Setting up a FES Clinic at City Hospital (NHS) Trust - Birmingham - Christine Singleton
Report from the 5th IPEMB clinical FES Conference - Amanda Lamb
References for recent publications


Almost two years after the first FES training course we are publishing the Newsletter of the FES user group. Our aim is:

In each Newsletter we will publish an up-to-date list of users, ( please let me know if any details are incorrect) references for recent publications and articles from the readership. We will also report any new developments, research projects and future courses and conferences.

Contributions to the newsletter will always be welcome, whether they be articles, case studies, questions, letters, whatever - anything relevant to FES - it is this that will make it interesting.

Setting up a FES Clinic at City Hospital (NHS) Trust - Birmingham

In 1996 as a part-time Senior II non rotational Physio working in Neurology I became very interested in the work Jane Burridge (research Physio) and her colleagues were doing with FES. A number of patients I was involved with had been referred to Salisbury by our Consultant Neurologist. A clinic was organised in Birmingham as I felt improved quality of care for the patients could be achieved by Jane and the team visiting Birmingham for FES Clinics instead of the patients having to travel to Salisbury . This would also make a transport cost saving. The added bonus of course was to myself and colleagues in observing Jane at work with FES and in particular the ODFS. Little did I know the can of worms on the funding aspect I was opening nor the path that lay ahead leading eventually, 9 months later, to setting up the first autonomous FES Clinic outside of Salisbury and many a grey hair on the way!

Jane and Paul Taylor (Clinical Engineer) came to Birmingham for 3 clinics involving a number of patients and a lot of interest from Administrators and Health Authorities. This activity inadvertently put the spanner in the works of funding as most of the patients had been treated as ECR's (extra contractual referrals) to go to Salisbury but now were being seen at City Hospital - Birmingham. Who was going to pay for their treatment and the inevitable travelling expenses of Jane and Paul? At this time the Physio Department did not have a Manager in Post to give assistance to the business side of contracts which we were discovering we knew very little about. One steep learning curve coming up!! Added to this, the Trust thought it would be a good idea to inform the media that these Clinics were taking place leading to articles in papers, radio interviews and television appearances. What the Trust didn't anticipate was the flood of inquiries that came from the general public - the phone never stopped!

As a temporary measure funding was forthcoming from the Health Authority for past activity but on the condition that a Business Plan Proposal was forthcoming for future activity. In other words the clinics had to stop until future direction and funding were sorted. Meanwhile patients had been started on treatment and the phone continued to ring. This of course came on top of the normal day to day running of the Physio Neuro Service which at the time was difficult due to staff shortages.

Despite all the above our confidence in FES being a successful tool for Physios and patients was so strong that a commitment was made to develop this service within the Physio Department. Considerable support was provided by our Consultant Neurologist - Dr Steve Sturman - and our newly appointed Physio Manager - Mrs Wendy Parton.

Training was our first priority and to this end Jane & Paul presented a 2 day course on the use of FES for a small group of Physios. Although trained we felt very inexperienced and felt that further support from Salisbury was required at future clinics.

In putting together a Business Plan for the Trust and the Purchasers our ultimate goal was to set up our own clinics in close liaison with Salisbury. Clinical effectiveness and value for money were key elements to our success in obtaining funding.

The essential ingredients (key stakeholders) for a successful goal outcome were therefore:-

All the above worked as a team with much negotiating and compromising along the way. Funding to continue current activity was provided from the Birmingham Health Authority and GPs and a contract secured with the Birmingham Health Authority for 1997/8. Jane attended two further clinics as support and in October 1996 we went live with our own Clinics. Equipment is supplied and purchased direct from Salisbury.

Activity to date consists of 59 patients assessed for FES treatment with 40 on treatment, 29 being ODFS and the remaining on exercise stimulators. Over 1/2 are CVAs, 1/4 MS and remainder with other Neurological conditions. Our waiting list stands at 16 and growing almost daily.

Current secured income and activity has funded a Senior I post to take the lead with FES service together with Out-patient Neurology. I have been appointed to this post and together with my colleague Pat Leckenby (Senior I on the Stroke Rehabilitation Unit) an interesting and exciting year lies ahead.

I wish to take this opportunity to thank Jane and Paul for their support and encouragement together with all the members of the team mentioned above. The setting up of the first FES clinic outside Salisbury has been very hard work but well worth it for the excitement of being on the cutting edge of research and for the benefits gained by our patients.

