Slide 1 Electrical Stimulation to Electrical Stimulation to Augment Muscle Strengthening: Augment Muscle Strengthening: Guidelines for Surgical Guidelines for Surgical Procedures, Diagnosis and Co- Procedures, Diagnosis and Co- Morbidities Morbidities Tara Jo Manal PT, OCS, SCS: Tara Jo Manal PT, OCS, SCS: Director of Clinical Services Director of Clinical Services Orthopedic Residency Director Orthopedic Residency Director University of Delaware Physical University of Delaware Physical Therapy Department Therapy Department [email protected][email protected]302-831-8893 302-831-8893
Transcript
Slide 1
Slide 1 Electrical Stimulation to Augment Muscle Strengthening:
Guidelines for Surgical Procedures, Diagnosis and Co-Morbidities
Tara Jo Manal PT, OCS, SCS: Director of Clinical Services
Orthopedic Residency Director University of Delaware Physical
Therapy Department [email protected]@udel.edu 302-831-8893
[email protected]
Slide 2
Slide 2 Properties of Electrical Stimulation Tara Jo Manal PT,
OCS, SCS University of Delaware
Slide 3
Slide 3 Properties of Electric Stimulation Voltage Voltage
Voltage represents the driving force that repels like charges and
attracts opposite charges Current Current Current is the movement
of charged particles in response to voltage Ampere represents an
amount of charge moving per unit time The higher the voltage, the
higher the current
Slide 4
Slide 4 Magnitude of Charge Flow Conductance Conductance
Relative ease of movement of charged particles in a charged medium
If the ease of movement is high, the resistance to movement is low
Resistance Resistance Opposition to movement of charged particles
Lower resistance provides greater comfort/tolerance by patient for
higher intensity stimulation since less charge is needed to
penetrate the skin
Slide 5
Slide 5 Ohms Law I = V/R I = V/R Current increases as the
driving force (V) is increased or as the Resistance (R) to movement
is decreased As the skin resistance decreases, more of the current
can flow, increasing the response As the skin resistance decreases,
more of the current can flow, increasing the response
Slide 6
Slide 6 Properties Impedance Impedance Opposition to
alternating currents Higher frequency stimulation can pass with
greater ease Impedance is the best word to describe resistance to
flow in human tissue since it is comprised of the tissue resistance
and the insulator (subcutaneous fat) effects of tissue Greater the
impedance, greater the intensity required to achieve therapeutic
goal High frequency stimulation is more comfortable because
impedance is lower
Slide 7
Slide 7 Current Density Represents the intensity/area under a
stimulation pad Represents the intensity/area under a stimulation
pad At fixed voltage smaller the electrode the greater the
intensity of the stimulation compared to larger electrodesmaller
the electrode the greater the intensity of the stimulation compared
to larger electrode Caution in setting intensity level with smaller
electrodes or damaged electrodes Very high current density can be
related to biological damage or burnsVery high current density can
be related to biological damage or burns Large electrodes Can the
unit produce sufficient current intensity?Can the unit produce
sufficient current intensity?
