Neuromuscular Electrical Stimulation of the Quadriceps Femoris

Thanks for the post Chris. Do you have a copy of the article? I couldn’t find it online?

A question for you – Why would the patient remain completely relaxed with the stimulation on the quads? Wouldn’t you want to patient to perform at least some form of voluntary contraction of the quads? I thought the whole idea was to strengthen the neuromuscular connection from the brain to the quads, so the quads can become less inhibited. If the machine is doing all the work for the patient, then it is a completely passive strengthening exercise, much like the abtronic on tv infomercials. Unless research shows the point of being relaxed with the NMES is to help dissapate some of the extra-articular swelling.

Please let me know if this is inaccurate, as my knowledge on the area is not up to date.

Thanks,

Ben

Is proud to say I ha e enjoyed 28 years of successful prctise without ever using ES. I teach it is a waste of time for outpt ortho cases. I also teach this the base way to be different then my local POPTS that stim everything and do nothing.

Bruce,

Talk is cheap! I spent four years in Lynn Snyder-Mackler’s lab and think it is important for you to revisit some of her work…particularly the JBJS article which demonstrated that patients who received stim combined with volitional exercises had significantly greater strength than those who did not receive it and this also correlated with increased knee flexion excursion at midstance. During the gait cycle. This is the only type of stim I use and I only do it in the context of patients s/p ACLR. So let’s speak in denominators and base things on good evidence.

Ok, this sounds counterintuitive to what’s taught in schools and what I’ve been following for the past 10 years, but hey, I’m open to change. What’s the purpose of being completely relaxed during the stimulation?
So you’re saying that the patient just sits there and lets the machine do all the work? What’s the Snyder-Mackler article title?

I think the application of ES is cheap and way over utilzed. Exspensive in proper PT done by a PT.

Based on the body of evidence, the research by Lynn Snyder-Mackler et al clearly demonstrates the efficacy of electrical stimulation for regaining quadriceps strength and function when combined with volitional exercises following ACL reconstruction. And yes, the patient is to remain completely relaxed throughout the electrically elicited contractions. This is most likely due to the fact that the estim recruits the quad muscle in a more random fashion versus volitional activation which relies on the size principle to more finely grade muscle contraction. Not sure why most PT programs fail to teach their students to use the estim as described by Lynn. I know that Uninverity of Delaware and Pittsburgh teach this approach. The study which I encourage people to read is listed below. It is also critical for PTs to understand that for a therapist to get published in the J Bone Joint Surg Am is am amazing accomplishment as this is a very prestigious journal.

Snyder-Mackler et al. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the ACL. A prospective randomized clinical trial of electrical stimulation. J Bone Joint Surg Am. Aug 1995;77:1166-1173

say it again. I have great results and dominate my market without ever using stim.

Thanks for everyone’s comments. I think one thing that we can all agree on is that clinicians seem to mindlessly use estim. If you do not have a clearcut reason don’t waste your patient’s time. I basically lived in Lynn Snyder-Mackler’s lab at UD for ~4 years and I rarely use electrical stim except in very specific cases.

Onward,
Chris

Do you think if you did everything else but not the stim it would make any diffrence? I say it would make a big diffrence in the pts perception of your care. Very diffrent.

Chris,
Great post. NMES is vital for neuromuscular reeducation of the quadriceps as a group in individuals who have inhibition or have had recent surgery which caused inhibition. I went back to this article and find the on/off time to be interesting. I generally was using a 1:2 ratio but I assume the greater off time allows relaxation and more of an optimal contraction. I do believe that NMES is vital for many individuals in early rehab, especially after ACL reconstructions, and believe it would make a difference in progressing the protocol and meeting goals quicker than not using it. Long term, I doubt there would be much of a difference in high level individuals but it just may take longer to progress that patient.

I hopes some day to have evidence that compare real PT with and without ES. My guess is no diffrence. Till then I teach ES is a waste of time in outpt orth.

I understand your point Bruce, but evidence does exist to support the use of NMES and believe that was Chris’ point in this article. The article Chris is referring to looked at 110 patients who had an ACL reconstruction. Out of these 110 patients, 31 had NMES, 34 had high volitional exercise, 25 had low intensity NMES and 20 had a combo of high intenisty and low intensity NMES. The individuals who recieved NMES (high or low intensity) had statistically significant more strength vs. those who only had exercise. This was performed early on and as I said in my last reply, this is signficant and can be applied to our practice to progress our patients quicker early on. I can send you a .pdf copy of this article if you want, but NMES may be something that you may want to incorporate into your practice since you do seem to treat many runners and likely ACL reconstructions. I do agree TENs and other estims are over utilized and I am against that, but we must stay current with literature and not become too opinionated bc our practice is constantly evolving and we must constantly reform our techniques to shadow this.

