Goals:

• Electrical Stimulation is often described in terms of

the goals for which it is being used to accomplish.
• Edema reduction
• Pain reduction
• Muscle strengthening
• Muscle re-education
• Reduction in muscle guarding
Goals that require a motor
response:
• Edema reduction
• Pain reduction

• Muscle strengthening
• Muscle re-education
• Reduction in muscle guarding
 What’s in a name?
• Since different goals can be accomplished with the
“same” modality……they are referred to by what
they are being used for.
– FES-Functional Electrical Stimulation
– aka-EMS
» Electrical Muscle Stimulation
– NMES-Neuromuscular Electrical Stimulation
– aka-EMS
» Electrical Muscle Stimulation
 Physiology Review
• Neuron • Types of Neurons
– Cell body – A fibers
– Axon – Motor fibers
– Dendrite – Nociceptors
 Types of Nerve Fibers
• A fibers (A Beta)
– Sensory, motor, fast
pain, heat, cold,
proprioception,
pressure, touch and
vibration
– (mechanoreceptive)
 Types of Nerve Fibers

• Nociceptors
– Slow and fast pain,
temperature excesses,
tissue damage
 Characteristics of Neurons

• Myelinization
– Insulation covering the
axon, enables more rapid
conduction for impulses
along the axon
 Characteristics of Neurons
• Diameter
– The greater the diameter of the nerve fiber, the more
easily the nerve is stimulated and the lower the
threshold of excitability to electrical stimulus.
– Shorter duration of an excitatory response
– The greater the diameter, the shorter the refractory
period
 Physiology
• Neuron Characteristics
– Excitability
– Threshold for Action potential
– Stimulation Sites
• Motor Point
– Muscle belly
» neuromuscular junction
• Distal on the muscle belly
– Longitudinal conduction through the muscle fibers
 Nerve Fiber Excitability
• Propagation of an impulse
– The transmission of the electrical information along a
nerve fiber
– Diameter and myelinization of the nerve fiber
– The stimulus must be of an adequate intensity and
duration to meet or exceed the threshold of the nerve
fiber
 Nerve Fiber Excitability
• Thresholds for nerve are lower than thresholds
for muscle that is de-nervated
– The conduction is poorer
– Muscle fibers must be stimulated directly
– instead of the motor nerve which is unavailable
 Physiology
• Refractory Period
– The amount of time that it takes the nerve fiber to
return to its pre-stimulus state
– to re-polarize following de-polarization
• To be able to carry another impulse
• To continue the sensation or response of the fiber
• Information may only be transmitted when the
nerve fiber re-polarizes
 Characteristics of Neurons:
• Excitability
– Action Potential
• The “message unit” of the nervous system to
transmit information along a nerve fiber
 Waveform Considerations
• General Considerations when
applying Electrical
Stimulation for a motor
response
– Think first…
What purpose does the skin serve?
Skin Stratum Corneum
If you want to accomplish your goal….

• You have to be able to cross over the skin!

 Neuromuscular Electrical
Stimulation
• NMES
– Stimulation of the neuromuscular
junction for the purpose of eliciting a
motor response of the muscle
– In accomplished whenever there is
an electrically induced muscle
contraction
• Requiring that motor points be utilized
 Indications for NMES
• Pain relief
• To enhance blood flow
• To fatigue a muscles that are guarding
• To “re-educate” muscle
• To enhance muscle contraction strength and
endurance
 Types of Motor Responses
• Twitch link
– Response to one long duration pulse of
electrical stimulus
– Single motor unit response to stimulus
– Non-physiological
– Occurs in response to low frequency stimulus
delivery

Less than 15 pps

 Types of Motor Responses
• Tetany
– The final fusion of muscle twitches
– Tension is much greater than for individual twitches
– It is a function of the applied frequency of the
electrical stimulus at an amplitude sufficient to elicit a
motor response
• 35-50pps = optimal to limit fatigue
 Selective Stimulation
Parameters
• SD Implications
– Pulse duration
• For motor responses of innervated muscle
– At least 200 usec
– Intensity
• For motor responses of innervated muscle,
– it must be more than just sensory
 Selective Stimulation
Parameters
• Frequency
– Less than 15 pps will produce a twitch response
– More than 15 pps will produce more of a tetanic
contraction
• 35-50pps for smooth tetanic responses
• 50+pps will produce a smooth tetanic contraction
that will quickly fatigue
 NMES for muscle strengthening
• What about ON times?
– Are they important
• Actually the recovery time for the muscle is more
important!
– It can take up to 50 seconds for a muscle to recover after
a 10 second maximal contraction

– Here’s an overview
 Electrically Induced Muscle
Contraction
• Following an electrically induced muscle
contraction,
– Marked increase in the blood flow in the
treated extremity
• Hmmmm… I wonder what effect that could have?
 Electrically Induced Muscle
Contraction
– Muscle contractions have been studied in
response to different frequencies of ES
• 8-32 pps significant increase in blood flow (Wakim
1953)

• Above 32 pps smaller increases in blood flow than

8-32 pps (Wakim, Randall, Imig & Hines 1953)
 Electrically Induced Muscle
Contraction
• Direct stimulation of the afferent neurons causes peripheral
vasodilation
• Recruitment of muscle fibers will occur in the opposite pattern to
voluntary recruitment
– With ES deeper, slower fatiguing muscles respond first
• Also fatiguing more quickly
• In other words, you will not get this, from this…
 Electrically Induced Muscle
Contraction
• Physiologic Response
– Lymphatic return
– Blood flow increase
– Strength increase
• ONLY IF
– Against resistance
– Exercised to the point of fatigue, etc.
 Electrically Induced Muscle
Contraction
What about electrical stimulation as an aide to ambulation?
After a CVA it has been helpful in alleviating foot drop.

