NMES – a complement to cruciate ligament rehabilitation

NMES (Neuromuscular electrical stimulation) is an excellent

complementary treatment on cruciate ligament injury. Elin

Johansson is a physiotherapist working with the Swedish

National Athletics Team. She uses electrical muscle stimulation

on Sweden’s top athletes as well as on patients exercising on

a recreational basis. Below is Elin’s rehabilitation program for

injured cruciate ligaments in which NMES takes a natural part.

“Anterior cruciate ligament injury is a common sports injury that I have to deal with on a daily basis. Treatment of injured anterior cruciate ligament consists of a gradually intensified rehabilitation program and my view is that NMES is an important tool throughout the entire rehabili-tation process.

Initial stage: Focus on getting the circulation and mobility of the knee joint going as well as getting the structures accustomed to increased workload. A lot of patients have difficulties finding the muscular function of the quadri-ceps muscles after surgery. When “open chain” is allowed, electrical muscle stimulation will help them regain control of these muscles in an optimum and effective way. The patient can preferably use the hand switch to increase con-trol of the stimulation.

Intermediate stage: Focus on improving balance and knee control, gradually increase muscle strength and endurance. During this stage the stimulator is an obvious comple-ment to many of the exercises I choose for my patients. A few examples of exercises to be carried out with electrical muscle stimulation are: Knee flexion (“closed chain”), leg extension and single leg standing on a balance board. There is often a specific need to exercise the vastus medialis obli-que. This muscle is important for optimum knee extension but it also has a stabilising function of the kneecap. With electrical muscle stimulation I manage to exercise this mus-cle in an optimum way. It even works as a perfect home exercise for the patient.

Late stage: To be able to return to sports training after a cruciate ligament injury muscle strength, endurance and proprioception need to be at their best. Besides all exercises becoming harder the patient needs to be prepared for his/her specific sport. When performing sports specific train-ing, it is a strong advantage to combine the training with electrical muscle stimulation.

Goal: An athlete, with complete function, back on the sports arena with new gold medals in sight.

Advantages with NMES:

• I can be very specific when exercising the muscles.• My patients receive effective training at home. • With NMES I can give very accurate doses of training. • Electrical muscle stimulation also has a pain relieving effect.”

By Elin Johansson. Physiotherapist in National Swedish Athletics Team’s Medical Team and at the Sports Injury Clinic in Johanneshov, Sweden.

References:A. Delitto, et al. Electrical Stimulation Versus Voluntary Exxercise in Strengthening Thigh Musculature After Anterior Cruciate Ligament Surgery. Physical TherapyB. I. Wigerstad-Lossing et al. Effects of electrical muscle stimulation combined with voluntary contractions after knee ligamnet sugery. Medicine and Science In Sportsand Exercice C. L. Snyder-Mackler. Strength of the Quadriceps Femoris Muscle and Funtional Recovery after Reconstruction of the Anterior Cruciate Ligamnet. The Journal of Bone and Joint Surgery.

M1011-4CEFAR Medical AB | Murmansgatan 126 | SE-212 25 Malmö | Sweden

Tel +46 (0)40-39 40 00 | Fax +46 (0)40-39 40 99 | E-mail info@cefar.se | www.cefar.se

TENS eases nausea

ExplanationThe reasons for nausea can vary. Postoperative nausea can for instance be caused by the anesthesia itself, the method of surgery or be the result of the medication of various morphine drugs. While treating cancer, chemo-therapy can cause nausea and radiation is also likely to release substances that will trigger nausea.

Today it is established that TENS treatment on acu-puncture point PC6 reduces the sensation of nausea, but the theoretical explanation is still not fully establis-hed. TENS treatment has for instance the following effects: increased sympathetic activity, influence on the serotonin level and inhibition of the vagal activity. These effects influence the sensation of nausea on their own or more likely in cooperation.

How does the treatment works?• Concentrate stimulation to acupuncture point PC6,

a well-known location for treating nausea. It is situa-ted on the inside of the lower arm, 2 cun (approx. 3 fingers widths) from the wrist between the flexor tendons. Place the black (the most active) electrode here. The red electrode is preferably placed on TE5, the corresponding point on the outside of the same lower arm.

• Set the frequency to 10 Hz and increase the current strength until the stimulation is felt in the fingers (Median nerve), without being painful. A light vibra-tion of the fingers will often occur.

