PROCEDURE NEUROMUSCULAR ELECTRICAL STIMULATION (NMES) IONTOPHORESIS

Able to establish rapport to Good afternoon, Ma’am/Sir, I am __________. I’ll be your physical therapist this afternoon. Before we begin, may I know your
the simulated patient. name and birthday, please? For validation purposes
Ma’am/Sir, what brings you to the center today? What type of pain do you feel? When did the pain start?

Able to ask and determine VAPS

the complaint/s of the Ma’am/Sir, this is the Visual Analog Pain Scale that will give me an idea on the pain you’re feeling right now. As you can see, 0
simulated patient. means no pain, 5 means moderate pain, and 10 means the worst pain possible. Now, on this scale how would you rate your
pain?
ChLORIDPP
This afternoon, the treatment will allow you to…
o Facilitation of Muscle Contraction – When the patient is
unable to produce a muscle contraction or finds difficulty in
doing so, electrical stimulation may be of use in assisting o Relief of Pain –
voluntary contraction. The patient can voluntarily contract the o Adhesion – Renotin +
muscle simultaneous with the electrical stimulator. o Chronic Congestion – Zinc Sulfate +
o Re-education of Muscle Action – The inability to contract a o Calcium Deposits – Acetic Acid +
muscle voluntarily can result in prolonged disuse; applying o Idiopathic Hyperhidrosis – Glycopyrronium Bromide +
electrical stimulation can produce contraction that helps to
restore the sense of movement. The patient is advised to o Anti-Inflammatory – Dexamethasone +
Able to state the rationale actively contract the muscle (even just to attempt) at the o Increase Calcium Deposits Solubility – Acetic acid -
of treatment to the same time with the electrical stimulation. o Sclerolytic Effects – Iodine
simulated patient. o Training a New Muscle Action – After tendon transplantation o Local Anasthetic Effects – Lidocaine
or other reconstructive operation, electrical stimulation can o Analgesic and Anti-Inflammatory – Salicylates
be applied to train the muscle of its new action. o Dispersion of Local Edema – Hyaluronidase
o Improve Venous and Lymphatic Drainage – As there is muscle o Decreased Excitability of Peripheral Nerves and
contraction, the pumping action is expected to improve the Skeletal Muscle – Calcium Chloride
venous and lymphatic drainage. o Muscle Relaxant – Magnesium Sulfate
o Prevention and Loosening of Adhesions – Letting the muscle o General Antiseptic and Increase Tissue Healing – Zinc
contract can move the joint, moving the joint can prevent or Oxide
loosen adhesion. o Decreased Sweating (palms, feet, axillae) – Tap Water
o Retard Atrophy – Since there is muscle contraction, it can
help in slowing down the atrophic condition of the muscle.
At this point Ma’am/Sir, I will take your vital signs. May I touch you? Assuming that I’ve already taken the vital signs of the
patient, I will now inform him/her of the results. Your vital signs seem to be within normal ranges so we can now proceed.
Able to note the vital signs
o Temperature – 37 degrees Celsius; 97.7 degrees Fahrenheit
before and after treatment.
o Pulse Rate – 60-100 beats per minute
o Respiratory Rate – 12 to 16 breaths per minute

Able to assess and check the
contraindications in o Cardiac Pacemakers – The device may be affected with the current that passes through it.
applying the modality.
o Blood Pressure – 120/80 mmHg
May I know Ma’am/Sir if you have any of the following:
o Fractures – Especially nonunion. If muscle contracts, it can further displace the fractured bone.
o Areas of Active Bleeding – Further bleeding can happen.
o Malignancies – Metastasize.
o Thrombophlebitis – Can cause embolus to dislodge.
o Superficial Metal Implants – Current can concentrate on the metal surface and can damage the structures surrounding it.
o Anterior Neck – Can stimulate delicate structures that cause adverse effects such as vagus nerve that can affect the rhythmic
beat of the heart.
o Excessive Edema – Requires greater intensity to stimulate the structures as the structures are found deeper and using
greater intensity can cause pain and risk of encountering electrical burns.
o Scar Tissue – Large amount of scar tissue will be difficult to penetrate for the current causing an increase in the intensity
which has a greater risk of encountering burns.
o Skin Lesions – Any large cuts and abrasions that cannot be insulated with Vaseline will offer less resistance to the current
and the possibility of encountering electrical burns.
o Unreliable Patients – Unable to understand instructions that can contribute to the risk of encountering overdosage.
o Infection – Infection may spread to the adjacent areas.
o Cold Muscle – Cold can reduce conductivity to the current.

