NMES, The Missing Link.

The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education

Following any type of surgery, significant weakness of the primary and secondary musculature is common. For example, quadriceps weakness has been documented during the immediate post-operative phase following surgery (Snyder-Mackler et al), as well as years following rehabilitation (Rosenberg et al). Additionally, patients who undergo Total Knee Arthroplasty (TKA) exhibit similar findings. According to Mizner et al and Stevens et al, quadriceps strength drops 50-60% of pre-operative levels one month following TKA, despite the initiation of rehabilitation within 48 hours of surgery. Following this trend, Rokito et al found external rotation deficits following rotator cuff repair of 79% and 90% at six months and one year, respectively. Considering the severity and chronicity of these strength deficits, more effective interventions are warranted to restore strength and improve long-term outcomes. One particular modality that has been shown to improve these deficits is neuromuscular electrical stimulation (NMES).

Kim et al recently published a systematic review investigating the utility of NMES following ACL reconstruction to improve quadriceps function and strength. In this review, which involved 8 randomized controlled trials (RCTs), it was demonstrated that NMES in conjunction with exercise, compared to exercise alone or in combination with electromyographic bio-feedback, results in greater quadriceps strength recovery. As discussed in a previous article, return to sport is the ultimate goal for most patients and quadriceps femoris strength is of the utmost importance. Schmitt et al conducted a cross-sectional study to determine the impact of quadriceps weakness on return to sport functional testing. Those patients who presented with a quadriceps index (quadriceps strength involved/uninvolved) of < 85% performed inferiorly when compared to those with a quadriceps index of > 90%. Additionally, quadriceps weakness predicted performance on single-leg hop testing regardless of graft type, presence of meniscus injury, knee pain, and knee symptoms. Similarly, Fitzgerald et al not only measured increased quadriceps strength, but also length of time until progression to agility/plyometric training.  This randomized controlled trial found that those in the NMES group met the criteria for progression in a greater proportion than those in the control group. At 16 weeks, 85.7% (18/21) of patients receiving NMES achieved progression to agility training, whereas only 68% (15/22) of those in the control group achieved similar results.

In addition to ACL rehabilitation, those undergoing total knee arthroplasty enjoyed similar benefits. Stevens-Lapsley et al conducted a prospective, longitudinal, randomized controlled trial investigating the effects of NMES on patients following TKA. Patients were randomized into a group receiving standardized rehabilitation or to a group receiving the same rehabilitation in addition to NMES, which was initiated 48 hours following surgery. In both the short-term (3.5 weeks) and long-term (52 weeks), patients in the NMES group demonstrated superior quadriceps strength, hamstring strength, and functional performance (Timed “Up & Go” Test, the Stair-Climbing Test, and the Six-Minute Walk Test). Additionally, Walls et al investigated the pre-operative utility of this modality. Those individuals who received NMES achieved significant increases in quadriceps strength from weeks 6-12, whereas the control group did not achieve the same feat. Lastly, in a case report published by Petterson et al, a cyclist presenting 12 months following bilateral TKA displayed significant impairments with regards to quadriceps strength and volitional muscular contraction. Following six weeks of NMES and volitional therapeutic exercise, this patient achieved a 25% improvement in left quadriceps femoris maximal volitional force output and his central activation ratio (CAR) also improved from 0.83 to 0.97 as quantified by the burst superimposition technique. Furthermore, strength gains continued after the end of treatment as his quadriceps strength index was 94% of his right leg at 12 months following treatment.

While the majority of research pertaining to the efficacy of NMES has been done in the lower extremity, this is not the only region where its benefits can be found. As previously stated, muscular deficits frequently accompany patients following rotator cuff repair. To this end, Reinold et al investigated the ability of NMES to affect maximum voluntary contraction of the infraspinatus muscle. In comparison to trials without NMES, peak force production was significantly greater with an average force of 3.75 kg in comparison to just 3.08 kg. This increase was present regardless of patient age, size of the tear, intensity of the current, or the number of days following surgery. While this preliminary study does not give credence to the effect during a full course of rehabilitation, it does speak to the ability of NMES to increase the ability of this musculature to contract safely and more efficiently following surgery. Further research will define the effectiveness of this intervention following rotator cuff pathology, however this study lends hopeful possibilities.

Neuromuscular electrical stimulation should play an integral role in your practice regardless of setting. Patients presenting with strength deficits and impairments will benefit from NMES when combined with volitional exercise. Meryl Gersh, PT, PhD goes into great detail with regards to electrode placement, optimal dosage, and indication criteria in her course “Applying Electrical Stimulation in Your Physical Therapy Practice”. Increasing your patients’ volitional muscular contraction is of the utmost importance when it comes to fostering improved long term outcomes and NMES in conjunction with their current program should yield enhanced results.

