1)  Electrical muscle stimulation as an adjunct to exercise therapy in the treatment of nonacute low back pain: a randomized trial.

J Pain. 2001 Oct;2(5):295-300.

Glaser JA, Baltz MA, Nietert PJ, Bensen CV.

Department of Orthopaedic Surgery, University of Iowa, Iowa City, 52242, USA. john-glaser@uiowa.edu

A prospective, randomized, double-blind, placebo-controlled clinical trial was performed to investigate the efficacy of electrical muscle stimulation when combined with a therapist-guided, standardized exercise therapy program in the treatment of nonacute low back pain. Eighty patients with low back pain of at least 6 weeks' duration were randomized into the following 2 groups: standardized exercise therapy with functional electrical muscle stimulation or standardized exercise therapy with placebo electrical stimulation. Subjects were evaluated at baseline, 2 months, and 6 months with a standardized back pain questionnaire and objective measurements of lumbar spine function. Exercise therapy was continued for 6 months, but electrical stimulation was discontinued at the 2-month interval. Of the 80 patients initially enrolled, 42 discontinued or withdrew before completing the entire study protocol. At the 2-month follow-up interval, subjects in the treatment group had statistically significantly improved lumbar spine function compared with the control subjects. This effect continued during the last 4 months of the study after electrical stimulation had been discontinued. This suggests that electrical muscle stimulation can be an effective adjunctive treatment modality for nonacute low back pain. The effects of this combined therapy seem to last beyond the duration of electrical stimulation treatment.

2)  Normal trunk muscle strength and endurance in women and the effect of exercises and electrical stimulation. Part 1: Normal endurance and trunk muscle strength in 101 women.

Nordin M, Kahanovitz N, Verderame R, Parnianpour M, Yabut S, Viola K, Greenidge N, Mulvihill M.

Spine. 1987 Mar;12(2):105-11.

The lack of trunk muscle strength and endurance has frequently been cited as a suspected factor in the etiology of low-back pain. Several investigators have suggested that asymptomatic patients have stronger trunk muscles than patients with low-back pain. People who are physically fit appear to have a decreased incidence of low-back pain. Increased trunk muscle endurance also have been observed to decrease the incidence of low-back pain. The objective evaluation of the strength and endurance of trunk musculature may, therefore, be significant. Part 1 of this study was designed to develop a reproducible strength-endurance screening procedure and to establish normal isometric-isokinetic trunk muscle strength and endurance parameters for women. This study showed that isometric trunk flexion varied from 19-109 Nm and trunk extension from 38-168 Nm. Peak values for isokinetic trunk flexion at two speeds (30 degrees per second and 60 degrees per second) varied from 17-191 Nm and isokinetic trunk extension from 14-208 Nm. The average endurance time for trunk extensors tested with the Sorensen test was 196 seconds.

3)  Normal trunk muscle strength and endurance in women and the effect of exercises and electrical stimulation. Part 2: Comparative analysis of electrical  stimulation and exercises to increase trunk muscle strength and endurance.

Kahanovitz N  Nordin M  Verderame R  Yabut S  Parnianpour M  Viola K Mulvihill M

Spine (1987 Mar) 12(2):112-8

Several studies have shown positive correlations between muscle strength, flexibility, and the frequency of low-back pain. Weak trunk musculature and decreased endurance have thereby come to be  identified as significant risk factors in the development of occupational back problems. Because it is widely accepted that exercise plays an important role in the conservative treatment and prevention of low-back pain, the goals of most rehabilitative programs involves improving the strength and endurance of the low- back pain patient. Whereas electrical stimulation has been shown to increase the muscle strength of the lower extremities, this effect  has not been demonstrated for the trunk muscles. Part 2 is a  prospective controlled study designed to document and to compare objectively  the effects of electrical stimulation and exercise on  trunk muscle strength. A total of 117 healthy women were divided randomly into four groups. Two groups received electrical stimulation with different electrical parameters, one group received exercises, and one group acted as a control group. The results showed that low-frequency electrical stimulation and exercises significantly (P less than .05) increased isokinetic back-muscle strength compared to the control and medium-high-frequency electrical stimulation groups. Both types of electrical stimulation, however, significantly increased (P less than .05) the endurance in the back muscles compared with the control and the exercise groups. This study showed that electrical stimulation may be a valuable treatment in the early care of low-back pain patients in maintaining and increasing strength and endurance of   back muscles when a more active exercise program is too painful to perform.

4)  Combined neuromuscular electrical stimulation and transcutaneous electrical nerve stimulation for treatment of chronic back pain: a double-blind, repeated measures comparison.

Moore SR, Shurman J.

Arch Phys Med Rehabil. 1997 Jan;78(1):55-60.

Center for Neurologic Study, San Diego, CA 92121, USA.

OBJECTIVES: A preliminary examination of NMES and combined NMES/TENS for the management of chronic back pain. DESIGN: Double-blind, placebo-controlled, randomized repeated measures. SUBJECTS AND SETTING: Consecutive sample of 24 chronic back pain patients (16 women and 8 men) attending an outpatient pain clinic (mean age 51.67 years, mean pain duration 3.83 years). All treatments were administered at home. INTERVENTIONS: Subjects self-administered NMES, combined NMES/TENS, TENS, and placebo treatments. Each treatment had a duration of 5 consecutive hours per day over 2 consecutive days, with a 2-day hiatus between treatments to minimize carryover effects. MAIN OUTCOME MEASURES: Pain reduction was assessed through pretreatment to posttreatment differences on the Present Pain Intensity (PPI) scale, and a visual analogue scale of Pain Intensity (VAS-I). Posttreatment pain relief was assessed using a visual analogue scale of Pain Relief (VAS-R). RESULTS: Combined treatment, NMES, and TENS each produced significant pretreatment to posttreatment reductions in pain intensity as measured by both the PPI and VAS-I (p < .05). Combined treatment was superior to placebo on pain reduction (p = .001, p = .016) as well as pain relief (p < .001). Combined treatment was also superior to both TENS and NMES for pain reduction and pain relief (p < .01). NMES and TENS were superior only to placebo for pain relief (p < .001). CONCLUSIONS: Combined NMES/TENS treatment consistently produced greater pain reduction and pain relief than placebo, TENS, or NMES. NMES alone, although less effective, did produce as much pain relief as TENS. Although preliminary, this pattern of results suggests that combined NMES/TENS may be a valuable adjunct in the management of chronic back pain. Further research investigating the effectiveness of both NMES and combined NMES/TENS seems warranted.

5)  Histochemistry and morphology of erector spinae muscle in lumbar disc herniation.

Zhu XZ, Parnianpour M, Nordin M, Kahanovitz N.

Spine. 1989 Apr;14(4):391-7.

Occupational & Industrial Orthopaedic Center, New York, New York.

The purpose of this study was to detect any changes in the erector spinae muscles in patients undergoing surgery for lumbar disc herniation (LDH) and to analyze which factors (sex, age, the level and site of disc protrusion, and duration of symptoms) would be related to these changes. The percentage of mean area of the type I fibers was significantly larger in males and in the older age group (P less than 0.05), due to the decreasing size of type IIa and IIb fibers. Patients with LDH have: 1) angulated and selective atrophy of type II fibers with a higher type IIb/IIa ratio; 2) with increasing age and duration of symptoms, more marked atrophy of type II fibers; and 3) other unspecific pathologic changes.

6)  Measures for low back pain: a proposal for clinical use.

Nordin M, Alexandre NM, Campello M.

Rev Lat Am Enfermagem. 2003 Mar-Apr;11(2):152-5. Epub 2003 Sep 02.

School of Medicine and School of Arts and Sciences, New York University, Occupational and Industrial Orthopaedic Center (OIOC), Hospital for Joint Disease Institute, Mt Sinai NYU Health, New York, NY, USA.

Low back pain represents a serious public health problem. Therefore, great efforts have been made in order to improve and assess the efficacy of its treatment. Reports in international literature have presented important studies concerning instruments to assess pain and functional incapacity in patients with low back pain. This study presents a clinical protocol which was developed by a multidisciplinary team. This protocol consists of the evaluation and distribution of pain, The Spitzer Quality of Life, The Oswestry Low Back Pain Disability Questionnaire, and The Center for Epidemiological Studies Depression Scale. Instruments must be urgently developed or adapted in order to be used according to the Brazilian reality.

7)  The use of muscle relaxant medications in acute low back pain.

Bernstein E, Carey TS, Garrett JM.

Spine. 2004 Jun 15;29(12):1346-51.

Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7590, USA.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To determine the characteristics of patients who take muscle relaxants for back pain after seeking care and to determine the relationship of muscle relaxant use with recovery from the episode of low back pain. SUMMARY OF BACKGROUND DATA: Low back pain is a common condition with a generally favorable short-term prognosis. Physicians in the acute setting commonly prescribe muscle relaxants. The indications for use and outcomes are not clear. METHODS: We performed a secondary data analysis of a cohort of 1633 patients who sought care from a variety of practitioners (primary care, physician of chiropractic, orthopedic surgeon, Health Maintenance Organization) for low back pain. Patients were enrolled in the physician's office and interviewed at baseline, 2, 4, 8, 12, and 24 weeks. Pain, functional status, medication use, health care utilization, and satisfaction with care were assessed. RESULTS: Muscle relaxants were used by 49% of patients; among those who sought care from doctors, 64% used muscle relaxants. Muscle relaxant users were more impaired at baseline. Over time, among patients with greater functional status impairment (Roland disability score > 12) at baseline, muscle relaxant users had somewhat slower recovery from the episode of back pain. This finding persisted after controlling for baseline functional status, age, worker's compensation status, and use of nonsteroidal inflammatory agents. CONCLUSIONS: Use of muscle relaxants was very common among patients with acute low back pain. Muscle relaxant use was not associated with more rapid functional recovery.

8)  Chronic low back pain-associated paraspinal muscle dysfunction is not the result of a constitutionally determined "adverse" fiber-type composition.

Crossman K, Mahon M, Watson PJ, Oldham JA, Cooper RG.

Spine. 2004 Mar 11;29(6):628-34.

Musculoskeletal Research Group, University of Manchester, United Kingdom.

STUDY DESIGN: Investigative case control study. OBJECTIVES: To determine whether excessive paraspinal muscle fatigue in chronic low back pain results from a paucity of muscle type I fiber content. SUMMARY OF BACKGROUND DATA: Paraspinal muscle function is vital for spinal protection. Prospective studies suggest that excessive paraspinal muscle fatigability may increase risk of first-time low back pain. As contractile performance of the paraspinal muscles is governed by their constitutionally determined fiber composition, the question arises whether a constitutionally determined "adverse" composition could predispose to low back pain through impaired spinal protection. METHODS: Thirty-five male patients with chronic low back pain were compared with 32 male control patients of similar age and anthropometry. During Sorensen and 60% of maximum voluntary isometric contraction fatigue tests, median frequency declines in the paraspinal muscle surface electromyograph signal were monitored and correlated with muscle histomorphometry. RESULTS: Patients were weaker than controls during maximum voluntary isometric contractions (84.47 [28.44]vs. 98.74 [18.11] kg, respectively; P = 0.02) and more fatigable during their Sorensen tests (endurance time 105.29 [28.53]vs. 137.50 [40.38] sec, respectively; P < 0.01). There were no between-group differences in median frequency declines during the Sorensen (-0.37 [0.16]vs. -0.36 [0.12]%.sec) or 60% maximum voluntary isometric contraction (-0.42 [0.31]vs. -0.51 [0.29]%.sec) tests, for patients and controls, respectively. There were no between-group differences in the percent number of paraspinal muscle type I fibers (64 [11]vs. 64 [9]%) or the percent area occupied by type I fibers (67 [11]vs. 69 [9]%), for patients and controls, respectively. Type I and II muscle fiber narrow diameters were similar for both groups. CONCLUSION: In the patients with chronic low back pain tested, their associated paraspinal muscle dysfunction was not the result of a constitutionally determined "adverse" fiber type composition.

9)  The effect of neuromuscular electrical stimulation on arthritis knee pain in older adults with osteoarthritis of the knee.

Gaines JM, Metter EJ, Talbot LA.

Appl Nurs Res. 2004 Aug;17(3):201-6.

The objective of this study was to examine the short- and long-term effects of a home-based, 12-week neuromuscular electrical stimulation (NMES) of the quadriceps femoris to decrease arthritis knee pain in older adults with osteoarthritis of the knee. The study sample (N = 38) was randomly assigned to the NMES treatment plus education group or the arthritis education-only group. Pain was measured in both groups with the McGill Pain Questionnaire (MPQ) at baseline, during the intervention at weeks 4, 8, 12, and at follow-up and with the Arthritis Impact Measurement Scale 2-Pain Subscale (AIMS2-PS) at baseline and week 12. The NMES Pain Diary (PD) was completed 15 minutes before and after each stimulation session. There was a significant 22% decline in pain 15 minutes after as compared with immediately before each NMES treatment (p <.001), as measured by the PD. No significant group differences were found between the 2 groups over the course of the intervention and follow-up. These findings indicate that a home-based NMES intervention reduced arthritis knee pain 15 minutes after a NMES treatment.

10)  Percutaneous neuromuscular electrical stimulation (P-NMES) for treating shoulder pain in chronic hemiplegia. Effects on shoulder pain and quality of life.

Renzenbrink GJ, IJzerman MJ.

Clin Rehabil. 2004 Jun;18(4):359-65.

Roessingh Research and Development and Rehabilitation centre Het Roessingh, Enschede, The Netherlands. g.renzenbrink@roessingh.nl

OBJECTIVE: To evaluate the effect of percutaneous neuromuscular electrical stimulation (P-NMES) of the shoulder muscles on shoulder pain intensity and health-related quality of life in chronic hemiplegia. DESIGN: Prospective, open label design. SETTING: The outpatient services of a large teaching rehabilitation hospital in The Netherlands. SUBJECTS: Fifteen stroke survivors with chronic (> six months) hemiplegia and a therapy-resistant painful shoulder with subluxation. All patients suffered from clinically relevant shoulder pain, as assessed by a score of at least 4 out of 10 on a numerical rating scale. Shoulder subluxation was indicated by at least 1/2 fingerbreadth of glenohumeral separation on palpation. INTERVENTION: Six hours of P-NMES per day for a total of six weeks. MAIN OUTCOME MEASURES: Shoulder pain (Brief Pain Inventory), shoulder subluxation (clinical and radiographic), shoulder pain-free external rotation (hand-held goniometer), motor impairment (Fugl-Meyer Motor test) and quality of life (SF-36) were assessed before treatment, after six weeks of intramuscular stimulation, at three months and six months follow-up. RESULTS: A significant reduction in pain was found on the Brief Pain Inventory. Pain reduction was still present at six months follow-up. All domains, in particular bodily pain, of the SF-36 showed improvement in the short term. After six months of follow-up, bodily pain was still strongly and significantly reduced, whereas social functioning and role physical demonstrated a nonsignificant improvement of more than 10% compared with baseline. CONCLUSION: This pilot suggests that P-NMES potentially reduces shoulder pain in chronic hemiplegia. To establish the clinical value of P-NMES in treating hemiplegic shoulder pain a randomized controlled trial is needed.

11)  Intramuscular neuromuscular electric stimulation for poststroke shoulder pain: a multicenter randomized clinical trial.

Yu DT, Chae J, Walker ME, Kirsteins A, Elovic EP, Flanagan SR, Harvey RL, Zorowitz RD, Frost FS, Grill JH, Feldstein M, Fang ZP.

Arch Phys Med Rehabil. 2004 May;85(5):695-704.

Departments of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH 44109, USA.

OBJECTIVE: To assess the effectiveness of intramuscular neuromuscular electric stimulation (NMES) in reducing poststroke shoulder pain. DESIGN: Multicenter, single-blinded, randomized clinical trial. SETTING: Ambulatory centers of 7 academic rehabilitation centers in the United States. PARTICIPANTS: Volunteer sample of 61 chronic stroke survivors with shoulder pain and subluxation. INTERVENTION: Treatment subjects received intramuscular NMES to the supraspinatus, posterior deltoid, middle deltoid, and trapezius for 6 hours a day for 6 weeks. Control subjects were treated with a cuff-type sling for 6 weeks.Main outcome measure Brief Pain Inventory question 12 (BPI 12), an 11-point numeric rating scale administered in a blinded manner at the end of treatment, and at 3 and 6 months posttreatment. RESULTS: The NMES group exhibited significantly higher proportions of success based on the 3-point or more reduction in BPI 12 success criterion at the end of treatment (65.6% vs 24.1%, P<.01), at 3 months (59.4% vs 20.7%, P<.01), and at 6 months (59.4% vs 27.6%, P<.05). By using the most stringent "no pain" criterion, the NMES group also exhibited significantly higher proportions of success at the end of treatment (34.4% vs 3.4%, P<.01), at 3 months (34.4% vs 0.0%, P<.001), and at 6 months (34.4% vs 10.3%, P<.05). CONCLUSIONS: Intramuscular NMES reduces poststroke shoulder pain among those with shoulder subluxation and the effect is maintained for at least 6 months posttreatment.

12)  Neuromuscular electrical stimulation for quadriceps muscle strengthening after bilateral total knee arthroplasty: a case series.

Stevens JE, Mizner RL, Snyder-Mackler L.

J Orthop Sports Phys Ther. 2004 Jan;34(1):21-9.

Department of Physical Therapy, University of Florida, Gainesville, FL, USA.

