Fes

STIWELL med4Studies & Literature

Contents

Symptom-Oriented Training

Eligibility of Stroke Patients for Symptom-Oriented Functional Electrical Stimulation (FES) ..........................................................................................................................6Electromyographically Triggered Electric Muscle Stimulation for Chronic Hemiplegia .................................................................................................................................7Chronic Motor Dysfunction After Stroke:Recovering Wrist and Finger Extension by Electromyography-Triggered Neuromuscular Stimulation ..............8Treatment of Stroke-Induced Spastic Hemipareses with EMg-Triggered Electrostimulation ..........................................................................................................9EMg-Triggered Electrical Muscle Stimulation for Chronic Brachial Plexus Palsy – A Pilot Study ................................................................................ 10Electromyogram-Triggered Neuromuscular Stimulation for Improving the Arm Function of Acute Stroke Survivors: A Randomized Pilot Study .......................11Electromyographic Biofeedback for Neuromuscular Reeducation in the Hemiplegic Stroke Patient: A Meta-Analysis ......................................................................12Clinical Evaluation of Functional Electrical Therapy in Acute Hemiplegic Subjects ....13Functional Electrical Stimulation Improves Motor Recovery of the Lower Extremity and Walking Ability of Subjects with First Acute Stroke: A Randomized Placebo-Controlled Trial ...........................................................................................14Early and Repetitive Stimulation of the Arm Can Substantially Improve the Long-Term Outcome After Stroke: A 5-Year Follow-up Study of a Randomized Trial .........15A Functional Electric Stimulation-Assisted Exercise Therapy System for Hemiplegic Hand Function .................................................................................................................16Analgetic Effects on the Neuropathic Pain of a Patient with Paraplegia, Comparing of Two Electrotherapies: EMg-Triggered Electrical Stimulation (Biofeedback) – TENS (Transcutaneous Electrical Nerve Stimulation) .............................17

Urology

Intravaginal Electro-Stimulation as Additional Form of Therapy to Pelvic Floor Exercises Against Urge Incontinence ........................................................................ 20Pelvic Floor Rehabilitation in the Treatment of Incontinence .................................................21Pelvic Floor Muscle Biofeedback in the Treatment of Urinary Incontinence: A Literature Review .....................................................................................................................................22Biofeedback in the Treatment of Faecal Incontinence ............................................................... 22Role of Pelvic Floor Intravaginal Surface EMg in the Diagnosis and Therapy of Female Urinary Incontinence ................................................................................ 23Defecation Function of Children Patients after Treatment with Biofeedback Training ......................................................................................................................... 24EMg-Biofeedback Assisted Pelvic Floor Muscle Training Is an Effective Therapy of Stress Urinary or Mixed Incontinence: A 7-Year Experience with 390 Patients ............................................................................................ 26Randomized Clinical Trial of Intra-Anal Electromyographic Biofeedback Physiotherapy with Intra-Anal Electromyographic Biofeedback Augmented with Electrical Stimulation of the Anal Sphincter in the Early Treatment of Postpartum Faecal Incontinence ............................................................................................................ 28Comparison of Pelvic Floor Muscle Training, Electromyography Biofeedback, and Neuromuscular Electrical Stimulation for Bladder Dysfunction in People with Multiple Sclerosis: A Randomized Pilot Study ..................................................................... 29

Denervated Muccles

Recovery of Long-Term Denervated Human Muscles Induced by Electrical Stimulation ........................................................................................................... 32Long Pulse Biphasic Electrical Stimulation of Denervated Muscle ....................................... 32Electrical Stimulation of Denervated Muscles: First Results of a Clinical Study ............ 33

Muscle Strengthening

Beneficial Effects of Chronic Low-Frequency Stimulation of Thigh Muscles in Patients with Advanced Chronic Heart Failure ........................................ 36The Use of Neuromuscular Electrical Stimulation to Improve Activation Deficits in a Patient with Chronic Quadriceps Strength Impairments Following Total Knee Arthroplasty ...................................................................................................... 37

Sports

Effect of Neuromuscular Electrical Stimulation as a Supplement to Conventional Training in Female Elite Handball Players ...................................................... 40Electrical Stimulation and Swimming Performance .......................................................................41Improvement in Isometric Strength of the Quadriceps Femoris Muscle after Training with Electrical Stimulation ........................................................................................... 42

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Symptom-Oriented Training

STIWELL med4 Programmes

Functional ProgrammesFeedback Programmes

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BackgroundResults of functional electrical stimulation (FES) studies legitimate intensive efforts to improve its practicability. Combining electromyographic (EMg) feedback with EMg-triggered muscle stimulation programs is of particular interest in attempting to influence neurological symptoms. Prerequisite for FES, however, is a certain degree of cognitive ability and motor control.

MethodsThe author evaluated 57 consecutive stroke patients in order to assess their ability to use an EMg-triggered electrical stimulation device (Stiwell – Myofeedback) and to determine indications based upon the use of various modes of electrotherapy. Following a protocol, therapists documented the patients’ handling of the device, the amount of help required from the therapist, and the extent of response of the desired movement (active wrist extension).

ResultsOf all patients, 35% were able to use the device alone, 53% required therapeutic assistance, and 12% were unable to use it. The occupational therapists subjectively selected the following modes of therapy: 58% chose biofeedback programs without muscle stimulation, 38% combined EMg-triggered FES and biofeedback programs, and 4% EMg-triggered FES alone.

Conclusion88% of the stroke patients investigated were candidates for FES. EMg-triggered stimulation devices, however, do not provide the therapy of choice in all cases: combining this form with existing electrotherapy practice, with and without muscle stimulation, would be desirable.

Eligibility of Stroke Patients for Symptom-Oriented Functional Electrical Stimulation (FES)Köchl G., Kofler M., Mayr A., Quirbach E., Saltuari L.Department of Neurology, Hospital Hochzirl, Austira

Study was performed with STIWELL

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Electromyographically Triggered Electric Muscle Stimulation for Chronic HemiplegiaPhys Med Rehabil 1987; 68:407-414, Fields RW

Electromyographically triggered electric muscle stimulation (EMS) was evaluated in combination with conventional treatment in 69 consecutive postcerebrovascular accident outpatients whose onset of hemiplegia was four months to 14 years earlier.

