Neuromascular electric stimulation is often an intimidating and poorly understood form of therapy. There are different acronyms that often describe very similar things. It's easy to get put off by seemingly complex technology, or conflicting configuration parameters. As a father to 6 year old daughter with Cerebral Palsy, I invested and continue to invest time in learning about this technology with hopes that it will help my daughter to better deal with her condition. In this blog, I'll attempt to share what I have learned about electric stimulation and how it can be applied to children with cerebral palsy as well as other conditions with similar symptoms. I have deliberately stayed away from overly complex scientific explanations. This post was not meant for professional physical therapists. It was meant for regular people dealing with Cerebral Palsy who are looking to learn more about alternative therapies for their condition. With that said, if you are a physical therapist and/or a medical doctor your comments are more than welcome.
Why Electric Stimulation?
- Improve motor function and muscle re-education
Conditions such as cerebral palsy, often cause mobility disorders/deficits. By using neuromascular electric stimulation, it is possible to artificially trigger correct movement that the patient is unable to produce voluntarily. Properly applied electric stimulation can also contribute to muscle re-education whereby a patient will eventually be able to produce the same movement without electrical stimulation device. - Improve strength and muscle tone
Another common issue among CP patients is weakness in key muscle groups required for mobility. In some of the more severe cases, this is a catch 22. Patient is unable to exercise correctly because they're too weak but they're weak because they're not able to exercise correctly. How can one break out of this vicious cycle? By using neuromascular Electric Stimulation, it is possible to build muscle tone in the key muscle groups required for mobility even while patient is not moving at all. This is something that has been used for rehabilitation of post-stroke patients for many years, but not so much for patients with cerebral palsy. It is unfortunate because in the end, mobility issues for both conditions have similar cause: broken or damaged neuromascular function.
How does Electric Stimulation work?
Electric Stimulation device is commonly a hand-held device that has 2 or 4 lead wires coming out of the device with sticky pads at the end of each wire. The sticky pads can be placed on the skin over muscle groups or nerves. By placing the pads on the correct muscles and/or nerves one can create muscle contractions that are very similar to the muscle contractions created during physical exercise and therefore improve muscle strength and tone. In cases where a patient is unable to perform certain movements, the same electric pads can be used to stimulate correct muscles and/or nerves to help the patient complete such movements with assistance of the electrical stimulation device. This may include inability to lift toes during walking, or even evert or invert toes to correct feet position as well as many other similar conditions. In the next section below I'll describe some of the electric stimulation devices available without prescription today and how they can help.
What does Electric Stimulation Look like?
Video is worth a thousand words. Below is a link that shows practical application of Electric Stimulation used to trigger functional movements. This is by far not a complete reference, but should give you an idea of what we're talking about.
Electrode Placement for Functional Movement
Consumer TENS & EMS devices
These are sold all over Amazon.com and many other online retailers. Most of them come with TENS and/or EMS modes with various pre-programmed configurations. One of the key differences between these mass market TENS/EMS devices and ES devices used in clinical setting is that these come with pre-programmed modes that are meant to accomplish specific goals (pain relief and/or building muscle tone). Parameters for these modes cannot be changed. I am referring to parameters such as frequency and pulse width/duration (more on this later). A question that comes up often is: What is the difference between TENS and EMS. See below:
- TENS - Transcutaneous Electrical Stimulation
In the simplest terms, TENS works mostly on nerves. Its main goal is pain relief. It basically fools the brain into thinking that there is no pain. TENS is commonly used for various forms of back pain, shoulder pain and/or just to relax otherwise tense muscles. There have been some interesting studies in recent history indicating that high frequency TENs can be used to reduce spasticity. All of this is in a highly experimental phase but appears to be interesting and very promising. - EMS - Electric Muscle Stimulation
As the name implies, this electric stimulation works on muscles and helps to build muscle tone. They key here is to artificially create muscle contractions that one would otherwise create during regular exercise with the intent of building muscle mass and strength even without regular exercise.
iReliev device above was the first electric stimulation device that I purchased. It is very highly rated, FDA approved device, which made it a good device to start with. It comes with pre-programmed modes for TENS and EMS. My main goal was to see the effects of the electric stimulation first hand on something that is pre-configured at least until I learned more about electric stimulation parameters. After trying the device on myself and observing its effects first-hand, I went on to use it on my daughter. I user the device in EMS mode to help her build muscle in key muscle groups required for mobility and balance (quadriceps, hamstrings, calves, abdominal muscles and glutes). Note, I was applying this electric stimulation to her muscle groups while she was on a couch watching her favorite cartoons with minimal or no discomfort to her. After a few weeks of this stimulation (2-3 times a week), it was quite inspiring to see my daughter feel her newly gained strength and watch her run and jump like never before. Please note that this is not an ideal way of applying EMS. The best way to apply electric stimulation is during psychical exercise. I didn't do that with my daughter because I was still learning the process and my daughter was only 5 at the time which presents its own challenges. We will get to doing it the right way though, in baby steps. For those curious what settings I used for this device, it's very simple. I used EMS Mode, Program Mode 6 - Muscle Strengthening.
