Functional Electrical Stimulation in Spinal Cord Injury rehabilitation

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Use of FES in SCI

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Functional Electrical Stimulation in Spinal Cord Injury rehabilitation

  1. 1. GoodMorning
  2. 2. FES IN SCIREHABILITATION RECENT ADVANCES
  3. 3. CONTENTS• FES• Ventilatory support• Prevention of DVT, CVD• Reducing muscle tone• Orthostatic hypotension• Bladder training• Trunk stability• Gait training• Exercise training
  4. 4. ORIGIN Liberson 1961 Functional ElectrotherapyNew era of advanced Rehab Foot Drop
  5. 5. RENAMED Moe and Post 1962 Functional Electrical Stimulation"Electrical stimulation of muscle deprived of nervouscontrol with a view of providing muscular contraction and producing a functionally useful moment“ - Gracanim et al (1967)
  6. 6. Spinal Cord (2009) 47, 508–518
  7. 7. AS VENTILATOR• Functional electrical stimulation has a 40-year history in providing ventilator support Surgery. 1970;93: 25–28• The first pacer units were installed for hypoventilation syndromes J Thorac Cardiovasc Surg. 1990;99:35–39
  8. 8. VENTILATORY SUPPORT• Tetraplegia above the C3 level• Phrenic and diaphragmatic pacing - In ventilator- dependent tetraplegic patients• Anthony et al - Implantable electrodes - Laparoscopy Chest 2005;127:671–678
  9. 9. VENTILATORY FES PARAMETERS• Intensity – 25 mA• Pulse width – 0.1-0.15 ms• Frequency – 20 Hz• Inspiratory time – 1.1 s• RR – 10-12 bpm Chest 2005;127:671–678
  10. 10. OUTCOME PARAMETERS• Magnitude of inspired volume – Pneumotachograph• ABG RESULTS• 1,100 to 1,240 mL increased in inspired volumes when compared to ventilator-dependent
  11. 11. MINIMIZES MECHANICAL VENTILATIONFES of the diaphragm have been successful ineliminating the need for mechanical ventilation inpatients with tetraplegia Chest 2005;127:671–678 LOE-4 (SCIRE)
  12. 12. DISADVANTAGES• Bronchial Hygiene• Expensive outlay for the surgery and equipment• Expertise is required• Manipulation of minute ventilation• Pneumothorax• Subcutaneous emphysema Chest 2005;127:671–678
  13. 13. PREVENTION OF CVD, DVT• Persons with SCI have limited options for exercise• Exercise has been shown to reduce blood coagulation and platelet aggregation Thromb Res. 2004;113(2):129–136
  14. 14. FES IN DVT PREVENTION• William et al studied Functional electrical stimulation leg cycle ergometry (FES-LCE) exercise training on platelet aggregation and blood coagulation in persons with SCI J Spinal Cord Med. Apr 2010;33(2):150–158
  15. 15. FES PARAMETERS• 6 channels• Intensity – 0 to 132 mA• Frequency – 30 Hz• Pulse width – 350 microseconds• Time – 30 minutes• Warm-up – 2 minutes• Cool-down – 2 minutes J Spinal Cord Med. Apr 2010;33(2):150–158
  16. 16. ON CVD & DVTFES in SCI patient improves their hemostatic profileand reduce the risk of CVD and DVT J Spinal Cord Med. Apr 2010;33(2):150–158
  17. 17. IN SPASTICITY• Lennon et al says cycling leg movements induced by the ergometer passively reduces spastic muscle tone Disabil Rehabil 2000; 22: 665–74• Krause et al found Low-frequency rectangular pulse is superior to middle frequency alternating current stimulation in cycling of people with spinal cord injury Arch Phys Med Rehabil 2007; 88: 338–45
  18. 18. REDUCING MUSCLE TONE• Phillip et al showed that FES can be more effective than passive movements at reducing spastic muscle tone increase in patients with spinal cord injury Clinical Rehabilitation 2008; 22: 627–634