Christine Singleton (Mrs)
Senior I Physio in Neuro City Hospital (NHS) Trust
Dudley Road
Birmingham B18 7QH
June 1997

5th IPEM Clinical Functional Electrical Stimulation Meeting

by Amanda Lamb (Salisbury District Hospital)

Over one hundred delegates from all over the UK, Ireland and Europe converged on Salisbury on the 13th - 14th March to discuss the hows and wherefores of electrical stimulation. This meeting was initiated by the Salisbury centre ten years ago and has been held biannually since. There was a marked contrast between the first meeting - when the technique was in its infancy and researchers were discussing the basic principles - and this meeting, in which the discussion centred on commercialising the technology and training clinicians to use it routinely and via telematics, with many types of stimulators and applications presented. Indeed the technical programme of over fifty presentations, posters and demonstrations was extraordinary for a two day meeting - the hard work of the organisers, and the concentration of the delegates, which produced interesting discussion throughout the conference should be commended.

Two particularly interesting sessions involved discussion by the delegates on challenges laid out by a clinical panel - the need for doing placebo trials was stressed and the difficulty of this discussed: masking using tactile stimuli was suggested. The abnormally high forces on the ankle in foot drop gait when corrected by common peroneal stimulation, and thus the need to combine orthotic treatment with physiotherapy were also highlighted. The user feedback session was also a success with comments and suggestions from users of the drop foot system, a hand control implanted system and an implanted standing system. All stressed the need for low maintenance implanted systems and the necessity of development work to follow from research findings and commercialise systems successfully. The use of publicity to raise money without generating a media circus was thought necessary by all users.

The first session, chaired by Malcolm Granat of the University of Strathclyde, was on the use of FES to correct dropped foot - the original application of FES first implemented by Lieberson in the sixties. This system is now in routine clinical practice at Salisbury and Ian Swain detailed the history of the service which made the transition from research to clinical use abruptly following an article in The Independent in August 1992 which unleashed demand for the system from across the UK. Anna Dunkerley presented data from 99 subjects who have used the system showing significant improvements walking speed and reduction in PCI when using the system and also a small training effect. Two channel stimulation, of the peroneal nerve and one other muscle group is now underway for foot drop at Salisbury and Paul Taylor presented eight case studies of people who use the system, often finding that stimulation had a greater training effect than the single channel stimulator as well greater improvement in gait when the stimulator was used. Rosie Jones from the University of Bristol talked about patient selection for people with MS and John Williams from the University of Bath gave a lively outline of a microcontroller based stimulator that uses closed loop control and Hall effect sensors to alter each stimulation pulse to stance phase parameters. The following session, chaired by Thomas Sinkjaer from Aarlborg University, Denmark detailed research on spasticity and physiological effects from FES, research which attempts to examine the reasons for the individual variation in response to the treatment. Jane Burridge from Salisbury has measured muscle activation, torque around the ankle and tracking ability during the course of FES treatment in the hope of using these as parameters for patient selection and prognosis. R Samarji from the University of Manchester presented a double blind placebo controlled trial of electrical stimulation for the treatment of spasticity in cerebral palsy in which a treatment effect was found from stimulation of the adductor muscles, even though this was not timed to the gait cycle. Mohammad Khaliti from Glasgow Caledonian University has found that FES produces significantly less torque than voluntary contraction of the elbow flexors and extensors, and N Mourselas from the University of Strathclyde presented interesting results showing an increase in force due to the doublet effect (two stimulation pulses close together), maximal at 5 ms between the doublet pulses but dropping at high intensity stimulation. J Parsons from the University of East London has investigated the strengthening effect of interferential current and found that an effect similar to other forms of stimulation exists and this is not affected by change of beat frequency over the clinical range.

After lunch presentations, chaired by Paul Taylor of Salisbury, focused on FES of the upper limb. The "NESS Handmaster" orthosis, a surface powered splint to give grips to C5 and C5/6 tetraplegics was found to be disappointing, with one successful user in ten case studies presented by M Clark from Stoke Mandeville. The results of three case studies of the "Neurocontrol Free Hand System" presented by J Esnouf from Salisbury and two presented by S Schepel from Enschede were more successful with all patients achieving their ADL targets. This is an implanted open loop system, originally designed by the Cleveland Ohio centre using stimulation of seven muscles of the forearm and controlled by the opposite shoulder, tendon transfers often being done simultaneously to assist function. Therapeutic effects from electrical stimulation have also been found - a beneficial effect in maintaining wrist range of movement after stroke, presented by J Powell from the University of Glasgow and an increase in the range of wrist movement in children with cerebral palsy presented by P Wright from the University of Strathclyde.

