u d u d electrical stimulation and lumbar stabilization training with performing artists tara jo...

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Electrical Stimulation and Electrical Stimulation and Lumbar Stabilization Training Lumbar Stabilization Training

with Performing Artistswith Performing Artists

Tara Jo Manal PT, DPT, OCS, Tara Jo Manal PT, DPT, OCS, SCSSCS

University of Delaware University of Delaware

Department of Physical TherapyDepartment of Physical Therapy

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Lumbar Extensor MusculatureLumbar Extensor Musculature

Erector spinae musculature are responsible Erector spinae musculature are responsible for extensor forcefor extensor force

Multifidus muscles are segmental extensors Multifidus muscles are segmental extensors responsible for stabilization of lumbar responsible for stabilization of lumbar motion segmentsmotion segments

Fritz et al 2000Fritz et al 2000

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Muscle Strength and Low Back Muscle Strength and Low Back PainPain

In firefighters, muscle strength of the low In firefighters, muscle strength of the low back was a good indicator for the back was a good indicator for the development of low back paindevelopment of low back pain

Cady et al 1979Cady et al 1979

In manual material workers there was a In manual material workers there was a positive correlation between strength and positive correlation between strength and frequency of low back painfrequency of low back pain

Chaffin 1974Chaffin 1974

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Figure Skating and Low Back Figure Skating and Low Back PainPain

Lumbar extensor Lumbar extensor strength is needed to strength is needed to achieve many achieve many positions and positions and successfully land successfully land jumpsjumps

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Low Back StrengthLow Back Strength

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Electrical Stimulation for Electrical Stimulation for StrengthStrength

Snyder-Mackler et al, Snyder-Mackler et al, 19951995– Conclusion: For Conclusion: For

quadriceps weakness, quadriceps weakness, high-level e-stim with high-level e-stim with volitional exercise is volitional exercise is more successful than more successful than exercise aloneexercise alone

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Electrical Stimulation for Electrical Stimulation for StrengthStrength

Snyder-Mackler et al., 1995– Conclusion: For Quadriceps

Weakness, High-Level E-stim with Volitional Exercise is more successful than Exercise alone

– Fitzgerald et. al., 2003

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Electrical Stimulation for LB Electrical Stimulation for LB StrengtheningStrengthening

The application of this same type of Electrical Stimulation to the LB may help increase strength and recovery of Low Back Musculature following injury

– Kahanovitz et al., 1987

– McQuain et al., 1993

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Parameters of Electrical Parameters of Electrical StimulationStimulation

2500 Hz Variable wave form

– triangle, sine, square

75 bursts/second 2 second ramp 12 seconds on time 50 second rest time 10-15 contractions

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Patient Positioning: IsometricPatient Positioning: Isometric

Prone over pillows Pelvis strapped to the

table in Posterior Pelvic Tilt

Assess movement to active lumbar extension and tighten as necessary

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Current IntensityCurrent Intensity

In quadriceps 50% maximal volitional isometric contraction

Look for visible contraction Maximal tolerable

contraction by the patient A single channel is placed on

the right and left side of the spine

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Electrical Stimulation for Electrical Stimulation for StrengtheningStrengthening

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Treatment AdministrationTreatment Administration

Patient motivation factorsPatient motivation factors– Assist your patient in tolerating treatmentAssist your patient in tolerating treatment

Monitor Monitor – set targets, watch output, give articleset targets, watch output, give article

BlunterBlunter– wear headphones, towel over head, body relaxationwear headphones, towel over head, body relaxation

(Delitto et al PT 1992)(Delitto et al PT 1992)

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Give the Patient ControlGive the Patient Control

Self trigger if possible

Therapist manually resuming stim

Count down to the stim

Explain to the patient the value of the modality

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What we do when things are What we do when things are not going well …not going well …

