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Course Objectives
1.! Discuss the current evidence for the use of FES for people with SCI 2.! Discuss FES parameter applications and modifications to achieve optimal outcomes in individuals with neurologic disabilities 3.! Discuss the opportunities and challenges of implementing FES in the clinical setting. 4.! Understand multiple uses of FES from the perspectives of the consumer and clinician. 5.! Assess practical applications for successful implementation in the clinic and the home environment for FES 6.! Discuss lower cost alternatives to commercially available FES technologies and the financial implications of FES programs and technologies 7.! Explore current technology surrounding implantable FES systems and current functional applications for implantable FES systems
Course Agenda
! ! ! ! ! !
Introductions Parameters and Evidence for Common FES Applications: Therese Johnston Implementing a Clinical Program for FES: Candy Tefertiller Short Session Break Implantable FES Systems: Lisa Lombardo Consumer & Clinical Perspectives: Panel Question & Answer
Anderson, K.D. (2004) J. Neurotrauma, 21: 1371-1383.
Parameters used in Clinical FES FES Parameters and Evidence for FES in SCI
Therese E. Johnston, PT, PhD, MBA Thomas Jefferson University Philadelphia, PA ! Important to understand parameters
! To understand how units differ ! To make best decisions for the intervention
Property of French, Johnston, Lombardo & Tefertiller, not to be copied without permission
Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
Current (I)
! Rate of movement of charged particles in a conductor ! Involves transfer of energy that causes physiological change ! Directly related to the voltage ! Measured in amperes ! Our applications: milliamps (mA) ! On e-stim machines, often is the intensity dial
Resistance
! Defines the ease of ! Ohms Law I = V/R movement within V=IxR the conductor ! Measured in Ohms
! Therefore, as R increases, V needs to increase to maintain a constant I
Alternating Current
! Uninterrupted bidirectional flow of particles ! Polarity reverses as electrons move in one direction & then reverse
+ -
+ -
Pulsed Current
! Each pulse is an isolated electrical event
+ -
+ -
+ -
+ -
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Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
Other Terms
! *Interpulse interval = time between pulses ! *Period = pulse duration + interpulse interval duration
Interpulse interval
*Frequency
! The number of pulses each second ! Important in fatigue
+ + + 1 sec 0 + + -
+ -
+ -
Period
+ -
*Balance of Charge
! A waveform is balanced when: The area under the negative phase = the area under the positive phase
Balanced
Amplitude Characteristics
! Peak Amplitude ! Peak to peak amp
Peak amp Peak to peak amp
Unbalanced
! RMS amp: takes the shape of waveform into account. Is about 70% of peak amp for a true sinusoidal wave
This unbalanced waveform gives you a net positive charge for the pulse
Clinical Stimulators
! Primary Parameters
! Pulse duration: usually less than 400 sec ! Amplitude: up to 100 mA ! Frequency: up to 100 pps
Property of French, Johnston, Lombardo & Tefertiller, not to be copied without permission
+ -
+ -
! These 3 parameters together are all important in how strong the electrical stimulus is & what effects it can create
Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
! Amplitude
FES Applications
! This talk will include
! Walking ! Cycling
! Pulse Duration
! Increases force production (& pain over 400sec)
! Frequency
! Increases firing rate ! Increases force ! Increases fatigue
! Frequency:
! To obtain tetany
! Amplitude:
! To create a 3- to 3+/5
(Diagram: Robinson, Snyder-Mackler pg 178)
! On/off time:
! Times with persons gait ! Need a control source
Possible Stimulators
! Portable stimulator that can use a trigger
! Foot/heel switch ! Hand trigger
Portable Stimulator
! Programmable parameters
! Pre-set ! Custom allows wide range
Property of French, Johnston, Lombardo & Tefertiller, not to be copied without permission
Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
WalkAid
! One-channel stimulator ! Uses a Tilt or Heel Sensor to control stimulation ! Parameters
! 25-300 !sec ! 16.7- 33 pps ! Up to 200 mA ! Up to 3 sec on time (for exercise)
Bioness L300
! Gait Sensor
! In shoe and attached to shoe ! Detects speed & surface changes
! Parameters
! 200 !sec ! 30 pps ! 30-35 mA
! Parameters: 24Hz, pulse width 150 !sec, & intensity up to 300mA ! The user can chose from
! sit/stand, stand/sit, right step & left step, and can increase or decrease the stim intensity while walking
Parastep
! Series of 5 papers from Miami Project published on its effects (1997, Arch Phys Med Rehabil)
! 16 subjects, trained 32 sessions ! Outcomes
! ! ! ! ! ! " walking distance, standing duration, & pace " thigh and calf girth No change in BMD ! self-concept and " depression ! blood flow " time to fatigue, " workload, " VO2 during UE ergometry
Papers by Guest et al., Jacobs et al., Klose et al., Nash et al, Needham-Shropshire et al.
