April 1999

No 4

Department of Medical Physics and Biomedical Engineering

Salisbury District hospital



Telephone 01722 336 262 ext 4065

Fax 01722 425 263


Table of Contents


Equipment News

Abstracts from the FES users meeting March 3rd 1999

Long Pulse Stimulation for Lower Motor Neurone Lesions

The CREST project

Case presentation on the use of FES for the upper limb

The use of FES to Improve foot-drop and knee hyperextension using a two channel stimulator and gait laboratory analysis – A case history

Case study of a young FES user

Use of FES in the upper limb rehabilitation of a CVA suffering right hemiplegia, 8 years post onset.

Salisbury District Hospital (Medical Physics) Web Page

FES courses and meetings



The NHS white paper that has abolished ECRs, just as we were beginning to make them work, has led to a few grey hairs. Undeterred we are finding a way to make the new system work; hopefully better than the last! This is the proposal that we are putting to Health Authorities where we are currently running FES clinics and to any Authorities where new clinics have been suggested. The proposal is for a Consultancy service:

Approximately 4 clinics per year – max. 6 patients per day per clinician charged at £400 per day per clinician

We will submit a worksheet to identify: patients seen, equipment provided and travel and accommodation expenses.

The advantage of this system for you will be that you do not have to ask us to see patients for routine follow-ups; but you can ask us to see patients if they have problems and you want our help or advice. We envisage that a clinic will therefore consist mainly of initial assessments and set-ups with a few reviews of patients with problems. It will give you more autonomy, will be more economic and therefore we hope will allow you to use FES with more patients.

In areas where we do not hold clinics the new system will be much the same as the old but based on cost per clinic slot rather than per patient. This is estimated at £200 per slot and will be the same regardless of what stimulation the patient is using.

On March 3rd 1999 we held the third FES user group meeting. This was the best attended yet with 34 participants. The day was not long enough, I think everyone would have liked more time for discussion. There were some interesting talks and presentations. Abstracts from some of these are included in this newsletter.

There has been a great deal of interest in the use of Botulinum toxin in the treatment of spasticity. Over the last year we have had some encouraging results from combining FES with Botulinum toxin injections into the calf muscles; usually tibialis posterior and the medial and lateral heads of gastrocnemius. We were approached by the Drug Company IPSEN who produce Dysport, one of the two types of Botulinum toxin on the market, about our experience with this combination. We were invited to submit a proposal for a pilot study, which we did and which they have agreed to fund. The subjects will be sub-acute strokes with demonstrable calf spasticity, they will be recruited from Salisbury and Christchurch hospitals and the study is expected to take about twelve months. The funding has meant we have been able to appoint a new research physiotherapist.

Salisbury FES is going into Europe. Paul has been asked to give a course at a hospital near to Milan, some of the literature has been translated into Italian. This has only been possible because our stimulators have been CE marked. Now the clinical service has also been ISO 9002 registered. Both have meant a lot of work, organisation and nagging for Steve Crook, the department’s number two.

The Action Research Compustim 10B project finishes in September. Almost all the patients have completed the study. The results so far are encouraging and we have submitted a proposal for a larger Randomised Control Trial (RCT) to compare the effects of the Compustim 10B with the standard AFO. We have also submitted two proposals to NEAT, New and Emerging Applications of Technology. The first is for a study to investigate stimulation of the arm and is called, Stimulation of the Upper limb to Restore Function (SURF) and the second to design a simple low cost gait analysis system called Gait Rehabilitation Invoked By Biofeedback and Intelligent Technology (GRIBBIT). With a good acronym you can’t go wrong!


Last year we ran a course for people who had done the basic two-day course and who wanted to be able to use the 02CH stimulator. There has been a demand for this to be repeated – details are included in the courses and meetings section at the end of the newsletter.

Jane Burridge


Equipment News

New Foot-switch

We have been carrying out some trials of a new foot-switch design. The new device is similar to the old one except the silver print ‘fingers’ of the sensor are covered with an anti-oxidant. Oxidation of the silver may be responsible for the short life of the switches, accelerated possible by sweaty feet! So far the prototypes have been lasting on average up to three times as long as the old switches. Results have been encouraging enough to make this our standard foot switch. From mid summer all new switches will be of this design. The price will be unchanged.