Slide 8
Slide 8 Current Modulation Timing Timing Altering the time
characteristics of stimulation Train Train a continuous, repetitive
series of pulses at a fixed frequency
Slide 9
Slide 9 Current Modulation Burst Burst a package of train
pulses delivered at a specified frequency e.g. 2 bursts per
second
Slide 10
Slide 10 Carrier Characteristics Carrier frequency Carrier
frequency Pulse duration is 1/f To increase pulse duration to
improve muscle force output you would decrease the train frequency
2000Hz = 1/2000 or 500 second pulse duration 1000Hz = 1/1000 or
1000 second (1 millisecond) pulse duration
Slide 11
Slide 11 Frequency and Pulse Duration If the f is 5 Hz or 5
cycles/second The duration is 1/5 or 20milliseconds
Slide 12
Slide 12 Pulse Duration Increases recruitment of motor units
Increases recruitment of motor units Improves the muscle
contraction Improves the muscle contraction Often labeled width or
pulse width Often labeled width or pulse width
Slide 13
Slide 13 How to Achieve High Force Activate more motor units
(recruitment) Drive the motor units more quickly (Rate coding)
Slide 14
Slide 14 NMES Increasing Recruitment How to recruit more motor
units electrically? Increase recruitment via phase charge How to
increase phase charge Increase amplitude Increase pulse duration Or
BOTH Phase Charge Mixed Nerve
Slide 15
Slide 15 Frequency Increasing frequency Increasing frequency
Tetanic contraction Tetanic contraction Force production reaches a
plateau maximum between 50-80 pulses per second Force production
reaches a plateau maximum between 50-80 pulses per second For
muscle strengthening you want 50-80 pulses/second or 50-80
bursts/second For muscle strengthening you want 50-80 pulses/second
or 50-80 bursts/second
Slide 16
Slide 16 Frequency Controls Usually labeled Rate or Pulse Rate
Usually labeled Rate or Pulse Rate Set the number of pulses (or AC
cycles) delivered through each channel per second Set the number of
pulses (or AC cycles) delivered through each channel per second As
frequency is increased, impedance is decreased As frequency is
increased, impedance is decreased
Slide 17
Slide 17 NMES Increasing frequency How to achieve high force
Rate Coding Increase the frequency of stimulation But increased
frequency increased fatigue
Slide 18
Slide 18 Quality of Contraction Goal = strong tetanic
contraction Stimulation frequency 50-80 pps
Slide 19
Slide 19 Understanding the Manuals Presets Presets Advantages
& Disadvantages Adjustable Controls Adjustable Controls
Waveform Selection Amplitude Controls AC: generally have a maximum
of 100 200mAAC: generally have a maximum of 100 200mA Independent
vs. Shared amplitude control for multiple channelsIndependent vs.
Shared amplitude control for multiple channels
Slide 20
Slide 20 Cycle time controls On & Off Time On & Off
Time Duration of stimulation and rest Rest time dependent on goal
of treatment Strengthening- Adequate rest to avoid
fatigueStrengthening- Adequate rest to avoid fatigue
Slide 21
Slide 21 Ramp Controls Controls the rate the amplitude
increases Controls the rate the amplitude increases Provide for
more comfortable onset and cessation of stimulus when very high
levels of stimulation are required Provide for more comfortable
onset and cessation of stimulus when very high levels of
stimulation are required Can adjust if contraction is coming on too
quickly or stopping too quickly Can adjust if contraction is coming
on too quickly or stopping too quickly
Slide 22
Slide 22 Waveform type Waveform Patient dependent Delitto Rose
PT 1986 UD PT Clinic Versastim Empi
Slide 23
Slide 23 Stimulation Parameters What can we modify? Pulse
Duration Pulse Frequency Waveform type Off time (time between
contractions) Ramp time
Slide 24
Slide 24 Stimulator Controls Programmed Stimulation Pattern
Controls Programmed Stimulation Pattern Controls Found on various
stimulation devices, mostly Can be limiting, if user is unable to
program stimulation patterns for a specific application Output
Channel Selection Output Channel Selection Simultaneous Alternate
or reciprocal mode
Slide 25
Slide 25 Line vs. Battery Powered
Slide 26
Slide 26 Test The Unit Empi 300 PV
Slide 27
Slide 27 EMPI 300PV Empi 300PV 1-800-328-2536
Slide 28
Slide 28 Dose of NMES Maximal tolerable current and device
