Neuromuscular electrical stimulation (NMES) is a common modality used in rehabilitation to help restore function and strength of inhibited muscles. As our professions continue to grow and expand our goal of restoring “function,” many have moved away from modalities like ultrasound and electrical stimulation, and probably for good reason. However, I still use NMES frequently in my practice to help kick start my strength recovery after injury or surgery. I like to superimpose NMES on a muscle that is weak or inhibited to help maximize my gains during both simple isotonic exercises and functional movement patterns.
NMES has bee shown in several studies, too many to cite here, to help restore strength faster than exercise alone following surgeries such as ACL reconstruction and total knee replacements. Furthermore, I have publish and presented on how I use NMES for the rotator cuff after injury and surgery as well. It appears that patients that have difficulty activating their muscle have difficulty training their muscles at intensities sufficient enough to promote strength gains.
If you want to learn more about how I use NMES for the shoulder, I have a webinar on this topic at RehabWebinars.com. I definitely recommend you try this as I can honestly say this is something that I do that produces really good results.
A common question regarding NMES involves the intensity of the stimulation. How strong of a stimulation should we be trying to achieve?
Even a Small Amount of NMES is Effective
In my article in AJSM, we reported that peak force production of external rotation with NMES applied was 22% greater than without NMES. Furthermore, the increase in peak force production was not significantly different based on the intensity of the stimulation. Essentially, it didn’t matter how high you turned up the ESTIM, you still saw a nice increase in force production.
Even low thresholds of NMES intensity could result in altered motor unit recruitment and subsequent improvement in muscle function. This doesn’t mean that a small amount of NMES is best, it just means that if you have a patient that doesn’t tolerate a strong contraction, it is still going to provide some benefit and is worth performing.
The More NMES Intensity the Better
A recent study was published in the journal Physical Therapy looking at the relationship between intensity of quadriceps NMES and strength recovery after total knee replacement. The authors concluded that there is a relationship between NMES intensity and change in torque and muscle activation. This is similar to past finds by Lynn Snyder-Mackler and her group that have published extensively on NMES.
While it does appear that “the more, the better” may be true, we should also careful consider the amount of discomfort and, if the patient is postoperative, the tissue healing status. We certainly don’t want to increase the patient’s pain to a level of perceived threat that may cause a negative effect on recovery. Because we know that even a small amount of NMES is beneficial, I generally use the patient’s comfort level as my guide. Patients are often apprehensive when receiving NMES for the first time. As their tissue heals and they become more comfortable, you will naturally be able to raise the NMES intensity to maximize gains. My comment is always “the more the better, but I would like it to be comfortable.”
What has your experience been with NMES? Are you using NMES more or less in recent years, and why?
To learn more about how I use NMES for the shoulder following injury and surgery, check out my webinar at RehabWebinars.com.
The potentional contribution of the role of the scapula and mechanics of the scapulothoracic joint have been well defined in the development of subsacromial impingemnt. Any alteration in the position or kinematics of the scapula will alter:
The size of the subacromial shape
The quality and quantity of scapulohumeral rhythm
The contribution and timing of force couple muscles around the joints
Interestingly, it is hard for me to say that scapular position causes each of the three items listed above. Rather, these realistically all work together to cause dysfunction.
While studies have shown strengthening programs focusing on these areas can be effective, the use of kinesiotape has also become popular. Despite the popularity, I can’t tell you how many theories I have heard as to why patients and clients like using kinesiotape.
Could it be the constant proprioceptive feedback? Could it be alignment corrections? Could it be improved blood flow or lympatic drainage? Could there be an impact on fascia? Could it simple be another way to alter efferent outputs through afferent inputs? Could it be neuroscience by combing cutaneous input, sensory gating, and decreasing the perceived threat towards movement? Could it inhibit the H reflex? Could it simply be placebo after seeing everyone in the Olympics wearing kinesiotape?
I don’t think there is a definitive answer to these questions, however there are boatloads of anecdotal experience and some research studies trying to demonstrate the effectiveness of kinesiotape.
