Electric Stimulation for Intermittent Claudication

Chronic transcutaneous electrical stimulation of calf muscles improves functional capacity without inducing systemic inflammation in claudicants. Eur J Vasc Endovasc Surg. 2004 Feb;27(2):201-9. Anderson SI, Whatling P, Hudlicka O, Gosling P, Simms M, Brown MD.

Abstract OBJECTIVES: To assess whether electrical stimulation of ischaemic calf muscles in claudicants causes a systemic inflammatory response and to evaluate effects of its chronic application on muscle function and walking ability. DESIGN: Prospective randomised controlled trial of calf muscle stimulation. MATERIALS AND METHODS: Stable claudicants were randomised to receive either active chronic low frequency (6 Hz) motor stimulation (n=15) or, as a control treatment, submotor transcutaneous electrical nerve (TENS) stimulation (n=15) of calf muscles in one leg, 3 x 20 min per day for four weeks.  Leucocyte activation was quantified by changes in cell morphology, vascular permeability by urinary albumin:creatinine ratio (ACR), calf muscle function by isometric twitch contractions and walking ability by treadmill performance pre- and post-intervention. RESULTS: Acute active muscle stimulation activated leucocytes less (28% increase) than a standard treadmill test (81% increase) and did not increase ACR. Chronic calf muscle stimulation significantly increased pain-free walking distance by 35 m (95% CI 17, 52, P<0.001) and maximum walking distance by 39 m (95% CI 7, 70, P<0.05) while control treatment had no effect. Active stimulation prevented fatigue of calf muscles during isometric electrically evoked contractions by abolishing the slowing of relaxation that was responsible for loss of force. CONCLUSIONS: Chronic electrical muscle stimulation is an effective treatment for alleviating intermittent claudication which, by targeted activation of a small muscle mass, does not engender a significant systemic inflammatory response.

My comments: Electric stimulation parameters of this study were:

  • Waveform: biphasic square wave
  • Rate: 6 Hz TENS
  • Pulse Duration: 250 uS
  • Amplitude: an intensity that elicits a visible, pain free muscle contraction
  • Electrode location: over the motor point and muscle belly of the triceps surae
  • Frequency and duration: 20 minutes performed 3 times per day for 4 weeks

The stim was only done on the worse leg rather than both legs. They were tested by walking on a treadmill at 2.5 kph (1.55 mph) with a 10% incline. Improvements were reasonably impressive increasing pain free walking distance (PFWD) 108% and maximal walking distance (MWD) 50%, which isn’t bad for 4 weeks.

  • PFWD increase per week = 27%
  • MWD increase per week = 12.5%
  • PFWD increase per workout = 9%
  • MWD increase per workout = 4.2%

Those increases are not that far different from what one gets with treadmill training and I would expect the treatments to be complementary.  I tried the TENS program like above on myself and my patients and thought it would help but I think you would get both increased strength and blood flow with a longer on and off time, 2 on 2 off (EMS pattern feels optimal to me) and I think the EMS current will better increase strength and likely decrease pain better at the same time. I would use a longer pulse width as well with the EMS, up to 450 uS if I had it available.  The control group in this study used a very light TENS pattern that did not cause muscle contraction and they had no improvement in function, and that’s what I would expect, it’s the electrically induced muscle contraction that is likely responsible the the improved function, which is why I would expect EMS with a higher intensity, longer muscle contraction and longer pulse with to be better still, though I think a short rest  is likely going to better improve circulation than you would get with some more classic strength EMS type protocols.

[Update 4-28-16] I’ve been meaning to take back what I said about 2 second on 2 second off being optimal. I think 2 on 2 off would work but after doing my EMS for aerobics tests I think the 6 hz they used in the study to be nearly ideal. However in my experience 5 hz was slightly better. I still expect a pulse duration of 450 uS to be considerably better than the 250 uS used in the study simply because it will reach more muscle thus further increase circulation. This would be particularly important for those with nerve damage often accompanying intermittent claudication.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

6 thoughts on “Electric Stimulation for Intermittent Claudication”

  1. Pad: Intermittent claudication.

    Can you recommend an EMS device?

    Can calf stimulation be used in addition with treadmill walking?

    I’m in NYC.

    • Hi Salvatore,

      My favorite EMS machine are the Globus Genesy models, and if on a budget the EV-906 is a good unit also. If there is sensory loss in the legs, however, the EV-906 might have enough power to fully activate the muscles. It kind of depends on the person.

      What electrodes you use is important too. I don’t like the sticky ones that come with the machines but much prefer rubber carbon electrodes held in place with elastic straps for comfort, effectiveness, and long term cost savings, because they last almost indefinitely. I did a blog about the differences in electrodes which might be worth reading. Also I need to do an update on this blog, because I wrote above that a two second on, two second off would be my preferred duty cycle. However having since done some self experiments with EMS for aerobic conditioning I think 5 hz is optimal for blood flow and is what I would do much of the time for intermittent claudication, but I might spend some time doing a 10 on 50 off for 10 minutes program (10-50-10) for muscle hypertrophy if needed. I think that’s why you want a programmable machine, so you can set it up however you want, and change those programs if you learn more, or experiment on your own to see what works best for you.

      Also I am considering adding a web store to my site to make available the EMS machines, and accessories I use all from the same place. However in the meantime, I have both the Globus Genesy and EV-906 units, pads and straps available in my office. So if you are interested you could call my office at (602) 867-2121 and we could ship you a set-up. Right now I have the Genesy model going for $500, the EV-906 for $150, and my pads and straps for $80 all together. In my EMS for aerobics blog I talked about using 5.5 x 8 inch rectangular electrodes, which might be worth trying as well. To adequately power the super-large electrodes, I think you would definitely want the Globus Genesy stimulator.