STUDY DESIGN: A case series. OBJECTIVES: The purpose of this case series was to assess the effect of high-intensity neuromuscular electrical stimulation (NMES) on quadriceps strength and voluntary activation following total knee arthroplasty (TKA). BACKGROUND: Following TKA, patients exhibit long-term weakness of the quadriceps and diminished functional capacity compared to age-matched healthy controls. The pain and swelling that results from surgery may contribute to quadriceps weakness. The use of high-intensity NMES has previously been shown to be effective in quickly restoring quadriceps strength in patients with weakness after surgery. METHODS AND MEASURES: All patients were treated for 6 weeks, 2 to 3 visits per week, in outpatient rehabilitation. Five patients (NMES group) participated in a voluntary exercise program for both knees and NMES for the weaker knee. Three patients (exercise group) participated in a voluntary exercise program for both knees without NMES. For each treatment session, 10 isometric electrically elicited muscle contractions were administered at maximally tolerated doses to the initially weaker leg of the NMES group. Quadriceps strength and muscle activation were repeatedly assessed up to 6 months after surgery using burst superimposition techniques. RESULTS: At 6 months, the weak NMES-treated legs of 4 of 5 patients in the NMES group had surpassed the strength of the contralateral leg. In contrast, none of the weak legs in the exercise group were stronger than the contralateral leg at 6 months. Changes in quadriceps muscle activation mirrored the changes exhibited in strength. CONCLUSION: When NMES was added to a voluntary exercise program, deficits in quadriceps muscle strength and activation resolved quickly after TKA.

13)  Quadriceps strength and volitional activation before and after total knee arthroplasty for osteoarthritis.

Stevens JE, Mizner RL, Snyder-Mackler L.

J Orthop Res. 2003 Sep;21(5):775-9.

Department of Physical Therapy and Graduate Program in Biomechanics and Movement Sciences, University of Delaware, Newark, DE 19716, USA. smack@udel.edu

INTRODUCTION: Patients with osteoarthritis (OA) of the knee have quadriceps weakness and arthrogenous muscle inhibition (AMI). While total knee arthroplasty (TKA) reliably reduces pain and improves function in patients with knee OA, quadriceps weakness persists after surgery. The purpose of this investigation was to assess contributions of AMI to quadriceps weakness before and after TKA and to assess the effect of pain on AMI. METHODS: Twenty-eight patients with unilateral, end-stage, primary knee OA were tested an average of 10 days before and 26 days after TKA. The mean age at time of operation was 63 years (range 49-82 years). Measurements on the involved and uninvolved knees were performed using the burst-superimposition technique, where supramaximal electrical stimulation is superimposed on a voluntary contraction. Knee pain during contraction was measured using a numeric rating scale. RESULTS: The involved quadriceps were significantly weaker than the uninvolved prior to TKA (p<0.05). Quadriceps strength decreased by 60% (p<0.001) and activation decreased 17% (p<0.001) after TKA. Changes in muscle activation accounted for 65% of the variability in the change in quadriceps strength (r(2)=0.65) (p<0.001). Knee pain during muscle contraction accounted for a small, but significant portion of the change in voluntary activation (r(2)=0.22) (p=0.006). DISCUSSION: Exercise regimens that emphasize strong muscle contraction and clinical tools that facilitate muscle activation like biofeedback and neuromuscular electrical stimulation may be necessary to reverse the quadriceps activation failure and weakness in the patients with knee OA that worsens after TKA. The failure of current rehabilitation regimens to directly address activation deficits within the first months after surgery may explain the persistent quadriceps weakness in patients after TKA.

14)  A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.

Talbot LA, Gaines JM, Ling SM, Metter EJ.

J Rheumatol. 2003 Jul;30(7):1571-8.

The Johns Hopkins University, School of Nursing, Baltimore, Maryland 21205-2110, USA. ltalbot@son.jhmi.edu

OBJECTIVE: To determine whether home-based neuromuscular electrical stimulation (NMES) applied to the quadriceps femoris (QF) muscle increases strength, physical activity, and physical performance in older adults with knee osteoarthritis (OA). METHODS: Thirty-four adults (> 60 yrs) with radiographically confirmed symptomatic knee OA were randomized to NMES plus education or education only (EDU). The primary outcome was isometric QF peak torque (PTIso), with secondary outcomes of daily step counts, total activity vector magnitude, 100-foot walk-turn-walk, timed stair climb, chair rise, and pain. The NMES group used a portable electrical muscle stimulator 3 days a week for unilateral QF training with incremental increases in the intensity of isometric contraction to 30-40% of maximum over 12 weeks. Both groups received the 12-week Arthritis Self-Management course and were followed an additional 12 weeks. RESULTS: The stimulated knee-extensor showed a 9.1% increase in 120 degrees PTIso compared to a 7% loss in the EDU group (time x group interaction for 120 degrees PTIso; p = 0.04). The chair rise time decreased by 11% in the NMES group, whereas the EDU group saw a 7% reduction (p = 0.01, time; p = 0.9, group). Similarly, both groups improved their walk time by approximately 7% (p = 0.02, time; p = 0.61 group). Severity of pain reported following intervention did not differ between groups. CONCLUSION: In older adults with knee OA, a home-based NMES protocol appears to be a promising therapy for increasing QF strength in adults with knee OA without exacerbating painful symptoms.

15)  Electromagnetic interference by transcutaneous neuromuscular electrical stimulation in patients with bipolar sensing implantable cardioverter defibrillators: a pilot safety study.

Crevenna R, Stix G, Pleiner J, Pezawas T, Schmidinger H, Quittan M, Wolzt M.

 Pacing Clin Electrophysiol. 2003 Feb;26(2 Pt 1):626-9.

Departments of Physical Therapy, Rehabilitation, Allgemeines Krankenhaus Wien, Austria.

Neuromuscular electrical stimulation (NMES) is a frequently applied therapy for the treatment of pain and a therapeutic option to increase thigh muscle strength and endurance capacity in patients with heart failure. Electromagnetic interference (EMI) by the signals with sensing of ICDs is possible. Eight patients with subpectoral ICD systems and different transvenous bipolar sensing leads were subjected to electrical stimulation of the neck and shoulder and of the thighs using different stimulation algorithms. EMI with ventricular sensing was detectable in three of eight subjects. EMI occurred during stimulation of the neck (n = 2) and thigh (n = 2). EMI by NMES with atrial sensing was seen in two of four subjects with dual chamber ICDs. The safety of peripheral NMES has to be individually tested as EMI can also occur in ICD patients with bipolar sensing.

16)  Neuromuscular stimulation of the quadriceps muscle after hip fracture: a randomized controlled trial.

Lamb SE, Oldham JA, Morse RE, Evans JG.

Arch Phys Med Rehabil. 2002 Aug;83(8):1087-92.

Interdisciplinary Research Centre in Health, Coventry University, UK. s.lamb@coventry.ac.uk

OBJECTIVE: To study the feasibility and effect of neuromuscular stimulation on recovery of mobility after surgical fixation for hip fracture. DESIGN: Double-blind study with stratified randomization. SETTING: Home-based rehabilitation program. PARTICIPANTS: Twenty-four women over the age of 75 years with hip fracture. INTERVENTIONS: Neuromuscular or placebo stimulation of the quadriceps muscle of the fractured leg, applied for 3 hours a day, for 6 weeks, commencing 1 week after surgery. MAIN OUTCOME MEASURES: Recovery of walking speed and ability, postural stability, lower-limb muscle power, and pain at 7 and 13 weeks after surgery. RESULTS: Women in the neuromuscular stimulation group showed faster recovery of mobility. Of the women receiving stimulation, 9 of 12 recovered their prior levels of indoor mobility ability by 13 weeks compared with 3 of 12 in the placebo group (Fisher exact test, P=.046). There were no differences in recovery of walking speed in the first 7 weeks, but women in the stimulation group had greater recovery between 7 and 13 weeks (mean difference=-.13m/s; 95% confidence interval, -.23 to -.01). CONCLUSIONS: Neuromuscular stimulation at home is feasible and may be effective in speeding recovery of mobility after surgical fixation of hip fracture.

17)  Efficacy of neuromuscular stimulation of the quadriceps femoris during continuous passive motion following total knee arthroplasty.

Haug J, Wood LT.

Arch Phys Med Rehabil. 1988 Jun;69(6):423-4.

Mayo Clinic, Rochester, MN 55905.

The effect of neuromuscular stimulation of the quadriceps femoris combined with continuous passive motion (CPM) on the active extension range of motion and force of patients with total knee arthroplasty was investigated. The experimental group received three one-hour periods of electric stimulation per day in the extension cycle of the continuous passive motion. The control group received continuous passive motion without quadriceps electric stimulation. Both groups engaged in physical therapy consisting of active range of motion, quadriceps femoris setting, flexion and extension stretches, and ambulation. Manual goniometry and tensiometry were used to evaluate knee active extension range of motion and quadriceps strength. Upon dismissal, the stimulated group was able to generate more force at 90 degrees, 35 degrees, 20 degrees, and terminal extension of the involved knee, but none of these values was found to be statistically significant. Active extension range of motion of the stimulated group on dismissal showed a significant decrease in active extension lag (degrees) as compared to the control group. The experimental group averaged ten days in the hospital as compared to 12.5 for the control group, and subjectively noted decreased pain during stimulation.

