Functional Electrical Stimulation

Front 1

What are 8 goals for Functional Electrical Stimulation (FES)

Back 1

1) Muscle reeducation

2) Address disuse atrophy

3) Address impaired ROM

4) Decrease muscle spasm

5) Manage spasticity

6) Act as an alternative for or a supplementto orthotics

7) Maintain postural alignment untilrecovery occurs

8)The above are examples of impairments

Front 2

What is FES used for?

Back 2

Functional Electrical Stimulation - to facilitate or improve purposeful movement

Front 3

What does FES functional do?

Back 3

Produces functional useful movement

Front 4

FES think ____ ___ function?

Back 4

Long Term

Front 5

What are the two motor control theories

Back 5

1) Sensorimotor integration theory

2) Dynamical systems theory

Front 6

NOTE

Back 6

Some therapists will refer to FES as a type of NMES. Others will refer to FES and NMES as subcategories of EMS

Front 7

What type of level of electrical stimulation is used for FES?

Back 7

Low

Front 8

What is low level electrical stimulation used for?

Back 8

Enhance functional ability

Front 9

How is Russian different from FES

Back 9

Russian is used for strength

FES is used for function

Front 10

Examples of conditions FES used for

Back 10

-Upper extremity & hand function in CVA & SCI patients.

-Controlling the lower extremity in CVA & SCI patients for drop foot, locomotion, standing.

-Scoliosis.

-Reducing Spasticity.

Front 11

The sensorimotor integration theory primary bas the building blocks of the CNS is?

Back 11

Senses

Front 12

What are the 3 special senses of the sensorimotor integration theory.

Back 12

1) Vestibular

2) Tactile

3) proprioception

Front 13

All other skills are complex processes base on what strong foundation?

Back 13

Sensory integration

Front 14

What is theory changes over time?

Back 14

Dynamical System theory

Front 15

Developing organism are ?

Back 15

Multidimensional

Front 16

How does movement develop?

Back 16

Result of many subsystems

Front 17

Movement change from one form to another W/O ____ ______ states?

Back 17

Stable intermediate states

Front 18

What do therapist attempt to influence?

Back 18

Movement patterns

Front 19

What are 5 body dysfunctions conditions that FES is used for?

Back 19

1) Disuse atrophy

2) impaired ROM

3) muscle spasm

4) muscle reeducation

5) spasticity management

Front 20

What are two other names that FES is also called?

Back 20

1) Neuromuscular electrical stimulation

2) functional neuromuscular electrical stimulation

Front 21

What does this lecture focus FES used for?

Back 21

Orthotic devices

Front 22

5 Most common patient conditions for Tx W/ FES

Back 22

1) Spinal Cord Injury

2) CVA (stroke)

3) Multiple Sclerosis

4) Cerebral Palsy

5) Traumatic brain injury

Front 23

3 Main problems FES is used for?

Back 23

1) Shoulder subluxation due to CVA

2) Dorsiflexion assist in gait training

3) Gait protocol

Front 24

5 Indications for FES

Back 24

1) Orthotic substitution

2) Bracing in idiopathic scoliosis

3) Gait re-education

4) UMN/LMN to assist with impaired bodyfunction

5) Shoulder subluxation due to flaccidparalysis s/p CVA

Front 25

1-5 Containdications

Back 25

1) Where active motion is contraindicated

2) Over metal implants

3) Malignancies

4) First trimester of pregnancy

5) Over anesthetic skin whenever possible

Front 26

6-8 contrandications

Back 26

6) Extreme edema

7) Thick scarring or adipose tissue

8) Over laryngeal or pharyngeal muscles or carotid sinus

Front 27

9-13 contraindications

Back 27

9. Avoid open wounds & active bleeding

10. Disoriented pts (pts should be able to provide feedback)

11. Avoid areas of PVD such as DVT

12. Do not use W/ pts who have uncontrolled hyper/hypotension

13. Do not use in regions of pacemakers, spinal cord simulators, near the bladders or phrenic nerve

Front 28

Shoulder Subluxation are associated with what type of patient

Back 28

Cerebrovascular accident - CVA

Front 29

Shoulder subluxation may cause what to the muscles supporting the glenohumeral joint

Back 29

weakness or flaccid paralysis

Front 30

What two muscles are most affected with shoulder subluxation

Back 30

1) Supraspinatus

2) Posterior Deltoid

Front 31

FES wave form:

Asymmetrical Biphasic square-

Back 31

Half the amplitude then twice the duration

-Rectangular

Balance, have to have the same amount of charge below the isometric line & above

Front 32

What does the force of gravity do on the upper extremity with a CVA?

Back 32

Stretch the ligamentous structures surrounding the GH joint.

Front 33

What does the force of gravity do on a paralysis of muscles in the shoulder and where is there severe pain ____ upper extremity function?

Back 33

Stretches the ligamentous structures surrounding the glenohumeral joint.

