Electrical Stimulation and Lumbar Stabilization Training with Performing Artists

1. Electrical Stimulation and Lumbar Stabilization Training with Performing Artists Tara Jo Manal PT, DPT, OCS, SCS University of Delaware Department of Physical Therapy

2. Lumbar Extensor Musculature • Erector spinae musculature are responsible for extensor force • Multifidus muscles are segmental extensors responsible for stabilization of lumbar motion segments Fritz et al 2000

3. Muscle Strength and Low Back Pain • In firefighters, muscle strength of the low back was a good indicator for the development of low back pain Cady et al 1979 • In manual material workers there was a positive correlation between strength and frequency of low back pain Chaffin 1974

4. Figure Skating and Low Back Pain • Lumbar extensor strength is needed to achieve many positions and successfully land jumps

5. Low Back Strength

6. Low Back Strength

8. Electrical Stimulation for Strength • Snyder-Mackler et al, 1995 • Conclusion: For quadriceps weakness, high-level e-stim with volitional exercise is more successful than exercise alone

9. Electrical Stimulation for Strength • 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

10. Electrical Stimulation for LB Strengthening • 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

11. Parameters of Electrical Stimulation • 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

12. Patient Positioning: Isometric • Prone over pillows • Pelvis strapped to the table in Posterior Pelvic Tilt • Assess movement to active lumbar extension and tighten as necessary

13. Current 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

14. Electrical Stimulation for Strengthening

15. Treatment Administration • Patient motivation factors • Assist your patient in tolerating treatment • Monitor • set targets, watch output, give article • Blunter • wear headphones, towel over head, body relaxation (Delitto et al PT 1992)

16. Give 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

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

18. Case #1 • 21 year old figure skater • 1 year following a L5/S1 titanium cage fusion • 5 months following hardware removal • Pain limiting her ability to return to skating (2 months) • Pain limiting her ability to attend college classes

19. Case #1 - Evaluation • Constant LBP (L5) Avg. 4/10 • Oswestry score 20% • Intermittent “electric shock” from back into left buttocks (always with landing on ice) • Increased pain • standing >30 minutes • prone lying

20. Case #1 - Evaluation • Pain with return to extension from full flexion (alleviated with traction by PT) • Pain at end range flexion, extension and bilateral sidebending • Joint hypomobility L4/L5 (recreated pain to buttock)

21. Case #1 - Early Intervention • Lumbar mobilizations L4/5 unilateral • Stabilization exercises (pelvic neutral) • lower extremity t-band • quadruped arm/leg raises • ball exercise program • side planks

22. Case #1 - Response • After 6 Treatments • Improvement in the ability to return to upright from flexed posture following treatment but return to baseline by next day • Overall pain levels were intermittent rather than constant • Difficulty with stabilization exercises due to fatigue and substitution of larger muscles

23. Case # 1- Hypothesis • Patient was responding positively to treatment intervention, however, gains were slow and fatigue and weakness made correct exercise performance difficult • Electrical stimulation may help assist patient in rapid strengthening and be a successful adjunct to her strengthening program

24. Case #1 - Electrical Stimulation • 7th Treatment • Clearance with physician on the use of electrical stimulation with titanium cage • High Intensity Electrical Stimulation was added to assist in the recovery of the lumbar paraspinal musculature • Patient complained of muscle soreness that resolved within 24 hours

25. Case #1- Progress • 15 treatments of electrical stimulation • Oswestry 12% • Gym work-outs for 1 hour/ 4 times weekly • Run 2 miles pain-free

26. Case #1 - Skating Progression • Progressive return to skating (40 minutes without shooting pain into buttock) • 2 weeks later complained of localized back pain with stopping turns • 4 weeks later returned to compulsories and complained of LBP with twisting - no buttock pain

27. Case #1 - Skating Progression • 3 months later has progressed to Pilates strengthening program • 9 months later she can skate 2-3 times weekly for 1.5 hours before any LBP and no reoccurrence of L buttock pain

28. Discussion • Electrical stimulation has been successfully added to programs of lumbar stabilization with figure skaters • There were no negative effects to the high intensity stimulation treatments • fusion • stress response

29. Discussion • Electrical stimulation may show promise in assisting patients in recovering following lumbar injury especially when returning to demanding activities • Electrical stimulation may be beneficial for patients who are unable to perform other exercise programs due to pain

30. Further Research • Research must be done to determine the effectiveness of the addition of electrical stimulation to a rehabilitation program for low back pain • Work aimed at determining the forces generated in the lumbar spine during these contractions will help therapists determine who can best benefit from this intervention

31. Case 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

32. Case Example: HNP L3/4 • Strength Assessment • Left - 105 ft # • Right - 170 ft # • Quad Index - 62%

33. Case Example: HNP L3/4 • 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

34. Case Example: HNP L3/4 Quadriceps Strength

35. Case 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

36. Neurological Impairments • Sensory deficit • Dermatomal distribution • Light touch • Deep Tendon Reflexes • Strength deficit • Myotomal distribution

37. Case Example: Stenosis • MMT on Initial Evaluation Right Left Ankle DF 4-/5 4-/5 Ankle EV 3+/5 5/5 Great 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

38. Case Example: Stenosis • 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

39. Case Study: Stenosis Eval Right Left Ankle DF 4-/5 4-/5 Ankle EV 3+/5 5/5 After 10 sessions of NMES Right Left Ankle DF 4/5 4-/5 Ankle EV 4/5 4+/5

40. Case Example: Stenosis • 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