Using Electrical Muscular Stimulation (EMS) for CVA patient

[hasanj]

Hi, Is there any useful indication for the use of EMS in the CVA patient?

thanks

[Gawaine]

totally...

i use it on the shoulder to decrease subluxation as well as on the dorsiflexors to help correct drop foot...

some people use it to stimulate quads, gluts, glut med, and wrist/finger extensors...

are these applications useful??? i think they are if 1) they "wake up" a muscle that was previously flaccid AND 2) you can grade the use of the e-stim machines down to nothing so the patient can use their affected limb...


does that answer your question?

patrick, MPT

[ramywhite]

Yes, I think so. I used to apply it as a stimulatory technique in flacid stage.

[sdkashif]

Electrical Stimulation has a number of indications in the stroke patient.

In flaccid stage electrical stimulation can be used to prevent the disuse atrophy and to preserve the joint range in immobile joints by producing and inducing movements. In spastic stage, it can be used to reduce the spasticity by producing movement in antagonist and relaxing the agonists by reciprocal innervation. It can also reduce spasticity by producing the tetanic contractions of spastic muscle by producing fatigue in them. Electrical stimulation can also be used in muscle strengthening of the weak and spastic muscles. Furthermore, Functional electrical stimulation can be used to produce movement in any joint or part to compensate any loss of movement due to inactivity.

[ramywhite]

Originally Posted by sdkashif

It can also reduce spasticity by producing the tetanic contractions of spastic muscle by producing fatigue in them.

Please could you explain that in some details?
Thanks

[sdkashif]

The NEMS of spastic muscles with a frequency of 100 to 350 Hz result in a fair reduction of spastic tone that lasted for hour. The neurophysiological rationale for the effectiveness of NEMS activation of the spastic muscles may be two fold. First it could lead to fatigue of the peripheral system. It is theorized that either neuromuscular junction fatigue or a possible depletion of Ca++ release at post synaptic binding sites might have been responsible for the reduction in muscle tension.

A second neurophysiological mechanism by which NEMS of the spastic muscle might affect a reduction of muscle tone rests in antidromic activation of alpha motor neuron axon. Antidromic propogation may provide a spinal level response that could lead to longer lasting modulation of spastic tone. With each voluntary and stimulated action potential, the alpha motor neurone activates the motor unit and excites a pool of Renshaw cells through recurrent collaterals. The Renshaw cells inhibit the alpha motor neurons of the activated pool and motor neurons of synergistic muscles.

[ramywhite]

Hello sdkashif,
Thank you for these valuable information. But I'd like to know if the current is pulsed or continues and where to put the negative electrode and where the positive one. what is the proper intenisty.
But the main problem to me is how we can prevent that current from spreading to the antagonist group specially when we deal with small muscle group.
Many thanks!

[sdkashif]

Procedure used has the following settings.

1-Parameter Setting:

a-Waveform: Symmetrical Biphasic preferred, but monophasic or polyphasic can also be used.

b-Phase duration: depends upon the type of current used.

c-Pulse rate: 100 to 350 Hz

d-Polarity: Makes no difference

e-Amplitude: Motor Nerve Stimulation

2-Current Modulation Mode: Continuous Pulses

3-Electrode Placement: Bipolar over target muscles

4-Treatment Time: No clinical data to suggest the treatment time.

[shinydan]

its mainly used in the flaccid stage to produce the onset of spasticity. it initiates the motor reactions too when it is applied on the weaker group of muscles. it should be applied on the appropriate position to derive the opitimum result.....
fr eg: to stimulate the dorsiflexors to reduce the foot drop..you have to apply the anode on the head of the fibula and the cathode on the motor point or the bulk of the dorsiflexors....ie, the tibialis anterior...
the electrical stim also used as functional,ie gait training...i
EMS used in pulsed mode...