  19. 19. FES PARAMETERS• 8 channels• Intensity – 0 to 99mA• Frequency – 20 Hz• Pulse width – 500 microseconds• Time – 60-100 minutes Clinical Rehabilitation 2008; 22: 627–634
  20. 20. OUTCOMES• Modified Ashworth Scale• Pendulum testing of spasticity
  21. 21. SPASTICITY GAVE UP• Improvements in MAS & Relaxation index (RI)• Reduced muscle tone lasted up to 6 hours, and sometimes even longer (for 24 hours) Clinical Rehabilitation 2008; 22: 627–634 LOE-3 (SCIRE)
  22. 22. SYMPATHETIC REACTION• FES to the lower extremities appears to cause an increase in blood pressure and decrease in hypotension related symptoms in subjects with SCI that is independent of site of stimulation.• Autonomic dysreflexia type reflex sympathetic reaction. Arch Phys Med Rehabil 2000; 81: 139–143 LOE-3 (SCIRE)
  23. 23. STANDING VS STANDING+FES• FES-induced contraction of the leg muscles during standing increases stroke volume and cardiac output, and stabilizes blood pressure• May prevent circulatory hypokinesis and orthostatic hypotension in SCI Arch Phys Med Rehabil 2001; 82:1587-1597
  24. 24. TILTING VS TILTING+FESFES-induced leg muscle contraction is an effective adjuncttreatment to delay orthostatic hypotension caused bytilting Arch Phys Med Rehabil 2005; 86: 1427-1433
  25. 25. OH – A CRITICAL REVIEWDespite variations in experimental protocols, FES hasconsistently proven to attenuate the fall in BP byapproximately 8/4mmHg during an orthostaticchallenge under experimental conditions Spinal Cord (2008) 46, 652–659
  26. 26. BLADDER TRAINING• Hyper Reflexive Bladder• Incontinence• Decreased bladder capacity• Neuromodulation• Surgical implantation of epineural electrodes• Praxis stimulation system Spinal Cord (2005) 43, 713–723
  27. 27. NEUROMODULATION - FES PARAMETERS• Amplitude - 2.5 mA• Pulse width - 350 ms• Frequency - 14 or 50Hz• Applied bilaterally to S3 Spinal Cord (2005) 43, 713–723
  28. 28. EFFECT OF FES – BLADDER TRAINING• Suppression of bladder hyper-reflexia (low amplitude stimulation of the S3 root bilaterally inhibits reflex bladder contractions)• Facilitates urine filling• Controls urine voiding
  29. 29. LIMITATIONS• Surgical implantation• Low level of evidence• Further research – inconclusive Spinal Cord (2005) 43, 713–723 LOE-4 (SCIRE)
  30. 30. TRUNK STABILITYStimulation of hip and trunk muscles can improveperformance of activities of daily living as well as enableindependent wheelchair and bed mobility Arch Phys Med Rehabil 2009;90:340-7
  31. 31. OUTCOMES1. Spinal alignment and pelvic orientation2. Pulmonary function and ventilatory volumes3. Maximal force and speed of rowing-like movements Arch Phys Med Rehabil 2009;90:340-7
  32. 32. RESULTS• Improvement in spinal alignment – X-ray• Lateral convexity of 38° to 12°• Kyphosis of 55° to 34°• FEV1 increased by 10% (from 3.3 to 3.7L)• FVC and VC each increased by 22% (from 3.7 to 4.5L)
  33. 33. GAIT TRAINING-LET’S TURN BACK• Kantrowitz et al (1963) - T-7 paraplegic patient standing by surfacestimulation of m.quadriceps and m.glutei,
  34. 34. FES WITH ELBOW CRUTCHES• Reswick et al (1970) T-5 complete paraplegic patient standing with bilateral femoral and inferior gluteal nerve stimulation
  35. 35. FIRST IMPLANT ELECTRODE• Thomas et al, 1978 – SCI patient walking withcrutches by 8-channel implant• In 1979 Turk et al made T-10 paraplegic patient walking in parallelbars.
