1. U D U D Electrical Stimulation and Lumbar Stabilization Training with Performing Artists Tara Jo Manal PT, DPT, OCS, SCS University of Delaware Department of Physical Therapy

2. U D U D Lumbar Extensor Musculature n Erector spinae musculature are responsible for extensor force n Multifidus muscles are segmental extensors responsible for stabilization of lumbar motion segments Fritz et al 2000 Fritz et al 2000

3. U D U D Muscle Strength and Low Back Pain n In firefighters, muscle strength of the low back was a good indicator for the development of low back pain Cady et al 1979 Cady et al 1979 n In manual material workers there was a positive correlation between strength and frequency of low back pain Chaffin 1974 Chaffin 1974

4. U D U D Figure Skating and Low Back Pain n Lumbar extensor strength is needed to achieve many positions and successfully land jumps

5. U D U D Low Back Strength

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8. U D U D Electrical Stimulation for Strength n Snyder-Mackler et al, 1995 –Conclusion: For quadriceps weakness, high-level e-stim with volitional exercise is more successful than exercise alone

9. U D U D Electrical Stimulation for Strength n n Snyder-Mackler et al., 1995 – –Conclusion: For Quadriceps Weakness, High-Level E- stim with Volitional Exercise is more successful than Exercise alone – –Fitzgerald et. al., 2003

10. U D U D Electrical Stimulation for LB Strengthening n n The application of this same type of Electrical Stimulation to the LB may help increase strength and recovery of Low Back Musculature following injury – –Kahanovitz et al., 1987 – –McQuain et al., 1993

11. U D U D Parameters of Electrical Stimulation n n 2500 Hz n n Variable wave form – –triangle, sine, square n n 75 bursts/second n n 2 second ramp n n 12 seconds on time n n 50 second rest time n n 10-15 contractions

12. U D U D Patient Positioning: Isometric n n Prone over pillows n n Pelvis strapped to the table in Posterior Pelvic Tilt n n Assess movement to active lumbar extension and tighten as necessary

13. U D U D Current Intensity n n In quadriceps  50% maximal volitional isometric contraction n n Look for visible contraction n n Maximal tolerable contraction by the patient n n A single channel is placed on the right and left side of the spine

14. U D U D Electrical Stimulation for Strengthening

15. U D U D Treatment Administration n Patient motivation factors –Assist your patient in tolerating treatment n Monitor –set targets, watch output, give article n Blunter –wear headphones, towel over head, body relaxation (Delitto et al PT 1992)

16. U D U D Give the Patient Control n n Self trigger if possible n n Therapist manually resuming stim n n Count down to the stim n n Explain to the patient the value of the modality

17. U D U D What we do when things are not going well … n n General – –Tens Clean Cote – –Change the waveform – –Decrease pulse duration » »may need to also increase the frequency for comfort n n Specific – –Increase ramp time – –Self trigger – –Increase rest time » »Only if you see them fatiguing drastically

18. U D U D Case #1 n 21 year old figure skater n 1 year following a L5/S1 titanium cage fusion –5 months following hardware removal n Pain limiting her ability to return to skating (2 months) n Pain limiting her ability to attend college classes

19. U D U D Case #1 - Evaluation n Constant LBP (L5) Avg. 4/10 n Oswestry score 20% n Intermittent “electric shock” from back into left buttocks (always with landing on ice) n Increased pain –standing >30 minutes –prone lying

20. U D U D Case #1 - Evaluation n Pain with return to extension from full flexion (alleviated with traction by PT) n Pain at end range flexion, extension and bilateral sidebending n Joint hypomobility L4/L5 (recreated pain to buttock)

21. U D U D Case #1 - Early Intervention n Lumbar mobilizations L4/5 unilateral n Stabilization exercises (pelvic neutral) –lower extremity t-band –quadruped arm/leg raises –ball exercise program –side planks

22. U D U D Case #1 - Response n After 6 Treatments n Improvement in the ability to return to upright from flexed posture following treatment but return to baseline by next day n Overall pain levels were intermittent rather than constant n Difficulty with stabilization exercises due to fatigue and substitution of larger muscles

