ehind Practice
`
`THIRD EDITION
`
`Alain-Yvan Belanger
`
`® Wolters Kluwer
`Health
`
`LUMENIS EX1011
`Page 1
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`

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`Evidence Behind Practice, Third Edition
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`• Board-Style Review Questions
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`LUMENIS EX1011
`Page 2
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`

`

`ce Behind Practice
`
`THIRD EDITION
`
`I
`
`LUMENIS EX1011
`Page 3
`
`

`

`nee Behind Practice
`
`THIRD EDITION
`
`Alain-Vva·n Belanger, PhD, PT
`
`Retired Professor
`Laval University
`Canada
`
`Owner and Consultant
`Physiometrix Inc.
`
`• • Wolters Kluwer I Lippincott Williams & Wilkins
`
`Healt h
`
`Philadelphia • Baltimore • New York• London
`Buenos Aires • Hong Kong• Sydney • Tokyo
`
`LUMENIS EX1011
`Page 4
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`

`

`Acquisitions Edi.tor: Emily Lupash
`Product Manager: Matt Hauber
`Marleeting J\tlanager: Leah Thomson
`Prodttction Project Ma.nagerc Marian Bellus
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`Third Edition
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`lww.com (products and sen~ces).
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`98765432
`
`Library of Congress Cataloging-in-Publication Data
`
`Belanger, Alain, author.
`Therapeutic electrophysical agents : evidence behind practice/ Alain-Yvan Belanger.-Third edition.
`p. ; cm.
`Includes bibliographical references and index.
`ISBN 978- 1-451 1-8274-3 (alk. paper)
`I. Title.
`[DNLM:
`Handbooks.
`Handbooks.
`RM84 1.5
`615.8' 3-dc23
`
`I. Therapeutics-1-lanclbooks. 2. Therapeutics-Outlines. 3. Evidence-Based Medicine-
`4. Evidence-Based Medicine-Outlines. 5. Physical and Hehabilitation Medicine-
`6. Physical and Rehabilitation Medicine-Outlines. WB 39]
`
`2013035769
`
`Care h as been taken to confirm the accuracy of the information present and to describe generally accepted
`practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
`consequences from application of the information in this book and make no warranty, expressed or implied,
`with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this
`information in a particular situation remains the professional responsibility of the practitioner; the clinical
`treatments described and recommended may not be considered absolute and universal recommendations.
`The authors, ed itors, and publisher have exerted every effort to e nsure that drug selection and dosage set
`forth in th is text are in accordance with the current. recommendations and practice at the time of p ublication.
`However, in view of ongoing research, changes in government regulations, and the constant flow of informa·
`tion relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug
`for an)' c hange in indications and dosage and for added warnings and precautions. This is particularly impor(cid:173)
`tant when the recommended agent is a new or infrequently employed drug.
`Some drugs and medical devices presented in rhis publication have Food and Drug Administration
`(FDA) clearance for limited use in restricted research settings. It is the responsibility of the healt h care
`provider to ascertain the FDA status of each drug or device planned for use in rheir clinical pr.ictice.
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`a:
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`LUMENIS EX1011
`Page 5
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`

`DEDICAT I ON
`
`I dedicate this third edition to all educators, students, and clinicians in their journey to become the best
`evidence-based teachers, students, and practitioners of therapeutic electrophysical agents they can be.
`
`00
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`0 r-(cid:173)... (/) a: a:
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`LUMENIS EX1011
`Page 6
`
`

`

`QUOTES
`
`Learning never exhausts the mind.
`Leonardo da Vinci
`
`Any fool can know. The point is to understand.
`Albert Einstein
`
`I never learn anything talking. I only learn things when I ask questions.
`Lou Holtz
`
`Great things are not accomplished by those who yield to trends and fads and popular opinion.
`Jack Kerouac
`
`Absence of evidence is not evidence of absence.
`Carl Sagan
`
`vi
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`LUMENIS EX1011
`Page 7
`
`

