Functional Electrical Stimulation (FES)

[Guest guest]

I recall several members were discussing FES so when I saw this article in the current issue of Action magazine I thought I should look it up and send it along.Sharonhttp://www.unitedspinal.org/publications/action/2008/11/17/functional-electrical-stimulation-the-future-of-rehabilitation/Functional Electrical Stimulation: The Future of

Rehabilitation?

Functional Electrical Stimulation (FES) offers numerous benefi ts to

individuals living with disabilities. But education is paramount to

ensure the safety and efficacy of this experimental treatment strategy.

By Tom

The application of electrical stimulation in a rehabilitative

setting was initiated nearly half a century ago. In 1960, W.T.

Liberson, a physical rehab specialist and medical researcher, began

developing a heel switch-triggered personal electronic stimulator

device to correct foot drop (weakness or paralysis of the muscles

involved in lifting the front part of the foot). Liberson provided the

basic groundwork for future rehabilitative techniques involving

functional electrical stimulation (FES). His work has led to the

present explosion of FES-related research engaging countless

scientists, propelling it to a legitimate and viable treatment option

for many patients with spinal cord injuries and disorders (SCI/D). FES

utilizes electrical currents to activate nerves in areas of a patient’s

body (i.e., arm and leg muscles) affected by paralysis, stroke,

traumatic brain injuries, and other neurological disorders to restore

some movement and function. Most FES devices have similar

components––electronic stimulator, a feedback or control unit,

leads/sensors, and electrodes– and can range in size from as small as a

calculator to as large as a computer workstation. Perhaps the

best-known FES system is the pacemaker for the heart.

FES treatment is accomplished by placing electrodes on–or surgically

implanting them under—the patient’s skin close to peripheral nerves

that control specific muscles or muscle groups. The electrodes

(self-adhesive or gel-type) are connected by leads to an FES device

(i.e., portable FES electrode unit) that generates low-voltage

electrical impulses. These impulses excite the nerves causing the

paralyzed muscles to contract, thereby facilitating basic movement. In

some FES applications, tissues instead of muscles may be targeted.

Risks vs. Rewards

There are numerous advantages and disadvantages to using FES. The

disadvantages include muscle tears, blisters, burns, dizziness, and

autonomic dysreflexia, or AD, which is an over-activity of the

autonomic nervous system causing an abrupt onset of excessively high

blood pressure.

FES-users with high-sensitivity may also feel some discomfort during

treatment, such as “pins and needles” under their skin, and a tingling

sensation caused by the flow of electrical currents passing through

their body. A majority of users will overcome these sensations, but it

is still extremely important that the device is tuned to the user’s

comfort level (i.e., current type, modulation, waveform, pulse duration

and repetition rate, and intensity) or treatment may be unsuccessful.

On rare occasions the FES electrode’s adhesive or gel may cause

users to develop skin irritation and rashes. Most often, this is

addressed by replacing the electrodes with a hypoallergenic version.

Individuals with cardiac pacemakers or implanted defibrillators should

be extremely cautious using FES-type devices and should consult their

doctors before beginning treatment.

FES treatment should not be administered to women who are pregnant;

or individuals with congestive heart failure (blood clots or

circulation issues); cardiac arrhythmias; chronic or severe kidney or

lung diseases; active and non-healing wounds; severe muscle

contractions; tendency for worsening AD due to FES; or sensitivity to

electrodes.

Advantages to FES treatment include increased muscle strength and

range of motion. FES also offers therapists and rehabilitation

specialists a means of re-educating voluntary muscles in patients with

SCI/D and has proven useful in treating the various underlying symptoms

that accompany these types of clinical diagnoses, including pain;

spasms; lack of sensation; urinary and bladder infections; bladder and

bowel control; skin breakdown or pressure sores; sexual dysfunction;

atrophy; osteoporosis; mobility issues; and poor blood circulation

(blood clots caused by deep vein thrombosis). This ultimately leads to

improved cardiovascular health, functionality, and greater independence

and quality of life.

