1. Electrotherapy (aka. clinical electrophysiological intervention) is the safe and competent use of electrical current for a therapeutic purpose.

2. 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.

3. Electricity Knowledge Map

4. Identifying type, form, and descriptive characteristics Phases: number of; applies to Pulsed Current onlyPhases: number of; applies to Pulsed Current only Symmetry: are the phases mirror images? (size and shape)Symmetry: are the phases mirror images? (size and shape) Balance: is the area under each (+) and (-) phase equal? (eg. amount of charge)Balance: is the area under each (+) and (-) phase equal? (eg. amount of charge)

5. Practice using the Descriptive Characteristics of Electrical Pulses

6. Quantitative Characteristics of Pulsed Currents

7. Effects of changing Amplitude, Width, and Rate

10. Electrical Stimulation of Tissues Conductivity of tissuesConductivity of tissues Directional flow of current in tissuesDirectional flow of current in tissues Excitable tissues in the body and comparable thresholdsExcitable tissues in the body and comparable thresholds

12. More.. Classification of peripheral nerve fibers

13. Strength (amplitude) and Duration (width)

14. Electrode Arrangement Terminology: Monopolar Placement Bipoloar Placement Quadpolar Placement

15. 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.

16. What’s the target with NMES?

17. Classic Responses all apply

18. Motor Responses are KEY

19. Electrode Size & Placement :

20. Electrode Placement 20 Figure 12-05. Electrodes placed over the proximal and distal ends of the quadriceps muscles for maximum efficacy.

21. Voluntary vs. Electrically Induced Muscle Contractions 2 main differences related to recruitment: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 typeSlow twitch type I firstFast twitch type II first Contraction forceLowHigh Speed of contractionSlowFast FatigueFatigue resistantFatigues quickly AtrophyAtrophy resistantAtrophies quickly RecruitmentAsynchronousSynchronous

22. Clinical Implication & Application of Order or Recruitment Differences NMES can be more effective at specifically strengthening muscle fibers weakened by disuse. Why?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?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.Since NMES contractions are more fatiguing than voluntary contractions, long rest times should be provided between contractions.

23. 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

24. Biphasic Pulsed Current: same as what we used with TENS; now we will increase the pulse width to 250 u s and greater. Common current used on battery operated NMES units Types of pulsed currents approp for NMES

25. Timing Modes for NMES parameters

26. Ramp-Surge Mode: Parameters

28. Physiologic Effects of NMES Increasing vascular flow via ms. pumpIncreasing vascular flow via ms. pump Decreasing painful muscle spasm / guardingDecreasing painful muscle spasm / guarding Muscle re-education (facilitating innervated ms with impaired motor control); improve motor controlMuscle re-education (facilitating innervated ms with impaired motor control); improve motor control Muscle strengthening or to slow the rate of muscle atrophyMuscle strengthening or to slow the rate of muscle atrophy Maintain or increase joint range of motionMaintain or increase joint range of motion Temporarily reduce muscle spasticity / hypertonicityTemporarily reduce muscle spasticity / hypertonicity Act as an orthotic device to improve function at a moveable area. (Functional Electrical Stimulation [FES] )Act as an orthotic device to improve function at a moveable area. (Functional Electrical Stimulation [FES] ) –State the impairment and treatment goal

29. Example NMES setups

34. Relating Muscle Fatigue and NMES Parameters

35. NMES summary Rx chart

36. Cameron’s NMES summary Rx chart

37. 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

40. US / E-stim Combo

41. 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??

42. 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 ??