`

`ABOUT THE AUTHOR
`--.___----------==========------'-;'--'
`-
`-:::===-- - - - - ---------------'--;--- - - - -- - -- - - - - -- -- - -- -
`
`f\lain-Yvan Belanger, BSc, MSc, PhD, PT is a retired
`Professor from the Department of Rehabilitation, Physio(cid:173)
`therapy program, Faculty of Medicine, Laval University,
`Quebec C ity, Canada. Dr. Belanger holds a bachelor's
`degree in physiotherapy from the University of l\liontreal,
`a master's of science degree in kinesiology from Simon
`Fraser University, and a doctoral degree in neurosciences
`from McMaster University. He has extensive experience
`as a teacher, researcher, consultant, and author in the field
`
`of human neuromuscular physiology and therapeutic elec(cid:173)
`trophysical agents. Dr. Belanger has held the positions of
`Scientific Editor of the journal Physiotherapy Canada and
`President of the Canadian Physiotherapy Association. He
`has also served as Associate Editor of several journals. He is
`the sole author of the first and second editions of this book.
`An avid golf and poker player, Alain still dreams of playing a
`sub 80s round of golf and winning the next World Series of
`Poker Seniors Championship!
`
`vii
`
`LUMENIS EX1011
`Page 8
`
`

`

`ACKNOWLEDGMENTS
`
`I want to express my deepest gratitude to all of you
`who chose the previous two editions of this textbook to
`learn, teach, and practice therapeutic electrophysical
`agents.
`Thank you to Julie Stegman, LWW Publisher, for
`her continued trust and support, and to Emily Lupash,
`Acquisition Editor, for her dedication to see a third
`edition.
`
`Thanks to all of the reviewers for their thoughtful com(cid:173)
`ments and suggestions related to the preparation of this
`third edition.
`l want to express a very special thank you to my Prod(cid:173)
`uct Development Editor, Matt H auber, for his advice,
`direction, skillful work, and professionalism.
`To everyone at L\i\TW, thank you for giving me the
`opportunity to make my work a published reality.
`Alain-Yvan Belanger; BSc, MSc, PhD, PT
`
`viii
`
`LUMENIS EX1011
`Page 9
`
`

`

`REVIEWERS
`
`Misha Bradford, PT, DPT, OCS
`Assistant Professor (Clinical)
`University of Utah
`Salt Lake City, U tah
`
`Joseph Gallo. DSc. ATC, PT
`Director, Athletic Training Program
`Salem State University
`Salem, f\/lassachusetts
`
`Leigh Ann Hewston, PT, Med
`Instructor
`Thomas Jefferson University
`Ph iladelphia, Pem1sylvan ia
`
`Paul Higgins, DPT, MPT, ATC, CSCS
`Assistant Professor of Physical Therapy
`University of Hartford
`West H artford, Connecticut
`
`Martha Hinman, PT, EdD
`Professor
`Hardin-Simmons University
`Abilene, Texas
`
`Michael S. Krackow, PhD, ATC, PTA, CSCS
`Associate Professor
`Virginia l\llilitary Institute
`Lexington, Virginia
`
`Scott Livingston, PhD, PT, ATC, SCS, LAT
`Assistant Professor
`University of Kentucky
`Lexington, Kentucky
`
`Sara Maher, PT, DScPT, OMPT
`Associate Professor
`Oakland University
`Rochester, Michigan
`
`Byron Smith, PT, DPT, MPE. OCS
`Instructor
`University of Miami
`Coral Gables, Florida
`
`Andrew Priest. EdD
`Dean of College of Health and Human Services
`Touro U nive rsity Nevada
`Henderson, Nevada
`
`Teresa Hoppenrath, PT, DPT, GCS
`Assistant Professor, Director of Clinical Education
`Ithaca College
`Ithaca, New York
`
`Robert Rowell, DC, MS
`Associate Professor
`Palmer College of Chiropractic
`Davenport, Iowa
`
`Carrie Hoppes, PT, DPT, NCS, OCS, ATC
`Adjunct Professor
`Baylor University
`Fort Sam H ouston, Texas
`
`ix
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`LUMENIS EX1011
`Page 10
`
`

