● Electrically stimulated contractions, which first activate the larger type II muscle

fibers, can very effectively strengthen the muscle fibers atrophied and weakened
by disuse.
● However, because these stimulated contractions are more fatiguing than
physiological contractions, longer rest times should be provided between them
● patients should perform physiological contractions together with electrically
stimulated contractions to optimize recruitment of all muscle fibers and functional
integration of strength gains.
● Denervated muscle will not contract with the usual electrical stimulus used for
NMES but will contract if DC, or a pulsed current with a pulse duration of 10 ms
or longer, is applied directly to the muscle.
● This stimulates APs in the muscle cells directly without input from a motor nerve.
This is known as electrical muscle stimulation (EMS). EMS is usually achieved
using a DC applied for a number of seconds.
● To grade the strength of contraction in a denervated muscle, the current
amplitude (intensity) can be gradually increased to reach full amplitude over a
number of seconds.
● Strength gains in healthy muscle with contraction, whether stimulated or
voluntary, depend on the force of the contraction, with contractions of at least
50% of the maximum voluntary isometric contraction (MVIC) force required to
increase strength in healthy muscles and greater gains requiring more forceful
contractions.
● NMES can also reduce edema caused by poor peripheral circulation due to lack
of motion but should be avoided in the presence of edema caused by
inflammation because muscle contractions generally aggravate inflammation.
● Contraction of the limb muscles compresses the veins and lymphatic vessels,
promoting the return flow of fluid from the periphery.
● Edema of this type can be treated by applying motor-level electrical stimulation to
the muscles around the main draining veins.
● To control edema, NMES should be applied in conjunction with elevation and
followed by use of a compression garment
● The improvement in blood flow produced by NMES can also accelerate tissue
healing and help reduce the risk of deep venous thrombosis (DVT) formation.
● Electrically stimulated contractions should be avoided when muscle contraction
may disrupt healing or aggravate symptoms such as when there is an order for
no active motion or for no resisted motion or when there is a tear or inflammation
in the muscle or tendon that would be aggravated by muscle contraction.
● With denervation, there will be no active contraction without stimulation, and
atrophy may limit the strength of the stimulated contractions.
● When stimulating contractions in denervated muscle, generally a small- diameter
probe is used as the active electrode to focus the stimulation and produce the
contractions, while a larger, self-adhesive electrode is used as the inactive
electrode to complete the electrical circuit.
● The active electrode should be placed on the most electrically responsive point
on the muscle to be stimulated.
● The inactive electrode, which is used only to complete the circuit and not to
cause contractions,should be placed over a muscle in the same limb as the
active electrode.
● The electrodes should be placed closer together to stimulate contractions in
more superficial muscles and further apart to stimulate contractions in deeper
muscles.
● Since DC and not a pulsed waveform is used for stimulating contractions in
denervated muscle, no pulse duration is set.
● For treating denervated muscle, the on-time (contractions) usually lasts 5 to 10
seconds, and the off-time is four to five times longer than the on- time to minimize
fatigue.
● When electrical stimulation is applied to denervated muscle, the goal is generally
to produce as strong a contraction as possible to most effectively retard disuse
atrophy and fibrosis.