Six subjects initially exhibited no residual volitional activity in targeted muscles, and all patients had undergone conventional therapy with little or no functional recovery. Electromyographic (EMg) recordings and EMS directed to prime movers of impaired movements were accomplished by way of skin-sur face electrodes. Prescribed treatment (patient compliance was frequently substandard) involved several months of four to f ive sessions per week, focusing on wrist extension and/or ankle dorsif lexion initially, and often other movements later. During 30 to 300 movement attempts per session, EMgs that exceeded a preset threshold triggered immediate stimulation to force movement completion.

Over sessions, patients commonly realized substantially improved increases in voluntary EMg capabilities generally proportionate to the frequency of treatment session. Parallel improvements were also found for subjectively scaled functional measures of range-of-motion and ambulation. Motivation was important to success, but side and nature of stroke, age, and poststroke interval were not. Progress often far exceeded that of previous conventional therapy (each patient served as his/her own control).

Regarding mechanisms, impaired proprioceptive feedback is considered central to stroke-disrupted sensorimotor control. EMg-triggered EMS is intended to improve brain relearning by reinstating proprioceptive feedback time-locked to each attempted movement. Clinical results were consistent with this theory; further assessment of the new EMg-triggered EMS modality integrated into conventional treatment regimens seems warranted.

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Background and PurposeAfter stroke, many individuals have chronic unilateral motor dysfunction in the upper extremity that severely limits their functional movement control. The purpose of this study was to determine the effect of electromyography-triggered neuromuscular electrical stimulation on the wrist and finger extension muscles in individuals who had a stroke ≥1 year earlier.

MethodsEleven individuals volunteered to participate and were randomly assigned to either the electromyography-triggered neuromuscular stimulation experimental group (7 subjects) or the control group (4 subjects). After completing a pretest involving 5 motor capability tests, the poststroke subjects completed 12 treatment sessions (30 minutes each) according to group assignments. Once the control subjects completed 12 sessions attempting wrist and finger extension without any external assistance and were posttested, they were then given 12 sessions of the rehabilitation treatment.

ResultsThe Box and Block test and the force-generation task (sustained muscular contraction) revealed signif icant f indings (P<0.05). The experimental group moved signif icantly more blocks and displayed a higher isometric force impulse after the rehabilitation treatment.

ConclusionsTwo lines of evidence clearly support the use of electromyography-triggered neuromuscular electrical stimulation treatment to rehabilitate wrist and finger extension movements of hemiparetic individuals ≥1 year after stroke. The treatment program decreased motor dysfunction and improved the motor capabilities in this group of poststroke individuals.

Chronic Motor Dysfunction After Stroke: Recovering Wrist and Finger Extension by Electromyography-Triggered Neuromuscular StimulationStroke 2000 Jun; 31:1360-1364Cauraugh J, Light K, Kim S, Thigpen M, Behrman A

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The present study investigates the influence of EMg-triggered electrostimulation (EMg-ES) on spastic hemiparesis following stroke in comparison to conventional electrotherapy and to mototherapy (MT, physiotherapy and occupational therapy).

We present a study on 44 patients, who were treated for 4–16 weeks. At the onset of therapy, duration of anamnesis was 6 weeks (1–9 weeks, 3 special cases with a duration of 1, 2.5 and 8 years). group 1 (EMg-ES plus MT):n=22, group II (conventional electrotherapy plus MT):n=12, group III (MT alone):n=10.

Following therapy, all the patients of the three groups showed a distinct reduction of spasticity, as evaluated by the modified Ashworth-scale and the pendulum test. In addition, an increase of contraction force was observed as well as an improvement of voluntary movement, measured by a hand-held myometer and ADL-scores (Barthel, FIM), and, following therapy, life quality was estimated higher by all patients using the well-being scale of von Zerssen.

With regard to reduction of spasticty, the combination of electrotherapy plus MT proved to be superior to MT alone, with no statistically signif icant difference between both types of electrotherapy. With regard to the improvement of force and mobility, EMg-triggered electrostimulation proved to be superior to the other groups, and good results were seen even in the three special cases.

EMg-triggered electrostimulation, as investigated in the present form, can be recommended as a valuable additive method in rehabilitation of stroke, even when the event occurred years ago.

Treatment of Stroke-Induced Spastic Hemipareses with EMg-Triggered ElectrostimulationNeurol Rehabil 2 1997; 82-86Mokrusch T.

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EMg-Triggered Electrical Muscle Stimulation for Chronic Brachial Plexus Palsy – A Pilot StudyPhys Med Rehab Kuror 2002; 12:203-207Paternostro-Sluga T, Rakos M, Hofer C, Mayr W, Schuhfried O, Fialka-Moser V

PurposeTo assess whether EMg-triggered electrical muscle stimulation increases muscle strength in chronic brachial plexus palsy.

MethodSix patients with chronic brachial plexus lesion due to mechanical injury since at least three years; four patients underwent treatment and two served as controls; manual muscle strength testing, according to an extended Medical Research Council scale, active range of motion measurement by goniometry and assessment of function by a visual analogue scale two months before, at the beginning and the end of the treatment period, and two months later were assessed.

ResultsMuscle strength increased in all treated patients by 1 or 2 grades on the extended Medical Research Council scale; active range of motion and function increased in two patients.

ConclusionEMg-triggered electrical muscle stimulation increased muscle strength in chronic brachial plexus palsy.

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Electromyogram-Triggered Neuromuscular Stimulation for Improving the Arm Function of Acute Stroke Survivors: A Randomized Pilot StudyArch Phys Med Rehabil. 1998 May; 79(5):570-5Francisco G, Chae J, Chawla H, Kirshblum S, Zorowitz R, Lewis G, Pang S

ObjectiveTo assess the eff icacy of electromyogram (EMg)- triggered neuromuscular stimulation (EMg-stim) in enhancing upper extremity motor and functional recovery of acute stroke survivors.

DesignA pilot randomized, single-blinded clinical trial.

SettingFreestanding inpatient rehabilitation facility.

PatientsNine subjects who were within 6 weeks of their f irst unifocal, nonhemorrhagic stroke were randomly assigned to either the EMg-stim (n=4) or control (n=5) group. All subjects had a detectable EMg signal (>5µV) from the surface of the paretic extensor carpi radialis and voluntary wrist extension in synergy or in isolation with muscle grade of <3/5.