[physiobob]

Originally Posted by ramywhite

Please could you explain that in some details?
Thanks

Or perhaps better still use it on the antagonists to muscles with increase tone to inhibit them. Although EMS does have some uses it should first be considered why the patient has increased tone and if this is due to a more proximal instability (and therefore a compensatory strategy that increased the tone) then this should be worked on as a priority. This takes time but gives a much better result.

Look at the works by Bobath (UK PTs) to read more about this.

[ramywhite]

Hey every body,
In fact I understand physiologically how inhibition could be possible for the spastic muscles by applying EMS or other stimulatory techniques on the antagonist( the non-spastic group) by reciprocal inhibition. But I don't get how the reverse could be possible. I mean physiologically what happened when you apply specific type of EMS on the spastic muscle to end with relaxation.
many thanks....

[physiobob]

Originally Posted by ramywhite

But I don't get how the reverse could be possible. I mean physiologically what happened when you apply specific type of EMS on the spastic muscle to end with relaxation.
many thanks....

This doesn't really work other than as a contract relax type treatment to get a hypertonic muscle to 'let go' sometimes by fatigue sometimes by trying to restore more normal joint and muscle receptor activity locally. Read more on proprioceptive neuromuscular facilitation (PFN) on this one.

[sdkashif]

Originally Posted by ramywhite

Hey every body,
In fact I understand physiologically how inhibition could be possible for the spastic muscles by applying EMS or other stimulatory techniques on the antagonist( the non-spastic group) by reciprocal inhibition. But I don't get how the reverse could be possible. I mean physiologically what happened when you apply specific type of EMS on the spastic muscle to end with relaxation.
many thanks....

I think that I have already explained it. So I'm repeating it again here.

The NEMS of spastic muscles with a frequency of 100 to 350 Hz result in a fair reduction of spastic tone that lasted for hour. The neurophysiological rationale for the effectiveness of NEMS activation of the spastic muscles may be two fold. First it could lead to fatigue of the peripheral system. It is theorized that either neuromuscular junction fatigue or a possible depletion of Ca++ release at post synaptic binding sites might have been responsible for the reduction in muscle tension.

A second neurophysiological mechanism by which NEMS of the spastic muscle might affect a reduction of muscle tone rests in antidromic activation of alpha motor neuron axon. Antidromic propogation may provide a spinal level response that could lead to longer lasting modulation of spastic tone. With each voluntary and stimulated action potential, the alpha motor neurone activates the motor unit and excites a pool of Renshaw cells through recurrent collaterals. The Renshaw cells inhibit the alpha motor neurons of the activated pool and motor neurons of synergistic muscles.

Procedure used has the following settings(Motor Nerve Inhibition).

1-Parameter Setting:

a-Waveform: Symmetrical Biphasic preferred, but monophasic or polyphasic can also be used.

b-Phase duration: depends upon the type of current used.

c-Pulse rate: 100 to 350 Hz

d-Polarity: Makes no difference

e-Amplitude: Motor Nerve Stimulation

2-Current Modulation Mode: Continuous Pulses

3-Electrode Placement: Bipolar over target muscles

4-Treatment Time: No clinical data to suggest the treatment time.


An other procedure (contract relax Method) has the following setting.

1-Parameter Setting

a-Wavew forrm: Symmetrical Biphasic is preferred but monophasic and polyphasic (Burst) can also be used.

b-Phase Duration: 20 to 200 micro seconds

c-Pulse rate: 40 to 50 pps

d-Polarity make sno difference

e-Amplitude: Motor Nerve stimulation

Current Modulation Mode: Interrupted pulses

a-On time: 5 to 10 seconds

b-Off time: 60 to 120 second

3-Electrode placement: Bipolar over target muscles

4-Treatment Time: No clinical data to suggest treatment time.


If you want further detail information, you have a look over the electrotherapy and electrophysiology texbooks for detail which are:

Clinical Electrotherapy, 2nd Edition by Roger M.Nelson & Dean P. Currier

Clinical Electrophysiology, Electrophysiology and Electrophysiological testing By Lynn Snyder Mackler & Andrew J.Robinson

[ramywhite]

Thanks sdkashif