• Stimulate for about 10 minutes per session. Repeat the treatment more often in the beginning. Start for instance by stimulating every second hour and then slowly reduce the number of treatments.

• IMPORTANT! Start the first treatment session befo-re nausea occurs (before operation or chemotherapy).

Nausea and vomiting is first of all defense mechanisms

occurring when the body wants to defend itself from a

strange substance. Nausea is a common and often unplea-

sant condition in connection with surgery but also during

radiation and chemotherapy. Studies show that TENS is a

successful method in treating nausea and in comparison

with drugs doesn’t have any negative side effects.

What does the studies say?• The correct acupuncture point, PC6: Studies show that

it is important that stimulation takes place on this acu-puncture point.

• Stimulation bilaterally or unilaterally: No difference in results has been shown.

• Treatment time: Several studies show that a treatment time between 5-10 minutes gives the best effect.

• Enhanced effect: Studies show that TENS in combina-tion with Ondansetron (i.e. Zofran) give an enhanced effect.

• Treatment start-up: The best results are achieved on a conscious patient with a well functioning nervous system. Start the first treatment session before nausea occurs.

References:1. JW Dundee, RG Ghaly, KM Bill, WN Chestnutt, KJ Fitzpatrick,

AGA Lynas Effect of stimulation of the P6 antiemetic point on posto-perative nausea and vomiting. Br J Anaesth 1989,63, 612-618.

2. PF White, T Issioui, J Hu, SB Jones, JE Coleman, JP Waddle, SD Markowitz, M Coloma, AR Macaluso, CH Ing Comparative efficiacy of acustimulation (Relief Band) versus Ondansetron Zofran in combination with droperidol for preventing nausea and vomiting. Anesthesiology 2002 Nov; 97 (5) 1075-81.

3. CM McMillan, JW Dundee The role of transcutaneous electrical stimulation of Neiguan anti-emetic acupuncture point in controlling sickness after cancer chemotherapy. Physiotherapy, July 1991, vol 77 no 7.

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CEFAR Medical AB | Murmansgatan 126 | SE-212 25 Malmö | Sweden

Tel +46 (0)40 39 40 00 | Fax +46 (0)40 39 40 99 | E-mail info@cefar.se | www.cefar.se

TENS treatment for postoperative pain

Studies show that ...• TENS used for postoperative pain relief will decrease

the need for analgesics and reduce the intake of opioids. Opioid-related side effects, such as dizziness, nausea and drowsiness also decline.

• Postoperative TENS treatment results in fewer lung com-plications for thoracic surgery patients.

• Patients who have received effective pain relief are mobili-zed much faster. Postoperative TENS treatment gives the patient greater autonomous control of pain relief.

• High-frequency TENS close to the operation site gives the best effect.

How to treat with TENS?• Instruct the patient before the operation.

• Place the electrodes near the operation site on healthy skin, where sensitivity is normal.

• Stimulate with high-frequency TENS. It should be a strong sensation, but without pain.

• Stimulate often (at least 30 minutes at a time, 4–5 times a day), the first 0–3 postoperative days, depending on the surgery.

• For postoperative pain relief, it is normal to stimulate with high frequency TENS for several hours in a row. Start the TENS treatment immediately after the patient wakes up.

• TENS treatment can be combined with other types of pain relief.

Referenser:1. Bjordal JM et al, Transcutaneous electrical nerve stimula-

tion (TENS) can reduce postoperative anagesic consump-tion. A meta-Analysis with assesment of optimal treatment parameters for postoperative pain. European Journal of Pain 7 (2003) 181-188.

2. Grahn L, Persson R; Transkutan elektrisk nervstimulering. Ett komplement vid postoperativ smärta. Smärta Nr 4, 5-10, 2000.

3. Hamza MA et al; Effect of the frequecy of transcu-taneous electrical nerve stimulation on the postopera-tive opioid analgesic Requirement and recovery profile. Anesthesiology, V 91. No 5, Nov 1999.

4. Jameel A ; The effect of transcutaneous electric nerve sti-mulation on postoperative pain and pulmonary function. Surgery, Apr 1981, 507-512.

5. Roos E; Transkutan nervstimulering vid rehabilite-ring efter operation med unikompartmentell knäprotes. Sjukgymnasten vetenskapligt Supplement 1/92.