InterventionAll subjects received two 30-minute sessions per day of wrist strengthening exercises with EMg-stim (experimental) or without (control) for the duration of their rehabilitation stay.

Main Outcome MeasuresUpper extremity Fugl-Meyer motor assessment and the feeding, grooming, and upper body dressing items of the Functional Independence Measure (FIM) were assessed at study entry and at discharge.

ResultsSubjects treated with EMg-stim exhibited signif icantly greater gains in Fugl-Meyer (27.0 vs 10.4; p=.05), and FIM (6.0 vs 3.4; p=.02) scores compared with controls.

ConclusionData suggest that EMg-stim enhances the arm function of acute stroke survivors.

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Electromyographic Biofeedback for Neuromuscular Reeducation in the Hemiplegic Stroke Patient: A Meta-AnalysisArch Phys Med Rehabil 1993 Dec; 74(12):1301-4Schleenbaker RE, Mainous AG III

The eff icacy of electromyographic biofeedback (EMg-BF) for neuromuscular reeducation in stroke patients has been diff icult to establish. The purpose of this study was to assess EMg-BF eff icacy through meta-analysis.

We searched the English-language clinical studies of biofeedback, stroke, and cerebral vascular disease between 1966 and 1991 using MEDLINE, PsycINFO, REHABDATA, and Dissertation Abstracts International. Studies were included in the analysis if (1) the patients sustained a cerebral vascular accident that resulted in hemiplegia, (2) the study had a randomized or matched control group, (3) the study measured a functional outcome, and (4) EMg-BF was the independent variable. Eight studies met the inclusion criteria (n=192). Their average effect size was 0.81. The 95% confidence interval for the effect size was 0.5 to 1.12.

These results indicate that EMg-BF is an effective tool for neuromuscular reeducation in the hemiplegic stroke patient.

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Clinical Evaluation of Functional Electrical Therapy in Acute Hemiplegic SubjectsJ Rehabil Res Dev 2003 Sep-Oct; 40(5):443-53Popovic MB, Popovic DB, Sinkjaer T, Stefanovic A, Schwirtlich L

This paper describes a clinical randomized single-blinded study of the effects of Functional Electrical Therapy (FET) on the paretic arms of subjects with acute hemiplegia caused by strokes.

FET is an exercise program that comprises voluntary arm movements and opening, closing, holding, and releasing of objects that are assisted by a neural prosthesis (electrical stimulation). FET consisted of a 30 min everyday exercise for 3 consecutive weeks in addition to conventional therapy. Twenty-eight acute hemiplegic subjects participated in a 6 mo study. The subjects were divided into lower functioning groups (LFgs) and higher functioning groups (HFgs) based on their capacity to voluntarily extend the wrist and f ingers against the gravity, and were randomly assigned to controls or FET groups.

The outcomes included the Upper Extremity Function Test, the coordination of elbow and shoulder movements, spasticity of key muscles of the paretic arm, and Reduced Upper Extremity Motor Activity Log. FET and control groups showed a recovery trend in all outcome measures.

The gains in FET groups were much larger compared with the gains in control groups. The speed of recovery in FET groups was substantially faster compared with the recovery rate in control groups during the first 3 weeks (treatment). The LFg subjects showed less improvement than the HFg in both the FET and control groups.

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Functional Electrical Stimulation Improves Motor Recovery of the Lower Extremity and Walking Ability of Subjects with First Acute Stroke: A Randomized Placebo-Controlled TrialStroke 2005 Jan; 36(1):80-85Yan T, Hui-Chan CW, Li LS

Background and PurposeThe effectiveness of functional electrical stimulation (FES) has been investigated in chronic hemiplegia. The present study examines whether FES, given during acute stroke, was more effective in promoting motor recovery of the lower extremity and walking ability than standard rehabilitation alone.

MethodsForty-six subjects, 70.9 ±8.0 years and 9.2 ± 4.1 days after stroke, were assigned randomly to 1 of 3 groups receiving standard rehabilitation with FES or placebo stimulation or alone (control). FES was applied 30 minutes and placebo stimulation 60 minutes, 5 days per week for 3 weeks. Outcome measurements included composite spasticity score, maximum isometric voluntary contraction of ankle dorsi-f lexors and planter-f lexors, and walking ability. They were recorded before treatment, weekly during the 3-week treatment, and at week 8 after stroke.

ResultsNo signif icant differences were found in the baseline measurements. After 3 weeks of treatment, there was a signif icant reduction in the percentage of composite spasticity score, and a signif icant improvement in the ankle dorsif lexion torque, accompanied by an increase in agonist electromyogram and a reduction in electromyogram cocontraction ratio in the FES group, when compared with the other 2 groups (P<0.05). All subjects in the FES group were able to walk after treatment, and 84.6% of them returned home, in comparison with the placebo (53.3%) and control (46.2%, P<0.05) groups.

ConclusionsFif teen sessions of FES, applied to subjects with acute stroke plus standard rehabilitation, improved their motor and walking ability to the degree that more subjects were able to return to home.

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Early and Repetitive Stimulation of the Arm Can Substantially Improve the Long-Term Outcome After Stroke: A 5-Year Follow-up Study of a Randomized TrialStroke 2004 Apr; 35(4):924-9Feys H, De Weerdt W, Verbeke G, Steck GC, Capiau C, Kiekens C, Dejaeger E, Van Hoydonck G, Vermeersch G, Cras P

Background and PurposeSeveral studies have investigated the effect of therapeutic interventions for the arm in the acute phase after stroke, with follow-ups at a maximum of 12 months. The aim of this study was to examine the effect of repetitive sensorimotor training of the arm at 5 years after stroke.

Subjects and MethodsOne hundred consecutive stroke patients were randomly allocated either to anexperimental group that received daily additional sensorimotor stimulation of the arm or a control group. The intervention period was 6 weeks. Assessments of the patients were made before, midway and after intervention, and at 6 and 12 months after stroke. In this study, 62 patients were reassessed at 5 years after stroke. The Brunnström-Fugl-Meyer (BFM) test, Action Research Arm (ARA) test, and Barthel index (BI), were used as the primary outcome measures.