dependent- MVIC above blue line Maximal tolerable current and
device dependent- MVIC above blue line
Slide 29
Slide 29 Dose of NMES Be sure your machine is capable of
current necessary Be sure your machine is capable of current
necessary
Slide 30
Slide 30 Test The Electrodes
Slide 31
Slide 31 Electrodes How to improve the lifespan Proper storage
Keep them moist Placed properly on plastic Improves
conductivity
Slide 32
Slide 32 Another Brand of Electrodes
Slide 33
Slide 33 Same Intensity- Different Electrodes
Slide 34
Slide 34 Electrodes Model F216 Model F216 Size 3 x 5 Size 3 x 5
8 x 13 cm Rectangle Qty 2 Qty 2 1-800-538-4675 1-800-538-4675
Slide 36 Tens Clean Cote Uni-Patch Uni-Patch 1-800-328-9454
1-800-328-9454 Function Function Improves conductivity Improves
conductivity
Slide 37
Slide 37 Pad Placement Typically include motor points of muscle
of interest Typically include motor points of muscle of
interest
Slide 38
Slide 38 Pad Placement Relationship between Pad placement and
current- Non-tetanic contraction Relationship between Pad placement
and current- Non-tetanic contraction
Slide 40 Treatment Administration Patient motivation factors
Patient motivation factors Assist your patient in tolerating
treatment Monitor Monitor set targets, watch output, give article
Blunter Blunter wear headphones, towel over head, body relaxation
(Delitto et al PT 1992)
Slide 41
Slide 41 Give the Patient Control Self trigger if possible
Therapist manually resuming stim Count down to the stim Explain to
the patient the value of the modality
Slide 42
Slide 42 What we do when things are not going well General Tens
Clean Cote Change the waveform Decrease pulse duration may need to
also increase the frequency for comfort Specific Increase ramp time
Self trigger Increase rest time Only if you see them fatiguing
drastically
Slide 43
Slide 43 Evidence to support the clinical use of electrical
stimulation for muscle strengthening
Slide 44
Slide 44 Increased Functional Load For muscle to hypertrophy
and/or gain strength the overload principle of high weight at low
repetitions is necessary For muscle to hypertrophy and/or gain
strength the overload principle of high weight at low repetitions
is necessary Currier and Mann Currier and Mann Looked at healthy
male college students Utilized an intensity of at least 60% MVIC
paralleling voluntary exercise protocols for functional overload
Conclusion: NMES and volitional exercise were equivalent training
stimuli (Delitto,Snyder-Mackler, 1990)
Slide 45
Slide 45 Increased Functional Load Kots Therapeutic efficacy
reported for electrical stimulation greater than volitional
exercise, when strengthening healthy muscle Therapeutic efficacy
reported for electrical stimulation greater than volitional
exercise, when strengthening healthy muscle Intensity was 10-30%
greater than MVC Strength gains of 30-40% (Delitto,Snyder-Mackler,
1990)
Slide 46
Slide 46 Increased Functional Load Conclusions on Overload
Conclusions on Overload Significant strength gains can be achieved
in healthy muscle with an electrically augmented training program
The intensity however needs to be extremely high (>100%MVIC)The
intensity however needs to be extremely high (>100%MVIC)
Electrical stimulation offers equivalent muscle strengthening
effects to voluntary exercise in healthy subjects If intensity
level parallels volitional exercise intensitiesIf intensity level
parallels volitional exercise intensities (Delitto,Snyder-Mackler,
1990)
Slide 47
Slide 47 Increased Functional Load Conclusion on Overload
Conclusion on Overload Lower loads may still help in muscle
recovering from injury/surgery Most studies using subjects other
than healthy male college students demonstrated greater strength
gains in subjects training with NMES compared to volitional
exercise aloneMost studies using subjects other than healthy male
college students demonstrated greater strength gains in subjects
training with NMES compared to volitional exercise alone
(Delitto,Snyder-Mackler, 1990)
Slide 48
Slide 48 Electrical Stimulation for Strength Snyder-Mackler et
al., 1991 Purpose: To ascertain the effects of electrically
elicited co-contraction of the thigh muscles on several parameters
of gait and on isokinetic performance of muscles in patients who