Now Maam/Sir, may I check your site of pain for any open lesions or inflammation? There seems to be no open lesions or
inflammation in the area.

PIN-PRICK SENSATION
*Test the affected area. Use reflex hammer for sharp and dull sensations.*
At this point, I will check for your sensation on the affected area using the dull and sharp ends of the reflex hammer. Can you feel
the sharp end? How about the dull end? I want you to close your eyes and tell me whether the test tube is hot or cold. Your pin-
prick sensation seems to be normal.
If you have any jewelry around the area to be treated or in your pockets, please remove them before we start because it might
interfere with the treatment.
*Choose a position wherein the area to be treated is accessible for the application of the modality.*
Ma’am/Sir, I want you to sit down/lay on your back/lay on your belly/lay on your left/right side. Are you comfortable with your
position Ma’am/Sir?
Able to position the patient
*Drape the patient such that the area to be treated is exposed. Drape if necessary especially those sensitive body parts.*
comfortably and
I will put towels as draping over some sensitive areas.
appropriately with proper
o PRONE – Pillows are placed under the head, abdomen, and lower legs. There is draping over sensitive areas.
draping.
o SUPINE – Pillows are placed under the head and under the thighs. There is draping over sensitive areas.
o SIDE LYING – Pillows are place under the head and between the thighs. There is draping over sensitive areas.
o SHORT SITTING – Pillows are placed on the lower back of the patient. There is draping over sensitive areas.
Able to introduce the This treatment method called Neuromuscular Electrical This treatment method called iontophoresis is the
modality and state the Stimulation (NMES) is the stimulation of your nerve and introduction of medicinal agents through your skin using
purpose of using it. (innervated) muscle using electricity through the NMES machine. mild electrical currents.
Able to properly instruct the
Throughout the duration of the treatment, you will feel a prickling sensation. Let me know if you feel any undesirable sensation
simulated patient. or painful contraction.
Able to state the
Ma’am/Sir, I don’t want you to fall asleep during the treatment. Also, please don’t touch the electrodes, cables and machine
precautionary measures. during the treatment.
The cables and cords are properly attached to the machine. The The cables and cords are properly attached to the machine.
controls are in proper starting position and the machine is The controls are in proper starting position and the
Able to properly grounded so as to prevent earth shock. machine is grounded so as to prevent earth shock.
prepare/set-up the
modality. I am soaking the pads and squeezing off the excess water. I am I am soaking the pads and squeezing off the excess water. I
covering the electrodes with the pads. I am performing a self-test am covering the electrodes with the pads. (If underwater
on the machine and making sure the patient sees the contraction. technique is used, pads and gels are not used.)
The parameters are (refer below). I have attached the electrodes
to the patient and secured it with Velcro or adhesive tapes.
NOTE:
o Group muscle action is attained if one electrode is over the
nerve trunk or ne
o rve roots at the spine; the other is on the motor point. I will place the medication under the electrode (depending
o Individual muscle action is attained if one electrode is placed on which component of the medication would be
over the motor point of the specific muscle introduced [positive ion – place under anode; negative ion;
place under cathode]). If the medication is in power form,
I have tested the ability of the patient’s muscle to respond to the then I will mix it with water. If it is in the form of cream,
machine, and there are no problems in doing so. then I will mix it with gel.
Able to properly apply the
modality to the treatment *One problem might be that there is more skin resistance to the I am performing a self-test on the machine.
area. current. If it exists, then wash the area with soap & water, rinse,
and then apply a warm moist pad to reduce skin resistance. The parameters are (refer below). I have attached the
Remove some of the hair if there is presence of more hair at the electrodes to the patient and secured it with Velcro or
area as it can also increase skin resistance.* adhesive tapes.

Ma’am/Sir, can you perform a few gentle contractions so you can I will gradually increase the intensity up to your tolerance
get used to the current? I will now increase the intensity gradually. without any muscle contraction.
*Abrupt increase of intensity can cause electric shock.*

I want you to contract voluntarily with the current as well.

