Neuromuscular Stimulation (NMS) - Neurotrac · Electrical stimulation can act as a life ... This...

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NeuroTrac® Electrode Placement Manual

Electrode Placement Manual

Visit our website: www.veritymedical.co.uk for detailed application protocols

Neuromuscular Stimulation (NMS)


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Contents Page

Introduction 4 Muscleprofile 4 Classificationofthevarioustypesofmuscularfibres 5 Howdoesthemusclecontract 5 Redmusclefibretype1 8 WhitemuscleF.O.GfibretypeIIa 8 WhitemuscleF.O.GfibretypeIIb 9 TypeIImfibres 9 Limitationsofthepresentfibreclassifications 9 Musclefibredistribution 10

Muscle Profile (trained muscle) 11 Typesofmusclefibres 11

Selection of parameters 12 Pulsewidthselection 13 Channelselection 13 Work/Restselection 13 Selectionofelectrodesizes 14

Electrodes positioning forSTIM(NMS),EMGandETS 14

Electrode placement 15 Abdominals 15 Waistlineshaping 16 Intestinaltension 16 Deltoids 17 Shoulders 17 Latimusdorsi 18 Trapezius 18 Lowerback 19

Contents

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Contents Page

Erectorspinalis 20 Elbows 20 Triceps 21 Biceps 21 Extensorofthewrist 22 Flexorofthewrist 22 Wrist 23 Handregeneration 24 Handstimulation 25 Back&legs 26 Gluteus 26 Adductors 27 Innerthigh 27 Outsidethigh 28 Femoralbiceps 28 Hamstrings 29 Quadriceps 29 Fluidtension 30 Innerknee 30 Calves 31 Tibialisanterior 31 Peroneus 32 Knee 32 Anklemalaise 33 Ankles 33 Metataraus 34 Soleoffoot 35 Heel 35


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Ithasbeenshownthatnervescontrolmusclebytransmittinganeurologicalcode.Thiscodeormessageoccursintwofrequencyrangesaccordingtothetypeofmusclefibrerequired.Posturalfibresrequireatonicfeedingattherateof10pulsespersecond[Hz].Ifappliedforperiodsofapprox.onehoureveryday,itispossibletosupporttheessentialcharacteristicsofthemuscle.Electricalstimulationcanactasalifesupportuntilthenormalfunctioncanberesumed.Thisisachievedbypreservingcapillarybeddensity,musclebulkandtheessentialabilitytouseoxygen.

Thesecondfrequencyrangeoccursat30pulsespersecond[Hz].Thisfrequencyrelaysinformationtothefastmusclefibres,whichsupportspowertomusclemovement.Thisfeedingofthemuscleoccursnaturallyinaphasicway.Electricalstimulationtreatmentprotocolstopromotethesefibresaregivenformuchshorterperiodsthantheslowtwitchfibres.

Thisphysiologicalapproachtoneuromuscularstimulationalsorequirespulsesthatareshapedsimilartothenaturallyoccurringnervesignalsthathaveverybriefpulsewidths.Bymimickingnatureasaccuratelyaspossible,electricalstimulationhasbeenusedforlongperiodswhenrequired,withoutcausingsideeffects.

Muscle profileWhenthemusclereceivesanelectricalimpulseitstartstocontract,whetherthepulseoriginatesfromthebrainorisproducedbyelectricalstimulation.Averyshortelectricalstimulationburst,howeveronlyproducesashortcontractionor“singleshock”afterwhichthemuscleimmediatelyreturnstoitsnaturalshapeandlengthwhenatrest.However,ifthestimulationisrepeatedrapidlymanytimesinsuccession,weobservethattheeffectsofthecontractionareadditiveduetothesuperimpositionofthecontractionstagesandtheinabilityofthemuscletorelax.Thisphenomenoniscalledincompletetetanus.Neither“singleshock”norincompletetetanusisnormallyobservedinvoluntaryactioninhumans.

However,astateofmuscularcontractioncausedbyrepeatedelectricalstimulationofthemotornerveswithafrequencysufficientlyhightomergetheindividualshocksandmakethemindistinguishablefromeachotheriscalled“completetetanus”Inthisscenario,themusclecontractsandbecomesfirmduetothevoltagegeneratedwithinthemuscleand,exertsameasurableforceatitstendonousends.Almostall-muscularcontractionsnormallyoccurringinhumanmusclehavethecharacteristicsofa“completetetanus.