had reconstruction of the ACL Purpose: To ascertain the effects of
electrically elicited co-contraction of the thigh muscles on
several parameters of gait and on isokinetic performance of muscles
in patients who had reconstruction of the ACL 2 groups: NMES +
volitional exercise Volitional exercise only Treatment intervention
from 3 rd to 6 th week post- op
Slide 49
Slide 49 Electrical Stimulation for Strength Snyder-Mackler et
al., 1991 Results: Results: Significantly greater average and peak
torque of the quadriceps femoris at both 90/sec and 120/sec in the
NMES group No significant difference in performance of the
hamstring muscles between groups Torque produced in the involved
hamstrings averaged 80% of the strength in the uninvolved legTorque
produced in the involved hamstrings averaged 80% of the strength in
the uninvolved leg
Slide 50
Slide 50 Electrical Stimulation for Strength Snyder-Mackler et
al., 1991 Conclusions: Conclusions: The quadriceps muscles of these
patients were stronger in the eighth post-operative week than
reported averages for similar patients even years after
surgery
Slide 51
Slide 51 Electrical Stimulation for Strength Snyder-Mackler et
al., 1995 Purpose: To assess the effectiveness of common regimens
of electrical stimulation as an adjunct to ongoing intensive
rehabilitation in the early postoperative phase after
reconstructions of the anterior cruciate ligament Purpose: To
assess the effectiveness of common regimens of electrical
stimulation as an adjunct to ongoing intensive rehabilitation in
the early postoperative phase after reconstructions of the anterior
cruciate ligament
Slide 52
Slide 52 Electrical Stimulation for Strength Snyder-Mackler et
al., 1995 Training Intervention 4 Groups Training Intervention 4
Groups High intensity NMES + volitional exercise High level
volitional exercise Low intensity NMES + volitional exercise
Combined high & low intensity NMES + volitional exercise
Slide 53
Slide 53 Electrical Stimulation for Strength Snyder-Mackler et
al., 1995 High Intensity NMES High Intensity NMES 15 electrically
elicited isometric contractions 2500Hz triangular AC current Burst
rate of 75bps Amplitude to maximal tolerance Low Intensity NMES Low
Intensity NMES Portable electrical stimulation Pulse duration of
300 microseconds Frequency of 55pps Amplitude >50mA to maximal
tolerance 15 minutes 4 times/day
Slide 54
Slide 54 Electrical Stimulation for Strength Snyder-Mackler et
al., 1995 High Level Volitional Exercise High Level Volitional
Exercise 3 sets of 15 repetitions of the quadriceps femoris
Intensity was maximum effort for 8 seconds Visual Feedback provided
High Intensity and Low Intensity Electrical Stimulation Combined
High Intensity and Low Intensity Electrical Stimulation Combined
All groups followed a standard volitional exercise protocol beyond
the experimental treatment interventions All groups followed a
standard volitional exercise protocol beyond the experimental
treatment interventions
Slide 55
Slide 55 Electrical Stimulation for Strength Snyder-Mackler et
al., 1995 At least 70% recovery of the quadriceps by 6 weeks after
the operation, vs. 51% in the groups that did not include high
intensity stimulation High intensity electrical stimulation leads
to more normal excursions of the knee joint during stance
Slide 56
Slide 56 Snyder-Mackler et al, 1995 Conclusion: For quadriceps
weakness, high-level NMES with volitional exercise is more
successful than volitional exercise alone Electrical Stimulation
for Strength
Slide 57
Slide 57 Modified NMES Protocol for Quadriceps Strength
Fitzgerald et. al., 2003 Fitzgerald et. al., 2003 Subjects
receiving the modified NMES treatment combined with exercise
demonstrated greater quadriceps strength and higher ADLS scores
than the comparison group
Slide 58
Slide 58 Fitzgerald et. al., 2003 Their data support the
modified NMES protocol in clinics without access to a dynamometer
Their data support the modified NMES protocol in clinics without
access to a dynamometer Option of using a dynamometer Option of
using a dynamometer Authors choose the high intensity NMES
protocol
Slide 59
Slide 59 NMES for Strength in the Early Post-op Phase Haug et
al., 1988 Purpose: Efficacy of NMES of the quadriceps femoris