Surgical procedures affect the patient in many ways. Untreated,

severe postoperative pain can have many harmful effects,

such as weakened lung function, increased risk for thrombosis,

cardiovascular changes and a risk for developing long-term pain

conditions. The patient often experiences an increased sensation

of pain during the first days after surgery. Prescription painkil-

lers alleviate the pain, but also cause negative side effects like

nausea, dizziness, or drowsiness. It is in the best interests of

the patient and of the entire health care system that the period

after surgery is as pleasant as possible.

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CEFAR Medical AB | Murmansgatan 126| SE-212 25 Malmö| Sweden

Tel +46 (0)40 39 40 00 | Fax +46 (0)40 39 40 99 | E-mail info@cefar.se | www.cefar.se

TENS – a complement to wound healing

TENS treatment on wounds gives:

• Pain Relief

A painful wound heals more slowly since the body produ-ces adrenalin, which prevents the transportation of oxygen and nutrients to the tissue.

• Increased blood flow

The electrical impulses during TENS treatment also sti-mulate blood circulation, which probably accelerates the wound healing process. Circulation also increases because the patient becomes more mobile when the pain is redu-ced.

• Antibacterial effect

One study indicates that TENS increases the amount of leucocytes and phagocytes.

• Effects on a cellular level

The same study indicates that TENS increases protein production.

Treatment options1. Two or four small electrodes are placed on both sides of

the wound - see picture. Note! It is important that the patient has normal sensory of touch. Set the stimulator to high-frequency stimulation (Program 1 in CEFAR PRIMO). Turn on the stimulation and slowly increase the current strength until the patient feels a pleasant ting-ling sensation. A common treatment time is 30 minutes, 2 times/day.

2. TENS treatment on the acupuncture points of the hand has proven to give a general increase of circulation. Two small electrodes are placed on acupuncture points LI4 and SI3 - see picture. Set the stimulator to low-frequency stimulation (Program 2 in CEFAR PRIMO). The sti-mulation should give light muscle vibrations in the hand without being painful. A common treatment time is 30 minutes, 2 times/day.

Things to consider about TENS treatment

© The Municipality of Eksjö, Sweden

• TENS does not replace surgical procedures if needed, or any other relevant wound healing treatment.

• Place the electrodes as close to the wound as possible, but on healthy skin. Leave the bandage closest to the wound in place during treatment, so as not to disturb the healing process.

• Draw a sketch of the wound once a month.

• The wound normally becomes bigger and fluid-filled in the first couple of weeks. This is normally a result of the cleaning phase.

• Treatment with antibiotics or the presence of other infections does not prevent TENS treatment. Contact a physiotherapist if the skin is red and infected so that the electrodes can’t be placed properly. The therapist will suggest a new electrode placement, or advise you to temporarily discontinue the TENS treatment.

References:1. TENS team, Municipality of Eksjö.2. Wikström, S. O., et al. Effect of transcutaenous nerve stimula-

tion on microcirculation in intact skin and blister wounds in healthy volunteers. Scand J Plast Reconstr Surg Hand Surg, 1999 Jun; 33(2): 195-201.

3. Gentzkow, G. D., Miller, K. H. Electrical Stimulation for Dermal Wound Healing. Clinics in Podiatric Medicine and Surgery, 1991 (vol. 8); 4: 827-841.

4. Kaada, B. Promoted healing of chronic ulceration by transcuta-neous nerve stimulation (TNS). VASA, Band 12, 1983; Heft 3: 262-269.

Is it possible that the traditional TENS (Transcutaneous Electrical

Nerve Stimulation) pain relief method also has positive effects on

the wound healing process?

The results of a preliminary project in Eksjö, Sweden indicate that

this may be the case. When 46 chronic leg ulcers had been trea-

ted with TENS, an amazing 75% healed on average in 3.5 months.

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CEFAR Medical AB | Murmansgatan 126 | SE-212 25 Malmö| Sweden

Tel +46 (0)40 39 40 00 | Fax +46 (0)40 39 40 99 | E-mail info@cefar.se | www.cefar.se

Pain Relief Experts for 20 Years©04/2013 Omron Healthcare, Inc.

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Jeffrey S. Mannheimer, P.T., Ph.D, Co-Author: Clinical TENS, F.A. Davis, 1984

©07/2012 Omron Healthcare, Inc.Pain Relief Experts for 20 Years

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LowerIntensity

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Step 1Unit should be off. Insert 2 “AAA” batteries.

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1 Session 15 Minutes Automatic Shutoff

Maximum Minutes per Session

30 Minutes or 2 Sessions

Maximum Sessions per Day

3 Sessions per Day