Introduction

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Classification of the various types of muscular fibresTheskeletalmusclesarecomposedofacollectionofmuscularfibresandhavevariationshapesaccordingtothemechanicalfunctionstheyarerequiredtoperform;broaddifferences,however,maybediscoveredinahistologicalexaminationofthefibresandthesearestrictlyconnectedwiththemethodbywhichaparticularmuscleisrequiredtoperformitstask.Analysisofthefibresusingachemicalcolourationtechniquehasrevealedthepresenceofvariousdifferentanaerobicandaerobicenzymesandthesametechniquehaspermittedthevariousoccurringintheactivitiesoftheseenzymestoberevealed.

How does the muscle contractSkeletal[striated]muscleismadeofnumerouslongthinparallelfilamentsnamedmuscularfibresrunningbetweentendonsbymeansofwhichtheyareconnectedtothebones[seeFigure1].


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Figure1

SARCOMEREACTIN ACTIN

MYOSIN

MYOFIBRIC

MUSCLEFIBRE

BUNDLEOFMUSCLEFIBRES

MUSCLE

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Muscularfibrescontainbundlesoffilaments,surroundedbythesarcoplasmaticnetworkknownasmyofibrilandeachmyofibrilconsistsinturnofasequenceofmanymicroscopiccylindricalelements,thesarcomeres,connectedtogetherlongitudinallycreatingthecontractilemotorofthemuscle.Thesarcomerehasastructureofcylindricalformandinsideitcontainsthisfilamentsofactinthatareconnectedatisends[lineZ]interspersedwiththickerfilamentsofmyosin{seeFigure2}.

Figure2

Whenanelectricalimpulsereachesthemuscle,anactivatedvoltagetravelsalongtheperimeterofthecellularmembraneandthroughthesystemoftubesatTpenetratesdeeplyintothemusclecellcreatingthereleaseofcalciumionsinsidethesarcomere.Thereleaseofcalciumcausesattachmentsofspecificpartsofthethickfilamentofmyosintothethinfilamentsofactinandtheconstructionofbridgesbetweenmolecules{acto-myosinbridges}.

Therotationthatoccursonthedistalportionofthebridge–headproducesaslidingofthefilamentsbetweeneachother,whichistheactualmechanismofcontraction.

Figure3

ACTINMYOSINMYOSIN

ACTIN

MYOSIN

ACTIN


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Therotationoftheheadofthemyosinfromposition2toposition3producesreciprocalmotionofthefilamentsofactinandmyosin;thismechanismisthebasisofallmuscularcontraction.ThemutualslidingproducesthelinesZtoapproacheachotherandshorteningofthesarcomeres,whichbeingaddedtothatofallthesarcomeresplacedinseries,generatestheoverallshorteningofthemusclethatoccursineverymuscularcontraction.

Thefilamentsdonotchangetheirlengthwhenthemusclecontracts,butslidebetweeneachotherchangingtheirmutualposition.

Red muscle fibre type 1ThesetypeoffibresarealsocalledSTfibres[slowcontractingfibres]orSOfibres[slowfibreswithoxidativemetabolism].

Themotorneuronethatinnervatesthemistonicandhasalowspeedofconduction.Fibresofthisnatureareredincolour[therednessduetothepresenceofthemyoglobinmolecule].Insidethemthereisalargenumberofmitochondriaandoxidativeenzymesthatexplainsthereasonwhythemajorityoftheintramitochondrialoxidativephosphorilationprocesstakeplaceinthesefibres.Averyhighcontentoflipidsandmyoglobinisalsoassociatedwiththesemetabolicfunctions.Thesetype1muscularfibresarehighlyresistanttofatiguesincetheyareresponsibleforalltypesofactivitiesofatonicnature,slowactingandassociatedwithmaintainingposture.Theseslowfibresaresurroundedbyadensenetworkofcapillariesthatpermitoptimumperformanceoftheaerobicmetabolisminaprolongedactivityassociatedwiththemodestexertionofforce.Theseredmusclefibresgivethestrengthtothemuscleandsupportthejoint.Theyarefibresthatareveryimportantinallendurancesports,suchascycling,running,swimming,tennis,etc.

White muscle F.O.G fibre type IIaThesearecalledFTa[rapidcontractingfibres]fibresofFOG[rapidfibreswithoxidative-glycolyticmetabolism]fibres.Thesefibresareinnervatedbyaphasictypemotorneurone,characterisedbyhigherspeedofconductionofthetonicmotorneurone.Theyarewhiteincolour,duetoabsenceofmyoglobinand,arecharacterisedbyamixedmetabolicactivity.Thesefibresarerichinglycogenandglycolyticenzymes,butalsocontainmitochondriaenzymes;theoverallmetabolismismoreanaerobicthantheaerobicoxidative.