18)  Effects of neuromuscular electric stimulation on muscle soreness and plasma creatine kinase concentration: A pilot study. Dinesh A. Kumbhare, MD, MSc (McMaster Univ, Hamilton, ON, Canada); William L. Parkinson, PhD; Brad Balsor, BSc; Kevin Fernandes, MSc; Andrew Gwardjan, MD; Pauline Boulos, MD, e-mail: dkumbhar@stjosham.on.ca.

[No authors listed]

Arch Phys Med Rehabil. 2004 Sep;85(9):E34.

DISCLOSURE: D.A. Kumbhare, None; W.L. Parkinson, None; B. Balsor, None; K. Fernandes, None; A. Gwardjan, None; P. Boulos, None. OBJECTIVE: To investigate the tolerability and safety of neuromuscular electric stimulation (NMES) using measures of muscle soreness and plasma creatine kinase concentrations. Design: Randomized controlled trial with repeated measures. Subjects were stratified by age and quadriceps maximal isometric force, and randomly assigned to 2 groups differing on eccentric versus concentric muscle contractions. Setting: Rehabilitation clinic in a teaching hospital. Participants: 12 men between the ages of 21 and 55y, with no medical conditions precluding exercise. Interventions: Maximal isometric force was measured for the right leg on a KinCom machine before and after NMES. During NMES, the KinCom produced nonvolitional movement in the concentric or eccentric direction for 20 repetitions. NMES was delivered to 4 electrodes on the right quadriceps. NMES frequency started at 30Hz; the pulse width was increased until contractions were 70% of peak voluntary contraction. Main Outcome Measures: Muscle soreness using a 10-cm visual analog scale (VAS) immediately prior to NMES, immediately after NMES, at 5h, and daily for 4d; muscle injury indexed by plasma creatine kinase (CK) concentration immediately prior to NMES, immediately after NMES and at 5h and on day 4; and peak force measured immediately before and after NMES to establish fatigue. Results: Data were analyzed using analysis of variance. NMES produced a trend toward reduced peak force (P=.07), indicating sufficient NMES intensity. Mean VAS pain increased over time (P<.01), peaking at day 2 and returning to baseline by day 4 in both groups. Mean CK concentration did not change over time. There were nonsignificant trends toward greater fatigue or muscle soreness in the eccentric group compared with the concentric group. Conclusions: NMES produced temporary discomfort consistent with delayed-onset muscle soreness characteristic of volitional exercise. CK levels indicated no muscle injury.

19) Transcutaneous magnetic stimulation of the quadriceps via the femoral nerve.

Kremenic IJ, Ben-Avi SS, Leonhardt D, McHugh MP.

Muscle Nerve. 2004 Sep;30(3):379-81.

Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, 130 East 77th Street, 10th Floor, New York, NY 10021, USA. ian@nismat.org

We investigated the efficacy of different frequencies and intensities of magnetic stimulation for activating the quadriceps muscles; a painless method for stimulating the quadriceps would be useful in the rehabilitation of patients who have difficulty in voluntarily activating their muscles after injury or surgery. Eleven subjects underwent magnetic stimulation of the femoral nerve over a range of frequencies and intensities using a MagStim Rapid magnetic stimulator. Magnetic stimulation at 30 Hz at 80% of the power output of the stimulator used was capable of generating 72% of quadriceps maximal voluntary contraction torque. Subjects reported little or no pain during the procedure. Magnetic stimulation of the femoral nerve is a well-tolerated way to activate the quadriceps muscles.

20)  Conservative treatment for shoulder pain: prognostic indicators of outcome.

Ginn KA, Cohen ML.

Arch Phys Med Rehabil. 2004 Aug;85(8):1231-5.

Faculty of Health Sciences, University of Sydney, Lidcombe, Australia. K.Ginn@fhs.usyd.edu.au

OBJECTIVES: To investigate the long-term clinical outcome and to identify factors that predict that outcome, after conservative treatment of patients who have shoulder pain with or without accompanying stiffness. DESIGN: Cohort study. SETTING: Outpatient clinic. PARTICIPANTS: Eighty-two subjects who had participated in a randomized controlled trial that compared the short-term effectiveness of conservative treatment for chronic, unilateral shoulder pain of mechanical origin with and without accompanying stiffness, and who were available for longer term follow-up 6 months after the cessation of formal treatment. INTERVENTIONS: Conservative treatment consisting of various combinations of exercise therapy, passive joint mobilization, electrophysical modalities, and corticosteroid injections. MAIN OUTCOME MEASURES: Pain intensity, functional limitation, perceived change in symptoms, active range of motion, muscle force, and clinical and demographic variables. RESULTS: Patients showed significant improvement in all outcome measurements in the long-term whether or not their shoulder pain was accompanied by stiffness. Long-term outcome was not predicted by hand dominance, clinical history of the shoulder condition, severity of the shoulder problem, or shoulder mechanics. CONCLUSIONS: Patients with chronic shoulder pain, with or without accompanying stiffness, can expect significant decreases in shoulder pain and improvements in shoulder function in the long term after conservative treatment.

21)  Functional electrical stimulation treatment of postradiculopathy associated muscle weakness.

Abdel-Moty E, Fishbain DA, Goldberg M, Cutler R, Zaki AM, Khalil TM, Peppard T, Rosomoff RS, Rosomoff HL.

Arch Phys Med Rehabil. 1994 Jun;75(6):680-6.

University of Miami, School of Medicine, Department of Neurological Surgery, Miami Beach, FL 33139.

Eighteen chronic pain patients (CPPs) with postradiculopathy-associated muscle weakness were entered into a nonrandomized functional electrical stimulation (FES) clinical treatment study to determine if FES can improve postradiculopathy associated muscle weakness. Because of the clinical nature of the unit, the CPPs could not be denied treatments other than FES. To control for these other treatments, the CPPs were used as their own controls with two control conditions, ie, where possible, the contralateral probable normal muscle was used as a control (control 1) and; in a subgroup of CPPs (n = 6), FES treatment was initially withheld to the probable weak muscle (control 2). Strength was measured as isometric maximum voluntary contraction (IMVC) and was used as the outcome treatment variable. IMVC was measured in both the probable weak and contralateral probable normal muscles at entrance into the Pain Center, at beginning of FES treatment, at completion of FES treatment, and for the control 2 condition at the end of the non-FES treatment period. Statistical analyses of the IMVC strength results using the two control conditions indicated (1) both the FES-treated and untreated muscles increased significantly in IMVC strength, (2) improvement in IMVC strength for FES-treated muscles was significantly greater than for probable normal FES-untreated muscles and, (3) improvement in IMVC strength in FES-treated muscles was significantly greater during the FES-treatment period than during the non-FES treatment period. FES treatment of postradiculopathy-associated muscle weakness in CPPs seems to increase the strength of the probable weak muscle above the increase in strength provided by other concurrent treatments.

22)  Electric muscle stimulation of the quadriceps in the treatment of patellofemoral pain.

Callaghan MJ, Oldham JA.

Arch Phys Med Rehabil. 2004 Jun;85(6):956-62.

Centre for Rehabilitation Science, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. michael.callaghan@man.ac.uk

OBJECTIVE: To compare a commercially available electric muscle stimulation regimen with a novel form of stimulation for the rehabilitation of the quadriceps muscle, in patients with patellofemoral pain syndrome. DESIGN: Double-blinded randomized trial with a parallel control group and stratified randomization. SETTING: Home-based rehabilitation program assessed in research center. PARTICIPANTS: Eighty patients (47 women, 33 men) with patellofemoral pain syndrome. INTERVENTIONS: One group (EMPI) received 1 uniform constant frequency component of 35Hz. The other (EXPER) group received an experimental form of stimulation that contained 5 simultaneously delivered frequency components of 125, 83, 50, 2.5, and 2Hz. Stimulation was applied to the quadriceps muscles of the affected leg for 1 hour daily for 6 weeks, a total of 42 treatments. MAIN OUTCOME MEASURES: Lower-limb isometric and isokinetic torque, quadriceps fatigue, knee flexion, patellar pain, a step test, quadriceps cross-sectional area, and Kujala patellofemoral score for pain before and after treatment. RESULTS: Seventy-four patients (43 women, 31 men) completed the trial. Patients in both groups showed significant improvements in all outcomes (P<.05). No significant differences existed between the 2 stimulators in any outcome (P>.05) except for quadriceps cross-sectional area (P=.023). CONCLUSIONS: One form of stimulation was just as efficacious as the other in improving subjective and objective measures.

23)  Effects of TENS frequency, intensity and stimulation site parameter manipulation on pressure pain thresholds in healthy human subjects.

Chesterton LS, Foster NE, Wright CC, Baxter GD, Barlas P.

Pain. 2003 Nov;106(1-2):73-80.