ResultsAt the 5-year follow up, there was a statistically signif icant difference for both the BFM and ARA tests in favor of the experimental group. The mean differences in improvement between the groups from the initial evaluation to the 5-year assessment corresponded to 17 points in the BFM and 17.4 on the ARA. No effect was found for the BI. The treatment was most effective in patients with a severe initial motor deficit.

ConclusionsAdding a specif ic intervention for the arm during the acute phase after a stroke resulted in a clinically meaningful and long-lasting effect on motor function. The effect can be attributed to early, repetitive, and targeted stimulation.

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A Functional Electric Stimulation-Assisted Exercise Therapy System for Hemiplegic Hand FunctionArch Phys Med Rehabil 2004 Jun; 85(6):881-5Gritsenko V, Prochazka A

ObjectiveTo test a functional electric stimulation (FES)-assisted exercise therapy system for improvement of motor function on the hemiplegic upper extremity.

DesignA before-after trial, with 2-month follow-up.

SettingA university research laboratory.

ParticipantsA convenience sample of 6 subjects (3 men, 3 women). Main inclusion criteria were that stroke had occurred more than 1 year before the study (mean time poststroke, 5.6 ± 4.4 y) and had resulted in hemiplegia, and that FES produced adequate hand opening.

InterventionA prototype workstation with instrumented objects was used by subjects to perform a set of tasks with their affected hand during 1-hour sessions for 12 consecutive workdays. A FES stimulator was used to assist hand opening.

Main Outcome MeasuresKinematic data, provided by the workstation sensors, and 3 clinical tests.

ResultsKinematic data indicated statistically signif icant improvement in subjects’ performance (pre-/posttreatment effect size [pre/post ES] of the mean performance scores = 5.46; mean pretreatment/follow-up ES [pre/FU ES]=3.44). Two of 3 clinical tests showed improvement in the hand function (mean pre/post ES=.51; mean pre/FU ES=.61).

ConclusionsImprovement in hemiplegic hand function because of FES-assisted therapy was documented in a small group of people with hemiplegia whose motor impairment would exclude them from participation in constraint-induced movement therapy. However, the long-term clinical relevance of such improvement needs further study.

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Analgetic Effects on the Neuropathic Pain of a Patient with Paraplegia, Comparing of Two Electrotherapies: EMg-Triggered Electrical Stimulation (Biofeedback) – TENS (Transcutaneous Electrical Nerve Stimulation)EURAK—European Academy for Health ProfessionalsAusbildungszentrum für Physiotherapie, diploma thesis by Veronika Silberberger, 2006 Dec

Study was performed with STIWELL

This diploma thesis comprises a case study about a patient with paraplegia using electrotherapy as an „add-on-therapy“ parallel to physiotherapy. It will be examined if the follwing two electrotherapies

• TENS (transcutaneous electrical nerve stimulation)• EMG-triggered electrical stimulation (biofeedback)

have analgetic effects on the neuropathic pain for the patient.

The period of examination comprises eight months. Each second month is designed to be a wash out period. The pain-level is recorded in a journal and visualised in the form of charts. At f irst the records were made without consideration of external effects like warmth, coldness, sleep quality and length, dejection etc. In the course of the study it turned out to be that the mentioned external effects have a signif icant inf luence on the electrotherapy. For the analysis of the study those external effects were considered. As a result of the study biofeedback has a greater analgetic effect compared to TENS.

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Urology

STIWELL med4 Programmes

Urology Feedback Programmes

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The study “Intravaginal electro-stimulation as additional form of therapy to pelvic f loor exercises against urge incontinence” was conducted by Veronika Wiborny as master thesis at the academy for physiotherapy at “Landesklinikum Waldviertel Horn”, Spitalgasse 10, 3580 Horn, Austria in 2006/07.

Background and ObjectivesSeveral diverse studies showed different results for the eff iciency of pelvic f loor exercises and intravaginal elecro-stimulation as therapy against urge incontinence. Because of the incongruity in literature, this study was performed to evaluate the eff iciency of pelvic f loor exercises and intravaginal elecro-stimulation as therapy against urge incontinence.

MethodSix test persons voluntarily took par t in this empiric experimental study. They were divided into two groups for six weeks. The experimental group as well as the control group took part in a weekly group therapy where pelvic f loor exercises were performed for one hour. Both groups also did 20 minute exercises every day at home. Additionally, the test group received intravaginal electro-stimulation twice a week for 20 minutes with a frequency of 15 Hz. The measurment parameters were: the weight of the pad after a 24h-pad measurement, the muscular endurance, the maximal strength and the the subjective perception of interference of everyday life by urge incontinence.

ConclusionThe results showed a statistically signif icant improvement of the test group as well as of the control group, and proved that physical therapy and electro-therapy are effective against urge incontinence, thus rebutting the theory of SMITH et al.3

The statistically relevant improvement by transvaginal electric stimulation, as claimed by BARROSO et al.,4 could be confirmed.

3 Smith et al. (2006), S.12334 vgl. Barroso et al. (2004), S. 219

Intravaginal Electro-Stimulation as Additional Form of Therapy to Pelvic Floor Exercises Against Urge IncontinenceLandesklinikum Waldviertel Horn (Akademie für Physiotherapie)Diploma thesis by Veronika Wiborny, 2006/2007

Study was performed with STIWELL

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This study assessed the effectiveness of a pelvic f loor rehabilitation program in a clinical practice.

A retrospective convenience sample of 48 women was evaluated pretreatment and posttreatment with follow-up interviews from six months to three years. This group consisted of 81% with stress urinary incontinence, 6% with unstable bladder and 10% with mixed incontinence. Fecal incontinence was present as well in 35% of the subjects. The patients were taught pelvic f loor muscle exercises and instruction reinforced with electromyographic biofeedback. Neuromuscular electrical stimulation was used when clinically indicated. Two women did not continue the program beyond the f irst visit and were excluded.

Sixty-two percent of patients with two or more visits demonstrated an improvement. Thir teen percent were completely dry, and 49% demonstrated a signif icant improvement. Patients with genuine stress urinary incontinence, unstable bladder and mixed incontinence showed a 66%, 33% and 50% improvement rate, respectively. Fecal incontinence was improved in 63% of women trained in pelvic f loor muscle exercises. A signif icant decrease (P<.001) was found in the frequency of self-reported leakage at the six-month to three-year follow-up. The strength and duration of a pelvic muscle contraction was signif icantly greater between the first and last visit in all patients, regardless of the subjective improvement.