COMPEX PERFORMANCE 2.0 MUSCLE STIMULATOR KIT WITH TENS
This one is more expensive than iReliev but it comes with 4 channels instead of 2 and is easier to use.I haven't tried the device yet, but it is also very highly rated. It has the same basic idea as IReliev, but more portable or even wireless electrodes, which would make it easier to use.
NMES - Neuromascular Electric Stimulation Devices
COMPEX PERFORMANCE 2.0 MUSCLE STIMULATOR KIT WITH TENS
This one is more expensive than iReliev but it comes with 4 channels instead of 2 and is easier to use.I haven't tried the device yet, but it is also very highly rated. It has the same basic idea as IReliev, but more portable or even wireless electrodes, which would make it easier to use.
NMES - Neuromascular Electric Stimulation Devices
NMES is an acronym that describes electric stimulation devices that are commonly used in a clinical/hospital setting for rehabilitation. Since 2016, these devices have become available to the public without prescription in the U.S.. These devices are created by different vendors and come with different configurations. One important thing to note is that parameters for these devices are fully configurable. This is important for therapeutic purposes because different parameters (frequency and pulse width/duration) are recommended for different types of therapies.
Current Solutions DS5002 TwinStim Plus 2nd Edition
After gaining some hands-on experience with pre-programmed iRelieve device above, and having read a great deal of studies describing parameters that need to be used for electric stimulation, I decided that it was time to purchase NMES device that was fully programmable. Most NMES devices used in clinics tend to be rather expensive. The prices tend to start at $400+ and may go as high as double that amount. DS5002 comes with the same parameters as its expensive counterparts but is much more affordable. Plus, it has 4 channels, which means that it can be used on more than one muscle group at the same time. Although it takes a tad longer to enter parameters into this device compared to iReliev, it is worth the time because it provides that flexibility to enter exact parameters that may be recommended for the specific condition and age of the patient. It also has configurable ramp, on and off time Although I describe specific parameters that I used with this device, your ideal path is to find a physical therapist experienced in the Electric Stimulation and have that therapist provide guidance on proper usage of devices like this. From experience, I know that it's not an easy task to find such therapists, so I had to rely on my own research.
Current Solutions DS5002 TwinStim Plus 2nd Edition
After gaining some hands-on experience with pre-programmed iRelieve device above, and having read a great deal of studies describing parameters that need to be used for electric stimulation, I decided that it was time to purchase NMES device that was fully programmable. Most NMES devices used in clinics tend to be rather expensive. The prices tend to start at $400+ and may go as high as double that amount. DS5002 comes with the same parameters as its expensive counterparts but is much more affordable. Plus, it has 4 channels, which means that it can be used on more than one muscle group at the same time. Although it takes a tad longer to enter parameters into this device compared to iReliev, it is worth the time because it provides that flexibility to enter exact parameters that may be recommended for the specific condition and age of the patient. It also has configurable ramp, on and off time Although I describe specific parameters that I used with this device, your ideal path is to find a physical therapist experienced in the Electric Stimulation and have that therapist provide guidance on proper usage of devices like this. From experience, I know that it's not an easy task to find such therapists, so I had to rely on my own research.
NMES Device Parameters
This is a big subject. ES device parameters will vary depending on the types of therapy being applied and even depending on specific therapist applying the treatment. There is no uniform standard for exact parameters that need to be used. I had a very specific goal, to improve my daughter's muscle tone and hopefully decrease spasticity. I've read a lot of studies on the subject that contained recommendations for these parameters. Parameters below are some of the most commonly used parameters used for muscle strength/tone. This is what I used with my daughter.
Frequency: 40hz
Pulse Width: 300
Ramp time: 2 seconds
On Time: 10 seconds
Off time: 4 seconds
Amplitude: Increase until there is a visible muscle contraction and good tolerance. Patient should not be in pain.
There is also a option to run the device in synchronous and alternating modes. Synchronous mode means that the electric stimulation on the left and right channels will be delivered at the same time. Asynchronous mode means that stimulation will alternate between right and left channels. I prefer to run the device in synchronous mode.
For anyone considering using this device with their children, I highly advise to try it on yourself first to get a better idea of how the device works and feel the effects of the electric stimulation first hand.