Further benefits of FES treatment is that it can reduce clinical

visits and medical costs. Although the costs of FES systems vary with

each application, a majority of cutaneous or skin electrode systems

(most commonly used) are relatively inexpensive. There may also be

rental or lease options available to the patient to cut costs even

further.

Surgically implanted FES systems tend to be more expensive. These

types of systems are generally recommended for users with high-level

quadriplegia to assist in regaining hand function and to restore

bladder and bowel function in patients with spinal cord injury (SCI).

The Bigger Picture

FES is not a cure for SCI/D, but a therapeutic option. A majority of

FES treatment approaches are still experimental in nature and there are

no preferred methods or standards. FES is most successful when

integrated into a rehabilitation plan that includes many different

components. The ultimate objective for the patient undergoing FES

treatment, however, remains simple. FES should lead to a marked

improvement in quality of life. If it does not foster this outcome,

treatment should be discontinued.

One of the common pitfalls of FES treatment is that it can sometimes

take years to see results. In some cases FES needs to be employed

beyond the clinical setting in order to be effective (i.e., daily use

at home, work, or school).

So is FES treatment right for you? Those interested in FES should

speak to a knowledgeable and experienced clinician or clinical team to

determine if they are good candidates for treatment or to participate

in a clinical trial. A rehabilitation specialist can also assist in

identifying the most suitable FES devices to fit your needs.

Presently, a majority of FES devices have not been FDA-approved and

are still undergoing research and testing. Unfortunately, this process

can take many years, but many are hopeful that the future will be

bright for FES technology. “I believe we will see an increase in use of

FES in rehabilitative settings in the future,” says Boggs, a

physical therapist at the Cleveland FES Center. “With the refinement of

surface FES applications clinicians will find them much more user

friendly. Advancements in technology will decrease some of the current

barriers. Also clinicians may come into contact with an increased

number of patients who are currently using FES systems and will need to

incorporate them into their rehab plan. For example, one of our recent

subjects with an implanted neuroprosthesis for walking is going to a

rehabilitation center and will continue working on walking with his

implanted device.”

According to Buckett, who works in the Communications

department at the Cleveland FES Center, most individuals are seeking

options to regain additional movement and/or control that they have not

yet achieved with previous therapies. She shared some of the feedback

from research participants in varying programs at the Cleveland FES

Center:

• Arm extension and hand grasp program––“Being able to move my arm

and do something for myself again – it’s the best.”• Hand grasp

program––“I just can’t express enough how its changes my whole outlook,

my demeanor. I’m a happy person and I’m going to be a grandma. I can’t

wait to hold her, both arms.”

• Walking program––“Gave me 100% independence again.”• Stand/transfer program––“Now I can be of use at home. Before, I

was either sitting in the wheelchair or lying on the bed. That wasn’t

life at all.”

The Spectrum FES Applications

There is a long list of applications for FES––standing and

transfers; limited ambulation; improving circulation; controlling

spasticity; walking; cycling; manual grasping and reaching; bowel and

bladder control; male sexual and reproductive assistance; breathing and

cough assistance; pressure sore prevention; and airway clearance––just

to name a few. The box on this page lists a few examples of the types

of devices that are being investigated or have obtained regulatory

approval. The Cleveland FES Center (fescenter.case.edu/site2/index.php)

is a valuable resource for information on FES devices and application

and a good starting point to research treatment options online. They

also offer an in-depth guide (fescenter.case.edu/site2/ fes_guide.php) that covers FES eligibility, outcomes, and costs for a wide range of devices.

Conclusion

FES has the potential to help millions of people with SCI/D improve

their quality of life and independence. More research, however, is

needed before many FES treatment strategies can be considered safe and

effective. Although there is great potential for such devices in the

near future, patients must use caution and good judgment when

considering their use.

Tom is staff editor.

[Guest guest]

Thank you, Sharon; this is fascinating.

Off to read further, having scanned

over it all just once.

Love to you,n

To: mserslife Sent: Saturday, November 22, 2008 2:20:31 PMSubject: Functional Electrical Stimulation (FES)

I recall several members were discussing FES so when I saw this article in the current issue of Action magazine I thought I should look it up and send it along.Sharonhttp://www.unitedsp inal.org/ publications/ action/2008/ 11/17/functional -electrical- stimulation- the-future- of-rehabilitatio n/

Functional Electrical Stimulation: The Future of Rehabilitation?