The Effect of Kinesiotape on Scapular Mechanics
One such study was recently release from Taiwan in the Journal of Electromyography and Kinesiology. In the study, the authors examined the effect of Kinesiotape of the lower trapezius on baseball players with impingement signs and shoulder weakness. The authors used a form of placebo tape (nonelastic) in a control group for comparison.
I have always had one primary concern with studies examining Kinesiotape. There is a lot of variability with kinesiotape – what type of tape? How much tension? Should muscle be short or long? In this article, the authors applied Kinesiotape to “envelope” the lower trapezius with minimal tension on the tape. Although it isn’t decsribed exactly, it looks like to me that they applied the tape without stretch in a shortened position for the lower trapezius in the photo. The scapula should be posteriorly tilted and upwardly rotated in this position, though I guess there is also some protraction. This is more along the lines of traditional Kinesiotaping.
During the study, the authors found:
Kinesiotape significantly increased upward rotation of the scapula above 60 degrees of elevation
Kinesiotape showed a trend towards increased posterior tilt with significant increase below 90 degrees of elevation
Placebo tape increased upper trapezius activity from 90-120 degrees of elevation.
Both tape decreases lower trap EMG until the eccentric lowering phase when the kinesiotape increased and the placebo tape decreased lower trapezius EMG
Kinesiotape increased lower trapezius muscle strength testing by 6% while the placebo tape actually showed a touch of a loss of strength of a little more than 1%
At first glance, I though the results were a little contradictory when the authors reported that lower trapezius EMG activity was lower during the concentric phase of elevation. However, if you combine their other results of altered scapular kinematics, one could argue that the altered kinematics resulted in better movement quality with the need for less lower trapezius contribution. The tape somehow imprioved the functional performance of elevating the arm.
I also wanted to point out that I thought it was interesting to see that the placebo tape increased upper trapezius activity. perhaps the use of noneleastic tape somehow restricted the movement.
Comparing scapula studies like this is often hard. There is such a wide variability in scapular position and kinematics in any group of he healthy or sympotamic subjects, which in turn creates variable EMG activity. I like that the authors used the subjects as their own controls with placebo tape instead of just simply using a separate control group.
What is the take away from all this? Kinesiotape isn’t magic. But perhaps there is a role? There is always going to be debate and doubters, I don’t think we know why there may be a benefit to kinesiotaping. Some thought to start discussion:
There may be a role for kinesiotape during the phases of injuries when motion is painful. If the kinesiotape helps increase motion with less pain, I am all for it.
There may be a role for kinesiotape when working on strength and motor control to enhance movement dysfunction. If kinesiotape helps enhance movement quality, I am all for it.
Kinesiotape is not a substitute for what we are already doing, but perhaps it may enhance our results or at least make it a little easier to achieve some of our goals.
I am sure there are a lot of opinions on the use of Kinesiotape. We had a nice chat on this on Facebook yesterday. I would love to here more from people. What has been your experience? What pathologies do you think kinesiotaping helps most with? Why do you think kinesiotape works or doesn’t work?
Today’s guest post is from Ann Wendel on trigger point dry needling and the effect of dry needling for lateral epicondylitis. Dry needling is gaining more popularity and becoming another great option when dealing with trigger points. Ann went through Myopain Seminar’s dry needling certification. I have had the pleasure to get to learn from some of the instructors of the trigger point program, including Katie Adams, and definitely recommend them if this is of interest to you.
Trigger Point Dry Needling
Dry Needling is a physical therapy modality used in conjunction with other interventions to treat myofascial pain and dysfunction caused by trigger points. Myofascial trigger points (MTrP’s) are defined as hyperirritable nodules located within a taut band of skeletal muscle (Simons et al., 1999). Palpation of a MTrP produces local pain and sensitivity, as well as diffuse and referred pain patterns away from the affected area. Painful MTrP’s activate muscle nociceptors that, upon sustained noxious stimulation, initiate motor and sensory changes in the peripheral and central nervous systems. (Shah et al., 2008).
