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1. VP oe er ree me oe Nee EN Never apply the electrodes e Near the head e On the front and sides of the neck e Counter laterally i e do not use two poles connected to the same channel on opposite sides of the body e On or near skin lesions of any kind wounds swelling burns irritation eczema cancerous lesion etc Precautions when using electrodes and motor point pen e Only use electrodes and motor point pen supplied by the manufacturer Other electrodes and motor point pens may have electrical properties that are unsuitable for or may damage the Wireless Professional Always exercise extreme caution with current densities greater than 2 mA cm e Always turn off the stimulator before moving or removing any electrodes during a session Do not place the electrodes or pen in water e Do not apply solvents of any kind to the electrodes or pen e Do not try to place electrodes on a body part not directly visible without assistance e For best results wash and clean the skin of any oil and dry it before attaching the electrodes e Attach the electrodes in such a way that their entire surface is in contact with the skin e For obvious reasons of hygiene each patient must have his her own set of electrodes Do not use the same electrodes on different patients e Never use a set of adhesive electrodes for more than 15 sessions as the quality of the contact between the electrode and the skin which is essential for th
2. Two further channels are needed for the simultaneous stimulation of the lumbar muscles Two channels are used one for the right side and the other for the left side Two small electrodes are placed on the muscle body at the level of the lowest lumbar vertebrae at one finger s breadth distance from the spinous processes on both sides Two small electrodes are placed 2 finger s breadths above the body of the paravertebral muscles For optimum effectiveness the positive poles of each module pod with an illuminated button should preferably be positioned on the lower electrodes 4 Patient position For the first two weeks The patient is seated on a firm seat with the forearms resting on armrests and a straight back without leaning against the back of the chair For the following two weeks The patient is seated on a balance ball feet resting on the ground pelvis width apart Pee ee ree RES S TONAT EN 5 Associated exercises For the first two weeks On each contraction induced by the stimulation the patient must Breathe out slowly Pull in the stomach Elongate the body along its axis The patient then returns to the starting position during the rest phase and slowly breathes in For the following two weeks The basis of the exercises stays the same combine an electrically induced contraction with breathing out pulling in the stomach and elongating the body Depending on the patient s prog
3. Stimulation does not produce the normal sensation e Check that all settings are correct and check the correct positioning of the electrodes e Modify the positioning of the electrodes Stimulation causes discomfort The electrodes lose their adhesive power and no longer have adequate contact with the skin The electrodes are worn and must be replaced e Modify the positioning of the electrodes The device is not working e Ensure the remote control and the module are charged When the batteries are very discharged charging for a few minutes may be required before the unit turns on e Try to restart the remote control and modules e Place the module and the remote control on the same docking station in order to pair them e If despite this the device is still not working contact the customer services that have been stipulated and approved by the manufacturer a a a a S TONAT EN 6 EMC TABLES ELECTROMAGNETIC COMPATIBILITY The Wireless Professional needs special EMC precautions and must be installed and started according to the EMC information supplied in this manual All RF wireless transmission systems can affect the Wireless Professional The use of accessories sensors and cables other than those recommended by the manufacturer may result in stronger emissions or reduce the immunity of the Wireless Professional The Wireless Professional should not be used beside or stacked on top of any other equipment If you mu
4. The hemiplegic shoulder 2 Treatment frequency One 25 minute session per day five days per week for 4 weeks Regular treatment carried out in one single session per week may then be necessary in the absence of significant recovery or the persistence of considerable spasticity of the pectoralis major muscle 3 Electrode position Two channels are used to stimulate the abductor muscles of the arm One channel for the deltoid and the other for the supraspinatus A small electrode is placed on the lateral aspect of the shoulder in the middle of the deltoid muscle another small electrode is placed on the outer part of the supraspinatous fossa For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the small electrodes which correspond to motor points The other pods are connected to the two outputs of a large electrode placed on the acromion like an epaulette If there is painful irradiation towards the hand and forearm TENS stimulation is available on channels 3 and 4 The order the modules are switched on determines the order in which the channels provide stimulation You must therefore be careful when doing this For TENS two large electrodes are used for each module positioned to cover or follow the painful area or irradiation EN Wee ce SS reo RES S TONAT 4 Patient position The patient is seated beside a table with his her elbo
5. The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned to cover areas with cellulite Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment TENS Option No CONDITIONING II Indication POTENTIATION For optimal muscle preparation immediately before a competition The session should be carried out 10 minutes prior to the start To increase the speed of contraction and increase power Reduces nervous control to attain or maintain a specified level of exertion Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option Indication No ENDURANCE For athletes who wish to improve their performance during long sport
6. activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned according to the specific indication Intensity Stimulation energies must be increased as high as possible whilst still remaining comfortable for the patient TENS Option No CRAMP PREVENTION For people suffering from cramps which may appear spontaneously at rest during the night or following prolonged muscular effort These cramps can be partially due to an imbalance in the flow of blood through the muscles To improve the circulatory system to prevent the occurrence of cramps This programme consists of two different phases an 8 Hz sequence to improve blood flow and develop blood capillaries A 3 Hz sequence to relax muscular tonus and increase the well being of the patient Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity An essential factor in the effectiveness of electrotherapy is the ability to cause visible muscle twitches The mi RANGE function activated by default can be used to determine
7. patterns of glenohumeral contact Orthop Trans 15 803 1991 Gibb TD Sidles JA Harryman DT McQuade KJ Matsen FA The effect of capsular venting on glenohumeral laxity Clin Orthop 268 120 6 1991 Harryman DT Sidles JA Clark JM McQuade KJ Gibbs TD Matsen FA Translation of the humeral head on the glenoid with passive glenohumeral motion J Bone Joint Surg 72A 1334 1990 Howell SM Galinat BJ The glenoid labral socket A constrained articular surface Clin Orthop 243 122 1989 Ww Matsen F Lippit S Iserin A M canismes patho anatomiques de l instabilit gl no hum rale Pathoanatomical mechanisms of glenohumeral instability Expansion scientifique francaise Paris Cahier d enseignement de la SOFCOT Teaching book of the French Society of Orthopaedic Surgery pp 7 13 Itoi E Motzkin NE Morrey BF An KN Bulk effect of rotator cuff on inferior glenohumeral stability as function of scapular inclination angle a cadaver study Tohoku J Exp Med 171 4 267 76 1993 1 Rotator cuff tendinopathy The anatomical location of the rotator cuff exposes it in particular to significant stress and rotator cuff tendinopathy therefore constitutes a real public health problem A study conducted in the United Kingdom in 1986 showed that 20 of the population has consulted a doctor for shoulder problems The pathogenesis of these cases of tendinopathy is associated with multiple factors intri
8. Level 2 mi ACTION mode EN VP ee Se er ree RES S TONAT 2 Treatment frequency e Phase 1 One to several consecutive TENS sessions for the first to third initial treatments before performing the manual joint realignment techniques In case of hypertonicity of the pectoralis major muscle a session can be carried out using the Decontracture programme on the pectoralis major muscle to reduce excessive muscular tension that could impede the medial spin correction techniques e Phase 2 Three to five sessions per week until the pain disappears e Phase 3 Three to five sessions per week until the end of treatment When the patient has recovered good motor control of the stabilizing muscles it is beneficial to perform the last sessions of the treatment in mi ACTION mode When this function is active the initiation of the electrically induced contraction requires voluntary contraction on the part of the patient For this exercise it is recommended that the pod with the illuminated button be positioned on the electrode placed on the infraspinous muscle and to ask the patient to perform a voluntary isometric contraction of his her lateral rotators 3 Electrode position e Phase 1 Four large electrodes are placed in such a way as to cover the whole shoulder as well as possible e Phase 2 A small electrode is placed on the fleshiest part of the infraspinous fossa and the other small electrode is positioned on
9. The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned according to the specific indication Intensity Adjust the stimulation energy in order to produce pronounced but comfortable muscle contractions The stimulation energies must be greater on channels 1 and 2 than on channels 3 and 4 TENS Option No Note Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels Wee Ce Sr rem or herr ARTERIAL INSUFFICIENCY 1 Arterial insufficiency in the lower limbs is conventionally divided into four clinical stages These four stages I Il Ill IV depend on the approximate severity of the loss of blood flow and the tissue related consequences The arterial insufficiency 1 programme is to be used to treat Stage Il In Stage Il arterial occlusion is responsible for pain that occurs on exertion and is relieved by resting this is known as intermittent claudication To improve the absorption of oxygen by the muscles increase tolerance on exertion and walking distance To avoid further reducing the supply of oxygen to the muscle fibres the contractions remain infra tetanising 9 Hz and are separated by long periods of active rest 3 Hz in order to avoid muscular fatigue Pulse width To make it as co
10. a a al ais EN These are independent from each other This means that to a large extent 2 can be modified by experiment separately to k by changing the ionic concentration of Calcium Ca These two constants have values that are very different to each other but A is always much larger 100 to 200 times than k In the case of human motor neurons approximate values of 300 us can be retained for k and 50 ms for A This means that k must be lower than A for the excitation process to occur The local potential V can therefore increase more quickly than the threshold Sand catch up with it If k were greater than 4 the threshold would increase more quickly than the local potential which would never catch up with the threshold B Study of the excitation process using a constant current For the sake of simplicity at this stage we will only study the excitation process produced by a constant current The same study can be carried out using exponential sinusoidal linear progressive or any other type of current as the results are similar For example let us use the values k 1 ms A 50ms The issue in the excitation process is whether Vwill catch up with S or will Shave time to escape The local potential Vstarts at Vo and increases exponentially according to the relationship to a final value depending on the intensity of the current V V Vo V max 1 e The threshold S starts from So and increases according to a mor
11. a session Intensity An essential factor in the effectiveness of electrotherapy is the ability to cause visible muscle twitches The mi RANGE function activated by default can be used to determine the minimum level of energy required o produce an appropriate muscle response TENS Option Indication No This programme can be ANTI STRESS MASSAGE used for relaxation and well being after physical activity or a stressful situation It provides very effective muscle relaxation through comfortable stimulation of the muscles which aids circulation and helps the muscles relax Increases vascularisation of the tissues reduces muscle tension Pulse width To make it as comfortab chronaxies of the motor e as possible for the patient use pulse widths equivalent to the nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Precision in positioning tl muscle quality The electi electrodes needed and s he electrodes is less significant than for programmes aiming to develop rodes can be placed in an alternative way reducing the number of imulating more muscles during a session Intensity An essential factor in the effectiveness of electrotherapy is the ability to cause visible muscle twitches The mi RANGE function activated by default can be used to de
12. address of manufacturer and manufacturing date This device must be separated from household waste and sent to special collection facilities for recycling and recovery The On Off button is a multi function button Non ionising radiation Keep away from sunlight Keep dry Latex Free Reference Number 3 10 TECHNICAL CHARACTERISTICS A General information Remote control battery Lithium polymer LiPo rechargeable 3 7 V 1500 mAh Module battery Lithium polymer LiPo rechargeable 3 7 V 450 mAh AC Adaptor Only 5 V 3 5 A adapters with the reference number 6490xx can be used to recharge the Wireless Professional B Neuro stimulation All electrical specifications are given for an impedance of 500 1 000 ohms per channel Outputs four independent and individually adjustable channels that are electrically isolated from each other Pulse shape constant rectangular current with pulse compensation to eliminate any direct current component to prevent residual polarisation at skin level aximum pulse intensity 120 mA Pulse intensity increments manual adjustment of stimulation intensity from O to 999 energy in minimum increments of 0 25 mA Pulse width 30 to 400 us Maximum electrical charge per pulse 96 micro coulombs 2 x 48 uC compensated Standard pulse ramp up time 3 us 20 80 of maximum current Pulse frequency 1 to 150 Hz C RF data Transmission and
13. altered during the muscle disuse atrophy process and to develop the active stability of the knee Depending upon the diagnosis stimulation will either involve all of the heads of the quadriceps muscle or it will be limited solely to the vastus medialis The three levels of the programme correspond to the Disuse atrophy level 1 and 2 programmes and the Reinforcement level 1 programmes respectively for which the low frequencies have been removed so as not to cause micro trauma in the patella Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the quadriceps muscles The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes lectrodes positioned on the quadriceps or only on the vastus medialis in accordance with the pecific indication Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used Progressively increase the level of energy during the course of a treatment session TENS Option Yes A minimum of 1 channel with muscular work imposed by the Patellofemoral syndrome programme Amaximum of 3 channels with the TENS programme e Electrodes positioned on the p
14. and the hand resting on an armrest the upper limb is placed in the reference position with neutral rotation In phase 2 and on the condition that the position remains painless the arm can gradually be placed in slight abduction not exceeding 30 5 Stimulation energy e Phase 1 The stimulation energy must be gradually increased to obtain a clear tingling sensation e Phase 2 The stimulation energy must be gradually increased to the maximum threshold the patient can tolerate VI Cardiac Rehabiliation Chronic heart failure causes functional impairment associated with the intricate physiopathological mechanisms involved between the cardiac dysfunction and the peripheral changes associated with a deconditioning syndrome The skeletal muscle abnormalities are morphological and functional They include a reduction in muscle mass a reduction in slow twitch type 1 fibres and a reduction in capillary density Metabolically the muscle changes are characterised by a reduction in the density of the mitochondria and a reduction in the mitochondrial oxidative capacity Appropriate physical exercise which improves one s capacity for exertion is known to be one of the essential components in the treatment of chronic heart failure However some patients are excluded from the cardiac rehabilitation programmes due to the severity of their cardiac condition or due to co morbidities limiting the practice of physical exercise It is becau
15. around the shoulder but can also radiate into the upper limb towards the hand through stretching of branches of the brachial plexus Vasomotor and trophic disorders of the hand such as those seen in algoneurodystrophy complex regional pain syndrome may be combined resulting in classic shoulder hand syndrome B Use of neuromuscular electrical stimulation NMES NMES of the abductor muscles of the arm deltoid and supraspinatus may be used to prevent or treat atrophy and reduce spasticity in the latissimus dorsi and pectoralis major muscles This technique is indicated in the prevent or treatment of subluxation of the shoulder in hemiplegic patients Radiological investigations show evidence of re centring of the humeral head in relation to the glenoid cavity Moreover pain in the shoulder and upper limb often associated with subluxation is effectively reduced by this type of treatment However in the event of pain radiating in the upper limb the analgesic action can be supported by using TENS Gate control which is programmed on the third and fourth channel In shoulder hand syndrome in addition to shoulder pain which is itself a secondary problem associated with hemiplegia complex regional pain syndrome CRPS can occur which affects the hand In this situation CRPS should be treated using the programmes and method described in this chapter which deal with this disorder algoneurodystrophy VI METHOD Protocol
16. docking station and the AC adaptor hardware and labour but not the batteries electrodes or the motor point pen All defects resulting from poor quality material or workmanship are covered This guarantee does not cover damage resulting from impact accidents misuse inadequate protection against moisture immersion in water or repairs made by unauthorized personnel Vee oe er ree me oe Nee EN 3 3 MAINTENANCE Clean using a soft cloth and an alcohol based solvent free cleaning product Use only a minimum amount of liquid when cleaning the device Never dismantle the remote control the modules the docking station or the AC adapter as they contain high voltage parts with a risk of electric shock This may only be done by persons or repair services authorised by the manufacturer Your Wireless Professional does not require calibration If your stimulator contains parts that seem worn or defective please stop using it and contact the customer service centre that has been stipulated and authorised by the manufacturer regarding an upgrade 3 4 STORAGE AND TRANSPORT CONDITIONS The device must be stored and transported in accordance with the following conditions Temperature 20 C to 45 C Maximum relative humidity 75 Atmospheric pressure 700 hPa to 1 060 hPa Do not store the modules and remote control for a long time with empty batteries 3 5 CONDITIONS OF USE Temperature 0 C to 40 C Relative humidity 30
17. electrode placed on the upper part of the calf just below the popliteal fossa r a E 4 Patient position Place the patient in a comfortable position 5 Stimulation energy Adjust the stimulation energy to the maximum level the patient can tolerate to recruit as many fibres as possible 2 Stage III arterial insufficiency The same benefit can be obtained using low frequency electrostimulation in Stage III arterial insufficiency In this case because of the more severe obstruction of the arterial width and the more serious deterioration of the muscle qualities stimulation frequencies lower than those used for intermittent claudication must be used To carry out a Stage III arterial insufficiency session we will proceed in the same way as in stage Il but using a programme adapted to more severe deterioration of the arterial capital METHOD Protocol Arterial insufficiency 2 The protocol is absolutely identical apart from the patient position 4 Patient position The difficulty with which the arterial blood is transported to the distal extremities makes it preferable to position the patient in such a way that gravity aids the arterial circulation The patient is therefore placed on a comfortable seat in such a way that does not compress the posterior arterial trunks DJO GLOBAL AUSTRALIA DJO Australia PO Box 2057 Normanhurst NSW 2076 AUSTRALIA T 1300 66 77
18. energy curve at the minimum energy point Fig 6 Fig 6 7 W minimum The derivative of W q t 2qi it Risdw dt q t i R The derivative is the slope of the tangent at any point of a curve As at the minimum energy point this slope is at zero since it is parallel to the abscissa we can therefore state that for W minimum dw dt q t i R O therefore qt R R t q t q i As we have seen above R does not influence the determination of the pulse duration corresponding to the minimum energy The electrical energy passing through the skin and tissue is therefore minimum when the rectangular pulse duration is equal to q i which is in fact as we have seen in the article on the fundamental law of electrostimulation the chronaxy value Furthermore this is why at the start of the century pioneers in electrophysiology chose the chronaxy as the value that characterises tissue excitability that is independent from variations in skin resistance To reduce electrical energy to its minimum the rectangular pulse duration will therefore have to equal the chronaxy of the nerve structure that needs to be excited dj WTRECES a a a S TONAT EN 5 Compensation for the rectangular pulse Every time stimulation needs to be produced a rectangular pulse current is sent out which has the same duration as the chronaxy of the nerve structure that needs to be stimula
19. give the patient the free choice of triggering a contraction making the practice of electrostimulation more comfortable e They ensure even more effective work as they combine voluntary exercises and electrostimulation that together allow for greater recruitment of muscle fibres e They promote the restoration of the body map and motor relearning in patients with impaired neuromuscular control e They allow the stimulation of stabilising muscles to be integrated during an overall functional movement The mi ACTION mode is active during muscle work sequences it is not operational during sequences of warm up and relaxation The first muscle contraction of the work sequence starts automatically At the end of the first contraction an active rest phase begins characterised by muscular twitches The voluntary triggering of a new contraction is only possible after a minimum rest period which varies depending on the programme As soon as the voluntary triggering of a contraction is possible the remote control emits a beep to inform the user Wee ce Sse ree RES SIONA EN Once the user hears the first sound signal composed of a beep the triggering of voluntary contraction is possible If no voluntary contraction has occurred after a certain period of time the unit will automatically pause To function properly the mi ACTION needs a good muscular twitches during the active rest phase If the twitches are not significant e
20. i e by using a minimum amount of electrical intensity 7 a pulse duration t and electrical energy W Having set out the conditions we will now determine the qualities of the current that fulfils these conditions B Characteristics of the optimal current 1 Electrical stimulation wave produced by the current generator We can already state that pulses of current i e produced by a current generator must be used for the following reasons e The first point shown by Weiss is the importance of the quantity of electrical charges provided by the stimulation current however the quantity of charges can only be controlled by a current generator e Only a current generator can ensure stable and reproducible conditions given the variations in skin resistance e If a certain electrical pulse shape is required only a current generator can maintain a constant current wave shape as it passes through the skin and tissue 2 Type of establishment of the electrical stimulation wave According to Weiss law Q it q therefore I t it q therefore J i t q with i rheobase iis a current which resists the stimulation current I EN a a a el als If the stimulation current J has a value lower than i i e the rheobase it cannot be used because it cannot change the resting potential by accumulating electrical charges in the excitable membrane Fig 1 Fig 1 a R Analysis of the different ways to establish
21. muscle contractures in the low back region It will also reduce tension in the contracted muscles to facilitate manual handling techniques To reduce muscular tension and to provide a relaxing effect Highly individualised muscular twitching that is induced by a very low frequency 1 Hz has a relaxing effect Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles in the lumbar region The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes A small electrode preferably connected to the positive pole of the module pod with an illuminated button is placed on the most painful area of the paravertebral muscles which can be detected by palpation The other electrode is placed on the same muscles 2 or 3 finger widths away from the first one Intensity An essential factor in the therapeutic efficacy is to cause visible muscle twitching which may in certain cases require higher stimulation energies to be used The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option Yes A minimum of1 channel with muscular work imposed by the Lumbago programme Amaximum of 3 channels with the TENS programme e Electrodes positioned on the painful a
22. muscles depending on the patient tibialis anterior extensor of the toes lateral peroneal hamstrings tensor fascia lata deltoid supraspinatus triceps brachii extensors of the fingers and wrist g EN VP Ree ee sr ree RES S TONAT METHOD Protocol Spasticity length of treatment to be adjusted depending on progress If the patient is experiencing associated pain symptoms TENS stimulation can be performed in addition on the other channels In this case the specific practical rules for TENS electrode placement regulation of intensity should be followed for each channel used for this purpose 2 Treatment frequency One or two 20 to 30 minute sessions per day 3 Electrode position Place the electrodes on the muscle antagonist to the spastic muscle to be treated The stimulation does not act on the spastic muscle but on its antagonist 4 Patient position The patient and body part being treated are positioned in such a way as to achieve the maximum range of motion In fact unlike the conventional rules for using NMES it is worthwhile for these treatments to allow for isotonic contraction of the antagonist muscle causing movement to the maximum range of motion thus causing maximum stretching of the spastic muscle e Lower limb leg patient seated thigh prone position e Pelvic girdle supine position e Shoulder girdle patient seated arm abducted at 30 to the body elbow resting on an ar
23. of RSD is pain The pain is most often located at the end of the traumatised imb It is described by the patient as a burning pain The intensity of the pain is high and often disproportionate to the initial trauma It increases with stress and activity and decreases when the patient is calm and resting Mobilisation and massage accentuate it simply touching the skin may be very painful Depending on the stage of development other signs may appear The skin becomes cold with sweating oedema and cyanosis developing in the more advanced stages The muscles in the affected area become atrophied The underlying bone develops osteoporosis Sudeck s atrophy The precise mechanism of development of RSD is not yet exactly known However it is well established that the sympathetic nervous system plays a major role Indeed vasomotor disorders associated with hyperactivity of the orthosympathetic system innervating the region concerned have been observed 2 Treatment There are two aspects to the treatment of RSD the relief of pain and the reduction in the activity of the orthosympathetic system However mobilisations massages and all techniques likely to cause or accentuate the pain must be ruled out as they could potentially aggravate the RSD Few therapeutic methods meet these criteria which makes transcutaneous electrical nerve stimulation TENS the first treatment of choice available to physiotherapists for treating RSD Ho
24. of haemarthrosis intra articular bleeding may lead to actual cases of arthropathy which cripple haemophiliacs especially as they are usually accompanied by a loss of joint stability Specific programmes for haemophiliacs aim to improve the active joint stability by restoring the qualities specific to each type of muscle fibre The characteristic of the programmes for haemophiliacs is to induce muscular contractions very gradually to avoid any risk of causing microlesions in the muscle fibres and or supporting connective tissue and secondary bleeds Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used Very gradually increase the level of energy during the course of a treatment session TENS Option Yes A minimum of 1 channel with muscular work imposed by the Atrophy or Reinforcement programme Amaximum of 3 channels with the TENS pro
25. of the pen in contact with the conductive gel Before each use of the motor point pen clean and disinfect the tip of the pen that comes into contact with the skin 5 Switch on the remote control select the Motor point programme then switch on the module and start the programme 6 Very gradually increase the energy of channel 1 until a value between 5 and 25 is reached while continuously moving the pen tip over the gel layer but without ever losing contact with the gel to avoid triggering an electrode fault message 7 As soon as you observe a muscle response in form of twitching you have located the vastus medialis motor point Visually locate this motor point and apply a small electrode that should be centred over the motor point 8 Remove the pen from the positive pod and connect the positive pod to the small electrode which should be correctly centred over the motor point of the vastus medialis a N a 2 a If while you are doing this the pen loses contact with the skin coated in gel even if this is just for a fraction of a second the stimulation will be interrupted and the equipment will signal an electrode fault In such a case ignore the message put the tip of the pen back in contact with the skin and gradually increase the energy while moving the pen over the gel layer VP eS er ree me oe Nee EN Reflex sympathetic dystrophy or Complex regional pain syndrome Reflex sympath