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Thesefibresarealsoprovidedwithanetworkofcapillariesthatcarrytheoxygenrequiredfortheaerobicprocess.TypeIIafibresaretherefore,abletoperformrapidcontractionscharacterisedbyasignificantexertionofforce,whichisalsosustainedovertimegivingarelativeresistance[endurance]tofatigue.

White muscle fibre type IIbThesefibresarecalledFTb[rapidcontractingfibres]fibresorFG[rapidfibreswithglycolyticmetabolism]fibres.Thistypeoffibreisinnervatedbyaphasicmotorneuronewithacellularbodyandaverylargeaxonthattransmitspulsestothemuscleatveryhighspeed.Thesefibresarewhitetolookatandhaveveryhighglycogenandglycolyticenzymecontentinordertoproduceaveryhigh-energyoutputoftheanaerobictype.Contractionisfairyrapidandcreatesahighlevelofforce;thealmostcompleteabsenceofmitochondriarendersthesefibresincapableofsustainingprotractedactivityandtherefore,easilyfatiguedparticularlyintheuntrainedmuscle.TypeIIbfibresplayaverysignificantpartinallhumanactivitiesrequiringtheexertionofexplosiveforceand,naturally,inallpowersandexplosivesportssuchassprinting,weightlifting,swimming,jumping,etc.

Type IIm fibresAtypeoffibrethathasbeendescribedwithcharacteristicssimilartothoseoftheIIbtype,butwitharesponsetostimulationshiftedtohigherfrequencies[approx.100–110Hz].

a}Synchronousrecruitmentb}Disinhibitsapprox.30%ofmaximumeffortc}Theconstantglycogendemandsproducesamoreefficientreplacementsystem. Limitations of the present fibre classificationsThecurrentclassificationsofthemusclefibresisdeterminedmorebythenecessityofestablishingasetofcharacteristicstobeusedforpracticalpurposesratherthanbythebiological-functionalrealityofthehumanmuscularsystem.Itisassuredthatthefibresformpartofacontinuousrangeofvariouslevelsofmetabolicorganisationthatareproducedbythefunctionalrequirementsofthevariousformsofhumanactivityingeneralandsportingactivityinparticular.


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Muscle fibre distributionThefibretypesashasbeendetailedabovecanbefoundinvariouspercentagesinmusclesandtheratiobetweentypeIandtypeIIfibrescanvaryconsiderably.SomemusclegroupsconsistoftypicallytypeIfibresi.e.thesoleusandmusclesthathaveonlytypeIIsuchastheorbicular,butinthemajorityofcasesvarioustypesoffibrearefoundtogether.

Figure4

Infigure4onecanseethephasicandtonicfibresmixedtogethersidebyside,butthevariousfibresdorespondtotheirrespectivemotorneurones.Therehavebeenclinicalstudiesconductedonthedistributionoffibresinthemusclethathavedemonstratedtherelationshipbetweenthemotorneurone–tonicandphasic,andthefunctionalcharacteristicsofthefibresinnervatedbyitandshownhowaspecificmotoractivity,inparticularsportingactivitiescananddocauseafunctionaladaptationofthefibresandamodificationoftheirmetaboliccharacteristics.

TONIC

PHASIC

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[Trained Muscle]SlowOxidative: Increaseinsizeofexistingfibres[SO] Increaseinnumberofredfibres Increaseinsizeofmitochondria Increaseinoxidativeenzymes

FastOxidativeGlycolytic Possesglycolyticandoxidative [FOG] metabolicpathways.Earlyonsetof fatigueispreventedbythedevelopment ofF.O.Gfibreswhichworklongperiods withoutfatigue.

FastGlycolytic Localmuscleglycogenstoresaredepleted [FG] with10-15rhythmicalcontractions. [HirchETAL1970]

Types of muscle fibres:

Muscle profile

Motorunit Motorneurone

Typeofmetabolism

Typeofmusclecontraction

Muscle fibretype

Frequencyrangeofstimulation

TonicLow speedofconduction

SOSlow Oxidative

ST Slow Contraction Ia 10-40Hz

PhasicMediumspeedofconduction

FOGFastOxidativeGlycolytic

FTaRapidContraction IIa 50-70Hz

PhasicHighspeedofconduction

FGFastGlycolytic

FTbRapidContraction IIb 70-100Hz

PhasicHighspeedofconduction

FGFastGlycolytic

FTmRapidContraction IIm 100-120Hz


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Frequency selection5 ppsorbelow:Tointroducethestimulustoanerveorthemusclestimulation,thatmaynotrespondimmediatelyormaynothavefunctionforaperiodofmonthsorevenyears.

