FES Newsletter

Editorial

Welcome to the 9th edition of the Salisbury FES (Functional Electrical Stimulation) Newsletter. The Newsletter is a biannual publication with the purpose of promoting the clinical use of FES. It is distributed chiefly to clinicians who have attended the Salisbury introductory FES course but also those who have an interest in the field or those we hope may be interested. FES is a means of producing functional movement in paralysed muscles by the application of electrical impulses to the nerves of those muscles. FES is increasingly used in neurological rehabilitation to improve mobility and upper limb function. The most common use is for the correction of dropped foot in hemiplegic gait, an intervention now recommended by the Royal College of Physicians in their publication "National clinical guidelines for stroke".

In this edition we have the second in our series of updates to the Introductory FES Course notes with an article on the use of electrical stimulation in the upper limb in hemiplegia and SCI. We have news from an active FES clinic in Hong Kong and their solution to finding electrode positions for common peroneal stimulation. There is also a report from Royal Bucks in Aylesbury of their experience of using FES in the rehabilitation of SCIs. We have a selection of abstracts from The FES User Day, which this year was held in Birmingham at City Hospital. Thanks to Christine Singleton for hosting the meeting which I think was generally believed to be an interesting and enjoyable day. One issue that was raised at the meeting was the need for greater guidance on upper limb stimulation applications so we have decided to offer a new one day course on this area. See later for details. There is also a growing interest in applications in paediatrics and I am pleased to announce that Queen Mary's Hospital Roehampton will be hosting a one day workshop on this topic in June. Book early for both events, as places will be limited! As ever, we welcome contributions from you for the Newsletter. Please send articles to the address below for the July edition.

Finally, we are receiving increasing numbers of enquiries from people seeking FES treatment in their home area. We therefore wish to start a directory of clinicians that are willing to receive referrals. Please fill in and return the form at the back of the newsletter, which will enable us to pass on information to potential clients.

Paul Taylor

Department of Medical Physics and Biomedical Engineering,

Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ, UK

Tel: 01722 429 119, Fax: 01722 425 263

Email: p.taylor@salisburyfes.com

Web page: www.salisburyfes.com

This and all back issues of the FES Newsletter can be found on our web page.

Upper limb electrical stimulation exercises.

P Taylor, G Mann, C Johnson, L Malone

 

In this article we wish to document some of the electrical stimulation techniques we use for the upper limb, primarily with hemiplegics, in the Salisbury FES clinic. There is a growing body evidence for the effectiveness of the use of electrical stimulation in the upper limb but it is not the intention that it is reviewed here. Instead, we refer you to the excellent recent review articles by John Chae et. al1, 2 and the comprehensive review in the Rancho Book.3 The Rancho Book also includes a very useful description of electrical stimulation techniques and treatment regimes.

Electrical stimulation can be used for the following purposes:

As with any repetitive exercise, muscle bulk and strength will be increased. This will also lead to greater capillary density and therefore improved local blood supply and tissue condition.
Electrical stimulation can provide regular stretching, similar to passive stretching but performed over a more extended period. Be careful that some joints are not over stretched while trying to increase the range of others. For example it is sometimes useful to use MCP joint extension blocking splint to protect the MCP joints and improve the effectiveness of the action on the PIP and DIP joints. Another example might be the use of wrist flexion blocking splints when exercising finger flexors. Care must be taken that repetitive movement does not lead to skin marking.
This can be done in two ways. Firstly, it has been shown that botulinum toxin is more easily taken up by the receptors if the muscle is active. This can be achieved by direct stimulation of the target muscle or by exercise of the antagonist muscle leading to stretch reflexes in the target muscle. Botulinum take up occurs over the first two days following injection. The second method is to use electrical stimulation to enhance relearning of movement in the three month window before spastic tone returns.
When a muscle contracts, activity in the muscle spindles is relayed via inhibitory interneurones to the a motor neurones of the antagonist muscle reducing its activity. This is known as reciprocal inhibition and its effect can be exploited by stimulating the antagonist muscle to the spastic muscle. As the Ia afferents, the nerves that pass from the muscle spindles to the spinal cord and inhibitory interneurones, are of large diameter, they require only a low level of stimulation to excite them so will always be excited even if the stimulation produces only a small contraction. Consequently stimulation will have a direct effect as well as via mechanical changes of tension in the muscle itself. Commonly, after exercising the antagonists to the spastic muscles there is a period of reduced spasticity which can last from minutes to hours. By repetition of these exercises the synaptic connections can be strengthened via long term potentiation and spasticity reduced for an extended time. However, most studies have shown that the treatment needs to be maintained long term for continuing therapeutic benefit.
Stimulation of the spastic muscles themselves has also been shown to have a relaxing effect. This is thought to be due to antidromic stimulation of the a motor neurones, that is stimulation that cause a nerve impulse to travel up the nerve towards the spinal cord, acting upon Renshaw interneurones. The Renshaw interneurones have an inhibitory effect on the a motor neurones, reducing their excitability and therefore reducing spastic activity. Reciprocal stimulation of agonist and antagonist pairs can be an effective way of reducing spasticity. However, there are some concerns that by strengthening spastic muscles, spasticity may be stronger when it returns. Generally, we restrict stimulation to the antagonist muscles unless strengthening and retraining of the spastic muscle is also a clinical goal.
When a muscle contraction is produced by electrical stimulation, a whole range of sensory inputs is produced. This includes the direct sensation from the stimulation and the proprioceptive feedback from joints, tendons, muscles and mechanoreceptors. There will also be antidromic stimulation of a and g motor neurones. All this will cause a significant increase in activity along the remaining pathways to the cortex and other centres, stimulating the production of new synaptic connections. Excitation of the Ia afferents will have the same effect as activating muscle spindles by stretching them, causing excitation of the a motor neurone to cause a muscle contraction. However, this increased level of a motor neurone excitation will also make it easier for weak descending inputs to activate the motor neurone and therefore produce a voluntary contraction. It is good practice to ask the patient to try and assist the action of the stimulator with voluntary movement to enhance this effect. However, this voluntary effort must not be so great that it cause a rise in spasticity and inhibits the desired movement.
As described above, the sensory input will encourage new synaptic connections in the sensory cortex and increase sensory awareness. Many anecdotal comments have been reported of improved sensory ability and this has been illustrated by improvements in 2 point discrimination and reduction of neglect syndrome.
By reducing spasticity and improving the resting position of joints, pain can be reduced or eliminated. The stimulation itself will also have an effect similar to TENS, as the stimulation waveforms are similar chiefly differing in only intensity.

To be effective the exercises should be performed on a regular basis, ideally once or twice daily. As ours is an outpatient clinic, patients take stimulators home. Exercise times commence for only 10 minutes sessions at a time, increasing to up to 30 minutes over a period of one month. Regular follow up is required to ensure the exercises are performed correctly. It is not uncommon that electrode positions will need adjusting as patients progress or simply because they have forgotten the correct positions. For this reason, patient and carer education is very important. We supply written instructions, electrode position diagrams or digital photographs and we mark electrode positions with indelible marker pens. To assess their progress we use the Jebsen-Taylor hand function test or the Action Research Arm Function Test. We also record active and passive ROM, Ashworth and 2 point discrimination.

