Neuromuscular electrical stimulation

Presented by :
Dr. Hemangi Parmar
1st MPT
 contents
• Introduction
• How NMES works?
• Muscle responses to NMES
• Electrical waveforms used in NMES
• Stimulus parameters in NMES
• Precautions and contraindications of NMES
• Application of NMES
• References
 introduction
• Neuromuscular Electrical Stimulation (NMES) uses a
device that sends electrical impulses to nerves. This
input causes muscles to contract.

• The electrical stimulation can increase strength and

range of motion, and offset the effects of disuse.
• It is often used to “re-train” or “re-educate” a muscle to
function and to build strength after a surgery or
period of disuse.

• Therapeutic NMES – Use of repetitive stimulation of

activation of paralyzed muscles to minimize specific
impairments like limited ROM

motor weakness

spasticity

cardiovascular de conditioning.
• Functional NMES – Use of NMES to activate paralyzed
muscle at a precised sequence to assist in the
performance of ADLs or to provide stability to a joint or
maintain biomechanical integrity and therefore
function.

• Functional Electrical Stimulation or FES

FES involves the use of NMES to activate muscles in a

specific order and degree to complete a functional task.
 How nmes works?
• An electric current is the directed flow of charged
particles in some conducting medium.

• Electric currents also occur naturally in human body,

and for that there are two conducting mediums :

1. ionic fluids

2. nerves
• Nerves are specialized , excitable tissues , designed to
carry waves of ion fluxes in the form of action
potentials, action potentials carry the impulses
transmitted within the central and peripheral nervous
system.

• Skeletal muscles are innervated by peripheral motor

nerves organized in a functional units known as
Motor units.
• The electrical current activates the motor units by
inducing action potentials in the motor nerve.

• Activation always takes place through the motor

nerves because the nerves are much more excitable .
Intact motor nerve is a pre-requisite for activating a
muscle with NMES.
 Generation of Action potential in the circuit

Action potential travels down the neuron to the motor

end plate, where the sarco-plasmic reticulum becomes
depolarized , and ca is released

Cross-bridge cycling between actin and myosin

filaments of the muscle results in overlapping of sliding
filaments , causing the muscle to shorten (contract).
 Muscle response to NMES
• 3 types of muscle fibers,

a) Slow oxidative

b) Fast Oxidative-Glycolytic

c) Fast Glycolytic
 Electrical waveforms used in NMES
1. Mono-phasic {one polarity only}

2. Biphasic {alternating polarity}

3. Pulsed {isolated pulses of current between which

there is no current flow}

4. Bursted {bursts of currents between which there is

no current flow}
• Any of these waveforms can work well , but there are
relative advantages depending upon the application.

• Examples :
• Pulsed current , are especially useful for activating small
muscles.

• When there is a requirement of strong contractions of

lower extremities , biphasic waveforms will be more
effective.
 Stimulus parameters in nmes
1. Pulse amplitude and duration control
• Both together regulates the charge of each pulse and so
determine the number of peripheral nerve fibers
recruited with each stimulus.

• Amplitude control accompanies by balance control

which effectively shifts between the channels. As the
balance control is adjusted , the output amplitude on
one channel rises while of the other channel falls.
• optimal pulse duration likely lies between 50 and 1000
microseconds.

2. Frequency
• A train of electrically induced action potentials in rapid
sucession will result in corresponding series of twitches in
targeted muscle.

• A frequency of 30-50 pulses per second produces a

smooth tetanic contraction.
3. Intensity
• Intensity in miliamperes varies with pulse duration.
• Short duration pulses require relatively higher intensities
, where as relatively low intensities are adequate with
long-duration pulses.
• As intensity increases , force of contraction increases
because more motor units are recruited within motor
nerve.
• Intensity should be tolerable for the subject as well as
able to elicit motor response.
4. Duty Cycle
• It is used to avoid fatigue.

• The off part allows ionic gradients and

neurotransmitters to recover in nerve and muscle.

• On : off ratio of 1:7 minimizes fatigue but its time

consuming. And ratio of 1:1 is rapid. So , 1:3 ratio is used
clinically.
• 4 second of stimulation and 12 seconds of rest.
5. Ramping
• Ramp modulation controls are included in
neuromuscular electrical stimulation so that the pulse
charge of phase of each stimulus may be gradually
increased or decreased.

• The gradual rise allows the gradual recruitment of

nerve fiber and comfortable initiation of contraction
for subject.
• It is most effectively used in neurologically impaired
patients.

• The gradual decline allows smooth movement.

 Electrode size and placement
• If one of the electrode is smaller than other , the current
density will be greater under the electrode because the
current pass through a smaller area.

• Small electrodes are sometimes used to focus current

over a particular motor point, allowing isolated
contraction in targeted muscle.

• Larger electrodes are used for back region.

 Precautions and contraindications of nmes

• Contraindications,

1. Unstable cardiac conditions

2. Implanted pacemakers

3. Acute danger or hemorrhage

4. Acute danger of thromboembolism

• Precautions
1. Epilepsy
2. Decreased sensation
3. No stimulus over carotid sinus
4. No stimulus across of through thorax
5. No stimulus over larynx area
6. Do not stimulate diseased skin
7. Prosthetic joint motion restriction
8. Avoid grounding faults
 Applications of NMeS
1. Effects of neuromuscular electrical stimulation on
cytokines in peripheral blood for healthy participants: a
prospective, single‐blinded Study.