General – Tens Clean Cote

– Change the waveform

– Decrease pulse duration

» may need to also increase the frequency for comfort

Specific– Increase ramp time– Self trigger– Increase rest time

» Only if you see them fatiguing drastically

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Case #1Case #1

21 year old figure skater21 year old figure skater 1 year following a L5/S1 titanium cage 1 year following a L5/S1 titanium cage

fusionfusion– 5 months following hardware removal5 months following hardware removal

Pain limiting her ability to return to skating Pain limiting her ability to return to skating (2 months)(2 months)

Pain limiting her ability to attend college Pain limiting her ability to attend college classesclasses

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Case #1 - EvaluationCase #1 - Evaluation

Constant LBP (L5) Avg. 4/10Constant LBP (L5) Avg. 4/10 Oswestry score 20%Oswestry score 20% Intermittent “electric shock” from back into Intermittent “electric shock” from back into

left buttocks (always with landing on ice)left buttocks (always with landing on ice) Increased painIncreased pain

– standing >30 minutesstanding >30 minutes– prone lying prone lying

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Case #1 - EvaluationCase #1 - Evaluation

Pain with return to extension from full Pain with return to extension from full flexion (alleviated with traction by PT)flexion (alleviated with traction by PT)

Pain at end range flexion, extension and Pain at end range flexion, extension and bilateral sidebendingbilateral sidebending

Joint hypomobility L4/L5 (recreated pain to Joint hypomobility L4/L5 (recreated pain to buttock)buttock)

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Case #1 - Early InterventionCase #1 - Early Intervention Lumbar mobilizations Lumbar mobilizations

L4/5 unilateralL4/5 unilateral Stabilization exercises Stabilization exercises

(pelvic neutral)(pelvic neutral)– lower extremity t-bandlower extremity t-band

– quadruped arm/leg quadruped arm/leg raisesraises

– ball exercise programball exercise program

– side planksside planks

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Case #1 - ResponseCase #1 - Response

After 6 TreatmentsAfter 6 Treatments Improvement in the ability to return to Improvement in the ability to return to

upright from flexed posture following upright from flexed posture following treatment but return to baseline by next daytreatment but return to baseline by next day

Overall pain levels were intermittent rather Overall pain levels were intermittent rather than constantthan constant

Difficulty with stabilization exercises due to Difficulty with stabilization exercises due to fatigue and substitution of larger musclesfatigue and substitution of larger muscles

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Case # 1- HypothesisCase # 1- Hypothesis

Patient was responding positively to Patient was responding positively to treatment intervention, however, gains were treatment intervention, however, gains were slow and fatigue and weakness made slow and fatigue and weakness made correct exercise performance difficultcorrect exercise performance difficult

Electrical stimulation may help assist Electrical stimulation may help assist patient in rapid strengthening and be a patient in rapid strengthening and be a successful adjunct to her strengthening successful adjunct to her strengthening programprogram

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Case #1 - Electrical StimulationCase #1 - Electrical Stimulation

7th Treatment7th Treatment Clearance with physician on the use of Clearance with physician on the use of

electrical stimulation with titanium cageelectrical stimulation with titanium cage High Intensity Electrical Stimulation was High Intensity Electrical Stimulation was

added to assist in the recovery of the lumbar added to assist in the recovery of the lumbar paraspinal musculatureparaspinal musculature

Patient complained of muscle soreness that Patient complained of muscle soreness that resolved within 24 hoursresolved within 24 hours

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Case #1- ProgressCase #1- Progress

15 treatments of 15 treatments of electrical stimulationelectrical stimulation

Oswestry 12%Oswestry 12% Gym work-outs for 1 Gym work-outs for 1

hour/ 4 times weekly hour/ 4 times weekly Run 2 miles pain-freeRun 2 miles pain-free

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Case #1 - Skating ProgressionCase #1 - Skating Progression

Progressive return to skating (40 minutes Progressive return to skating (40 minutes without shooting pain into buttock)without shooting pain into buttock)

2 weeks later complained of localized back 2 weeks later complained of localized back pain with stopping turnspain with stopping turns

4 weeks later returned to compulsories and 4 weeks later returned to compulsories and complained of LBP with twisting - no complained of LBP with twisting - no buttock painbuttock pain

