1. EMS helps in physical medicine and rehabilitation by moving injured muscles and reducing pain
   
   
2. EMS reduces overall recovery time by increasing blood flow and lubrication (synovial fluid) of joints
    
3. EMS can be used for rehabilitation and recovery for hip and knee repair, back issues, high-level sports injuries, arthritis and joint replacement rehab, reduction of swelling, and reduction of muscle guarding

1. An EMS device is a powered muscle stimulator that uses a small battery paired with computer programs to send out timed (microseconds) sequenced bursts of electrical currents
   
   
2. Timing patterns can be adjusted to different speeds (example: quick like a sprinter or slow like a weightlifter)
   
   
3. Electrical current bursts create a muscle contraction while the user voluntarily resists the contraction
   
   
4. Activates 20-30% of the user’s MVC (maximum voluntary contraction)

1. PEMS is a type of electrical muscle stimulation that provides precise timing patterns that the nervous system applies to muscles
   
   
2. Normal neurophysiology:
   1. Brain activates the spine electrically by sending a nerve signal to the muscle to tighten and then back to the spine after the tightening
   2. The spine circuit then shuts down opposing muscles to facilitate the movement
   3. The movement back-and-forth with the timing of the muscles contracting and opposing muscles releasing creates a spinal generator motor circuit
   4. PEMS replicates these timing patterns through various programs (training modes)
      
      
3. Prior to Neuro20, PEMS programs stimulated 2-4 muscles at a time in these patterns
   
   
4. Neuro20 stimulates up to 40 muscles in a pattern artificially creating a motor chain
   
   
5. Neuro20’s precision neurophysiology – the biomechanics combined with advanced materials and computers’ algorithms – replicate movement patterns unlike anything previously

1. Strength, endurance, power, speed, positional awareness, balance, upper/lower body precision
   
   
2. Specific training modes include: strength, body toning, cool down, massage, TENS, PEMS, throwing, walking, jogging, sprinting, jumping, cycling, kicking. 
   
   
3. Also includes golf swing and various occupational therapy patterns including standing, sitting, bending from various joints, and reaching are currently in development

All techniques can be used in healthy training as well as post-injury rehabilitation.

Strength and Endurance Training

1. Resistance exercises with weights or bands with greater than 30%MVC
   
   
2. Typical protocol of ascending or descending reps to fatigue
   
   
3. Add co-contraction of agonist/antagonist muscles to change the MVC to 10-20% (will result in more agonist work)
   
   
4. Stimulation of deltoids increases recruitment for abduction exercises, added recruitment increases maximum motor output/number of reps tolerated
   
   
5. Abdominals plus lumbar paraspinals increases time tolerance for core stabilization exercises
   
   
6. Glutes, quads, and hamstring assist in eccentric and concentric extension exercises
   
   
7. Increased free weight loading while standing and flexing / extending the hips and knees plus relatively high intensity stimulation of the glutes, quads/hamstrings as well as the lumbar paraspinals allows an increase in the number of reps
8. All are standard techniques for strengthening the thighs and buttocks while stabilizing the lower back
   
   

Power Protocols

1. The same as ‘Strength and Endurance’ training with a faster maneuver
   
   
2. Warm-up with repeated sets of high intensity max speed reps
   
   
3. Full body constant stimulation with higher levels of intensity
   
   
4. Revved up for HIIT training in the sprint/cycling modes
   
   
5. Brief bursts 5-10 seconds repeated for 10-15 reps
   
   
6. Increase speed of upper body exercises
   
   

Speed and Endurance

1. Improved by a combination of power plus efficiency of movement
   
   
2. Balance and precise muscle timing improves efficiency
   
   
3. Cardiopulmonary improved by training to the anerobic threshold
   
   
4. Metabolic activity of muscles (not heart and lungs) determines shift into anerobic or lactate generation phase
   
   
5. Stimulation increases microcirculation blood flow into the muscles which increases glucose consumption and metabolic enzymes in the muscles
   
   
6. Coupled with exercise it increases the mitochondria size and numbers
   
   
7. Combining stimulation with endurance exercise increases O2 utilization approx. 30%
   
   
8. Improved sensory nerve feedback increases position sense thereby improving balance and muscle sequence timing
   
   
9. Net result is increase in both speed and endurance

1. Body toning comes from an increase in total calories burned
   
   
2. Static stimulation (i.e not moving) of the abdominals alone does not result in fat loss
   
   
3. Stimulation will increase strength and reduce aches and pains which results in increased activity, which increases calorie consumption, which then sculpts the body

1. Muscle stimulation increases local blood flow which leads to increased joint lubrication in synovial joints (knees, hips, shoulders)
   
   
2. Occurs without active exercise and can be passive in approx. 5 minutes
   
   
3. Simultaneously, the Neuro20 PRO reduces muscle guarding and inhibition
   
   
4. The result is reduced joint pain and improved coordination

Adding the full body stimulation of the Neuro20 to any of dozens of exercises provides an excellent workout. The American College of Sports Medicine provides extensive examples categorized by the athletes’ objectives.