26. on the four channels The order in which the channels provide stimulation depends on the order in which the different modules are switched on For this program it is therefore particularly important to follow the order of channel numbers below 1 Start the 2 modules connected to the calves 2 Start the 2 modules connected to the thigh e For the calf channels 1 and 2 A small electrode is placed just under the head of the fibula on the common peroneal nerve and another small electrode in the upper part of the popliteal fossa over the tibial nerve For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on these two small electrodes The two other pods are connected to the two outputs of a large electrode placed on the upper part of the calf just below the popliteal fossa 3 e For the thigh channels 3 and 4 For the quadriceps channel 3 a large electrode is placed diagonally on the lower third of the quadriceps a second large electrode is placed at the top of the thigh For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the large lower electrode For the hamstrings channel 4 a large electrode is placed diagonally on the lower third of the hamstrings a second large electrode is placed diagonally on the upper third of these muscles For optimum effectiveness
27. provided for this purpose To do this place the pod without the On Off button in the location indicated with the dotted line Do the same for the other modules Once the modules are placed for charging their battery level is shown by the blue LEDs of the docking station A First LED blinking low battery Second LED blinking battery level average a session can be performed Third LED blinking good battery level All LEDs are lit and not blinking any more battery completely full VJ 5 5 PROBLEMS AND SOLUTIONS Electrode failure The remote control shows the symbol of an electrode and a disconnected module for the channel in question in this case channel 1 e Check that the electrodes are properly connected to the module e Check if the electrodes are outdated worn and or the contact is poor try with new electrodes Module out of range The remote control shows the out of range symbol on the channel where the problem was detected in this case channel 1 e Check that the module and the remote control are less than 2 metres away e Ensure you are not in an isolated place without any obstacles that may deflect the signals from the remote control e Ensure you are in a place that allows the signal from the remote control to be reflected e Check the module is switched on The module is discharged During the stimulation a module may turn out to be discharged In this case a d
28. reception frequency 2 4 GHz ISM 2 4 2 4835GHz The characteristics of the modulation type and frequency GFSK 320 kHz deviation Effective transmission power 4 4 dBm The Wireless Professional may be affected by other devices even if they are compliant with CISPR EMISSION requirements D Information on electromagnetic compatibility EMC The Wireless Professional is designed to be used in typical environments that have been approved in accordance with the EMC safety standard EN 60601 1 2 This device complies with the CISPR standard indicating that radio frequency RF emissions are not likely to cause interference with electronic equipment installed nearby radios computers telephones etc The Wireless Professional is designed to withstand foreseeable disturbances from electrostatic discharge magnetic fields from the mains power supply or RF transmitters Nevertheless it is not possible to ensure that the stimulator will not be affected by powerful RF radio frequency fields from other sources For more detailed information concerning electromagnetic emissions and immunity refer to the EMC tables J Were ce SS ree ma oo her Narr EN 4 QUICK START It is strongly advised to carefully read the contraindications and safety measures described earlier in this manual before using your device 4 1 DESCRIPTION OF THE DEVICE REMOTE CONTROL A On Off button press briefly to switch on press and hold for more t
29. should preferably be positioned on the motor point a S 4 Patient position First of all the patient is seated on the rehabilitation table barefoot and without touching the floor In this position the therapist gradually increases the stimulation energy until a motor response is manifested by an eversion of the foot As soon as this response is obtained most often after 2 or 3 contractions the barefoot patient is put into standing position This position is particularly useful because it requires an associated proprioceptive effort which can be of increasing difficulty two feet one foot balance board etc 5 Stimulation energy In NMES the stimulation energy is directly responsible for spatial recruitment the higher the stimulation energy the higher the percentage of motor units recruited and the greater the impact of the progress The general rule is to always try to increase the energy to the maximum level tolerated by the patient The therapist plays a fundamental role by encouraging and reassuring the patient who can then tolerate levels of energy that produce powerful contractions The levels of energy reached must increase throughout the session and also from session to session because the patients quickly get used to the technique EN Vee oe er ree MES STONA Rehabilitation of low back muscles Muscular insufficiency of the muscles that provide stability of the lumbar re
30. small extent of the painful area 2 small electrodes are usually sufficient to cover the whole of the desired area Intensity The intensity must be increased gradually until the patient feels a tingling sensation that is pronounced without being painful The mi TENS function prevents any kind of muscle contraction If the sensor detects a muscle response the stimulator automatically reduces the stimulation energy in order to stop the muscle response TENS Option No WAP ee re RES S TONTE TORTICOLLIS This type of treatment is indicated to relieve pain following acute muscle contractures in the neck region It will also reduce tension in the contracted muscles to facilitate manual handling techniques To reduce muscular tension and to provide a relaxing effect Highly individualised muscular twitching that is induced by a very low frequency 1 Hz has a relaxing effect Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles in the neck region The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes A small electrode preferably connected to the positive pole of the module pod with an illuminated button is placed on the most painful area which can be detected by palpation A second electrode is placed on the paravertebral
31. spasticity of the pectoralis major can often be a cause of a lower subluxation of the shoulder in hemiplegic patients This is always painful and often develops into a complex regional pain syndrome To reduce shoulder pain and to treat or prevent subluxations of the shoulder Stimulating the deltoid and the supraspinatus facilitates a reduction of spasticity in the pectoralis major by reciprocal inhibition reflex This programme has a very gradual rate of tensioning and does not use low frequencies in order to avoid myotatic reflex stretching monosynaptic stretch reflex of the spastic muscle To make it as comfortable as possible for the patient use pulse widths equivalent to the Pulse width chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned according to the specific indication Use the necessary energy to effect strong contractions of the deltoid and the supraspinatus to Intensity elevate the shoulder stump whilst ensuring that this electrically induced activation does not spread to the adductor and depressor muscles of the shoulder Yes forced 2 channels with muscular work imposed by the Hemiplegic shoulder programme 2 channels with the TENS programme e Electrodes positioned on the painful area Sufficient stimulation energy to prod
32. stimulated muscle is in a mid range position The end of the stimulated limb must be securely tied down so that the electrically induced contraction does not cause any movement The stimulation will therefore be carried out using isometric contractions J EN Vee oe Sr ree RES STONA 5 Stimulation energy In NMES the stimulation energy is directly responsible for spatial recruitment the higher the stimulation energy the higher the percentage of motor units recruited and the greater the impact of the progress The general rule is to always try to increase the energy to the maximum level tolerated by the patient The therapist plays a fundamental role by encouraging and reassuring the patient who can then tolerate levels of energy that produce powerful contractions The levels of energy reached must increase throughout the session and also from session to session because the patients quickly get used to the technique When the patient has difficulty in reaching satisfactory levels of stimulation energy it can be useful to ask the patient to add voluntary co contractions which improves mediocre spatial recruitment and also makes the stimulation more comfortable The levels of energy can then be gradually increased over time For this the mi ACTION is a useful tool because it requires the patient to contract his her muscle voluntarily to initiate and or accompany the electrically induced contraction depending on the giv
33. stimulation can also be applied please refer to the positions recommended for the muscle being stimulated Intensity An essential factor in the therapeutic efficacy is to cause visible muscle twitching which may in certain cases require higher stimulation energies to be used The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option Yes A minimum of 1 channel with muscular work imposed by the Decontracturing programme Amaximum of 3 channels with the TENS programme e Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active In addition the mi functions apart from mi SCAN and mi RANGE are no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels VASCULAR HEAVY LEGS The problem of heavy legs occurs when venous blood return sometimes does not take place but does not cause any damage to the body Heat certain stages of the menstrual cycle prolonged standing and long continuous periods sitting down may cause swelling stasis oedema with a considerable feeling o
34. stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used Progressively increase the level of energy during the course of a treatment session TENS Option Yes A minimum of 1 channel with muscular work imposed by the Neuro rehabilitation programme A maximum of 3 channels with the TENS programme e Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels Vere oo er ree me oer Nene EN AESTHETIC TONING Use initially to tone and prepare the muscles prior to more intensive firming work The muscle Indication stress produced is of a low intensity making it particularly suitable for less active people learning the technique Toning the muscles To make it as comfortable as possible for the patient use pulse widths equivalent to the Pulse width chronaxies of the motor nerves of the muscles being stimulated The mi SCAN functio
35. stress on the vertebral structures and discs To develop the support qualities of the abdominal and lumbar muscles and to restore awareness of postural control By simultaneously stimulating the abdominal and lumbar muscle groups using parameters adapted to restoring the qualities of type muscle fibres used in postural control Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the abdominal and lumbar muscles The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes lectrodes positioned jointly on the abdominal and lumbar muscles in accordance with the pecific indication Intensity The maximum tolerable stimulation energy which is one of the key factors determining the ffectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used Progressively increase the level of energy during the course of a treatment session TENS Option No WA Pe ee re MES S TONAT CARDIAC REHABILITATION In addition to the aerobic exercises suggested during cardiac rehabilitation Heart failure limits the capacity for exertion linked in part to changes in the peripheral muscles Electrostimulation allows muscle qualities to be improved in particular aerobic capacity which con
36. the external part of the supraspinous fossa but not over rear deltoid as this results in unwanted shoulder extension For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the infraspinous muscle If the patient is still experiencing pain TENS can be combined using the other channels The specific placement of electrodes for TENS used for phase 1 will be applied to channels 2 and 3 Ww fin case of persistant pain and e Phase 3 Continuation of the stimulation of the supraspinous and infraspinous muscles The electrodes are a in the same way as for kai 2 4 Patient position The patient is seated with the arm against his her body the forearm and the hand resting on an armrest the upper limb is placed in the reference position with neutral rotation In phases 2 and 3 and on the condition that the position remains painless the arm can gradually be placed in slight abduction not exceeding 30 5 Stimulation energy Phase 1 The stimulation energy must be gradually increased to obtain a clear tingling sensation e Phase 2 and 3 The stimulation energy must be gradually increased to the patient s maximum sub painful threshold for the stimulation of the infraspinous and supraspinatus muscles channel 1 and until they experience a tingling sensation for the channels using TENS phase 2 in case of as
37. the minimum level of energy required to produce an appropriate muscle response TENS Option No WrReECE SS reo mt oo TONAT CAPILLARISATION The 8 Hz frequency produces the greatest increase in blood flow in young patients who are ina good state of physical health Use of the Capillarisation programme must therefore be restricted to sport rehabilitation and will be proposed in situations where a hyperaemia is desired e g to accelerate the scarring process The Capillarisation programme can also be used for non injured athletes as part of their physical preparation to achieve a variety of ends e To supplement endurance training e To optimise the overcompensation phase prior to an endurance or resistance competition e Supplementary use of the Hypertrophy programme To induce the greatest circulatory activation in patients who are athletes To increase the capillary network and make the muscle fibres more resistant to fatigue When using low stimulation frequencies of 8 Hz the increase in blood flow is greatest in young people who are in good physical condition However a frequency of 8 Hz may cause early muscle fatigue and a depletion in the muscular response in patients with underperforming muscles To make it as comfortable as possible for the patient use pulse widths equivalent to the Pulse width chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can b
38. the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity Gradually increase the stimulation energy until there is clear visible muscle twitching During the tetanic contraction phases ensure that the energy stimulation is sufficient to impose significant muscle contractions TENS Option No Were Ce Sr ree mo TONAT Indication RELAXING MASSAGE To eliminate uncomfortable or painful sensations resulting from an exaggerated increase in muscle tone To allow a decrease in mi uscle tension To drain away the toxins responsible for the increase in muscle tone The programme produces a sense of well being and relaxation Pulse width To make it as comfortab chronaxies of the motor e as possible for the patient use pulse widths equivalent to the nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Precision in positioning tl he electrodes is less significant than for programmes aiming to develop muscle quality The electrodes can be placed in an alternative way reducing the number of electrodes needed and si imulating more muscles during
39. the positive pole of the module pod with an illuminated button should preferably be positioned on the large lower electrode 4 Patient position The patient must be in a supine position with his her legs inclined so that gravity encourages venous return 5 Stimulation energy Adjust the stimulation energy to obtain significant contractions for the 4 channels and if possible at a higher level on channels 1 and 2 than on channels 3 and 4 DP ee re er on TONAT EN Treatment of arterial insufficiency in the lower limbs We will limit this chapter to insufficiency of the arteries in the lower limbs High blood pressure smoking cholesterol and diabetes are among the main causes of progressive deterioration of the arterial walls arteriosclerosis This presents as narrowing of the arteries with consequently a reduction in the blood flow in the tissues downstream of the narrowed arteries The less well irrigated tissues suffer and become hypoxic all the more so because the width of the arteries has shrunk and more intense activity requires more oxygen Arterial insufficiency in the lower limbs is conventionally divided into four clinical stages These four stages I Il Ill IV depend on the approximate severity of the loss of blood flow and the tissue related consequences Stage is asymptomatic In a clinical examination an arterial murmur can be heard which is evidence of narrowing although the patient has n
40. the ratio q i V a This means that since Rh i when 2 Rh therefore 2i and t is the chronaxy t ch when 2 Rh therefore from the equation q t i the result is 2i q tch i C therefore i q tch gt tch q i d We can note that the chronaxy can be calculated mathematically from Weiss fundamental formula as shown in Figure 4 Fig 4 i q tch a The chronaxy corresponds to the time value when Q 0 i e Q q it if Q O therefore q it O therefore it q and t q i 1 t B Summary Electrical stimulation i e reducing resting potential to the stimulation threshold using an electric current is a phenomenon that fulfils a fundamental physiological law This shows us that VI a a as a a li ls EN a 1 The factor determining stimulation is the quantity of electrical charges created by the current Stimulation must be considered in terms of the amount of current which is the product x t of the intensity times the duration of the pulse t 2 This amount of current fulfils a fundamental formula Q q it where Q is a linear function of time Lapicque expresses this formula in another way by the intensity pulse duration ratio I q t i and he deduced that a the rheobase Rh minimum intensity that must be reached in order to produce stimulation using an infinite pulse duration Rh i b the chronaxy tch min
41. the stimulation current Rheobase The pulse times t1 t2 and t3 cannot be used since during these periods lt i Only one way of establishing the electrical stimulation wave is effective immediately which is vertical Fig 2 In this case there is no delay in its efficacy and the duration of the electrical wave is further reduced by it Fig 2 a D The stimulation current established vertically with a value higher than i the rheobase instantaneously produces an accumulation of charges modifying the resting potential a d I 3 Shape of the electrical stimulation wave When the stimulation current has vertically reached an intensity higher than the rheobase how should it develop in order to offer maximum comfort With minimum intensity it must provide in time t the quantity of electrical charges Q it q required to trigger the action potential Since Q Lt it is clear that the rectangle is the wave shape capable of providing the quantity of charges Q with minimum intensity 7 Fig 3 1 Comparison of different electrical pulse shapes of equal duration established vertically and providing the same quantity of electrical charges which correspond graphically to identical areas In order to create the same quantity of charges with pulses with shapes other than rectangular higher intensities must be used which are as a result even less comfortabl
42. this case the specific practical rules for TENS electrode placement regulation of intensity should be followed for each channel used for this purpose 2 Treatment frequency One to two 20 minute sessions per day 3 Electrode position A single module is sufficient to stimulate the extensor muscles of the fingers and the wrist A small electrode is placed on the fleshy part of the epicondylar muscles approximately two finger widths below the epicondyle The second electrode also small is placed on the dorsal aspect of the forearm where the lower and middle thirds meet The position of these electrodes must be adjusted so as to firstly obtain extension of the fingers and then extension of the wrist Extension of the wrist alone with flexion of the proximal and distal interphalangeal joints will not produce optimum results Extension of the interphalangeal joints is therefore the first objective VI 4 Patient position The patients is seated beside a table The elbow and forearm rest on the table the shoulder is in a functional position with the elbow bent and the hand in pronation 5 Stimulation energy Always work with an energy that is too low to produce diffusion of stimulation to the flexors of the fingers and wrist Ideally the stimulation energy should be adjusted so that the contraction of the extensors extends the fingers and wrist to the maximum range of movement The complete mo
43. to 75 Atmospheric pressure 700 hPa to 1 060 hPa Do not use in areas where there is a risk of explosion 3 6 DISPOSAL Every product bearing the WEEE mark a crossed out rubbish bin must be separated from household waste and sent to special collection facilities for recycling and recovery 3 7 STANDARDS To guarantee your safety the Wireless Professional has been designed manufactured and distributed in compliance with the requirements of European Directive 93 42 EEC as amended on medical devices The Wireless Professional also complies with the IEC 60601 1 standard on general safety requirements for electro medical devices the IEC 60601 1 2 standard on electromagnetic compatibility and the IEC 60601 2 10 standard on particular safety requirements for nerve and muscle stimulators Current international standards require that a warning be given concerning the application of electrodes to the thorax increased risk of cardiac fibrillation The Wireless Professional also complies with Directive 2002 96 EC on waste electrical and electronic equipment WEEE 3 8 PATENTS The Wireless Professional incorporates several innovations with patents pending or already issued EN WP ee re ro TONAT 3 9 STANDARDISED SYMBOLS AG 5 my Caution Read the user manual or operating instructions The Wireless Professional is a class II device with internal electric power and type BF applied parts Name and
44. to adjust the energy levels of channels 3 and 4 without having previously increased levels on channels 1 and 2 This is an additional safety feature that prevents contraction of the quadriceps if it is not preceded by contraction of the hamstrings As usual a patient who tries to work with the maximum energies he she is capable of tolerating will reach higher energy levels for channels 3 and 4 quadriceps than for channels 1 and 2 hamstrings EN Vee ee er ree RES SIONA Rehabilitation of the gluteal muscles following total hip replacement Orthopaedic surgery to the hip and in particular the fitting of a prosthesis results in disuse atrophy of the gluteus muscles with loss of strength in the active stability of the hip when standing on one foot and walking In addition to active physiotherapy exercises neuromuscular electrical stimulation of the gluteus maximus and medius is a technique particularly indicated for the effective treatment of weakness in these muscles It is recommended to start treatment as soon as possible after the operation The very low frequency sequences such as the warm up active rest between tetanic contractions and final recovery phase at the end of the treatment sequences generate individualized muscle twitches producing vibration in the prosthetic material The three levels of the Hip prosthesis programme correspond respectively to the programmes Disuse atrophy Level 1 Disuse atrophy Level
45. treated Then the energy level is adjusted on the other two channels modules started in first and second position so that the patient feels an increase in the tingling sensation During the session because of the habituation phenomenon the sensation of paresthesia will gradually be reduced and even disappear It is then recommended that the energy be increased slightly to maintain the sensation but without causing muscle contractions The mi TENS function eliminates this possibility by automatically reducing the stimulation energy to below the motor excitation threshold Endorphinic treatment of Rachialgia and Radiculalgia This chapter deals with the analgesic treatment of spinal pain Rachialgia and nerve root pain Radiculalgia The practical methods of treatment described in this chapter are based on the following reference publications Hollt V Przewlocki R Herz A Radioimmunoassay of beta endorphin basal and stimulated levels in extracted rat plasma Naunyn Schmiedebergs Arch Pharmacol 1978 303 2 171 174 Viru A Tendzegolskis Z Plasma endorphin species during dynamic exercise in humans Clin Physiol 1995 15 1 73 79 Pierce E F Eastman N W Tripathi H T Olson K G Dewey W L Plasma beta endorphin immunoreactivity response to resistance exercise J Sports Sci 1993 Tl 6 499 452 Dzampaeva E T Hearing loss correction by endogenous opioid stimulation Vestn Otorinolaringol 1
46. types of muscle fibres disuse atrophy then reinforcement to give mobility across the full range of movement of the joint This type of use is particularly interesting for combating adhesion There are four different programmes Atrophy 1 1 and Reinforcement 1 1 These programmes produce identical length contractions for the agonist and the antagonist Atrophy 2 1 and Reinforcement 2 1 These programmes produce contractions for the agonist which are twice as long as for the antagonist Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The stimulation energies must be adjusted successively for each muscle group to obtain joint mobility in the desired range TENS Option No For 2 channel configuration channels 1 and 2 alternate Take care to properly position module 1 on the agonist and module 2 on the antagonist This programme only works with 2 modules switched on For 4 channel configuration channels 1 2 alternate with channels 3 4 Take care to properly position modules 1 and 2 on the agonist and modules 3 and 4 on the antagonist This pr
47. units being used TENS Option Indication No CORE STABILISATION The abdominal muscles and the muscles in the low back area are very important for all sporting activities Good neuromuscular control and stabilisation of the trunk are essential for the optimal positioning of the lumbar spine and to ensure the effective transmission of strength in any complex movement Effects Increase postural control of the trunk muscles May be combined with or supplement active dynamic exercises Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Place the electrodes on the paravertebral muscles of the low back region and on the abdominal muscles Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option No Indication RECOVERY PLUS To promote muscle recuperation following an exhausting exertion that caused cramps or is likely to induce them when the activity is stopped To increase blood flow to drain away toxins that have accumulated in the muscles To relie
48. up treatment with a few weekly sessions 3 Electrode position Two channels are required for each leg A small electrode is placed just under the head of the fibula on the common peroneal nerve and another small electrode in the upper part of the popliteal fossa over the tibial nerve For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on these two small electrodes The two other pods are connected to the two outputs of a large electrode placed on the upper part of the calf just below the popliteal fossa 4 Patient position The patient must be in a supine position with his her legs inclined so that gravity encourages venous return 5 Stimulation energy For the draining stage contraction the energy must be gradually increased until a significant and balanced contraction is being caused for all stimulated muscles For the activation stage of blood circulation the energy must be increased until clearly visible muscle twitches are obtained VI 2 Venous insufficiency with oedema The presence of oedema particularly when it does not go upon wakening completely changes the electrical stimulation programme Oedema is caused by blood plasma leaking through the venous membranes due to hyperpressure in the distal veins In this case it is not possible to use the low arterial flow increase frequencies because they reduce peripheral vascul
49. which are contained in the neuromuscular bundle of the muscle and which have a lower stimulation threshold Stimulating these activates the a motor neurons of this muscle and also inhibits the a motor neurons of the antagonist muscle reciprocal inhibition reflex It is this last action that NMES uses in the treatment of spasticity NMES of a muscle antagonist to a spastic muscle makes it possible to reduce the spasticity by inhibiting the a motor neurons of the spastic muscle via the reciprocal inhibition reflex This phenomenon of inhibiting a motor neurons through NMES of the antagonist muscle is clearly demonstrated by electromyography In fact Hoffmann s reflex in a muscle produced by a stimulus is reduced in amplitude when the motor nerve of the antagonist muscle is stimulated NMES is an effective technique in the treatment of spasticity not only because it reduces hypertonia but also because it allows strengthening of the antagonist muscle as well preventive or curative stretching of the retraction of the spastic muscles this is much more effective than the conventional passive methods However care must be taken in the treatment of spasticity to ensure that NMES is used correctly to achieve a positive effect It is particularly necessary to avoid stimulating spastic muscle by diffusion which can occur when the electrical energy is too high It is also necessary that the antagonist muscle is tensed extremely gradually
50. 2 and Reinforcement Level 1 from which the very low frequencies are removed The three levels of the Hip prosthesis programme therefore induce only tetanic contraction phases separated by complete rest phases METHOD 1 Protocol e Hip prosthesis Level 1 Week 1 e Hip prosthesis Level 2 Weeks 2 3 e Hip prosthesis Level 3 Week 4 If the patient is experiencing associated pain symptoms TENS stimulation can be performed in addition on the other channels In this case the specific practical rules for TENS electrode placement regulation of intensity should be followed for each channel used for this purpose 2 Treatment frequency Once daily 5 days per week for 4 weeks J 3 Electrode position Two channels are used one for stimulation of the gluteus maximus and the other for the gluteus medius A small electrode is placed at the intersection of the orthogonal axes dividing the buttock into four quadrants with the same area motor point of the gluteus maximus A second small electrode is placed above and outside of the upper external quadrant of the buttock on the gluteus medius at the point where it passes over the gluteus maximus For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the motor point The other module pods are connected to the two outputs of one large electrode positioned diagonally in the lower lateral quadrant of the bu