Where spasticity is present it is important that a stimulator with a long rising ramp of at least 2 seconds is used. This is because a sudden contraction will rapidly stretch the antagonist muscle and induce a stretch reflex resulting in a reduced ROM. A long ramp will also be more comfortable which in its self may reduce tone levels. We have not found that the stimulation frequency is very critical in practice but generally 40 Hz produces a smooth and comfortable contraction. All exercises are performed using cyclical stimulation with stimulation on times of 8 -10 seconds followed by a rest period of the same time (Microstim modes 6 or 7). A standard pulse width of 300m s is fine but it is sometimes useful if using the Odstock 4 Channel Exercise Stimulator to reduce the pulse width to 100m s as this allows finer control of the amplitude controls.

It is our impression that patients have a greater re-education effect if they have some motor ability before treatment begins. As a minimum, there should be some finger movement and it should be possible to take the hand to the mouth. Patients with less ability than this may still benefit from use of stimulation to reduce spasticity for cosmesis, pain reduction or assistance ADL tasks such as dressing. As a general rule, the number of muscle groups exercised should be kept to a minimum. Most patients will find more than 2 muscle groups hard to cope with. Less able patients will need assistance from a carer to perform the exercises. Cardiac demand pace makers are contraindicated. This is because interference from the stimulator may prevent the detection of bradycardia. Poorly controlled epilepsy should also be avoided, as there are some anecdotal incidents of increased symptoms when using electrical stimulation. However, where it is controlled by drugs there should be no problem.

Upper limb FES applications in hemiplegia

Shoulder subluxation

Subluxation occurs when muscle tone around the shoulder is reduced, resulting in a loss of continuity at the gleno-humeral joint. Tissues around the socket become stretched and pain is frequently a problem as well as reduced function. Often, when spasticity follows a period of flaccid paralysis, muscle tone will not be balanced and over active pectoral muscles can pull the humerus into internal rotation. The muscles around the shoulder can be divided into two groups, those such as the supraspinatus or teres minor which principal role is to locate the humeral head in the socket and those such as the deltoid or pectorals, which primarily move the whole limb. The deltoid is easy to stimulate as it is the most superficial muscle but it is useful to target supraspinatus because of its central role in locating the numeral head. If there is no internal rotation, place one electrode over middle deltoid and the second over supraspinatus. Chose which electrode to make the active by which you wish to have the strongest effect. For example if placing the active over the deltoid produces too much abduction, reverse the polarity.

If the arm is internally rotated, place the deltoid electrode over the posterior deltoid. If greater external rotation is required, stimulation of the teres minor and infraspinatus can be tried. Stimulation of the supraspinatus can be difficult to achieve without activation of upper fibres of trapezius resulting in elevation of the shoulder girdle. If this is the case it is often better to stimulate the middle and posterior deltoid. Two channels of stimulation can be used, alternating between the electrode positions.

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Scapula Stabilisation

Scapula winging is a common problem following hemiplegia and is due to weakness in muscle such as the trapezius and rhomboids. These muscles can be exercised using electrical stimulation with the electrode positions shown. The rhomboids will retract and elevate the scapula while the more superficial lower trapezius will adduct and depress it. This exercise can be combined with other exercises, for example reaching exercises.

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Elbow extension

The triceps is easily stimulated by placing an active electrode over its motor point and the indifferent over the tendon at the elbow. As this is a fairly large muscle, it is sometimes useful to use larger electrodes, 50mm x 50mm for example, which may produce a more effective movement with greater comfort. Patients can be asked to assist with the movement. Practising "table polishing" by sliding the hand on a table using a cloth to reduce friction can be effective. The triceps action can be supplemented by placing the indifferent over the anterior deltoid to assist shoulder flexion. Posterior deltoid can be added in the same way to extend the shoulder and this is sometimes done in the swing phase of gait using an ODFS or O2CHS, controlled using a foot switch. If the biceps are weak, triceps contraction can be alternated with biceps. The active is placed over the belly of the biceps with the indifferent 2 fingerbreadths lower.

 

Wrist, finger and thumb extension

This is best achieved by stimulation of the radial nerve, which will produce a general extension pattern. It is often a problem to get good thumb extension so it is good practice to place the indifferent over the motor points of EPL and AbPL, about three fingerbreadth proximal to the wrist. 

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If thumb extension is still not good, make this electrode the active, assuming this does not significantly reduce finger and wrist extension. Care should be taken to avoid either radial or ulnar deviation of the wrist. If there is excessive ulnar deviation move the active electrode towards the extensor carpi radialis brevis on the radial side of the arm. If radial deviation occurs, move the electrode towards the ulnar side and the extensor carpi ulnaris. If finger extension is poor, perhaps due to spasticity of the finger flexors, while wrist extension is present, it is some times possible to stimulate the finger extensors alone by placing the active electrode more distally. As the extensor digitorum communis is deeper than the wrist extensors it can be difficult to achieve pure finger extension.

Lumbricals and abductor pollicis

Radial nerve stimulation is often used to reduce the tone of spastic wrist, finger and thumb flexors. However, its effectiveness can sometimes be improved by alternating it with lumbrical stimulation to produce MCP joint flexion with extension of the interphalangeal joints, producing a two phase stretch of the finger extensors. This exercise can also be effective at reducing oedema of the hand. The two groups can also be stimulated together, to improve finger extension with wrist and thumb extension. Use a long thin active electrode placed just proximal to the knuckles of the hand. A 30x50mm Pals electrode is sometimes adequate or you can cut down a 70mm round pals electrode using scissors. As the index and middle finger lumbricals are activated by the median nerve, while the others are of the ulnar nerve, make sure the electrode is over the index side. The active can be placed over the back of the wrist or often more effectively over the ulnar nerve as it enters the wrist. The later placement will bring in the adductor pollicis and other intrinsics, which is often an advantage.

Thumb Abduction and Opposition

Radial nerve stimulation can effective at opening the hand but thumb extension alone can leave the thumb in a less than functional position. Abduction and opposition can be produced by stimulating the thenar eminence. Place the active electrode over the motor point of Abductor pollicis brevis or opponens pollicis and the indifferent over the back of the wrist. To combine this movement with a general extension pattern it can be useful to use a "Y" connector. The diagram shows how the indifferent electrode lead can be shared between two electrodes, one over the extensor pollicis longus (hidden behind the arm) and the other over the abductor pollicis brevis while the common active is over the radial nerve (also hidden). Stronger abduction may be obtained, if required, by sharing the active electrode lead instead of the indifferent. However, be aware of unusual conduction paths using this method as multiple electrodes can lead to unwanted over spill to neighbouring muscles and nerves.