But all indivuals needed to have proper PT and compare. That said try defining proper PT. I know that trouble and the limits in PT.

I’m sorry bruce but am extremely confused by your argument. You wanted to see an experimental study which examined those who received estim + PT and those who received PT only and this whole study was just that. I am sure you are a great PT but not sure you are understanding the application of literature to practice. I wish you all the luck with your approach without NMES but believe for our profession to survive we must strive for an evidence-based approach to all pts.

I say you can argue who gives better stim but I say the outcome of stim treatments makes your PT services look like every cheap PT clinic in Miami.

Bruce,

It isn’t cheap PT if you are giving the patient skilled treatments (proved by the latest and best evidence). What Joseph and Christopher are saying is that we should employ the best treatment options to our patients. If we supply them with, in this case NMES and combine them with our manual skills, patient education, nueromuscular re-education, and our expertice in exercises, then the outcome (according to the research article) will be better.
If you had to go to a surgeon and were given two options:
a) an older procedure with a long recovery and greater risk of infection
b) a newer procedure with shorter recovery and decreased risk of infection

which would you pick?

The point of this website is to create/discuss/share and promote physical therapy best evidence practices. I am sure you have fantastic results as a physical therapist (which is why you are successful), however Christopher was just sharing the newest and best evidence article on NMES combined with PT.

I do respect your point of veiw. Please respect mine. Once the pt can activly fire their muscles the stim point is mute. My point is our profesion over relies on stim.

To keep my clinical reasoning and treatment rationale up to date, I always look for new evidence to PT treatment interventions, generally going by the adage: “Everything you thought was correct 5 years ago is WRONG today”. That way, I can stay current as a clinician.

That being said, I’ve looked over the Snyder-Mackler article and couldn’t find the mention of the “relaxed patient during NMES application” section. All the other methods, findings, and discussion make sense to me. Sure, estim or NMES can be a ‘controversial’ component to a regular PT program for patients with post-op ACLs, but I believe that it has a place, especially after surgery where a patient has a hard time “cueing” in to contracting the VMO. I agree that it has a place in our clinical tool belt.

However, I don’t agree with the “relaxed” patient variety of NMES application. Maybe I should re-read the article but I couldn’t find it mentioned. Besides the article is from 1998, over 10 years old. Surely our clinical knowledge has progressed from following a 10 year old protocol.
I suppose that’s why most schools don’t teach their PT students to perform the NMES passively.

Being passive during the treatment just didn’t make sense to me, even after thinking about the recruiting the “…quad muscle in a more random fashion…” rationale.
In my opinion, actively contracting the VMO during NMES allows the reeducation of the VMO, creating a ‘pathway’ from the muscle to the brain so to speak, enabling the VMO to contract more completely after treatment…
Just like Occam’s razor (if you hear hoofbeats, think horses, not zebras), it just makes more sense to me to have the patient work along with the NMES, and besides, it’s more comfortable that way. Like in your Vimeo video, the patient was relaxed during the NMES, you got a great contraction on the left leg, but the right leg was squirming away…

Paul,

Thanks for your comment. I would like to make a couple points…

1)I want to remind you that the research did not start when you were born. Years of work has taken place to get us to this point. It’s always important to know where we came from to better understand our current situation and know where we need to direct our efforts moving forward.

2) Most of what you “think” to be the reality of a situation in the clinic will turn out to be wrong (sorry to be the bear of bad news). This is why we always need to research things and base things on factual information.

3) You can try to reestablish pathways between the brain and muscle but I would also like to remind you of something referred to as reflex inhibition of the quadriceps and decreased central activation

4) I was in the trenches when this study was being performed and what they refer to as electrically elicited contractions means that the patient is completely relaxed otherwise we’d call it electrical stimulation superimposed on a volitional contraction.

5) I would also like to say that there is no solid research identifying preferential recruitment of the VMO so don’t know why any PT focuses on preferentially trying to recruitment that portion of the muscle. The quad muscle is supplied by the femoral nerve. If you find an article that clearly demonstrates that humans can selectively activate the VMO, please share with the rest of the medical community.

6) The other leg was squirming because of the intensity of the electrical stimulation on the involved extremity, which most clinicians are afraid to take it up to.

I was just at a course this weekend given by Chris Powers on PFP. He described the PF joint stress (joint reaction force/contact area) as being high at full knee extension and recommended against SLR and SAQ. He also recommended NMES be done at 45-60 degrees of flexion so that the patella forces were reduced by the greater contact area. Can you comment?

Cool.
1.) True.
2.) True.
3.) True.
4.) Cool and interesting.
5.) True.
6.) I LOL’d. Show the patient’s facial expression in the video next time. I’m all for cranking up that intensity and seeing the face they make.