`

`PREFACE
`
`There are several electrophysical agent (EPA) text(cid:173)
`books on the market, and l truly appreciate your con(cid:173)
`tinued interest in this one. I am particularly exc ited by
`this third edition because it brings us to another level in
`our journey to become the best evidence-based learners
`and practitioners of EPAs we ca n be. In the first edi(cid:173)
`tion, my goal was to introduce the concept of evidence(cid:173)
`based practice into the field of EPAs using a pocket-style
`format. ft is fa ir to say that the focus of textbooks pub(cid:173)
`lished prior to the year 2000 was m uch more on how
`to safely and effectively apply EPAs rather than on the
`treatment effectiveness related to these agents. In other
`words, texts on th is subject were m uch more oriented
`to application safety and efficacy, and less orie nted to
`treatment effectiveness based on the evidence-that is,
`on results of published research-based human trials. In
`the second edition, the goal was to expand on the con(cid:173)
`cept of evidence behind the pract ice of EPAs by adding
`more content on key re lated topics such as pain and soft
`tissue healing, as wel l as case studies and a n illustrated
`glossary of terms related to EPAs. The purpose then was
`to c reate a textbook that faculty could use to teach
`undergraduate and graduate students . With this third
`edition, my goal is to offer the most comprehensive
`and practical textbook in the field of EPAs by provid(cid:173)
`ing updated and new materials, as well as unique and
`practical ancillary tools.
`
`ENHANCED AND NEW CONTENT
`PRESENTATION
`
`T his edition now offers a full-color presentation designed
`to maximize text and image quality, clarity, and accuracy.
`T he textbook h as also been reorganized into five logical
`parts containing 2 1 chapters. Part I, Foundations, includes
`six chapters. A new Chapter 2 , Toward a Practice Based
`on Evidence, explains how the adoption of evidence can
`optimize the clinical decision making process. l n addition,
`a new Chapter 5, Purchase, Electrical Safety, and Main(cid:173)
`tenance, consolidates the content of two former chap(cid:173)
`ters, Purchase of T herapeutic Electrophysical Agents and
`Electrical Shocks, Safety Measures, and Maintenance of
`Line-Powered Devices. Part II, Tiiermal Agents, includes
`three chapters: T hermotherapy, Cryotherapy, and Hydro(cid:173)
`therapy. T he c hapter on thermotherapy now integrates
`four previous chapters, Hot Pack and Paraffin Baths,
`
`F luidotherapy, Skin Sensory Heat and Cold Discrimina(cid:173)
`tion Testing, and Skin and Electrophysical Agents Tem(cid:173)
`perature Measurement. Part III, Elect.romagnet:ic Agents,
`is also composed of three chapters: S hortwave Diathermy,
`Low-Level Laser Therapy, and Ultraviolet. Part TV, Elec(cid:173)
`trical Agents, includes four chapters. A new Chapter l 3,
`Neuromuscular Electrical Stimu lation, now integrates
`two former chapters, Hussian C urrent Therapy and Inter(cid:173)
`ferential Current Therapy. The former chapter on Oiady(cid:173)
`namic Current Therapy has been deleted because of lack
`of evidence to support its therapeutic effectiveness. A new
`C hapter 15, Electrical Stimulation for Tissue Healing
`and Repair, incorporates two former chapters, M icrocu r(cid:173)
`rent Therapy and High-Voltage Pulsed Current Therapy.
`Part V, Mechanical Agents, includes five chapters. A new
`C hapter 21, Extracorporeal Shockwave T herapy, is added
`to cover the latest mechanical source of energy used For
`the management of chronic soft tissue disorders.
`Learning objectives are rewritten to reflect recent
`updates made to Bloom's Taxonomy. The illustrated
`glossary of electrophysical terminology, formerly Chap(cid:173)
`ter 5, is now integrated into re lated c hapters to enhance
`the learn ing experience, meaning that there is no lon(cid:173)
`ger a need for readers to go back and forth to this chap(cid:173)
`ter when studying a particular agent. Each chapter now
`incorporates a new feat ure, The Bottom Line, which
`highlights key e lements. New updated and revised
`Application, Contraindications, and Risb boxes, cou(cid:173)
`pled with Research-Based Indications boxes, eliminate
`some of the redundancies in the previous edition whi le
`concisely providi ng all essential elements required to
`enhance treatment safety, efficacy, and effectiveness.
`Revised Case Studies are now based on the concepts
`of evidence-based practice; the International Classi(cid:173)
`fication of Functioning, Disab il ity, and Health (JCF)
`model; and SOAP (subjective, objective, assessment,
`·plan) note format.
`
`NEW AND UNIQUE ANCILLARY
`MATERIAL
`
`This third edition offers new and u nique tools designed
`to help you master the practice of EPAs. Readers can
`now access Online Dosi.metric Calculators, a u nique tool
`in the field, to simplify the often complex and confusing
`dosimetric aspect of EPA practice while maintaining
`
`xi
`
`LUMENIS EX1011
`Page 11
`
`