  36. 36. FES IN STAIR CLIMBINGKobetič et al in 1983 by the entry of Multi-channelstimulation (percutanes electrodes)
  37. 37. FES + PBWSTTPWB supported treadmill training with FES had apositive effect on overground gait parameters and couldpotentially accelerate gait training in subjects withincomplete SCI Arch Phys Med Rehabil 2004;85:604-10 LOE-3(SCIRE)
  38. 38. Arch Phys Med Rehabil 2004;85:604-10
  39. 39. MOTOR LEARNING• FES reduces the need for therapist assistance• Applying FES during the appropriate phase of the gait cycle may enhance sensory input to the central nervous system, thus facilitating motor relearning as well as inhibiting antagonist spasticity Arch Phys Med Rehabil 2004;85:604-10 LOE-3 (SCIRE)
  40. 40. A CRITICAL REVIEW• BWSTT• Robotic-Assisted Locomotor training - LOKOMAT• BWSTT + FESInsufficient evidence to conclude that any 1 approach tolocomotor training is more effective than any other forimproving the walking function of people with SCI Spine 2008;33:E768–E777
  41. 41. NEUROPROSTHESIS• Gait training with the implanted FES system resulted in improvements in volitional function• Walking performance was improved beyond maximal voluntary function by the application of FES during walking
  42. 42. IMPLANTED MUSCLES(1) Iliopsoas - hip flexion(2) Tensor fasciae latae - hip flexion and abduction,(3) Gluteus medius - hip abduction(4) Posterior portion of adductor magnus - hip extension(5) Gluteus maximus - hip extension(6) Vastus lateralis - knee extension(7) Tibialis anterior - ankle dorsiflexion(8) Peroneus longus - foot eversion Journal of Rehabilitation Research & Development 2010;47:7-16
  43. 43. FES PARAMETERS• Constant current amplitude (20 mA)• Pulse width (0-200 µs)• Frequency (0-30 Hz) Journal of Rehabilitation Research & Development 2010;47:7-16
  44. 44. OUTCOMES(1) 6-minute walk distance(2) Speed during 6-minute walk(3) Maximum walk distance(4) Speed during maximum walk(5) Double support time(6) 10 m walking speed(7) Peak knee flexion in swing(8) Peak ankle dorsiflexion in swing(9) Peak isokinetic knee extension moment
  45. 45. Outcome Measure Baseline Volitional Posttraining Volitional FES-Assisted6-Minute Walk Distance (m) 28.0 ± 8.7 80.1 ± 2.3* 96.5 ± 2.9†Speed During 6-minute Walk (m/s) 0.17 ± 0.02 0.22 ± 0.00* 0.27 ± 0.01†Maximum Walk Distance (m) 33.90 ± 16.57 80.08 ± 2.54 248.18 ± 43.72† Speed During Maximum Walk (m/s) 0.07 ± 0.02 0.22 ± 0.01* 0.26 ± 0.01† Double Support Time (s) 3.24 ± 0.45 2.34 ± 0.24* 1.81 ± 0.09† 10 m Walk Speed (m/s) 0.12 ± 0.01 0.24 ± 0.02* 0.28 ± 0.02Peak Knee Flexion in Swing (°) 17.13 ± 2.21 19.42 ± 4.79 55.48 ± 6.61† Peak Ankle Dorsiflexion in Swing (°) 7.56 ± 2.37 3.88 ± 3.27 15.37 ± 3.31† Peak Isokinetic Knee Extension Moment (Nm) NA 8.78 ± 2.59 30.22 ± 1.07† Journal of Rehabilitation Research & Development 2010;47:7-16
  46. 46. BENEFITS OF FES IN GAIT TRAININGThe neurotherapeutic benefits of gait training with FES andthe neuroprosthetic effects of FES-assisted gait to anambulatory individual with long-standing chronicincomplete SCI have been shown to significantly improvegait performance in this single-subject case study. Journal of Rehabilitation Research & Development 2010;47:7-16 LOE-4 (SCIRE)
  47. 47. AS A ORTHOSIS• The first application of electric stimulation to prevent footdrop during the swing phase of gait was by Liberson et al Arch Phys Med Rehabil 1961;42:101-5• Twelve years later, Kralj and Grobelnik proposed the use of functional electric stimulation (FES) to restore walking in persons with SCI Bull Prosthet Res 1973;10:75-102