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Reaching

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It is often useful to combine muscles to produce a gross pattern of movement, similar to the combination movements used in every day life. In this way it may be possible to more effectively re-train function rather than by practising individual muscle activity. Such a movement is reaching where finger, thumb and wrist extension from radial nerve stimulation are combined with elbow extension and shoulder flexion by stimulation of triceps and anterior deltoid. This can be done using an Odstock 4 Channel Stimulator bringing all channels on together. If scapula stability is a problem, a 4th channel for rhomboids and lower trapezius can be added. Alternatively a 2 channel Microstim can be used combining the stimulation of triceps and anterior deltoid together as previously described.

Applications in tetraplegia

Electrical stimulation can be used to strengthen weak, partially denervated or paralysed muscles using the same electrode positions as above. Additionally it can be useful to stimulate the ulna and median nerves, thereby recruiting all the muscles in the forearm. However, it must always be born in mind that frequently some or many of the muscles may be denervated due to peripheral nerve damage at the site of the spinal lesion. These muscles will not be excitable. The stimulation wand can useful to isolate individual muscles and determine which muscles are denervated. Place the indifferent electrode behind the elbow and place the wand on the target muscles using conductive gel.

It is also possible to strengthen the tenodesis grasp of C6 lesion tetraplegics by exercise of the wrist extensors. Use a small electrode over extensor carpi radialis brevis/longus to avoid over spill to the radial nerve and therefore finger extension. The indifferent can be placed over the back of the wrist or elbow. We have also used electrical stimulation to strengthen and retrain muscles following tendon transfer. For example the posterior deltoid following transfer to the triceps for elbow extension or the brachiolradialis transferred to the extensor carpi radialis/brevis for wrist extension. In all the above cases the patient is asked to assist the effect of the stimulation, thereby re-enforcing the recruitment of the movement.

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Conclusion

This article has been a summary of the techniques used in Salisbury. While there is much evidence in the literature to justify their use, more work is required to establish clinical effectiveness. We would be very pleased to hear from you about the methods you use so we can expand our knowledge and pass on ideas to readers of the Salisbury FES Newsletter.

References

1. Chae J, Bethoux F, Bohinc T, Dobos L Davis T, Friedl A. Neuromuscular Stimulation for Upper Extremity Motor and Functional Recovery in Acute Hemiplegia. Stroke 1998; 29: 975-979

2. Chae J, Yu D. A critical review of neuromuscular electrical stimulation for treatment of motor dysfunction in hemiplegia. Asst Technol 2000; 12: 33-49

3. Baker LL, Wederich CL, McNeal DR, Newsam C, Waters RL. Functional Electrical Stimulation - a practical guide. Rancho Los Amigos Rehabilitation Engineering Centre, Rancho Los Amigos Hospital, Downey, California, USA. 4th Edition. Available from Nidd Valley Medical. Tel: (++44) (0)1423 799 113


FESnet

FESnet was official launched last November. It is a network for promoting collaboration between clinical, academic and industrial parties who are interested in FES. The net is co-ordinated by Prof. Ken Hunt of Glasgow University who has received money from EPSRC, the university funding body, to set up and run the network. As interest grows in the field there is an increasing need for communication between disciplines ensure that research is clinically relevant and efforts are not needlessly duplicated. The FESnet will be a means to find collaborative partners for projects and provide a central point for seeking advice and swapping ideas. There will also be opportunity for end users to feedback their experiences and requirements. FESnet will hold a 2 day multi disciplinary scientific meeting every second year and numerous speciality meetings to promote specific applications of FES. The First 2 day meeting will be held in Glasgow in September 2002. The group will raise the profile of FES in the clinical community and provide clinical training for biomedical engineers.

Any one can join FESnet. This can be done from their website: http.//fesnet.eng.gla.ac.uk (linked from our web site www.salisburyfes.com) or by contacting Nicola Coffield, FESnet Administrator, James Watt South Building, University of Glasgow, G12 8QQ Tel 0141 330 2468. Members will receive a newsletter and receive notice of meetings etc.


THE COMBINATION OF FES WITH TREADMILL WALKING IN SCI

Ruth Obeten, Superintendent Physiotherapist

International Spinal Injuries & Rehabilitation Centre, Royal Bucks Hospital,

Aylesbury.

 

For those of you who have never heard of ISIRC, we are a small private rehab centre, (20 beds) originally set up to treat the overflow of overseas SCI patients coming into the country in the late 70s. In those days our clientele was 100% overseas patients: these days it is more like 70:30 overseas: UK, and increasingly we are being asked to treat people with TBI, strokes and other neurological conditions. And, wherever they come from, someone is paying for them and expecting results in the shortest possible time. Over the years the average length of stay for patients not requiring surgery has been reduced from six to two months; not very long to achieve rehabilitation! The following is a short account of one approach we have used and adapted over the years to reduce length of stay whilst still achieving our overall rehab goals.

In the mid-late 80s the constant pressure to deliver results led us to try electrical stimulation as a way to kick-start/ re-educate working muscles. As muscle stimulators have become both more sophisticated and smaller, and therefore portable, we have been able to develop and expand our use of functional electrical stimulation. Ideally, all incompletes receive a daily session of stimulation on all four limbs to encourage movement, maintain muscle bulk, improve circulation, maintain muscle length and joint ROM. All tetraplegics receive stimulation to shoulders and upper limbs for the same reasons, plus the marked result that they do not seem to develop shoulder pain quite so readily as untreated patients. This is extended to encouraging hand function, often using an OB frame to allow movement in the whole upper limb including the shoulder. When we start standing para- and tetraplegics in standing frames we stimulate the trunk muscles, usually starting with the long extensors of the back and the abdominals, as this is a great aid to upright posture, and everything that goes with that, whilst boosting confidence. This particular application is also effective in enhancing the use of Walkabout calipers (our preferred orthosis for paraplegic walking) as it discourages jack-knifing and helps with balance in higher lesions. Just about all our incomplete patients start walking using a one or two channel Salisbury drop foot stimulator, often in conjunction with the treadmill. We also successfully use these with stroke, walking TBI, and MS patients. A welcome side effect of both weight-bearing and electrical stimulation is reduction in spasm; when combined and applied regularly most people experience so much lasting (carry over) reduction in spasm that they can eventually dispense with any anti-spasmodics they might be using.

We first started using a treadmill with incomplete patients in 1997. This was very hit and miss, and not very satisfactory, as we could only do it with the odd patient who was able to support themselves on the side bars! At about this time two of us attended the Salisbury FES course and discovered the joys of the one channel DFS, which we used increasingly with very satisfactory results. (This was later followed up by attending the two channel course; and recently two more physios have attended a Salisbury course.) Also at this time we were hearing the claims from Germany about Treadmill Therapy, as were our patients, who are always better informed than we are, thanks to the Internet. Like most departments we then started the long haul of persuading management that we really should have some suspension equipment to use with the treadmill, that the expense could be justified etc, and in early 1999 we became the proud owners of a Lite Gait "partial weight bearing gait therapy device". We chose the Lite Gait because a) it was less expensive than others on the market, and b) because it could be used away from the treadmill, so was more versatile than the fixed rigs. The harness was relatively easy to put on anyone. As part of our explorations we then proceeded to "treadmill" everyone, regardless of lesion level with interesting results. All patients enjoyed it, all patients felt better for it, most showed a marked improvement in upper body posture and balance and, as a result, their transfers. Incompletes who were benefiting from using DFSs benefited even more when using them on the treadmill; all of them became stronger and more confident, and four of the younger ones were able to jog quite impressively, using a two channel DFS. One was eventually able to do this for about 5 yards on the flat without any support at all.