`

`xii
`
`Preface
`
`an emphasis on scientific-based treatment . By enter(cid:173)
`ing dosimetric parameters, you can obtain the results
`and chart them into a patient's file without the need for
`memorizing form ulas or doing hand calculations. Also
`available are links to Onl-ine Videos to help students bet-
`
`ter visualize EPA equipment and accessories, as well as
`application to patients. Finally, Online Board-Style Ques(cid:173)
`tions are included to help students with the all-important
`preparation for licensing.
`Alain-Yvan 136/angei; BSc, MSc, PhD, PT
`
`LUMENIS EX1011
`Page 12
`
`

`

`CONTENTS
`
`PART I • FOUNDATIONS 1
`
`PART IV • ELECTRICAL AGENTS 219
`
`13
`
`14
`
`15
`
`Neuromuscular Electrical Stimulation 220
`
`Transcutaneous Electrical Nerve
`Stimulation 256
`
`Electrical Stimulation for Tissue
`Healing and Repair 281
`
`16
`
`lontophoresis 300
`
`PART V • MECHANICAL AGENTS 325
`
`17
`
`18
`
`19
`
`20
`
`21
`
`Spinal Traction 326
`
`Limb Compression 344
`
`Continuous Passive Motion 366
`
`Ultrasound 379
`
`Extracorporeal Shockwave Therapy 411
`
`INDEX 429
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`Therapeutic Electrophysical Agents in
`Health Care 2
`
`Toward a Practice Based on Evidence 7
`
`Soft-Tissue Healing Process 13
`
`Pain Following Soft-Tissue Pathology 31
`
`Purchase, Electrical Safety, and
`Maintenance 54
`
`Therapeutic Spectrum, Selection, and
`Indication 62
`
`PART II • THERMAL AGENTS 67
`
`7
`
`8
`
`9
`
`Thermotherapy 68
`
`Cryotherapy 95
`
`Hydrotherapy 120
`
`PART Ill ~ ELECTROMAGNETIC
`AGENTS 145
`
`10
`
`11
`
`12
`
`Shortwave Diathermy 146
`
`Low-Level Laser Therapy 170
`
`Ultraviolet 198
`
`xiii
`
`LUMENIS EX1011
`Page 13
`
`