GH joint has severe pain

-Decreased function

Front 34

2 ES characteristics of FES

Back 34

1) Wave form: assymmetrical biphasic square

2) Modulation: interrupted

Front 35

Parameters

Waveform:

Back 35

Asymmertrical Biphasic Square

or

Symmetrical Biphasic rectangular

Diagram SLIDE 14

Front 36

Parameters

Rate

Back 36

25 pps

Front 37

Parameters

Pulse width:

Ramp time:

Cycling:

Back 37

-300 μsec

-2 sec

-synchronous

Front 38

Electrode placement for Shoulder subluxation

Back 38

-Bipolar

-Supraspinatus & posterior Deltoid

Front 39

Tx parameters for shoulder subluxation

Amplitude:

Pulse Rate:

Duration:

Back 39

Amplitude: Tetanic muscle contraction to patient's tolerance

-turn up high, unlike IFC to pt's comfort)

-MOTOR response vs (IFC was sensory)

Pulse Rate: 12-25 pps

Duration: 15-30 mins

Front 40

Duration for Tx time for shoulder subluxation

______ daily up to ______ hours

Back 40

3x daily to 6-7 hrs

Front 41

-On/off ratio:

-Progressing to:

Back 41

-1:3 (2 sec : 6 sec)

-12:1 (24 sec: 2 sec)

Front 42

Supraspinatus & posterior deltoid are two muscles that prevent what?

Back 42

Inferior Humeral Head Subluxation

Front 43

What are the two disadvantages in using slings to prevent shoulder subluxation?

Back 43

1) Most slings are not effective forsubluxation prevention.

2) The slings that do prevent subluxation, promote non-use of the arm & may result in contracture.

Front 44

Explain to patients, the research proven caregiver use of FES, Because?

Back 44

They will just go back to shoulder sling because they wont see anything working at first with FES & shoulder sling is easier.

Front 45

GH joint middle deltoid can be useful in preventing _______ ________

Back 45

Shoulder Subluxation

Front 46

If the supraspinatus & the posterior deltoid cannot be stimulated, try what muscle?

Back 46

Middle Deltoid

Front 47

FES for the glenohumeral joint subluxation should be used for ______ hours a day

-what does this mean for caregivers

Back 47

4 to 7 hours a day

-they must be educated in the use of FES

Front 48

CVA patients may have ____ or _____ paralysis of the rotator cuff, especially the _____ & ____ _____

Back 48

Weak or Flaccid

-Supraspinatus & Posterior Deltoid

Front 49

force of gravity will do what at the glenohumeral joint & result in severe ___ & ______ function

Back 49

It will stretch the ligaments and result in severe pain & Decreased function

Front 50

Shoulder Subluxation Protocol

Waveform:

Modulation:

Electrode placement:

Amplitude

Pulse rate:

Tx times:

-on/off ratio:

Back 50

Waveform: Asymetrical, biphasic, square

Modulation: Interrupted

Electrode placement: bipolar, electrodes on Supraspinatus & posterior deltoid

Amplitude: Tetanic contraction to patient tolerance

Pulse rate: 12-25 pps

Tx times:

1) 15- 30 mins

2) 3x/day up to 6-7 hours total.

-on/off ratio: 1:3 (2 sec/6 sec) ---> progress 12:1 (24 sec/2 sec)

Front 51

Review pictures

electrode placement

Back 51

SLIDE 20

Front 52

Electrode placement for-->

small electrodes (1.5 inches) FES is used for what muscles?

Back 52

Small

Front 53

How large are the electropads for large muscles?

Back 53

3 inches or bigger

Front 54

Large electrodes stimulate _____ ____ of large muscles

Back 54

Titanic Contaction

Front 55

Review bracing & taping picture

Back 55

SLIDE 22

Front 56

What phase of gait does FES stimulate for Dorsiflexion assistance?

Back 56

Swing Phase

Front 57

Patients with Hemiplegia exhibit what 2 problems?

Back 57

1) Paralyzed Dorsiflexor

2) Evertor muscles

Front 58

ES characteristics -->

Wave form:

Pulse duration:

Modulation:

Back 58

-asymmetric biphasic square

- 20-250 μsec

-interrupted by foot switch

Front 59

Dorsiflexion Gait training Electrode placement

Back 59

Bipolar

–Peroneal (fibular) nerve near head of fibula or anterior tibialis muscle.

Front 60

Dorsiflexion Gait training Tx parameters

Amplitude:

Pulse rate:

Back 60

Amplitude:

- Tetanic muscle contraction sufficient to decrease plantar flexion

( sustained muscle contraction)

Pulse rate:

- 30-300 pps

Front 61

Treatment mode

-Heel switch contains _____ sensitive contact which stops stimulation during _____ phase & activates stimulation during ______ phase

-there is also a hand switch

Back 61

-Pressure

-Stance

-Swing

Front 62

Dropped Foot Randomized control trail for CVA with FES reported two main effects?

Back 62

1) Increased over ground walking velocity

2) Decreased physiological cost index

Front 63

What was the weakness of the Randomize Control (RCT) for the CVA study involving FES?

Back 63

Lack of standardized technique such as walking for 20 minutes while using NMES.