Department of Physiotherapy Studies, Keele University, Staffordshire ST5 5BG, UK. l.s.chesterton@keele.ac.uk

This study evaluated the effects of varying frequency, intensity and stimulation site, of transcutaneous electrical nerve stimulation (TENS) in an experimental model of pain. In a double-blind design 240 volunteers were randomised to one of six experimental TENS groups, a sham TENS or control (n=30 per group; gender balanced). Two TENS frequencies (110 or 4 Hz) and two intensities (strong but comfortable or highest tolerable) at a fixed pulse duration (200 micros) were applied at three sites relative to the measurement site (segmentally, extrasegmentally or a combination of these), for 30 min. Pressure pain thresholds (PPT) were measured using a pressure algometer, in the first dorsal interosseous muscle, every 10 min, during stimulation and for a further 30 min. The high frequency, high intensity segmental, and combined stimulation groups, showed rapid onset and significant hypoalgesic effects. This effect was sustained for 20 min post-stimulation in the high frequency segmental group. All other TENS intervention groups showed hypoalgesic responses similar to the sham TENS group, and none of these groups reached a clinically significant hypoalgesic level. CONCLUSIONS: The role of TENS frequency, intensity and site are pivotal to achieving optimal hypoalgesic effects, during and after stimulation. Clinical applications of these parameter combinations require further investigations.

24)  Shoulder pain in hemiplegia revisited: contribution of functional electrical stimulation and other therapies.

Vuagnat H, Chantraine A.

J Rehabil Med. 2003 Mar;35(2):49-54;

Loex Hospital, University Hospitals of Geneva, Geneva, Switzerland. hubert.vuagnat@hcuge.ch

OBJECTIVES: Post-stroke shoulder pain is probably the most frequent complication in hemiplegia and has repercussions on motor rehabilitation and the psychological equilibrium of the patient. The strategies for prevention and treatment are presented. AETIOLOGY: Among the various factors contributing to the occurrence of shoulder pain in hemiplegia, some are related to the joint, such as lesion of the rotator cuff tendons, reflex sympathetic dystrophy, inferior-anterior subluxation of the head of the humerus, whereas others are related to the neurologic lesion such as central post-stroke pain, lack of sensibility, unilateral neglect and spasticity. PREVENTION: Efforts should be made from the start to keep the shoulder in an ideal position at all times and movement of the shoulder and upper limb should be carried out with care. TREATMENT: Will be aimed to the cause of pain and passive or active range of motion exercises will be encouraged. Physical, medical and surgical treatments have improved over the last few decades. Functional electrical stimulation in patients with shoulder pain and subluxation, applied early after onset of the stroke, has shown beneficial positive effects on subluxation, pain and mobility. Efforts should therefore be made to better understand the post-stroke shoulder pain in order to provide better outcomes of rehabilitation and thus improve quality of life for patients.

25)  Vastus medialis electrical stimulation to improve lower extremity function following a lateral patellar retinacular release.

Robertson VJ, Ward AR.

J Orthop Sports Phys Ther. 2002 Sep;32(9):437-43; discussion 443-6.

School of Physiotherapy, La Trobe University, Bundoora, Australia. V.Robertson@latrobe.edu.au

STUDY DESIGN: A single-case study design. OBJECTIVES: To examine the effect of electrical stimulation of the vastus medialis muscle on stiffness, pain and function for a patient with delayed functional progress following a lateral patellar retinacular release. BACKGROUND: Five months after an arthroscopic lateral patellar retinacular release, the patient, although highly motivated, had made little progress using routine exercises and taping. METHODS AND MEASURES: An electrical stimulation program producing approximately 300 contractions daily of the vastus medialis muscle was implemented. The electrical stimulation applied for 33 of the 36 days was a rectangular and balanced biphasic pulse of 625-micros duration, 70-Hz frequency, 8-second peak on-time, 3-second off-time, 1-second ramp-up, and 0.5-second ramp-down. Objective measures of stair climbing and hopping, together with the subjective measure of therapist-palpated superomedial patella displacement force, were recorded for each treatment visit. Other subjective measures were the patient's daily recordings of knee pain and stiffness. RESULTS: Patient-reported stiffness reduced rapidly as the actual and cumulative number of daily contractions of the vastus medialis muscle increased. After 8 days of electrical stimulation, the patient was able to ascend stairs unassisted and after another 21 days to hop unsupported. CONCLUSIONS: Stiffness rapidly reduced and function started to improve once the electrical stimulation program was implemented. Recovery during the 36 days of treatment with electrical stimulation was greater than during the previous 5 months using other methods. Compliance was not an issue, nor was muscle soreness.

26)  Neuromuscular stimulation of the quadriceps muscle after hip fracture: a randomized controlled trial.

Lamb SE, Oldham JA, Morse RE, Evans JG.

Arch Phys Med Rehabil. 2002 Aug;83(8):1087-92.

Interdisciplinary Research Centre in Health, Coventry University, UK. s.lamb@coventry.ac.uk

OBJECTIVE: To study the feasibility and effect of neuromuscular stimulation on recovery of mobility after surgical fixation for hip fracture. DESIGN: Double-blind study with stratified randomization. SETTING: Home-based rehabilitation program. PARTICIPANTS: Twenty-four women over the age of 75 years with hip fracture. INTERVENTIONS: Neuromuscular or placebo stimulation of the quadriceps muscle of the fractured leg, applied for 3 hours a day, for 6 weeks, commencing 1 week after surgery. MAIN OUTCOME MEASURES: Recovery of walking speed and ability, postural stability, lower-limb muscle power, and pain at 7 and 13 weeks after surgery. RESULTS: Women in the neuromuscular stimulation group showed faster recovery of mobility. Of the women receiving stimulation, 9 of 12 recovered their prior levels of indoor mobility ability by 13 weeks compared with 3 of 12 in the placebo group (Fisher exact test, P=.046). There were no differences in recovery of walking speed in the first 7 weeks, but women in the stimulation group had greater recovery between 7 and 13 weeks (mean difference=-.13m/s; 95% confidence interval, -.23 to -.01). CONCLUSIONS: Neuromuscular stimulation at home is feasible and may be effective in speeding recovery of mobility after surgical fixation of hip fracture.

27)  Shoulder pain after stroke: a review of the evidence base to inform the development of an integrated care pathway.

Turner-Stokes L, Jackson D.

Clin Rehabil. 2002 May;16(3):276-98.

Regional Rehabilitation Unit, Northwick Park and St Mark's Hospital Trust, Harrow, Middlesex, UK. lynne.turner-stokes@kcl.ac.uk

BACKGROUND: Shoulder pain is a common complication of stroke. It can impede rehabilitation and has been associated with poorer outcomes and prolonged hospital stay. This systematic review was undertaken to inform the development of an evidence-based integrated care pathway (ICP) for the management of hemiplegic shoulder pain (HSP). AIMS AND OBJECTIVES: 1) To provide a background understanding of the functional anatomy of the shoulder and its changes following stroke. 2) To review the literature describing incidence and causation of HSP and the evidence for factors contributing to its development. 3) To appraise the evidence for effectiveness of different interventions for HSP. METHODS: Data sources comprised a computer-aided search of published studies on shoulder pain in stroke or hemiplegia and references to literature used in reviews (total references = 121). MAIN FINDINGS: Although a complex variety of physical changes are associated with HSP, these broadly divide into 'flaccid' and 'spastic' presentations. Management should vary accordingly; each presentation requiring different approaches to handling, support and intervention. (1) In the flaccid stage, the shoulder is prone to inferior subluxation and vulnerable to soft-tissue damage. The arm should be supported at all times and functional electrical stimulation may reduce subluxation and enhance return of muscle activity. (2) In the spastic stage, movement is often severely limited. Relieving spasticity and maintaining range requires expert handling; overhead exercise pulleys should never be used. Local steroid injections should be avoided unless there is clear evidence of an inflammatory lesion. CONCLUSIONS: HSP requires co-ordinated multidisciplinary management to minimize interference with rehabilitation and optimize outcome. Further research is needed to determine effective prophylaxis and document the therapeutic effect of different modalities in the various presentations. Development of an integrated care pathway provides a reasoned approach to management of this complex condition, thus providing a sound basis for prospective evaluation of different interventions in the future.

28)  Effect of pain reduction on postural sway, proprioception, and quadriceps strength in subjects with knee osteoarthritis.

Hassan BS, Doherty SA, Mockett S, Doherty M.

Ann Rheum Dis. 2002 May;61(5):422-8.

Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK.