51. 30 F 1300 66 77 40 E service djortho com au CHINA DJO China A312 SOHO ZhongShan Plaza 1055 W ZhongShan Road Shanghai 200051 CHINA T 8621 60319989 F 8621 6031 9709 E information_china DjOglobal com GERMANY DJO Deutschland ORMED GmbH Merzhauser Str 112 D 79100 Freiburg GERMANY T 49 761 4566 01 F 49 761 456655 01 E infoservice D Oglobal com SWITZERLAND Compex M dical SA Ch du D vent ZI Larges Pi ces A 1024 Ecublens SWITZERLAND T 41 0 21 695 2360 F 41 0 21 695 2361 E info compex ch DJO GLOBAL EXPORT CENTERS ASIA PACIFIC DJO Asia Pacific Limited Unit 1905 19 F Tower II Grand Central Plaza 138 Shatin Rural Committee Road Shatin HONG KONG T 852 3105 2237 F 852 3105 1444 E info asia DJOglobal com e DIVO GLOBAL BENELUX DJO Benelux Welvaartstraat 8 2200 Herentals BELGIUM T Belgium 0800 18 246 T Netherlands 0800 0229442 T Luxemburg 8002 27 42 E benelux orders DJOglobal com DENMARK FINLAND NORWAY amp SWEDEN DJO Nordic AB Murmansgatan 126 21225 Malm SWEDEN T Sweden 040 39 40 00 T Norway 8006 1052 T Finland 0800 114 582 T Denmark 46 40 39 40 00 E info nordic DjOglobal com ITALY DJO Italia Srl Via Leonardo Da Vinci 97 Trezzano Sul Naviglio 20090 Milano ITALY T 39 02 484 63386 F 39 02 484 09217 E it info DjOglobal com UK amp IRELAND DJO UK Ltd la Guildford Business Park Guil
52. 998 3 13 16 Ulett G A Han S Han J S Electroacupuncture mechanisms and clinical application Biol Psychiatry 1998 44 2 129 138 Wang H H Chang Y H Liu D M Ho YJ A clinical study on physiological response in electroacupuncture analgesia and meperidine analgesia for colonoscopy Am J Chin Med 1997 25 1 13 20 Chen B Y Yu J Relationship between blood radioimmunoreactive beta endorphin and hand skin temperature during the electroacupuncture induction of ovulation Acupunct Electrother Res 199 16 1 2 1 5 Boureau F Luu M Willer J C Electroacupuncture in the treatment of pain using peripheral electrostimulation J Belge Med Phys Rehabil 1980 3 3 220 230 Wu G C Zhu J Cao X Involvement of opioid peptides of the preoptic area during electroacupuncture analgesia Acupunct Electrother Res 1995 20 1 1 6 EN WIRELESS PRO Ba al ait Spinal pain is an extremely common painful state that can result from a wide variety of anatomical lesions and various physiopatholog ical mechanisms Whatever the triggering factors the quasi systematic occurrence of contracture of the paravertebral muscles is often directly responsi The increase in the tension of the contractured ble for spinal pain muscle fibres and the crushing of the capillary network resulting from this causes a decrease in the blood flow and a gradual accumulation of acid metabolites and
53. Burst 68 Burst TENS alternated 68 Decontracturing 69 Specific programmes REHABILITATION II NEUROLOGICAL REHABILITATION Hip prosthesis 78 Hemiplegic foot 99 Patellofemoral syndrome 79 Spasticity 100 ACL 80 Hemiplegic shoulder 101 Rotator cuff 81 Slow start neuro rehabilitation 102 Lumbar stabilisation 82 AESTHETIC Cardiac rehabilitation 83 Toning 103 Agonist antagonist 84 Firming 103 Atrophy and Reinforcement Shaping 104 Atrophy modulated frequency 85 Elasticity 104 Reinforcement 86 modulated frequency Calorilysis 105 Programmes for haemophiliacs 87 Adipostress 105 Atrophy and Reinforcement CONDITIONING II PAIN RELIEF II Potentiation 106 TENS Gate control 80Hz 88 Endurance 106 Knee pain 88 Explosive strength 107 Trapezius muscle pain 89 Plyometry 107 Shoulder pain 89 Hypertrophy 108 Fracture pain 90 Muscle building 108 Cervical pain 91 Low back reinforcement 109 Thoracic back pain 92 Core stabilisation 109 Low back pain 93 Recovery plus T10 Lumbosciatica 94 Toning massage T10 Lumbago 95 Relaxing massage mM Epicondylitis 96 Anti stress massage mW Torticollis 97 Arthralgia 98 EN WTRECESS PRO mt oo TONAT REHABILITATION TREATMENT OF DISUSE ATROPHY A muscle that is normally innervated after a period of immobilisation or diminished mov
54. EI 61000 4 8 Magnetic fields at the mains frequency should be at a level characteristic of a typical location in a typical commercial or hospital environment NOTE VT is the AC supply voltage before application of the test level WTRECESS PRO mi oo he Nate RECOMMENDATIONS AND DECLARATION BY THE MANUFACTURER CONCERNING ELECTROMAGNETIC IMMUNITY Wireless Professional is designed for use in the electromagnetic environment stipulated below The buyer or user of the Wireless Professional must ensure it is used in this recommended environment Immunity Test level Observance Electromagnetic environment recommendations test IEC 60601 level Portable and mobile RF communication devices must only be used relative to the Wireless Professional and its wiring at a distance which is not less than the spacing recommended and calculated using the appropriate equation for the transmitters frequency Recommended spacing Conducted d 1 2 VP RF IEC 3 Vrms d 1 2 VP 80 MHz to 800 MHz 61000 4 6 150 kHz to 80 MHz d 2 3 VP 800 MHz to 2 5 GHz where P is the maximum output power of the transmitter in Radiated RF 3V m watts W set by the manufacturer s specifications and where d IEC 80 MHz to is the recommended spacing in metres m 61000 4 3 2 5 GHz The field intensity of RF fixed transmitters as determined by an electromagnetic survey a must be less than the observance level to be found in each frequency rangeb Interfe
55. ES SPRO RES S TONAT Selection of the body area mi SCAN automatic Just before starting a session of neuro muscular electrostimulation mi SCAN analyses the characteristics of excitability in the muscle subjected to stimulation mi SCAN detects the chronaxy of the muscle in approximately 10 seconds and allows the stimulator to adjust the width duration of the pulse to the measured chronaxy value Using a width duration of the pulse corresponding to the chronaxy of the stimulated muscle allows the use of the minimum power to obtain the same muscle response As soon as the mi SCAN function is activated each active channel performs the chronaxy measurement Manual If the manual mode is activated the user must manually select the area to be treated An average chronaxy value is used based on the area selected by the user This choice is made after selecting the desired programme Energy management mi RANGE This function indicates the minimum energy threshold for programmes whose effectiveness requires obtaining vigorous muscular twitches The mi RANGE function is therefore only available for programmes using low stimulation frequencies below 10 Hz For programmes that allow the mi RANGE function the stimulator first prompts you to increase the energy level A beep will accompany the flashing symbols When a muscle pumping is first detected the symbols stop flashing You are at the minimum energy level to provide therap
56. Q chattanooga WIRELESS PROFESSIONAL gt DJO GLOBAL EN A ee ee er en ee eee 1 INTRODUCTION 2 WARNINGS 2 1 COUNTRAINDICATIONS 2 2 SAFETY MEASURES w N 3 PRESENTATION 31 EQUIPMENT AND ACCESSORIES 3 2 GUARANTEE 3 3 MAINTENANCE 34 STORAGE AND TRANSPORT CONDITIONS 3 5 CONDITIONS OF USE 3 6 DISPOSAL 3 7 STANDARDS 3 8 PATENTS 3 9 STANDARDISED SYMBOLS 310 TECHNICAL CHARACTERISTICS 4 QUICK START 41 DESCRIPTION OF THE DEVICE 4 2 EXAMPLE OF AN ELECTROSTIMULATION SESSION o o oonu Naa OD 5 5 HOW IT WORKS 51 SELECTING A PROGRAMME 511 PROGRAMME OPTIONS 52 CONNECTING MODULES TO THE ELECTRODES 5 3 STARTING THE SESSION 54 RECHARGE 5 5 PROBLEMS AND SOLUTIONS 6 EMC TABLES ELECTROMAGNETIC COMPATIBILITY 31 7 PRACTICAL GUIDE 71 FUNDAMENTAL PRINCIPLES 7 2 PRACTICAL RULES 7 3 NEUROSTIMULATION PROGRAMMES 74 SPECIFIC INDICATIONS VJ 35 35 56 59 12 1 INTRODUCTION Please read this manual carefully and section 2 in particular before using your Wireless Professional device The Wireless Professional is a stimulator designed for use by health professionals to ensure electric muscular stimulation treatments 2 WARNINGS 2 1 COUNTRAINDICATIONS e Cardiac stimulator pacemaker e Epilepsy e Pregnancy do not use on abdominal region e Serious arterial circulation problems in lower limbs e Abdominal or inguinal hernia Do not use chest stimulation on pat
57. actions The levels of energy reached must increase throughout the session and also from session to session because the patients quickly get used to the technique VI Locating a motor point e g locating the motor point of the vastus medialis of the quadriceps Muscular electrostimulation programmes are programmes which subject the muscles to work The progress achieved depends on the kind of work to which the muscles are subjected that is to say the programme chosen The electrical pulses generated by these programmes are transmitted to the muscles via the motor nerve through self adhesive electrodes The positioning of the electrodes is one of the determining factors in ensuring a comfortable electrostimulation session It is therefore essential to devote special care to this aspect The correct placement of the electrodes and the use of significant energy allow a large number of muscle fibres to work The greater the energy the greater the spatial recruitment that is to say the number of fibres working and therefore the greater the number of fibres that make progress One stimulation channel is a module consisting of two pods e A positive pole the pod with an illuminated button e A negative pole the other pod of the module The positive electrode is the one connected to the positive pod with an illuminated button It must be attached at the motor point of the muscle The motor point is a po
58. ainful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels As a supplement to rehabilitation of a ligamentoplasty of the anterior cruciate ligament of the knee The programme can be used early as it does not put any stress on the tendon graft To restore the muscular qualities of the quadriceps and the hamstrings and recover a stable knee to allow the safe resumption of active sport The ACL programme is specifically designed for the rehabilitation of ligamentoplasties It allows intensive use of the quadriceps while protecting the tendon graft during the first few post operative weeks due to co activation of the hamstring muscles Stimulation starts with the hamstrings channels 1 and 2 While they are contracted stimulation continues on the quadriceps channels 3 and 4 thus preventing any risk of anterior draw movement Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the quadriceps and hamstring muscles The mi SCAN funct
59. al level The shoulder must be capable of providing significant mobility of the upper limb whilst providing a stable base The limited congruence of the joint surfaces the humeral head within the glenoid cavity although partially compensated by the labrum exposes the joint to misalignment that the passive capsular ligament elements cannot control Neuromuscular control must constantly compensate for the deficiencies in passive stability by maintaining coordinated forces capable of opposing the unstable component resulting from intrinsic forces contraction of muscles generating translational forces pectoralis major biceps brachii coracobrachialis triceps brachii caput longum or extrinsic forces fall contact etc Owing to the numerous advances in the fields of biomechanics physiology and physiopathology the therapeutic approach to shoulder pathologies has evolved considerably in recent years In this chapter we will discuss three pathological conditions of the shoulder for which neuromuscular electrostimulation is a preferred treatment among the established rehabilitation techniques These three conditions are e 1 Rotator cuff tendinopathy e 2 Shoulder instability e 3 Adhesive capsulitis The protocols proposed have been developed on the basis of the following publications Flatow EL Soslowsky LJ Ateshian GA Pawluk RJ Bigliani LU Mow VC Shoulder joint anatomy and the effect of subluxations and size mismatch on
60. annels 1 and 2 are used to stimulate the hamstrings and channels 3 and 4 are used to stimulate the quadriceps For this program it is therefore particularly important to follow the order of channel numbers below 1 Start the 2 modules connected to the hamstrings 2 Start the 2 modules connected to quadriceps For each muscle group it is recommended that the small electrodes be placed precisely on the motor points as shown in the illustration or better yet that the motor points be found using the instructions for the indication Locating a motor point in this manual For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the motor point VJ 4 Patient position The very first sessions the primary objective of which is to eliminate muscle wastage can be performed with the lower limb extended with a small cushion placed under the popliteal fossa For the subsequent sessions the patient will be placed in a sitting position with the knee bent at a comfortable angle After satisfactory recovery of joint mobility the knee is ideally bent between 60 and 90 5 Stimulation energy As always in NMES the objective of the rehabilitation therapist is to motivate the patient to tolerate the highest possible stimulation energy level With the ACL programmes and taking into account the particular sequential stimulation mode it is not possible
61. ar resistance increase the perfusion pressure of the capillaries and risk aggravating the oedema On the other hand tetanic contractions encourage drainage of the deep veins and drainage of the oedema provided they are carried out in a certain order and under certain conditions The most effective way consists of producing an initial ejection effect in the leg and then in the thigh without relaxing the compression of the deep veins in the leg In this way the venous blood is pushed in the first stage towards the thigh by a contraction of the leg muscles Then in the second stage the contraction of the thigh muscles eject the blood upwards provided however that the leg muscles remain contracted to prevent regurgitation METHOD 1 Protocol Venous insufficiency 2 2 Treatment frequency 3 to 6 sessions per week for approximately 6 weeks to treat the acute episode It is then recommended to keep up treatment with a few weekly sessions EN a a a RES S TONTE 3 Electrode position It is necessary to work in staggered contractions mode This means that only channels 1 and 2 start to produce a tetanic contraction while channels 3 and 4 are at rest After 3 seconds of tetanic contraction via channels 1 and 2 the contraction starts only on channels 3 and 4 while the contraction induced by channels 1 and 2 continues After 3 seconds of simultaneous contraction on the four channels there is a complete rest phase of 20 seconds
62. c effect on all shoulder pain Intensity The intensity must be increased gradually until the patient feels a tingling sensation that is pronounced without being painful TENS Option No FRACTURE PAIN n addition to other analgesic treatments during the first few days after a simple immobilisation or osteosynthetic surgery on a fracture Extended use for rib fractures where strict immobilisation is not possible resulting in severe pain over several weeks Why For the relief of pain How Using the Gate control principle This involves causing high levels of sensitivity impulses in order to imit the input of pain impulses when they return to the posterior horn of the spinal cord Pulse width The pulse width for the programme is 170 ps Electrodes Depending on the means of restraint and or the size of the dressing used access to the painful area may be awkward It is important to surround the painful area as much as possible Another possible strategy is to directly stimulate the large nerve trunks superior to the point of pain Intensity The intensity must be increased gradually until the patient feels a tingling sensation that is pronounced without being painful If the nerve trunks are stimulated the stimulation should cause the tingling to radiate into the painful area TENS Option No WA Pe ee re er on TONTE CERVICAL PAIN Neck pain most often results f
63. ched must increase throughout the session and also from session to session because the patients quickly get used to the technique With this programme the stimulation starts directly with a tetanic contraction because the warm up phase has been eliminated so as not to produce muscle twitches that are likely to cause unwanted microtraumas to the kneecap EN VP oe er ree RES STONA 2 Post traumatic condition Repeated traumas to the knee joint like those caused by the practice of certain sports may entail cartilaginous lesions of the kneecap These lesions can lead to pain of varying intensity and the occurrence of reflex inhibition which in turn can result in disuse atrophy of the entire quadriceps The resulting insufficiency of the quadriceps negatively affects the active stability of the joint and increases pain This vicious circle can be interrupted through electrostimulation of the quadriceps using the Patellofemoral syndrome programme the parameters of which are specially adapted to avoid any unwanted effects on the kneecap However for irreversible cartilaginous lesions it is always recommended that the benefits obtained should be maintained through maintenance treatments The protocol detailed below is also suitable for the rehabilitation of patello femoral athroposies METHOD 1 Protocol e Patellofemoral syndrome Level 1 Week 1 e Patellofemoral syndrome Level 2 Weeks 2 3 e Patellofemoral syndrome Leve
64. current This pulse must have the following characteristics a 1 Constant pulses of current i e produced by a constant current generator 2 Vertical establishment in order to be effective immediately and to reduce the application time of the current 3 Rectangular shape in order to apply the lowest possible electrical intensity 4 Pulse duration that is equal to the chronaxy of the nerve structure requiring stimulation is order to minimise electrical energy 5 Compensated pulse with an electrical mean of zero in order to prevent side effects C linked to polarisation P EN Wee ce Sor reo MES S TONAT Basic concepts of excitation electrophysiology A Introduction Passing an electrical current through an excitable living tissue results in a change to the resting potential Vo The changed resting potential is called the local potential V If the variation in the local potential is sufficiently intense and in the right direction a state of instability is reached and excitation i e the action potential occurs The value that the local potential V must reach so that action potential appears is called the excitation threshold So The local potential V caused by electrical charges provided by the current passing through the excitable tissue Comparable to a neuron returns to its initial value Vo when the current is stopped Returning to the resting conditions does not occur instantly but gradually in the
65. d for each programme the electrode connected to the positive pole pod with illuminated button may benefit from a prime location that is likely to increase the efficacy of the treatment This is the case particularly for muscular electrostimulation programmes requiring strong muscular contractions for which it is recommended that the electrode with positive polarity is placed on the motor point of the muscle The choice of electrode size large or small and the correct positioning of the electrodes on the muscle group that needs to be stimulated are determining factors and are essential for stimulation to be effective As a result always use the size of the electrodes shown on the images Unless advised otherwise by a doctor always follow the positions specified on the images Body position To determine the stimulation position to be used based on the position of the electrodes and the programme chosen please refer to the images of where the electrodes are positioned EN a a a a a ils A Body position B Positioning of the electrodes The position of the person to be stimulated depends on the muscle group that requires stimulation and on the programme chosen For programmes requiring muscle contractions tetanic contractions working the muscle isometrically is always recommended to prevent cramps and muscle soreness after the session For example when the quadriceps are stimulated the patient w
66. d on the infraspinous muscle g S 4 Patient position e Phases 1 and 2 The first stimulation sessions are conducted on a patient seated with the upper limb in the reference position the forearm resting on an armrest In subsequent sessions the arm will gradually be placed in increasing abduction to 60 The patient s position during stimulation should prevent any stress on the scar tissue and should always remain painless e Phase 3 The stimulation of the infra and supraspinous muscles can be performed simultaneously with active work such as for example proprioception exercises The patient can be placed in the push up position with the hands resting on a trampoline In this position he she is asked to bounce in time with the phase of electrically induced contraction of the spinal muscles This exercise is always performed after warm up and will first be performed with two handed support then one handed support The mi ACTION function can be used to greatly facilitate the combination of voluntary exercises with the stimulation 5 Stimulation energy The stimulation energy must be gradually increased to the maximum of the patient s sub painful threshold 3 Adhesive capsulitis The SECEC European Society for Surgery of the Shoulder and the Elbow gives the following clinical definition for retractile capsulitis limited active and passive mobility by a minimum of 30 in the 3 planes for m
67. des with considerable progress in particular owing to the use of arthroscopic techniques Associated with the improvement in the rehabilitation treatment of injured athletes the return time to athletic activity continues to decrease significantly and today is practically half what it was around ten years ago The return to athletic activity requires both satisfactory solidity of the tendon graft which must be capable of supporting significant mechanical stresses and more importantly good active joint stability This active joint stability requires muscles capable of opposing sometimes phenomenal stresses in the shortest time periods possible by activating the proprioceptive reflex One of the potential consequences of the operative procedure is significant disuse atrophy of the quadriceps muscles the treatment of which is one of the primary objectives of the rehabilitation therapist However during the first 3 4 months of quadriceps rehabilitation there must be no open kinetic chain exercises due to the anterior drawer component of the tibia which can endanger the tendon graft during the avascularisation phase The method described in this chapter is intended to describe an NMES protocol suitable for this particular problem of ACL ligamentoplasty avoiding any risk of a secondary lesion to tissue This safety is ensured by using specific ACL programmes that consist of appropriate sequential stimulation of the quadriceps and hamstring
68. des placed on the painful points depending on whether the pain radiates towards the neck or the lumbar region M x 4 Patient position The patient is placed in a position he she finds the most comfortable in the prone or side lying position or seated 5 Stimulation energy The energy must be increased gradually until it causes clearly visible muscle twitches which are required to induce hyperaemia The mi RANGE function makes it possible to work with certainty within a therapeutically effective range The stimulator prompts you to firstly increase the level of energy a beep sound accompanies the flashing symbols When it detects that the muscles have started to pump the symbols will stop flashing You are at the minimum level of energy that provides therapeutic results If the stimulation is well tolerated by the patient it is advised to increase the energy level slightly At the end of the treatment or during a break a statistic showing the percentage of time spent in the effective range will appear on the screen 3 Endorphinic treatment of low back pain Chronically contractured lumbar paravertebral muscles are often the source of pain felt by patients with lumbago Although a physiotherapist must naturally find the cause of the pain and treat it accordingly treatment of these chronic contractions using the Low back pain programme brings about fast significant pain relief In t
69. dford Surrey GU2 8XG UNITED KINGDOM T 44 0 1483 459 659 F 44 0 1483 459 470 E ukorders DJOglobal com EUROPE MIDDLE EAST amp AFRICA DJO Benelux Welvaartstraat 8 2200 Herentals BELGIUM T 32 0 14248350 F 32 0 14248358 E info emea DjJOglobal com Together in Motion CANADA DJO Canada 6485 Kennedy Road Mississauga Ontario LST 2W4 CANADA T 1 1866 866 5031 F 1 1866 866 5032 E canada orders DJOglobal com FRANCE DJO France S A S Centre Europ en de Fret 64990 Mouguerre FRANCE T 33 0 5 59 52 86 90 F 33 0 5 59 52 86 91 E sce cial DJOglobal com SPAIN DJO Ib rica Carretera de Cornel 114144 12 43 Esplugues de Llobregat 08950 Barcelona SPAIN T 34 943 638 167 F 34 943 638 174 E svc cial DJOglobal com UNITED STATES DJO Global Inc 1430 Decision Street Vista CA 92081 8553 USA T 1 800 336 6569 F 1 800 936 6569 LATIN AMERICA DJO Global Inc 1430 Decision Street Vista CA 92081 8553 U S A T 1 800 336 6569 F 1 800 936 6569 E info latam DJOglobal com CE 0473 wl 2013 DJO 4528163 EN Rev A DJO FRANCE Centre Europeen de Fret 3 rue de Bethar 64990 Mouguerre France
70. dorphinic stimulation is always used on channels 1 and 2 while the TENS stimulation is provided on channels 3 and 4 e For endorphinic treatment Two small electrodes are placed on the most painful points which can be easily located by palpitating the lumbar paravertebral muscles For optimum effectiveness the positive pole of each module pod with an illuminated button should preferably be positioned on the painful area Two large electrodes with two outputs are placed a finger width outside the small electrodes and are attached to the negative poles of the two previous modules e For the TENS treatment The free outputs of the two large electrodes are used to connect the third module 4 Patient position The patient is placed in the position he she finds the most comfortable in the side lying or prone position taking care to use a cushion or a specially designed table to prevent lordosis 5 Stimulation energy The energy must firstly be adjusted on the third channel TENS The energy is gradually increased until the patient feels a strong tingling sensation in the lumbar region The energy is then adjusted on channels 1 and 2 endorphinic The energy is gradually increased in order to cause muscle twitches visible if possibly or at least palpable If the patient finds it hard to tolerate the energy increase due to the discomfort it can cause it is recommended to temporarily stop increasing the en
71. e reduces the medullar input of the nociceptive impulse Gate control due to painful irradiation of the sciatic nerve Combining endorphinic stimulation with TENS stimulation is entirely appropriate here as on one hand it treats low back pain caused by chronic contractures of the muscles in that area and on the other hand relieves neurogenic pain of the sciatic nerve for which TENS is the treatment of choice METHOD Protocol Lumbosciatica 10 to 12 sessions The Lumbosciatica programme is designed to provide endorphinic stimulation on the first channel module started in the first position and TENS stimulation on the other three channels module started in the second position for this indication 2 Treatment frequency Three to five sessions per week for two to three weeks 10 to 12 sessions in total Asession should last at least 20 minutes Ideally it may be beneficial to carry out two successive stimulation sessions within the Lumbosciatica programme ensuring a ten minute rest period is taken between the two sessions to allow the stimulated muscles to recover 3 Electrode position Two stimulation modules are used ensuring they are switched on in the correct order as this determines the order in which the channels deliver stimulation With the Lumbosciatica programme the endorphinic stimulation is always provided on channel 1 whereas the TENS stimulation is delivered by channels 2 3 and 4
72. e atrophy programme A maximum of 3 channels with the TENS programme e Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels MUSCLE LESION It is well known that early but well controlled muscle work has a positive impact on the scarring process of the muscle fibres and the connective supporting tissues The Muscle Lesion programme can be used as soon as the scar begins to form and is considered satisfactory but as a general rule not until the 10th day after the initial lesion To direct and speed up the scarring process and prevent disuse atrophy To enable the patient to return to sport more quickly The muscle lesion programme is designed to cause extremely gradual muscle contractions using arate of tensioning 4 times longer than for standard programmes This aims to reduce the risk of adverse secondary ruptures Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulat
73. e nerves of the muscles being stimulated The mi SCAN function activated o determine the pulse widths suitable for the patient s muscles Electrodes Precision in positioning tl muscle quality The elect electrodes needed and s he electrodes is less significant than for programmes aiming to develop rodes can be placed in an alternative way reducing the number of imulating more muscles during a session Intensity An essential factor in the effectiveness of electrotherapy is the ability to cause visible muscle twitches The mi RANGE function activated by default can be used to determine the minimum level of energy required 0 produce an appropriate muscle response TENS Option No REHABILITATION II HIP PROSTHESIS Except where there are complications as soon as possible following the surgical implantation of a total hip replacement To restore the muscular qualities of the gluteus medius and gluteus maximus muscles to recover stability when standing on one foot and to prevent limping The three levels of the programme correspond to the Disuse atrophy level 1 and 2 and Reinforcement level 1 programmes for which the low frequencies have been removed so as not to cause vibration in the prosthesis Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the gluteal muscles The mi SCAN function act
74. e For endorphinic treatment Asmall electrode is placed on the top of the root of the sciatic nerve which is painful to palpate For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on this painful area Another small electrode is placed two finger widths above the previous electrode and is attached to the negative pole of the same module e For TENS treatment Two large electrodes are placed on the path of the sciatic nerve one on the lower part of the buttock and the other on the posterior thigh The second module is connected to these large single output electrodes Note the 3rd and or 4th channel TENS can be used in two situations n the event of more extensive irradiation in the common peroneal or tibial nerves Two large electrodes are therefore placed longitudinally on the calf tibial or laterally common peroneal on the lower leg and are connected by a module f the patient does not like endorphinic stimulation in the lumbar region two large electrodes are placed to the lumbar region and are connected by a module Vee oe er ree RES STONA EN 4 Patient position The patient is placed in the position he she finds the most comfortable in the prone position with a cushion or on a specially designed table to prevent lordosis or in the side lying position 5 Stimulation energy The energy is gradually increased on t