After a period of experimentation, and trial and error, by 2000 we had established our programme of routine muscle stimulation for all SCI patients. In 2001 we were contacted by Prof. Brian Andrews who was looking for subjects to try out his rowing machine using FES, via the Salisbury four channel stimulator. The routine training of the quads and hamstrings necessary for this showed us just what could be achieved in the way of moving paralysed legs, and as part of our innovative approach we were keen to explore and apply the technique for use with the treadmill. We found if we stimulated opposite quads and hamstrings alternately, the cycle fired by a hand switch operated either by the physios, or the patient if they were able, and with carbon fibre AFOs to stop the toes dragging, we achieved passable walking. It required minimum guiding effort from the physios (which was a great relief) and patients could keep going until their muscles fatigued. This length of time increases with practice and most can manage 20+ minutes. We have successfully tried coupling in another 4Ch stimulator to bring in dorsi flexors and glutes to even better effect, and even less effort from the physios. Recently we have changed the electrode placements to use the common peroneal nerve to activate hamstrings and dorsiflexors together, eliminating the need for the second 4CH stimulator. At the moment were working to develop a perfect return mechanism to replace the physios initial placing of the foot for each step. With incompletes this is easily done by tying their ankle to the front of the treadmill with a length of black Theraband (very high tech.), but so far we havent managed to get it right for the completes.

In charting our approach to using, applying and modifying techniques and therapies for our patients one has to state the obvious that we are not a research centre. However, new therapies/ treatments are researched by our team, and when we start using a treatment we work systematically, consult any available literature, and monitor the situations. We normally go through a period of exploration and observation before we begin a period of sustained practice and monitoring. This provides us with a robust practice-base from which we can work, continue to modify/ improve our procedures and techniques and best support patients and staff.

I'm often asked by fellow professionals why we are bothering with complete SCIs, as electrically stimulated walking on a treadmill is hardly functional, so should we be wasting time with it. We do it because its important for us to see what can be achieved with relatively simple equipment, and because without exception the patients enjoy it and feel they are benefiting, tying in with our philosophy and commitment to treating the whole patient. And of course happy patients make for happy sponsors. All patients show marked improvement in upper body posture, along with better sitting, transfers and wheelchair management. They report a general feeling of well-being that lasts several days, marked reduction in spasm, not just in the legs, reduction in swelling, and obvious increased circulation, in that legs in particular feel warmer. Not a bad result from half an hours activity.

Obviously, the next stage is to develop a research programme to help set up an evidence-base that will enable other practitioners to learn from the techniques, and for patients to have available alternative therapies that can bring real benefits to their lives. In the meantime our team here will continue to attempt to push back the boundaries by using established methods and techniques imaginatively.

 

Ruth Obeten MCSP SRP


Courses

Before clinicians can prescribe the ODFS or O2CHS for their patients, they must attend a course. This is mandatory. The course tutors are experienced both in the clinical provision of FES and also in its research.

 

Introductory Courses

The introductory course gives an introduction to FES and its application in neurorehabilitation. The course, which has a large practical content, is intended to enable clinicians to select candidates for the ODFS and to independently set the device up.

22nd & 23rd (Fri/Sat) February 2002 Weston Super-Mare. Contact Ms Fiona Henchie, Quantock Rehabilitation Unit, Weston General Hospital, Flange Road, Weston-Super-Mare, BS23 4TQ Tel 01934 647 164

28th & 29th (Thur/Fri) February 2002 London. Contact Ms Jo Keen, Physio, Frank Cooksey Rehab Unit, Mapother House, De Crespigny Park, London SE5 8AZ Tel 0207 346 5334

April 2002 (to be confirmed) Glasgow. Contact Paula Cowman, MS Therapy Centre, Unit 16, Chappell Street Industrial Estate, Mary Hill, Glasgow, G20 8BD

16th & 17th (Thu/Fri) MAY 2002 Salford. Contact Silvia Moss, Community Neurology team, MDT Office, Seymour Unit, Trafford General Hospital, More Side Road, Dairyhouse Road, Manchester. M41 5SL Tel/Fax 0161 746 2105

 

Other courses are planned for Falkirk and Reading but no dates are available yet.

2 Channel Courses

This course is for clinicians that have some experience of the ODFS and introduces the O2CHS.

20th & 21st June 2002 Salisbury. Contact Alison Leighfield Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ Tel. 01722 429065 Fax. 01722 425263

FES in hemiplegic upper limb

A new course which will cover the use of electrical stimulation to improve function and reduce spasticity. In the hand arm and shoulder of hemiplegics. The theory and evidence will be reviewed as well providing opportunity for practising practical applications.

7th September 2002, Salisbury Contact Alison Leighfield Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ Tel. 01722 429065 Fax. 01722 425263

ODFS Refresher course

It is suggested that we run a one day refresher course for people who have been trained in the use of the ODFS but not had the opportunity to consolidate there skills with experience. The course will cover the practical issues of using and setting up the device and provide practice with patients. We have not set a date for this course but if anyone would be interested or would like us to come and do a course at your hospital, please contact us.

If you would like a course to be held at your own hospital, please contact Alison Leighfield Tel. 01722 429065 Fax. 01722 425263 or e-mail p.taylor@salisburyfes.com

 




FES User Day Abstracts

November 30th 2001

Functional Electrical Stimulation augmented treadmill training for incomplete spinal cord injured patients - A pilot study.

 

Neil Postans

Research Fellow, Bioengineering Unit, University Of Strathclyde, Glasgow, G4 0NW.

 

Introduction

The main barrier to early gait training of the incomplete spinal cord injured patient is the inability of the patient to stand or walk independently. Both Partial Weight Bearing Support (PWBS) treadmill walking and Functional Electrical Stimulation (FES) have been proven to be effective in the rehabilitation of this patient group. This project aims to explore the combination of FES with PWBS treadmill gait training, eliminating the need for therapists to physically assist with the stepping of the swing leg by using FES to produce limb flexion and foot placement. We aim to use FES techniques to activate the patients weak or paralysed muscles to provide swing limb assistance. If the approach of PWBS treadmill gait training augmented with FES proves successful this will represent a substantial increase in the amount of gait re-education received by the incomplete SCI patient during their in-patient stay.

Study Design

Due to the non-homogenous nature of the patient group a single case experimental design is indicated. Single case designs are particularly suited to this patient group as, although all patients will have incomplete SCI, the exact nature of the impairment and the resulting disability can vary widely between individual patients. Each patient will undergo a control period (standard therapy) and an intervention period (combination therapy), each lasting four weeks. Patients will be randomly assigned to either an AB (control - intervention) or BA (intervention - control) sequence. During the control period patients will receive their normal physiotherapy routine. The intervention period will be based on the combination therapy of PWBS treadmill training with FES. The patient will be supported over the treadmill by means of a harness and the percentage of body weight support required will be recorded. Patients will receive one hour per day of combination therapy for five days per week during the intervention period.