during CPM following total knee arthroplasty Purpose: Efficacy of
NMES of the quadriceps femoris during CPM following total knee
arthroplasty CPM/NMES group Intensity at maximum toleranceIntensity
at maximum tolerance 3 times per day for 1 hour3 times per day for
1 hour Pulse width: 300 microsecondsPulse width: 300 microseconds
Frequency: 35ppsFrequency: 35pps On 15sec off 20 seconds at 40
setting and 65sec at 90 settingOn 15sec off 20 seconds at 40
setting and 65sec at 90 setting Ramp time: 2 seconds up and 1
second downRamp time: 2 seconds up and 1 second down CPM group
Slide 60
Slide 60 NMES for Strength in the Early Post-op Phase Haug et
al., 1988 Results: Stimulation group had significant reduction of
extension lag, and spent fewer days in the hospital Results:
Stimulation group had significant reduction of extension lag, and
spent fewer days in the hospital Intensity level was low compared
to the other studies mentioned Conclusion: Electrical stimulation
combined with CPM in the treatment of patients with total knee
arthroplasty is a worthwhile adjunctive therapy Conclusion:
Electrical stimulation combined with CPM in the treatment of
patients with total knee arthroplasty is a worthwhile adjunctive
therapy
Slide 61
Slide 61 Role of Strength in Physical Therapy Management
Strength losses can result in loss of the ability to perform
activities of daily living Strength losses can result in loss of
the ability to perform activities of daily living Strength recovery
following surgery is often incomplete Strength recovery following
surgery is often incomplete Strength deficits can place patients at
risk of further injury Strength deficits can place patients at risk
of further injury (Snyder-Mackler, 1991)
Slide 67 Various Surgical Grafts Hamstring Autograft/Allograft
Hamstring Autograft/Allograft Positioned at 60 of knee flexion
Bone-Tendon-Bone Autograft Bone-Tendon-Bone Autograft Positioned in
most comfortable angle flexion position > 40flexion position
> 40
Slide 68
Slide 68 NMES Post ACL Reconstruction Amplitude to minimum of
50% MVIC Amplitude to minimum of 50% MVIC Patient encouraged to
increase the intensity to maximum tolerated Dose-response curve
demonstrates greater intensities lead to greater strength gains
(Snyder-Mackler et al., 1994)
Slide 69
Slide 69 NMES for Muscle Strengthening On time- sufficient for
strong tetanic contraction 10-15 seconds On time- sufficient for
strong tetanic contraction 10-15 seconds Off time- sufficient for
rest/recovery before next contraction 30-90 seconds Off time-
sufficient for rest/recovery before next contraction 30-90 seconds
Ramp time- as needed for comfort Ramp time- as needed for comfort
Dose- maximal tolerable (no less than that needed for strength
gains to be seen) Dose- maximal tolerable (no less than that needed
for strength gains to be seen) Frequency 2-3 times/week until
strength recovers Frequency 2-3 times/week until strength recovers
Average 18 visits
Slide 70
Slide 70 NMES for Quadriceps Strengthening Following injury or
surgery to the knee, quadriceps weakness can be major impairment
Following injury or surgery to the knee, quadriceps weakness can be
major impairment We utilize electrical stimulation on all patients
who demonstrate quadriceps weakness of 80% involved/uninvolved
ratio or less We utilize electrical stimulation on all patients who
demonstrate quadriceps weakness of 80% involved/uninvolved ratio or
less
Slide 71
Slide 71 Post Operative Modification to ACL Protocol for Other
Knee Problems PCL30 Knee Flexion PCL30 Knee Flexion MCL30-60 Knee
Flexion MCL30-60 Knee Flexion Meniscal Excision/ RepairNone
Meniscal Excision/ RepairNone ChondroplastyNone ChondroplastyNone
Post surgical intervention- follow soft tissue healing 8wks to
protect surgical site or 12 weeks for bony healing Post surgical
intervention- follow soft tissue healing 8wks to protect surgical
site or 12 weeks for bony healing
Slide 72
Slide 72 Knee Flexion Angle If Pain if limiting toleration use
most comfortable angle If Pain if limiting toleration use most
comfortable angle If Range of motion is limiting toleration use
most comfortable angle If Range of motion is limiting toleration
use most comfortable angle As long as modification does not risk
surgical procedure As long as modification does not risk surgical
