slide 1 electrical stimulation to augment muscle strengthening: guidelines for surgical procedures,...

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]

Properties of Electrical Stimulation Tara Jo Manal PT, OCS, SCS University of Delaware

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

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

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

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

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?

Current Modulation Timing Timing Altering the time characteristics of stimulation Train Train a continuous, repetitive series of pulses at a fixed frequency

Current Modulation Burst Burst a package of train pulses delivered at a specified frequency e.g. 2 bursts per second

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

Frequency and Pulse Duration If the f is 5 Hz or 5 cycles/second The duration is 1/5 or 20milliseconds

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

How to Achieve High Force Activate more motor units (recruitment) Drive the motor units more quickly (Rate coding)

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

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

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

NMES Increasing frequency How to achieve high force Rate Coding Increase the frequency of stimulation But increased frequency increased fatigue

Quality of Contraction Goal = strong tetanic contraction Stimulation frequency 50-80 pps

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

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

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

Waveform type Waveform Patient dependent Delitto Rose PT 1986 UD PT Clinic Versastim Empi

Stimulation Parameters What can we modify? Pulse Duration Pulse Frequency Waveform type Off time (time between contractions) Ramp time

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

Line vs. Battery Powered

Test The Unit Empi 300 PV

EMPI 300PV Empi 300PV 1-800-328-2536

Dose of NMES Maximal tolerable current and device dependent- MVIC above blue line Maximal tolerable current and device dependent- MVIC above blue line

Dose of NMES Be sure your machine is capable of current necessary Be sure your machine is capable of current necessary

Test The Electrodes

Electrodes How to improve the lifespan Proper storage Keep them moist Placed properly on plastic Improves conductivity

Another Brand of Electrodes

Same Intensity- Different Electrodes

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

Electrodes Reflex Tantone 624 Reflex Tantone 624 Ref# EC89270 Ref# EC89270 Size 2in x 2in Size 2in x 2in 5.08cm x 5.08cm Qty 4 Qty 4 Tyco/Heathcare Tyco/Heathcare Unipatch 1-800-328-9454 1-800-328-9454

Tens Clean Cote Uni-Patch Uni-Patch 1-800-328-9454 1-800-328-9454 Function Function Improves conductivity Improves conductivity

Pad Placement Typically include motor points of muscle of interest Typically include motor points of muscle of interest

Pad Placement Relationship between Pad placement and current- Non-tetanic contraction Relationship between Pad placement and current- Non-tetanic contraction

Pad Placement Increase current, contraction becomes tetanic Increase current, contraction becomes tetanic

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)

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

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

Evidence to support the clinical use of electrical stimulation for muscle strengthening

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)

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)

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)

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

Neuromuscular Electrical Stimulators Indication Indication Muscular strength deficits

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

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)

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

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

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

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

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

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

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)

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

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

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

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)

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!!!

Compensation Strategies Unweighting involved leg for sit to stand Unweighting involved leg for sit to stand

Compensation Strategies Shifting weight in standing to uninvolved leg Shifting weight in standing to uninvolved leg

Compensation Strategies Not utilizing full extension during stance phase of gait Not utilizing full extension during stance phase of gait

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

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!

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

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)

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

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

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

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

Exercises with Electrical Stimulation Sit to Stand Sit to Stand

Exercises with Electrical Stimulation Standing Terminal Knee Extensions Standing Terminal Knee Extensions

Exercises with Electrical Stimulation Seated Knee Extensions Seated Knee Extensions

Quad Index Pre-operative QI = 77% Pre-operative QI = 77% 2 month post-operative QI = 87% 2 month post-operative QI = 87% 4 month post-operative QI = 29% 4 month post-operative QI = 29% 6 months post-op (16 visits) QI = 51% 6 months post-op (16 visits) QI = 51% 7 months post-op (28 visits) QI = 72% 7 months post-op (28 visits) QI = 72% 8 months post-op (37 visits) QI = 98% 8 months post-op (37 visits) QI = 98%

Patients Strength Over Time

Return to Soccer Progression Progression Self-management Self-management Coaching support Coaching support

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

Rotator Cuff Repair Parameters Parameters NMES Protocol Current Intensity: Maximal tolerable with visible contraction causing movement of the arm against the restraint

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

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

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

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

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

Lumbar Rehabilitation Look for visible contraction

Current Intensity Maximal tolerable contraction by the patient Maximal tolerable contraction by the patient

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

slide 1 electrical stimulation to augment muscle strengthening: guidelines for surgical procedures,...

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