5 Common Mistakes for Neuromuscular Electrical Stimulation to the Quad

Neuromuscular electrical stimulation (NMES or sometimes called “Russian stim”) is an effective way to improve quad activation, but unfortunately it is commonly used incorrectly by clinicians. I say unfortunately because when used incorrectly, it won’t provide your patients with its potential benefits and will waste their (and your) time. 

If you want to skip ahead to the video summarizing how to set NMES up, scroll down towards the end of the article (a written summary is also provided).

The 5 things commonly done incorrectly when using NMES:

1. Not using it at all

I don’t use modalities on my patients but the one exception I have is using NMES on a patient’s quad (I have also tried it out on the infraspinatus and on the gastroc but I didn’t find consistent results).  

The benefits of NMES after ACL reconstruction and knee replacement surgery have been clearly demonstrated in multiple studies – those patients demonstrated better quad strength and improved functional outcomes compared to those who did not receive NMES.

Typically, I use NMES on any patient that has had a significant knee injury/surgery that presents with quad atrophy, difficulty activating their quad, or has weightbearing limitations.  NMES is especially useful (and I would almost say mandatory) in anyone who is non-weightbearing.  In these NWB patients, NMES tends to be the most stimulus the quad will receive and thus, the most effective option for them to improve muscle activation and prevent/retard atrophy.

If you are not using NMES on this patient population, I feel that you are doing a disservice to them as you are not providing them with the most effective treatment strategy.  And if it’s because you are afraid/unsure how to use it, then this article should help clear things it up and make you feel more confident/comfortable in using it.

I didn’t know where to include the following statement, but I know someone will ask the question, so I just threw it in here – while I don’t necessarily think there is a superior place to put NMES in your treatment plan, I typically use it at the end of a patient’s treatment due to its potential to cause muscle fatigue.

2. Incorrect patient positioning

Most clinicians tend to have their patients in the long-sitting position with the knee fully extended when using NMES and this position will not give you the most effective results.  Having the patient seated with the knee in 60° flexion will provide better results as demonstrated by this study

I have found that patients are able to tolerate a higher stim intensity in the 60° position and I think because it’s more uncomfortable to have your patella pulled straight up towards your hip than to have it compressed into the joint.  Another important point to remember is that many times patients don’t have full knee extension yet, so being in the long-sitting position will actually allow their knee to move.

If you have a Biodex unit in your clinic, that is the easiest way to achieve the 60° isometric position.  If not, have the patient sit in the knee extension machine, secure their shin to the machine so their knee is in 60° of knee flexion, and then set the weight-stack to the heaviest setting (so it won’t move).

3. Incorrect electrode size

I commonly see clinicians using electrodes that they use for TENS and this will not work when trying to use NMES.  The electrodes should be much larger than ones typically used for TENS – I like to use 3” x 5” rectangular electrodes (I have used oval ones before too).  You need a larger electrode due to the amount of current that will be going through them – larger pads make it more comfortable for the patient.  If you try to put all that current through a smaller electrode, the patient won’t be able to tolerate it.

4. Incorrect electrode placement
The proper electrode placement is one over the distal quad/VMO area (and yes I’m fully aware that you can’t selectively activate the VMO and I hate when clinicians say someone needs to strengthen their VMO) and the other electrode should go over the quad’s proximal motor point.  The location of the motor point varies between individuals, but if you are using the proper size electrode (see above) and place it in the proximal quad area, there’s a good chance you’ll catch it.

Many times I’ll see the two electrodes placed a few inches apart over the distal quad area and this won’t give you good results.  Only the muscle between the two electrodes will be stimulated, so by placing them far apart you will stimulate a larger amount of muscle.  And if you are over the motor point, then you will get even more activation (with less intensity needed).

5. Inadequate intensity

This is probably the most common mistake I see clinicians make – not turning up the intensity enough to elicit a tetanic muscle contraction.  If you don’t get a tetanic contraction, your patient won’t be reaping the benefits of NMES and you will be wasting their time. 