Bioness has several products and interesting case histories.

 Contraindications to NMES
• Over a pregnant uterus
• In the presence of a pacemaker
• In anesthetic areas
Hmmm………..
• transcranially
Why is it
contraindicated
transcranially?
 Contraindications to NMES
• In the presence of a thrombus
– A blood clot
• In the vicinity of a thrombus
• These could cause…
Contraindications to NMES

• Unstabilized
fracture!!!!!!
 Current Flow
Electron Flow
(shown in red)
Between the generators and
electrodes
To and from the generator
Ion Flow
(shown in yellow)
Occurs within the tissues
+
Negative ions flow towards the -

anode and away from the +

-
cathode
Positive ions flow towards the
cathode and away from the
anode

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 Electrode Proximity
Determines the number
of parallel paths
The farther apart the
electrodes the more
parallel paths are formed
More current is required
to produce effects as the
number of paths
increases

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 Stimulation Points
• Motor Points
Superficial location of motor nerve
Predictably located
Motor nerve charts
• Trigger Points
Localized, hypersensitive muscle spasm
Trigger referred pain
Arise secondary to pathology
• Acupuncture Points
Areas of skin having decreased electrical resistance
May result in pain reduction
• Traumatized Areas
Decreased electrical resistance (increased current flow)

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 Phase Duration and
Nerve Depolarization
• Phase duration selectively depolarizes
tissues
Phase Duration Tissue
Short Sensory nerves
Medium Motor nerves
Long Pain nerves
DC Muscle fiber

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 Adaptations
• Patients “get used” to the treatment
• More intense output needed
• Habituation
Central nervous system
Brain filters out nonmeaningful, repetitive information
• Accommodation
Peripheral nervous system
Depolarization threshold increases
• Preventing Adaptation
Vary output (output modulation) to prevent
The longer the current is flowing, the more the current must be
modulated.

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 Electrical Stimulation Goals

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 Motor-level Stimulation
Comparison of Voluntary and Electrically-Induced Contractions
Voluntary • Electrically-induced
Type I fibers recruited • Type II fibers
first recruited first
Asynchronous • Synchronous
Decreases fatigue recruitment
GTO protect muscles – Based on PPS
• GTOs do not limit
contraction

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 Motor-level Stimulation
• Parameters:
Amplitude: Contraction strength increases as
amplitude increases
Phase duration: 300 to 500 µsec targets motor
nerves:
The shorter the phase duration, the more amplitude
required
Longer durations will also depolarize pain nerves
Pain often limits quality and quantity of the contraction
Pulse frequency: Determines the type of
contraction

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 Pulse Frequency
• Frequency determines the time for mechanical
adaptation
• Lower pps allows more time (longer interpulse
interverals)
Label Range Result
Low < 15 pps* Twitch: Individual contractions
Medium 15-40 pps* Summation: Contractions blend
High >40 pps* Tonic: Constant contraction

* Approximate values. The actual range varies from person-to-

person and between muscle groups
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 Effect of Pulse Frequency on Muscle
Contractions

1 pulse per second 20 pulses per second 40 pulses per second

Twitch Contraction Summation Tonic Contraction
The amount of time The amount of time The current is flowing so
between pulses – the between pulses allows rapidly that there is not
interpulse interval – is some elongation of the sufficient time to allow the
long enough to allow the fibers, but not to their fibers to elongate
muscle fibers to return to starting point.
their original position

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 Path of Least Resistance
Ion flow will follow the path of
least resistance
Nerves
Blood vessels
The current usually does not
flow from electrode-to-
electrode (the shortest path)
The path of least resistance is
not necessarily the shortest
path

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 Selective Stimulation of Nerves
• Nerves always depolarize in the same order
Sensory nerves
Motor nerves
Pain nerves
Muscle fiber
• Based on the cross-sectional diameter
Large-diameter nerves depolarize first
• Location of the nerve
Superficial nerves depolarize first

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 Electrical Stimulation Goals
Pain Control

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 Pain Control
Sensory-level Motor-Level Noxious Level
Target A-beta fibers Motor nerves A-delta
Tissue C fibers

Phase < 60 µsec 120 to 250 µsec 1 msec

Duration

Pulse 60 to 100 pps 2 to 4 pps Variable

Frequency 80 to 120 pps

Intensity Submotor Moderate to To tolerance

Strong contraction

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 Electrical Stimulation Goals
Edema Control and Reduction

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 Edema Control
Cathode placed over
injured tissues
High pulse frequency
Submotor intensity
Thought to decrease
capillary permeability
Do not use if edema has
already formed

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 Edema Reduction
Muscle contractions “milk”
edema from extremity
Electrodes follow the
vein’s path
Alternating rate targets
muscle groups
Elevate during treatment

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 Electrode size
& Placement

Electrode size and placement are key elements which the therapist
controls that will have great influence on results.
Electrode size will also change current intensity
If one electrode is larger and the other is smaller, the current density
beneath the smaller electrode is increased.
Using a large (dispersive) electrode remote form the treatment area while
placing a smaller (active) electrode as close as possible to the nerve or
muscle motor point will gibe greatest effect at the small electrode.
The larger electrode disperses the current over the large area
The small electrode concentrates the current in the area of the motor point
High current density close to the neural structure makes it more certain
that the treatment will be successful with the least amount of current.

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