23. U D U D Case # 1- Hypothesis n Patient was responding positively to treatment intervention, however, gains were slow and fatigue and weakness made correct exercise performance difficult n Electrical stimulation may help assist patient in rapid strengthening and be a successful adjunct to her strengthening program

24. U D U D Case #1 - Electrical Stimulation n 7th Treatment n Clearance with physician on the use of electrical stimulation with titanium cage n High Intensity Electrical Stimulation was added to assist in the recovery of the lumbar paraspinal musculature n Patient complained of muscle soreness that resolved within 24 hours

25. U D U D Case #1- Progress n 15 treatments of electrical stimulation n Oswestry 12% n Gym work-outs for 1 hour/ 4 times weekly n Run 2 miles pain-free

26. U D U D Case #1 - Skating Progression n Progressive return to skating (40 minutes without shooting pain into buttock) n 2 weeks later complained of localized back pain with stopping turns n 4 weeks later returned to compulsories and complained of LBP with twisting - no buttock pain

27. U D U D Case #1 - Skating Progression n 3 months later has progressed to Pilates strengthening program n 9 months later she can skate 2-3 times weekly for 1.5 hours before any LBP and no reoccurrence of L buttock pain

28. U D U D Discussion n Electrical stimulation has been successfully added to programs of lumbar stabilization with figure skaters n There were no negative effects to the high intensity stimulation treatments –fusion –stress response

29. U D U D Discussion n Electrical stimulation may show promise in assisting patients in recovering following lumbar injury especially when returning to demanding activities n Electrical stimulation may be beneficial for patients who are unable to perform other exercise programs due to pain

30. U D U D Further Research n Research must be done to determine the effectiveness of the addition of electrical stimulation to a rehabilitation program for low back pain n Work aimed at determining the forces generated in the lumbar spine during these contractions will help therapists determine who can best benefit from this intervention

31. U D U D Case Example: HNP L3/4 n n History: – –Left low back and anterior thigh pain – –Difficulty with bed and car transfers – –Weakness in the left quadriceps femoris – –MRI (+) HNP at L3/4

32. U D U D Case Example: HNP L3/4 n n Strength Assessment – –Left - 105 ft # – –Right - 170 ft # – –Quad Index - 62%

33. U D U D Case Example: HNP L3/4 n n NMES: treatment for quad weakness – –Carrier frequency 2500 Hz (400 μs pulse duration) – –Burst frequency 75 bps – –On time 10 seconds – –Off time 50 seconds – –Ramp on 2 seconds – –Intensity > 50% MVIC of involved – –10 contractions – –Electrodes: vastus medialis and rectus femoris

34. U D U D Case Example: HNP L3/4 Quadriceps Strength

35. U D U D Case Example: Stenosis n n Chief complaints – –Bilateral buttock and posterior thigh pain with walking – –Right anterior/lateral calf pain – –Foot slap on right > 1 year – –History of falls due to tripping

36. U D U D Neurological Impairments n n Sensory deficit – –Dermatomal distribution – –Light touch n n Deep Tendon Reflexes n n Strength deficit – –Myotomal distribution

37. U D U D Case Example: Stenosis n n MMT on Initial Evaluation RightLeft Ankle DF4-/54-/5 Ankle EV3+/55/5 Great toe DF3+/54-/5 n n Oswestry: 14% n n EMG: Bilateral L5 and S1 radiculopathy right > left n n MRI: Moderate congenital stenosis with disc herniations on the right at L1/2 and L5/S1

38. U D U D Case Example: Stenosis n n NMES to address weakness – –Carrier frequency 2500 Hz (400µs pulse duration) – –Burst Frequency 75 bps – –Ramp on 2 seconds – –On time 12 seconds – –Off time 50 seconds – –Intensity max tolerance – –Total time 15 minutes

39. U D U D Case Study: Stenosis EvalRightLeft Ankle DF4-/54-/5 Ankle EV3+/55/5 After 10 sessions of NMES RightLeft Ankle DF4/54-/5 Ankle EV4/54+/5

40. U D U D Case Example: Stenosis n n Functional recovery – –Reports no episodes of foot slap or ankle weakness – –Wife reports he no longer favors his right lower extremity n n Oswestry: 4% compared to 14% at eval