procedure Perform with support from the referring physician Perform
with support from the referring physician
Slide 73
Slide 73 Patellofemoral Joint Syndrome We perform burst
superimposition testing on all PFJ evaluations We perform burst
superimposition testing on all PFJ evaluations Identify true
maximal force generating capability Identify presence or absence of
inhibition Central activation deficitCentral activation deficit
NMES is performed at the most comfortable knee joint angle NMES is
performed at the most comfortable knee joint angle Tape is often
applied for pain control Tape is often applied for pain control
When necessary, treatments to calm irritated structures are added
When necessary, treatments to calm irritated structures are
added
Slide 74
Slide 74 Patellofemoral Joint Syndrome Joint angle adjusted to
patient comfort Joint angle adjusted to patient comfort Determined
by volitional contraction Subluxing Patella Subluxing Patella Joint
angle adjusted to increase congruency to prevent subluxation
Greater than 70Greater than 70 Patella taped medially
Slide 75
Slide 75 Proximal-Distal Patellar Realignment Knee stabilized
isometrically at 30 degrees of knee flexion Knee stabilized
isometrically at 30 degrees of knee flexion Patella taped medially
Patella taped medially Electrodes over the proximal quadriceps/
distal pad is moved central and superior (avoiding the VMO)
Electrodes over the proximal quadriceps/ distal pad is moved
central and superior (avoiding the VMO)
Slide 76
Slide 76 Proximal/Distal Realignment Precautions Initiate 1 st
Week of Treatment Initiate 1 st Week of TreatmentPrecautions
Proximal Realignment Proximal Realignment No MVIC for 8 weeks
Proximal/Distal Realignment Proximal/Distal Realignment No MVIC for
12 weeks Dosage is maximal tolerable rather than % MVIC Dosage is
maximal tolerable rather than % MVIC
Slide 77
Slide 77 Why NMES following TKA? Strength deficits can be
profound Quad weakness decreased by 60% following surgery Impaired
ability to perform ADLs Increased fall risk Chandler et al 1998
Arch Phys Med Rehab Wolfson et al 1995 J Gerontol A: Biol Sci Med
Stevens et al JOR 2003
Slide 78
Slide 78 Goal of NMES Quality muscle contraction Quantity
sufficient enough to produce strength gains Strength gains reflect
intensity tolerated Therefore Ultimate goal is to generate the
greatest tolerable force output
Slide 79
Slide 79 Total Joint Arthroplasty Amplitude targeted at a
minimum of 30% MVIC (Snyder-Mackler et al., 1994) Amplitude
targeted at a minimum of 30% MVIC (Snyder-Mackler et al., 1994)
Ramp time, frequency adjusted to increase comfort and tolerance for
higher intensity stimulation Ramp time, frequency adjusted to
increase comfort and tolerance for higher intensity stimulation
Modification of pulse duration by decreasing frequency to 2000Hz or
1500Hz (inc. pulse duration from 400 to 500 or 666 microseconds)
Modification of pulse duration by decreasing frequency to 2000Hz or
1500Hz (inc. pulse duration from 400 to 500 or 666
microseconds)
Slide 80
Slide 80 NMES for Quadriceps Strengthening Cannot Do It Alone
Weakness can lead to compensation strategies for daily activities
Weakness can lead to compensation strategies for daily activities
COMPENSATIONS MUST BE PREVENTED!!!
Slide 81
Slide 81 Compensation Strategies Unweighting involved leg for
sit to stand Unweighting involved leg for sit to stand
Slide 82
Slide 82 Compensation Strategies Shifting weight in standing to
uninvolved leg Shifting weight in standing to uninvolved leg
Slide 83
Slide 83 Compensation Strategies Not utilizing full extension
during stance phase of gait Not utilizing full extension during
stance phase of gait
Slide 84
Slide 84 Lack of use can lead to... Patellar baja Patellar baja
Lack of superior patellar migration with quadriceps contraction
Lack of superior patellar migration with quadriceps contraction
Quad dysplasia Quad dysplasia
Slide 85
Slide 85 Functional Use of Quadriceps Use of quadriceps during
daily activities must be relearned in order to eliminate
compensation strategies. Use of quadriceps during daily activities
must be relearned in order to eliminate compensation strategies. If
it gets to this pointyou are in a hole! If it gets to this pointyou
are in a hole!