We suggest:

1. Warm-up in the Neuro20 suit without stimulation
   
   
2. Exercise combined with a stimulation training mode
   
   
3. Cool down (with or without stimulation)

1. Lower extremity stimulation (quadricep) assists with standing and walking
   
   
2. Anterior tibialis stimulation of the peroneal nerve is used for ankle movement assist dorsiflexion, in patients with MS, Stroke, and Traumatic Brain Injuries (TBI)
   
   
3. Reciprocal stim (quads/hams) used to walk assist patients with incomplete spinal cord injuries
   
   
4. Electrical stimulation shown effective in some Parkinson’s patients helping balance and walking (gait and arm swing)

1. Neurological warm up before physical and occupational therapy retraining sessions
   
   
2. Once per-day at full intensity (if comfortable for the patient) or twice daily at lower intensity, such as “sensory – motor” levels

1. EMG biofeedback assisted retraining is currently in development 
   
   
2. Coupling EMG biofeedback with electrical stimulation once the patient reaches the desired threshold of wrist extension or ankle dorsiflexion would be helpful
   
   
3. Opposing muscles are primarily responsible for the lack of function – stimulating opposing muscles at a sensory-motor level helps reduce antagonist spasticity with our current system
   
   
4. EMG biofeedback to reduce the antagonist muscle activity will help improve motor function
   
   
5. EMG activity can be used to control biofeedback retraining video games and coupled with music which is a longer development cycle

1. Patterned electrical neuromuscular stimulation (PEMS) can be very effective in treating motor control in patients with Cerebral Palsy
   
   
2. Data on 18-consecutive patients results ranged from significant functional improvements using a rehab scale called the FIM (Functional Independence Measure)
   
   
3. The FIM is not a very sensitive measuring tool so little changes are not noted, only significant changes – a one-point move is a meaningful change in function or dependence
   
   
4. The FIM score changes ranged from 0 in 2 patients up to 11 in a very complex patient – median change was 4
   
   
5. Used 2 and 4 channel electrical patterned stimulation with patients who have CP – we have yet to collect data on Neuro20 PRO 20 channel system
   
   
6. Testimonials:
   1. A 28-year old patient stated the stimulation was the only therapy that ever helped her. Gone from being fully wheelchair bound to being able to transfer and walk functional distances without assistance.
   2. 20-year old patient with severe CP described as athetoid spastic quadriparesis. He weighed 60 lbs. and had to be restrained at the arms, knees, waist, and hips. He would flail his head back and forth and would choke and cough violently on his own saliva. After a few months of once weekly stimulation to his arms and neck, he was able to swallow without choking. He was able to keep his head steady and use his arms and hands to assist me in applying the electrode gel. He began to gain weight and his body length grew to the point where he required two new wheelchairs over the next 3 years. He did not need arm restraints anymore. He was able to write an autobiography about what it was like to be trapped in his out-of-control body for most of his life.

1. Frequencies run between 7-100 Hz for functional and full body contraction programs (frequencies specific to each training mode and can be found in the Operational Manual)
   
   
2. Amplitudes in milliwatts and increase up to about 60 maximum with a constant current controlled output – 40mA applied at 50Hz of 250uSec square wave pulses is strong enough to produce 20% MVC in the quads

Biphasic rectangular waves, net zero ion flow; pulse width 75-200 microseconds, however this varies based on the training mode (refer to the Operation Manual for each mode’s parameters)

1. Lactate is a fuel and is a potent signal irrespective of oxygen tension
   
   
2. VO2 increases dramatically with stimulation and movement

1. Cardiovascular endurance comes from an increase in muscle to extract and utilization of oxygen and glucose
   
2. Capillary dilation, a change in transport enzymes in the muscle fibers, and an increase in size and number of mitochondria is critical
   
   
3. Effective in patients with pulmonary disease such as COPD
   
   
4. The average improvement in the active group was 36% with no change in the control group receiving sham stim. (G. Bourjeily, 2003)