This is a big subject. ES device parameters will vary depending on the types of therapy being applied and even depending on specific therapist applying the treatment. There is no uniform standard for exact parameters that need to be used. I had a very specific goal, to improve my daughter's muscle tone and hopefully decrease spasticity. I've read a lot of studies on the subject that contained recommendations for these parameters. Parameters below are some of the most commonly used parameters used for muscle strength/tone. This is what I used with my daughter.
Frequency: 40hz
Pulse Width: 300
Ramp time: 2 seconds
On Time: 10 seconds
Off time: 4 seconds
Amplitude: Increase until there is a visible muscle contraction and good tolerance. Patient should not be in pain.
There is also a option to run the device in synchronous and alternating modes. Synchronous mode means that the electric stimulation on the left and right channels will be delivered at the same time. Asynchronous mode means that stimulation will alternate between right and left channels. I prefer to run the device in synchronous mode.
For anyone considering using this device with their children, I highly advise to try it on yourself first to get a better idea of how the device works and feel the effects of the electric stimulation first hand.
NMES or Regular EMS?
You may be asking yourself if you should bother with all the complexity of NMES devices if you can purchase EMS device with pre-programmed modes of operation. If you're only interested in building muscle tone, regular EMS device like the one from iReliev or others like it will do fine. In my case, I've read and continue to read a lot of studies which contain recommendations for very specific ES therapies which require very specific ES device parameters and/or methods of application. Because of that, I wanted to have a device that will give me the flexibility to configure parameters to match those recommendations.
FES - Functional Electric Stimulation
So what is FES and how is it different from NMES and EMS that I described above? FES refers to application of electric stimulation during specific physical task to the muscle group(s) required for this physical task. Why is this important?
How is FES applied?
FES is commonly applied via NMES devices but the key here is to apply the electric stimulation at just the right time when the patient is starting to complete a certain task. For that reason, NMES device required for this needs to have a hand-held trigger that will allow you to turn the stimulation on and off at just the right time. At this time, I'm aware of only one such device that does this. The device is listed below:
Empi Continuum
You may be asking yourself if you should bother with all the complexity of NMES devices if you can purchase EMS device with pre-programmed modes of operation. If you're only interested in building muscle tone, regular EMS device like the one from iReliev or others like it will do fine. In my case, I've read and continue to read a lot of studies which contain recommendations for very specific ES therapies which require very specific ES device parameters and/or methods of application. Because of that, I wanted to have a device that will give me the flexibility to configure parameters to match those recommendations.
FES - Functional Electric Stimulation
So what is FES and how is it different from NMES and EMS that I described above? FES refers to application of electric stimulation during specific physical task to the muscle group(s) required for this physical task. Why is this important?
- Application of electric stimulation to the correct muscle group required for a specific physical task helps the patient to complete the task that they may not otherwise be able to complete without electrical stimulation.For example: If a person has a difficulty getting up off the chair, application of electric stimulation to the quad muscles while the patient is trying to get up will allow the person to complete the task.
- Application of electric stimulation to muscle groups during physical exercise makes the exercise a lot more efficient and produces much better results in terms of gained strength and muscle tone.
- Some studies show that repeated application of FES promotes muscle re-learning as well as improved range of motion. Meaning that after some time, the patient will be able to complete the same movement without the help of FES.
- There are also numerous studies indicating that application of FES can help to reduce spasticity. One key thing to note here is that regular exercises also help to reduce spasticity. Combining regular physical exercises with FES improves efficiency of these physical exercises and consequently produces better results in terms of reduction of spasticity as well.
How is FES applied?
FES is commonly applied via NMES devices but the key here is to apply the electric stimulation at just the right time when the patient is starting to complete a certain task. For that reason, NMES device required for this needs to have a hand-held trigger that will allow you to turn the stimulation on and off at just the right time. At this time, I'm aware of only one such device that does this. The device is listed below:
Empi Continuum
I have not used the device myself but I have had extensive discussions about its benefits with a physical therapist who specializes in FES. I have also seen a very similar device in action once when my daughter attended physical therapy. I asked the head of the PT dept to show me how this works first-hand. FES was applied to my daughter during sit-up exercises. Her therapist placed electrode pads on my daughter's abdominal muscles and activated the device with a hand switch as she saw my daughter starting to raise her body off the mat, then turned it off as my daughter went back down. Similar approach can be used during squats exercises, in which case the electrode pads will be placed on quadriceps muscles and the device stimulation would be activated as the patient is rising up to standing position.
We did not use FES enough to see tangible results because I don't have the above mentioned Empi Continuum device and we don't have a PT office near us that we can visit on a regular basis. However, all the FES studies that I have read show a lot of promise for muscle re-learning. I have full intent on taking this approach to the next level with my daughter. Stay tuned for updates on this.