OBJECTIVE: To investigate whether alleviation of knee pain influences quadriceps function, proprioceptive acuity, and postural stability in patients with knee osteoarthritis (OA). METHODS: A crossover, within-subject, double blind study design involving 68 subjects with painful knee OA. Each subject received an intra-articular injection into one or both knees (both if symptomatic) of either 5 ml 0.5% bupivacaine or 5 ml 0.9% saline. Two weeks later they received an injection of the alternative agent. Subjects and observer were unaware of the order of injection, which was randomly assigned. Knee pain (100 mm visual analogue scale), static postural sway, knee proprioceptive acuity, maximum voluntary contraction (MVC), and percentage activation of the quadriceps were assessed immediately before and one hour after each injection. RESULTS: Significant pain reduction was achieved one hour post-bupivacaine (mean difference as a percentage change 56.85, 95% CI 31.01 to 73.65; p<0.001) and post-saline (mean difference as a percentage change 41.94, 95% CI 11.57 to 76.66; p< 0.001), with no significant difference between the two. Both MVC and activation increased significantly post-bupivacaine (mean percentage differences 18.83, 95% CI -31.79 to -0.26, and -11.90, 95% CI -39.53 to 2.97, respectively; both p<0.001) and post-saline (mean percentage differences -7.64, 95% CI -21.96 to 4.73, and -10.71, 95% CI -25.19 to 2.60 respectively; both p<0.001). Proprioception worsened after bupivacaine (mean percentage difference -28.15%, 95% CI -83.47 to 19.74; p=0.009), but there was no effect on postural sway; saline injection had no effects. There was no order effect, and comparison of median percentage changes showed no significant differences between injections for change in MVC, activation, proprioception, or sway. CONCLUSION: Reduction in knee pain through either peripheral (local anaesthetic) or central (placebo) mechanisms resulted in increased MVC. This increase, however, did not result in improvements in proprioception or static postural stability, suggesting that other mechanisms play a part in these functions, at least in this acute model.

29)  Neuromuscular electrical stimulation. An overview and its application in the treatment of sports injuries.

Lake DA.

Sports Med. 1992 May;13(5):320-36.

Department of Physical Therapy, Northeastern University, Boston, Massachusetts.

In sports medicine, neuromuscular electrical stimulation (NMES) has been used for muscle strengthening, maintenance of muscle mass and strength during prolonged periods of immobilisation, selective muscle retraining, and the control of oedema. A wide variety of stimulators, including the burst-modulated alternating current ('Russian stimulator'), twin-spiked monophasic pulsed current and biphasic pulsed current stimulators, have been used to produce these effects. Several investigators have reported increased isometric muscle strength in both NMES-stimulated and exercise-trained healthy, young adults when compared to unexercised controls, and also no significant differences between the NMES and voluntary exercise groups. It appears that when NMES and voluntary exercise are

combined there is no significant difference in muscle strength after training when compared to either NMES or voluntary exercise alone. There is also evidence that NMES can improve functional performance in a variety of strength tasks. Two mechanisms have been suggested to explain the training effects seen with NMES. The first mechanism proposes that augmentation of muscle strength with NMES occurs in a similar manner to augmentation of muscle strength with voluntary exercise. This mechanism would require NMES strengthening protocols to follow standard strengthening protocols which call for a low number of repetitions with high external loads and a high intensity of muscle contraction. The second mechanism proposes that the muscle strengthening seen following NMES training results from a reversal of voluntary recruitment order with a selective augmentation of type II muscle fibres. Because type II fibres have a higher specific force than type I fibres, selective augmentation of type II muscle fibres will increase the overall strength of the muscle. The use of neuromuscular electrical stimulation to prevent muscle atrophy associated with prolonged knee immobilisation following ligament reconstruction surgery or injury has been extensively studied. NMES has been shown to be effective in preventing the decreases in muscle strength, muscle mass and the oxidative capacity of thigh muscles following knee immobilisation. In all but one of the studies, NMES was shown to be superior in preventing the atrophic changes of knee immobilisation when compared to no exercise, isometric exercise of the quadriceps femoris muscle group, isometric co-contraction of both the hamstrings and quadriceps femoris muscle groups, and combined NMES-isometric exercise. It has also been reported that NMES applied to the thigh musculature during knee immobilisation improves the performance on functional tasks.

30)  A functional electric stimulation system using an electrode garment.

Patterson RP, Lockwood JS, Dykstra DD.

Arch Phys Med Rehabil. 1990 Apr;71(5):340-2.

Department of PM&R, University of Minnesota, Minneapolis.

A functional electric stimulation system for standing and ambulating that uses a commercially available electrode garment has been developed. The garment allows electrodes to be applied rapidly and securely. Two channels of a four-channel stimulator are used to stimulate the quadriceps muscles and permit the user to stand. The other two channels are used to stimulate the peroneal nerve, which causes a flexor withdrawal reflex and permits stepping. The user controls stepping by hand-held switches. The system provides a means for standing, exercising, and limited ambulation.

31)  Therapeutic effect of TENS on post-IMF trismus and pain.

Fagade OO, Obilade TO.

Afr J Med Med Sci. 2003 Dec;32(4):391-4.

Department of Oral/Maxillofacial Surgery, Faculty of Dentistry, Awolowo University, Ile-Ife, Nigeria.

The study set out to investigate the therapeutic effect of Transcutaneous Electrical Nerve Stimulation (TENS) in the alleviation of pain and post-IMF trismus, in patients undergoing jaw exercises to hasten mouth opening after being treated for fractures of the mandible. Two groups of patients, with 10 patients in each group, were used for the study. The groups were the experimental and the control groups. They were all treated for mandibular fractures, and had their jaws immobilized for 6 weeks, immediately after which they were started on jaw exercises. The Inter-incisal distances and number of acceptable wooden spatulae that the jaws could accommodate were noted and recorded. The experimental group was then placed on the TENS therapy for 20 minutes, after which the new inter-incisal distances and the number of acceptable wooden spatulae were recorded. The control group had no TENS therapy; the patients only waited for 20 minutes without any stimulation, before the new inter-incisal distances and the number of acceptable wooden spatulae were measured and recorded. It was observed that the inter-incisal distance and the number of acceptable wooden spatulae significantly increased in patients in the experimental group compared to the control group. It was concluded that TENS could be useful in relieving the pain associated with forced mouth-opening exercises aimed at overcoming trismus caused by muscle spasm, which is associated with prolonged immobilization of the jaws for the treatment of facial fractures.

32)  Electrical stimulation in the treatment of pelvic pain due to levator ani spasm.

Fitzwater JB, Kuehl TJ, Schrier JJ.

J Reprod Med. 2003 Aug;48(8):573-7.

Departments of Obstetrics and Gynecology, Pathology, and Medical Biochemistry and Genetics, Scott & White Clinic and Memorial Hospital, Texas A&M University System Health Sciences Center, College of Medicine, Temple, TX, USA.

OBJECTIVE: To evaluate experience with intravaginal electrical stimulation for the relief of pain when used as adjunctive therapy in women with chronic pelvic pain and levator ani spasm. STUDY DESIGN: A retrospective cohort of consecutively treated patients from 1999 and 2000 was identified using billing records. Systematic chart review was completed using standardized data collection forms for all patients receiving electrical stimulation for pain from levator ani spasm. Data collected were objective for major variables and subjective for outcomes. Demographic data were reported as means and standard deviations. Stimulation characteristics were compared using ANOVA. Survival analysis was performed using life table methods. RESULTS: Medical records from 66 consecutive patients treated during an 18-month interval were reviewed. Demographic characteristics included mean age of 38.7 years, 13 years of education and parity of 2. Married women composed 75% of the study group, with 81% white, 10% Hispanic and 9% black. Of the 66 patients studied, 50 had follow-up documentation with an average duration of 14.5 weeks. Overall, 34 patients (52%) demonstrated improvement in pelvic pain following vaginal electrical stimulation. Using survival analysis, 51% of patients had persistent improvement 30 weeks after treatment. There were no differences in age, race, education or parity between patients reporting a sustained benefit of stimulation and those not reporting a benefit. CONCLUSION: Vaginal electrical stimulation may help a selected population of women with pelvic pain due to levator ani spasm.

33)  The effectiveness of physical therapy in the treatment of chronic daily headaches.

Jay GW, Brunson J, Branson SJ.

Headache. 1989 Mar;29(3):156-62.

We investigated the adjunctive use of physical therapy, with the more standard modalities of medication and/or biofeedback-enhanced neuromuscular re-education, in patients with chronic daily headaches who had palpable muscle spasm in the neck and shoulder regions. Patients in group one received medication detoxification (when necessary), amitriptyline and (in some cases), biofeedback. Patients in group two received detoxification (when necessary), amitriptyline (in some cases) and physical therapy, including TENS (transcutaneous electrical nerve stimulation). Patients in group three received detoxification (when necessary), amitriptyline in (some cases), and TENS without other modalities of physical therapy. Patients in groups two and three, as judged by changes in Headache Index, showed a significantly faster and greater decline in headaches than patients in group one, and maintained this excellent relief through the six month follow-up period. From a biochemical perspective, this improvement may be related to the demonstrable increase in serotonin levels that attends TENS. From a behavioural perspective, improvement may be related to the change in "locus of control" from the headache to the patient that attends the more "active" modalities of TENS and physical therapy, as opposed to the more "passive" modality of medication alone.

34)  Onset of ischemic colitis following use of electrical muscle stimulation (EMS) exercise equipment.