Progression: patient holds the contracted position against the
decreasing current intensity but allow relaxation between each
 contraction.
o Pulse Duration: Innervated Muscles – 0.02-1ms; Denervated
Muscles – 10ms or greater (greater pulse duration = greater
tendency of muscle response)
o Pulse Interval: Innervated and Denervated Muscles – Twice
o Duration: 10-15 (20-40) minutes
the pulse duration (pulse duration ×2)
o Intensity: It would depend on the tolerance of the
o Pulse Waveform: Innervated Muscles – Rectangular
patient provided there is no muscle contraction that
Able to determine the Waveform; Denervated Muscles – Rectangular or Exponential
would be elicited. (If so, reduce the intensity.)
appropriate parameters for Progressive Waveform (triangular, saw-tooth, trapezoidal)
[Maximum until patient tolerance to intensity (The
the treatment (intensity, o Duration: 10-30 (5-10) minutes as tolerated, or 90-200
amplitude should be determined by patient comfort
duration, etc.). contractions with rest after 30 contractions (based on the
and should not exceed 4 mA.)]
number of muscle contractions)
o Frequency of Application: can be every day or every
o Intensity: It would depend on the tolerance of the patient
other day
provided there is no visible muscle contraction that would be
elicited. (If so, reduce the intensity.)
o Frequency of Application: can be every day; 2 to 3 treatment
sessions per day
Able to check the patient’s
condition from time to time Do you still feel a prickling sensation? Let me know if you feel any undesirable sensation or painful contraction.
during treatment.
Able to properly remove the
modality and placing it at Since the treatment is done, I will now turn all the knobs to the starting position and I will remove the electrodes before turning
the appropriate place after the machine off. I will now wash the area treated.
treatment.
I will now check your skin for presence of excessive erythema or pain. Your skin seems to be in normal condition since there is no
Able to check the skin reddening or pain.
condition after treatment. *If severe reddening and pain are noted, then it is indicative of chemical burns.*
*Burn is characterized by a dark red discoloration of the skin. Allergies are characterized by reddening and itchiness of the skin.*
At this point Ma’am/Sir, I will take your vital signs again. Assuming that I’ve already taken the vital signs of the patient, I will now
inform him/her of the results. Your vital signs seem to be within normal ranges so we can now proceed.
o Temperature – 37 degrees Celsius; 97.7 degrees Fahrenheit
CHECK VITAL SIGNS AGAIN
o Pulse Rate – 60-100 beats per minute
o Respiratory Rate – 12 to 16 breaths per minute
o Blood Pressure – 120/80 mmHg
CHECK MUSCLE
Can you voluntarily initiate the movement? I want you to hold the contraction and then relax the muscle. Do it 3x.
CONTRACTION
That’s it for this session. I want you to come back on *see above in terms of parameters* for another treatment session (if
RELEASE THE PATIENT
necessary).
Able to properly do *Do aftercare of the plinth, pillows, cloth blanket, chairs and modality. Clean up the area. Fold the towels and draping. Return
aftercare of the modality, the pillows. Return the IR lamp / MWD unit / electrodes/coils to the appropriate area.*
pillows, and bed sheets.
o NMES Machine
o NMES Electrodes
o Electrodes Cable
o Electrodes Pads
o Elastic Bandages
o Velcro or Adhesive Tapes
o Basin
MATERIALS NEEDED o Water
o Reflex Hammer
o Pillows
o Cloth Blanket
o Plinth
o Cart for the NMES Machine
o Chairs
o Medication (for Iontophoresis)
Various Techniques of NMES Application

1. NMES with Pressure (Use of Elastic Bandage)

o utilize if there is presence of edema, not advisable if there is excessive edema as the skin becomes more thinner that reduces the skin resistance to
current thus increasing the risks of encountering burns
o applied with the extremity in elevated position
o place the electrodes over the ‘circulation pumps’
• for the UE, flexor muscles group
 • for the LE, hip & knee extensors & flexors
o wrap the extremity with compression bandage covering the electrodes (bandage can secure the electrodes), there must be no gaps
o tetanic muscle contraction is preferable to be elicited
2. NMES Under Tension
o Utilize for spastic muscles (autogenic inhibition)
o Continuous tetanic (no relaxation) muscle contraction is preferable
o Electrodes are placed on the spastic muscles
3. NMES Underwater
o utilize if the entire surface of electrodes cannot be placed firmly on the treatment area (usually these areas are not evenly level – e.g. hands and feet);
electrodes that cannot be placed firmly on the treatment area can produce different current density that has greater risk for burn
o part to be treated is immersed in basin with water
o pads and gel are not utilized anymore for electrodes but a space or gap should exist between the electrodes and the treated structure
• to stimulate the lumbricals of the foot: one electrode under the metatarsal heads, the other under the heel
• to stimulate plantar interossei: one electrode under the medial border of the foot, the other on the lateral
• to stimulate the abductor hallucis: one electrode under the heel, the other on the motor point (button electrode)
4. Dynamic/Moving Tecnhique
o one electrode (active electrode) is move from one site of application to another site of application without lifting the electrode; electrode can only be lift
if the current is turn off