A pelvic f loor rehabilitation program was an effective alternative to surgical intervention in reducing the frequency of urinary leakage. Further studies are needed to identify factors predicting success and to determine the most cost-effective method of achieving pelvic f loor rehabilitation.

Pelvic Floor Rehabilitation in the Treatment of IncontinenceJ Reprod Med 1993 Sep; 38(9):662-666McIntosh LJ, Frahm JD, Mallett VT, Richardson DA

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Biofeedback is eff icacious in the training of the pelvic f loor musculature in order to enhance continence.This ar ticle reviews the anatomy and physiology of micturition as the underlying rationale for pelvic f loor muscle biofeedback in the treatment of urinary incontinence. It critically reviews 28 studies published in peer reviewed journals from 1975 to 2005 that were prospective, randomized studies with parametric statistical analyses, operationally defined patient selection criteria, treatment protocols and outcome measures.The overall mean treatment improvement for patients undergoing biofeedback for urinary incontinence was 72.61%. In 21 of 35 (60%) paired comparisons, biofeedback demonstrated superior symptomatic outcome to control or alternate treatment groups. Larger studies and a standardization of technology and methodology are required for more conclusive determinations.

Faecal incontinence is a distressing condition that affects approximately 1% of the population. Poor anal canal function can be determined by physiological testing using manometry and electromyographic techniques.Surgical repair of the anal canal does not always restore continence but biofeedback training either alone or in combination with other techniques such as muscle stimulation allows restoration of some degree of functional integrity of the anal canal musculature.Biofeedback training offers a non-surgical approach to incontinence with good success rates and prolonged after benefits. However, patient motivation is crucial as the exercise techniques taught need to be continued on a permanent basis if continence is to be maintained.

Pelvic Floor Muscle Biofeedback in the Treatment of Urinary Incontinence: A Literature ReviewAppl Psychophysiol Biofeedback 2006 Sep; 31(3):187-201Glazer HI, Laine CD

Biofeedback in the Treatment of Faecal IncontinenceEur J Gastroenterol Hepatol 1997 May; 9(5):431-434Barlow JD

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PurposeWhich factors affecting the strength of pelvic f loor contraction can be determined with pelvic f loor surface electromyography (sEMg)? How do different methods of conservative management of urinary incontinence change pelvic f loor function determined by sEMg?

Material and MethodsStandardised vaginal sEMgs were recorded in 120 females with stress and/or urge urinary incontinence. Sixty of the patients either participated in a group training programme with education and kinaesthetic, pelvic f loor and general exercises, underwent biofeedback and electrostimulation treatment under supervision, or received a home biofeedback/electrostimulation device. These patients underwent repeat sEMg after treatment.

ResultsThe sEMg values were shown to decline with age, BMI and parity and were lower in patients having undergone a gynaecological operation (p<0.05). The values did not correlate signif icantly with the grade and duration of incontinence, prior treatment with pelvic f loor exercises alone and the presence of urgency or stress incontinence. Patients treated by supervised biofeedback and electro-stimulation showed signif icantly greater increases in sEMg values than the other two groups. There were no differences in the subjective outcomes between the groups. 54 patients reported a signif icant improvement of urinary symptoms.

ConclusionA measurable effect on pelvic f loor weakness was found for age, parity, BMI and a history of gynaecological surgery. Mainly patients with poor pelvic f loor activity benefit from EMg-based biofeedback therapy. EMg values can help to select the most suitable conservative therapeutic method and to assess the outcome of therapy.

Role of Pelvic Floor Intravaginal Surface EMg in the Diagnosis and Therapy of Female Urinary IncontinencePhys Rehab Kur Med 2005; 15:20-26Jahr S, Gauruder-Burmester A, Tunn R, Reishauer A

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BackgroundEncopresis after operation for congenital ectopic anus can cause psychological, physiological and social ability disorders.

ObjectiveTo treat the children with encopresis with biofeedback training so as to improve the function of post-operative defecation.

DesignA self-controlled trial.

SettingDepar tment of Pediatric Surgery, Second Clinical College of China Medical University.

ParticipantsTotally 20 cases of encopresis after treatment with operation for ectopic anus, were recruited from the Department of Pediatric Surgery, Second Clinical College of China Medical University, between January 1998 and October 2004. Among them, there were 4 cases of complete encopresis, 7 cases of loose encopresis and 9 cases of blotch. All the cases were followed up. There were 9 cases of ectopic anus in the middle and lower parts, and 11 cases of ectopic anus at the high part.

MethodsThe objective measuring methods of biofeedback-training such as anorectal pressure and anus sphincter electromyography were used to train the patients with postoperative encopresis. After one-month self-directed training in anus contraction and defecation habit, the children received proper biofeedback training. 1 Biofeedback training to strengthen the muscles around the anus twice per day. The portable biofeedback-training machine was taken home after the children patients could automically contract the muscles around the anus 3 weeks later. 2 Biofeedback training to improve rectal sensitivity and coordination of anus sphincter, and repeated training in expanding saccus. A normal defecation reflex was established. Anus sphincter presented reflex contraction to prevent encopresis once the rectum expanded. 3 Defecation training was performed for 30 minutes after meals every day. 4 Electrostimulation combined with biofeedback training was performed for 10 minutes twice a day for 3 or 4 consecutive weeks.

Defecation Function of Children Patients after Treatment with Biofeedback TrainingChin J Clin Rehab 2005 Jun; 23(9):214-215Wang W, Shi LW, Yuan ZW, Wang WL

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Main outcome measures1 The maximum contraction anal pressure, vector volume, and electromyographic amplitude of external sphincter of anus; 2 positive rate of anorectal contraction reflex of the children patients before and after training.