75. e Wireless Professional can contribute to preventing electromagnetic interference distance between portable and mobile RF communication devices transmitters and the ing to the table of recommendations below and according to the maximum output power by maintaining a minimum Wireless Professional accord of the telecommunication device Spacing according to the frequency of the transmitter m From 800 MHz to 2 5 GHz d 2 3VP From 80 kHz to 800 MHz d 1 2 VP Maximum transmitter From 150 kHz output power W to 80 MHz d 1 2 VP 012 012 0 23 0 38 0 38 0 73 12 12 23 10 38 38 73 12 23 100 12 is not shown in the table above the recommended spacing In the case of transmitters whose maximum output power e equation for the transmitter frequency where P is the of d in metres m can be calculated using the appropriai maximum output power of the transmitter in watts W as set by the transmitter manufacturer NOTE 1 At 80 MHz and at 800 MHz the spacing for high frequency amplitude is applied NOTE 2 These guidelines may not be appropriate for some situations Electromagnetic wave propagation is modified by absorption and reflection due to buildings objects and persons EN VP oe er ree me oe Nee 7 PRACTICAL GUIDE 7 1 FUNDAMENTAL PRINCIPLES Introduction In recent years significant progress has been made in field of electrotherapy of which users are still largely u
76. e complicated curve which can only be shown in part and up to a value depending on the final stable value of V if excitation has not occurred in the meantime In Figure 2a the intensity of the current is set at a value we will take as 1 which without accommodation would allow V to reach So and to trigger excitation In fact V reaches the value So but in the meantime the threshold increased therefore V So lt S and excitation cannot occur To allow V to reach the value S the current must be 8 more intense This is shown in Figure 2b where the threshold has just been reached in 4 ms indicated by the arrow that is the principal useful time In Figure 2c a stronger current with a value of 1 2 is applied and V passes the threshold after 1 85 ms In Figure 2d an even stronger current value 2 is applied and V S after 0 7 ms Fig 2 Cathode v So So Vo Vo b c 0 K d We can therefore see the intensity duration relationship appear which gives the time at which V passes S for different current intensities The useful times are even shorter when the current is more intense Fig 3 Fig 3 a a 1 1 _ l e With lo rheobase and k excitation constant Chronaxy t lt d EN DP ee re er S TONAT This relationship applies to currents that are very short compared to the accommodation constant Accommodation can be disregarded and excitat
77. e for the patient 4 Duration of rectangular electrical pulse First of all it must be specified that this is in a specific pulse duration phase Weiss law is used for stimulation pulse durations close to the excitation constants k In the case of motor neurons this means a time period ranging from 100 to 3000 microseconds k Chronaxy In Chronaxy 0 693 J a a a lad yl EN The third electrical factor which should be minimised in order to produce the most comfortable possible stimulation is electrical energy W We know that electrical energy is given by the formula W F t R where I is the current intensity t its pulse duration R skin resistance A The Weiss or Lapicque relationship states N I q t i and we can replace I by its value in the energy equation We get W q t i t R by developing W q t 2 i q t i t R q t 2q i t R When t gt 0 W gt ce When t gt W gt o a The shape of this curve is given in Figure 4 P Fig 4 Relationship between energy and the pulse duration W minimum i d D Variations in electrical energy depending on skin resistance W q t 2 qit it Rn where R1 gt R2 gt R3 The electrical energy passing through the skin and tissue is minimal for duration of the stimulation current i e for a pulse duration which is found by calculating the derivative of the
78. e patient s comfort and the effectiveness of the stimulation gradually deteriorates e Some patients with very sensitive skin may experience redness under the electrodes after a session Generally this redness is completely harmless and usually disappears after 10 to 20 minutes Never start another stimulation session in the same area however if the redness is still visible e For information on use and storage please consult the instructions found on the electrodes packaging e Before each use clean and disinfect the motor point pen tip that is in contact with the skin 3 PRESENTATION 3 1 EQUIPMENT AND ACCESSORIES Your kit contains 1 remote control 65220XX 4 stimulation modules 984350 1 docking station 6831XX 1 AC adaptor 6490XX 1 USB cable 601163 2 bags of small electrodes 5x5 cm 1 snap connection 42204 2 bags of large electrodes 5x10 cm 2 snap connections 42203 2 bags of large electrodes 5x10 cm 1 snap connection 42223 1 user manual and practical guide 45281XX 1 bottle of gel 602047 1 motor point pen 980020 1 carrying case 680041 1 lanyard 1494 1 protection sleeve 5529024 3 2 GUARANTEE This guarantee is valid only if it is accompanied by proof of purchase Your statutory rights are not affected by this guarantee Your Wireless Professional stimulator is guaranteed for a period of 2 years from the date of purchase The guarantee covers the remote control the modules the
79. e spinal cord For this programme the frequency is modulated 50 150 Hz to avoid habituation Pulse width his programme uses very short duration impulses 50 us suitable for the higher level of excitability of the sensitive AB fibres Electrodes he electrodes are usually placed in such a way as to cover or surround the painful area Intensity he intensity must be increased gradually until the patient feels a tingling sensation that is pronounced without being painful The mi TENS function prevents any kind of muscle contraction If the sensor detects a muscle response the stimulator automatically reduces the stimulation energy in order to stop the muscle response TENS Option No al i a al ais EN NEUROLOGICAL REHABILITATION HEMIPLEGIC FOOT One of the problems faced by hemiplegics is the greater or lesser degree of difficulty in raising the toe of the foot Consequently this produces steppage during the swing phase of the gait This programme is not recommended if a stimulation of the levator muscles in the foot causes a spasm in the muscles of the lower limb due to reflex b the spasticity of the triceps surae is high In such cases use a preparation programme which inhibits the tone To prevent foot drop during the swing phase of the gait By manually triggering an electrically induced tetanic contraction in the levator muscles of the foot that is synchronised with the gait
80. e to be large enough to excite type A6 nerve fibres as well as type Aa which is shown by the production of muscle twitches The effects of endorphinic stimulation are described for frequencies between 2 and 8 Hz In addition to the general effect of increasing endorphin production in the hypothalamus which elevates the pain perception threshold there is a very significant localised effect The 5 muscle twitches induced every second by stimulation produce very significant hyperaemia which drains the acid metabolites and free radicals that had accumulated in the chronically contractured muscle areas Pulse width Endorphinic stimulation is primarily aimed at the sensitive A6 nerve fibres which are best stimulated with pulse width of 200us However the vascular effect is secondary to the co activation of the motor units which have a slightly higher chronaxy that is measured at the start of the session using the mi SCAN function activated by default Electrodes Electrodes must be placed after a thorough palpatory examination to locate the most painful point where a small electrode preferably connected to the positive pole of the module pod with an illuminated button will be placed The other electrode is placed at the end of muscle or muscle group being stimulated Intensity An essential factor in the therapeutic efficacy is to cause visible muscle twitching which may in certain cases require higher stimulation energies
81. e used to determine the pulse widths suitable for the patient s muscles Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Electrodes An essential factor in the effectiveness of electrotherapy is the ability to cause visible muscle Intensity twitches The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option No CONDITIONING I Indication RESISTANCE For athletes wishing to increase their ability to sustain intense and prolonged exertion or to develop their ability to maintain or repeat a muscular activity carried out at a high percentage of the maximum strength ncreased anaerobic lactic capacity in the muscles Increased strength endurance Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of m
82. ed The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes lectrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity arly use of this programme after a muscle lesion requires extremely gradual adjustment of the imulation energies It is necessary to be particularly careful during the first sessions and to always tay below the pain threshold TENS Option Yes A minimum of 1 channel with muscular work imposed by the Muscle lesion programme A maximum of 3 channels with the TENS programme e Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels Vee eo er ree MES STONA MOTOR POINT It is advisable to use this programme before all initial muscle electrostimulation sessions in order to precisely locate the motor points for each person Locating the motor points is recommended especially for long muscles such as those in the lower limb
83. ed channels Adjusting energy is always carried out on active channels To adjust energy individually per channel only keep active the channel on which you want to act and deactivate the other channels by pressing the corresponding buttons VI A Total remaining programme time B Energy level bar graph C Energy level D Dark background active channel Bright background inactive channel E Indication relating to the channel in question TENS channel providing a TENS current l Il channel group F Number of contractions remaining total number of contractions G Indicator of programme execution Disuse atrophy ORS Ori Pause mode By pressing the central button or the On Off button on one of the modules during stimulation the device pauses a A Maximum energy level achieved by the channel during contraction phases B Back to previous menu C Skip function allows you to skip programme sequences not available for all programmes D Resumes the stimulation session EN Wee ce SoS treo TESS TONAT End of session At the end of the session a screen appears with this view To turn the unit off simply press the On Off button on the remote control for more than 2 seconds This will switch off all modules A Average energy level of all the channels used during the 5 09 1 11 3 contraction phase Disuse atrophy B Maximum energy level achieved by the channel durin
84. egic Patient Alfieri V Arch Phys Med Rehabil 42 101 105 1961 Electrical Treatment of Spasticity Scand J Rehab Med 14 177 182 1982 Levin MG Knott M Kabat H Relaxation of Spasticity by Electrical Stimulation of Antagonist Carnstan B Larsson L Prevec T Muscles Improvement of Gait Following Electrical Stimulation Arch Phys Med 33 668 673 1952 Scand J Rehab Med 9 7 13 1977 The treatments discussed in this chapter are applicable through the programmes in the Neurological Rehabilitation category and some of these programmes require each contraction to be manually triggered All programmes used reduce spasticity as long as they are applied correctly to the muscles antagonistic to the spastic muscles Some of these programmes are intended solely for the treatment of spasticity while others are intended to treat situations or complications specific to the hemiplegic patient namely functional neuromuscular electrical stimulation of the foot and subluxation of the shoulder VP oe er ree oe Nene EN 1 Dorsiflexion of the hemiplegic foot One of the problems in hemiplegic patients is the greater or lesser degree of difficulty that they encounter when raising the foot voluntarily or even the total inability to do so For this reason the foot drops when walking during heel strike Neuromuscular electrical stimulation NMES in the area of the flexor muscles of the foot tibialis anterior extensors of the toe allows
85. ement rapidly decreases in volume This decrease depends on the degree and duration of the functional deficit Slow fibres type in particular are affected by disuse atrophy To reactivate the trophicity of the muscle fibres altered during disuse atrophy To reverse muscle wastage By using frequencies creating a tetanic contraction in type fibres to impose a significant workload on the atrophied muscle so that it recovers volume Recovery therefore takes place far more quickly than by simply using muscle activities Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity Use the maximum stimulation energies The first and second sessions help the patient become accustomed to the method by gradually increasing the stimulation energy every 3 or 4 contractions In the following sessions it is important to support the patient s progress by setting targets which go beyond the energy levels reached in the previous session TENS Option Yes Aminimum of1 channel with muscular work imposed by the Disuse atrophy programme Amaximum of 3 channels with the TENS p
86. en set point Rehabilitation of the peroneus muscles following an ankle sprain The purpose of the peroneus muscles is to maintain the stability of the talocrural joint and prevent the ankle from rotating inwards Following a sprain due to the functional disability reflex inhibition phenomena and immobilisation these muscles can undergo partial disuse atrophy a loss of proprioceptive reflexes and a considerable loss of strength Rehabilitation following such an accident must therefore focus essentially on the peroneus muscles in order to prevent recurrences To fulfil their function optimally the peroneus muscles must effectively put up resistance to brief and powerful stresses They must therefore be capable of responding with a powerful short contraction at that very moment when the stress being applied to the foot risks making the ankle tilt inwards There are therefore two main aspects of the rehabilitation of these muscles 1 The proprioceptive reflex Allows the peroneus muscles to sense the lower limb position relative to neighbouring parts and to contract at the right moment with an appropriate strength effort This aspect of rehabilitation consists of properly performing exercises on classic balance boards such as Freeman boards a sufficient number of times number of sessions 2 Muscle reinforcement Allows the peroneus muscles to contract with enough strength to oppose the stress applied to the ankle
87. ergy on the first two channels The energy is then increased again on the third channel TENS in order to increase the feeling of paresthesia in the lumbar region After a minute or two the energy can be increased again on the first two stimulation channels so that the muscle twitches can be seen It is essential to increase the energy on channels 1 and 2 sufficiently to cause visible or at least palpable muscle twitches In fact these muscle twitches are directly responsible for the significant hyperaemia effect and therefore guarantee the effectiveness of the treatment N B When TENS is used in combination with an endorphinic programme such as the Low back pain programme in this case the mi TENS function is inactive VP ee er ree oe Nee EN 4 Treatment of lumbosciatic pain Patients suffering from lumbosciatic pain most often present lumbar pain that commonly originates from chronic contractures of the lumbar paravertebral muscles In addition involvement of the spinal nerve root leads to irradiation of pain over a shorter or longer distance along the sciatic nerve and in some cases along one or the other of its branches common peroneal or tibial The combination of the Lumbosciatica programme and the TENS programme is the preferred treatment as it produces through its endorphinic effect Lumbosciatic programme a significant analgesic effect on chronic contractures of the lumbar region and through the TENS programm
88. es tactile sensitivity Pulse width The pulse width for the programme is 180 us Electrodes The electrodes are usually placed in such a way as to cover or surround the painful area Intensity The intensity must be increased gradually until the patient feels a tingling sensation that is pronounced without being painful TENS Option No KNEE PAIN To relieve knee joint pain irrespective of its cause gonarthrosis rheumatoid polyarthritis chondromalacia etc For the relief of pain Using the Gate control principle This involves causing high levels of sensitivity impulses in order to limit the input of pain impulses when they return to the posterior horn of the spinal cord Pulse width The pulse width varies continuously with this programme This avoids habituation by using a system of stimulation that is perceived as more pleasant by some patients Electrodes Depending upon the pain four large electrodes placed around the patella produce a significant analgesic effect on all knee pain Intensity The intensity must be increased gradually until the patient feels a tingling sensation that is pronounced without being painful TENS Option No WP ee SS ree me oo TONAT TRAPEZIUS MUSCLE PAIN As with all muscular pains pain in the trapezius muscles can best be relieved by endorphin stimulation However TENS stimulation may be preferable for the first sess
89. etermining the relationship which links it to the other factor that characterises excitation k The chronaxy is the useful time corresponding to a stimulation current which has an intensity double that of the rheobase i e 2 Jo It is therefore very easy to find the relationship between the chronaxy and the excitation constant based on the formula giving the intensity duration relationship Vd 1 10 1 e is the chronaxy 1 210 tch when therefore 210 10 1 e 210 1 e 10 2 1 1 2 2e k 1 2eth k 1 ek 1 2 el tehk 1 2 etch k 2 1n2 tch k therefore t 1n2 k This means that the chronaxy 0 693 E Hydraulic model of excitation It is possible to set up a hydraulic model that corresponds exactly to excitation This model allows a better understanding of excitation and may be used to represent the development of the local potential and the threshold under the effect of currents with variable durations and shapes Water flows from tank A towards tank B by means of pump P the stimulator current generator The flow of water corresponds to the intensity of the stimulation current and the water moved from A to B to the quantity of electrical charges The water level in tank B reaches a certain level representing the value of the membrane potential Vo at rest and Vlocal potential The stimulation threshold is given by a point D on float C Stimulation occur
90. etic dystrophy RSD is a disease that physiotherapists frequently see and which they must be able to diagnose and treat at an early stage The protocols proposed have been developed on the basis of the following publications Abram S Asiddao C Reynolds A Increased Skin Temperature during Transcutaneous Electrical Stimulation Anesthesia and Analgesia 59 22 25 1980 Owens S Atkinson R Lees DE Thermographic Evidence of Reduced Sympathetic Tone with Transcutaneous Nerve Stimulation Anesthesiology 50 62 65 1979 Richlin D Carron H Rowlingson J al Reflex sympathetic dystrophy Successful treatment by transcutaneous nerve stimulation The Journal of Pediatrics 93 84 86 1978 Abram S Increased Sympathetic Tone Associated with Transcutaneous Electrical Stimulation Anesthesiology 45 575 577 1976 Meyer GA Fields HL Causalgia treated by selective large fibre stimulation of peripheral nerve Brain 9 163 168 1972 1 Diagnostic definition RSD is a complication which most often occurs following a trauma In most cases this trauma is to the bone or joints of the limbs The type of trauma is generally a fracture or operation but may also involve dislocations wounds burns phlebitis infections etc RSD does not start immediately after the trauma or the operation but appears some time later n general it starts when physiotherapy begins This is why the role of the physiotherapist is vital The main sign
91. eutic results If you set the stimulation energy below the ideal range of treatment the stimulator prompts you to raise them again by continuously flashing signs Where possible the mi RANGE function is automatically activated mi TENS The mi TENS function can significantly reduce the appearance of unwanted muscular contractions thus providing maximum comfort and efficiency Short tests are performed regularly throughout the duration of the programme A testing phase takes place systematically after each increase in stimulation intensity In order to allow its smooth progress it is essential to remain perfectly still during this time According to the test results recorded by the device the level of stimulation intensities may be slightly decreased automatically The mi TENS function can be deactivated VI Triggering of contraction mi ACTION voluntary This is a way of working in which voluntary contraction triggers an electrical stimulation Contraction by electrostimulation is perfectly controlled by voluntary triggering of muscle contraction From the perspective of maximum efficiency the mi ACTION working mode requires good muscular qualities Underperforming muscles may in some cases impede the onset of electrically induced contraction Programmes used in the mi ACTION mode have undeniable advantages e They require active participation and encourage the patient to engage fully in his or her treatment They
92. f heaviness in the lower limbs A certain degree of muscle tension is often associated with this and female patients can experience cramps in their calves To accelerate venous blood return re oxygenate the tissues and produce a relaxing effect During the treatment session we move progressively and automatically through a series of clearly defined frequencies requiring a large increase in the flow to allow acceleration of the venous blood return 7 Hz produce an analgesic effect by increasing the production of endorphins 5 Hz and end by relaxing the muscles 3 Hz while keeping the blood flow noticeably high Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the calf muscles The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes A large electrode is placed transversely under the popliteal fossa and two small electrodes are positioned on the contour of the gastrocnemius muscles Intensity An essential factor in the effectiveness of electrotherapy is the ability to cause visible muscle twitches The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option No a a ah ES S TONTE VENOUS INSUFFICIENCY 1 In the event of venous insuf
93. ficiency without oedema To increase the general blood flow so as to improve the circulation of the interstitial fluid and increase oxygenation of the tissues and the intima of the veins To drain the veins as much as possible in order to combat stasis Send pulses so as to cause short tetanic contractions to drain the deep veins separated by long periods to increase the flow To make it as comfortable as possible for the patient use pulse widths equivalent to the Pulse width chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned according to the specific indication Adjust the stimulation energy so as to produce appropriate muscle responses both in the tetanic Intensi p contraction phase and in the phase to increase blood flow TENS Option No VENOUS INSUFFICIENCY 2 In the event of venous insufficiency with oedema To encourage drainage of the deep veins and of the oedema Encourage venous blood return using a sequenced stimulation starting in the leg muscles and continuing to the thigh muscles supporting the distal tetanic contraction to prevent regurgitation Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated
94. for dorsiflexion to be achieved This NMES is functional FES f the dorsiflexion achieved is synchronised with the gait so as to stop the foot from dropping when ifted from the ground 4 he aim of FES is to teach the hemiplegic patient to walk again by creating a functional gait pattern hat the patient is then able to reproduce more easily ct However this method of gait rehabilitation using FES is not suitable for all hemiplegic patients Two types of case must be considered 1 If the stimulation of the muscles lifting the foot produces a spasm reflex in the muscles of the lower limb this technique should no longer be used this phenomenon is rare in hemiplegics but more common in paraplegics 2 If the spasticity of the soleus muscle is considerable to the point where satisfactory dorsiflexion cannot be achieved programmes for the treatment of spasticity in the lower limb must be used initially before resuming work on the gait with FES when spasticity of the triceps surae has been sufficiently reduced METHOD USE CHANNEL 1 other channels are inactive for this programme 1 Protocol The hemiplegic foot 2 Treatment frequency Minimum of three sessions per week The length of treatment varies greatly depending on progress 3 Electrode position A single module is sufficient to stimulate the levator muscles of the foot A small electrode is placed on the motor point of the tibialis anterior For opti
95. free radicals This muscular acidosis is directly responsible for the pain which in turn sustain and reinforce the degree of contracture If left untreated there is a risk that the contracture will become chronic and real atrophy of the capillary network will gradually develop the aerobic metabolism of the muscle fibres deteriorates giving way to glycolytic metabolism which gradually becomes predominant This mechanism of chronic contracture is summarised in the following diagram a Muscle contracture Increased muscle activity Reduced blood flow Accumulation of acid metabolites sa d In addition to the general effect of increasing endorphin production which raises the pain Pain perception threshold stimulation with an endorphinic programme produces marked local hyperaemia and allows drainage of acid metabolites and free radicals The major analgesic effect obtained in this way during each session should not however lead to premature termination of treatment Indeed in order to restore the atrophic capillary network the treatment must be continued for a minimum of ten sessions or so 1 Endorphinic treatment of cervical pain Chronic contractures of the levator scapulae and or superior trapezius are often responsible for the painful symptoms in patients with neck pain The use of endorphinic treatment on these contractured muscles is thus the treatment of choice for this condition However
96. g contraction phases C Back to main menu HOME For programs using the mi range feature the percentage of time spent above the minimum threshold is displayed Ni d 5 4 RECHARGE Battery level The module battery level appears when you turn it on just before starting the stimulation session The battery level of the remote control is always visible in the upper right corner Small green indicators show how many modules are turned on and recognised by the remote control a A Module battery level B Remote control battery level C Number of modules switched on and recognised by the remote control a Connect the docking station Connect the AC adapter supplied with your device to the removable tablet of the docking station and plug it into a power socket Also connect the docking station s USB cable to the removable tablet It is highly recommended to fully charge the batteries of the remote control and modules before first use to improve their performance and life span C A Rear view of the docking station B Connector for the AC adapter C Connector for the USB cable Charging the remote control and modules At the end of your stimulation session it is strongly recommended to store the remote control and the modules in the docking station to recharge the units Were ee se ree TES SIONA EN Place the modules into the slots
97. ght increase in volume improvement in tone e Disuse atrophy Level 2 Weeks 3 6 The objective is the restoration of near normal muscle volume e Reinforcement Level 1 Weeks 7 8 The objective is to develop the maximum strength the muscle or muscle group can produce J 2 Treatment frequency One to two sessions every day if two sessions are carried out every day enough time must be given to rest between the two sessions Minimum three sessions per week 3 Electrode position During neurostimulation for motor stimulation purposes the general rule is to position a small electrode on the motor point of the muscle and the other electrode at one end of the same muscle For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the motor point The precise location of the motor point s is easy to ascertain by following the instructions for the indication Locating a motor point in this manual This step ensures that the electrodes will be positioned to provide optimum comfort to the patient and optimum effectiveness of the therapy 4 Patient position The stimulation of a muscle when it is at its maximum inner range is uncomfortable and quickly becomes painful due to the sensation of cramp that results from this position Consequently this position must be avoided and the patient should be placed in a position in which the
98. gion is often the cause of common low back pain or identified as a contributing factor which increases the risk of recurrence The particular benefit of electrostimulation is three fold e It enables treatment to be started at an early stage because unlike voluntary exercises the stress applied to the stabilising muscles in the lumbar region through electrostimulation is initially carried out in isometric mode which considerably reduces the mechanical stresses exerted on the vertebral and periarticular structures e It enables an appropriate work regime to be created to restore the quality of the postural muscles i e the muscles that are essentially made up of type high endurance fibres It promotes motor re learning and postural control by combining synchronised electrically induced contractions of the abdominal and lumbar muscles with voluntary proprioception exercises METHOD 1 Protocol e Lumbar stabilisation Level 1 Weeks 1 2 e Lumbar stabilisation Level 2 Weeks 3 4 2 Treatment frequency Three to five sessions a week for four weeks 3 Electrode position Two channels are needed for the stimulation of the abdominal muscles Four large electrodes are positioned on the abdomen one above one below and one either side of the belly button For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the upper electrode VI
99. gramme e Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels PAIN RELIEF II TENS 80 HZ Gate control which is activated during TENS stimulation is particularly effective for the relief of localised pain of non muscular origin It is particularly effective for relieving neuropathic pain and inflammatory conditions The sessions may be repeated at will and without restriction depending upon the intensity of the pain Without side effects TENS Gate control effectively relieves pain and improves the patient s level of comfort The sedation period that results from the stimulation allows the vicious self perpetuating cycle of pain to be broken The principle involves causing high levels of sensitivity impulses in order to limit the input of pain impulses when they return to the posterior horn of the spinal cord Apart from the 80 Hz frequency this programme specifically tries to stimulate other sensory fibres pressure vibration in addition to stimulation of the Af fibr