Trigger point dry needling can be used to achieve one of three objectives. First, trigger point dry needling can confirm a clinic diagnosis by relieving the patient’s pain or symptoms of nerve entrapment. Second, inactivation of a MTrP by needling can rapidly eliminate pain in an acute pain condition. Third, inactivation of the MTrP through needling can relax the taut band for hours or days in order to facilitate other therapeutic approaches such as physical therapy and self stretching (Dommerholt and Gerwin, 2006).
Universal precautions are always followed when utilizing dry needling in patient care. During the procedure, a solid filament needle is inserted into the skin and muscle directly at the myofascial trigger point. The trigger point is penetrated with straight in and out motions of the needle. The needle can be drawn back to the level of the skin and redirected to treat other parts of the trigger point not reached in the first pass (Dommerholt and Gerwin, 2006). During this procedure, it is essential to elicit twitch responses in the muscle. The local twitch response (LTR) is an involuntary spinal reflex contraction of muscle fibers within a taut band during needling. Research shows that biochemical changes occur after a LTR, which correlate with a clinically observed decrease in pain and tenderness after MTrP release by dry needling (Shah and Gilliams, 2008).
Trigger Point Dry Needling for Lateral Epicondylitis
Trigger point dry needling is an effective treatment modality for numerous acute and chronic musculoskeletal issues. One condition that responds favorably to dry needling is lateral epicondylitis. Therapists know that this problem has usually become chronic by the time the patient seeks treatment, and progress is usually frustratingly slow for both the patient and the therapist.
When dry needling is incorporated into the treatment plan, results are often seen after 2 or 3 visits. The entire forearm is easily treated with the patient supine on the treatment table, and multiple TrP’s can be treated in a matter of minutes. After a thorough history and physical exam, the therapist assesses the forearm for taut bands and trigger points. Muscles commonly involved in symptoms of lateral epicondylitis include: triceps, brachioradialis, extensor carpi radialis longus (and sometimes brevis), extensor digitorum, anconeus, and supinator. As always, the therapist should screen the neck and shoulder region for MTrP’s. Muscles that may refer pain to the lateral epicondyle include: supraspinatus, infraspinatus, teres major and scalenes.
The needling treatment is completed when all LTR’s are eliminated or the patient requests to stop the treatment. The needle is discarded in a sharps container and hemostasis is applied to the area to decrease bruising. The therapist provides manual therapy with a local stretch to the taut band, myofascial release and therapeutic stretch. The patient is taught a self stretch for home, and the treatment can be concluded with ice or heat to the area. The patient is instructed to stretch the area throughout the day and apply heat/ice as needed. It is not unusual to have some increased soreness at the needling site that may last for up to 48 hours. After 48 hours, most patients report a significant decrease in pain, increase in range of motion and some return of strength.
In conclusion, trigger point dry needling can be used in conjunction with other interventions to treat myofascial pain. At the current time, each state has made its own ruling with regard to the physical therapist’s ability to utilize dry needling. The therapist would be best served by reading the State Practice Act for the state in which they practice to determine their ability to use this modality. I went through 100 hours of classroom and practical training in dry needling and successfully passed both a written and practical exam to become a Certified Myofascial Trigger Point Therapist through Myopain Seminars. I highly recommend this course and I find dry needling to be a very effective part of my practice.
Great article Ann, thanks. Dry needling is something I have been exploring and integrating into my practice. I’d love to hear form others about their experiences as well, so please comment below. What works? What technique do you use? What diagnoses respond best?
Here is a video from Youtube for the extensor pollicis brevis. This technique is more aggressive in nature, utilizing and “in and out” pattern of needling rather than just different needles. Different groups teach it differently:
Ann is a graduate of Myopain Seminars program, which is great, but I also recommend Dr. Ma’s Integrated Dry Needling approach. They are both different models. Myopain is based on the trigger point theories of Janet Travell. Dr. Ma’s Integrative Dry Needling, Orthopedic Approach™ is a contemporary dry needling therapy developed by Dr Yun-tao Ma and based on the works of Dr Janet Travell, Dr Chan Gunn, clinical evidence, evidence-based research and Dr Ma’s own 40 years of clinical and research experience and neuroscience training.