`

`j Chapter 13
`
`Neuromuscular
`Electrical Stimulation
`
`Chapter Outline
`
`I. FOUNDATION
`A. Definition
`B. Electrical Currents
`C. Electrical Stimulators
`D. Electrodes and Coupling Medium
`E. Rationale for Use
`
`II. BIOPHYSICAL CHARACTERISTICS
`A. Current Waveform
`B. Frequency
`C. Biphasic Pulsed Current
`D. Russian Current
`E. lnterferential Current
`F. Comparative Biophysical Characteristics
`
`Ill. THERAPEUTIC EFFECTS AND INDICATIONS
`A. Muscle St rengthening
`B. Intestinal Motility
`C. Pain Modulat ion
`D. Research-Based Indications
`
`IV. DOSIMETRY
`A. Electrical Parameters
`B. ON:OFF Time Ratio
`
`Learning Objectives
`
`C. Ramp Up and Down Times
`D. Duty Cycle
`E. Online Dosage Calculator: Neuromuscular Electrical
`Stimulation
`
`V. APPLICATION, CONTRAINDICATIONS, AND RISKS
`A. Skin Preparation
`B. Electrodes and Cables
`C. Electrode Coupling
`D. Electrode Current Density
`E. Electrode Spacing
`F. Electrode Configuration
`G. Electrode Placement
`H. St imulat ion M odes
`I. Training Methods
`J. Training Protocol
`
`Application, Contraindications, and Risks
`Case Studies
`
`VI. THE BOTTOM LINE
`
`VII. CRITICAL THINKING QUESTIONS
`
`VIII. REFERENCES
`
`Remembering: Describe the biophysical characteristics
`associated w ith biphasic pulse, Russian, and interferent ial
`currents.
`Understanding: Distinguish between electrically evoked versus
`volit ional muscle contraction.
`Applying: Demonstrat e the four electrode conf igurations
`(monopolar, bipolar, quadripolar, multipolar) and the three
`stimulation m odes (synchronous, reciprocal, overlap).
`
`Analyzing: Explain how the current modulat ion underlying
`Russian current differs from the current modulation used
`to generate interferent ial current.
`Evaluating: Formulate the dosimetric parameters t hat
`practitioners need to consider and calculate to deliver safe
`and effective neuromuscular electrical stimulat ion.
`Creating: Discuss the evidence behind the therapeutic use of
`neuromuscular electrical stimulation.
`
`220
`
`LUMENIS EX1011
`Page 14
`
`