Functional Electrical Stimulation (FES) offers numerous benefi ts to individuals living with disabilities. But education is paramount to ensure the safety and efficacy of this experimental treatment strategy.

By Tom

The application of electrical stimulation in a rehabilitative setting was initiated nearly half a century ago. In 1960, W.T. Liberson, a physical rehab specialist and medical researcher, began developing a heel switch-triggered personal electronic stimulator device to correct foot drop (weakness or paralysis of the muscles involved in lifting the front part of the foot). Liberson provided the basic groundwork for future rehabilitative techniques involving functional electrical stimulation (FES). His work has led to the present explosion of FES-related research engaging countless scientists, propelling it to a legitimate and viable treatment option for many patients with spinal cord injuries and disorders (SCI/D). FES utilizes electrical currents to activate nerves in areas of a patient’s body (i.e., arm and leg muscles) affected by paralysis, stroke, traumatic brain injuries, and other neurological disorders to restore some movement and function.

Most FES devices have similar components––electronic stimulator, a feedback or control unit, leads/sensors, and electrodes– and can range in size from as small as a calculator to as large as a computer workstation. Perhaps the best-known FES system is the pacemaker for the heart.

FES treatment is accomplished by placing electrodes on–or surgically implanting them under—the patient’s skin close to peripheral nerves that control specific muscles or muscle groups. The electrodes (self-adhesive or gel-type) are connected by leads to an FES device (i.e., portable FES electrode unit) that generates low-voltage electrical impulses. These impulses excite the nerves causing the paralyzed muscles to contract, thereby facilitating basic movement. In some FES applications, tissues instead of muscles may be targeted.

Risks vs. Rewards

There are numerous advantages and disadvantages to using FES. The disadvantages include muscle tears, blisters, burns, dizziness, and autonomic dysreflexia, or AD, which is an over-activity of the autonomic nervous system causing an abrupt onset of excessively high blood pressure.

FES-users with high-sensitivity may also feel some discomfort during treatment, such as “pins and needles” under their skin, and a tingling sensation caused by the flow of electrical currents passing through their body. A majority of users will overcome these sensations, but it is still extremely important that the device is tuned to the user’s comfort level (i.e., current type, modulation, waveform, pulse duration and repetition rate, and intensity) or treatment may be unsuccessful.

On rare occasions the FES electrode’s adhesive or gel may cause users to develop skin irritation and rashes. Most often, this is addressed by replacing the electrodes with a hypoallergenic version. Individuals with cardiac pacemakers or implanted defibrillators should be extremely cautious using FES-type devices and should consult their doctors before beginning treatment.

FES treatment should not be administered to women who are pregnant; or individuals with congestive heart failure (blood clots or circulation issues); cardiac arrhythmias; chronic or severe kidney or lung diseases; active and non-healing wounds; severe muscle contractions; tendency for worsening AD due to FES; or sensitivity to electrodes.

Advantages to FES treatment include increased muscle strength and range of motion. FES also offers therapists and rehabilitation specialists a means of re-educating voluntary muscles in patients with SCI/D and has proven useful in treating the various underlying symptoms that accompany these types of clinical diagnoses, including pain; spasms; lack of sensation; urinary and bladder infections; bladder and bowel control; skin breakdown or pressure sores; sexual dysfunction; atrophy; osteoporosis; mobility issues; and poor blood circulation (blood clots caused by deep vein thrombosis). This ultimately leads to improved cardiovascular health, functionality, and greater independence and quality of life.

Further benefits of FES treatment is that it can reduce clinical visits and medical costs. Although the costs of FES systems vary with each application, a majority of cutaneous or skin electrode systems (most commonly used) are relatively inexpensive. There may also be rental or lease options available to the patient to cut costs even further.

Surgically implanted FES systems tend to be more expensive. These types of systems are generally recommended for users with high-level quadriplegia to assist in regaining hand function and to restore bladder and bowel function in patients with spinal cord injury (SCI).