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Case #1 - Skating ProgressionCase #1 - Skating Progression

3 months later has 3 months later has progressed to Pilates progressed to Pilates strengthening programstrengthening program

9 months later she can 9 months later she can skate 2-3 times weekly skate 2-3 times weekly for 1.5 hours before for 1.5 hours before any LBP and no any LBP and no reoccurrence of L reoccurrence of L buttock painbuttock pain

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DiscussionDiscussion

Electrical stimulation has been successfully Electrical stimulation has been successfully added to programs of lumbar stabilization added to programs of lumbar stabilization with figure skaterswith figure skaters

There were no negative effects to the high There were no negative effects to the high intensity stimulation treatmentsintensity stimulation treatments– fusionfusion– stress responsestress response

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DiscussionDiscussion

Electrical stimulation may show promise in Electrical stimulation may show promise in assisting patients in recovering following assisting patients in recovering following lumbar injury especially when returning to lumbar injury especially when returning to demanding activitiesdemanding activities

Electrical stimulation may be beneficial for Electrical stimulation may be beneficial for patients who are unable to perform other patients who are unable to perform other exercise programs due to painexercise programs due to pain

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Further ResearchFurther Research

Research must be done to determine the Research must be done to determine the effectiveness of the addition of electrical effectiveness of the addition of electrical stimulation to a rehabilitation program for stimulation to a rehabilitation program for low back painlow back pain

Work aimed at determining the forces Work aimed at determining the forces generated in the lumbar spine during these generated in the lumbar spine during these contractions will help therapists determine contractions will help therapists determine who can best benefit from this interventionwho can best benefit from this intervention

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Case Example: HNP L3/4Case Example: HNP L3/4

History:– Left low back and anterior thigh

pain

– Difficulty with bed and car transfers

– Weakness in the left quadriceps femoris

– MRI (+) HNP at L3/4

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Strength Assessment – Left - 105 ft #

– Right - 170 ft #

– Quad Index - 62%

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NMES: treatment for quad weakness– Carrier frequency 2500 Hz (400 μs pulse duration)

– Burst frequency 75 bps

– On time 10 seconds

– Off time 50 seconds

– Ramp on 2 seconds

– Intensity > 50% MVIC of involved

– 10 contractions

– Electrodes: vastus medialis and rectus femoris

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Quadriceps Strength

0

20

40

60

80

100

120

Initial 5 sessions Follow-up

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Case Example: StenosisCase Example: Stenosis

Chief complaints– Bilateral buttock and posterior thigh pain

with walking

– Right anterior/lateral calf pain

– Foot slap on right > 1 year

– History of falls due to tripping

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Neurological ImpairmentsNeurological Impairments

Sensory deficit– Dermatomal

distribution

– Light touch

Deep Tendon Reflexes Strength deficit

– Myotomal distribution

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Case Example: StenosisCase Example: Stenosis MMT on Initial Evaluation

Right LeftAnkle DF 4-/5 4-/5Ankle EV 3+/5 5/5Great toe DF 3+/5 4-/5 Oswestry: 14% EMG: Bilateral L5 and S1 radiculopathy right > left MRI: Moderate congenital stenosis with disc herniations

on the right at L1/2 and L5/S1

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NMES to address weakness– Carrier frequency 2500 Hz (400µs pulse duration)– Burst Frequency 75 bps– Ramp on 2 seconds– On time 12 seconds– Off time 50 seconds– Intensity max tolerance– Total time 15 minutes

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Case Study: StenosisCase Study: Stenosis

Eval Right LeftAnkle DF 4-/5 4-/5Ankle EV 3+/5 5/5

After 10 sessions of NMESRight Left

Ankle DF 4/5 4-/5Ankle EV 4/5 4+/5

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Functional recovery

– Reports no episodes of foot slap or ankle weakness

– Wife reports he no longer favors his right lower extremity

Oswestry: 4% compared to 14% at eval

u d u d electrical stimulation and lumbar stabilization training with performing artists tara jo...

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