`

`CHAPTER 13 Neuromuscular Electrical Stimulation
`
`221
`
`I. FOUNDATION
`
`B. ELECTRICAL CURRENTS
`
`A. DEFINITION
`1. Neuromuscular Nerve Stimulation
`The practice of NMES rests on the use of pulsed electri(cid:173)
`cal c urrents applied to skeleta l muscles with the objective
`to elicit contraction caused by the electrical depolariza(cid:173)
`tion of intramuscular nerve branches. Electrical stimuli
`are delivered using surface electrodes that are positioned
`over muscle bellies. The main purpose of NM ES is to
`preserve and recover muscle function in patients and to
`improve muscle strength in healthy individuals (Bax et al.,
`2005 ; Gonclin et al., 20 11 Hortobagyi et al., 2011; Kim
`el al., 20 IO; Filipovic et al., 2011, 2012).
`
`2. Functional Electrical Stimulation
`T he application of NMES for enhancing the control of
`movement and posture Falls under the field of functional
`electrical stim·ulation (FES). !\fore specifically, this ther(cid:173)
`apeutic field focuses on the enhancement of impaired
`motor functions, such as h and grasping, locomotion, and
`respiration, using complex transcutaneous and percuta(cid:173)
`neou s electrical muscle stimulation systems. The main
`purpose of FES is to enable motor function by replac(cid:173)
`ing, or assisting, a patient's voluntary ability to execute
`or control th e impaired functions . A subgroup of FES is
`the application of electrical current for dene111ated skel(cid:173)
`etal muscles, known as EMS, wh ich stands for elect:ri(cid:173)
`cal muscle stinziilation (APTA, 2001; Selkowitz, 2010).
`Coverage of FES, including EMS, is b eyond the scope
`of this chapter because it usually requires complex and
`specially designed th erapeutic eq ui pment available for
`research purposes but not commonly available on the
`market for regular clin ical applications (for a n overview,
`see Glinsky et al., 2007; Roche et al., 2009; Selkowitz,
`2010).
`
`Th e body of evidence presented in this chapter indi(cid:173)
`cates that three types of electrical currents are commonly
`used to deliver clinical NMES . P rac titioners can choose
`betvveen biphasic pulsed, Russian, and interferential
`currents. \ 1\/hen examining the force-generating capabil(cid:173)
`ity of these electrical currents, similarities among elec(cid:173)
`trical parameters must be considered before making any
`stateme nt as to which current waveform is better than
`the other for muscle strengthening (Bellew et al., 2012).
`The biophysical ch aracteristic of each of these currents
`is presented in the Biophysical Characteristics section .
`
`C. ELECTRICAL STIMULATORS
`NMES is delivered by using a variety of cabinet and por(cid:173)
`table electrical stimulators. Figure 13-IA illustrates a cab(cid:173)
`inet-type, multi-current, line-powered stimulator capable
`of generating Russian, interferential, and pulsed biphasic
`currents. The stimulator may be placed on top of a plain
`table or on a movable cart, as shown ; the cart integrates
`with the stimulator in addition to providing storage bins
`and mobility. Also shown are two portable, battery-pow(cid:173)
`ered stirnulators capable of generating Russian and inter(cid:173)
`ferential currents (see Fig. 13-1 B,C). There is evidence to
`suggest that battery-powered stimulators are as effective
`as line-powered stimulators in producing current ampli(cid:173)
`tudes necessary to generate the training muscle force out(cid:173)
`puts required for therapy (Laufer et al., 2001; Lyons et al.,
`2005) . Additionally illustrated are a cabinet, line-powered
`interferential stimulator w.ith a vacuum unit, wh ich allows
`the use of stimulating suction-type electrodes (see Fig.
`13-l D and later discussion ), as well as the newer, all-in(cid:173)
`one, garment-type electrical stimulator that is designed
`specifically for th e treatment of the quadriceps muscle
`(seeFig.13-lE).
`
`Historical Overview
`
`The foundation of neuromuscular electrical stimulation (NMES)
`rests on Italian Luigi Galvani's work on frogs, conducted in the
`1790s, showing that electrical current !static electricity) can
`evoke muscle contraction. A few years later, the discovery
`of electromagnetic induction by British Michael Farady led to
`the development of modern electrical stimulators. Then came
`the work of French Duchenne de Boulogne, in the 1800s, on
`human muscle showing that faradic current (pulsed current)
`applied with moistened surface electrodes can evoke muscle
`contraction. In 1950, Austrian Hans Nemec patented a concept
`that led to the creation of the first interferential current (IFC)
`therapy device (Nemec, 1959; Hooke, 1998). IFC therapy
`
`was first introduced in Europe during the 1960s and then in
`Australia, Canada, and the United States in the 1980s. The
`mid-1970s saw the introduction of Russian current, by Russian
`scientist Yakov Kots. His work opened the door to the use of
`NMES for enhancing muscle strength to healthy nonathletic
`and athletic individuals who want to increase their muscle
`strength without submitting themselves to traditional regimens
`of voluntary muscle training (Delitto, 2002; Ward et al., 2002).
`In response to scientific and public interests for this newly
`discovered -current, commercial production of Russian current
`stimulators began in Canada and the United States in the
`1980s.
`
`LUMENIS EX1011
`Page 15
`
`