Dommerholt, J. and Gerwin, R., Trigger Point Needling Course Manual, The Janet Travell, MD Seminar Series, 2006
Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov Ther. Oct 2008;12(4):371-384
Simons, D.G., Travell, J.G., Simons, L., 1999. Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams & Wilkins, Baltimore.
About the Author
Ann Wendel, PT, ATC, CMTPT holds a B.S. in P.E. Studies with a concentration in Athletic Training from the University of Delaware, and a Masters in Physical Therapy from the University of Maryland, Baltimore. She is a Certified Athletic Trainer (ATC) licensed in Virginia, a Licensed Physical Therapist, and a Certified Myofascial Trigger Point Therapist (CMTPT). Ann received her CMTPT through Myopain Seminars and utilizes Trigger Point Dry Needling as a treatment modality for many pathologies, including lateral epicondylitis.
One of the most common, yet least understood, treatment technique for patellofemoral pain may be patellar taping, or also referred to as McConnell taping. First introduced in 1984 by Jenny McConnell, a physical therapist in Australia, patellar taping has become increasingly popular. The original intent of performing patellar taping was to alter the tilt and position of the patella, most commonly by shifting a laterally displaced patella more medially to correct patellofemoral “tracking” problems.
To date, numerous research has been conducted on the efficacy of patellofemoral taping with conflicting results. For every study that shows altered patella kinematics, enhanced EMG and muscle function, improved dynamic alignment, and decreased patellofemoral joint reaction forces, there seems to be another study that shows just the opposite. One thing is certain, though, most studies do tend to agree that patellar taping decreases pain in patellofemoral pain syndrome patients (PFPS). The question is, why?
Patellar Taping – A Possible Reason as to Why it Works?
A study was published earlier this year that I think explains the mechanism by which patellar taping may work. Actually, the authors of the study didn’t mention this mechanism at all in the paper and it really wasn’t what they studied, but after I read the article, I had one of those “Ah-Ha” moments! I’ll explain later, but first let’s discuss the article.
McConnell Taping and Dynamic MRI
A recent study by Derasari et al in the Journal of Physical Therapy sought to examine patellar kinematics in patellofemoral pain patients after McConnell taping using dynamic MRI. This is the first study to assess patellofemoral kinematics in 6-degrees-of-freedom during active knee extension.
14 subjects that had PFPS for greater 1 year were included in the study and underwent dynamic MRI during active knee extension with and without patellar taping. Standard McConnell taping was apply in the lateral-to-medial direction in an attempt to glide the patella medially, such as in this photo:
Results of the study showed that patellar taping produced a significant shift of the patella in the inferiordirection, not medial. In fact, the study demonstrated that not all patients with PFPS had a laterally displaced patella to begin with, some were medially displaced. However (and this is when the light bulb went off for me), those with a medially displaced patella actually saw a lateral shift in patella position after taping, even though the tape was applied in the standard lateral-to-medial direction. The patella shifted against the tape direction! This is also probably why there is so much conflicting research in the literature.
Why Patellar Taping Really Works
This study was a big “Ah-Ha” moment for me, and I think we may have found a viable reason to explain why patellofemoral taping works. Think about it, patellar taping in the lateral-to-medial direction did cause a medial shift in the patella for those that were laterally displaced, but it produced just the opposite in people that were medially displaced, the patella actually moved against the direction of taping. Why?
After reading this study I think that taping doesn’t shift the patella in one direction, what it does is compress the patellofemoral joint. Take a look at the figures below. The figure on the left shows a patellofemoral joint with a laterally displaced patella, it does not sit centered within the trochlea groove. The figure to the right is that same knee, but now with patellar tape (orange line) applied. As you can see, it centers the patella within the groove but compressing it, the patella glides against the ridge of the trochlea:
The same holds true for the medially displaced patella, even if you tape in the lateral-to-medial direction, it doesn’t matter, the patellar actually shifts laterally in this case because again is glides with the trochlea groove:
This essentially causes a “centering effect” of the patellofemoral joint by compressing it within the trochlea groove. Subsequently, this “centering effect” increases the patellofemoral contact area, which likely has a significant impact on pain.