ResultsAccording to actual treatment analysis, all the 20 children patients entered the result analysis. 1 In middle and lower par ts groups, the maximum contraction anal pressure increased from (11.8 (plus or minus)5.61) kPa before training to (24.88(plus or minus)16.58) kPa after training; in high part group, they increased from (5.76(plus or minus)3.84)kPa to (18.18(plus or minus)13.71)kPa (P < 0.05). 2 In middle and lower parts groups, the vector volume increased from (139.17(plus or minus)130.02) cm (cmHg)² to 6O8.10(plus or minus)131.06 cm (middle dot)(cmHg)², whereas in high group it increased from (117.01(plus or minus)74.35) cm(cm Hg)² to (452.17(plus or minus) 69.43) cm(cm Hg)² (P < 0.05). 3 In middle and lower parts groups, the electromyographic amplitude of external sphincter of anus increased from (152.20(plus or minus) 37.42) (mu)V to (324.12(plus or minus)67.78) (mu)V; in high part group, it rose from (114.08(plus or minus)51.41)(mu)V to (266.18(plus or minus)49.38)(mu)V (P < 0.05). 4 The positive rate of anorectal contraction reflex improved from pretraining 55% (11/20) to post-training 90% (18/20).

ConclusionAfter biofeedback training, the maximum contraction anal pressure, anorectal sensitivity and the coordination of anus external sphincter, defecation habit, and contractibility of external sphincter of anus were all improved obviously, especially in those with ectopic anus in the middle or lower parts. Anus external sphincter function can be improved to the uttermost so as to cure encopresis.

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PurposeThe aim of the study was to determine the short and long-term eff icacy of an intensive and EMg-biofeedback-assisted pelvic f loor muscle training (PFMT) program as a therapy of female stress or mixed urinary incontinence.

Materials and MethodsAll women with stress or mixed urinary incontinence treated in the pelvic f loor reeducation program at our clinic between September 1996 and March 2003 were included. EMg-biofeedback assisted PFMT was performed by specially trained therapists (one registered nurse and one midwife). Electric stimulation preceded PFMT if the pelvic f loor muscle contractions were considered too weak for active training (Oxford<2). Examinations included among others: conventional urodynamic studies prior to therapy, a stress provocation test (cough test), and determination of maximal pelvic f loor muscle strength (Oxford-grading and electric EMg-potential). A retrospective char t review was performed. A questionnaire was administered for long-term follow-up.

ResultsFour hundred and thir ty four women attended our PFR-program in this 7-year period. All 390 women with stress (80%) or mixed (20%) urinary incontinence were evaluated. Mean age: 52 years. Mean duration of incontinence: 6.7 years. Two hundred and sixty three women completed the training (group 1, average number of training sessions: 8.7), 127 patients ended therapy prematurely (group 2, average number of training sessions: 4.1). Short-term results at the end of the PFR-program are available for group 1. There was a statistically signif icant improvement of the stress provocation test (cough test). The data before the therapy was 141x SUI degrees III (60 %); 50x SUI degrees II (21%), 24x SUI degrees I (10%), 20x SUI degrees 0 (9%) as opposed to after the therapy 9x SUI degrees III (5%), 34x SUI degrees II (19%), 48x SUI degrees I (26%), 91 x SUI degrees 0 (50%). There was a signif icant increase in the Oxford-score by 1.2 points (2.9-4.1; P<0.001). Self-reported improvement of incontinence symptoms was 95%. The electric EMg-potentials almost doubled (11.3-20.5 mu V; P<0.001). Long-term results (questionnaire) for all patients: the average follow-up time was 2.8 years (range: 3 months to 7 years).

EMg-Biofeedback Assisted Pelvic Floor Muscle Training Is an Effective Therapy of Stress Urinary or Mixed Incontinence: A 7-Year Experience with 390 Patients Arch Gynecol and Obstet 2005 Dec; 273(2):93-97Dannecker C, Wolf V, Raab R, Hepp H, Anthuber C

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Three hundred and twelve (80%) of the questionnaires returned. Seventy-one percent of them self-repor ted a persisting improvement of their incontinence symptoms. Thirteen percent of all women underwent incontinence surgery following the completion of conservative therapy (9.2% group 1, 25% group 1; P<0.001).

ConclusionAn intensive and EMg-biofeedback assisted PFMT is very effective. Often, avoidance of surgery is possible.

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ObjectiveThe purpose of this study was to compare intra-anal electromyographic biofeedback alone with intra-anal biofeedback that was augmented with electrical stimulation of the anal sphincter in the treatment of postpartum fecal incontinence. A secondary aim was to examine the impact of the treatment on continence-related quality of life.

Study DesignSixty symptomatic women were assigned randomly to receive intra-anal electromyographic biofeedback or electrical stimulation of the anal sphincter once weekly for 12 weeks and to perform daily pelvic f loor exercises between treatments. Therapeutic response was evaluated with a symptom questionnaire to determine continence score, anal manometry, and endoanal ultrasound scanning. Quality of life was assessed before and after treatment with a validated questionnaire.

ResultsFifty-four women completed the treatment; 52 women (96%) had ultrasonic evidence of an external anal sphincter defect. After the treatment, both groups demonstrated signif icant improvement in continence score (P<.001) and in squeeze anal pressures (P<.04). Resting anal pressures did not alter signif icantly. Quality of life improved after the completion of physiotherapy, but there were no differences in outcome between intra-anal electromyographic biofeedback and electrical stimulation of the anal sphincter.

ConclusionIntra-anal electromyographic biofeedback therapy was associated with improved continence and quality of life in women with altered fecal continence after delivery. The addition of electrical stimulation of the anal sphincter did not enhance symptomatic outcome.

Randomized Clinical Trial of Intra-Anal Electromyographic Biofeedback Physiotherapy with Intra-Anal Electromyographic Biofeedback Augmented with Electrical Stimulation of the Anal Sphincter in the Early Treatment of Postpartum Faecal IncontinenceAm J Obstet Gynecol 2004 Sep; 191(3):885-90Mahony R, Malone P, Nalty J, Behan M, O’connell P, O’herlihy C

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AimBladder dysfunction affects up to 90% of the multiple sclerosis (MS) population. Interventions such as Pelvic Floor Training and Advice (PFTA), Electromyography (EMg) Biofeedback, and Neuromuscular Electrical Stimulation (NMES) have received limited research attention within this population. This study aimed to determine the effectiveness of a combined programme of PFTA, EMg Biofeedback, and NMES for bladder dysfunction in MS.