 

Subject Recruitment

To meet recruitment criteria patients must have an incomplete lesion with some motor function below the level of the lesion. They will be either non-ambulatory or have significant walking dysfunction. Intervention will begin as soon as the patient is medically stable and can be stood without medical complications. Patients with potentially unstable fractures will not be treated until they receive medical clearance to use the harness support system. The control and treatment interventions will be repeated on 15 patients identified over a 12 month period.

 

Outcome Measures

Assessments will take place prior to the first randomly assigned period (control or intervention) and in the final week of each control and intervention period. Outcome measures include temporal and spatial parameters of gait, observational gait analysis, walking endurance, manual muscle testing, Ashworth scale and joint range of motion. Note that depending upon the patients ability it may not be possible to conduct all the tests at each assessment interval (e.g. walking tests in non ambulant patients).

 




 

Central Pattern Generators. Relevance to FES and a Clinical Example.

 

Jonathan Norton, Duncan Wood, Brian Day and Jon Marsden.

MRC Human Movement Group, Sobell Department of Neurophysiology, Institute of Neurology, University College London, London.

Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury.

 

Central Pattern Generators, CPGs, are networks of subcortical cells that produce a rhythmical, (in its broadest sense) output. We believe that these networks are important in the rehabilitation of the lower limb following Upper Motor Neuron lesions. FES may offer a particularly good approach to retraining these networks. The benefits of FES over conventional physiotherapy may lie in several areas;

A robust analytical technique, Coherence analysis, will be presented which may allow the examination of CPG training using surface EMG measurements. We suggest that strong coherence between muscles at frequencies other than 20Hz is suggestive of an origin for the activity that may be spinal in origin. Increases in strengths of coherence and across frequencies may represent an improved training of these circuits.

We have examined one patient with a complete spinal lesion who experiences regular, apparently unprovoked spasms. Coherence analysis suggests a common origin for some components of the spasms, which we suggest originate in a central pattern generator. If true then this suggests that care will be needed in CPG training to avoid training inappropriate CPGs. Inappropriate training may lead to increases in spasticity.

We wish to thank our patient, Carol McFadden for physiotherapeutic assistance, Dr Nick Donaldson and Mr Tim Perkins for assistance with the experiments and the MRC and UCL Graduate School for funding. Some of this work has been submitted to the Journal of Neurology, Neurosurgery and Psychiatry.

 




 

Changes in weight bearing on the contra lateral side following use of the ODFS, a case study

Van Vaerenbergh Jo

Briers Lucia

Research Assistant

Physiotherapist

Faculty of Physical Education and Physiotherapy

Centre for Movement Analysis and Therapy

Katholieke Universiteit Leuven

R.Reniersstraat 11

Tervuursevest 101

B-1090 Brussels

B-3001 Leuven

 

 

 

A 59-year-old secretary was diagnosed with multiple sclerosis (MS) in 1971 when she presented with neuritis retrobulbaris. At that time she noted some weakness in both legs, but recovered completely. Ten years later walking became more difficult and she developed a progressive form of MS characterised by a slow downhill course without remissions.

 

Now her gait is unsteady and slow. Muscle testing shows paretic lower limbs with some brisk tendon reflexes. There is a left drop foot with a shortened tendon of Achilles. The right foot is weak, but has a good mobility.

In the present case study we attempted to determine the influence of Functional Electric Stimulation (FES) of the left common peroneal nerve on the duration of single (SLS) and double leg stance (DLS), foot flat (FF), midstance (M), active (AP) and passive propulsion (PP) of both feet. The F-Scan (Tekscan) pressure and time assessment system was used. Ultra-thin insole sensors made up of 960 individual pressure-sensing locations were placed in the shoes of the subject. A shielded cable sent the information to the interface board in the computer.

An improved left foot lift resulted in a longer SLS (+ 9.2%) at the contra lateral side and reduced DLS (- 5.6%) without changing the cadence. The duration of the AP was increased (57%), whereas the peak pressure decreased with 10% during this phase .

 

Extending the stimulation to early weight bearing on the left foot prolonged the FF nine fold and the M with 18%. Propulsion time decreased dramatically (300%) during which a lower peak pressure (-39%) was reached.

The patient sensed these changes as a better stability during walking. We are convinced that FES not only plays a role in normalising the swing phase of the stimulated limb but also alters spectacularly the roll off of the collateral foot.

 

The F-Scan system is a valuable instrument to tune the FES to the patients appropriateness.



A case history of the use of the ODFS in MS

Christine Singleton

Clinical Specialist (FES), Sheldon Centre, City Hospital, Dudley Road, Birmingham

History - Patient is a 61 year old divorced lady diagnosed with MS in 1970. She works as a freelance journalist and enjoys frequent holiday breaks within the UK. In 1993 the patient received Physio treatment for low back pain. She was independently mobile but had reduced right knee control and dragging of the right leg when walking. She had a flexed standing/walking posture and double crossed her legs for stability when sitting. Re-education of posture and gait was helpful. In 1994 her MS condition deteriorated. She had a slow gait and needed a stick for balance. Support for her right knee hyperextension was not successful.

In Feb. 1996 she was assessed for FES and fitted with an ODFS II for her right leg in April. Recordings showed 35% increase in walking speed and 103% decrease in PCI. Settings - normal electrode position initially using 1.25 and then subsequently 2inch electrodes, a one-piece foot switch positioned on left heel triggering on heel strike, low power, output level 4, zero rising ramp and slight falling ramp.

June 1996 the patient reported an increase in walking confidence, walking distance and exercise tolerance. Her walking speed without stimulation equalled her original walking speed with stimulation. She did not have any back pain and right hyperextension was controlled. By December 1996 she had become dependent on the ODFS due to the substantial difference it made with mobility. In early 1997 she had a sustained period of deterioration and by May had stopped driving. In July she developed a skin reaction which was resolved using biphasic waveform and hyperallergenic electrodes. By October she was using a wheelchair for long distances.

Throughout 1997-8 she experienced a catalogue of problems with unreliable footswitches which was distressing for her due to her dependence on the ODFS. She has not experienced problems with the new footswitches. In November 1998 she was using a frame to mobilise. In April 1999 we changed the parameter to high power on output 3 and by October 1999 she had moved to sheltered accommodation. Her MS stabilised for the next two years but in June 2001 she unfortunately had a left mastectomy for Ca breast.

By November she had recovered well without the need for chemo or radiotherapy. Her MS is relatively stable although outcome measures show a deterioration in function since initial assessment of 281% reduction in speed and 352% increase in PCI. She is however very positive and determined. She continues to work and lives life to the full despite her disabilities. FES treatment is ongoing with annual reviews.