1. All exercise above 30% MVC eventually leads to hypertrophy
   
   
2. Initially, strength improved from neurological timing and neuromuscular coupling and feedback reflex strengthening
   
   
3. Blood flow increase, especially at the micro vascular level gives the appearance of increased muscle size
   
   
4. Muscle density coupled with increased muscle fiber water gives the appearance of increased hardness as well as muscle size
   
   
5. After 8 weeks of resistive exercise there is an increase in contractile protein production which is true of hypertrophy

1. We designed the system to focus on the interventions first and are developing sensor diagnostics now, since most wearable devices were focused on diagnostics not interventions
   
   
2. To close the loop between the intervention and diagnostic we are less than a year away from the following sensors – EMG, accelerometers for range of motion and articulation, and heart rate variability
   
   
3. A longer development project is to include sweat chemistry analysis
   
   
4. Once we integrate the sensor technology, we will enhance the software to be able to provide medical and fitness professionals, patients, athletes, and users an EMR (electronic medical record) for each training session
   
   
5. This information will be HIPAA and GDPR compliant, however the group data and trends will be valuable for corporate wellness, insurance programs and more
   
   
6. Eventually when the sample size becomes large enough algorithms will be predictive, and warnings will be sent if a participant’s data warrants a provider intervention

Motor nerves from the spine to the muscles are categorized by size. Small fibers are called 1st order motor neurons. Then comes medium or 2nd order and finally 3rd order, the largest nerve fibers are recruited last.

1. Without stimulation, motor neurons are voluntarily activated in healthy humans in this order- 1st then 2nd, then 3rd order
   
   
2. Electrical stimulation preferentially activates the larger fibers, the 3rd order motor axons first, then 2nd, and then 1st (known as ‘Reverse Order Recruitment’)
   
   
3. Muscles are also categorized by oxygen utilization as well as speed and strength of contraction – they do not follow the profiles of the motor neuron size
   
   
4. The only thing that matters is the ability of the muscles and nerves to sustain contractions
   
   
5. Once stimulation levels get to the higher intensities, all neurons are activated or depolarized – then there is a delay period as the nerves recover and can fire again
   
   
6. At 50 Hz, most neurons and muscles fibers have recovered from pulse to pulse at least for the first few pulses
   
   
7. Then fast twitch glycolytics drop out for about 150 to 200 mSec and fire again for a few pulses and drop out again – this continues for about 15 to 30 seconds, they then need time for prolonged recovery
   
   
8. In the meantime, fast twitch oxidative muscles and all the slow twitch oxidative muscles continue to respond for about another few seconds up to about 2 – 8 sec.
   
   
9. Then fast twitch oxidatives drop out and the only muscles continue to fire are the slow twitch muscles – the slow twitch oxidatives may continue for minutes.
   
   
10. Research demonstrates that long term stimulation with EMS equipment, classical 10 sec “On” or such, produce an increase in slow twitch fibers (this includes numbers and size) 
    
    
11. Weightlifting produces an increase in fast twitch oxidative muscles.
    
    
12. Only sprinting and very fast upper body exercises increase fast twitch glycolytics
    1. Paired with 10 – 30 seconds of very fast electrical stimulation, which is what the Neuro20 suit provides with our PEMS programs –  this is a differentiator!

1. Capillary blood flow to muscles and synovial joint lubrication

2. Learned recruitment – “muscle memory” learns to recruit precisely

3. Motor recruitment enhancement vs. AMI – output timing

4. Post injury motor recruitment re-education

5. Muscle fiber and neuron strengthening – TGF and BDNF, GDNF

6. Synaptic facilitation – mitochondria strength and receptor density

7. Improved sensory-motor feedback, position sense BG and cortex

8. Proprioception enhancement – sensory strengthening

9. Joint protection – decreased grinding during max contractions

10. Bone strengthening – density and matrix from increased loading

11. Lactate metabolism; it’s a fuel and a potent signal for angiogenesis

1. Muscle stimulation is also nerve stimulation
   
   
2. The stimulation parameters we utilize will increase:
   1. Nerve Growth Factor
   2. BDNF (Brain Derived Neurotropic Factor) – this is an important factor in brain healing, especially post-concussion/TBI (traumatic brain injury)
   3. Mitochondria Stress
   4. Receptor Density (facilitation)
   5. Motor Nerves transmit Ach
      
      
3. It is important to understand Ach and its effects from stimulation
   1. Ach dilates capillaries during the first 5 minutes in the suit
   2. After about 10 minutes Norepinephrine balances and then increases causing Vasodilation. This is critical for increased blood flow especially at the capillary and microcapillary level (all of which is critical for healing!)
      