Outside Manufacture

From last March ODFSIII and Microstim 2 stimulators and foot-switches are being made by outside contractors. This is due to increased demand. The more complicated devices will still be made in-house. All equipment will still be supplied through Medical Physics in Salisbury.



All equipment prices have been frozen for this financial year at last year’s prices.



As always, we welcome any feedback on the equipment or service we provide. Comments please to Paul Taylor 01722 336262 Ex 4060 or email

Paul Taylor




Abstracts from the FES users meeting March 3st 1999

Long Pulse Stimulation for Lower Motor Neurone Lesions


AH. Woodcock, PN.Taylor*, DJ.Ewins

Biomedical Engineering Group, University of Surrey, UK

*Salisbury District Hospital, Medical Physics and Biomedical Engineering Dept. UK

Clinical application of electrical stimulation of denervated muscle is far from routine in the UK because of the controversy regarding its effect on re-innervation and the limited therapeutic benefit from the conventionally used low frequency monophasic ‘galvanic’ pulses. By using charge balanced, biphasic pulses, the potential skin damage of higher frequencies may be avoided and permit tetanic contractions. In recent years, several studies of stimulation in humans using biphasic rectangular pulses of approximately 20-50ms have demonstrated significant improvements in tissue quality and muscle contractile capability. The technique therefore also offers the prospect of restored function by stimulation and perhaps enhanced voluntary recovery, by maintaining the muscle in a state suitable for re-innervation. However suitable commercial stimulators are not readily available.

A portable, programmable, micro-controller based stimulator unit has been developed, suitable for clinical and ‘home-use’, capable of producing a range of stimulation patterns and pulse shapes. Built in safety features and feedback controlled constant voltage output (up to 95V), provide protection against electrode peeling, component failure and operator misuse.

The unit is being used in a clinical pilot study to investigate the application of Long Pulse Biphasic (LPB) stimulation for a limited range of chronic denervation conditions where re-innervation is not expected; spinal cord injury (T12 level), brachial plexus injury, and peroneal nerve lesion. Gradual changes in stimulation intensity using trapezoidal shaped pulses have been found to alleviate sensory and motor nerve recruitment in partially denervated cases. Effectiveness of the treatment is evaluated by quantitative measurement of the muscle bulk, limb blood flow and skin temperature at regular intervals throughout the 6-month treatment and 6 month follow-up periods. Subject compliance and response to the treatment are also monitored.

The CREST project


Ben Heller (Ph.D.) Medical Physics and Clinical Engineering Royal Hallamshire Hospital, Sheffield

CREST stands For Clinical Rehabilitation using Electrical Stimulation via Telematics. It is a 3-year EU-funded project (under the Telematics Applications Programme) to develop FES telematics techniques to improve the rehabilitation of persons with incomplete spinal cord injury. The project partners are from England, Scotland, Holland, Denmark and Spain.

The hypothesis behind the project is that provision of FES strategies in incomplete spinal cord injury (ISCI) requires expertise to prescribe and apply bespoke stimulation strategies. This expertise is, at present, concentrated in a few centres in Europe whereas the ISCI population is distributed throughout Europe and is of low mobility. By using telematic techniques the necessary expertise can be shared remotely without the patient or 'expert' needing to travel. Thus a collaborative network of users can be built-up.

The first project task was the identification of users’ needs. A postal survey was conducted of all members of the UK and Dutch Spinal Injuries Associations. There were 426 Dutch replies (61%), and 1122 from the UK (21%). The target group for the project are 'marginal walkers', defined as "able to walk but with potential for improvement". Of all the UK replies, 14% described themselves as marginal walkers. Of these, 39% could walk 50m or more, 22% less than 50m, 27% less than 10m and

12% less than 5m. The respondents were asked to rate the following research areas as to how big a contribution they would make to their lives.

Marginal walkers non-walkers

Bowel management 62% 76%

Bladder management 66% 78%

Walking quality 81% 24%

Walking speed 61% 16%

Muscle size 59% 32%

The project has developed a user-friendly computer-based package that allows a suite of standard assessment protocols to be performed, collects video of the subject walking together with sensor information, allows different FES strategies to be quickly developed and downloaded to a programmable stimulator, and allows collaborative (telematic) working amongst different centres.

At present the system is being tested with 50 subjects in 5 different centres throughout Europe.

