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Contraindications
Neuromuscular and
Muscular Electrical 1. when placed over the carotid sinus
2. when the patient has a pacemaker
Stimulation (NMES) 3. when we have areas of active tissue
infection and devitalized skin
4. when the patient is unable to
Definition comprehend instructions and provide
feedback
Neuromuscular and Muscular Electrical
5. when the patient is pregnant
Stimulation (NMES) is a modality that 6. when the patient has a peripheral
sends electrical impulses to nerves which vascular disease
causes the muscles to contract mimicking
the action potential coming from the central Electrically Stimulated Muscle
nervous system. It may be applied during
functional movement or without functional
Contraction vs Physiological
movement. It has been used throughout the Muscle Contraction
years for strengthening and maintaining
muscle strength and preventing atrophy,
The two main differences
especially with immobilized patients.
between electrically stimulated muscle
contractions and physiological muscle
contractions are the order of motor unit
recruitment and the smoothness of the
Indications onset of contraction. During normal
physiological muscle contractions, the first
fibers to be recruited are the slow-twitch
1. To improve muscle strength and type 1 muscle fibers, and then later the
prevent muscle atrophy large diameter muscle fibers, which produce
2. To improve and maintain the range of low-force contractions and are fatigue and
motion around a joint atrophy resistant and the contraction is
3. To reduce muscle spasticity and smooth. On the contrary, during
spasms electrically stimulated muscle
4. To increase cardiovascular function contractions, the first muscle fibers to
through the activity of large muscle be recruited are the large-diameter fast-
groups twitch type 2 muscle fibers which
produce the strongest and quickest
contractions, fatigue, and atrophy
rapidly and produce jerky movements
which is why upon electrical stimulation
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by NMES long rest times should be on the distal end of the muscle. The size of the
provided between stimulated electrode depends on the size of the muscle or
contractions ]. muscle group to be stimulated where
stimulating muscles for example the
quadriceps or the hamstring muscles require
large electrodes ].
Application of NMES

First, the patient should be seated During electrical stimulation, it's

comfortably in a way that allows muscle important to increase the intensity of the
relaxation which is necessary for easier stimulation gradually and to the maximum
muscle stimulation. Then, the skin should tolerable extent by the patient. For
be inspected to make sure there are no skin innervated muscles normally, the shorter
abrasions and injuries. Following that the the pulse duration, the greater the pulse
skin should be properly cleaned with a piece amplitude should be whereas for
of cloth and water or alcohol-based wipes denervated muscles, both pulse duration
and it's very important to make sure the skin and pulse amplitude should be greater
has been properly dried before the than that of innervated muscles which is
application of the electrodes on the skin. particularly important to ensure
stimulation and sudden contraction of the
muscle.

There is a wide variety of electrodes that can

be used including self-adhesive electrodes
which are quick and easy to use due to them Parameters
already having a layer of conductive material
on their surface, unlike carbon-rubber
electrodes which are normally coupled to the 1. Frequency (Hz) is the number of
skin by electrical conductive gel. These pulses in one second (20-50
electrodes should be placed away from the pulses per second)
joints and properly attached to the skin to 2. Pulse Duration (microsecond) for
avoid pain and discomfort. These electrodes small muscles is approximately
can be placed either in a way where the 150-200 and for large muscles
cathode is placed on the motor point of the 200-300
target muscle and the anode proximally on a
nearby muscle supplied by the same nerve and 3. Ramp time is at least 2 seconds
this placement is called monopolar electrode 4. ON: OFF time ratio should be set
placement and used when targeting small in a way where off time is three
muscles. The bipolar electrode placement times the on time
involves placing both electrodes on the muscle
belly or one at the proximal end and another
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5. Treatment time should be Electro-migration: It is also referred

between 20 and 30 minutes to as electro-repulsion. There occurs
6. The frequency of the sessions movement of ions across a
should be three times a week membrane (the skin) under the direct
influence of an electric field. There
Iontophoresis are two electrodes, cathode and
anode. When an electric field is
passed, the negatively charged drugs
Introduction repel into the skin under the cathode
whereas, the transfer of positively
charged drugs happen under the
Iontophoresis is a procedure in anode.
which an electric current will be
passed through the skin which will
be soaked in tap water allowing
ionized or charged particles to cross Electro-osmosis: This is the second
the normal skin barrier. This method mechanism and electro-osmosis is
is considered as a non-invasive considered as the volume flow
transdermal drug delivery technique induced by the current flow. It
based on transfer of charged depends on the physiochemical
molecules using low-intensity electric properties of the molecules and the
current. polarity of the applied current. For
example- When negative charges are
placed on the cathode (-), they will
migrate trans dermally towards
Mechanism anode (+). [3][1]

There are two mechanisms that are

usually involved in iontophoretic Points to remember-
transport.

1. Drug deliver is local but only

 Electro-migration penetrates a few mm.
 Electro-osmosis
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2. Drug must ionize and have net MSCD =

charge (+ or -) MSCI/SAE
3. Negative charges are placed on
the cathode (-) and they migrate
transdermally to the anode (+)
Dosage- It is given as the product of
4. Positive drugs are placed on the
intensity and duration (D = Ma ×
anode (+) and they migrate
min)
transdermally to the cathode.
5. The electrode in which the drug
would be administered are
considered as active electrode. Typical dosage should be between 40
By default, the opposite and 80 mA×min. [4]
electrode would be dispersive
electrode.

Parameters Procedure

Maximum Safe Current Density There are various methods to

(MSCD)- perform iontophoresis depending
upon the condition of the patient.

-Cathode | 0.5 mA/cm²

1. To treat hyperhidrosis- The
patient sit with both hands or
both feet, or one hand and one
-Anode | 1.0 mA/cm² foot, immersed in shallow trays
filled with tap water for a short
period of time. The device will
send a small electrical current
Maximum Safe Current Intensity
through the water. Initially, the
(MSCI)- It is calculated by
procedure should be repeated
multiplying the MSCD by the surface
for three times per week until
area of the electrode.
the desired results are achieved.
Once satisfactory dryness or
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result has been reached, 4. Metal implant

patients are usually provided 5. Pregnancy
with the treatment for once per 6. Recent wounds, skin grafting or
week. The treatment will take scar.
around 15 to 40 minutes
depending on the machine.
2. To treat musculoskeletal
conditions- In this method,
transdermal drug delivery
(TDD) system are mainly used.
It utilizes electrical current to
push ionized drugs through the
skin (stratum corneum) which
is typically the main barrier to
drug transport. Usually
analgesic or anti-inflammatory
actions are applied directly into
the target area. Using the rule
of ‘likes repel,’ a positively
charged drug is loaded into the
positive side of the delivery pad
or electrode and these positively
charged molecules are driven
through the skin by the positive
current while negatively
charged medications are driven
in under the negative
pole. [1][3][4]

Contraindications

1. Epilepsy, Seizures
2. Pacemakers
3. Heart diseases