Slide 86
Slide 86 Use of Strength in Daily Activities Composite overview
of muscle performance Composite overview of muscle performance
Functional Testing Observation of compensatory patterns Observation
of compensatory patterns Avoidance patterns Lack of progress with a
strengthening programLack of progress with a strengthening program
Re-education in order to retain strength gainsRe-education in order
to retain strength gains
Slide 87
Slide 87 Case Report 17 y/o female soccer player 4 months s/p
ACL reconstruction 17 y/o female soccer player 4 months s/p ACL
reconstruction Quad Index (involved/uninvolved) Quad Index
(involved/uninvolved) Pre-operative = 77% (533 N) 2 month
post-operative = 87% (601 N) 4 month post-operative = 29% (200
N)
Slide 88
Slide 88 Patient Examination KOS-ADLS: 66% pre-operative
KOS-ADLS: 66% pre-operative 53% 4 months post- operative 53% 4
months post- operative Severe pain at infrapatellar tendon and
medial border of patella Severe pain at infrapatellar tendon and
medial border of patella Compensations to avoid use of involved leg
with functional activities secondary to anterior knee pain
Compensations to avoid use of involved leg with functional
activities secondary to anterior knee pain
Slide 89
Slide 89 Patient Examination No quadriceps inhibition with
burst superimposition test No quadriceps inhibition with burst
superimposition test Decreased superior migration of patella with
quad set and superior patellar hypomobility Decreased superior
migration of patella with quad set and superior patellar
hypomobility
Slide 90
Slide 90 Treatment Intervention Superior patellar mobilizations
Superior patellar mobilizations Pain control modalities Pain
control modalities Quadriceps strengthening Quadriceps
strengthening Quadriceps re-education Quadriceps re-education
Biofeedback Education to avoid compensation strategies
Slide 91
Slide 91 Quadriceps Re-education Two 4 x 6 inch pads over
distal VMO and proximal bulk of quad Two 4 x 6 inch pads over
distal VMO and proximal bulk of quad Intensity = maximum
contraction patient can tolerate Intensity = maximum contraction
patient can tolerate
Slide 92
Slide 92 Exercises with Electrical Stimulation Sit to Stand Sit
to Stand
Slide 97 Return to Soccer Progression Progression
Self-management Self-management Coaching support Coaching
support
Slide 98
Slide 98 Rotator Cuff Strengthening Patient Position Patient
Position Involved arm belted to the body with the elbow at 90 for
isometric contraction Forearm is blocked to avoid rotation during
the contraction
Slide 99
Slide 99 Rotator Cuff Repair Parameters Parameters NMES
Protocol Current Intensity: Maximal tolerable with visible
contraction causing movement of the arm against the restraint
Slide 100
Slide 100
Slide 101
Slide 101 Achilles Tendon Repair Early Phase - Tendon Gliding
Early Phase - Tendon Gliding 10days 4wks Modified surgical
procedure (loop tightens under tension) Patient prone, knee resting
in >50 of flexion and ankle in full plantar flexion Patient
prone, knee resting in >50 of flexion and ankle in full plantar
flexion Single Channel on the medial/lateral gastroc Single Channel
on the medial/lateral gastroc Current Intensity Current Intensity
Visible tendon gliding
Slide 102
Slide 102 Achilles Tendon Repair Late Phase Muscle Contraction
Late Phase Muscle Contraction >10weeks post op Patient prone
with knee extended and ankle in resting position Patient prone with
knee extended and ankle in resting position Can increase to
isometric against the wall Can increase to isometric against the
wall
Slide 103
Slide 103 Achilles Tendon Repair Current Intensity Current
Intensity Look for visible contraction Maximal tolerable
contraction by the patient Continue treatment until patient has
full active plantar flexion Continue treatment until patient has
full active plantar flexion
Slide 104
Slide 104 Lumbar Rehabilitation Patient Positioning - Isometric
Prone over pillows Patient Positioning - Isometric Prone over
pillows Pelvis strapped to the table in posterior pelvic tilt
Assess movement to active lumbar extension and tighten as
necessary
Slide 105
Slide 105 Lumbar Rehabilitation High Intensity Electrical
stimulation High Intensity Electrical stimulation A single channel
is placed on the right and left side of the spine A single channel
is placed on the right and left side of the spine
Slide 106
Slide 106 Lumbar Rehabilitation Look for visible
contraction
Slide 107
Slide 107 Current Intensity Maximal tolerable contraction by
the patient Maximal tolerable contraction by the patient
Slide 108
Slide 108 Thank You Noel Goodstadt PT, OCS, CSCS Noel Goodstadt
PT, OCS, CSCS Laura Schmitt PT, DPT, OCS, SCS, ATC Laura Schmitt
PT, DPT, OCS, SCS, ATC Airelle Hunter PT Airelle Hunter PT Faculty,
Residents, and Staff at UD Faculty, Residents, and Staff at UD
Patients who endure e-stim at UD Patients who endure e-stim at UD
[email protected][email protected][email protected] 302-831-8893
302-831-8893 www.udel.edu/PT/manal/estim
www.udel.edu/PT/manal/estim