Case presentation on the use of FES for the upper limb


Nicole Rutter Senior Physiotherapist Poole Hospital

This case study looked at the early use of F.E.S. for upper limb rehabilitation of a 31-year-old man following a left cerebral infarct. Mr G was suffering from Noonans syndrome, which lead to mild learning difficulties, atrial fibrillation, and mitral regurgitation. On initial assessment he had decreased tone throughout his right side, with no active movement in his upper limb. He was able to sit to stand with assistance, but was unable to control his right knee. His symptoms quickly resolved and within 5 days he had independent gait and early recovery around his shoulder.

By day 11 he was discharged home with reasonable shoulder and elbow control, but only a flicker of activity at the wrist. Mr G continued with physiotherapy, concentrating on shoulder stability and normal movement of the arm, but at 6 weeks his still had minimal activity at the wrist and hand. At this point he was assessed for F.E.S. using a 4-channel stimulator. Good wrist and finger extension was achieved, but it was difficult to get all his fingers flexing, as it tended to be just the middle two. This was attributed to too small electrode size. Problems were also experienced in stimulating his thumb.

Two weeks after stimulation was commenced Mr G had gross active flexion and extension of his fingers and was able to grasp and release a ball without FES. By 10 weeks post CVA he had active independent finger movement, but was tending to over squeeze into flexion. FES was therefore discontinued after a total of four weeks treatment, twice weekly, and physiotherapy concentrated on control of movement.

By 12 weeks post CVA Mr G had returned to work and was riding his bicycle. He had a pinch grip and key grip and was able to use his hand for functional activities, but needed pushing due to his mild learning difficulties. FES was used at an early stage in this young mans recovery to enhance his rehabilitation. It appeared to have been very successful but it is impossible to tell whether he would have recovered spontaneously.

The use of FES to Improve foot-drop and knee hyperextension using a two channel stimulator and gait laboratory analysis – A case history


Janet Cozens, Senior I Physiotherapist, Moor Green, Birmingham

Mr A suffered a spontaneous subdural haematoma in June 1997 with a resultant left hemiplegia. In April 1998 following a period of in-patient rehabilitation and some outpatient physiotherapy he started attending Moor Green Brain Injury Rehabilitation Unit. On initial presentation he was mobile for short distances only. He had no active dorsiflexion on the left and wore a hinged AFO. He had reduced proprioception on the left side and lacked knee control on that side tending to hyperextend. In his upper limb he had minimal movement and his shoulder was subluxed.

Mr A was initially set up with a single channel drop foot stimulator in April 1998. The use of the stimulator encouraged more even weight bearing in standing and also on sitting to standing. He was seen in the FES clinic in June and attended the gait laboratory where visual vectors were recorded with and without the stimulator. Walking without any FES his left femur externally rotated at toe off and there was marked pelvic rotation to assist swing phase progression. The left ankle was plantar flexed and inverted on swing phase with minimal hip and knee flexion occurring and the trunk side flexing.

The visual vector showed that initial contact of the left foot occurred on the lateral border of the hindfoot in an anterior position in the calcaneum. There was rapid progression to foot flat with active hip extension during loading to produce left knee hyperextension. There was delayed anterior sagittal vector progression during terminal stance delaying knee flexion and also indicating the lack of active foot plantar flexion. Therefore weight transference took place relatively passively. The coronal vector showed rapid pronation after initial contact, which increased, on loading producing a mild valgus movement. Gait analysis using the drop foot stimulator showed improved ground clearance which produced an improved initial contact position with normal heel strike transient in the mid calcaneum. Periodic knee hyperextension was still present.

In June 1998 he was set up with a 2 channel stimulator stimulating anterior tibialis and hamstrings in an attempt to prevent the knee hyperextension problem at initial stance phase.

Gait analysis showed that the hamstring stimulation produced consistent controlled knee flexion during loading, which prevented terminal stance knee hyperextension.

The overall response was good although it was difficult to identify if the improvement was due to straightforward contraction of the hamstrings or whether there was a sensory component increasing awareness of his knee at this stage of the gait cycle. Physiotherapy alongside the FES included a lot of treatment aimed specifically at improving knee control.

Mr A was reviewed again in the FES clinic in September. He had found the stimulation had been helpful but was then feeling that the stimulation of the hamstrings was not effective. Assessment showed that his knee control had improved considerably although he still tended to stand habitually in hyperextension. His knee control in walking had improved and it was felt that he no longer needed stimulation of the hamstrings.