`

`222
`
`PART IV Electrical Agents
`
`•~~ $Ji.
`--~ f
`~~
`
`/t
`
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`lite
`l 0,10
`
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`
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`
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`C
`
`FIGURE 13-1 A: Cabinet-type, line-powered, multi-current stimulator mounted on cart, capable of gen(cid:173)
`erating Russian, interferential, and pulsed biphasic currents. Portable, battery-powered Russian (B) and
`interferential (C) stimulators. D: Cabinet-type, line-powered, interferential with vacuum unit, to which is
`attached a pair of suction electrodes. E: Newer, one size fits all, battery-powered, garment-based electri(cid:173)
`cal stimulator designed specifically for the quadriceps muscle. (A-C: Courtesy of DJO Global; D: Courtesy
`of Astar; E: Courtesy of Neurotech Bio-Medical Research Ltd.)
`
`LUMENIS EX1011
`Page 16
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`CHAPTER 13 Neuromuscular Electrical Stimulation
`
`223
`
`--
`
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`~lt Dura-St:icl< L,
`Stid< D ura-Stid
`1< Dura-Stick 9
`t:icR Dura-Sci;:~
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`ticl< Dura-Stic
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`I
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`A
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`D
`
`B
`
`C
`
`E
`FIGURE 13-2 Surface rubber carbon-impregnated electrodes (A) and pliable stainless steel knit fabric
`electrodes (B). Reusable intravaginal (C) and intrarectal electrodes (D). Electroconductive gel (E).
`(A, B, and E: Courtesy of DJO Global; C, D Courtesy of Enraf-Nonius.)
`
`D. ELECTRODES AND COUPLING MEDIUM
`NMES is applied by using a variety of reusable and
`disposab le electrodes connect.eel to the stimulator using
`various cables. Figure 13-2 shows common surface plate
`electrodes made of carbon rubber material (A) or pliable
`stainless steel knit fabrics (B). These electrodes may be
`applied over Aat body areas, with the exception of the pel(cid:173)
`vic area, where attachment may be a problem. When the
`purpose is to deliver NMES to the pelvic floor muscles for
`conditions such as urinary incontinence, special stimulat(cid:173)
`ing electrodes may be required. One option is to use intra(cid:173)
`vaginal and intrarectal electrodes (Fig. l 3-2C,D, respec(cid:173)
`tively). IF patients are not comfortable with the invasive
`nature of these electrodes, practitioners may select suc(cid:173)
`tion cup electrodes as a second option. These electrodes,
`connected to a vacuum interferential u nit (see Fig.
`13- 1 D), can be q uickly and easily attached without adhe(cid:173)
`sive tape or straps, and adapt comfortably to the contours
`of the pelvic area, thus ensuring optimal contact between
`the electrode and the skin. For NMES of the q uadriceps
`
`muscle, practitioners may select a "one size fits all" gar(cid:173)
`ment electrode with stimulator u nit (see Fig. 13-1 E) as
`an alternative to traditional su rface plate electrodes. To
`optimize electrical ·conduction at the electrode- tissue
`interface, electrodes must be covered with a thin layer of
`electroconductive gel (Fig. 13-2E). Both intravaginal and
`intrarectal electrodes must also be covered with a sterile
`lubricant prior to use.
`
`E. RATIONALE FOR USE
`Common goals in the field of physical rehabilitation are
`to preserve, recover, and en hance muscle function in
`patients fo llowing disease and trauma, and in healthy indi(cid:173)
`viduals for recreational purpose. T here is unquestionable
`evidence in the scientific literature to show that the best
`method practitioners can use to enhance muscle function
`(i.e ., strengthening) is to submit individ uals to ·bouts of
`muscle maximum voluntary contractions (MVCs), done
`under isometric, isotonic, or isokinetic conditions. \Nhich
`muscle-strengthening method should clinicians use with
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`Page 17
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`