Research Review: Dry Needling – Peripheral and Central Considerations

Dry Needling

The use of Dry-needling by physical therapists has been a common place for discussion both inside and outside our profession. One of the most prevalent reason for this discussion stems from a lack of understanding as to what Dry-needling actual is and what benefits it provides for our patients… [Continue Reading]

The U Word.

The ‘U Word’ (Therapeutic Ultrasound) has had a lot of press recently thanks to everyone’s favorite “doctor” and unfortunately this modality just cannot be put to rest. Li et al conducted a survey attempting to determine the typical treatment approaches used for patients suffering from low back pain of varying intensities (Acute, Sub-acute, and Acute with Sciatica). The results indicated that almost 80% of therapists used physical modalities for all three scenarios, with Ultrasound (US) being utilized by almost 1/3 of all therapists. Additionally, this study showed that spinal mobilization (40%) and manipulation (5%) were used sparingly, despite the evidence supporting their efficacy. Honestly, I thought it would be worse. A more recent survey by Wong et al sought out the practice patterns of Orthopaedic Certified Specialists (OCS) with regards to the use of ultrasound. This survey of certified experts in our field concluded that of the over 200 respondents, 83.6% use US to decrease soft-tissue inflammation, 70.9% to increase tissue extensibility, 68.8% to enhance scar tissue remodeling, 52.5% to increase soft-tissue healing, 49.3% to decrease pain, and 35.1% to decrease soft-tissue swelling. With such widespread use of this intervention for so many varying reasons, there has to be supporting evidence, doesn’t there?

It has been theorized that US has the ability to heat deeper anatomical structures (i.e. muscle, tendon, and bone), accelerate tissue regeneration, increase pain threshold, stimulate bone growth, and increase tendon extensibility. Sounds pretty good, right?

Problem number one: The majority of the supporting research was conducted between 1950 and 1980.
Problem number two: Results of recent efficacy studies.

Gam et al completed a meta-analysis investigating the use of ultrasound in musculoskeletal disorders. After pooling the outcomes of 29 randomized controlled trials, they concluded that US contributed a negligible amount to the subjects’ rehabilitation. Later, in 1999, van der Windt et al conducted a systematic review of US therapy for musculoskeletal disorders. Of the 18 placebo-controlled studies evaluated, only 2 yielded results that showed US to be beneficial. It was determined that the magnitude of the reported treatment effects were small, and were probably of little clinical importance. To build upon these findings, Robertson et al published a systematic review once again looking into the efficacy of therapeutic ultrasound in the treatment of common musculoskeletal disorders (as determined by randomized controlled trials). Not too surprisingly, of the ten studies that met the inclusion criteria, only 2 studies showed statistically significant benefits (carpal tunnel syndrome and calcific tendinitis of the shoulder).

But, these studies compared treatments of different pathologies… Surely there are pathologies where US is supported?

There have been a few high quality systematic reviews conducted looking into ultrasound’s therapeutic effect on specific pathologies. Seco et al investigated its effecacy in the treatment of low back pain (remember the Li study?). 242 patients were included in the 4 studies that met the inclusion criteria and none of these studies showed statistically significant benefits. In addition, one of the studies included (Mohseni-Bandpei et al) looked into the effectiveness of US versus spinal manipulation. They evaluated the outcomes of 116 patients over 6 months and found that spinal manipulation demonstrated greater improvements in pain, disability, flexion ROM, and extension ROM (remember the Li study?). It is postulated that only tissues that are superficial can be effected, so maybe that’s why the effects on LBP are miniscule.

The lateral ankle ligaments are superficial, so surely US will be of benefit, right? A Cochrane Review was published by van den Bekerom et al investigating just that hypothesis. This review included 6 studies and over 600 patients, but once again US did not provide the benefits that many are led to believe. No statistically significant benefits were found for improvements in pain, swelling, functional disability, or range of motion in any of the 6 studies.

Clinical instructors and colleagues continue to use this poorly supported intervention, but shy away from those interventions supported by current research. The Li and Wong studies say it all. We need to educate our fellow colleagues about the ineffectiveness of what has become a mainstay in many outpatient physical therapy and chiropractic offices. Why do we continue to utilize old, outdated interventions? Is it fear of change? Is it stubbornness? Is it a lack of awareness?

Regardless of the reason, our clinical practice patterns need to change. The evidence is lopsided contrary to previous beliefs regarding ultrasound’s efficacy in treating musculoskeletal pain/dysfunction and we, as a profession, must adapt and move on. So, unless you are treating a huge proportion of calcific tendonitis of the shoulder or carpal tunnel syndrome, just keep your ultrasound machine in the storage closet.

Did you enjoy this blog post? If so, please take the time to vote for Orthopedic Manual PT as ‘Best Student Blog’ at Therapydia!