He was changed to a single channel stimulator and stimulation was delayed until slightly later in stance by moving the foot switch forward. This allowed more use of his calf muscles to more effectively roll forward. Stimulation was continued to just after heel strike to give more stability in early stance. With stimulation his walking speed increased by 14% and the effort of walking measured by PCI reduced by 2%. Both walking speed and PCI also improved without stimulation with his walking speed increasing by 20% and his PCI reducing by 8%.

Mr A was reviewed in December. He was continuing to use the stimulator to correct foot drop, and some extension was added to prevent foot flap. Ground reaction forces were recorded in gait analysis, which continued to show significant differences between no stimulation and the use of the stimulator.

Mr A was discharged from Moor Green but his FES was last reviewed in March 1999, when he felt that he was no longer benefiting from using the stimulation. On assessment his identical walking speed and PCI were almost identified both with and without the stimulator. His gait pattern had considerably improved with good heel strike and improved knee control. It was felt that he no longer needed to use the stimulator.

Case study of a young FES user


Rosalind Edwards. Senior Physiotherapist, Victoria Hospital, Frome. Somerset.

Claire is a 27-year-old lady with right congenital hemiparesis. She has an equinus deformity and such marked in-toeing of the right foot that she sometimes kicks her own foot. In primary school she had worn a POP for 3 months. Despite a leg length discrepancy being noted when she was 12, Claire does not remember having significant problems with gait or function. She could wear normal footwear.

However in November 1997 her foot suddenly became less stable and she started walking on the lateral border. Physiotherapy and an insole from the chiropodist did not improve the situation.

An orthopaedic surgeon assessed her in October 1998. He felt that the equinus deformity was partly compensating for the 1 inch shortening of the right leg and did not feel surgery would be likely to help at this stage. After much searching for appropriate footwear Claire had found just one pair of lace-up boots which gave her the support she needed to walk. However she did not feel she could tolerate a shoe raise on the right. Claire was assessed for a foot-drop stimulator in January 1999. She was fully independent, very active young woman, living in a top floor flat, driving, working and due to take a trip to USA in April, for which she was keen to be walking better. Her walking however was fast and basically safe. She was able to walk 4-5 miles. She has never used an AFO.

On examination she had 5 degrees contracture into plantarflexion and could not achieve a plantargrade foot, and could not lift her toes from the ground in sitting or standing. Spasticity at ankle and knee were not a feature. During gait there was marked equinus and intoeing on the right. In her boots she just achieved heel-strike.

On initial assessment and fitting care needed to be taken to avoid placing the electrodes over psoriatic lesions. The electrodes have not irritated the skin and the psoriasis is now more quiescent. It was initially difficult to find an electrode position, which corrected the foot well, but the best result was with the active just below the posterior crease of the knee on the lateral side. Subsequently the standard position below the fibula head proved satisfactory.

With the Odstock Foot Drop Stimulator ( ODFS) dorsiflexion was limited by the ankle contracture, but the correction into more eversion led to a much better gait. Claire commented that this was the best she had ever walked in her life. The stimulator was set on adaptive timing with hardly any rising or falling edge ramp. The heel-switch was on the ipsilateral side with the stimulator set on heel-rise and the time at 2. This seemed to accommodate well her naturally fast gait.

At the first check-up Claire’s walking speed was 3% higher and the Physiological Cost Index 6% lower when wearing the stimulator. Because she moves around so quickly, Claire finds she turns the ODFS on when she is outside, but not indoors where she would need to keep turning it on and off. She finds the ODFS a great benefit and is no longer kicking her own foot as she walks. She can now start wearing the shoes she had given away to her mother, instead of just one pair of lace-up boots.

Use of FES in the upper limb rehabilitation of a CVA suffering right hemiplegia, 8 years post onset.

Geraldine Whitehead

The role of FES in hemiplegia recovery has been mainly documented in the lower limb. Documented evidence on when exactly to apply/ withdraw a particular method of physiotherapy to achieve maximum benefit and function is a topical issue. This particular case study shows achievement of aims measured using FES and physiotherapy in upper limb rehabilitation.