`224
`
`PART IV Electrical Agents
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`patients who are unable to perform volitional exercise at
`adequate intensity and duration to gain benefits, because
`of related fac tors such as physical deconditioning, pain,
`severe muscle atrophy, or lack of motivation? T he use
`of NMES provides practitioners with an alternative
`muscle-strengthening method that mi1nics volitional train(cid:173)
`ing methods. By using NMES a lone, or by superimposing
`it on top of voluntary muscle contractions, practitioners
`can enhance muscle strengthening in both patients and
`healthy subjects by improving motor unit (MU) activation
`while inducing muscle hypertrophy. In other words, the
`main objective of Nl\lIES is to improve MU recruitment
`while inducing muscle hypertrophy through serial bouts
`of short duration maximal electrically evoked muscle con(cid:173)
`tractions done against resistance or load.
`
`II. BIOPHYSICAL CHARACTERISTICS
`
`As mentioned earlier, the delivery of NMES rests on
`using three different electrical currents, namely biphasic
`pulsed, Hussian, and interferential currents. To describe
`electrical current in terms of waveform and frequency
`is common in the field of NMES. Let us consider these
`two important concepts before addressing the biophysical
`characteristics of these three e.lectrical currents.
`
`A. CURRENT WAVEFORM
`v\-0veforin is the geometric configuration of a current,
`which is described based on its phase, symmet1y, elec(cid:173)
`trical balance, and shape. First, a current waveform may
`be monophasic or biphasic in nature. The word phase
`describes an electrical event that begins when the current
`departs from the isoelectric line and ends when it returns
`to the baseline (APTA, 2001). A 1non.ophasic current wave(cid:173)
`form is made of only one phase that moves in only one
`direction (+ or - polarity) from the zero baseline to return
`to it after a finite time (Fig. 13-3). A biphasic current wave(cid:173)
`form, on the other hand, is made of two phases: moving in
`one direction and then in the opposite direction from the
`zero baseline, then returning to that baseline after a finite
`time. Second, a biphasic current waveform may be sym(cid:173)
`metrical or asymmetrical. lt is sym1netri.cal when its posi(cid:173)
`tive phase is geometrically identical to its negative p hase
`and asymmetrical when its two phases are geometrically
`different (Fig. 13-4). Third, a biphasic waveform may also
`be balanced or unbalanced. T he waveform is balanced
`when there are equal electrical charges in each phase
`(see A in Fig. 13-4). Such a balanced waveform is often
`referred to as having "zero net charge" or "zero net DC,"
`because the amount of positive charges minus the amount
`of negative charges equa ls zero (APTA, 2001) . The wave(cid:173)
`form is said to be unbalanced when there are unequal elec(cid:173)
`trical charges in each phase-that is, when there is a net
`accumulation of charges within the waveform (see B in
`Fig. 13-4 ). Fourth, bipbasic waveforms may have various
`
`FIGURE 13-3 Monophasic waveforms with either positive (x) or
`negative (y) polarity.
`
`shapes such as rectangular, square, triangular, sinusoidal,
`or exponential. To summarize based on the mentioned ter(cid:173)
`minology, monophasic waveforms are neither symmetrical
`nor asymmetrical, but are always unbalanced. !Vloreover,
`biphasic waveforms are either symmetrical or asymmetri(cid:173)
`cal. Finally, symmetrical waveforms are always balanced,
`whereas asymmetrical waveforms are either balanced or
`unbalanced.
`
`B. FREQUENCY
`1\s discussed next, electrical currents used for NMES may
`be delivered in pulses, bursts, and beats. A pulse is a single
`momentary and sudden fluctuation of current. Pulses may
`have various shapes; when it has a sinusoidal shape, it is
`
`+
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`0
`
`FIGURE 13-4 Biphasic symmetrical (A) and asymmetrical (B) waveforms.
`
`LUMENIS EX1011
`Page 18
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`

`

`called a qcle. A burst, as wel l as a beat, is a group of tvvo
`or more successive pulses or cycles separated by a time
`interval during wh ich no electrical activity occurs (APTA,
`2001) . Du,ration, whether it is pulse duration (PD), cycle
`du ration (CD), burst duration (BuD), or beat duration
`(BeD), is the time elapsed between the beginning of the
`f-irst ph ase and the end of the last phase. The time elapsed
`between each corresponds to interpu lsc duration (IPD),
`intercycle duration (ICD), interburst duration (IBuD),
`and interbeat duration (IBeD), respectively, Frequency (f)
`is defined as the number of times per second that a pulse,
`cycle, burst, or beat will repeat itself. It is calculated using
`the formula f = 1/P, where P, the period, is equal to the
`summation of either PO and IPD, CD and ICD, BuD and
`TBD, and BeD and IBeD, respectively.
`
`C. BIPHASIC PULSED CURRENT
`
`A
`
`CHAPTER 13 Neuromuscular Electrical Stimulation
`
`225
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`+
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`T he use of biphasic p ulsed currents is very common in
`the fi.eld of NMES. Figure 13-5 illustrates a typical bipha(cid:173)
`sic pulsed waveform. This particular c urrent waveform
`may be described as biphasic, asymmetrical,