There are two ways that I think help you achieve adequate intensity of the sitm.  First, you need to use the proper electrode size (as I mentioned above).  If you don’t, then you won’t be able to turn the intensity up high enough.  Second, is to make sure you provide proper, thorough patient education on what NMES is/does.  You have to describe to the patient exactly what they will feel, why NMES is so beneficial, and that if they don’t like it to just say “stop” and you’ll turn it off.  I will actually give my patients the hand-held unit I use and show them where the “off” button is if they want to stop it – I don’t think I have had anyone ever actually do this though.  

I will also stick around for the first couple contractions so I can talk them about it and answer any questions.  Usually the first couple contractions are the most uncomfortable and then the patient gets used to it.  If for any reason a patient feels pain or if they can’t tolerate enough intensity to elicit a good quad contraction, I won’t use it (maybe you can revisit it later on).  

When I use NMES on my patients, I prefer to use the the Empi 300PV unit.  However, I don’t think they make this unit anymore and I’m not sure what they replaced it with – maybe someone can tell me what they replaced it with or another handheld unit that produces effective results.  

I couldn’t write up an article about NMES without mentioning the precautions and contraindications to using NMES:

Must have intact peripheral nervous system

  • No pacemaker or implanted electronic devices
  • No uncontrolled hyper- or hypotension
  • No peripheral vascular disorders (for fear of releasing blood clots)
  • No areas of neoplasm or infection
  • Not pregnant
  • Must be able to provide clear feedback
Here is a video of what it should look like:

A quick summary of how to use NMES to the quad:

  • Patient should be seated with the knee in approximately 60° of knee flexion
  • The leg should be secured in a way that it won’t move at all
    • if you have no way of doing this, then do it with the leg lying flat on the table (although not as effective as when positioned at 60° of knee flexion)
  • Electrode size – should be larger than ones typically used for TENS; I use 3″ x 5″ rectangular pads
  • One pad should be placed over the VMO region & the other should be on the motor point for the quad muscle (in the upper quad region)
  • Here are the technical parameters of the stim settings
    • Pulse duration: 400 µs (or carrier frequency of 2500 Hz)
    • Frequency: 50 Hz (can increase up to 100 Hz if needed)
    • Ramp up of 2 seconds (for comfort)
    • On for 12 seconds (10 seconds on plus the 2 second ramp up)
    • Off for 50 seconds
    • Repeat 10 times
  • Intensity: should be turned up enough so that your quad muscle has a strong, smooth muscle contraction (not twitching)
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic…

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Research-based evidence in stroke rehabilitation: an investigation of its implementation by physiotherapists and occupational therapists


Stroke rehabilitation is a multidimensional process that is designed to facilitate restoration of and/or adaptation to loss of functioning. Occupational therapy and physiotherapy constitute important contributions to rehabilitation.

The study aim was to investigate characteristics of the implementation of research-based evidence in stroke rehabilitation by occupational therapists and physiotherapists, using the International Classification of Functioning, Disability and Health as a conceptual framework.

In this prospective cohort study, all service levels within stroke rehabilitation were included. Consecutive patients with stroke admitted to a university hospital between May and December 2012 were enrolled by 13 therapists, with a total of 131 patients participating in the study. Documentation of daily practice was collected from medical records. Analysis compared the therapists’ documentation with the national clinical guidelines for physiotherapy and occupational therapy in the rehabilitation of adults with brain injury.

The therapists’ praxis was seen to be in agreement with the majority of the national clinical guidelines. However, joint goal-setting and evaluation using standardized measures were seldom documented. Although the therapists recognize evidence-based practice as a framework for achieving quality in rehabilitation, the study suggests that they do not employ research-based evidence to the fullest extent.  

With the intention of enabling meaningful participation the health professionals need to pay more attention to the importance of environmental factors. Both guidelines and clinical practice should consider all components of the International Classification of Functioning, Disability and Health when formulating, and implementing, recommendations in rehabilitation praxis in order to aim for rehabilitation that is based both on evidence and a holistic approach.

In order to individualize the rehabilitation offered, more attention and focus on involving and giving words to patients’ expectations, perceptions, experiences, and perspectives is needed.