      
4. Nerves transmit in both direction and as discussed prior we do reverse order transmission of the electrical signal than from normal physiology
   1. Sensory to motor reflex
   2. Sensory position sense to basal ganglia
   3. Sensory continues to cortex
   4. Sensory neurons reflex to motor cortex is the return

1. Healing – soft tissue
   1. Blood flow, nutrients, O2, waste extraction
      
      
2. Joint injury recovery
   1. Synovial flow, O2, nutrients, waste removal
      
      
3. Pain reduction
   1. Reduced spasm and increased local blood flow
   2. Getting back to pre-injury – burst and endurance without pain
      
      
4. Motor re-education
   1. Full recruitment vs AMI
   2. Extremity activation plus core stabilization
      
      
5. Concussions and BDNF
   1. Serum BDNF was increased in the NMES (p = 0.003) and voluntary exercise interventions (p
      = 0.004) after each intervention.
   2. At the post-timepoint, serum BDNF in the NMES intervention was highest among all interventions (p = 0.038) and significantly higher than in the voluntary exercise (p = 0.036). (K. Watanabe; T. Gordon)
      
      
6. Human performance benefits
   1. Speed and power will increase for approximately 15-20 weeks between 3%-15% and then generally plateaus for a period of time
   2. Flexibility and ROM will significantly increase
   3. Case study- D1 athlete had 2” thigh circumference gains after 13 uses of the system
   4. Reaction time (reflex) will significantly decrease, nerve signal time becomes faster

1. There are over 40,000 studies on electrical stimulation over hundreds of years.
   
   
2. The Neuro20 team has a database of studies relevant to the technology, albeit with limitations as the technology is advanced beyond most current products
   
   
3. A meta study was conducted of the 40,000 studies that first narrowed to 9,000 studies. Following the review of those studies the most relevant 40 studies were utilized in the development of the product
   
   
4. Minimum Viable Product case studies occurred in a physical therapy practice in New York City associated with the Hospital for Special Surgery
   
   1. These studies were without the deltoid muscles, with no contour shaping of the electrodes, and no patterned electrical stimulation
   2. Results are positive and available on request
      
      
5. Additional case studies occurred with the MVP for collegiate athletes recovering from different surgeries
   1. Protocols and results can be shared upon request
      
      
6. A University human performance pilot clinical trial occurred of collegiate athletes occurred with the MVP
   1. Overall results were positive
   2. Protocols may be shared, however due to publication rights of the University, some data is limited for release
      
      
7. Some of the research articles referenced in this document are:
   1. M. Latash Synergy, Kinesiology. Oxford Univ. Press 2008 (Penn State)
   2. K. Watanabe et al Effect of exercise intensity on metabolic responses on combined application of electrical stimulation and voluntary exercise. Physiological Reports Feb 2021
      K. Watanabe et al Relationships between muscle strength and multi-channel surface EMG parameters in eighty-eight elderly. Eur Review Aging and Physical Activity 2018 Apr 11;15:3
   3. T. Kimura et al Neuromuscular electrical stimulation increases serum brain-derived neurotrophic factor in humans. Experimental Brain Research Feb 2019
   4. T. Gordon The physiology of neural injury and regeneration: The role of neurotrophic factors.
      Journal of Communication Disorders Jul-Aug 2010;43(4):265-73
   5. J.F. Kramer et al Comparison of voluntary and electrical stimulation contraction torques. J Orthop Sports Physical Therapy 1984
   6. P. Hebisz, et al Changes in exercise capacity and serum BDNF following long-term sprint interval training in well-trained cyclists. Applied Physiology, Nutrition, and Metabolism Oct 2018
   7. R.G. Carson and A.R. Buick Neuromuscular electrical stimulation-promoted plasticity of the human brain. Jour. Physiol 2021 599.9 (2021) pp 2375–2399 Published on-line Sept 2019
   8. R.F. Escamilla and J.R. Andrews Shoulder muscle recruitment patterns and related biomechanics during upper extremity sports. Sports Med 2009; 39 (7): 569-590
   9. R.B. Souza An evidence-based videotaped running biomechanics analysis. Phys Med Rehab Clinics of N.A. 2016 Feb.
   10. A. Ross Neural influences on sprint running: training adaptations and acute responses. Sports Med 2001
   11. B. Ferguson, L.B. Gladden et al Lactate metabolism: current understanding. Eur J Appl Physiol 2018
   12. Groc L, Choquet D. Linking glutamate receptor movements and synapse function. Science 2020 Jun 12
   13. Segal, SS Regulation of blood flow in the microcirculation. Microcirculation 2005 Jan-Feb