  48. 48. AS AFO• Despite the extensive literature on the benefits of FES, studies on the effects FES on walking parameters in persons with incomplete SCI are scarce• Kim et al (2006) - Effect of FES with that of AFO and FES in conjunction with AFO in persons with incomplete spinal cord injury (SCI) Arch Phys Med Rehabil 2006;87:1718-23
  49. 49. EFFECT ON GAIT PARAMETERSAFO and FES used in combination provided greaterbenefit in overall gait function than either device alone Arch Phys Med Rehabil 2006;87:1718-23 LOE-4 (SCIRE)
  50. 50. AS A DIABETALOGIST• An increased risk for developing type 2 diabetes Mt Sinai J Med 1992;59:163-8• FES – cycling• FES – rowing
  51. 51. FES-ROWING IN SCI• Wheeler et al developed and tested the reliability and safety of an FES-rowing and FES-cycling exercise in SCI Arch Phys Med Rehabil 2002;83:1093-9• Andrews et al reported that FES rowing significantly improved VO2peak IEEE Trans Neural Syst Rehabil Eng 2002;10:197-203
  52. 52. ON GLUCOSEJustin et al studied the effects of exercise training with afunctional electrical stimulation (FES) rowing machineon glucose, insulin resistance, plasma leptin levels, andbody composition in people with SCI Arch Phys Med Rehabil 2010;91:1957-9
  53. 53. OUTCOME PARAMETERS PARAMETERS PRE-TEST POST-TEST SIGNIFICANCE P-value Weight 72.13±3.6 71±3 0.028 Glucose (mg/dl) 103.2±6.8 92.5±3.4 0.028 Insulin (μU/ml) 13.7±2.1 11.3±1.9 0.07 Leptin (ng/dl) 6.9±1.7 4.9±0.9 0.046 HOMA-IR 3.6±0.8 2.6±0.4 0.093 Fat mass 25.5%±1.8 24.4%±1.6 0.074Peak VO2 (ml/min/Kg) 21.4±1.23 23.1±0.8 0.024 Arch Phys Med Rehabil 2010;91:1957-9
  54. 54. RESULT OF TRAININGA 12-week training program that included FES rowingimproved aerobic fitness and fasting glucose and leptinlevels in the absence of significant change to bodycomposition, fasting insulin levels, or calculated insulinsensitivity in people with SCI Arch Phys Med Rehabil 2010;91:1957-9 LOE-4 (SCIRE)
  55. 55. AS FITNESS TRAINER• Improvements in both peripheral muscular effects and central cardiovascular effects have been reported after a program of FES cycling in adults with SCI Arch Phys Med Rehabil 1992;73:1085-93• Brian et al showed FES cycling leads to similar improvements in children with SCI as seen with adults Arch Phys Med Rehabil 2009;90:1379-88
  56. 56. FES CYCLING PARAMETERS• Target cadence – 50rpm• Warm-up – 10 min• FES cycling – 40 min• Cool-down – 10 min• Targeted muscle groups FES - quadriceps, hamstring, and gluteal muscles• Frequency – 33 Hz• Pulse duration – set at 150, 200, 250, or 300μs• Current amplitude – maximum of 140mA Arch Phys Med Rehabil 2009;90:1379-88
  57. 57. OUTCOME PARAMETERS• VO2 max• Heart rate• Triglycerides• Cholesterol• HDL• LDL Arch Phys Med Rehabil 2009;90:1379-88
  58. 58. Resting Heart RateVO2 max
  59. 59. FES CYCLING - SUPERIOR• Only children in the FES cycling group showed significant differences increase in VO2 max as compared with children in the passive cycling and electrical stimulation groups• No differences were found with resting heart rate, triglycerides, cholesterol, HDL and LDL among groups
  60. 60. ADULT VS CHILDREN• VO2 max - Similar effects were observed between adults and children with SCI• But not in other parameters Arch Phys Med Rehabil 2009;90:1379-88 LOE-1 (SCIRE)