Tsujimoto T, Takano M, Ishikawa M, Tsuruzono T, Matsumura Y, Kitano H, Yoneda S, Yoshiji H, Yamao J, Fukui H.

Intern Med. 2004 Aug;43(8):693-5.

Department of Gastroenterology, Ishinkai Yao General Hospital, 1-41 Numa, Yao, Osaka 581-0036.

Our patient was a 71-year-old man who presented with lower abdominal pain, and bloody and white mucosal stools. He purchased by mail-order an electrical muscle stimulation (EMS) device, which he strapped onto his lower abdomen, and for 2 consecutive days he underwent muscle stimulation comprising 600 contractions at 2.40 mA and 1.20 V over a 10 minute period. He experienced the onset of lower abdominal pain immediately following muscle stimulation on the second day, and then passed stools containing blood and white mucus. The cause was thought to be electrical and mechanical stimulation of the lower abdomen by the EMS equipment, either inducing colonic or vascular spasm, or dislodging thrombi associated with atrial fibrillation or atherosclerosis. This is the first known report of ischemic colitis associated with the use of EMS exercise equipment. We report this case in the belief that this condition is likely to become more common with increasing use of such devices.

35)  Biochemical change in joint fluid after isometric quadriceps exercise for patients with osteoarthritis of the knee.

Osteoarthritis Cartilage. 2003 Apr;11(4):252-9.

Miyaguchi M, Kobayashi A, Kadoya Y, Ohashi H, Yamano Y, Takaoka K.

Department of Orthopaedic Surgery, Osaka City University Medical School, Osaka, Japan.

OBJECTIVE: The purpose of this study was to analyze the biochemical changes in the joint fluid, and pain relief resulting from isometric quadriceps exercise in patients with osteoarthritis of the knee. DESIGN: Nineteen osteoarthritic knees in 17 patients with joint effusion were included. The patients performed isometric quadriceps exercise for 3 months. Isometric muscle torque at 30 and 60 degrees flexion, pain as measured using the visual analog scale and biochemical markers in joint fluid were evaluated before and after the exercise. RESULTS: Pain score decreased from 3.9 to 2.3 after 12 weeks of exercise (P<0.001). Extension torque at 30 and 60 degrees knee flexion significantly increased from 4.7 to 6.9 kgm (47% increase, P<0.001) and from 10.8 to 12.6 kgm (17% increase, P<0.005) after 12 weeks of exercise. The molecular weight of hyaluronan increased from 2.11 to 2.40x10(6)(P<0.05) and the viscosity of joint fluid increased from 45.8 to 59.8 mPas after 12 weeks of exercise (P<0.05). Chondroitin 4-, 6-sulfate concentration in joint fluid decreased from 81.9 to 75.5 nmol/ml (P<0.05).CONCLUSIONS: Isometric quadriceps exercise resulted in significant changes in joint fluid biochemical parameters, and these changes, at least in part, may explain the ameliorative effect of muscle exercise for osteoarthritis of the knee.

36)  Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritic knee pain?

Clin Rehabil. 2002 Nov;16(7):749-60.

Cheing GL, Hui-Chan CW, Chan KM.

Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon.

OBJECTIVE: To evaluate the cumulative effect of repeated transcutaneous electrical nerve stimulation (TENS) on chronic osteoarthritic (OA) knee pain over a four-week treatment period, comparing it to that of placebo stimulation and exercise training given alone or in combination with TENS. DESIGN: Sixty-two patients, aged 50-75, were stratified according to age, gender and body mass ratio before being randomly assigned to four groups. INTERVENTIONS: Patients received either (1) 60 minutes of TENS, (2) 60 minutes of placebo stimulation, (3) isometric exercise training, or (4) TENS and exercise (TENS & Ex) five days a week for four weeks. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) was used to measure knee pain intensity before and after each treatment session over a four-week period, and at the four-week follow-up session. RESULTS: Repeated measures ANOVA showed a significant cumulative reduction in the VAS scores across the four treatment sessions (session 1, 10, 20 and the follow-up) in the TENS group (45.9% by session 20, p < 0.001) and the placebo group (43.3% by session 20, p = 0.034). However, linear regression of the daily recordings of the VAS indicated that the slope in the TENS group (slope = -2.415, r = 0.943) was similar to the exercise group (slope = -2.625, r = 0.935), which were steeper than the other two groups. Note that the reduction of OA knee pain was maintained in the TENS group and the TENS & Ex group at the four-week follow-up session, but not in the other two groups. CONCLUSIONS: The four treatment protocols did not show significant between-group difference over the study period. It was interesting to note that isometric exercise training of the quadriceps alone also reduced knee pain towards the end of the treatment period.

 37)  Quadriceps femoris muscle torques and fatigue generated by neuromuscular electrical stimulation with three different waveforms.

Phys Ther. 2001 Jul;81(7):1307-16.

Laufer Y, Ries JD, Leininger PM, Alon G.

Physical Therapy Program, Faculty of Social Welfare and Health Studies, University of Haifa, Mount Carmel, 31905, Haifa, Israel. yocheved@research.haifa.ac.il

    BACKGROUND AND PURPOSE: Neuromuscular electrical stimulation is used by physical therapists to improve muscle performance. Optimal forms of stimulation settings are yet to be determined, as are possible sex-related differences in responsiveness to electrical stimulation. The objectives of the study were: (1) to compare the ability of 3 different waveforms to generate isometric contractions of the quadriceps femoris muscles of individuals without known impairments, (2) to compare muscle fatigue caused by repeated contractions induced by these same waveforms, and (3) to examine the effect of sex on muscle force production and fatigue induced by electrical stimulation. SUBJECTS: Fifteen women and 15 men (mean age=29.5 years, SD=5.4, range=22-38) participated in the study. METHODS: A portable battery-operated stimulator was used to generate either a monophasic or biphasic rectangular waveform. A stimulator that was plugged into an electrical outlet was used to generate a 2,500-Hz alternating current. Phase duration, frequency, and on-off ratios were kept identical for both stimulators. Participants did not know the type of waveform being used. Torque was measured using a computerized dynamometer. A maximal voluntary isometric contraction (MVIC) of the right quadriceps femoris muscle set at 60 degrees of knee flexion was determined during the first session. In each of the 3 testing sessions, torque of contraction and fatigue elicited by one waveform were measured. Order of testing was randomized. Torque elicited by electrical stimulation was expressed as a percentage of average MVIC. A mixed-model analysis of variance was used to determine the effect of stimulation and sex on strength of contraction and fatigue. Bonferroni-corrected post hoc tests were used to further distinguish between the effects of the 3 stimulus waveforms. RESULTS: The results indicated that the monophasic and biphasic waveforms generated contractions with greater torque than the polyphasic waveform. These 2 waveforms also were less fatiguing. The torques from the maximally tolerated electrically elicited contractions were greater for the male subjects than for the female subjects. DISCUSSION AND CONCLUSION: Muscle torque and fatigue of electrically induced contractions depend on the waveform used to stimulate the contraction, with monophasic and biphasic waveforms having an advantage over the polyphasic waveform. All tested waveforms elicited, on average, stronger contractions in male subjects than in female subjects when measured as a percentage of MVIC.

38)  Thoracic and lumbar spine in diastrophic dysplasia: a clinical and magnetic resonance imaging analysis.

Remes V, Tervahartiala P, Poussa M, Peltonen J.

Spine. 2001 Jan 15;26(2):187-95.

Hospital for Children and Adolescents, Helsinki University Central Hospital, Finland. ville.remes@helsinki.fi

STUDY DESIGN: Cross-sectional study to evaluate the thoracic and lumbar spine in patients with diastrophic dysplasia (DD). OBJECTIVES: To find the causative factors behind the spinal deformities and restricted mobility of the spine. SUMMARY OF BACKGROUND DATA: Typical findings in this skeletal dysplasia are short-limbed stature, multiple joint contractures, early degeneration of joints, and spinal deformities such as cervical kyphosis, scoliosis, and exaggerated lumbar lordosis. The pathogenic mechanism of scoliosis is unknown. METHODS: A physical examination was performed on 88 patients (55 females, 33 males) with an average age of 31 years (range, 3-56). Magnetic resonance (MR) images from T2 to S1 and radiographs were obtained. Degree of scoliosis was measured according to Cobb from standing radiographs.The anatomy of the medulla and the size of the spinal canal were assessed. The transverse dural tube area was measured from L2 to S1. Disc space, degeneration, and protrusions were evaluated. Vertebral abnormalities, if any, facet joint degeneration and the state of the spinal muscles were also assessed. RESULTS: Physical examination showed diminished mobility of the spine. Scoliosis was noted in 70 patients with an average of 42 degrees (range, 11-188 degrees ). The mean transverse area of the dural tube ranged from 94 mm(2) at L2-L3 to 57 mm(2) at L5-S1. The area was smaller at all levels compared with reference values (P < 0.001). One patient had severe thoracic and lumbar spinal stenosis. Five patients had compression of neural structures in the lumbar spinal canal in MR images, but had no clinical symptoms. All patients exhibited narrowed disc heights and a decrease in the signal intensity of discs on T2-weighted images. The prevalence of disc protrusions was low; three patients had a prolapse in the lumbar spine. Two patients displayed vertebral anomalies. All patients also had muscular atrophy and degenerative-like facet joint hypertrophy. The severity of these changes increased with age. CONCLUSIONS: Abnormal disc structure and rapid degeneration explain the diminished decreased mobility of the spine and may be a causative factor in the development of scoliosis. Muscular atrophy may be caused by reduced physical activity and rigid spinal deformities. The spinal canal is narrowed, but symptomatic lumbar spinal stenosis is uncommon.