100. han 2 seconds to switch off while browsing the lists press briefly to return to the main menu B 4 multifunction buttons e Functions related to icons are located on the screen e g info main menu placement of electrodes etc e Selection of stimulation channel to increase or decrease the energy level of stimulation C Navigation pad D Validation or pause button during stimulation E Port for the USB cable or the docking station connector MODULE A module is composed of two pods A On Off button press briefly to switch on press for 1 second to switch off during stimulation press to pause e Flashing green LED ready e Flashing yellow LED stimulation on B Groove to wind up the cable C Pod containing battery 3 a DOCKING STATION A Removable tablet B Connector to charge the remote control C Docking bay to position the modules to be recharged D Port for the AC adapter and for the USB cable connected to the front of the docking station E Storage bin EN VP ee re RES SIONA 4 2 EXAMPLE OF AN ELECTROSTIMULATION SESSION 1 Turn on your remote control 2 Select a programme category then a programme and confirm by pressing the centre button Home UserProgram Favourites Cele LELO Rehabilitation Muscle lesion Motor Point Disuse atrophy 1 4 mis gt Prevention of disuse atrophy Pain rel
101. he increase in the excitation threshold is known as accommodation Accommodation is an increase in the threshold S which is the result of the change in the local potential caused by the electrical charges provided by the current passing through the neuron I The increase in the threshold does not occur instantly but gradually and at a particular speed A second time factor A is therefore involved in the process of electrical excitation which defines the rate at which the threshold changes S When the local potential V is returned to its resting potential Vo S returns exponentially to its initial value So with 4 as the time constant according the mathematical law ds dt S So A 2 This equation is for S what equation 1 is for V with 4 replacing k The electrical charges provided by the current passing through the neuron change the membrane potential They produce a local potential V and this causes the threshold S to increase Excitation occurs if a sufficient quantity of electrical charges is provided to allow the local potential to catch up with the threshold value i e when V S Fig 1 Fig 1 a gt Vo Resting State Stimulation current is passed Excitation state through Vand Sincrease action potential V V Vo Vm ax 1 e d The excitation process is therefore determined by two time constants k the excitation constant A the accommodation constant VI a i a
102. he lumbar region the stimulation currents required to obtain visible or at least palpable muscle twitches are generally high and can be difficult to tolerate by some patients This is why it is generally recommended to combine TENS treatment with the Low back pain programme to make treatment more comfortable for the patient This treatment should be continued for at least ten sessions in order to restore the capillary network which is usually atrophic in chronically contractured muscles METHOD 1 Protocol Low back pain TENS 10 to 12 sessions The Low back pain programme is designed to provide endorphinic stimulation on the first two channels modules started in the first and second position and TENS stimulation on the other two channels module started in the third position for this indication 2 Treatment frequency Three to five sessions per week for two to three weeks 10 to 12 sessions in total Asession should last at least 20 minutes Ideally it may be beneficial to carry out two successive stimulation sessions within the Low back pain programme ensuring a ten minute rest period is taken between the two sessions to allow the stimulated muscles to recover EN VP Ree oe er ree RES STONA 3 Electrode position Three stimulation modules are used ensuring they are switched on in the correct order as this determines the order in which the channels deliver stimulation In the Low back pain programme en
103. he second channel TENS in order to cause a distinctive tingling sensation along the painful irradiation of the sciatic nerve The gradual energy increase on the first channel must be sufficient to obtain visible or at least palpable muscle twitches of the muscles of the lumbar region which cause hyperaemia N B When TENS is used in combination with an endorphinic programme such as the Lumbosciaticaprogramme in this case the mi TENS function is inactive Hemiplegia Spasticity This chapter examines the treatment of problems specific to the hemiplegic patient including spasticity which is found not only in hemiplegic patients but also in most disorders of the central nervous system tetraplegia paraplegia multiple sclerosis etc The practical methods of treatment described in this chapter are based on the following reference publications Wal J B Modulation of Spasticity Prolonged Suppression of a Spinal Waters R McNeal D Perry J Reflex by Electrical Stimulation Experimental Correction of Foot Drop by Electrical Stimulation Science 216 203 204 1982 of the Peroneal Nerve J Bone Joint Surg Am 57 1047 54 1975 Baker L L Yeh C Wilson D Waters R L Electrical Stimulation of Wrist and Fingers for Hemiplegic Liberson WT Holmquest HJ Scot D Patients Functional Electrotherapy Stimulation of the Peroneal Nerve Physical Therapy 59 1495 1499 1979 Synchronized with the Swing Phase of the Gait Hemipl
104. hird channel improves comfort during endorphin stimulation Pulse width Endorphinic stimulation is primarily aimed at the sensitive A5 nerve fibres which are best stimulated with pulse width of 2001s However the vascular effect is secondary to the co activation of the motor units which have a slightly higher chronaxy and which is measured at the start of the session using the mi SCAN function that is activated by default Channels 3 and 4 provide Gate control stimulation and use a larger pulse adapted to the chronaxy of the AB fibres Electrodes Electrodes positioned according to the specific indication Combining 2 stimulation currents Endorphin and TENS Gate control requires care to switch on the modules in the correct order Intensity The intensity must first be set on channels 3 and 4 which deliver the TENS programme according to the usual TENS rules tingling It will be gradually increased on channels 1 or 2 until visible or palpable muscle twitches are produced The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option Yes forced Aminimum of 2 channels with muscular work imposed by the Low back pain programme 2 channels with the TENS programme Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has bee
105. ief Reinforcement Vascular a I 3 Stick the electrodes on the patient and connect the modules 4 Turn on the modules being careful to respect the order of activation of the modules the turning on order corresponds to the channel numbering Validate everything by pressing the START button Disuse atrophy 5 If the mi SCAN function is activated a short sequence of measures is performed Throughout the duration of the test it is important to stay still and be perfectly relaxed When the test is complete the programme can begin 6 Start the stimulation by increasing the energies of the channels To pause the device press the centre button 7 At the end of the programme press the centre button to return to the main menu or press the On Off button to turn off the device For more details refer to the How it works section EN WTRECESS PRO lis 5 HOW IT WORKS 5 1 SELECTING A PROGRAMME Upon activation the screen displays a list that gives you access to the categories of programmes device settings or your favourite programmes To select an item use the navigation pad up down and confirm your choice with the centre button N B Once you have created your list of favourite programmes it will be displayed first after switching on the remote control Home UserProgram Favourites Rehabilitation Pain relief Vascular When the choice of programme category has been
106. ients with cardiac arrhythmia Osteosynthesis Equipment The presence of osteosynthesis equipment metallic equipment in contact with the bone pins screws plates prostheses etc is not a contraindication The electrical currents of the Wireless Professional are specially designed to have no harmful effect on osteosynthesis equipment EN VP oe er ree me oe Nee 2 2 SAFETY MEASURES e Do not open or modify the product e Do not apply stimulation near the area of an implant such as cochlear implants pacemakers skeletal anchorage or electric implants e Do not apply stimulation close to metal Remove jewellery piercings belt buckles or any other metallic product or device in the area of stimulation e If the person is pregnant or menstruating do not place electrodes directly on the uterus or connect pairs of electrodes on either side of the abdomen e Do not use the Wireless Professional in water or in a humid atmosphere sauna hydrotherapy etc e Be careful if the patient has sensitivity problems or is not able to communicate that he or she feels discomfort however light e Do not use the Wireless Professional in oxygen rich environments e Never begin an initial stimulation session on a person who is standing The first five minutes of stimulation must always be performed on a person who is sitting or lying down In rare instances people of a nervous disposition may experience a vasovagal reaction This is of p
107. ill be placed in a seated position with the ankles fixed with straps to prevent the knees extending For other types of programmes for example analgesic programmes which do not cause muscle contractions position the patient as comfortably as possible Stimulation energy settings For programmes which cause muscle contractions it is important to use the maximum stimulation energies i e always at the limit of what the patient is able to tolerate This means that in a stimulated muscle the number of fibres working depends on the stimulation energies The maximum stimulation energies must therefore be used in order to engage as many fibres as possible Below a significant stimulation energy the number of fibres engaged in the stimulated muscle is too low to considerably improve the quality of the muscles The maximum energy will not be reached during the first session but after at least 3 sessions during which the energy to produce strong muscle contractions will be increased gradually so that the patient becomes accustomed to electrostimulation After the warm up which should produce clear muscle twitching the stimulation energies must be increased progressively contraction by contraction throughout the work sequence The energies used should also be increased session by session VI For TENS treatments stimulation is only sensory The intensity must therefore be increased until the patient has a pins and needles sensatio
108. imum time in which a current with double the intensity of that of the rheobase must be applied in order to produce stimulation S tch q i d References e Physiologie Volume II Le Syst me nerveux et Muscle Charles Kayser ed Flammarion e Lapicque L D finition exp rimentale de l excitabilit Soc Biologie 77 1909 280 283 e Lapicque L La Chronaxie et ses applications physiologiques Hermann amp Cie Paris 1938 e Weiss G Sur la possibilit de rendre comparable entre eux les appareils servant l excitation lectrique Arch itali Biol 35 1901 413 446 e Irnich W The chronaxy time and its practical importance Pace 3 1980 292 301 e Cours de Physiologie Humaine Volume Prof Colin F Universit Libre de Bruxelles e Trait de Physiologie M dicale Arthur C Guyton ed Doin e Physiologie Humaine Philippe Meyer 2nd edition Flammarion M decine Science Optimum current A Introduction The reminders and ideas developed in the previous chapter The fundamental law of electrostimulation must be read before starting this chapter which describes the qualities of the optimum electrostimulation current The optimum current can be defined as being able to reduce the resting potential to the stimulation threshold value under Weiss law while also keeping the patient as comfortable as possible The second requirement is met by minimising the electrical parameters of the stimulation current
109. ing enthusiasts and athletes wishing to increase their muscle mass Possibility of combining this programme with voluntary training Effects ncrease the volume of stimulated muscles and improve muscular resistance Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with he instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option Indication No MUSCLE BUILDING For those who wish to improve overall muscle quality in balance with a discrete effect on increasing muscular volume To improve muscular trophicity and increase the tone and volume of the muscles in a balanced way Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electr
110. ing trials disciplines Effects To improve the oxidative capacity of the stimulated muscles and to aid in developing the athlete s aerobic performance Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option No a a a a a lg ls Indication EXPLOSIVE STRENGTH For athletes who practise a discipline where explosive strength is a significant performance factor To increase the maximum capacity for instantaneous power To increase the speed at which the maximum power is attained and to improve the effectiveness of explosive actions such as jumping sprinting etc Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the hronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated default can be used to determine the pulse widths s
111. int where the motor nerve enters the muscle which is an extremely localised area where the motor nerve is at its most excitable Although the location of the various motor points is now well known there may nevertheless be variations of up to several centimetres between different individuals The Motor point programme combined with the use of the motor point pen delivered with your equipment allows the user to determine with great accuracy the exact location of the motor points for each individual and thus ensure the greatest effectiveness of the programmes It is advisable to use this programme before any initial muscular electrostimulation session Once located the motor points can be easily identified using a skin marker pencil or in any other way thus avoiding the need to repeat this process before each session Recommended programme Motor point EN VP ree ee er ree oe Nee INSTRUCTIONS 1 Apply a large electrode at the top of the thigh 2 Connect the negative pod of the module pod without illuminated button to the output of the large electrode located towards the inner surface of the thigh 3 Spread a thin but even layer of conductive gel over the inner surface of the thigh in the position indicated for the positive electrode position spreading the gel a few extra centimetres in all directions 4 Connect the positive pod of the module pod with illuminated button to the tip of the motor point pen and bring the tip
112. involves reducing the membrane s resting potential to the threshold value by applying an electric current to the skin The first question is of course which stimulating current to choose Which type of current will we use A single current must obviously be used one which can reduce the resting potential to the threshold value but keep the patient as comfortable as possible In other words the electrical parameters of this current must be kept to a minimum and its stimulation energy and duration must be as low as possible Ww Fig 1 A 40 30 Action potential 20 10 10 20 30 40 50 Threshold 60 n 70 Rest potential 80 a b d We will therefore need to understand the fundamental law that it must observe in order to find the optimum qualities of this current This first chapter aims to provide a reminder and explanation of this law This is followed by a second chapter which on the basis of this fundamental law and ideas surrounding it determines the qualities of the optimum current At the turn of the last century well known physiologists such as Weiss Hoorweg Du Bois Reymond and Lapicque managed to discover the fundamental law of electrostimulation and its mathematical expression Based on Hoorweg s work Weiss a Parisian doctor and physiologist emphasised the importance of the quantity of electrical charges created by the stimulation current His experiments led to the fundame
113. ion SHAPING To be used when the firming phase is complete Effects To define and sculpt the body when the muscles are already firm Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option Indication No ELASTICITY To be used in addition to the firming and shaping programmes Effects To improve circulation and elasticity of the skin Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity An essential factor in the effectiveness of electrotherap
114. ion activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned on the gluteal muscles must correspond to the specific indication Intensity The maximum tolerable stimulation energy on the 4 channels which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used Progressively increase the level of energy during the course of a treatment session TENS Option No Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels This programme only works with 4 modules switched on WrReECE SS reo mt So TONAT ROTATOR CUFFS In addition to the rehabilitation of rotator cuff tendinopathies after sedation of acute pain and manual correction of joint misalignment To develop the active stability of the shoulder by restoring the functional attributes of the muscles supporting the glenohumeral joint Selective stimulation of the infraspinatus and supraspinatus muscles using parameters adapted to their postural function type fibres Combination with a TENS programme for a combined analgesic effect Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of
115. ion appears when V So This is why in the intensity duration relationship only the excitation constant k occurs as the duration of currents used have values close to k from 0 2 ms to 3 ms If the durations of current applied were longer the threshold would increase and excitation would only occur if V became equal to S In these cases the intensity duration relationship must be reconsidered as the rheobase does not keep the value Jo instead it increases to a value 71 gt Jo determined by the excitation and accommodation constants The actual rheobase Jo is linked to the observed rheobase 11 by the relationship _L x 11 a ig k C Excitation by a current with any shape It is possible to determine the equation for the local potential Vand to calculate its value at any given point in time with any given shape of current An equation can also be determined for the development of the threshold These equations required a solid understanding of mathematics and come under the field of specialist electrophysiology This is why we believe there is no purpose in expanding these equations as part of this work However it can be noted that using these equations which give the variation of Vand S it is possible to study the excitation process with any given shape of current and for any given duration D Chronaxy excitation constant relationship As the chronaxy is a value that characterises tissue excitability it is worth d
116. ion you need to turn on the modules one after the other by pressing their button On Off For each module detected by the remote control the device will prompt you to switch on another up to a maximum of 4 of modules for your session simply press the STA modules you want A corresponds to the channel numbering The screen below shows an overview of all availa Be careful to respect the order of activati modules If you want to use a limited number RT button after the detection of the number of on of the modules the activation order ble options and functions The availability of these options or functions is related to the programmes a Total programme time Module activation indication Module battery level Back to previous menu Skip function allows you to jump monw D gt programme sequences not available for all programmes or CA Programme time increase function not available for all programmes TENS function see explanation below G Session start H Programme architecture e 3 sequence programme Warm up Work Relaxation e Programme with 1 continuous sequence Active option in the programme J Programme name x D Disuse atrophy EN a a oa lis TENS function In many clinical situations a painful syndrome affects regions near the muscle group to be stimulated This pain may prevent the patient from working with the required high stimulation e
117. ions if there is acute pain in an area of inflammation For the relief of pain Using the Gate control principle This involves causing high levels of sensitivity impulses in order to limit the input of pain impulses when they return to the posterior horn of the spinal cord Pulse width The pulse width varies continuously with this programme This avoids habituation by using a system of stimulation that is perceived as more pleasant by some patients Electrodes The electrodes must be placed on the painful area preferably on the points of sensitivity Intensity The intensity must be increased gradually until the patient feels a tingling sensation that is pronounced without being painful TENS Option No SHOULDER PAIN To relieve shoulder pain following a mechanical conflict an inflammatory disorder shoulder surgery or inflammatory tendinopathy For the relief of pain Using the Gate control principle This involves causing high levels of sensitivity impulses in order to limit the input of pain impulses when they return to the posterior horn of the spinal cord Pulse width The pulse width varies continuously with this programme This avoids habituation by using a system of stimulation that is perceived as more pleasant by some patients Electrodes The electrodes must be positioned where the pain is located Four large electrodes surrounding the joint produce a significant analgesi
118. ironment Recommendations Electrostatic discharge DES CEI 61000 4 2 6 kV at the contact 8 kV in air 6 kV at the contact 8 kV in air Floors must be wood concrete or ceramic tile If floors are covered with synthetic material the relative humidity must be maintained at a minimum of 30 Fast transient electrical bursts CEI 61000 4 4 2 kV for power supply lines l kV for input output lines Not applicable Battery powered device The quality of the electrical power supply should be that of a typical commercial or hospital environment Shock waves CEI 61000 4 5 l kV differential mode 2 kV joint mode Not applicable Battery powered device The quality of the power supply should be that of a typical commercial or hospital environment Voltage dips short interruptions and voltage variations on power supply lines CEI 61000 4 1 lt 5 VT dips gt 95 de UT for 0 5 cycle lt 40 VT dips gt 60 de UT for 5 cycles lt 70 VT dips gt 30 de UT for 25 cycles lt 5 VT dips gt 95 de UT or 5 seconds Not applicable Battery powered device The quality of the power supply should be that of a typical commercial or hospital environment If the Wireless Professional user requires continuous operation during mains power cuts it is recommend that the Wireless Professional is powered by a UPS or a battery Magnetic field at grid frequency 50 60 Hz C
119. ischarged battery symbol appears on the channel where the problem was detected in this case channel 4 e Stop the stimulation and recharge the discharged module Disuse atrophy Disuse atrophy PIENET Line sling EN VP oe Sr ree TES S TONAT Behaviour of the module led The LED blinks alternately green and red the module is out of range or is not recognised by the remote control e Check the remote control is properly turned on e Check that the module and the remote control are less than 2 metres away e Try restarting the module e Place the module and the remote control on the same docking station in order to pair them The LED is constantly red e Check the module is charged e Try restarting the module e If despite this the LED is still red contact the customer services that have been stipulated and approved by the manufacturer Behaviour of the docking station leds The docking station s central LED is red Ensure that the modules are properly placed in their housing e Ensure the charging contacts are clean e Remove all modules e Remove the remote control e Disconnect the USB cable e Ensure the correct AC adapter is used Disconnect and reconnect the docking station and check the lighting sequence of the docking station upon activation e If despite this the LED is still red contact the customer services that have been stipulated and approved by the manufacturer
120. it must be ensured that the stimulation energy levels are sufficient to obtain clearly visible muscle twitches leading to a marked hyperaemic effect so that the acid metabolites swamping the capillary bed of the contractured muscle can be drained away This treatment should be continued for at least ten sessions in order to restore the capillary network which is usually atrophic in chronically contractured muscles METHOD 1 Protocol Cervical pain 10 to 12 weeks 2 Treatment frequency Three to five sessions per week for two to three weeks 10 to 12 sessions in total Each session should last at least 20 minutes Ideally it may be beneficial to carry out two successive stimulation sessions with the Neck pain programme ensuring a ten minute rest period is taken between the two sessions to allow the stimulated muscles to recover EN VP Ree oe er ree RES STONA 3 Electrode position Depending on the location of the pain unilateral or bilateral one or two stimulation channels are used A small electrode is placed on the most painful point that can be found by palpation In most cases this point of maximum contracture is found in the levator scapulae or superior trapezius In the case of bilateral pain another small electrode is likewise placed on the most painful point For optimum effectiveness the positive pole of each module pod with an illuminated button should preferably be positioned on the painful area O
121. itation are first to relieve pain in the acute phase and then to restore the biomechanical and neuromuscular qualities of the shoulder METHOD 1 Protocol e Phase 1 Acute phase TENS The criterion for moving from phase 1 to phase 2 is achieving a shoulder that is not painful at rest Clinical examination often exposes a set of symptoms similar to those of rotator cuff tendinopathy for which the same therapeutic approach can be used This clinical presentation is the result of the compensatory mechanisms established during the acute phase e Phase 2 Disuse atrophy Level 1 then Disuse atrophy Level 2 VI EN WP ee re MES STONA 2 Treatment frequency Three to five sessions per week 3 Electrode position e Phase 1 Four large electrodes are placed in such a way as to cover the whole shoulder as well as possible e Phase 2 One stimulation channel for the infraspinous and supraspinous muscles One small electrode is placed on the fleshiest part of the infraspinous fossa The other small electrode is positioned on the external part of the supraspinous fossa For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the infraspinous muscle 4 Patient position e Phase 1 The patient is placed in the most comfortable position for him or her e Phase 2 The patient is seated with the arm against his her body the forearm
122. itive level 1 2 or 3 respectively Electrodes As a general rule the electrodes are placed on or near the painful area The electrodes may also be placed at the nerve trunks depending on the conditions being treated Intensity The intensity must be increased gradually until the patient perceives a tingling sensation that is pronounced without being painful Acclimatisation is normal if a non modulated TENS programme is used In this case it is advisable to slightly increase the stimulation energies on a regular basis so that the patient continues to feel a tingling sensation The mi TENS function prevents any kind of muscle contraction If the sensor detects a muscle response the stimulator automatically reduces the stimulation energy in order to stop the muscle response TENS Option No PULSE WIDTH MODULATED TENS Gate control which is activated during TENS stimulation is particularly effective for the relief of localised pain of non muscular origin It is particularly effective for relieving neuropathic pain and inflammatory conditions The sessions may be repeated at will depending upon the intensity of he pain Pain relief is now a priority in therapy which must be provided by all healthcare professionals As TENS treatment is generally palliative it improves the patient s comfort and helps the therapist to start the process The principle is to cause a significant influx of tactile sens
123. itivity in order to restrict the entry of pain impulses upon their return to the posterior horn of the spinal cord We must therefore stimulate he sensitivity fibres on the skin of the painful area To do this it is necessary to use a frequency hat is the same as the operational frequencies for the tactile sensitivity nerve fibres i e from 50 to 150 Hz Pulse width The pulse width varies continuously with this programme This avoids habituation by using a system of stimulation that is perceived as more pleasant by some patients Electrodes As a general rule the electrodes are placed on or near the painful area The electrodes may also be placed at the nerve trunks depending on the conditions being treated Intensity The intensity must be increased gradually until the patient perceives a tingling sensation that is pronounced without being painful TENS Option No Vee ee ree on er Nene ENDORPHINIC An increase in the tension of the contractured muscle fibres and the crushing of the capillary network resulting from this causes a decrease in the blood flow and a gradual accumulation of acid metabolites and free radicals Without treatment there is a risk that the contracture will become chronic and genuine atrophy of the capillary network may gradually occur To relieve chronic muscle pain Studying publications about reducing pain by increasing endorphin production shows that the pulses hav
124. ivated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes lectrodes positioned on the gluteal muscles must correspond to the specific indication Intensity he maximum tolerable stimulation energy which is one of the key factors determining the ffectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used Progressively increase the level of energy during the course of a treatment session TENS Option Yes A minimum of 1 channel with muscular work imposed by the Hip prosthesis programme Amaximum of 3 channels with the TENS programme Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels WP ee SS ree me oo TONAT PATELLOFEMORAL SYNDROME In conjunction with the rehabilitation of centred post traumatic chondropathy or decentred external subluxation of the patella patellofemoral syndromes To restore the trophicity of muscle fibres
125. joint This aspect of rehabilitation consists of producing peroneus muscle contractions using electro stimulation and using programmes designed for developing explosive force Only this method is really capable of developing the strength of these muscles effectively given the impossibility of feasibly being able to carry out active methods with this level of load EN VP ree oe ree RES S TONAT METHOD Protocol Treatment at an early stage e Reinforcement Level 1 Weeks 1 2 e Reinforcement Level 2 Weeks 3 4 Treatment at a late stage e Disuse atrophy Level 2 Weeks 1 2 e Reinforcement Level 1 Weeks 3 4 e Reinforcement Level 2 Weeks 5 6 If the patient is experiencing associated pain symptoms TENS stimulation can be performed in addition on the other channels In this case the specific practical rules for TENS electrode placement regulation of intensity should be followed for each channel used for this purpose 2 Treatment frequency Three sessions per week After the proprioceptive session or alternating one day on one day off 3 Electrode position A single channel is enough for the stimulation of the peroneus muscles A small electrode is placed under the head of the fibula at the passage of the Common Peroneal nerve The large electrode is placed mid way up the external lateral side of the leg For optimum effectiveness the positive pole of the module pod with an illuminated button