Forexample:3ppsisusedasanintroductoryfrequencyfortheelectricalstimulationofspasticity.Thisfrequencyisagentleintroductiontotreatmentunlikelytocausespasms.3ppsiswithinthefrequencyrangefortheproductionofendorphinsforpainreliefandgeneralrelaxationanditisthenaturalfiringfrequencyofthefusimotorpathways,whichcontrolthemusclespindlesandinitiatethemovementsequence.

5 - 15pps Thisfrequencyrangeisselectedtoimprovemuscletone,improvejointsupportandstability.10ppsarethenaturalfrequencyoftheslowoxidativemusclefibres.Electricalstimulationwillimprovethemusclefatigueresistancebyimprovingitscapillarybeddensityandimprovethemuscletohandleoxygenbreakdown.ThisfrequencyrangemaybeusedforextendedperiodsofseveralhoursperdayforsportsandrelatedtreatmentandshorterperiodsforareassuchasContinence.

15 - 20ppsThesefrequenciesmaybeusedtopromoteenduranceinthemuscle.Thisfrequencyrangeisthenaturalbandforthefastoxidativeglycolyticmusclefibres.Treatmentinthisfrequencybandmaybeusedupto1hourperday.

30 - 50 ppsThesefrequenciesareselectedforstrengtheningamuscleandrecruitingthefastglycolyticmusclefibres.Treatmentusingthisfrequencybandwouldbeforshortperiodsonlyasfatiguingamuscletakesonlyafewminuteswithelectricalstimulation.

50 - 120ppsThesefrequenciesareusuallyselectedwheregreatpower/speedandstrengtheningofthemuscleisrequired.Whenstimulatingatthesehighfrequenciesitisimportantthatitisonlyforveryshortperiods.

pps = pulsespersecond

Selection of parameters

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Pulse width selectionTheselectionofpulsewidthismadeaccordingtothedepthofpenetrationrequiredforthetreatment.Theshorterthepulsewidththemorecomfortableandsuperficialthetreatmentreceived.

Pulsewidthexamples:Superficialmusclesoftheface- 70-80µS [Nohigher]uselowfrequenciesbelow20Hz

Superficialmusclesofthehand- 70-90µS Musclesoftheleg- 200-350µS Muscleofthearm- 150-300µS PelvicorAnalmuscles- 75-250µS

Channel selectionMostmusclestimulatorshavealternatingorsynchronousmodes,whichallowsforthereproductionofagonist/antagonistactivityaroundthejoint.Thealternatingoptionshouldalwaysbeconsidered,asitwillpreventtheproblemsassociatedwithmuscleimbalance.Alsoinputtingadelaytimebetweenthechangeoverfromonechanneltoanothermayassistvoluntarymovement.

Thesynchronouschannelmodeallowsforthereproductionofsynergicmuscleactivity.Thisisusefulforfunctionalactivitiesaccompanyingspecificphysiotherapyprogrammes.

Work / Rest SelectionTherestcycleshouldundermostcircumstancebeaslongastheworkcycletoallowthereactivehyperaemiatodisperse.

Ifthefrequencyandcurrentisraisedtoaleveltoinduceatetaniccontractionitmaybemoreappropriatetoenlistalongerrestcycletoallowamovementtooccur.Onewouldexpectthepatienttoproducevoluntarymovement[contraction]duringtherestcycle.

Example4secson4secsoff-increase rest time to between 6 –8 seconds or more.


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Selection of electrode sizes Thesizeofelectrodetobeuseddependslargelyonthepulsewidthtobeusedand,whichpartofthebodytheelectrodeistobeplaceupon.GenerallythewiderthepulsewidthandthehigherthemAcurrenttobeusedthelargertheelectrodeneedstobe.

Fortheface,fingersandhandswherethemuscleissuperficialthepulsewidthshouldbekeptdowntobelow90µS,allowingasmallersurfaceareaelectrodetobeusednormally26to30mmdiameter.

Forthearm,lowerpartsofthelegandanklethepulsewidthselectionideallyshouldbebelow300µSallowingthesurfaceareaelectrodetobemorethanwhenusedonsuperficialmusclesofapprox.40to50mmsquare.

Forthequads,upperarm,lower,upperbackandgluteusmaximusthepulsewidthideallyshouldbe350µSorbelow.Themusclemassislargerintheseareasthatallowslargersurfaceareaofelectrodetobeused.50x50or50x100beingthemostcommonsizes,althoughlargersurfaceareaelectrodescanbeused.