      As for treadmill walking with EMS I think both would be optimal. The EMS is good enough that you might be able to get away with less time on the treadmill, but I think using the treadmill is the best way to gauge your progress, both in how fast and how far you can walk.

  2. Thanks for your response.

    I have been diagnosed with PAD, severe in right leg, moderate in left leg. I have been to four Vascular surgeons and when I asked about EMS, all four said, “Don’t waste your money.” A lot they know. The last vascular doctor after he did the ABI test said the PAD was quite severe especially the right leg. He said to exercise and don’t smoke (my last cigarette was 55 years ago) and come back in 18 months

    Are there any pre-programmed devices you know of that would be helpful with PAD?

    I’m 90 years old and maybe programming your device would be a tad difficult for me. How often would the program have to be changed?

    I’m now using a device Unix 8100 (from Korea) that uses compressed air for stimulation. You insert your feet into sleeves and compressed air then compresses first the feet, then the calves, then the knees, then the thighs – this continues for 15 minutes and automatically shuts off.

    I have this unit a week and have no idea if it’s working. I will say the compression is quite forceful.

    About the Retitive unit you commented on which has fixed programs. For PAD this is what the device is programmed for the legs:

    20-53 Hz
    Bursts: 0.1 – 0.5 per second
    Burst Duration: 1.9 – 8.4 seconds
    Off Time: 1 – 1.5 seconds

    It has 15 different wave forms

    • Yeah, some physicians keep up with the research, and get all their new info from drug reps. Also EMS machines are very different, and most being of poor quality, so the one’s they have experience with probably were likely too weak to do much good. Also even the research studies that show EMS works for claudication is a bit obscure, so if I didn’t have direct experience with EMS myself, and the greater body of research on how EMS works in general, I’d be skeptical. I definitely think the one doctor is right about the exercise helping.

      As for machines with preset programs, I upload all of my favorite programs (I think there is only 7 or 8 now) onto the Globus Genesy 300s I sell. One of the programs is called a “10-50-10/5hz-30,” it’s 10 minutes at 10 on 50 off (my favorite for strengthening) immediately followed by a constant on at 5 hz for 30 minutes (my favorite for circulation). I wrote that program thinking it would be ideal for both PAD and neuropathy.

      So if you are in the USA I could ship you one of mine. If you are outside the USA I’d still look for a Globus Genesy 300, which I think are easy to get in Europe at least, and I could tell you how to program it. It’s not that difficult, and I have been looking for an excuse to do a youtube video on how it’s done. So if you got a machine from me it would have my presets already in it and you wouldn’t have to do any programming. If you got a Genesy from another source you would only have to program it once, and it would be saved in the machine.

      The best thing about a programmable machine is that if new research finds better parameters out of a given machine, you can just change your machine, or add a new program to match it, and the Globus Genesy is honestly the best unit I know of in that regard.

      As for the Unix 8100, I don’t have any direct experience with it but I could see that working to decrease edema, but I don’t think it would do much to get the muscles actually contracting on their own thus improving circulation organically. Even for edema I would expect the EMS to work better, particularly if done with the legs elevated. Most of the pneumatic compression devices I have seen only compress the legs a few times a minute, while I program my EMS units to contract the muscles (and thus compress the veins) 5 times a second. Patients of mine who had pneumatic devices at home to prevent blood clots after surgery said they could feel my EMS was more effective, by a long shot. Here’s a blog I did on a paper looking at EMS to prevent thrombosis. Here’s another paper I’m meaning to blog on comparing EMS to pneumatic compression, which backs up my patients reports, if I recall correctly, even with parameters I didn’t think were ideal.

      Also if it were me and I had PAD, I’d definitely be reading up on Intermittent Fasting. Might as well try and help things out from the inside while exercise and EMS is working from the outside.

  3. Chad:

    Ref: Pad with Intermittent Claudication.

    Do you have any current news on this disease?

    Using the Genesy 300, there are two intensity levels to set. What should I strive for in the 10-50/5Hz-30 program:

    For the 50 second phase?
    For the 10 second phase?

    Also how long should each session be?

    How many times a week?

    Sal Liggieri
    sligg1@gmail.com

    • Hi Salvatore,

      One thing new is the effects of caloric restriction/intermittent fasting and peripheral nerve health. I haven’t had any patients with neuropathy try it, but I expect it would help. However, nobody has tested either in people your age either so you would be moving into uncharted territory. Still I have written a number of blogs about intermittent fasting and health/aging in general so they might be of interest to you and in theory I would think a good diet/eating window would work synergistically with your electric stimulation and exercise.

      With both the 10-50-10 and the 5hz settings of your machine you want to turn it up as high as you can handle, so you get hard muscle contractions during the 10 seconds, to restore strength and muscle mass, and hard twitches during the 5hz setting to improve blood flow. When I was doing it myself on my calves I was able to work up to maybe 50 mA (which is more than most people) for both with the green electrode pads that you have. However, since you have claudication it’s reasonable to assume your nerves are damaged and you might need to go a lot higher than I can to get a good muscle contraction. On the bright side, that same nerve damage would mean you probably can go higher without it hurting as much as it would me. So go as high as you can.

      If it were me I would probably try and do the program 7 days per week, once per day, working up to higher intensities as tolerated. How has it been feeling so far?

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