@ Arthur Veilleux:
You blew my mind. Interesting concept.

Arthur,

In full extension the patella is not engaged in the trochlear groove so not sure why Chris would say that. The patella usually engages at 5-10 degrees of knee flexion based on the research that I am aware of. If you look at the weight bearing precautions for articular cartilage procedures on the retropatellar surface, they would not allow people to fully weight bear with the knee locked in full extension if there were high joint reaction forces. There is a great article in JOSPT entitled Biomechanical considerations of the patellofemoral joint, which Dr. Grelsamer wrote and is a must read

http://www.ncbi.nlm.nih.gov/pubmed/9809277d.

His point is well taken with re: to SAQs. Think of the PF joint at a snowshoe. With greater degrees of knee flexion there is more area on the retropatellar surface engaged so the contact area is greater and the stress is therefore decreased (force dispersed over a broader area). It all comes down to stress = force/area. Please stay tuned as I’m about to give to do a webinar on proximal and distal considerations in the treatment of PFPS. Always assess for hip ROM asymmetry too. Thanks for your comment and look forward to hearing more from you.

Also please check out my recent post on Mike Reinold’s blog about a pect minor stretch that I developed which Mike was kind enough to let me write about

Onward,
Chris

Good points overall. I’ll definitely give the relaxed muscle during NMES a shot.

I prefer to perform NMES in 30* knee flexion initially and progress into full knee hyperextension after ACL reconstruction. I begin at 30* with towel roll under knee, to no towel roll, to towel roll under the heel. I find this very helpful in regaining full knee hyperextension and volitional muscle contraction (which we all know to assist in decreasing post-operative knee pain). But to each their own.

I also like to perform NMES in weightbearing. Have you used this with any effectiveness?

Bruce, I think what everyone is trying to tell you is that just because you utilize NMES in conjunction with exercise and other forms of PT does not mean you are being a “lazy PT”. You are actually speeding recovery of muscle function and accelerating the rehab. However, I do agree that TENS is USUALLY a waste of time – you gotta use this stuff on the nutters to shut them up sometime ha!. Just remember, until you have tried something you cannot say that is just doesn’t work at all chief.

p.s. – Chris, I saw that pec stretch about a week or so ago and tried it out on a pitcher of mine. He liked it, felt a good stretch, and no additional stress on the shoulder. nice.

Hunter my pont remains that the bottom sucking PT in my market relies on all forms of ES to provide low cost and high profit PT. One reason I left corporate PT for independent practise was to provide hands on get to know my pts PT. By proper PT starting with ES the pts can not diffrentae the difference and once the pt is past beginning post op the benefits of the stim in voided. My other point is I have been very successful with this approach. We do have ES in my practise but I always find a reason not to use it. I have great outcomes for 28 years without stim. Better then when I forced in my first 2 years as a PT.

Okay, that ’s what I though going into the course.

At one point Chris presented a couple of slides on PFJ reaction forces form Journal of Applied Biomechanics and Medicine and Science in Sports and Exercise that he co-wrote and commented about the SLR and SAQ. Like you I can totally see this for the SAQ, but no one questioned him on the full extension SLR. Now if full extension is not possible, as it not might be during inhibition of the quads, then as little as 5 degrees of flexion may produce significant stress. To quote Mike’s site:

“The quadriceps provides the greatest compressive force near extension when the contact area of the patellofemoral joint is smallest. Thus, a high force on a small area produces considerable patellofemoral joint reaction forces.”

Wouldn’t it be great if Chris responded to this point himself?

PS: saw your pec minor stretch. Good stretch. What was novel was how long you held it. Five to seven minutes is a long stretch time.

Keep up the good work

Hmm. Maybe it’s just me, but I think that “bottom sucking” PTs aren’t going to be reading THE PT PROJECT… Just sayin…

Paul I know that. What I am saying in Miami ES, HUM, PT aides doing all the work is all around me so I do not do stim to be diffrent to an extreme. It is a fair discussion; not only what stim is best but do we even NEED to do it and why.

Chris,

I am intrigued by this concept of not having the patient contract with the e-stim. Do you know of any studies showing that superimposed contractions actually are less beneficial than NMES-induced contractions in post-op knee subjects?

What are your thoughts about the psychological aspects of having the patient contract with the e-stim? We know from a variety of literature – not just on the ACL – that patient perception of performance greatly affects their outcome.

Kramer et al 1987 found that healthy subjects’ perceptions of force output were higher with a superimposed contraction than with subjects’ own MVC. Given this, I would be more inclined to have the patient contract with the stim in order to get that psychological benefit.

Thanks-
Sylvia