The case study was male, DOB 24.11.33, a retired bank manager, suffering a right hemiplegia 27.12.86. The patient was naturally left-handed. He was diagnosed by a rehabilitation consultant as suffering a "severe" CVA and told he would never walk or regain function in the arm. He had 2 years physiotherapy, both in- patient and out- patient, and the help of speech and occupational therapists. On discharge in November 1998 he was mainly mobile in the wheelchair, used a stick for short distances only with a drop foot splint being used all the time. He had a painful shoulder, no active arm movement; the arm never having been touched in rehabilitation. In April 1989, the CVA being 2- 5 years post onset, he sought extra physiotherapy as the home carer was finding him increasingly difficult to manage. The tone was assessed as 4.5 on the Ashworth Scale.

He received physiotherapy for 40 minutes, twice weekly, one to one, with relatives present. Home exercises were performed daily. Continuous assessment based on the Carr and Shepherd upper limb assessment was used. Methods consisted of a "tool box" of mainly Bobath approach, Johnstone approach and use of Johnstone Splints after May 1994. Ice, acupuncture and interferential occasionally, until discovery of the Salisbury FES project. He was assessed on 21.04.95 by the FES team. Levels of spasticity were recorded as moderate. Shoulder movement with elbow, wrist and fingers extended were 75% normal, the patient being able to shrug and complaining of very occasional pain. Wrist extension was 75% and grip 50%. He was able to release grip. He walked unaided for a distance of around 500 metres and didn’t use a wheelchair. He was independent in dressing except for buttons. The time scale for these achievements was April 1989 to April 1995 ( 6 years ).

In June 1995 he was fitted with a FES 2 channel micro- stimulator to be used for 20 minutes, twice daily. Physiotherapy continued as normal. A timed Jebsen Test was used to record results, with pinch grip, key grip and power grip also recorded. Various aims, both personal, e.g. shake hands; specific- wrist extension with finger flexion, general- memory of movement, using FES it could be visual and sensory, were set. Placement of electrodes and aims were discussed between the FES team and myself at each visit. Recent advancements/ developments of the machines and switches were tried to aid function with variable success.

Results were excellent to the Jebsen Test and continued to improve to discharge on 5/02/96.

Follow up was 3/03/97 and it was interesting to note that little variation had occurred in the completion of 6 tasks, so the improvement gained had been maintained. Other benefits were reduction in tone Grade 1 Ashworth Scale, sensation increased and gait improved. This was not the expected result on follow up based on past work with FES. It is interesting the he also had physiotherapy on a weekly basis between his discharge and follow up. In this particular case study the aims were achieved.

It proved user friendly and another valuable " tool " to aid the physiotherapist. It was successful on a stroke that was 8 years post onset. The patient would fall into " ideal patient " mode on actively seeking physiotherapy, having a lot of support and help at home and a lot of personal discipline and determination.

Salisbury District Hospital (Medical Physics) Web Page

Stacey Finn

For those of you who haven’t seen it yet, our web site address is:

We have just updated these pages updated and we hope you find them useful, so don’t forget to add it to your ‘bookmarks’ list. And if there is anything you would like to add to our page e.g. the work you are carrying out, please do not hesitate to contact us and we can add it on.

FES courses and meetings

FES courses that are planned are:


Salisbury 02CH course for people who have completed the basic two day course. Salisbury District Hospital on Thursday September 16th (starting at 2.00pm) and all day Friday, September 17th 1999. Contact Jane Burridge 01722 336262 ext 4060

Royal United Hospital Bath on October 2th and 3rd The person to contact is Sue Kershaw Senior Physiotherapist or Liz Townsend, Course secretary Royal United Hospital, Combe Park, Bath BA1 3NG Telephone 01225 824293

County Hospital Cod-y-Gric Rd, Griffithstown, Pontypool. On November 4th and 5th. the person to contact is Ruth Jones, Senior Physiotherapist, Telephone 01495 768679 or FAX 01495 768707

Birmingham on November 29th and 30th. This is being run jointly by Christine Singleton and us. Contact Christine Singleton, Senior Physiotherapist City Hospital Dudley Rd Birmingham Telephone 0121 554 3801 ext 4438 or ask switchboard to bleep her.

A clinical FES meeting will be held in Sheffield next year April 17th and 18th 2000. This will be an international conference and important in the FES calendar. Make a note of it. If you would like to be sent details and the call for abstracts contact:

Dr Ben Heller Medical Physics and Clinical Engineering Royal Hallamshire Hospital, Sheffield.

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