The Bigger Picture

FES is not a cure for SCI/D, but a therapeutic option. A majority of FES treatment approaches are still experimental in nature and there are no preferred methods or standards. FES is most successful when integrated into a rehabilitation plan that includes many different components. The ultimate objective for the patient undergoing FES treatment, however, remains simple. FES should lead to a marked improvement in quality of life. If it does not foster this outcome, treatment should be discontinued.

One of the common pitfalls of FES treatment is that it can sometimes take years to see results. In some cases FES needs to be employed beyond the clinical setting in order to be effective (i.e., daily use at home, work, or school).

So is FES treatment right for you? Those interested in FES should speak to a knowledgeable and experienced clinician or clinical team to determine if they are good candidates for treatment or to participate in a clinical trial. A rehabilitation specialist can also assist in identifying the most suitable FES devices to fit your needs.

Presently, a majority of FES devices have not been FDA-approved and are still undergoing research and testing. Unfortunately, this process can take many years, but many are hopeful that the future will be bright for FES technology. “I believe we will see an increase in use of FES in rehabilitative settings in the future,” says Boggs, a physical therapist at the Cleveland FES Center. “With the refinement of surface FES applications clinicians will find them much more user friendly. Advancements in technology will decrease some of the current barriers. Also clinicians may come into contact with an increased number of patients who are currently using FES systems and will need to incorporate them into their rehab plan. For example, one of our recent subjects with an implanted neuroprosthesis for walking is going to a rehabilitation center and will continue working on walking with his implanted device.”

According to Buckett, who works in the Communications department at the Cleveland FES Center, most individuals are seeking options to regain additional movement and/or control that they have not yet achieved with previous therapies. She shared some of the feedback from research participants in varying programs at the Cleveland FES Center:

• Arm extension and hand grasp program––“Being able to move my arm and do something for myself again – it’s the best.”• Hand grasp program––“I just can’t express enough how its changes my whole outlook, my demeanor. I’m a happy person and I’m going to be a grandma. I can’t wait to hold her, both arms.” • Walking program––“Gave me 100% independence again.”

• Stand/transfer program––“Now I can be of use at home. Before, I was either sitting in the wheelchair or lying on the bed. That wasn’t life at all.”

The Spectrum FES Applications

There is a long list of applications for FES––standing and transfers; limited ambulation; improving circulation; controlling spasticity; walking; cycling; manual grasping and reaching; bowel and bladder control; male sexual and reproductive assistance; breathing and cough assistance; pressure sore prevention; and airway clearance––just to name a few. The box on this page lists a few examples of the types of devices that are being investigated or have obtained regulatory approval. The Cleveland FES Center (fescenter.case. edu/site2/ index.php) is a valuable resource for information on FES devices and application and a good starting point to research treatment options online. They also offer an in-depth guide (fescenter.case. edu/site2/ fes_guide.php) that covers FES

eligibility, outcomes, and costs for a wide range of devices.

Conclusion

FES has the potential to help millions of people with SCI/D improve their quality of life and independence. More research, however, is needed before many FES treatment strategies can be considered safe and effective. Although there is great potential for such devices in the near future, patients must use caution and good judgment when considering their use.

Tom is staff editor.

[Guest guest]

I've had a TENS unit for several years that I use when i have back

pain and stiffness. I bought it through my chiropractors office and

they showed me how to use it and drew a little diagram on the back of

the booklet that shows how they want me to set it up. There are

fairly good instructions in the book that comes with the unit. And

the chiropractor gave me some additional xeroxed pages that show the

different placements of the jell pads that they use in the office. It

is real easy to adjust the intensity level. I have always been one

that have to start with a lower level at first then turn it up a bit

more as I get muscles warmed up.

My chiropractor often uses this therapy on patients to help loosen

up tense muscles before you go in and get your adjustment.

I think my unit was around $120 about 7 years ago. And is the size

of a deck of cards.

Debbie and Ian McKinley (BMD since 93)no

litters Kansas http://home.hit.net/~dimck/

http://www.flickr.com/photos/dimck23/ (200 carting photo)