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Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
FES Cycling
! RT300
! 0-140mA, 100-1000 !sec, 10-100 pps
! Motomed/Hasomed
! 0-126 mA, 20-500 !sec, up to 180 pps (using doublets)
! In practice
! See 30-60 minutes 3-5x/week
Property of French, Johnston, Lombardo & Tefertiller, not to be copied without permission
Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
Conclusions
! Understand parameters needed and rationale for decision making ! Some evidence exists for the use of FES applications in SCI
FES Research
Electrical Stimulation and FES may offer an important avenue to facilitate movement in an injured musculoskeletal system and facilitate improved function via. **Neuroplasticity and/or **Improved Compensation
! ! ! ! ! ! ! ! ! ! Daly 2011: ! gait coordination; effects X 6 months Kesar 2011: ! AGRF, trailing limb angle, knee flexion (swing) Kesar 2010: !muscle performance with VFTs vs. CFTs Forssberg et al. 1977: phase dependent modulation Fung et al 1994: ! H-Reflex Perez et al 2003: " spasticity Bajd et al 1997: ! vertical swing Barbeau et al 2002: Therapeutic Effect Field-Fote et al 2005, 2011 (RCTs): ! OG speed Thompson 2012: SCI ! CST activity with 30 min PNS
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Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
! Foot/Thigh Control
! Bioness L300 Plus
! FES Cycles
! Restorative Therapies (UE and LE cycles) ! Motomed (UE and LE cycles) ! Ergys
! FES Elliptical
! Restorative Therapies
Neuroprosthetics
Nerve stimulation devices designed to replace or improve function of an impaired nervous system
Evaluate:
!Spasticity !Isolated Movement !Trunk Control
Transition:
!FES Bike#RT600 Commercially available for home and clinical use
! Combined with developmental sequencing ! Combined with manually assisted BWS LTing
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Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
1.! 2.!
Assess unilaterally for all tasks As patient continues to progress, discharge FES unilaterally when standard is met.
FES
FES
No FES
FES
No FES
FES
Property of French, Johnston, Lombardo & Tefertiller, not to be copied without permission
Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
Enabling technology
! Implanted StimulatorTelemeter (IST) Pacemaker for the body
! 12 - 16 stimulus channels ! up to 2 biosignal sensing (EMG) channels
Developing technology that improves the quality of life of individuals with disabilities through the use of Functional Electrical Stimulation and enabling the transfer of the technology into clinical deployment.
Functional Electrical Stimulation (FES) is the application of electrical stimulation to restore function. FES can be applied for therapeutic purposes or for replacement of lost function. Neural Prosthesis: A device that connects directly with the nervous system and uses FES to replace or supplement function.
! Intramuscular electrode ! Multicontact spiral cuffs ! Universal External Control Unit (UECU)
! Exclusion
! ! ! ! ! ! ! Pacemaker Cardiac arrythmia Pregnancy Contractures Seizure disorder Obesity Untreated substance abuse ! Immunodeficiency ! Frequent UTIs ! Pressure sores
! Standing
! Transfers ! Balance
! Stepping
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Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
Standing System
Transfer & Balance
Stepping System
Acknowledgements
Website: www.fescenter.org
Department of Veterans Affairs; Rehabilitation Research and Development Service National Institutes of Health: National Institute on Child Health and Human Development, National Center for Medical Rehabilitation Research, National Institute of Neurological Disorders and Stroke, National Institute of Biomedical Imaging and BioEngineering, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute on Deafness and Other Communication Disorders, National Institute on Disability and Rehabilitation Research U.S. Department of Education State of Ohio: Third Frontier Program Department of Defense: Army, Telemedicine and Advanced Technology Research Center (TATRC) Craig H. Neilsen Foundation, Davis Phinney Foundation, Lincy Foundation, Medtronic Foundation, Michael J. Fox Foundation, NDI Medical Inc, Case Western Reserve University, Cleveland Clinic Foundation, Paralyzed Veterans of America, SPR Therapeutics, Thomas Jefferson University, Wallace H. Coulter Foundation, Wiegand Family Foundation
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Functional Electrical Stimulation Programs for People with SCI: Clinician and Consumer Perspectives for Clinic and Home
References
1.! Behrman AL, Harkema SJ. Physical rehabilitation as an agent for recovery after spinal cord injury. Phys Med Rehabil Clin N Am. May 2007;18(2):183-202, v. 2.! Beekhuizen KS, Field-Fote EC. Sensory stimulation augments the effects of massed practice training in persons with tetraplegia. Arch Phys Med Rehabil. Apr 2008;89(4):602-608. 3.! Hoffman JR, Ratamess NA, Cooper JJ, Kang J, Chilakos A, Faigenbaum AD. Comparison of loaded and unloaded jump squat training on strength/power performance in college football players. J Strength Cond Res. Nov 2005;19(4):810-815. 4.! Dobkin B, Apple D, Barbeau H, et al. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology. Feb 28 2006;66(4):484-493. 5.! Field-Fote EC, Lindley SD, Sherman AL. Locomotor training approaches for individuals with spinal cord injury: a preliminary report of walking-related outcomes. J Neurol Phys Ther. Sep 2005;29(3):127-137. 6.! Lam T, Eng J, Wolfe D, Hsieh J, Whattaker M. A systematic review of the Efficacy of Gait Rehabilitation Strategies for spinal cord injury. Topics in Spinal Cord. Injury Rehabilitation: Apr 2007 13(1):32-57. 7.! Backus D, Tefertiller C. Incorporating manual and robotic locomotor training into clinical practice: Suggestions for Clinical Decision Making. Topics in Spinal Cord. Injury Rehabilitation: 2008 14(1):23-33. 8.! Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. A physiologically based clinical measure for spastic reflexes in spinal cord injury. Arch Phys Med Rehabil. Jan 2005;86(1): 52-59.