It is well documented that a displaced patella causes the patellofemoral contact area to decrease, causing the same amount of force to be applied to a more focal area. By centering the patella within the trochlea, this force is distributed across a larger surface area and stress on the cartilage is decreased (for more information on this, subscribe to my newsletter and read my free eBook Solving the Patellofemoral Mystery). As you can see in the below figures, if the same amount of force is applied to a larger area of contact, the force is distributed more evenly across the cartilage:
Obviously, more research needs to be conducted, but this hypothesis seems to have some potential validity and may explain why why patellar taping works and why there is so much conflict in the literature. If you like this kind of thing like I do, read my eBook Solving the Patellofemoral Mystery, free to all my newsletter subscribers.
Based on your experience, do you agree? Think differently? Why do you think patellar taping works?
I found an interesting article in the American Journal of Sports Medicine on the effects of low-level laser on the treatment of Achilles tendinopathy. I must admit that I am, and have been, an avid user of laser energy. Over the years I have tried at least 5 different light/laser units, ranging from one the size of a closet (that required cool green goggles) to simplistic infrared light therapy. Lately, my laser of choice has been the Vectra Genisys by my friends at Empi and Chattanooga.
Lasers are definitely one of those modalities that are trendy right now. This is actually funny to me as the technology is certainly not new. While many clinicians may think laser treatments are “gimmicks,” I challenge those next time they whip out an ultrasound or TENs unit to show me such overwhelmingly positive documentation of it’s efficacy. To date, there have been more than 2 dozen studies on the use of laser technology on tendinopathies. I can tell you that lasers are gaining huge popularity in professional sports, where everyone is looking for an edge. The problem may arise from the lack of popularity in the USA, and thus the lack of knowledge regarding how best to use this modality, making clinical studies important.
The authors of this study sought to examine the effects of laser treatment in conjunction with standard treatment (including stretching and eccentric exercises) on chronic tendinosis of the Achilles in athletes over an 8 week period. One group performed exercises with laser treatments 2x a week for the first 4 weeks and then 1x a week for the next 4 weeks. Another group performed the same exercises but received a sham laser of the same frequency.
The results of the study overwhelming support the use of the laser for chronic tendinopathies.
The subjects in the laser group showed significantly less pain at the 4, 8, and 12 week marks. Pain was reduced by almost 50%.
Interestingly, the laser group had less pain at 4 weeks than the control group did at 12 weeks. The laser group also had significant less crepitation during palpation, tenderness during palpation, and morning stiffness and also increased their active dorsiflexion range of motion.
Laser energy is an effective modality for the treatment of tendonopathies. According to the authors, laser is effective on producing an anti-inflammatory effect and a stimulating effect of the tissue repair process. With more and more studies showing that NSAIDs and steroid injections actually impair the healing of acute injuries, treatments like laser energy should be considered.
The results may be dependent on the settings of your laser. There are many different lasers on the market and I will be the first to say that it can get confusing. The authors of the study made a specific point to mention that they notice the best results with lower power densities. They used a power density of 30 mW/cm2 and a low energy dose of 1.5 J. In laboratory studies with power densities > 50 mW/cm2, fibroblast activity and collagen production have been shown to be inhibited.
By reducing pain, laser energy may also allow a faster return to more aggressive stages of rehabilitation and eventually functional activities. I use laser daily to rehabilitate injuries but also to help repair tissue on my athlete’s “regen days.” My patients have reported subjective improvements, but I truly became a believer when I tried the laser on an open wound. The wound healed faster than any other wound I have treated.
I still believe that we have a lot to learn about the use of laser energy, but we are taking steps in the right direction. Please share your experience with lasers. What model are you using? What injuries have you seen success with laser energy? What settings do you use?
Mike is the President and Co-Founder of Champion Physical Therapy and Performance, located in Boston, MA. Champion offers an integrated approach to elite level physical therapy, personal training, and sports performance.
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