MethodFemales (n=30) who fulf illed strict inclusion/exclusion criteria were recruited. Outcome measures (weeks 0, 9, 16, and 24) included: 3-day Voiding Diary; 24 hr Pad-Test; Uroflowmetry; Pelvic Floor Muscle Assessment; Incontinence Impact Questionnaire (IIQ); Urogenital Distress Inventory (UDI); King’s Health Questionnaire (KHQ), and the Multiple Sclerosis Quality of Life-54 Instrument (MSQoL-54). Following baseline (week 0) assessment, par ticipants were randomly allocated, under double blind conditions, to one of the three groups: group 1 (PFTA); group 2 (PFTA and EMg Biofeedback); and group 3 (PFTA, EMg Biofeedback, and NMES). Treatment was for 9 weeks.

ResultsBaseline severity (measured by number of leaks and pad weight) showed some variation between groups, although not statistically signif icant (P>0.05); with the caveat that this baseline imbalance makes interpretation diff icult, a picture emerges that at week 9, group 3 demonstrated superior benefit as measured by the number of leaks and pad test than group 2, with group 1 showing less improvement when compared to week 0; this was statistically signif icant between groups 1 and 3 for number of leaks (P=0.014) and pad tests (P=0.001), and groups 1 and 2 for pad tests (P=0.001). A similar pattern was evident for all other outcome measures.

ConclusionResults suggest that these treatments, used in combination, may reduce urinary symptoms in MS. Fur ther research will establish the effectiveness of these interventions.

Comparison of Pelvic Floor Muscle Training, Electromyography Biofeedback, and Neuromuscular Electrical Stimulation for Bladder Dysfunction in People with Multiple Sclerosis: A Randomized Pilot StudyNeurourol Urodyn 2006 25(4):337-48McClurg D, Ashe RG, Marshall K, Lowe-Strong A

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Denervated Muscles

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We investigated the restorative potential of intensive electrical stimulation in a patient with long-standing quadriceps denervation.Stimulation started 18 months after injury. After 26 months, the thighs were visibly less wasted. Muscle cross-sectional areas, measured by computerized tomography, increased from 36.0 cm² to 57.9 cm² (right) and from 36.1 cm² to 52.4 cm² (left). Knee torque had become suff icient to maintain standing without upper extremity support. Biopsies revealed evidence of both growth and regeneration of myofibers.The results suggest that electrical stimulation may offer a route to the future development of mobility aids in patients with lower motor neuron lesions.

In recent years a number of studies have employed long pulse biphasic stimulation as a treatment for denervated muscle to improve tissue quality and in some cases to improve contractile capability suff icient to restore function.However, in the U.K., this treatment is yet to be widely adopted clinically. A 5 subject, case based pilot study of long pulse biphasic direct stimulation of peripheral limb denervated muscle is being conducted and its effect on the tissue evaluated by measurement of muscle bulk, limb blood flow, and skin temperature.In cases of partial denervation, trapezoidal shaped pulses are used to minimize sensory and motor nerve fiber recruitment.

Recovery of Long-Term Denervated Human Muscles Induced by Electrical StimulationMuscle & Nerve 2005 Jan; 31(1):98-101Kern H, Salmons S, Mayr W, Rossini K, Carraro U

Long Pulse Biphasic Electrical Stimulation of Denervated MuscleArtif Organs 1999 May; 23(5):457-9Woodcock AH, Taylor PN, Edwins DJ

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To evaluate the effects of electrical stimulation on denervated muscles in spinal cord injured humans, the EU Project RISE was started in 2001.The aims of this project are: to design and build suff icient stimulators; to develop stimulation protocols by means of mathematical models, animal experiments, and practice in humans with denervated lower limbs; to develop examination methods and devices for evaluation of electrical stimulation training effects; and to acquire basic scientif ic knowledge on denervated and stimulated denervated muscle.In the clinical study 27 spinal cord injured individuals were included, furthermore 13 pilot patients participated. After a series of initial examinations they underwent an electrical stimulation program for their denervated lower limb muscles. Some of the patients have already follow up examinations.A marked increase of muscle mass and quality was observed, the trophic situation of the denervated lower limbs had improved obviously.

Electrical Stimulation of Denervated Muscles: First Results of a Clinical StudyArtif Organs 2005 Mar; 29(3):203-6Mödlin M, Forstner C, Hofer C, Mayr W, Richter W, Carraro U, Protasi F, Kern H

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Muscle Strengthening

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AimsPatients with chronic heart failure (CHF) exhibit detrimental changes in skeletal muscle that contribute to their impaired physical performance. This study investigates the possibility of counteracting these changes by chronic low-frequency electrical stimulation (CLFS) of left and right thigh muscles.

Methods and Results(mean±SD) 32 CHF patients (53±10 years) with an LVEF of 22±5%, NYHA II-IV, undergoing optimized drug therapy, were randomized in a CLFS group (CLFSg) or a control group (controls). The groups differed in terms of the intensity of stimulation, which elicited strong muscle contractions only in the CLFSg, whereas the controls received current input up to the sensory threshold without muscle contractions. Functional capacity was assessed by peak VO2, work capacity, and a 6-min-walk (6-MW). Muscle biopsies were analyzed for myosin heavy chain (MHC) isoforms, citrate synthase (CS) and glyceraldehydephosphate dehydrogenase (gAPDH) activities. Peak VO2(mlmin-1kg –1) increased from 9.6±3.5 to 11.6±2.8 (P<0.001) in the CLFSg, and decreased from 10.6±2.8 to 9.4±3.2 (P<0.05) in the controls. The increase in the CLFSg was paralleled by increases in maximal workload (P<0.05) and oxygen uptake at the anaerobic threshold (P<0.01). The corresponding values of the controls were unchanged, as also the 6-MW values, the MHC isoform distribution, and both CS and gAPDH activities. In the CLFSg, the 6-MW values increased (P<0.001), CS activity was elevated (P<0.05), gAPDH activity decreased (P<0.01), and the MHC isoforms were shifted in the slow direction with increases in MHCI at the expense of MHCIId/x (P<0.01).

ConclusionOur results suggest that CLFS is a suitable treatment to counteract detrimental changes in skeletal muscle and to increase exercise capacity in patients with severe CHF.

