The document summarizes recent advances in functional electrical stimulation (FES) for rehabilitation. It discusses uses of FES for ventilatory support, prevention of deep vein thrombosis and cardiovascular disease, reducing muscle tone, treating orthostatic hypotension, bladder training, improving trunk stability, and aiding gait training. Studies show FES can effectively support ventilation, improve hemostatic profiles, decrease spasticity, attenuate drops in blood pressure, suppress bladder reflexes, enhance spinal alignment, and improve gait performance. FES has benefits when used for gait training, as an orthosis, and for exercise to reduce diabetes risk factors in spinal cord injury patients.

1. Good
Morning

2. FES IN SCI
REHABILITATION
RECENT ADVANCES

3. CONTENTS
• FES
• Ventilatory support
• Prevention of DVT, CVD
• Reducing muscle tone
• Orthostatic hypotension
• Bladder training
• Trunk stability
• Gait training
• Exercise training

4. ORIGIN
Liberson
1961
Functional Electrotherapy
New era of advanced Rehab
Foot Drop

5. RENAMED
Moe and Post
1962
Functional Electrical Stimulation
"Electrical stimulation of muscle deprived of nervous
control with a view of providing muscular contraction
and producing a functionally useful moment“
- Gracanim et al (1967)

6. Spinal Cord (2009) 47, 508–518

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. 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. 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. 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. MINIMIZES MECHANICAL VENTILATION
FES of the diaphragm have been successful in
eliminating the need for mechanical ventilation in
patients with tetraplegia
Chest 2005;127:671–678 LOE-4 (SCIRE)

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. 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. 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. 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

17. ON CVD & DVT
FES in SCI patient improves their hemostatic profile
and reduce the risk of CVD and DVT
J Spinal Cord Med. Apr 2010;33(2):150–158

18. 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

19. 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

20. 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

21. OUTCOMES
• Modified Ashworth Scale
• Pendulum testing of spasticity

22. 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)

23. 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)

24. 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

25. TILTING VS TILTING+FES
FES-induced leg muscle contraction is an effective adjunct
treatment to delay orthostatic hypotension caused by
tilting
Arch Phys Med Rehabil 2005; 86: 1427-1433

27. OH – A CRITICAL REVIEW
Despite variations in experimental protocols, FES has
consistently proven to attenuate the fall in BP by
approximately 8/4mmHg during an orthostatic
challenge under experimental conditions
Spinal Cord (2008) 46, 652–659

28. BLADDER TRAINING
• Hyper Reflexive Bladder
• Incontinence
• Decreased bladder capacity
• Neuromodulation
• Surgical implantation of epineural electrodes
• Praxis stimulation system
Spinal Cord (2005) 43, 713–723

29. 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

30. 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

31. LIMITATIONS
• Surgical implantation
• Low level of evidence
• Further research – inconclusive
Spinal Cord (2005) 43, 713–723 LOE-4 (SCIRE)

32. TRUNK STABILITY
Stimulation of hip and trunk muscles can improve
performance of activities of daily living as well as enable
independent wheelchair and bed mobility
Arch Phys Med Rehabil 2009;90:340-7

33. OUTCOMES
1. Spinal alignment and pelvic orientation
2. Pulmonary function and ventilatory volumes
3. Maximal force and speed of rowing-like movements
Arch Phys Med Rehabil 2009;90:340-7

34. 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)

35. GAIT TRAINING-LET’S TURN BACK
• Kantrowitz et al (1963) - T-7 paraplegic patient standing
by surfacestimulation of m.quadriceps and m.glutei,

36. FES WITH ELBOW CRUTCHES
• Reswick et al (1970) T-5 complete paraplegic patient
standing with bilateral femoral and inferior gluteal
nerve stimulation

37. 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.