The last session of the day focused on new applications for FES, with presenting groups stimulating areas of the body never before reached. The role of magnetic stimulation was explored by M Craggs from UCL who found it useful for diagnostic use in the cervical region to assess for phrenic nerve pacing and for use in the sacral region to control unstable contractions to assessing patients for neuromodulator-neurostimulator implants. Electrical stimulation as effective therapy for upper eyelid paralysis, enabling patients to completely close their eyes was outlined by J Gittins from Leicester Royal Infirmary and the many clinical studies done on vagus nerve stimulation as a preventative treatment for epilepsy discussed by Stephen O’Connor from Cyberonics Europe. Thomas Sinkjear from Aarlborg University discussed the use of nerve cuff electrodes around sensory nerves as feedback devices in practical FES systems.

A tour of Salisbury Cathedral tower and a pleasant meal in the town’s Medieval Hall whilst listening to chamber music rounded off the fist day.

The second day of the conference emphasised surgical technique and engineering technology. In the cardiomyoplasty session the conditioning of muscle to avoid damage by electrical stimulation was outlined by Jonathan Jarvis of the University of Liverpool while his colleague Andy Shortlands presented his model of the hydraulic properties of the latissimus dorsi muscle when formed into a separate pumping chamber. Latissimus dorsi can also be wrapped around the heart and stimulated each heartbeat, a technique known as dynamic cardiac myoplasty. O Tasedmir from Turkey presented the results from trials of this technique and some delightful slides of Turkey!

The paraplegia session, chaired by Tony Tromans from Salisbury, focused on the Lumbar Anterior Root Standing Project, presented by Duncan Wood also from Salisbury, which has achieved implanted standing, stepping and tricycling with one patient. The operating conditions of the electrodes were outlined by P Donaldson, who considered the monphasic stimulating approach taken justified. Suggestions for improving the operation of hybrid orthoses were made by P Dall from Strathclyde, who found wrapped spring clutches a small improvement on a 2:1 flexion-extension ratio for an RGO, and by S Gharooni from Sheffield who presented a new type of orthosis using a spring at the knee and controlled braking at the hip to generate knee flexion, knee extension and hip flexion using only quadriceps stimulation. The CREST project to use of teleconsultation in FES was outlined by G Baardman. The session was rounded off by a talk on the role of the Medical Devices Agency by Peter Solesbury.

The last two sessions, chaired by Nick Donaldson from UCL and Dave Ewins from the University of Surrey covered sensor methods and FES control. One popular control theme was the use of finite state controllers and qualitative modelling - the history of finite state controllers was reviewed by P Sweeny from the University of Limerick, and implementations outlined by Ben Heller from Sheffield, who is developing a visual programming language based on this concept, and Y Yang who has used inductive learning tools for control successfully in one patient. Two innovations were reported by W Peasbody and T Whitlock from Bristol University - an optical fibre sensing technique for ankle angle and an array of self-optimising electrodes which should enable patients to put on electrodes quickly and easily and might improve control and reduce fatigue during use. K Louison from Sheffield has measured EMG of trunk muscles and found some anticipatory reactions which could be used as inputs to a closed loop standing system. Lastly K Tong from Strathclyde presented the use of virtual sensors for FES control, finding that many different types of sensors could be simulated in a gait analysis laboratory and the type of sensors used and their optimal placement determined.

A poster session lasted throughout the conference which detailed some of the background work to the above presentations and a very enjoyable demonstration session took place on the second day, some of the demonstrations have been photographed. To summarise: this conference showcased the range of FES work now in the clinical research stage and stressed the need to alert more clinicians, especially physiotherapists, to the success of many of the applications. The next meeting will be hosted by the Bristol Group

References for recent publications

  1. Bogataj U, Gros N, Malezic M, Kelih B, Kilajic M, Acimovic R. (1989) Restoration of gait during two to three weeks of therapy with multichannel electrical stimulation. Physical Therapy 69 (5): 319-27
  2. Burridge,J. Taylor,P. Swain,I. (1997) Cinical Experience of the Odstock Drop Foot Stimulator. Artificial Organs 21 (3): 254-260
  3. Burridge,J. Taylor,P. Hagan, S. Swain,I (1997) The effect of Common Peroneal Nerve Stimulation on Quadriceps Spasticity in Hemiplegia Physiotherapy vol 83, no 2
  4. Burridge,J. Taylor,P. Hagan, S. Swain,I (1997) The effect of Common peroneal stimulation on the effort and speed of walking. A randomised controlled trial with chronic hemiplegic subjects. Clinical Rehabilitation 11.3
  5. Carmick J. (1995) Managing equinus in children with cerebral palsey: electrical stimulation to strengthen the triceps surae muscle. Developmental medicine and child neurology 37: 965-975
  6. Granat, M.H, Maxwell, DJ, Ferguson, ACB, Lees, KR, Barbanel, JC. (1996) Evaluation of common peroneal stimulation for the correction of drop foot in hemiplegia. Arch Phys Med Rehab 77: 19-24

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