For the sake of completeness, I want to add that at least in theory, it is possible to use NMES or even standard mass market EMS devices to apply FES therapy without hand-held trigger. The trick here is to correctly time the patient's movement (standing up, or doing a sit up) and then configure ramp, on, and off time to match. This works even better if a patient can be advised to time their own movements with the stimulation delivered by the device such that the patient will start the movement when they feel the stimulation. I haven't been very successful in application of this approach with my daughter but she's only 6 and doesn't always listen, so it's a challenge :)
Bioness - Taking Electrical Stimulation to the next level
As mentioned earlier, due to my daughter's CP condition, she has spasticity in her lower extremities. One of the side effects of this spasticity is her limited ability to raise her toes during walking which in turn results in feet dragging and frequent falls. During my FES related research, I run into several FES devices, all of which use the same basic idea. The device is wrapped around patient's leg (or legs) right below the knee. It has an ability to detect when a patient raises their leg off the surface. Once the foot is raised off the ground, the device sends electric stimulation to the patient's tibialis anterior muscle and peroneal nerve which in turn triggers dorsiflexion response lifting the patient's toe. Once the foot goes back down on a flat surface, the device ends the stimulation. The concept is simple but very effective. This immediately made me think of applying the same approach with my daughter. It is important to note that Cerebral Palsy does make things more complex due to the spasticity that the patient needs to overcome when attempting to raise their toes. When I brought up the idea of using such device to my daughter's Neurologist, he wasn't convinced. However, he was open-minded enough to give us a referral to undergo a trial of one such device, Bioness. Separate Bioness unit was placed on each of her legs by a physical therapist at her PT office. The device is light and compact. When she started walking, it wasn't by any means perfect but we could clearly see that the device helped her raise her toes as she walked and it even everted her otherwise inverted toes. It was a significant improvement. At this time we're in the process of obtaining this device for every day use and are looking forward to it. It is worth noting that these devices are rarely covered by health insurance companies in the U.S. and are rather expensive. In our case, my daughter needed a separate Bioness unit for each leg, at the cost of $5,200 each. For those wanting to learn more about this type of devices, below are links to all of the devices of this kind that I have run into thus far. One of the devices appears to be a Chinese copy of the same idea. The Chinese version costs a bit over $600 and appears to use the same idea. I can't vouch for how well it works but am including all of the links for the sake of completeness.
Bioness vs. Braces
Braces have been prescribed by therapists for all sorts of movement disorders for decades. More recent studies question if braces are always appropriate or even effective. In some cases, braces can do more harm than good. Why? Braces limit the range of movement. Limited range of movement means that less muscles are engaged which consequently contributes to weakness, or worse, muscle atrophy. Muscle weakness brings us back to the P.T. office for more exercises meant to strengthen weak muscles. This is beginning to look like a vicious circle doesn't it? It's not always this dramatic, but I think you see my point. For my daughter, one of the key reasons for wearing braces was to prevent her toes from pointing down while she walks in order to limit feet dragging and falling. Devices like Bioness appear to achieve this without the use of braces. For a 6 year old who wants the to enjoy the freedom to run around and play without being confined by braces, Bioness seemed like a much better option. I am not advising others to stop using braces and am aware that braces may also provide needed leg support. Every case is different. This was meant to be an encouragement to keep an open mind and at least explore other ways of achieving the same results.
Restorative Therapies Devices
Restorative Therapies is a company dedicated to creation of rehabilitation devices that utilize Function Electric Stimulation. I bring it up here because my daughter has undergone trials of RT 300 FES Bike along with Bioness.The bike takes application of FES to the next level. It applies electric stimulation to the correct muscles at the right time while patient is on the bike. This in turn greatly improves effectiveness of the physical exercise and consequently translates into better results in terms of muscle strength and tone. I think the device and technology are very promising and have a real potential to improve strength and muscle tone in the legs and trunk. This in turn can contribute to improvements in gait (walking) and even stability on the feet. With that said, it was tough to really evaluate its effectiveness because our trial sessions were limited to only 10 minutes sessions once per week for a total of 4 trial sessions. For those interested in learning more, below is the device that we are talking about. It can be used in a PT office or prescribed for home use.
To try Bioness or RT300 bike, you'll need to find a physical therapy office that has those devices and get a referral from your treating physical for a trial of the devices. Good luck!
Relevant Studies & Resources
- Direct effect of percutaneous electric stimulation during gait in children with hemiplegic cerebral palsy
- Electrical stimulation in cerebral palsy: a review of effects on strength and motor function
- Neuromuscular Electrical Stimulation for Skeletal Muscle Function
- Neuromuscular Electrical Stimulation for Motor Restoration in Hemiplegia
- Functional Electrical Stimulation
- Daily functional electrical stimulation ...
- 5 Common Mistakes for Neuromuscular Electrical Stimulation to the Quad
- ELECTRODE PLACEMENTS Tips
- EMS and TENS Settings
- Restoring meaningful movement
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