References
9.! Barbeau H, Ladouceur M, Mirbagheri MM, Kearney RE. The effect of locomotor training combined with functional electrical stimulation in chronic spinal cord injured subjects: walking and reflex studies. Brain Res Brain Res Rev. Oct 2002;40(1-3):274-291. 10.! Fung J, Barbeau H. Effects of conditioning cutaneomuscular stimulation on the soleus Hreflex in normal and spastic paretic subjects during walking and standing. J Neurophysiol. Nov 1994;72(5):2090-2104. 11.! Perez M, Field-Fote C. Impaired posture-dependent modulation of disynaptic reciprocal Ia inhibition in individuals with incomplete spinal cord injury. Neuroscience Letters. 341 (2003): 225-228. 12.! Field-Fote EC. Electrical stimulation modifies spinal and cortical neural circuitry. Exerc Sport Sci Rev. Oct 2004;32(4):155-160. 13.! Musselman KE. Clinical significant testing in rehabilitation research: what, why and how? Phys Ther Rev. 2007; 12: 287-296 14.! Baily, SN, Hardin EC, Kobetic R, Boggs LM, Pinault G, Triolo, RJ. Neurotherapeutic and neuroprosthetic effects of implanted functional electrical stimulation for ambulation after incomplete spinal cord injury. J Rehabil Res Dev. 2010; 47(1): 7-16. PMD: 20437323 15.! Dutta A, Kobetic R, Triolo RJ. Gait initiation with electromyographically triggered electrical stimulation in people with partial paralysis. J Biomech Eng. 2009 Aug 131(8):081002. PubMed PMID: 19604014.
References
16.! Lambrecht JM, Audu ML, Triolo RJ, Kirsch RF. Musculoskeletal model of trunk and hips for development of seated-posture-control neuroprosthesis. J Rehabil Res Dev. 2009;46(4): 515-28. PubMed PMID: 19882486. 17.! Johnson T, G. Nemunaitis, J. Nagy, M. Boulet, L. Boggs, M. Miller, J. Anderson, H. Hoyen, M. Keith, K. Nicolackis, L. Murray, R. Triolo Trunk muscle neuromuscular stimulation: A case study of the effects on spinal alignment and respiratory function in a tetraplegic, American Spinal Injury Association (ASIA) meeting, June 19-22, 2008. 18.! Nataraj R, Audu ML, Kirsch RF, Triolo RJ. Comprehensive joint feedback control for standing by functional neuromuscular stimulation-a simulation study. IEEE Trans Neural Syst Rehabil Eng. 2010 Dec;18(6):646-57. Epub 2010 Oct 4. PMID: 20923741 19.! Triolo RJ, Boggs L, Miller ME, Nemunaitis G, Nagy J, Bailey SN. Implanted electrical stimulation of the trunk for seated postural stability and function after cervical spinal cord injury: a single case study. Arch Phys Med Rehabil. 2009 Feb;90(2):340-7. PubMed PMID: 19236990; PubMed Central PMCID: PMC2648134. 20.! Boninger M, French J, Abbas J, Nagy L, Ferguson-Pell M, Taylor SJ, Rodgers M, Saunders N, Peckham H, Marshall R, Sherwood A. Technology for mobility in SCI 10 years from now. Spinal Cord. 2012 Jan 17. doi 10.1038/SC. PubMed PMID: 22249329
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