Electrode positioning for STIM (EMS), EMG and ETS

Attachtheelectrodestoyourbody(seeelectrodeplacementdiagrams).Uselargerelectrodessizesforvastmusclegroups.PlacenegativeBlack-pinneartheupperinsertionortopofthemuscle.PositiveRed-pinmustbeplacedatthemotorpointofthemuscle.Themotorpointisusuallylocatedatthecentreofthemusclemasswherethemotornerveentersthemuscle.Findthebestpositionbyslightlymovingthepositiveelectrodearound.Yourobjectiveistofindthespotwheretheminimumamountofelectricalstimulationwilleasilyexcitethegreatestmuscularcontractionwithoutcausingpain.

Pleasenote,forTENS-painrelief,theelectrodeplacementcriteriaaredifferent!

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Abdominals 1

SuggestedSettings ElectrodeSize: 50x50mm PulseWidth: 250µS

Abdominals 2


Electrode placement

Ch.A

Ch.B

Ch.A

Ch.B

Ch.C

Ch.D

PositiveRedmustbeplacedonthemotorpointofthemuscle.Findthebestpositionbyslightlymovingthepositiveelectrodearound.

+ = Red- = Black


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Intestinal tension

SuggestedSettings ElectrodeSize: 50x50mm PulseWidth: 220-250µS

Ch.A

Ch.B

Ch.C

Ch.D

Waist line shaping


Ch.A Ch.B


+ = Red- = Black

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Deltoids


Ch.A

Ch.B


Shoulders


Ch.A Ch.B Ch.C Ch.D


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Latimus Dorsi

SuggestedSettings ElectrodeSize: 50x50mm or 50x100mm PulseWidth: 250-275µS

Ch.A

Ch.BCh.C

Ch.D


Trapezius

SuggestedSettings ElectrodeSize: Shoulders 50x50mm Back 50x50mm or 50x100mm PulseWidth: 220-250µS

Ch.A Ch.B

+ = Red- = Black

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Lower back


Ch.A Ch.B



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Elbows


Ch.A

Ch.B

Erector spinalis


Ch.CCh.D


+ = Red- = Black

21


Biceps


Ch.A

Triceps


Ch.A

Ch.B



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Extensor of the wrist


Flexor of the wrist


Ch.B Ch.A


+ = Red- = Black

23


Wrist

SuggestedSettings ElectrodeSize: 50x50mm or 30mmdia PulseWidth: 220µS

Ch.A

Ch.B



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Hand regeneration


Ch.A


+ = Red- = Black

25


Hand stimulation


Ch.A Ch.B



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Back & legs


Ch.A

Ch.B

Ch.C

Ch.D

Gluteus


Ch.A

Ch.B

Ch.C

Ch.D


+ = Red- = Black

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Adductors


Ch.A

Ch.B

Inner thigh


Ch.A Ch.B



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Femoral biceps


Ch.A

Ch.B

Outside thigh


Ch.A Ch.B


+ = Red- = Black

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Ham strings


Ch.ACh.B Ch.C

Ch.D

Quadriceps SuggestedSettings ElectrodeSize: 50x50mm or 50x100mm PulseWidth: 250-300µS

Ch.A

Ch.B



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Fluid tension

SuggestedSettings ElectrodeSize: UpperLeg 50x50mm or 50x100mm Ankle 50x50mm PulseWidth: 220-275µS

PleaseNote: Ch.C&Ch.DpositionsontheleftlegareidenticaltotheCh.A&Ch.Bposi-tionsontherightleg.TheelectrodeforCh.Disnotvisibleonthispicture.

Ch.ACh.B

Ch.C Ch.D

Inner knee


Ch.ACh.B


+ = Red- = Black

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Calves


Ch.A Ch.B

Tibialis anterior


Ch.A Ch.B



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Knee


Ch.A

Ch.B

Peroneus


Ch.A


+ = Red- = Black

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Ankles


Ch.A Ch.B

Ankle malaise


Ch.A

Ch.B



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+ = Red- = Black

Metataraus


Ch.BCh.A


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Feet regeneration


Ch.A

Ch.B



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Feet stimulation


Pleasenote:Ch.Aelectrodesareplacedontheleftfoot.Ch.Belec-trodesareplacedontherightfoot.

+ = Red- = Black

Ch.A

Ch.B


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Sole of foot


Ch.A Ch.B

Heel


Ch.A

Ch.B



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Notes

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Electrodeplacement

manual(English)

ECS900-OM-EN08-10-11-16

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