39)  The relationship between depression, clinical pain, and experimental pain in a chronic pain cohort.

Giesecke T, Gracely RH, Williams DA, Geisser ME, Petzke FW, Clauw DJ.

Arthritis Rheum. 2005 May;52(5):1577-84.

University of Michigan, Ann Arbor, USA.

OBJECTIVE: Individuals with chronic pain frequently display comorbid depression, but the impact of symptoms of depression on pain processing is not completely understood. This study evaluated the effect of symptoms of depression and/or clinically diagnosed major depressive disorder (MDD) on pain processing in patients with fibromyalgia (FM). METHODS: Results of quantitative sensory testing and neural responses to equally painful pressure stimuli (measured by functional magnetic resonance imaging [fMRI]) were compared with the levels of symptoms of depression and comorbid MDD among patients with FM. RESULTS: Neither the level of symptoms of depression nor the presence of comorbid MDD was associated with the results of sensory testing or the magnitude of neuronal activation in brain areas associated with the sensory dimension of pain (primary and secondary somatosensory cortices). However, symptoms of depression and the presence of MDD were associated with the magnitude of pain-evoked neuronal activations in brain regions associated with affective pain processing (the amygdalae and contralateral anterior insula). Clinical pain intensity was associated with measures of both the sensory dimension of pain (results of sensory testing) and the affective dimension of pain (activations in the insula bilaterally, contralateral anterior cingulate cortex, and prefrontal cortex). CONCLUSION: In patients with FM, neither the extent of depression nor the presence of comorbid major depression modulates the sensory-discriminative aspects of pain processing (i.e., localizing pain and reporting its level of intensity), as measured by sensory testing or fMRI. However, depression is associated with the magnitude of neuronal activation in brain regions that process the affective-motivational dimension of pain. These data suggest that there are parallel, somewhat independent neural pain-processing networks for sensory and affective pain elements. The implication for treatment is that addressing an individual's depression (e.g., by prescribing an antidepressant medication that has no analgesic properties) will not necessarily have an impact on the sensory dimension of pain.

40)  Risk of myocardial infarction in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis.

Hippisley-Cox J, Coupland C.

BMJ. 2005 Jun 11;330(7504):1366.

Institution 13th floor, Tower Building, University Park, Nottingham NG2 7RD. Julia.hippisley-cox@nottingham.ac.uk

AIMS: To determine the comparative risk of myocardial infarction in patients taking cyclo-oxygenase-2 and other non-steroidal anti-inflammatory drugs (NSAIDs) in primary care between 2000 and 2004; to determine these risks in patients with and without pre-existing coronary heart disease and in those taking and not taking aspirin. DESIGN: Nested case-control study. SETTING: 367 general practices contributing to the UK QRESEARCH database and spread throughout every strategic health authority and health board in England, Wales, and Scotland. SUBJECTS: 9218 cases with a first ever diagnosis of myocardial infarction during the four year study period; 86 349 controls matched for age, calendar year, sex, and practice. OUTCOME MEASURES: Unadjusted and adjusted odds ratios with 95% confidence intervals for myocardial infarction associated with rofecoxib, celecoxib, naproxen, ibuprofen, diclofenac, and other selective and non-selective NSAIDS. Odds ratios were adjusted for smoking status, comorbidity, deprivation, and use of statins, aspirin, and antidepressants. RESULTS: A significantly increased risk of myocardial infarction was associated with current use of rofecoxib (adjusted odds ratio 1.32, 95% confidence interval 1.09 to 1.61) compared with no use within the previous three years; with current use of diclofenac (1.55, 1.39 to 1.72); and with current use of ibuprofen (1.24, 1.11 to 1.39). Increased risks were associated with the other selective NSAIDs, with naproxen, and with non-selective NSAIDs; these risks were significant at < 0.05 rather than < 0.01 for current use but significant at < 0.01 in the tests for trend. No significant interactions occurred between any of the NSAIDs and either aspirin or coronary heart disease. CONCLUSION: These results suggest an increased risk of myocardial infarction associated with current use of rofecoxib, diclofenac, and ibuprofen despite adjustment for many potential confounders. No evidence was found to support a reduction in risk of myocardial infarction associated with current use of naproxen. This is an observational study and may be subject to residual confounding that cannot be fully corrected for. However, enough concerns may exist to warrant a reconsideration of the cardiovascular safety of all NSAIDs.

41)  Acupuncture--from empiricism to science: functional background to acupuncture effects in pain and disease.

Andersson S, Lundeberg T.

Med Hypotheses. 1995 Sep;45(3):271-81.

Department of Physiology, University of Goteborg, Sweden.

Acupuncture is part of Traditional Chinese Medicine, a system with an empirical basis which has been used in the treatment and prevention of disease for centuries. A lack of scientific studies to prove or disprove its claimed effects led to rejection by many of the western scientific community. Now that the mechanisms can be partly explained in terms of endogenous pain inhibitory systems, the integration of acupuncture with conventional medicine may be possible. Its use for pain relief has been supported by clinical trials and this has facilitated its acceptance in pain clinics in most countries. Acupuncture effects must devolve from physiological and/or psychological mechanisms with biological foundations, and needle stimulation could represent the artificial activation of systems obtained by natural biological effects in functional situations. Acupuncture and some other forms of sensory stimulation elicit similar effects in man and other mammals, suggesting that they bring about fundamental physiological changes. Acupuncture excites receptors or nerve fibres in the stimulated tissue which are also physiologically activated by strong muscle contractions and the effects on certain organ functions are similar to those obtained by protracted exercise. Both exercise and acupuncture produce rhythmic discharges in nerve fibres, and cause the release of endogenous opioids and oxytocin essential to the induction of functional changes in different organ systems. Beta-endorphin levels, important in pain control as well as in the regulation of blood pressure and body temperature, have been observed to rise in the brain tissue of animals after both acupuncture and strong exercise. Experimental and clinical evidence suggest that acupuncture may affect the sympathetic system via mechanisms at the hypothalamic and brainstem levels, and that the hypothalamic beta-endorphinergic system has inhibitory effects on the vasomotorcenter, VMC. Post-stimulatory sympathetic inhibition which proceeds to a maximum after a few hours and can be sustained for more than 12 hours, has been demonstrated in both man and animals. Experimental and clinical studies suggest that afferent input in somatic nerve fibres has a significant effect on autonomic functions. Hypothetically, the physiological counterpart lies in physical exercise, and the effect can be artificially reproduced via various types of electrical or manual stimulation of certain nerve fibres.

48)  Understanding work-related upper extremity disorders: clinical findings in 485 computer users, musicians, and others.

Pascarelli EF, Hsu YP.

J Occup Rehabil. 2001 Mar;11(1):1-21.

Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, USA. efp1@columbia.edu

determine the extent of their illness. The group had a mean age of 38.5 years. Sixty-three percent of patients were females. Seventy percent were computer users, 28% were musicians, and 2% were others engaged in repetitive work. The time between the onset of symptoms and our initial visit ranged from 2 weeks to over 17 years. A majority sought care within 30 months with the greatest number of them seeking care before 12 months. Fifty nine percent of subjects were still working when seen despite increasing pain and symptoms such as weakness, numbness, tingling, and stiffness. Following a history, a physical assessment utilizing commonly employed clinical tests were performed including evaluation of joint range of motion, hyperlaxity, muscle tenderness, pain, strength, and imbalance. Neurologic tests included Tinel's sign performed in wrist, elbow, tricipital sulcus, and neck and tests for thoracic out syndrome (TOS). Specific tests such as Finkelstein's test for deQuervain's tenosynovitis, Phalen's test for carpal tunnel syndrome and grip strengths were included in the examination protocol. Significant findings included postural misalignment with protracted shoulders (78%), head forward position (71%), neurogenic TOS (70%), cervical radiculopathy (0.03%), evidence of sympathetic dysfunction (20%), and complex regional pain syndrome (RSD) (0.6%). Hyperlaxity of fingers and elbows was found in over 50%, carpal tunnel syndrome in 8%, radial tunnel syndrome in 7%, cubital tunnel in 64%, shoulder impingement in 13%, medial epicondylitis in 60%, lateral epicondylitis in 33%, and peripheral muscle weakness in 70%. We conclude that despite initial presentation distally, work-related upper-extremity disorders are a diffuse neuromuscular illness with significant proximal upper-body findings that affect distal function.