PCI -

NoStim

0.67

0.5

1.1

1.83

1.18

1.7

2.46

2.8

1.28

3.03

PCI - Stim

0.33

0.45

0.55

0.54

0.47

1.1

1.38

1.65

1.25

1.68

WS(m/sec) NoStim

0.42

0.57

0.32

0.12

0.17

0.16

0.1

0.1

0.12

0.1

WS(m/sec)Stim

0.57

0.63

0.48

0.4

0.32

0.28

0.2

0.2

0.2

0.2



Feb

1996

June

1996

Oct

1996

April

1997

Oct

1997

May

1998

Nov

1998

Oct

1999

May

2000

Nov

2001

 


Correction of dropped foot following multiple sclerosis by functional electrical stimulation, an

audit of walking speed and physiological cost index

 

P Taylor, C Singleton* P Wright, G Mann, C Johnson, I Swain

 

Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ, UK.

*Neurophysiotherapy Department, City Hospital, Dudley Road, Birmingham. B18 7QH. UK

 

Introduction

The Odstock Dropped Foot Stimulator (ODFS) is a single channel, foot switch triggered stimulator designed to elicit dorsiflexion of the foot by stimulation of the common peroneal nerve. Skin-surface electrodes are placed, typically, over the common peroneal nerve as it passes over the head of the fibula bone and the motor point of tibialis anterior. Following recommendation by the South and West Regional Health Authority Development and Evaluation Committee, a clinical service was set up in Salisbury and Birmingham. This paper is an audit of that service to people who have Multiple Sclerosis.

Methods

The ODFS is fitted over two clinic sessions on consecutive days. On the fist day the user is taught how to apply the device while on the second day there ability to do so is assessed and further training given if necessary. Additionally their performance with the device is also assessed by measurement of walking speed and physiological cost index. Follow up is made at 6 weeks, 18 weeks, 45 weeks and 73 weeks from first use and then yearly for as long as the device is used. This paper examines data recorded at the initial, 18, 45 and 73 week assessments.

Subject selection

The audit contains all subjects who were referred to the Department of Medical Physics and Biomedical Engineering, Salisbury or the Neurophysiotherapy Department, City Hospital for correction of unilateral dropped foot due to MS between January 1997 and July 1999. Patients were referred by a medical Consultant or general practitioner.

Assessments

Assessment was by Walking speed both with and without the ODFS over 10m and Physiological Cost Index (PCI).

Results over 18 weeks

In the audit period, 145 MS patients who fitted the audit criteria began treatment. Of these, 46 had insufficient data recorded although they were known to be continuing using the device. This may have been due to missed appointments, problems with equipment or administrative problems. Of the remaining 99, 14 changed to use of a 2 channel device for correction of bi-lateral dropped foot within the first 18 weeks of treatment. Seven patients discontinued use of FES before 18 weeks. Two stopped because they did not like the use of the device while two did not receive sufficient help from the device. The final three users discontinued because their condition deteriorated as their disease progressed.

Table 1 gives walking speed and PCI results for the remaining 78 patients (average age and time since diagnosis, 51 years and 12 years), expressed in percentage changes with p values calculated using the Wilcoxon signed rank test. Results show a statistically significant improvement in both walking speed and PCI when the ODFS is used at the first assessment that is increased at 18 weeks. No significant changes were seen in these parameters when the device was not used indicating that while no training effect was observed, mobility had been maintained over this period.

 

Table 1. Mean percentage change in walking speed and PCI at 0 and 18 weeks, with and without the stimulator. N=78



Speed %

p-val

PCI %

p-val

NS 0W v S 18W

Total orthotic effect

20.3

P< 0.001

-7.1

P< 0.01

NS 0W v S 0W

Initial orthotic effect

12.1

P< 0.001

-13.1

P< 0.001

NS 0W v NS 18W

Training effect

2.7

P=0.267

8.4

P=0.489

NS 18W v S 18W

Continuing orthotic effect

19.3

P< 0.001

-12.3

P< 0.001

Key: NS - No Stimulation, S - With Stimulation, W - Weeks

 

Results over 72 weeks

Of the above group, 49 patients had begun treatment earlier enough to be still using the ODFS after 72 weeks. However, 8 patients had missing data for one or more of the assessments (but were know to be continuing to use the ODFS) while 3 patients were lost to follow up. Also not included in the following data are 4 subjects who progressed to using a bilateral dropped foot stimulator and 6 subjects who entered a separate research project. Eight patients discontinued treatment between 18 and 72 weeks, six because their general condition deteriorated due to MS while one stopped due to increased calf tone and the other due to non-related medical complications.

The results are shown graphical form in figure 1. Similar changes are seen in this sub group as the 78 ODFS users followed over 18 weeks in the same period. Performance is maintained at the 45 week assessment and at 72 weeks in terms of speed, while there is a statistical significant rise in PCI at the 72 week assessment both with and without the ODFS. However, at 72 weeks users still received a significant orthotic benefit from using the device and their walking speed with the device was higher than that measured without the device at the first assessment.

Discussion and conclusion

As MS is a progressive disease, proceeding at different rates in individuals and subject to periods of relapse and remission, it is difficult to conclude definitive answers from an audit such as this. The large number of missing data samples is to be regretted and it can not be ruled out that this may not have skewed the result. Exclusion of those patients who went on to use a bilateral dropped foot stimulator may also have an affect as these patients condition presumably had deteriorated at a greater degree than ODFS users. However, use of the ODFS gave consistent improvements in walking speed and PCI, providing practical benefit to its users. The relatively high compliance rate of 91% at 18 weeks and 83% at one year indicates that the ODFS was well accepted by its users.

While no overall carryover effect was seen, 24 (31%) of those followed to 18 weeks, did have an improvement in walking speed when not using the ODFS of more than 10%. This suggests that while the disease state is steady, a training benefit can be obtained from use of the devices. Without comparison with a control group, it can not be determined if use of the device had any influence on the decline of unassisted mobility. However, there was no statistical significant fall in unassisted walking speed over the 78 week period and walking with the device was faster than unassisted gait at the initial assessment.

 

At the user day there was some discussion about why a carryover effect is seen in most stroke ODFS users and not in most MS ODFS users. It was suggested by Jo Van Vaerenbergh, Jonathan Norton and Paul Taylor that as demyelination may occur in the spinal cord, this may effect the training of pattern generators in the cord, an effect that would not be seen in stroke ODFS users.

References

1Burridge J, Taylor P, Hagan S, Swain I. Experience of clinical use of the Odstock Dropped Foot Stimulator. Artificial Organs. 1997. 21(3). 254-260.

2) Burridge J, Taylor P, Hagan S, Wood D, Swain I. The effects of common peroneal nerve stimulation on the effort and speed of walking: A randomised controlled clinical trial with chronic hemiplegic patients. Clinical Rehabilitation. 1997. 11. 201-210.

3) Burridge J, Taylor P, Hagan SA, Wood DE, Swain ID. The effect on the spasticity of the quadriceps muscles of stimulation of the Common Peroneal nerve of chronic hemiplegic subjects during walking. Physiotherapy vol. 83, no 2 1997

4) Taylor PN, Burridge JH, Wood DE, Norton J, Dunkerly A, Singleton, C, Swain ID. Clinical use of the Odstock Drop Foot Stimulator - its effect on the speed and effort of walking. Archives of Physical Medicine and Rehabilitation, 80: 1577-1583, 1999.Taylor PN, Burridge JH, Wood DE, Norton J,

5) Dunkerly A, Singleton, C, Swain ID. Patient perceptions of the Odstock Drop Foot Stimulator. Clinical Rehabilitation,13: 333-340, 1999.