  61. 61. UB EX VS FES-CYCLINGFES-cycling appears to be a feasible and promisingtraining alternative to upper body exercise for subjectswith spinal cord injury. 4 to 8 hr of FES-cycling arenecessary to reach the recommended weekly exercisecaloric expenditure that seems to be essential to inducepersistent health benefits by Berry et al J Rehabil Med. 2010 Oct;42(9):873-5 LOE-4(SCIRE)
  62. 62. HOME PROGRAMME‘Home-based daily FES training is a safe and effectivetherapy that may maintain life-long physical exercise byactive muscle contraction as a procedure to recover theearly-lost tetanic contractility of denervated muscle, andto counteract muscle atrophy in order to prevent clinicalcomplications Neurol Res. 2010 Feb;32(1):5-1
  63. 63. CYCLINGA case series by Brian et al suggests that cycling with orwithout FES may have positive health benefits and was apractical home exercise option for these children withSCI J Spinal Cord Med. 2008;31:215–221 LOE-4 (SCIRE)
  64. 64. TRAINING AND DETRAININGHunt et al says it is possible to increase maximal poweroutput, cardiopulmonary fitness, and bone parametersof the paralyzed limbs in tetraplegia by high-volumecycle training. However, if training is not maintained,these improvements are lost. Phys Med Rehabil 2008;87:56–64 LOE-5 (SCIRE)
  65. 65. ONGOING RESEARCH• FES induced an 82-86% increase in cell birth in the spinal cord• Controlled FES of the spinal cord may enhance spontaneous regeneration after neurological injuries Exp Neurol. 2010 Apr;222(2):211-8
  66. 66. CONCLUSION Areas Author Result Evidence Ventilation Anthony et al Inconclusive 4 DVT prevention William et al Inconclusive 4 Tone reduction Phillip et al Inconclusive 3Orthostatic Hypotension Evan et al, Gillis et al Inconclusive 3,4 Trunk Stability Ronald et al Inconclusive 5 Gait training Murray et al Inconclusive 3,4 Orthosis Maria et al Inconclusive 4 Exercise training Brian et al , Mary et al, Improves Aerobic 1,4,5
  67. 67. REFERENCES• Phrenic nerve pacing via intramuscular diaphragm electrodes in tetraplegic subjects. Chest. 2005;127:671–678• Lower-Extremity FES decreases platelet aggregation and blood coagulation in persons with chronic spinal cord injury: A Pilot Study. J Spinal Cord Med. Apr 2010;33(2):150–158• Changes in spastic muscle tone increase in patients with spinal cord injury using functional electrical stimulation and passive leg movements. Clinical Rehabilitation 2008; 22: 627–634• Functional Electrical Stimulation Effect on Orthostatic Hypotension After Spinal Cord Injury. Arch Phys Med Rehabil 2000;81: 139-43
  68. 68. REFERENCES• Circulatory Hypokinesis and Functional Electric Stimulation During Standing in Persons With Spinal Cord Injury. Arch Phys Med Rehabil 2001;82:1587- 95.• The Effects of Lower-Extremity Functional Electric Stimulation on the Orthostatic Responses of People With Tetraplegia. Arch Phys Med Rehabil 2005; 86:1427-33• Non-pharmacological management of orthostatic hypotension after spinal cord injury: a critical review of the literature. Spinal Cord (2008) 46, 652– 659
  69. 69. REFERENCES• Implantable FES system for upright mobility and bladder and bowel function for individuals with spinal cord injury. Spinal Cord (2005) 43, 713–723• Outcomes of a Home Cycling Program Using Functional Electrical Stimulation or Passive Motion for Children With Spinal Cord Injury: A Case Series. J Spinal Cord Med. 2008;31:215–221• A Randomized Controlled Trial on the Effects of Cycling With and Without Electrical Stimulation on Cardiorespiratory and Vascular Health in Children With Spinal Cord Injury. Arch Phys Med Rehabil 2009;90:1379-88
  70. 70. Thank you

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