126. l 3 Week 4 then maintenance If the patient is experiencing associated pain symptoms TENS stimulation can be performed in addition on the fourth channel In this case the specific practical rules for TENS electrode placement regulation of intensity should be followed for this channel 2 Treatment frequency Five sessions per week during the first four weeks then one session per week to maintain the results after week four 3 Electrode position In this programme 3 stimulation channels are used for the quadriceps This is side of the patella Indeed this position places the quadriceps in inner range which is not general electrostimulation techniques since in this position the patient very often fee energies that ensure significant spatial recruitment can be difficult to achieve and therefore the effectiveness of the treatment Three small electrodes are pl just above For optimum effectiveness the positive pole of the module pod with an illum should preferably be positioned on the motor point 4 Patient position For this indication it is recommended to carry out the session with the patien because of the need to work with the knee extended in order not to cause excessive pressure on the posterior ly favourable to Is the contraction as being uncomfortable and even painful cramp sensation The use of high stimulation in some patients The third stimulation channel overcome
127. lated in accordance with the instructions Intensity Use the maximum stimulation energies The first and second sessions help the patient become accustomed to the method by gradually increasing the stimulation energy every 3 or 4 contractions In the following sessions it is important to support the patient s progress by setting targets which go beyond the energy levels reached in the previous session TENS Option Yes A minimum of 1 channel with muscular work imposed by the Reinforcement programme A maximum of 3 channels with the TENS programme e Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels VPC ee er ree me oo hear PREVENTION OF DISUSE ATROPHY After an operation or a bone fracture a limb or a section of a limb is immobilised the muscles of this part of the body are affected very quickly by disuse atrophy This rapid decrease in muscle volume is mainly due to reflex inhibition and a total absence of muscle activity It is also important to note that di
128. llows J Q q Fit gt or Q It I stimulation current intensity t pulse duration therefore It q it by dividing the two by t Lapicque obtained l q tti which is the relationship between the intensity of the current and the time period in d which it must be applied to achieve stimulation Fig 3 Y a a a a al is EN Fig 3 Intensity duration curve 2Rh Rheobase ie N d Hyperbolic relationship between the current intensity and pulse duration demonstrated by Lapicque and given by the formula q t i derived from Weiss fundamental formula Lapicque s development also shows that even when the length of time that the current is applied is infinite t ce the current must have a minimum intensity known as the rheobase Rh in order to produce stimulation if t co therefore q t O in this case is the rheobase Rh and Rh i The rheobase which is the minimum intensity that must be achieved in order to produce stimulation even if the pulse duration is very long actually corresponds to the coefficient i of the Weiss formula which has dimensions of electrical intensity Lapicque gave the name chronaxy to the minimum length of time in which a current with double the intensity of the rheobase must be applied in order achieve stimulation In fact he realised that the chronaxy is a time constant which characterises the excitability of tissue and that its value is
129. luntary proprioception exercises until the recovery of strength and endurance corresponding to functional requirements 2 Treatment frequency 3 Electrode position should preferably be posi Three to five sessions per week supraspinous fossa connected to th For optimum effectiveness the pos tioned on e Phases 1 and 2 Three channels for stimulation of the deltoid and the spinal muscles For the deltoid one small electrode is placed on the anterior bundle of the deltoid and another small electrode is placed on the middle bundle A large two way electrode is placed on the shoulder above the acromion For optimum effectiveness the positive poles of the modules pods with an illuminated button should preferably be positioned on the small electrodes For the spinal muscles a small elec fossa connected to the positive pole A small electrode is positioned at the external part of the trode is placed on the fleshiest part of the infraspinous e negative pole but not over the rear deltoid itive pole of the module pod with an illuminated button the infraspinous muscle EN AP ee ee er en ee eee e Phase 3 A small electrode is placed on the fleshiest part of the infraspinous fossa and the other small electrode is positioned on the external part of the supraspinous fossa For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positione
130. lways Moreover this oedema may be present or absent in the same patient depending on the time of day and how much time the patient has spent standing up We must therefore distinguish between 1 Venous insufficiency without oedema 2 Venous insufficiency with oedema The implications for the type of the electrostimulation programme are different depending on whether there is or is not an oedema associated with varicose veins 1 Venous insufficiency without oedema On one hand electrical stimulation must allow for an increase in the general blood flow arterial as well as venous so as to improve the circulation of the interstitial fluid and increase oxygenation of the tissues and the intima of the veins On the other hand it is necessary to drain the veins as much as possible to combat stasis The increase in arterial flow and therefore capillary flow and therefore venous flow is achieved by means of the optimum low frequency for increase of flow i e 8 Hz The deep veins are drained by being compressed which is caused by tetanic contractions of the leg muscles The programme therefore consists of short tetanic contractions of the leg muscles separated by long active pauses to increase the flow VI EN Wee ce SS reo RES S TONTA METHOD 1 Protocol Venous insufficiency 1 2 Treatment frequency 3 to 6 sessions per week for approximately 6 weeks to treat the acute episode It is then recommended to keep
131. made you can access the programmes themselves To select an item use the navigation pad up down and confirm your choice with the centre button Rehabilitation Muscle lesion A Name of the programme category Motor Point B Additional programme information 4 Disuse atrophy 1 B C Visualisation of programme options D Back to main menu Prevention of dishise atrophy Reinforcemen E Adding programme to Favourites list A a fr F Selection of programme level G Configuration of programme options o F c Additional information about the programme is available using the navigation pad left right A Placement of electrodes applicable to the programme B Programme parameters C Programme explanation HOW By using frequencies creating a tetanic contraction in type fibres to impose a significant workload 4 on the atrophied muscle so that it gt recovers volume Recovery therefore takes place far more qui than by simply using muscle activities ELECTRODES a 5 1 1 PROGRAMME OPTIONS For most programmes options can be enabled or disabled To select an item use the navigation pad up down and display the different choices using the central button a i a N Options Synchronisation signal A Validation of choices E The options described below are not available for all programmes EN WTRECT
132. mfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned according to the specific indication Intensity Stimulation energies must be increased as high as possible whilst still remaining comfortable for the patient TENS Option No ARTERIAL INSUFFICIENCY 2 Arterial insufficiency in the lower limbs is conventionally divided into four clinical stages These four stages I Il Ill IV depend on the approximate severity of the loss of blood flow and the tissue related consequences The Arterial insufficiency 2 programme is used to treat Stage III At Stage III the severity of the arterial occlusion causes constant pain which occurs even at rest To improve oxygen uptake by the muscles to reduce muscular pain at rest and partially restore muscular tolerance to exertion To avoid further reducing the supply of oxygen to the muscle fibres the contractions remain infra tetanising 7 Hz and are separated by long periods of active rest 2 Hz in order to avoid muscular fatigue Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function
133. mrest e Upper limb patient seated triceps elbow in supination Extensors of the fingers and wrist wrist in pronation g 5 Stimulation energy Always work with an energy that is too low to produce muscle fibre stimulation in the spastic muscles The stimulation energy must however be adjusted manually so that the isotonic contraction of the antagonist muscle causes movement to the maximum range of motion thus creating maximum stretch of the spastic muscle This action cannot be carried out if the agonist antagonist imbalance is too great this occurs when spasticity of a muscle exceeds the contraction strength of its atrophied antagonist Stimulation then only allows for more or less reduced movement or even no movement at all However the treatment should be carried out even in this situation because stimulation even subliminal has a beneficial effect on the reduction of spasticity 6 Manual activation of stimulation When the mi SCAN is activated by default the stimulation session starts automatically with a measurement of the chronaxy This is a short test lasting around ten seconds which allows the optimum duration of the stimulation pulse to be adjusted ensuring maximum comfort The energy should then be gradually increased to cause the first contraction of the antagonist muscle Each contraction is followed by a five second rest period Once this rest period has finished press any button on any channel t
134. mulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used Progressively increase the level of energy during the course of a treatment session TENS Option Yes A minimum of 1 channel with muscular work imposed by the Reinforcement programme A maximum of 3 channels with the TENS programme e Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels VP eo er re mo TONAT Programmes for haemophiliacs ATROPHY REINFORCEMENT To prevent disuse atrophy or restore muscular qualities in haemophilia patients suffering from arthropathy Repeated episodes
135. mum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the lower electrode which corresponds to the motor point of the tibialis anterior N ee A 4 Stimulation energy Use the energy necessary to achieve slight dorsiflexion that is enough to prevent the foot from dropping while walking In this application there is nothing to be gained from producing a more powerful contraction that might diffuse into the antagonists Activate the contraction by pressing any key on any channel As this contraction phase is very short rapidly increase the energy of channel 1 until satisfactory dorsiflexion is achieved 2 Spasticity A Reminder Spasticity or spastic hypertonia is a term which describes the condition of paretic or paralysed muscles showing different symptoms to varying degrees including in particular an increase in muscle tonus mainly in the antigravity muscles hyperreflexia and clonus During passive stretching of a spastic muscle there is resistance at the beginning of the movement which then diminishes in the course of extension The more rapid the passive stretching movement the stronger this resistance If passive stretching is very rapid and is maintained clonus may occur i e a contractile oscillation of 5 to 7 Hz which persists for 40 to 60 cycles for as long as the stretching is maintained g A ee ee RES STONA EN Spas
136. n activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Electrodes The maximum tolerable stimulation energy which is one of the key factors determining the Intensity effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option No FIRMING Indicati For use as a primary treatment for muscle toning The firming programmes produce moderately ndication p intense exercise and aim to increase the tension in the muscle fibres Effects To regain muscle firmness and restore the support function of the muscles To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the Pulse width patient s muscles Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Electrodes The maximum tolerable stimulation energy which is one of the key factors determining the Intensity ffectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option No Indicat
137. n automatic trigger In this case the programme options must be modified 7 Associated actions e Passive mobilisation When contraction of the extensors is insufficient to mobilise the fingers and wrist to their maximum range the movement should be completed by passive extension The electrically induced contraction is allowed to develop until the maximum extension it can produce is achieved The movement is then completed by applying gentle and gradual pressure I EN Vee oe er rere RES STONA 4 The hemiplegic shoulder A Reminder One of the specific problems commonly encountered in hemiplegic patients is subluxation of the paretic or paralysed shoulder Atrophy with loss of strength which affects the abductor muscles of the arms deltoid and supraspinatus muscles results in an inability to provide satisfactory support for the head of the humerus In addition more or less pronounced spasticity of the depressor muscles of the shoulder pectoralis major and latissimus dorsi causes a downward pull on the head of the humerus which adds to the pull caused by the weight of the limb This situation commonly leads to the displacement of the head of the humerus from the glenoid cavity Radiologically it is clear that the axis of the anatomical neck of the humerus no longer passes through the centre of the glenoid cavity This is inferior subluxation This subluxated shoulder can often cause pain The pain can remain localised
138. n tingling that is not considered painful For neuromuscular electrostimulation programmes which do not cause tetanic muscle contractions frequencies lt 10Hz the energies must be increased gradually until muscle twitching is produced that can be clearly seen or felt Progression through the different levels Generally speaking it is not advisable to progress through the levels too quickly and to aim to reach the maximum level too quickly The different levels correspond to progression in rehabilitation using electrostimulation Furthermore and without exception level 1 is the starting point and should be used until the therapeutic targets have been reached One of these targets is for the patient to be able to tolerate a significant amount of stimulation energy Stimulation energies should therefore be given priority in order to have a many fibres working as possible before changing the level a a a SPRO RES S TONTA EN 7 3 NEUROSTIMULATION PROGRAMMES REHABILITATION VASCULAR Treatment of disuse atrophy 61 Heavy legs 70 Reinforcement 62 Venous insufficiency 71 72 Prevention of disuse atrophy 63 Arterial insufficiency 73 Muscle lesion 64 Cramp prevention 74 Motor point 65 Capillarisation 75 PAIN RELIEF CONDITIONING TENS Gate control 100Hz 65 Resistance 76 Frequency modulated TENS 65 Strength 76 Pulse width modulated TENS 66 Active recovery 77 Endorphinic 67
139. n activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active In addition the mi functions apart from mi SCAN and mi RANGE are no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels LUMBOSCIATICA Patients with lumbosciatica have lumbar pain which is most commonly caused by chronic contractures of the paravertebral lumbar muscles In addition involvement of the spinal nerve root leads to irradiation of pain over a shorter or longer distance along the sciatic nerve and in some cases along one or the other of its branches common peroneal or tibial For pain relief and relaxation of muscle contractures in the lumbar area and to relieve neurogenic sciatic pain he release of endorphins and the elimination of acidic toxins allow lumbar pain to be treated ffectively The TENS Gate control effect works more specifically on sciatic nerve neuralgia Pulse width Endorphinic stimulation is primarily aimed at the sensitive A5 nerve fibres which are best stimulated with pulse width of 2001s However the vascular effect is secondary to the co activation of the motor units which have a slightly higher chronaxy that is measured at the start of the session using the mi SCAN function activated by default Channels 2 3 and 4 provide Gate control stimulatio
140. n and use a larger pulse adapted to the chronaxy of the AB fibres Electrodes ectrodes positioned according to the specific indication Combining 2 stimulation currents Endorphin and TENS Gate control requires care to switch on the modules in the correct order Intensity he intensity must first be set on channels 2 3 and 4 which deliver the TENS programme according to the usual TENS rules tingling It will be gradually increased on channel 1 until visible or palpable muscle twitches are produced The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option Yes forced A minimum of 1 channel with muscular work imposed by the Lumbosciatica programme 3 channels with the TENS programme Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from mi SCAN and mi RANGE are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels Were ce oS Sr ree MES STONA LUMBAGO This type of treatment is indicated to relieve pain following acute
141. naware Changes and improvements in electrotherapy are so numerous that this discipline appears to be a new concept that can only be applied correctly and effectively using sophisticated high tech equipment The aim of these articles is to develop this new concept for potential users and provide anyone already working with this equipment with explanations and data that will allow them based on current knowledge and scientific work carried out to optimise the use of their stimulators A The fundamental law of electrostimulation Electrostimulation is a technique which involves producing action potentials in the excitable cells nerve and muscle using an electric current Nerve cell membranes have a resting potential with an average value of 70mV as the internal face of the membrane has negative polarity compared to the external face To excite the membrane of the nervous fibre i e causing an action potential to appear at its surface the resting potential simply has to be reduced to a certain threshold value which is 50 mV on average Fig 1 Once this threshold value has been reached the membrane changes from a state of rest to a state of activity An action potential appears which then moves along the nerve fibre The nerve impulse either goes towards the muscles to instruct them to contract or returns from the surrounding areas towards the brain to relay information regarding the senses Electrostimulating the nerve fibre essentially
142. ne or two small electrodes are placed on the cervical paravertebral muscles at C3 C4 level 4 Patient position The patient is placed in the position most comfortable for him her prone position or seated facing a medical table with a chest support 5 Stimulation energy The energy must be increased gradually until it causes clearly visible muscle twitches which are required to induce hyperaemia The mi RANGE function makes it possible to work with certainty within a therapeutically effective range The stimulator prompts you to firstly increase the level of energy a beep sound accompanies the flashing symbols When it detects that the muscles have started to pump the symbols will stop flashing You are at the minimum level of energy that provides therapeutic results If the stimulation is well tolerated by the patient it is advised to increase the energy level slightly At the end of the treatment or during a break a statistic showing the percentage of time spent in the effective range will appear on the screen Vd 2 Endorphinic treatment of thoracic back pain Whatever the trigger chronic contractures of the dorsal paravertebral muscles erector spinae are responsible for the pain that incapacitates patients suffering from thoracic back pain Provided that sufficient stimulation energy is used to obtain clear muscle twitches the dorsalgia treatment thanks to the remarkable hy
143. neck muscles Intensity An essential factor in the therapeutic efficacy is to cause visible muscle twitching which may in certain cases require higher stimulation energies to be used The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option Yes A minimum of 1 channel with muscular work imposed by the Torticollis programme Amaximum of 3 channels with the TENS programme e Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from mi SCAN and mi RANGE are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels ARTHRALGIA Various factors such as obesity age trauma poor posture etc are detrimental to the joints These detrimental factors may cause the joints to deteriorate and to become inflamed and painful To relieve acute and chronic joint pain The principle is to cause a significant influx of tactile sensitivity in order to restrict the entry of pain impulses upon their return to the posterior horn of th
144. nergy To overcome this problem the TENS function allows you to combine a TENS programme with a selected basic programme To activate this function simply press the TENS button and the last activated channel will be switched to TENS and the word TENS will appear next to the relevant channel To activate other channels in TENS simply re press the TENS button N B The first channel cannot be switched to TENS under any circumstances Depending on the programmes or placement of electrodes the number of TENS channels available may vary Start of stimulation session Mi scan measurement This function adjusts the electrostimulation session to the physiology of each patient Just before starting the work session mi SCAN tests the muscle group and automatically adjusts the settings of the stimulator to the excitability of this area of the body This is a truly personalised measurement Therefore in order to ensure optimum efficiency and comfort of the session it is strongly advisable to perform the mi SCAN measurement before each session This function is implemented at the beginning of the programme by a short sequence in which measurements are made Throughout the duration of the test it is important to stay still and be perfectly relaxed When the test is complete the programme can begin During the stimulation session Stimulation always starts at 0 Use the navigation pad up down to increase or decrease the stimulation energy on select
145. note This programme has two distinct energy levels First adjust the intensity level for 80 Hz TENS until a tingling sensation is felt then repeat the procedure for 2 Hz endorphinic in order to produce visible muscle twitches TENS Option No VAP ee ee re eo her ere DECONTRACTURING This type of treatment is indicated to relieve pain following acute muscle contractures torticollis lumbago etc It will also reduce muscle tension in the contracted muscles to facilitate manual handling techniques To decrease muscle tension Current experiments show that muscles twitches caused by a very low frequency of 1 Hz can effectively remove contractures or decrease resting muscle tension of the stimulated muscle Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes must be placed after a thorough palpatory examination to locate the most painful point where a small electrode preferably connected to the positive pole of the module pod with an illuminated button will be placed The other electrode is placed at the end of muscle or muscle group being stimulated If a contracture affects all the muscle fibres the electrodes suitable for neuromuscular
146. nough the unit beeps and a sign appears on channels you must increase the stimulation energy to get good shaking Similarly in order to make these twitches possible it is imperative that the muscles are properly relaxed during the resting phase Care should be taken at the end of each contraction phase to get back into a position allowing the best muscle relaxation Trigger ON Manual triggering Automatic stop It is an operating mode in gt which the contraction from electrostimulation is triggered by the user by sill pressing any button on any channel multifunction buttons on the remote control Contraction will stop automatically at the end of the time set by the programme The Trigger ON mode is active during muscle work sequences it is not operational during sequences of warm up and relaxation Synchronisation signal fl Synchronisation signal This function allows you to notify the user by means of l a sound signal of the beginning of a muscle contraction 4 Il Before each contraction by electrostimulation the remote control emits beeps This function is only available for programmes inducing powerful muscular contractions and is functional only during the muscular work sequence contraction active rest 5 2 CONNECTING MODULES TO THE ELECTRODES Once the electrodes are stuck to the skin of the patient fix the pods by sliding them onto the electrode snap until it clicks into place To remove the module from
147. nsic factors vascularisation deficiency structural abnormality of collagen fibres etc or extrinsic factors excessive mechanical stress kinematic defects etc sometimes combined these can be considered as causes of tendon dysfunctions Kinematic defects appear to play an important role and most often involve limitations in range of motion pain phenomena and functional constraint The limitations in range of motion observed in specific tests involve flexion elevation and or abduction A limitation in flexion shows anterosuperior misalignment while a limitation in abduction shows misalignment in medial rotation spin Recovery of range of motion is obtained after correction of the joint misalignment which must be performed using appropriate techniques Neuromuscular control work must be focused on the coordination muscles the muscles depressing the humeral head and the lateral rotators The priority given for many years to the latissimus dorsi and pectoralis major muscles is strongly disputed today due to the medial rotation component of these muscles In fact the only muscles enabling these mechanical requirements to be satisfied are the supraspinous and infraspinous muscles which neuromotor rehabilitation including electrostimulation will focus on as a primary objective METHOD 1 Protocol e Phase 1 TENS and Decontracture if required Phase 2 Rotator cuff Level 1 TENS in case of persistent pain e Phase 3 Rotator cuff
148. ntal observation that to achieve stimulation it is not the type of current that is significant but the quantity of current in a specified period of time In other words if the stimulation threshold values are given as a quantity of electricity in electrical charges that must be created to achieve these the values are similar even if the electrical pulse with the same overall duration is a different shape As areminder the quantity of electrical charges supplied by an electric current with intensity in a given time 2 is the product of the intensity multiplied by the time Q xt VI EN WTRECTES a ad ty al Since the quantity of electrical charges provided by the stimulation current is the fundamental factor Weiss studied the way in which the necessary quantity of charges is modified in order to achieve the threshold i e to cause stimulation based on the duration of the current being applied He performed a series of measures to determine the relationship between the quantity of current and the duration of the pulse for durations ranging from 0 23 to 3 ms From his experiments Weiss found that there is a linear relationship between the quantity of charges required to reach the stimulation threshold and the duration of the pulse Fig 2 Fig 2 Q Quantity of current required to reach the stimulation threshold d Duration of the pulse 0 2 ms 3 ms t Linear relationship between the dura
149. o complaint In Stage II the reduction in the flow causes pain in the legs when walking At rest the flow is sufficient but it cannot meet tissue requirements during physical activity the patient suffers from intermittent claudication IC This means that pain occurs after walking a certain distance the shorter the distance the more severe the condition in the end this pain makes the patient stop then after a recovery period the pain lessons and the person can resume walking until the cycle starts again Stage III is characterised by constant pain including when at rest Blood flow is so reduced that the tissues constantly suffer from hypoxia with a continual presence of acid metabolites Stage IV corresponds to suffering that is so advanced that tissue necrosis with gangrene occurs This is then called critical ischaemia a condition which often leads to amputation Only Stages II and III can benefit from treatment by electrostimulation Stage IV is an emergency situation and requires surgical treatment Stage is asymptomatic and the patient has no complaint 1 Stage II arterial insufficiency With intermittent claudication Stage II the muscle fibres suffer from an oxygen shortage during physical activity The narrowed arteries cannot meet the fibres need for oxygen which increases with walking With a chronic reduction in blood flow and a lack of oxygen the capillary network degenerates and the fibres lose
150. o trigger the next contraction By doing so each contraction is triggered and therefore controlled by a manual action This technique provides a clear psychological benefit for the patient who can trigger contractions with his her good hand and it also makes it possible to work synchronously with the associated movements The manual trigger of the contraction function activated by default can be replaced by an automatic trigger In this case the programme options must be modified 7 Associated actions Passive mobilisation When the severity of spasticity causes a marked imbalance between the spastic muscle and its antagonist and there is a risk of joint stiffness the therapist can complete the movement induced by stimulation using passive mobilisation or gravity assisted posture EN VP oe er ree oe Narn 3 The hemiplegic hand In hemiplegic patients the hand and wrist show paresis or even paralysis with more or less pronounced spasticity of the flexor muscles and atrophy of the extensors This highly debilitating situation can develop into retraction stiffening and misalignment if regular treatment is not initiated This specific indication is an example of using the Spasticity programme for the area most commonly affected by debilitating spasticity METHOD Protocol Spasticity If the patient is experiencing associated pain symptoms TENS stimulation can be performed in addition on the other channels In