6) "Clinical Guidelines on Stroke" Royal College of Physicians

7) Bailey M, Ratcliffe C. Reliability of Physiological Cost Index in walking normal subjects using steady-state and non-steady-state and post-exercise. Physiotherapy. 1995. 81(10). 618-623.

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An investigation into the effects of Functional Electrical Stimulation
to assist the gait of children with Cerebral Palsy

Christopher Stevens

Project investigators Sally Durham, Queen Marys Hospital, London; Linda Eve, Guys Hospital, London; David Ewins and Christopher Stevens, University of Surrey, Guildford.

1. Introduction

One of the current problems in paediatrics is that of toe gait in children with cerebral palsy (CP). What is toe walking? In normal walking the heel hits the ground first, followed by the toes. The time interval between these two events is called the heel toe interval and is a good measure of how "normal" the walking pattern is. In toe walking the toe hits the ground before the heel - as is seen in toddlers. In the short term toe gait means that the child is unstable and so tends to fall more frequently, with resulting risk of injury. In the longer term we often see increasing asymmetry, as usually one leg is more affected than the other. This can give rise to fixed deformities, which in turn can lead to further disability.

Current treatment methods, such as splinting and surgery have mixed results. This study is one of a number planned to investigate the efficacy of FES to assist the gait of children. Key questions we are trying to address include: is FES helpful to children with CP toe gait? Or is it only helpful to some? If so, for which children may it be helpful? If it is helpful, which approach is best? How can these be assessed? Earlier research suggests that stimulating tibialis anterior and triceps surae are useful. However it is not clear which should be the treatment method of choice. Previous studies give limited information because they have involved either: very low numbers of participants, limited outcome measures, short periods of treatment, low treatment intensity, little or no use in everyday activities, manual triggering of the stimulation, or they were confounded by the use of extra treatments.

2. Present Study

In this study we used: an ABA approach, each phase lasting 3 months, with stimulation of tibialis anterior only, sufficient subjects for a statistical analysis, kinematic, kinetic, energy consumption, and clinical measures, extended stimulation in everyday activities, automatic triggering to allow a more natural use of the stimulator, and a continuance of existing physiotherapeutic treatments. A questionnaire to measure the effects of intervention from users and helpers perspective was also used.

Preliminary Results

In general, stimulation was found to make walking more symmetrical as measured by the heel toe interval. Children walked faster and were more efficient in the use of energy.

In their responses to the questionnaire they reported less falling and fatigue. However some reported dissatisfaction with the size of the equipment and the need for wires.

Work in progress

Completing the processing of data and statistical analysis.

Improving data processing methods.

3. Future work

Carrying out a similar study on triceps surae stimulation. Further ahead, perhaps evaluating usefulness of two channel stimulation of both tibialis anterior and triceps surae. In parallel with the clinical work, improving the stimulation equipment to make it less bulky and intrusive and improving the sensors.

4. Acknowledgements

This study was made possible by funding from: Remedi, South West London Community Health Care Trust, University of Surrey, Engineering and Physical Sciences Research Council. With thanks to: Faye Bater for help with measurements; the children, their parents and carers. 

User Day Discussion

The meeting was asked to consider four questions:

Lack of time to develop a new speciality was highlighted as a problem and also a lack of financial resources. It was felt that there was a lack of awareness amongst clinical and managerial colleagues of what could be achieved with FES. This could be improved by greater dissemination of clinical evidence for the techniques and it was felt that more evidence was required for its use in acute and upper limb in stroke. It was suggested that in areas where there is a large variation in patient presentation, there is a need for collection of case series data. This is something that could be done by all clinicians. Clinical guidelines for FES treatments should be produced and circulated.

It was suggested that the traditional 10 metre walk was inadequate for some patients, particularly those that exhibit fatigue after walking a few 10's of metres. It was therefore suggested that recording the distance walked in 6 minutes might better illustrate the advantage of using the ODFS in these cases. Activity monitors could be used to show increases in mobility and this could also be shown using questionnaires. A greater use of gait analysis was desired, looking at parameters such as hip stability, base of gait and stride length. Where gait analyse was not available, Observational Gait Analysis could be used which scores the gait from analysing video recordings of gait. Falls diaries were suggested to illustrate that gait was safer and SF36 was recommended as a well validate quality of life measure.

It was suggested that a training course / workshop specific to upper limb applications be provided. A workshop on paediatric applications was also suggested. It was also thought a video or CD-ROM to illustrate the benefit from using FES devices would be useful, particularly for convincing managers!

Christine Singleton recommended the use of 50mm round electrodes for common peroneal stimulation in adults as she felt patients experienced fewer problems with electrode location than with the smaller 38mm electrodes. Larger electrodes can also be useful to reduce the sensation from the stimulation because the current density is reduced. Another participant said she always used 50x50 mm Blue Pals electrodes and had never had skin allergy problems. It is useful to have a range of electrodes available so the best solution can be found for individual patients


FES service in Hong Kong

Kai-yu Tong, Ph.D.,

Rehabilitation Engineering Clinic, Jockey Club rehabilitation Engineering Centre, The Hong Kong Polytechnic University.

Phone: (+852) 2766 7683 Fax : (+852) 2362 4365 Email : rctong@inet.polyu.edu.hk

FES Web site: http://www.polyu.edu.hk/rec/fes

 

The Rehabilitation Engineering Clinic (REClinic) in the Hong Kong Polytechnic University is the first clinic to provide a continuous service and expertise advice to Functional Electrical Stimulation (FES) users in Hong Kong. This clinic provides FES consultations and services for patient with drop-foot after diseases or injuries such as stroke and incomplete spinal cord injuries. One-year follow up period will be arranged to each FES user to monitor their progress in every few months. According to Mortality and Morbidity Statistics (Hospital Authority, HK) in 1999, about 25,000 people were suffered from stroke in HK and admitted to the hospital.

A portable and user-friendly FES system (ODFS) is used to restore the function of paralysed muscles to prevent drop-foot during walking. This gives an alternative solution for our patients to improve their walking ability. The whole system is so small and convenient to use at home and in outdoor environment, which help the users to resume their normal daily activities. If the user is suitable for using FES, he can try the FES system in his first visit and be able to walk with the system in half an hour time. The patient also could choose to rent the system home for practice immediately. Maintenance service is included in the first year of our FES programme.

 

Careful application, support and training of users using these devices are important. Two phases are proposed in our clinic: Trial Period and Application Period.

 

1. Trial Period

The first two weeks will be used as a trial period to evaluate the patient whether he/she is suitable to use FES system. Three sessions will be arranged in two-week time to help users to set up the whole system and to ensure that they can operate it effectively. FES system will be practised at home initially for half an hour and then gradually increase the duration.