The use of conventional transcutaneous electrical nerve stimulation in chronic facial myalgia patients

Woman with headache touches her face, nose, cheekbone. Chronic pain, fatigue, facial myalgia

The aim of this study was to evaluate the efficacy of conventional transcutaneous electrical nerve stimulation (TENS) in women affected by chronic facial myalgia.

The study was performed on 49 women affected by chronic facial myalgia randomly allocated in the TENS group (34 women) and the control group (15 women). The subjective level of pain was assessed by the Visual Analogue Scale indicating the mean (VAS MEAN), the maximum (VAS MAX) and the current intensity of pain (VAS NOW). The level of pain at the muscular palpation sites was assessed by the Pericranial Muscle Tenderness Score (PTS) and the Cervical Muscle Tenderness Score (CTS). The TENS therapy lasted for 10 weeks, and data were collected at baseline, after 5, 10, 15 and 25 weeks. The differences between groups before and after treatment were compared with the Mann-Whitney and the Kolmogorov-Smirnov tests. The intra-group differences were compared with the one-way ANOVA test.

The results showed that the VAS MEAN, VAS MAX, PTS and CTS were significantly reduced in the TENS group compared to the control group after 10 weeks of TENS.

The study demonstrated the efficacy of conventional TENS in patients with chronic facial myalgia and the decrease in both subjective and objective pain.

The Importance of Medical Screening

As physical therapists, one of our most vital roles is to determine whether or not the patient sitting in front of you is safe to treat. We have a wide range of knowledge of medical screening that allows us rule in or out serious medical conditions (and potentially make an appropriate referral).

At Nxt Gen, we have developed an amazing course with Dr. DuVall, that goes through in-depth medical screening education for the physical therapist. For the next few days, we are offering 50% off (use promocode: manualtherapist) the cost of this course (brings course from $129 down to $64.50). I would highly encourage checking it out and purchasing today (last date of this sale is 5/14/2016). Purchase Now. You can watch a sample below:

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic…

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Register today for WebPT’s Ascend 2016, The Ultimate Rehab Therapy Business Summit

WebPT’s Ascend 2016, The Ultimate Rehab Therapy Business Summit

WebPT, the leading EMR for physical therapists, occupational therapists and speech-language pathologists, has opened registration for Ascend 2016, the third-annual, two-day summit focused on business best practices for physical therapists (PTs) and occupational therapists (OTs). Ascend will take place Sept. 9-10, 2016, at the Omni Fort Worth Hotel in Fort Worth, Texas.

The rehab therapy conference will feature an all-star speaker lineup including:

  • Rick Gawenda, founder and president of Gawenda Seminars and Consulting
  • Tom Ambury, compliance officer at PT Compliance Group
  • Justin Moore, executive VP of the American Physical Therapy Association (APTA)
  • Larry Benz, Confluent Health president and CEO
  • Heidi Jannenga, WebPT president and co-founder
Speakers at WebPT’s Ascend 2016, The Ultimate Rehab Therapy Business Summit

Speakers at WebPT’s Ascend 2016, The Ultimate Rehab Therapy Business Summit

Highly collaborative sessions will cover topics ranging from evolving payment models and CPT code changes, to digital marketing and revenue growth strategies.

“Ascend brings together some of the best and brightest in private practice physical and occupational therapy with the goal of inspiring innovation and discussion around the ever-changing business of rehab therapy,” Jannenga said. “Practical business strategy is often left out of the equation in traditional PT and OT education. This summit aims to fill that knowledge gap and support PTs and OTs in growing their practices.”

Ascend attendees also will have the opportunity to earn up to nine continuing education units (CEUs) from the American Occupational Therapy Association (AOTA) and the New York, California, Texas and Florida APTA chapters. Pre-registration is now open, with early-bird pricing starting at $499 per ticket.

Each year at Ascend, one private practice is honored with the “Ascend Practice of the Year Award,” a program that recognizes outstanding business performance in rehab therapy. Learn more or submit an application here.

Register today!