151. odes Electrodes positioned depending on the muscle to be stimulated in accordance with he instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option No We ee re er on TONAT Indication LOW BACK REINFORCEMENT The low back muscles play an important role in protecting the lumbar region Some sporting activities such as rowing require specific work from the low back muscles Effects Improve the active stability and contraction qualities of the lumbar region This programme enables these muscles to be worked in an intense and isolated manner in order to maintain and improve the strength of the low back muscles Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles in the lumbar region The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Place the electrodes on the paravertebral muscles of the low back area Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor
152. ogramme only works with 4 modules switched on Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels WTRECTESS PRO a STONA ATROPHY MODULATED FREQUENCY Use on weakened muscles following immobilisation or restricted activity The programme imposes a work regime adapted to the physiology of the type fibres where the qualities have been altered during muscle disuse atrophy Progressive incrementation of the frequency 25 40Hz at the beginning of each contraction may improve the comfort of the stimulation in hypersensitive patients To make it as comfortable as possible for the patient use pulse widths equivalent to the Pulse width hronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes positioned depending on the muscle to be stimulated in accordance with Electrodes the instructions The maximum tolerable stimulation energy which is one of the key factors determining the it effectiveness of the treatment The higher the stimulation energy the higher the number of ntensi ty uscle fibres motor units being used Progressively increase the level of energy during the course of a treatment session Yes A minimum of 1 channel with muscular work imposed by the At
153. ore than 3 months This limitation results from the thickening inspissation and fibrosis of the joint capsule with recess disappearance which translates into a loss of active and passive shoulder mobility This affliction is idiopathic in a third of cases but in the other two thirds there is a prior shoulder pathology that can be of a highly variable nature shoulder trauma shoulder surgery hemiplegia subacromioncoracoid impingement etc The diabetic population is particularly at risk with 20 of this population presenting capsulitis at some stage Note that the initial development is a reflex sympathetic dystrophy even if this does not exactly conform with a strict definition of the term since it essentially affects the limb extremities this reflex sympathetic dystrophy then regresses as the capsule fibrosis and the joint ankylosis develop Clinically we see the development of a first entirely painful acute phase then the shoulder gradually loses mobility as the pain recedes then the shoulder is just stiff and painless At this point there is a loss of active and passive mobility affecting especially the abduction and external rotation of the shoulder external rotation is reduced to at least 50 compared to the healthy side There is spontaneous evolution towards recovery for a period of time that varies from 3 months to 2 years depending essentially on the quality of the rehabilitation treatment used The objectives of rehabil
154. over the whole shoulder A small electrode is placed at the level of the supraclavicular cavity and another small electrode is positioned on the bony protrusion of the acromion Lower limb Distal RSD of the lower limb Four large electrodes are used to surround the ankle and foot A small electrode is placed in the middle of the Popliteal fossa another small electrode is placed similarly one finger s breadth above Were ce SS reo RES S TONAT EN RSD of the knee Four large electrodes are used to cover the knee and surround the kneecap A small electrode is placed at the level of the inguinal fossa just beside the femoral artery and another small electrode is placed similarly one finger s breadth above it 4 Patient position The most comfortable position for the patient To improve the irradiation of the tingling sensation caused by neural stimulation it is recommended to exert a slight pressure on the small electrodes placed on the nerve being targeted bag of sand weighing 1 or 2 kg cushion placed between the chest and arm etc 5 Stimulation energy The stimulation energy must first be adjusted on the third channel module started in third position which stimulates the target nerve at the axilla supraclavicular popliteal or inguinal regions The energy level is gradually increased until the patient feels paresthesia tingling at the end of the limb being
155. peraemia it causes will be particularly effective for draining the metabolic acids that have built up in the contractured muscle A significant analgesic effect will therefore usually be observed in the first treatment sessions This treatment should however be continued for at least ten sessions in order to restore the capillary network which is usually atrophied in chronically contractured muscles METHOD Protocol Thoracic back pain 10 to 12 sessions 2 Treatment frequency Three to five sessions per week for two to three weeks 10 to 12 sessions in total A session should last at least 20 minutes Ideally it may be beneficial to carry out two successive stimulation sessions within the Thoracic back pain programme ensuring however a ten minute rest period between the two sessions to allow the stimulated muscles to recover Were Ce er ree RES STONA EN 3 Electrode position The points of maximum contraction are usually bilateral but not always symmetrical therefore two stimulation channels are used Two small electrodes are placed on the most painful points which can be easily located by palpatory examination of the painful area For optimum effectiveness the positive pole of each module pod with an illuminated button should preferably be positioned on the painful area Two other electrodes also small ones are placed on the top of the erector spinae muscles a few centimetres above or below the electro
156. phase where the foot is lifted off the ground To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves for the levator muscles of the foot tibialis anterior The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Pulse width Electrodes Electrodes positioned on the levator muscles of the foot corresponding to the specific indication In this case use an intensity that is sufficient to provide a degree of contraction that can cause Intensi ty dorsiflexion of the ankle during the swing phase of the gait TENS Option No SPASTICITY Spastic hypertonia develops in the different types of lesions of the central nervous system pathways Since it is no longer under the control of the higher nervous centres the myotatic reflex becomes hyperactive and hypertension develops predominantly in the anti gravity muscles Over time spasticity may lead to muscle contractures and a decreased range of movement To reduce spasticity by inhibiting the motor neurons of the spastic muscle through reciprocal inhibition reflex Stimulating the antagonistic muscle to the spastic muscle by reciprocal inhibitory reflex This programme has a very gradual rate of tensioning and does not use low frequencies in order to avoid triggering the myotatic reflex monosynaptic stretch reflex of the spastic mu
157. ple disuse atrophy of the quadriceps Traumas of the locomotive system can be extremely diverse fractures sprains dislocations etc and have varied functional repercussions Despite immense progress in orthopaedic medicine it is still common practice to have a period of immobilisation of the area concerned which can be total or partial The result is always a significant reduction in the normal activity of the muscles in the traumatised region The rapid disuse atrophy which occurs reduction in the muscle volume and the muscle tissue s ability to contract can sometimes compromise the functional future of the patient The physiological mechanisms involved in the alteration of the different muscle fibres under such circumstances are well known and therefore extremely specific treatments can be proposed which can produce optimum benefits on their own This standard protocol is recommended for the majority of cases of functional disuse atrophy However this protocol can be adapted depending on the pathology the treatment objectives and the speed of the patient s recovery METHOD 1 Protocol e Disuse atrophy Level 1 Weeks 1 2 During the first two weeks of treatment the following 3 objectives must be worked towards and achieved Eliminate muscle wastage Familiarise the patient with the NMES technique so that the patient can work with high levels of stimulation energy Obtain the first signs of regain of trophicity sli
158. rea e Sufficient stimulation energy to produce a Clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from mi SCAN and mi RANGE are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels EPICONDYLITIS Epicondylitis is manifested by acute pain located at the point of insertion of the extensor muscles for the wrist and fingers onto the lateral epicondyle The Epicondylitis programme is used during the acute and inflammatory phase of the complaint It can also be used for localised pain at the medial epicondyle which results from functional overwork of the flexor muscles epicondylitis or medial epicondylitis To relieve pain during the acute and inflammatory phase of the complaint Using the Gate control principle This involves causing high levels of tactile sensitivity impulses in order to limit the input of pain impulses when they return to the posterior horn of the spinal cord For this programme the frequency is modulated 50 150 Hz to avoid habituation Pulse width This programme uses very short duration impulses 50 ps suitable for the higher level of excitability of the sensitive AB fibres Electrodes Due to the
159. rence may occur close to any appliance identified by the following symbol o NOTE 1 At 80 MHz and at 800 MHZ the high frequency amplitude is applied NOTE 2 These guidelines may not be appropriate for some situations Electromagnetic wave propagation is modified by absorption and reflection due to buildings objects and persons a The field intensity from fixed transmitters such as radio telephone base stations cellular wireless and a mobile radio amateur radios AM and FM radio transmissions and TV transmissions cannot be predicted with any accuracy It may therefore be necessary to consider an analysis of the electromagnetic environment of the site to calculate the electromagnetic environment coming from fixed RF transmitters If the field intensity measured in the environment where the Wireless Professional is located exceeds the appropriate RF observance level above the Wireless Professional should be monitored to ensure it is operating properly In the event of abnormal operation new measures may then be imposed such as realignment or movement of the Wireless Professional b Above the frequency amplitude from 150 kHz to 80 MHz the field intensity must be lt 3 V m RECOMMENDED SPACING BETWEEN A PORTABLE AND MOBILE COMMUNICATION DEVICE AND THE WIRELESS PROFESSIONAL is designed for use in an electromagnetic environment in which radiated RF waves are The Wireless Professiona controlled The buyer or user of th
160. ress the following can gradually be added to the exercises Additional movement of an upper limb lifting up an arm Additional movement of a lower limb taking one foot off the floor Quick movements of two upper limbs throwing and catching a ball lC 6 Stimulation energy In NMES the stimulation energy is directly responsible for spatial recruitment the higher the stimulation energy the higher the percentage of motor units recruited and the greater the impact of the progress The general rule is to always try to increase the energy to the maximum level tolerated by the patient The therapist plays a fundamental role by encouraging and reassuring the patient who can then tolerate levels of energy that produce powerful contractions The levels of energy reached must increase throughout the session and also from session to session because the patients quickly get used to the technique Treatment of patellofemoral syndrome A distinction must be made between two types of patellofemoral syndrome 1 With patellar mal tracking which means the patella is not running centrally in the trochlear groove commonly being pulled laterally 2 Without patellar mal tracking i e with a centred patellofemoral syndrome as in post traumatic chondropathy The proposed protocols are based mostly on the studies carried out by Dr Gobelet University Hospital of Lausanne Switzerland Physical Medicine Department and by Dr D
161. rhezen College of Physiotherapy Li ge Belgium 1 Lateral tracking An essential cause of the mal tracking of the patella is determined by an imbalance between the different heads of the quadriceps muscle A particularly significant weakness of the vastus medialis in comparison with the vastus lateralis creates a lateral displacement of the patella with hyperpressure between the lateral condyle and the adjacent retropatella surface Specific reinforcement of the vastus medialis is the ideal way to treat this pathology It can be enhanced effectively with electrostimulation EN VP ree oe ree RES S TONAT METHOD Protocol e Patellofemoral syndrome Level 2 Weeks 1 2 e Patellofemoral syndrome Level 3 Weeks 3 4 If the patient is experiencing associated pain symptoms TENS stimulation can be performed in addition on the other channels In this case the specific practical rules for TENS electrode placement regulation of intensity should be followed for each channel used for this purpose 2 Treatment frequency Three sessions per week 3 Electrode position Only one channel is used Place a small electrode on the distal motor point of the vastus medialis which innervates the oblique fibres A second electrode is placed at the upper end of the vastus medialis at around mid thigh level For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be po
162. rical medical equipment e Exercise caution when using electrotherapy while the patient is connected to monitoring equipment with electrodes attached to the body Stimulation could disrupt the signals sent to the monitoring equipment e Do not disconnect any module that is switched on during the stimulation session They must be switched off first e Always use the AC adaptor provided by the manufacturer to recharge the unit e Never use the Wireless Professional or the AC adaptor if it is damaged or open There is a risk of electric shock e Disconnect the AC adaptor immediately if there is abnormal heating or smell or if smoke comes from the AC adaptor or the device e Do not place the docking station in a confined space carrying case drawer etc when charging the device There is a risk of electrocution e Keep the Wireless Professional and its accessories out of reach of children Do not allow any foreign bodies soil water metal etc to penetrate the device or the AC adaptor e Sudden temperature changes can cause condensation to build up inside the stimulator Only use the device once it has reached ambient temperature e Do not use the stimulator while driving or operating machinery e Do not apply stimulation during sleep Do not use the stimulator at altitudes of over 3 000 metres e When the remote control is not connected to a docking station the USB connector can only be used to connect to a computer
163. rogramme Electrodes positioned on the painful area e Sufficient stimulation energy to produce a Clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels REINFORCEMENT For use either on previously atrophied muscles which have regained their volume as a result of electrostimulation through disuse atrophy treatment programmes or as a first line on non atrophied muscles which have lost their strength and speed of contraction To restore the strength of the contraction in the case of muscle insufficiency without pronounced disuse atrophy or after restoration of muscle volume By using frequencies creating a tetanic contraction in the quick fibres type IIb which are the strength and speed fibres Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimu
164. rom chronic contractures of the levator scapulae muscle and or the upper trapezius and is due for example to non ergonomic work posture For pain relief and relaxation of muscle contractures Endorphin stimulation aids pain relief by increasing production of endogenous opioids The associated vascular effect results in effective drainage of acidic metabolites and enables the elimination of muscular acidosis Pulse width Endorphin stimulation first targets the sensitive Ad nerve fibres which are best stimulated with a larger pulse of 200s However the vascular effect is secondary to the co activation of the motor units which have a slightly higher chronaxy that is measured at the start of the session using the mi SCAN function activated by default Electrodes Electrodes positioned according to the specific indication Intensity An essential factor in the effectiveness of electrotherapy is the ability to cause visible muscle twitches The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option Yes A minimum of1 channel with muscular work imposed by the Cervical pain programme Amaximum of 3 channels with the TENS programme Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the me
165. rophy programme A maximum of 3 channels with the TENS programme Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation TENS Option Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels REINFORCEMENT MODULATED FREQUENCY For use either on previously atrophied muscles which have regained their volume as a result of electrostimulation with disuse atrophy treatment programmes or as a first line treatment on non atrophied muscles which have lost their strength and speed of contraction The programme imposes a work regime adapted to the physiology of the type II fibres to restore contraction strength in the case of muscular insufficiency without marked disuse atrophy or following recovery of muscle volume Progressive incrementation of the frequency 35 60 Hz at the beginning of each contraction may improve the comfort of the stimulation in hypersensitive patients Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being sti
166. s N B This particular stimulation mode does not allow for work in mi ACTION For ligamentoplasty using the patellar tendon as the graft the NMES can be started promptly When using doubled semitendinosus and gracilis tendons for ligamentoplasty NMES must not be used before the standard healing period of these tendons EN VP ree oe ree RES S TONAT METHOD Protocol e ACL Weeks 1 16 During the first two weeks of treatment the following 3 objectives must be worked towards and achieved Eliminate muscle wastage Familiarise the patient with the NMES technique so that the patient can work with high levels of stimulation energy Obtain the first signs of regaining trophicity slight increase in volume improvement in tone etc During the following weeks the objective is the restoration of near normal muscle volume When open kinetic chain exercises are permitted which is normally at the end of the fourth month after the operation NMES of the quadriceps can be continued using the Reinforcement programmes Level 1 then 2 2 Treatment frequency One to two sessions every day if two sessions are carried out every day enough time must be given to rest between the two sessions Minimum three sessions per week 3 Electrode position The stimulation sequence means that the order of channel numbers must be complied with as the stimulation of the hamstrings must start before that of the quadriceps Ch
167. s quadriceps etc In order to guarantee optimum effectiveness of the programmes PAIN RELIEF A motor point pen must be used to locate the motor points See the example on the section on specific indications 100 HZ TENS OR FREQUENCY MODULATED TENS Gate control which is activated during TENS stimulation is particularly effective for the relief of localised pain of non muscular origin It is particularly effective for relieving neuropathic pain and inflammatory conditions The sessions may be repeated at will and without restriction depending upon the intensity of the pain Pain relief is now a priority in therapy which must be provided by all healthcare professionals As TENS treatment is generally palliative it improves the patient s comfort and helps the therapist to start the process The principle is to cause a significant influx of tactile sensitivity in order to restrict the entry of pain impulses upon their return to the posterior horn of the spinal cord We must therefore stimulate the sensitivity fibres on the skin of the painful area To do this it is necessary to use a frequency that is the same as the operational frequencies for the tactile sensitivity nerve fibres i e from 50 to 150 Hz Pulse width Use very short pulse widths corresponding to the chronaxies of the tactile sensitivity fibres i e 30 50 or 70 ps depending on whether the patient is very sensitive normal or not very sens
168. s require higher stimulation energies to be used The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option Yes A minimum of 1 channel with muscular work imposed by the Thoracic back pain programme A maximum of 3 channels with the TENS programme Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active In addition the mi functions apart from mi SCAN and mi RANGE are no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels WP ee SS ree me oo TONAT LOW BACK PAIN Low back pain most frequently results from chronic contractures of the paravertebral lumber muscles It may be caused by a mechanical conflict vertebral osteoarthritis disc space narrowing etc For pain relief and relaxation of muscle contractures Endorphin stimulation aids pain relief by increasing production of endogenous opioids The associated vascular effect results in effective drainage of acidic metabolites and enables the elimination of muscular acidosis TENS Gate control applied using the t
169. s this disadvantage by optimising spatial recruitment aced respectively on the motor points of the vastus medialis the vastus lateralis and the rectus femoris A large two way electrode is placed at the top of the thigh and a further small electrode is positioned inated button t s knee extended EN Vee oe Sr ree RES STONA 5 Stimulation energy In NMES the stimulation energy is directly responsible for spatial recruitment the higher the stimulation energy the higher the percentage of motor units recruited and the greater the impact of the progress The general rule is to always try to increase the energy to the maximum level tolerated by the patient The therapist plays a fundamental role by encouraging and reassuring the patient who can then tolerate levels of energy that produce powerful contractions The levels of energy reached must increase throughout the session and also from session to session because the patients quickly get used to the technique With this programme the stimulation starts directly with a tetanic contraction because the warm up phase has been eliminated so as not to produce muscle twitches that are likely to cause unwanted microtraumas to the kneecap ACL ligamentoplasty Ruptures of the Anterior Cruciate Ligament ACL of the knee are among the most common accidents in sports trauma Reconstructive surgery of the ACL has been subject to continuous developments in recent deca
170. s when level Vin the tank B reaches point D by submerging the float When pump P injects liquid from A to B therefore increasing level V part of the liquid goes back to A through tap K representing the excitation constant k In the tank B float C is linked to piston E that works by means of the level of liquid in tank F This is linked to B by tap L representing the accommodation constant A TWO EXAMPLES A Currents of long duration and low intensity In order that level Vreaches threshold D a certain volume of water is necessary likened to a certain quantity of electrical charges If this water is supplied slowly by the pump current of long duration and low intensity some of the water has time to go through L and raise piston E therefore increasing the threshold level accommodation The quantity of liquid the current will therefore have to be greater because level Vhas to reach point D higher up Moreover a large amount of liquid returns from B to A through tap K It is easy to understand that all these extra quantities that P has to transport indicate that we have an unfavourable stimulation current EN a i a ld me ls B Currents of short duration and higher intensity The durations intended here are close to the excitation constant value k In this case as the flow is high the pump action is short As almost no liquid has gone through L the float does not rise and accommodation is therefore negligible Never
171. same way as discharging a capacitor The mathematical law for the return of V to its initial rest value is dV dt V Vo k 1 3 Where k has time dimensions and is the excitation time constant The excitation time constant characterises the tendency of the local potential to return to its initial value at a particular speed when the neuron is no longer subjected to the current While the current is being passed the local potential V does not increase instantly but exponentially in the same way as the charge of a capacitor with k as the time constant This constant therefore defines the tendency of the neuron to oppose or resist the variation in potential caused by electrical charges provided by the stimulation current which is identical to the charge of a capacitor It must be stated that k does not depend on the shape and qualities of the stimulation current it is a feature of the neuron itself which expresses the time factor of its tendency to return the membrane potential to the resting value The critical value that the local potential V must reach to trigger excitation i e the excitation threshold So is only a constant value if the pulse duration is extremely short If however the current lasts longer the threshold increases S This phenomenon is demonstrated by the well known fact that a current which increases slowly must reach a higher value in order to produce stimulation than a current which increases quickly T
172. scle Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Place the electrodes over the muscle that is antagonistic to the spastic muscle in accordance with the instructions Intensity Use the necessary energy to produce a contraction that is capable of causing movement across the whole of its range Care must always be taken to ensure that the stimulation does not spread as far as the spastic muscle TENS Option Yes A minimum of1 channel with muscular work imposed by the Spasticity programme Amaximum of 3 channels with the TENS programme Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels WP ee SS ree me oo TONAT HEMIPLEGIC SHOULDER The shortage of suspensory muscles in the humeral head combined with
173. se of this that neuromuscular electrostimulation has been proposed as an alternative or complementary treatment to physical exercise for heart failure as it enables muscular performance and capacity for exertion to be improved The protocols proposed have been developed on the basis of the following publications Karavidas A Arapi SM Pyrgakis V Adamopoulos S Maillefert JF Eicher JC Walker P et al Functional electrical stimulation of lower limbs in patients with Effects of low frequency electrical stimulation of quadriceps chronic heart failure and calf muscles in patients with chronic heart failure Heart Fail Rev 2010 Nov 15 6 563 79 Review J Cardiopulm Rehabil 1998 18 4 277 282 Banerjee P Clark A Witte K Crowe L Caulfield B Deley G Kervio G Verges B et al Electrical stimulation of unloaded muscles causes Comparison of low frequency electrical myostimulation and cardiovascular exercise by increasing oxygen demand Eur J conventional aerobic exercise training in patients with chronic Cardiovasc Prev heart failure Rehabil 2005 12 503 508 Eur J Cardiovasc Prev Rehabil 2005 12 3 226 233 Quittan M Wiesinger G Sturm B et al Improvement of thigh muscles by neuromuscular electrical stimulation in patients with refractory heart failure Am J Phys Med Rehabil 2001 80 3 206 214 VP ee er ree oe Nee EN METHOD 1 Protocol Cardiac rehabilitation 2 Treatment frequency Three to six sessions a week for fo
174. sitioned on the lower electrode corresponding to the distal motor point of the vastus medialis This placement of electrodes makes it possible to focus contraction of the vastus medialis which cannot be achieved during voluntary exercises 4 Patient position The focused contraction of the vastus medialis moves the patella upward and inward thus re centring the kneecap and reducing the joint stresses in the lateral compartment of the knee This makes it possible to place the patient in a sitting position with the knee bent at 60 90 in order to apply high stimulation energies to the vastus medialis During stimulation the patient s ankle will be tied firmly to the chair or the medical table on which he she is seated In case the patient finds this position painful the first sessions will be carried out with the knee in full extension After this we will try to gradually put the knee in a flexed position 5 Stimulation energy In NMES the stimulation energy is directly responsible for spatial recruitment the higher the stimulation energy the higher the percentage of motor units recruited and the greater the impact of the progress The general rule is to always try to increase the energy to the maximum level tolerated by the patient The therapist plays a fundamental role by encouraging and reassuring the patient who can then tolerate levels of energy that produce powerful contractions The levels of energy rea
175. sociated pain EN VP oe er ree me oo TONAT 2 Shoulder instabilities Shoulder instabilities are one of the most common pathologies and their treatment remains a difficult challenge Trauma repeated microtraumas or a constitutional laxity can compromise the stability of the shoulder either by injuring the passive structures distension or tear of the inferior glenohumeral ligament detachment of the labrum progressive stretching of the capsule etc or by disturbing the motor systems causing a reduction in the coordination component resulting from the action of the scapular and scapulohumeral muscles The supra and infraspinous muscles are the main coordination muscles of the glenohumeral joint however their efficacy is reinforced by the tone and muscle mass of the deltoid Unlike in the rehabilitation of rotator cuff tendinopathy in which the work of the deltoid must be prescribed due to the subacromial interference combined muscular electrostimulation of the deltoid and the supra and infraspinous muscles is beneficial in this case because it allows for the stabilising musculature of the shoulder to be optimised METHOD 1 Protocol e Phase 1 Disuse atrophy Level 1 until full painless mobility is obtained e Phase 2 Disuse atrophy Level 2 until there is no pain during physical examination e Phase 3 Disuse atrophy Level 2 mi ACTION mode Stimulation of of the infra and supraspinous muscles combined with vo