38. FES IN STAIR CLIMBING
Kobetič et al in 1983 by the entry of Multi-channel
stimulation (percutanes electrodes)

39. FES + PBWSTT
PWB supported treadmill training with FES had a
positive effect on overground gait parameters and could
potentially accelerate gait training in subjects with
incomplete SCI
Arch Phys Med Rehabil 2004;85:604-10 LOE-3(SCIRE)

40. Arch Phys Med Rehabil 2004;85:604-10

41. 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)

42. A CRITICAL REVIEW
• BWSTT
• Robotic-Assisted Locomotor training - LOKOMAT
• BWSTT + FES
Insufficient evidence to conclude that any 1 approach to
locomotor training is more effective than any other for
improving the walking function of people with SCI
Spine 2008;33:E768–E777

43. 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

44. 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

45. 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

46. 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

47. Outcome Measure Baseline Volitional Posttraining Volitional FES-Assisted
6-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 ± 0.02
Peak 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

48. BENEFITS OF FES IN GAIT TRAINING
The neurotherapeutic benefits of gait training with FES and
the neuroprosthetic effects of FES-assisted gait to an
ambulatory individual with long-standing chronic
incomplete SCI have been shown to significantly improve
gait performance in this single-subject case study.
Journal of Rehabilitation Research & Development 2010;47:7-16 LOE-4 (SCIRE)

49. 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

50. 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

51. EFFECT ON GAIT PARAMETERS
AFO and FES used in combination provided greater
benefit in overall gait function than either device alone
Arch Phys Med Rehabil 2006;87:1718-23 LOE-4 (SCIRE)

52. AS A DIABETALOGIST
• An increased risk for developing type 2 diabetes
Mt Sinai J Med 1992;59:163-8
• FES – cycling
• FES – rowing

53. 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

54. ON GLUCOSE
Justin et al studied the effects of exercise training with a
functional electrical stimulation (FES) rowing machine
on glucose, insulin resistance, plasma leptin levels, and
body composition in people with SCI
Arch Phys Med Rehabil 2010;91:1957-9

55. 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 0.074
Peak VO2 (ml/min/Kg) 21.4±1.23 23.1±0.8 0.024
Arch Phys Med Rehabil 2010;91:1957-9

56. RESULT OF TRAINING
A 12-week training program that included FES rowing
improved aerobic fitness and fasting glucose and leptin
levels in the absence of significant change to body
composition, fasting insulin levels, or calculated insulin
sensitivity in people with SCI
Arch Phys Med Rehabil 2010;91:1957-9 LOE-4 (SCIRE)

57. 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

59. 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

60. OUTCOME PARAMETERS
• VO2 max
• Heart rate
• Triglycerides
• Cholesterol
• HDL
• LDL
Arch Phys Med Rehabil 2009;90:1379-88

61. Resting Heart Rate
VO2 max

62. 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

63. 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)

64. UB EX VS FES-CYCLING
FES-cycling appears to be a feasible and promising
training alternative to upper body exercise for subjects
with spinal cord injury. 4 to 8 hr of FES-cycling are
necessary to reach the recommended weekly exercise
caloric expenditure that seems to be essential to induce
persistent health benefits by Berry et al
J Rehabil Med. 2010 Oct;42(9):873-5 LOE-4(SCIRE)

65. HOME PROGRAMME
‘Home-based daily FES training' is a safe and effective
therapy that may maintain life-long physical exercise by
active muscle contraction as a procedure to recover the
early-lost tetanic contractility of denervated muscle, and
to counteract muscle atrophy in order to prevent clinical
complications
Neurol Res. 2010 Feb;32(1):5-1

66. CYCLING
A case series by Brian et al suggests that cycling with or
without FES may have positive health benefits and was a
practical home exercise option for these children with
SCI
J Spinal Cord Med. 2008;31:215–221 LOE-4 (SCIRE)

67. TRAINING AND DETRAINING
Hunt et al says it is possible to increase maximal power
output, cardiopulmonary fitness, and bone parameters
of the paralyzed limbs in tetraplegia by high-volume
cycle training. However, if training is not maintained,
these improvements are lost.
Phys Med Rehabil 2008;87:56–64 LOE-5 (SCIRE)

68. 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

69. CONCLUSION
Areas Author Result Evidence
Ventilation Anthony et al Inconclusive 4
DVT prevention William et al Inconclusive 4
Tone reduction Phillip et al Inconclusive 3
Orthostatic 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

70. 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

71. 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

72. 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

73. Thank you