. Frequency A train of electrically induced action potentials in rapid sucession will result in corresponding series of twitches in targeted muscle. A frequency of 30-50 pulses per second produces a smooth tetanic contraction.

14. 3 . Intensity Intensity in miliamperes varies with pulse duration. Short duration pulses require relatively higher intensities , where as relatively low intensities are adequate with long-duration pulses. As intensity increases , force of contraction increases because more motor units are recruited within motor nerve. Intensity should be tolerable for the subject as well as able to elicit motor response.

15. 4. Duty Cycle It is used to avoid fatigue. The off part allows ionic gradients and neurotransmitters to recover in nerve and muscle. On : off ratio of 1:7 minimizes fatigue but its time consuming. And ratio of 1:1 is rapid. So , 1:3 ratio is used clinically. 4 second of stimulation and 12 seconds of rest.

16. 5. Ramping Ramp modulation controls are included in neuromuscular electrical stimulation so that the pulse charge of phase of each stimulus may be gradually increased or decreased. The gradual rise allows the gradual recruitment of nerve fiber and comfortable initiation of contraction for subject.

17. It is most effectively used in neurologically impaired patients. The gradual decline allows smooth movement.

18. Electrode size and placement If one of the electrode is smaller than other , the current density will be greater under the electrode because the current pass through a smaller area. Small electrodes are sometimes used to focus current over a particular motor point, allowing isolated contraction in targeted muscle. Larger electrodes are used for back region.

19. Precautions and contraindications of nmes Contraindications, Unstable cardiac conditions Implanted pacemakers Acute danger or hemorrhage Acute danger of thromboembolism

20. Precautions Epilepsy Decreased sensation No stimulus over carotid sinus No stimulus across of through thorax No stimulus over larynx area Do not stimulate diseased skin Prosthetic joint motion restriction Avoid grounding faults

21. Applications of NMeS Effects of neuromuscular electrical stimulation on cytokines in peripheral blood for healthy participants: a prospective, single‐blinded Study. 2 . The effectiveness of quadriceps strengthening exercises combined with neuromuscular electrical stimulation on patellofemoral pain syndrome : pilot study.

22. 3. The effects of transcutaneous neuromuscular electrical stimulation on the activation of deep lumbar stabilizing muscles of patients with lumbar degenerative kyphosis . 4. Effects of Neuromuscular Electrical Stimulation Training on Endurance Performance.

23. Neuromuscular electrical stimulation in stroke Effects of Electrical Stimulation in Spastic Muscles After Stroke Systematic Review and Meta-Analysis of Randomized Controlled Trials. Neuromuscular Electrical Stimulation for Motor Restoration in Hemiplegia

24. Effectiveness of neuromuscular electrical stimulation for management of shoulder subluxation post-stroke: a systematic review with meta-analysis Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study

25. Neuromuscular electrical stimulation in spinal cord injury Abdominal functional electrical stimulation to improve respiratory function after spinal cord injury: a systematic review and meta-analysis. Rehabilitation of hand in subacute tetraplegic patients based on brain computer interface and functional electrical stimulation: a randomised pilot study

26. others Neuromuscular electrical stimulation in mechanically ventilated patients: A randomized, sham-controlled pilot trial Training postural control and sitting in children with cerebral palsy: Kinesio taping vs. neuromuscular electrical stimulation

27. Effectiveness of neuromuscular electrical stimulation during gait in children with cerebral palsy Neuromuscular Electrical Stimulation Cycling Exercise for Persons with Advanced Multiple Sclerosis Neuromuscular electrical stimulation to improve exercise capacity in patients with severe COPD: a randomised double-blind, placebo-controlled trial.

28. BLADDER management with NMES : Patients with suprasacral spinal cord lesions can have electrical stimulation applied to the intact sacral nerves or nerve roots to produce effective micturition and improve bowel function, significantly reducing complications

29. references Andrew J. Robinson , Lynn snyder-mackler ; Clinical Electrophysiology : Electrotherapy and electrophysiologic testing ; 3 rd edition. Brain reed ; Physiology of neuromuscular electrical stimulation.; 1997 Truong AD, Kho ME, Brower RG, Feldman DR, Colantuoni E, Needham DM. Effects of neuromuscular electrical stimulation on cytokines in peripheral blood for healthy participants: a prospective, single‐blinded Study. Clinical physiology and functional imaging. 2017 May 1;37(3):255-62. Çelik D, Argut SK, Kılıçoğlu Ö. The effectiveness of quadriceps strengthening exercises combined with Neuromuscular Electrical Stimulation on patellofemoral pain syndrome: Pilot study. Physical Therapy in Sport. 2017 Nov 30;28:e16 Kim SY, Kim JH, Jung GS, Baek SO, Jones R, Ahn SH. The effects of transcutaneous neuromuscular electrical stimulation on the activation of deep lumbar stabilizing muscles of patients with lumbar degenerative kyphosis . Journal of physical therapy science. 2016;28(2):399-406.

30. 6. Veldman MP, Gondin J, Place N, Maffiuletti NA. Effects of neuromuscular electrical stimulation training on endurance performance. Frontiers in physiology. 2016 Nov 16;7:544. Stein C, Fritsch CG, Robinson C, Sbruzzi G, Plentz RD. Effects of electrical stimulation in spastic muscles after stroke: Systematic review and meta-analysis of randomized controlled trials. Stroke. 2015 Jan 1:STROKEAHA-115 . Chae J, Sheffler L, Knutson J. Neuromuscular electrical stimulation for motor restoration in hemiplegia . Topics in stroke rehabilitation. 2008 Sep 1;15(5):412-26 . Lee JH, Baker LL, Johnson RE, Tilson JK. Effectiveness of neuromuscular electrical stimulation for management of shoulder subluxation post-stroke: a systematic review with meta-analysis. Clinical rehabilitation. 2017 Nov;31(11):1431-44 . Xu Q, Guo F, Salem HM, Chen H, Huang X. Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study. Clinical rehabilitation. 2017 Dec;31(12):1583-91.

31. 11.McCaughey EJ, Borotkanics RJ, Gollee H, Folz RJ, McLachlan AJ. Abdominal functional electrical stimulation to improve respiratory function after spinal cord injury: a systematic review and meta-analysis. Spinal cord. 2016 Sep;54(9):628 . 12. Osuagwu BC, Wallace L, Fraser M, Vuckovic A. Rehabilitation of hand in subacute tetraplegic patients based on brain computer interface and functional electrical stimulation: a randomised pilot study. Journal of neural engineering. 2016 Oct 14;13(6):065002.