Plank to Punchess: THE Importance of Core Work In Combat Training

Most fighters understand the importance of cross training, strength training, and developing general strength outside of the ring. However, many don’t realize just how integral a role core work can be in force development during specific combat skills. For example, punching and kicking are movements that are generated at the hips/glutes. However, the power must be transmitted through a stiff core; otherwise there will be losses of power referred to as energy leaks. This concept can be described with the analogy “you can push a stone but you cannot push a rope” (McGill 2010).

Much of the work that I do with my combat athletes around developing their core is based on the studies of spine biomechanist Stu McGill. There are 2 components to a functional core for combat athletes:

  1. Core Stiffness
  2. Rate of muscle contraction and relaxation

Core stiffness is generally a low-threshold task. This means that the core muscles must be contracted for long periods of time, but only at a low level. This is not a challenge of strength; rather it is a challenge of endurance and stability / motor control. Typically, corrective exercises that target this will look like movement around a stable core.

As prior discussed, the ability to maintain a stiff core will prevent energy leaks while performing striking movements. The most effective way to develop core stiffness has been shown to be isometric exercises (Lee 2015). A study by McGill showed that the duration of these exercises should be less than 10 seconds with endurance built up by increasing repetitions, rather than overall hold time. A few examples of my favorite isometric exercises for improving core stiffness are included at the end of this post.

Speed of combat techniques is directly related to rate of muscle contraction. This is why coaches will often integrate a component of “nonstop” time blocks during training. However, the rate of muscle contraction is only as good as the rate of muscle relaxation. This is due to the double pulse phenomenon seen in core musculature during striking movements. Typically there is a peak in core muscle contraction just before the limb moves, and then again close to impact. Between the two periods of core stiffness there is a relaxation phase (McGill et al 2010).

Performance can be limited by either the rate of muscle contraction OR by the rate of muscle relaxation. Thus, it may be helpful to train both of these components. Unfortunately, there are no studies yet published that provide an effective guide to this specific training; however some untested strategies mentioned in Mcgill’s work are:

  • Isometrics into speed work
  • Double pulse imagery techniques
  • Training double pulse at slow speed and then increasing speed

I think an integration of all 3 of these techniques could result in improvements in the rate of muscle contraction and relaxation, and an efficient double pulse. The 3rd strategy is particularly interesting and I would like to see some research done with variable speeds and perhaps use of a metronome to help with automaticity.

In summary, it’s very important that combat athletes devote time to developing a functional core in order to maximize their technical skill performance. Otherwise, all of the force development and skills training will be lost to energy leaks. Finally, core work must address both overall ability to generate stiffness, as well as rate of muscle contraction and relaxation.
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Photo Credits: Personal, McGill, Bodybuilding.com, SpiderSport.com, Functionalmovement.com

Lee, Benjamin C. Y.; McGill, Stuart M. 2015. Effect of Long-term Isometric Training on Core/Torso Stiffness. Journal of strength and conditioning research. 29 (6): 1515-1526.
McGill SM. 2010. Core training: evidence translating to better performance and injury prevention. Strength & Conditioning journal. 32(3).
McGill SM, Chaimberg JD, Frost DM, Fenwick MJ. 2010. Evidence of a double peak in muscle activation to enhance strike speed and force: an example with elite martial art fighters. Journal of strength and conditioning research. 24 (2): 348 – 357.

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic…

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3D printed bone made using bone ‘powder’ and plastic

A sample 3-D printed scaffold that matches the lower jaw of a female patient. Johns Hopkins Medicine

Using pulverized bone and a biodegradable plastic, researchers at Johns Hopkins University have 3D printed bone replacements in mice. 

This is yet another example of the potential of regenerative medicine to replace body parts using a mix of cells and plastics. In many ways it is similar to another technique that uses living tissue to 3D print body parts, which we talked about in an earlier post. Both techniques use a mixture of cells and plastics to encourage tissue growth once the bone or tissue has been implanted.

3D printing appears to be the method of choice for researchers looking to creating replacement bones and other tissues as well as developing prosthetics. How soon will it be before we see a 3D printed human heart or femur? Let us know in the comments section below!