 

2. Application Period

The user will be evaluated after the trial period to determine whether he/she is suitable to use FES. Then user will have his/her own stimulator and practice the system both at home and outdoors environment. The system can be used all day as an orthotic aid or as a training aid in gait re-education. The frequent of using this device depends on the adaptation of the FES system and the physical condition of the user. The users progress will be monitored closely and follow-up sessions are required (refer to the figure below). In every follow-up session, users will be evaluated using gait parameters and pendulum spasticity test.

 

image

 

From Jan 2001 to Dec 2001, REClinic has served 95 stroke patients (40 females; 55 males) with FES services and the age range is from 9 to 89. After first visit, 59% of patients have taken FES back home for practice. Based on the results from our FES users, therapeutic benefits have been found, increasing their walking speed and increasing their confidence by making a bigger walking step. The patient has a trial period for two weeks before they decide to buy the FES system and the related consultation services.

 

Sometimes problems are experienced by patients when placing the electrodes, they found that it was difficult to identify the electrode position based on the anatomical landmark. Therefore in the trial period, we used an indelible pen to mark the locations. In the application period, an "electrode placement locator", which was made of thermoplastics (Orfit Micro), was used to model the shape of the shank and then two holes were cut for the electrode placement (refer to the figure below). The user just need to use this locator when they forgot the placement and the locator would be taken off after the electrodes was attached on the correct position. The patients found this locator was useful and made them feel more confident with the FES system.



image

In the near future development, our FES service will be extended to upper extremity impairment. (e.g. hand, shoulder, etc)


 

A BIG THANK YOU FROM BIRMINGHAM

You may like to know that 40% of the questionnaires sent to many of you before Xmas have been returned. A BIG thank you to all those who have given their attention to this valued survey. The information gathered will inform Salisbury & Birmingham about FES service provisions in place nationally and barriers encountered in trying to set up FES services. It is not too late to complete your questionnaire and a reminder has been sent to help increase the return rate. A final second reminder will be sent in February. As indicated in my introduction letter, I intend to publish the results when my dissertation is completed later this year. Who knows, I may even get my Masters!!

I am acutely embarrassed about the numerical & spelling mistake in the questionnaire. I recently came upon this quotation which partly explains & amuses!

"To err is human, but to really foul things up requires a computer"

Anonymous

Sincere thanks.

Christine Singleton


Autonomic Effects of electrical stimulation

Autonomic dysreflexia is a known complication of electrical stimulation of muscles in patients who have a spinal cord lesion above T6. The main symptom is a rise in blood pressure in response to stimulation, which will quickly fall once the stimulation stops. The same effect has never been reported in people who have had a stroke and we have not experienced it in Salisbury. However we have received an anecdotal report of an ODFS user (cerebral haemorrhage) who complained of headaches following use of the device and it is believed that this may have been due to increased blood pressure. The patient had a history of hypertension in relation to exercise stress. While this is a rare case, we recommend that where there is a history of poorly controlled hypertension, blood pressure should be monitored at the initial trial of the device.

 

Please let us know if you experience any adverse or unexpected effects from using Salisbury FES equipment. We will always pass on any problems via this newsletter.

Paul Taylor


 

Supply of FES Equipment

It has always been our policy that we only supply FES equipment to people who have been trained its use. We therefore always ask for the name of the clinician who has been trained when we receive and order for equipment. Where patients our buying the equipment privately (but using it under the supervision of a trained clinician) we have until now been happy to receive payment directly from them. However, for contractual reasons and following advice from our finance department we now ask that all payments should be made through the clinician or department involved. Of course, the patient can reimburse the clinician or department. This will bring us in to line with the normal procedure for supply of orthotic devices in most NHS hospitals. I apologise for any inconvenience this may course. Please contact us if you have any specific problems.

Paul Taylor




FES Equipment Order Form

Name of supervising clinician or therapist

that has attended the Salisbury FES course:________________________________________

 

Name & address to send the equipment to: ________________________________________

___________________________________________________________________________

___________________________________________________________________________

 

Name & address to send the invoice to: ___________________________________________

___________________________________________________________________________

___________________________________________________________________________

 

Contact phone number for queries with this order: __________________________________

 

Code Items Number required

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

Stimulators can be supplied with electrodes, electrode and foot switch lead lengths and shoe inner sole size of your choice. Please specify your requirements.

Please send order to:

Mr Stacey Finn, Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ. UK

Fax: 01722 425 263, Tel: 01722 429 118, E-mail: s.finn@salisburyfes.com

 






 

ONE DAY WORKSHOP

Upper and Lower Limb Electrical Stimulation in Paediatrics

To be held at Queen Mary's Hospital, Roehampton, London

Thursday, 13th June 2002, 10:30am to 5pm

 

The aim of the workshop is to promote discussion and the exchange of ideas in an informal setting. The workshop will review the evidence to support the use of electrical stimulation in paediatrics, report on current research and clinical techniques, and present case studies.

 

We would be very pleased to receive presentations from attendees. Presentations should be of 20 minutes duration and may be on any aspect of the clinical application of electrical stimulation. This includes original research, clinical experience or case studies.

 

Please provide a 300-500 word abstract (on disc or through email).

PowerPoint, slides, OHP and video will be available for your use.

 

The cost of the meeting will be £30. Please make cheques payable to: South West London Community NHS Trust.

 

Please complete the slip below and return it, together with payment, to:

 

Mrs Sally Durham or Dr David Ewins

Gait Laboratory

Roehampton Rehabilitation Centre

Queen Marys Hospital, Roehampton

London SW15 5PN

 

Telephone: 020 8355 2175

Fax: 020 8355 2952

email: gaitlab@swlct.sthames.nhs.uk

 

************************************************************************

Upper and Lower Limb Electrical Stimulation in Paediatrics, 13th June 2002

 

 

 

 

Name

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

 

 

I will attend the Workshop

Yes / No

I wish to give a presentation

Yes / No

 

 

 

 

Title of presentation

 

 

 

 

 

 

 

 

 

 

 

 






 

Service provision

The Clinic in Salisbury receives enquiries every day from people who want to receive FES treatment in their home area. While we try and help them by providing what information we can are hands are tied by the Data Protection Act, preventing us from releasing the names of people who have received FES training. Additionally, many trained clinicians are not in a position to receive referrals. We therefore need to produce a directory of clinicians who are willing to receive referrals and for their details to be passes on. The information will be used for the sole purpose of connecting potential clients with FES trained clinicians. However, if desired, we can add information to our web page so clinicians can be contacted directly. Please fill out and return the form below.

 

Name: __________________________________________________________

Work Address: ___________________________________________________

________________________________________________________________

________________________________________________________________

Tel: _______________________________________

Fax: _______________________________________

E-mail: ___________________________________________

Web page: _________________________________________

I am able to receive referrals for the Odstock Dropped Foot Stimulator Y / N

The service is NHS funded Y / N

The service is privately funded Y / N

Please add my details to the directory Y / N

Please add my details to the web page Y / N

 

Signed ___________________________________________________

Date ___________________

 

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