2. The effectiveness of quadriceps strengthening exercises

combined with neuromuscular electrical stimulation
on patellofemoral pain syndrome : pilot study.
3. The effects of transcutaneous neuromuscular electrical
stimulation on the activation of deep lumbar stabilizing
muscles of patients with lumbar degenerative kyphosis.

4. Effects of Neuromuscular Electrical Stimulation Training

on Endurance Performance.
 Neuromuscular electrical stimulation in stroke

 Effects of Electrical Stimulation in Spastic Muscles After

Stroke Systematic Review and Meta-Analysis of

Randomized Controlled Trials.

 Neuromuscular Electrical Stimulation for Motor

Restoration in Hemiplegia
 Effectiveness of neuromuscular electrical stimulation for
management of shoulder subluxation post-stroke: a
systematic review with meta-analysis

 Effects of mirror therapy combined with neuromuscular

electrical stimulation on motor recovery of lower limbs
and walking ability of patients with stroke: a randomized
controlled study
 Neuromuscular electrical stimulation in spinal cord injury

 Abdominal functional electrical stimulation to improve

respiratory function after spinal cord injury: a systematic
review and meta-analysis.

 Rehabilitation of hand in subacute tetraplegic patients

based on brain computer interface and functional
electrical stimulation: a randomised pilot study
 others

 Neuromuscular electrical stimulation in

mechanically ventilated patients: A randomized,
sham-controlled pilot trial

 Training postural control and sitting in children

with cerebral palsy: Kinesio taping vs.
neuromuscular electrical stimulation
 Effectiveness of neuromuscular electrical stimulation
during gait in children with cerebral palsy

 Neuromuscular Electrical Stimulation Cycling Exercise

for Persons with Advanced Multiple Sclerosis

 Neuromuscular electrical stimulation to improve exercise

capacity in patients with severe COPD: a randomised
double-blind, placebo-controlled trial.
BLADDER management with NMES :

• Patients with suprasacral spinal cord lesions can

have electrical stimulation applied to the intact sacral
nerves or nerve roots to produce effective micturition
and improve bowel function, significantly reducing
complications
 references
1. Andrew J. Robinson , Lynn snyder-mackler ; Clinical Electrophysiology :
Electrotherapy and electrophysiologic testing ; 3rd edition.
2. Brain reed ; Physiology of neuromuscular electrical stimulation.; 1997
3. Truong AD, Kho ME, Brower RG, Feldman DR, Colantuoni E, Needham DM.
Effects of neuromuscular electrical stimulation on cytokines in peripheral
blood for healthy participants: a prospective, single‐blinded Study. Clinical
physiology and functional imaging. 2017 May 1;37(3):255-62.
4. Çelik D, Argut SK, Kılıçoğlu Ö. The effectiveness of quadriceps strengthening
exercises combined with Neuromuscular Electrical Stimulation on
patellofemoral pain syndrome: Pilot study. Physical Therapy in Sport. 2017 Nov
30;28:e16
5. Kim SY, Kim JH, Jung GS, Baek SO, Jones R, Ahn SH. The effects of transcutaneous
neuromuscular electrical stimulation on the activation of deep lumbar
stabilizing muscles of patients with lumbar degenerative kyphosis. Journal of
physical therapy science. 2016;28(2):399-406.
6. Veldman MP, Gondin J, Place N, Maffiuletti NA. Effects of neuromuscular
electrical stimulation training on endurance performance. Frontiers in
physiology. 2016 Nov 16;7:544.
7. Stein C, Fritsch CG, Robinson C, Sbruzzi G, Plentz RD. Effects of electrical
stimulation in spastic muscles after stroke: Systematic review and meta-
analysis of randomized controlled trials. Stroke. 2015 Jan 1:STROKEAHA-
115.
8. Chae J, Sheffler L, Knutson J. Neuromuscular electrical stimulation for
motor restoration in hemiplegia. Topics in stroke rehabilitation. 2008 Sep
1;15(5):412-26.
9. Lee JH, Baker LL, Johnson RE, Tilson JK. Effectiveness of neuromuscular
electrical stimulation for management of shoulder subluxation post-
stroke: a systematic review with meta-analysis. Clinical rehabilitation.
2017 Nov;31(11):1431-44.
10. Xu Q, Guo F, Salem HM, Chen H, Huang X. Effects of mirror therapy
combined with neuromuscular electrical stimulation on motor recovery
of lower limbs and walking ability of patients with stroke: a randomized
controlled study. Clinical rehabilitation. 2017 Dec;31(12):1583-91.
11.McCaughey EJ, Borotkanics RJ, Gollee H, Folz RJ, McLachlan AJ. Abdominal
functional electrical stimulation to improve respiratory function after
spinal cord injury: a systematic review and meta-analysis. Spinal cord.
2016 Sep;54(9):628.
12. Osuagwu BC, Wallace L, Fraser M, Vuckovic A. Rehabilitation of hand in
subacute tetraplegic patients based on brain computer interface and
functional electrical stimulation: a randomised pilot study. Journal of
neural engineering. 2016 Oct 14;13(6):065002.