176. ssage TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from mi SCAN and mi RANGE are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels THORACIC BACK PAIN Thoracic back pain is most commonly a result of chronic contractures of the paravertebral back muscles erector spinae and is for example due to spinal osteoarthritis or postures where the spinal muscles remain tense for long periods of time For pain relief and relaxation of muscle contractures Endorphin stimulation aids pain relief by increasing production of endogenous opioids The associated vascular effect results in effective drainage of acidic metabolites and enables the elimination of muscular acidosis Pulse width Endorphin stimulation first targets the sensitive A8 nerve fibres which are best stimulated with a larger pulse of 200p1s However the vascular effect is secondary to the co activation of the motor units which have a slightly higher chronaxy that is measured at the start of the session using the mi SCAN function activated by default Electrodes Electrodes positioned according to the specific indication Intensity An essential factor in the therapeutic efficacy is to cause visible muscle twitching which may in certain case
177. st be placed after a thorough palpatory examination to locate the most painful point where a small electrode preferably connected to the positive pole of the module pod with an illuminated button will be placed The other electrode is placed at the end of muscle or muscle group being stimulated Intensity An essential factor in the therapeutic efficacy is to cause visible muscle twitching which may in certain cases require higher stimulation energies to be used TENS Option No BURST TENS ALTERNATED Described by Han modulated stimulation Burst TENS successively activates every 3 seconds the Gate control mechanism and releases endogenous opioid substances This is a therapeutic option which may be worth considering for poorly classified pain with multiple causes To improve the patient s comfort and to enable the therapist to start the process more easily Burst modulated TENS is based on the Gate control theory TENS effect and on the release of morphine like substances produced by the body endorphins Endorphinic effect The stimulation frequencies vary every 3 seconds producing a combined stimulation of 80 Hz and 2 Hz Pulse width The pulse width for the programme is 180 ps Electrodes As a general rule the electrodes are placed on or near the painful area Intensity The stimulation should produce a sharp but pleasant tingling sensation and visible muscle twitches Please
178. st use it side by side or on top of another system you should check that the Wireless Professional works properly in the chosen configuration RECOMMENDATIONS AND DECLARATION BY THE MANUFACTURER CONCERNING ELECTROMAGNETIC EMISSIONS The Wireless Professional is intended for use in the electromagnetic environment specified below The customer or user of the Wireless Professional should ensure that it is used in this environment Emissions test Compliance Electromagnetic environment Guide The Wireless Professional uses RF energy only for its internal RF emissions operation Consequently its RF emissions are unlikely CISPR Tl to interfere with any adjacent electrical device radios computers telephones etc RF emissions CISPR Tl Wireless Professional is suitable for use in any establishment Harmonic emissions other than a private dwelling or a place connected directly IEC 61000 3 2 to the low voltage mains supply which powers residential buildings Voltage fluctuations emission Not applicable oscillations IEC 61000 3 3 RECOMMENDATIONS AND DECLARATION BY THE MANUFACTURER CONCERNING Wireless Professional is d ELECTROMAGNETIC IMMUNITY esigned for use in the electromagnetic environment stipulated below The buyer or user of the Wireless Professional must ensure it is used in this recommended environment Immunity test Test level IEC 60601 Observance level Electromagnetic env
179. suse atrophy tends to disproportionally affect type fibres more than type II To compensate for total or partial inactivity of the muscle following an osteoarticular injury In order to prevent disuse atrophy electrostimulation has to compensate for the total inactivity of the muscle by reproducing a series of contractions similar to the different ways in which the muscle functions when it is working normally The main treatment phases are carried out with conventional operational frequencies for slow fibres to compensate for their tendency towards disuse atrophy Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity Use the maximum stimulation energies The first and second sessions help the patient become accustomed to the method by gradually increasing the stimulation energy every 3 or 4 contractions In the following sessions it is important to support the patient s progress by setting targets which go beyond the energy levels reached in the previous session TENS Option Yes A minimum of 1 channel with muscular work imposed by the Prevention of disus
180. sychological origin and is connected with a fear of the muscle stimulation as well as surprise at seeing one of their muscles contract without having intentionally contracted it themselves A vasovagal reaction causes heart to slow down and blood pressure to drop which produces a feeling weakness and a tendency towards fainting If this does occur all that is required is to stop the stimulation and for the person to lie down with the legs raised until the feeling of weakness disappears 5 to 10 minutes e Never allow muscular contraction during a stimulation session to result in movement You should always stimulate isometrically this means that the extremities of the limb in which a muscle is being stimulated must be firmly fixed so as to prevent any movement that results from contraction e Do not use the Wireless Professional if you are connected to a high frequency surgical instrument as this could cause skin irritation or burns under the electrodes e Do not use the Wireless Professional within one metre of short wave or microwave devices as this could alter the currents generated by the stimulator If you are in any doubt as to the use of the stimulator in close proximity to another medical device seek advice from the manufacturer of the latter or from your doctor e Do not use the Wireless Professional in areas where unprotected devices are used to emit electromagnetic radiation Portable communications equipment can interfere with elect
181. ted Repetition of stimulation is obtained by repeating the electrical impulse Whether this is with analgesic or motor stimulation electrotherapy the stimulations correspond to a Series of stimulations set by streams of pulses Repeating the pulses if they are not compensated for will result in polarisation because the electrical mean is not zero Fig 7 Fig 7 i gt Non compensated series of pulses The electrical mean is not zero which causes polarisation __ Electrical Mean d The polarised current equates to a continuous current with a value equal to the mean intensity Applying this kind of polarised current to the skin has the same disadvantages as a galvanic current i e risk of skin burns in all cases and sometimes ionisation if there is metal osteosynthetic material To resolve the issue of polarisation the positive wave must be compensated for by a negative wave with the same quantity of electrical charge i e the same area on the graph Fig 8 The electrical mean is therefore zero the current is completely compensated for and the risks of polarisation are eliminated VI Fig 8 a gt Compensated rectangular pulse S1 S2 therefore the electrical mean is zero Electrical mean O d C Summary The pulse current that is able to produce excitation action potential and also offer the patient the maximum amount of comfort can be called the optimum
182. termine the minimum level of energy required o produce an appropriate muscle response TENS Option No 7 4 SPECIFIC INDICATIONS Disuse atrophy rehabilitation Endorphinic treatment of standard protocol be Rachialgia and Radiculalgia 1 Endorphinic treatment of Rehabilitation of the peroneus neck pain muscles following an 116 2 Endorphinic treatment of 152 ankle sprain thoracic back pain 3 Endorphinic treatment of Rehabilitation of 119 low back pain ow back muscles 4 Treatment of lumbosciatic pain Treatment of patellofemoral syndrome 122 Hemiplegia Spasticity 1 Lateral tracking 1 Dorsiflexion of the 2 Post traumatic condition hemiplegic foot 164 2 Spasticity ACL ligamentoplasty 128 3 The hemiplegic hand Rehabilitation of the gluteal Thenemiplegie shoulder muscles following total hip 131 Treatment of venous replacement insufficiency Rehabilitation of the shoulder l tdi bea 176 1 Rotator cuff tendinopathy 133 2 Venous insufficiency 2 Shoulder instability with oedema 3 Adhesive capsulitis P Treatment of arterial Cardiac rehabilitation 142 insufficiency in the lower limbs 181 1 Stage II arterial insufficiency Locating a motor point 144 2 Stage III arterial insufficiency Reflex sympathetic dystrophy or Complex regional pain 147 syndrome EN VP oe er ree oe Nee Disuse atrophy rehabilitation standard protocol Exam
183. the electrode simply make the opposite movement E Ni A Pulling the pods without respecting their pulling direction can damage the attachment system N B The insertion direction is recognisable by the marking the On Off button on the main pod and a small vertical line on the hull of the other pod EN WP ee re ee on ea eee 5 3 STARTING THE SESSION Before starting the stimulation session Lock function Lock function if enabled allows you to lock the device in a certain configuration before giving it to the patient When the function is active the patient can perform only the basic operations increase or decrease the intensity pause the device but he or she cannot exit the programme or turn off the device a A Deactivation of the Lock function B Activation of the Lock function Enter new code To enter the code you just need to press a combination of any four buttons To deactivate the Lock during treatment pause the device and then hold down the On Off button on the remote control until the display prompts you to insert your key combination to unlock the programme If you forget the code just put the remote control on the charging station to unlock N B The Lock function can be activated i e offered at the beginning of each session or disabled in the Settings menu of the device VI Switching on the modules Before starting the stimulat
184. the motor nerves of the infraspinatus and supraspinatus muscles The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned according to the specific indication Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used Progressively increase the level of energy during the course of a treatment session TENS Option Yes A minimum of 1 channel with muscular work imposed by the Rotator cuff programme Amaximum of 3 channels with the TENS programme Electrodes positioned on the painful area e Sufficient stimulation energy to produce a clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels LUMBAR STABILISATION After an episode of low back pain once the pain has been relieved Muscular work by electrostimulation has the advantage of being carried out isometrically with very little
185. their oxidative power They use the little oxygen that they still receive increasingly badly Therefore the problem becomes twofold very little oxygen provided and poor use of what oxygen there is Low frequency stimulation can act on the fibres capacity to use oxygen Considerable studies have shown that low frequency stimulation leads to an improvement in the oxidative capacity of the stimulated muscle increase in the number and size of mitochondria increase in oxidative enzymatic activity Electrostimulation therefore improves the tolerance of muscle fibres to physical activity in the case of arterial insufficiency and thus increases the walking range of patients suffering from intermittent claudication METHOD Protocol Arterial insufficiency 1 2 Treatment frequency 5 sessions per week for 12 weeks to treat the acute episode It is then recommended to keep up treatment with a few weekly sessions Wee ce SS reo RES S TONTA EN 3 Electrode position Two stimulation modules are required for each leg A small electrode is placed just under the head of the fibula on the common peroneal nerve and another small electrode in the upper part of the popliteal fossa at the nerve trunk of the tibial nerve For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on these two small electrodes The two other pods are connected to the two outputs of a large
186. theless a certain quantity of water returns through Kand has to be compensated for by P The Weiss law applies to these kinds of current please refer to the fundamental law of electrostimulation a Q q itorIt q it N Qis the total quantity of liquid provided by P with I intensity of the stimulation current t pulse duration qis the volume of liquid separating Vo from So i e the quantity of charges that would have to be provided if there were no leak K In other words if the membrane potential varied instantaneously and not exponentially in accordance with a time constant K a it the quantity of liquid that returns from B to A through tap K o A h IAEA E A Errr M A 7 2 PRACTICAL RULES The principles of use set out in this section are the general rules for neurostimulation programmes In all cases the information and instructions for use in this practical guide should be read carefully Positioning of the electrodes Compliance with the specified positioning of the electrodes is advised Illustrations of the electrodes positions are available directly in the remote control or in the chapter Specific indications A stimulation module consists of two poles e A positive pole the pod with an illuminated button e A negative pole the other pod of the module A separate electrode must be connected to each of the two pods Depending on the characteristics of the current use
187. ticity is caused by a lesion in the central nervous system which affects the tractus pyramidalis cerebral spinal tract This interruption in central control releases the activity of the myotatic stretch reflex which becomes hyperactive As this stretch reflex is responsible for muscular tonus hypertonia develops affecting mainly the antigravity muscles extensions of the lower limbs and flexors of the upper limbs since these contain more neuromuscular spindles than their antagonist muscles In time spasticity leads to the shortening of muscle tendon structures and a reduction in the range of articular movement which can lead to stiffening and misalignment of the joints B Use of neuromuscular electrical stimulation NMES Starting in the neuromuscular bundles are afferent proprioceptive nerve fibres which are directly associated with the a motor neurons of the same muscle and which are indirectly associated via interneurons with the a motor neurons of the antagonist muscle Stretching a muscle therefore stimulates the afferent proprioceptive nerve fibres of the neuromuscular bundles and they monosynaptically activate the a motor neurons of the muscle being stretched myotatic stretch reflex and inhibit via an interneuron the a motor neurons of the antagonist muscle reciprocal inhibition reflex NMES of a muscle excites not only the a motor neurons of that muscle but also and even more readily the afferent proprioceptive nerve fibres
188. tion of the electrical pulse and the amount of electricity applied to reach the stimulation threshold Q q it Weiss therefore discovered the mathematical relationship that links the pulse duration with the amount of electricity required to produce the stimulation Understandably he called this relationship the fundamental formula a oai D Q the amount of current required to reach the threshold This is also the quantity of electrical charges provided by the stimulation current as the Q value is given by the product x t of the stimulation current intensity multiplied by its application time t length of time that the current is applied which is known as the pulse duration i a coefficient determined by experiment with the same quantity as an electric current intensity q a coefficient determined by experiment with the same dimensions as a quantity of electrical charges q corresponds to the intersection of the straight line with the S y axis and may be calculated as the Q value when t is equal to zero d Lapicque an electrophysiologist who is more widely known than Weiss did not actually discover a new law of electrostimulation but he performed a number of experiments which confirmed the fundamental formula He defined it differently to mathematically deduce coefficients called the rheobase and chronaxy which he gave physiological meaning Lapicque developed the fundamental formula as fo
189. to avoid over stretching the spastic muscle and thereby increasing its spasticity This is achieved through the gradual rate of contraction specific to the Spasticity programme Another particularity of this programme is the absence of all low frequencies which can also increase spasticity by generating repeated micro stretches of the spastic muscle Spasticity mainly affects the antigravity muscles of the lower limbs and the flexor muscles of the upper limbs but out of these muscles the ones most affected and the severity of spasticity vary greatly depending on the type of disorder of the cerebro spinal tract hemiplegia tetraplegia paraplegia or multiple sclerosis Moreover for the same type of disorder of the cerebro spinal tract the severity of spasticity and the muscles in which it is most apparent varies from one patient to another For these reasons each case has to be considered individually It is therefore the task of the therapist to carry out an accurate clinical evaluation of each patient in order to select the muscles on which the treatment is to be concentrated In general spasticity mainly affects the following muscles e In the lower limbs triceps surae quadriceps adductors gluteus maximus e In the shoulder pectoralis major latissimus dorsi e In the upper limbs biceps brachii flexors of the fingers and wrist In the treatment of spasticity NMES is applied to one or more of the following
190. to be used The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option Yes A minimum of 1 channel with muscular work imposed by the Endorphinic programme Amaximum of 3 channels with the TENS programme e Electrodes positioned on the painful area e Sufficient stimulation energy to produce a Clear tingling sensation Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active In addition the mi functions apart from mi SCAN and mi RANGE are no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels The Burst programme is an type of endorphinic programme which has a less pronounced vascular effect than endorphinic It may be used in the same way to relieve pain following a chronic contracture To relieve chronic muscle pain The Burst mode involves replacing the emission of an isolated electric pulse by an emission of a very short burst of 8 pulses In this way the Burst programme emits 2 burst per second which can produce the same endorphinic results as for a standard frequency of 2 Hz Pulse width The pulse width for the programme is 180 ps Electrodes Electrodes mu
191. tributes to improving tolerance of exertion and the quality of life in patients suffering from severe Cardiac failure The work regime imposed by the cardiac rehabilitation programme uses the oxidative metabolism through contractions which are of low power but very long and repeated over a long period I hour Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes The quadriceps muscles are a priority because of their volume and their functional importance Electrodes must be positioned according to the specific indication Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used Progressively increase the level of energy during the course of a treatment session TENS Option No Agonist Antagonist ATROPHY REINFORCEMENT The alternate stimulation of the two antagonistic muscle groups has the advantage of allowing the active mobilisation of a joint while inducing muscle work which is beneficial to functional recuperation To combine muscle work aimed at successively restoring the two
192. ttock taking care to avoid placing this electrode on a scarred wounded area 4 Patient position If the patient s condition allows the patient is placed in a standing position which requires him her to exert additional effort that is beneficial for proprioceptive control If this is not possible all or part of the session can be conducted in a side lying or prone position 5 Stimulation energy In NMES the stimulation energy is directly responsible for spatial recruitment the higher the stimulation energy the higher the percentage of motor units recruited and the greater the impact of the progress The general rule is to always try to increase the energy to the maximum level tolerated by the patient The therapist plays a fundamental role by encouraging and reassuring the patient who can then tolerate levels of energy that produce powerful contractions The levels of energy reached must increase throughout the session and also from session to session because the patients quickly get used to the technique With this programme the stimulation starts directly with a tetanic contraction because the warm up phase has been eliminated so as not to produce muscle twitches that are likely to cause unwanted vibrations on the prosthesis VI EN WAP ee re ro TONAT Rehabilitation of the shoulder The specific properties of the shoulder joint are complex and particularly demanding at a function
193. uce a clear tingling sensation TENS Option Once the TENS combination has been activated the message TENS appears on the screen with respect to the channel or channels where the treatment is active The mi functions apart from the mi SCAN are also no longer accessible Take care to properly observe the correct order for switching on the modules the order of switching on that corresponds to the numbering of the channels SLOW START NEURO REHABILITATION Electrostimulation is an excellent complement to traditional kinesiotherapy for many central neurological diseases such as hemiplegia Treatment must be used in conjunction with passive mobilisation but should also preferably be combined with active movement as soon as the patient s recovery permits To help facilitate motor control and motor relearning The programme has a very gradual rate of tensioning followed by a long period of rest Mobilisation must be synchronised with the contraction induced by the stimulation Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the hronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable
194. uitable for the patient s muscles Electrodes lectrodes positioned depending on the muscle to be stimulated in accordance with he instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option Indication No PLYOMETRY To develop muscular explosive power by imposing a stress similar to that induced by voluntary plyometry exercises while reducing stress on joints and tendons Effects Increase the speed of contraction and the capacity to perform actions at maximum strength jump bound shoot etc Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option No Indication HYPERTROPHY For body build
195. ur to eight weeks 3 Electrode position A The quadriceps are the priority muscles due to their functional importance and their high volume of muscle mass Two channels are needed per thigh for quadriceps stimulation Two small electrodes are placed on the motor points S of the vastus medialis and the vastus lateralis Two large electrodes are positioned at the top of the thigh For optimum effectiveness the positive pole of the module pod with an illuminated button should preferably be positioned on the motor point A 4 Patient position The patient should preferably be placed in a sitting position with his her knees bent at approximately 90 the ankles must be restrained to avoid the knees from being extended which can induce contractions If the patient is not able to stay seated the session can be carried out in a lying position taking care to place a large cushion under the popliteal fossae so that the knees are flexed 5 Stimulation energy In NMES the stimulation energy is directly responsible for spatial recruitment the higher the stimulation energy the higher the percentage of motor units recruited and the greater the impact of the progress The general rule is to always try to increase the energy to the maximum level tolerated by the patient The therapist plays a fundamental role by encouraging and reassuring the patient who can then tolerate levels of energy that produce powerful contr
196. uscle fibres motor units being used TENS Option Indication No STRENGTH For athletes practising a discipline which requires strength and speed Effects An increase in maximum strength and muscle contraction speed Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option No WTRECESS PRO i oo he Nee Indication ACTIVE RECOVERY To facilitate and accelerate muscle recuperation after intense exertion Use this programme during the three hours which follow a period of intense training or a competition Strong increase in blood flow accelerated elimination of waste products from muscle contraction and a relaxing endorphinic effect Pulse width To make it as comfortab chronaxies of the motor by default can be used ti e as possible for the patient use pulse widths equivalent to th
197. ve and or prevent aching pains To promote muscle relaxation To accelerate restoration of the muscular qualities following a workout or competition Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Precision in positioning the electrodes is less significant than for programmes aiming to develop muscle quality The electrodes can be placed in an alternative way reducing the number of electrodes needed and stimulating more muscles during a session Intensity An essential factor in the effectiveness of electrotherapy is the ability to cause visible muscle twitches The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option Indication No TONING MASSAGE Specific massage programme that includes some short muscle contractions This programme can supplement traditional heating or even replace it if traditional heating is difficult to use Effects Activates circulation and revives of the contractile properties of the muscles Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of
198. vement cannot be carried out if the spasticity of the flexor muscles exceeds the contraction strength of the atrophied extensors Stimulation will only cause reduced movement or even no movement at all in extreme cases Treatment with NMES should be carried out even in these situation because even subliminal stimulation has a beneficial effect on the reduction of spasticity To complete the extension passive stretching is also necessary Combined treatment of stimulation and passive motion is therefore given 6 Manual activation of stimulation When the mi SCAN is activated by default the stimulation session starts automatically with a measurement of the chronaxy This is a short test lasting around ten seconds which allows the optimum duration of the stimulation pulse to be adjusted ensuring maximum comfort The energy should then be gradually increased to cause the first contraction of the antagonist muscle Each contraction is followed by a five second rest period Once this rest period has finished press any button on any channel to trigger the next contraction By doing so each contraction is triggered and therefore controlled by a manual action This technique provides a clear psychological benefit for the patient who can trigger contractions with his her good hand and it also makes it possible to work synchronously with the associated movements The manual trigger of the contraction function activated by default can be replaced by a
199. w and forearm resting on a cushion on the table 5 Stimulation energy The energy is gradually increased for each contraction until the maximum tolerable energy level is reached The therapist plays a fundamental role in encouraging and reassuring the patient who can then tolerate levels of energy that produce powerful contractions If the TENS programme is used on channels 3 and 4 the energy will be adjusted on these channels so that the patient clearly feels moving tingling However care must be taken to ensure that the energy is low enough to avoid any muscle contraction Treatment of venous insufficiency Unlike occasionally experiencing heavy legs venous insufficiency is a result of organic damage to the vein walls which clinically manifests as large or small varicose veins These are the result of a permanent dilation secondary to the hyperpressure and stasis of the venous blood to which is added progressive hypoxia of the intima inner layer of the wall The deficiency of the valves of the deep veins and the perforating veins is behind this process Their role in preventing the regurgitation of venous blood is no longer guaranteed Hydrostatic pressure is accentuated and muscle contractions are no longer sufficient to evacuate the venous blood The blood stagnates and causes hyperpressure in the superficial veins until varicose distensions are produced Stasis oedema is often associated with venous insufficiency but not a
200. wever it is essential here to limit the stimulation to the myelinated nerve fibres of the tactile sensory system only the type AR fibres as these are the only fibres which have an inhibiting effect on the orthosympathetic system This is not the case for the other nerve fibres A6 B C as these activate this orthosympathetic nervous system This selective targeting of the AB fibres which are the most excitable nerve fibres tactile sensory system is possible if very short pulse widths lt 50 us are used i e the TENS programme o J EN VP ee er ree oe Nee METHOD 1 Protocol TENS 1 for very sensitive or hyperalgesic patients TENS 2 for all other patients 2 Treatment frequency A minimum of 20 to 40 minutes of treatment every day 3 Electrode position Use three channels and therefore three modules Two channels are used with four large electrodes to cover the painful area The third channel uses small electrodes to excite the nerve path s supplying the extremity of the limb concerned Upper limb Distal RSD of the upper limb Four large electrodes are used to cover the palms and backs of the hand and fingers Two small electrodes a finger s width apart are placed as high as possible on the inner side of the arm the upper electrode is thus positioned at the level of the brachial wall of the axilla pC uP RSD of the shoulder Four large electrodes are used to c
201. y is the ability to cause visible muscle twitches The mi RANGE function activated by default can be used to determine the minimum level of energy required to produce an appropriate muscle response TENS Option No WP ee SS ree me oo TONAT Indication CALORILYSIS To be used in conjunction with a low calorie diet to increase the calorie deficit Effects To increase calorie expenditure Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated The mi SCAN function activated by default can be used to determine the pulse widths suitable for the patient s muscles Electrodes Electrodes positioned depending on the muscle to be stimulated in accordance with the instructions Intensity The maximum tolerable stimulation energy which is one of the key factors determining the effectiveness of the treatment The higher the stimulation energy the higher the number of muscle fibres motor units being used TENS Option Indication No ADIPOSTRESS To be used as an adjuvant to other anti cellulite treatments Effects To create electric stress and vasodilatation in fat cell masses and areas of cellulite Pulse width To make it as comfortable as possible for the patient use pulse widths equivalent to the chronaxies of the motor nerves of the muscles being stimulated

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