Beneficial Effects of Chronic Low-Frequency Stimulation of Thigh Muscles in Patients with Advanced Chronic Heart FailureEur Heart J 2004 Jan; 25(2):104-6Nuhr MJ, Pette D, Berger R, Quittan M, Crevenna R, Huelsman M, Wiesinger GF, Moser P, Fialka-Moser V, Pacher R

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BackgroundLong-term def icits in quadriceps femoris muscle strength and impaired muscle activation are common among individuals with total knee arthroplasty (TKA). Failure to address strength-related impairments results in poor surgical and functional outcomes, which may accelerate the progression of osteoarthritis in other lower extremity joints. The purpose of the current case report was to implement a neuromuscular electrical stimulation (NMES) treatment protocol in conjunction with an intense weight-training program, with the aim of reversing persistent quadriceps muscle impairments after TKA.

Case DescriptionThe patient was a 62-year-old male cyclist 12 months following simultaneous, bilateral TKA with impairments in left quadriceps strength and volitional muscle activation. His left quadriceps strength was 26% weaker than his right and central activation ratio (CAR) of his left quadriceps was 13% lower than his right quadriceps CAR. NMES to the left quadriceps was implemented for 6 weeks, in addition to an intense volitional weight-training program with emphasis on unilateral lower extremity exercises.

OutcomesThe patient demonstrated a 25% improvement in left quadriceps femoris maximal volitional force output following 16 treatments of combined NMES and volitional strength training over a 6-week period. The patient’s volitional muscle activation improved from a CAR of 0.83 before treatment to 0.97 after treatment. At discharge from physical therapy and at his 18-month postoperative follow-up, the patient’s left quadriceps strength was only 4% lower than his right quadriceps strength. At the 24-month follow-up, the patient’s left quadriceps strength was 6% stronger than his right quadriceps strength.

DiscussionThe patient was able to achieve symmetrical quadriceps strength and complete muscle activation following 6 weeks of NMES and volitional strength training. An intense strengthening program may have the potential to reverse persistent strength-related impairments following TKA.

The Use of Neuromuscular Electrical Stimulation to Improve Activation Deficits in a Patient with Chronic Quadriceps Strength Impairments Following Total Knee ArthroplastyJ Orthop Sports Phys Ther 2006 Sep; 36(9):678-85Peterson S, Snyder-Mackler L

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Sports

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ObjectiveThe purpose of this study was to verify the effects of training using transcutaneous neuromuscular electrical stimulation (NMES) as a complement for the ordinary training routine with respect to strength, power, speed and endurance characteristics in highly trained female subjects.

Experimental DesignAn eight-week prospective design with random assignment to groups

ParticipantsTwenty-four female top level team handball players were divided on the basis of age and performance characteristics into two experimental groups (n=12 per group).

Experimental DesignBoth groups undergoing the same handball training program over 8 weeks. One group additionally receiving NMES treatment at both legs (STIWELL 1200 portable stimulator with four independently programmable channels) for 29 minutes/every second day. A battery of performance tests were administrated pre-training and post-training.

ResultsPerformance test prof iciency tended to increase for both groups following the training phase in all tests. Consistent signif icant improvements p<0.01 following the training period between both groups were established only in NMES group where the movement velocities (sprint time) as well as power output and vertical jump distance during a stretch-shortening cycle of a vertical jumping test were signif icantly improved.

ConclusionThe results of this investigation indicated that NMES treatment signif icantly improved sprint running performance and stretch-shortening cycle indicators (SSC) but did not increase isokinetic peak torque, squat power output or endurance parameters in highly trained subjects. The results indicate that this specif ic type of NMES in combination with an active muscle training increases mainly power and speed-strength characteristics which both are abilities to exert maximal force during high-speed movements.

Effect of Neuromuscular Electrical Stimulation as a Supplement to Conventional Training in Female Elite Handball PlayersTschan H, Baron R, Bachl NInstitute of Sport Sciences, University of Vienna, Austria

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The purpose of the study was to examine the inf luence of a 3-wk period of electrostimulation training on the strength of the latissimus dorsi m. and the swimming performances of 14 competitive swimmers divided into 7 electrostimulated (Eg) and 7 control swimmers (Cg).

The peak torques registered during the f lexion-extension of the arm was determined with the help of an isokinetic dynamometer at different velocities (from -60 degrees.s(-1) to 360 degrees.s(-1)). Performances were measured over a 25-m pull buoy and a 50-m freestyle swim.

For Eg, a signif icant increase of the peak torques was measured in isometric, eccentric, and concentric conditions (P<0.5). The swimming times declined signif icantly (P<0.01) by 0.19 +/- 0.14 s, for the 25-m pull-buoy, and by 0.38 +/- 0.24 s, for the 50-m freestyle.

For Cg, no signif icant difference was found for any of the tests. For the whole group, the variations of the peak torques, measured in eccentric condition (-60 degrees.s(-1)) were related to the variations of the performances (r=0.77; P<0.01). These results showed that an electrostimulation program of the latissimus dorsi increased the strength and swimming performances of a group of competitive swimmers.

Electrical Stimulation and Swimming PerformanceMed Sci Sports Exerc 1995 Dec; 27(12):1671-76Pichon F, Chatard JC, Martin A, Cometti G

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The purpose of this investigation was to determine if training isometrically with electrical stimulation (ES) alone would signif icantly increase isometric strength of the quadriceps femoris muscle. The relationships between the strength changes and the relative force and duration of training contractions were also studied.An experimental group (group 1) and a control group (group 2), 12 subjects in each, underwent pretesting and posttesting to obtain their maximum voluntary isometric contractions (MVICs). group 1 trained with maximally tolerable isometric contractions induced by ES, three days a week for four weeks.

Results showed that although both groups demonstrated increases in isometric strength of their quadriceps femoris muscles, training isometrically with ES produced a signif icantly greater increase (p less than .01) than not training with ES. The relative strength improvement in group 1 was positively and signif icantly correlated with training-contraction intensity and duration.

The relative increase in isometric strength, using only ES, may be determined by the ability of the subjects to tolerate longer and more forceful contractions. Suggestions for further research and implications for the clinical use of ES for strength-training are discussed.

Improvement in Isometric Strength of the Quadriceps Femoris Muscle after Training with Electrical StimulationPhys Ther, 1985 Feb; 65(2): 186-96Selkowitz DM

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Following 30 years of pioneering research and product development MED-EL today is an acknowledged front runner in providing advanced medical devices in the field of neuromodulation, one of the most exciting development areas in current healthcare.

MED-EL Elektromedizinische geräte gmbHDepartment STIWELLFürstenweg 77a6020 Innsbruck, Austria

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