Front 64

Protocol for Dorsiflexion assist

Waveform:

Modulation:

Pulse Duration:

Electrode placement:

Amplitude

Pulse rate:

Tx times:

Back 64

Waveform: Asymetrical, biphasic, square

Modulation: Interrupted by foot switch

Pulse Duration: 20 – 250 μsec

Electrode placement:

- Bipolar, electrodes on Fibular nerve near the head of the fibula & the anterior tibialis muscle

Amplitude:

-Tetanic contraction sufficient to decrease plantar flexion

Pulse rate: 30-300 pps

Tx times:

- Pressure sensitive heel switch stops stimulation during stance & activates it during swing phase

Front 65

What are other gairt considerations that FES is used for?

Back 65

Partial Spinal Cord injury

Front 66

What are the phases of gait that FES helps with depending on electrode placement?

Back 66

-Push-off [Plantar Flexors]

- Late swing phase [Hamstrings]

-Stance Phase [Quads & Gluts]

Front 67

For other gait assisted conditions the FES parameters, application are similar to what protocol?

Back 67

Dorsiflexion

Front 68

For other gait assisted considerations therapist may need a ___ ___ to control stimulation during gait?

Back 68

Hand Switch

Front 69

Picture of FES device

Back 69

slide 28

Front 70

Picture

Dorsiflexor placement

Back 70

slide 29

Front 71

WalkAide is generated at the proper time based on _____ _____ during the ____ & ______ to match the patient's gait speed.

Back 71

-Tibial position

-Step

-Time

Front 72

FES is programmed to stimulate what nerve & cause a contraction of what two muscles.

This assists with or create dorsiflexion during _____ phase of gait

Back 72

-Common Fibular nerve

1) Anterior tibialis

2) Fibularis Longus

3) Swing phase

Front 73

What product is the only device approved by the APTA for Drop foot ES?

Back 73

Bioness

Front 74

Foot Drop often occurs in people who have what conditions

Name 5

Back 74

1) Stroke

2) multiple sclerosis

3) traumatic brain injury

4) incomplete spinal cord

5) Cerebral palsy

Front 75

What are some aspects for patient position

Back 75

-comfort

-let them see the stimulated contraction

Front 76

For gait re-education progress patient is Long sitting to _____ with feet on floor to ____

Back 76

Sitting & standing

Front 77

3 main patient instructions

Back 77

1) Train patient in clinic

2) Insure that the patient understand (checkout form)

3) Give pt. written instructions

Front 78

Where are electrodes place muscles & what phases are ES used for gait training?

Back 78

- Push-off (Plantar Flexors)

-Late Swing phase (Hamstrings & quadriceps)

- Stance phase (gluteals)

Front 79

Dosiflexion protocol & method application is similar for what other protocol?

Back 79

Gait-assisted training

Front 80

Picture gait training- ParaStep 1 system

Back 80

SLIDE 34

Front 81

Gait training with SCI patients may be performed 30 – 60 minutes a day 3 times a week.

Picture

Back 81

Slide 35

Front 82

What are the two adaptive methods to maximize training in patients W/ incomplete SCI or stroke?

Back 82

1) Partial BW supported treadmill locomotion

2) Stimulation flexor withdrawal reflex to get multi muscle activation during swing phase

Front 83

What does FES in SCI patients allow for them to do?

Back 83

-Walking can help improve CV function

Front 84

What are two gait limitations in patients with stroke

Back 84

1) Activating three or more muscle groups in a functional gait pattern is difficult.

2) Several support staff are needed to train one patient who does not have a functional gait pattern.

Front 85

Hand function

What are the two Txs that can produce synergistic effect for hand recovery in stroke patients

Back 85

1) EMG- triggered NMES on the involved side

2) Voluntary wrist & finger extension on the uninvolved side

Front 86

Hand function Fx

Treatment

Back 86

30 contractions done 2X/day

-3X/day

for 2 weeks

(360 contractions)

Front 87

Grips: two graps that can be produced with implantable neuroprothesis

Back 87

1) Lateral pinch grasp

2) Palmar grasp

Front 88

What nerve levels are the appropriate area for implantable neuroprosthesis to restore grasp

Back 88

C5-C6

Front 89

FES hand grasp system stimulates _____ & ___ to produce movement of the paralyzed hand

Back 89

Muscles & nerves

Front 90

Bionic glove was developed for?

Back 90

-grasping function

Front 91

List 3 Difficulties with bionic glove

Back 91

1) difficulty w/ donning & doffing

2) electrode shifts - changes hand function

3) small objects are difficult to handle

Front 92

Evidence for hand function

Back 92

slide 42

Front 93

Evidence for hand function

use of EMG-triggered NMES can help what

Back 93

Chronic motor dysfunction after stroke recovering wrist & finger extension

Front 94

Scoliosis picture

Back 94

slide 43

Front 95

What type of ES has been used for scoliosis

Back 95

FES

Front 96

Patient's ______ & ____of motion need to be taken into account.

Back 96

Strength & Range

Front 97

What has been more effective than FES in treating idiopathic scoliosis, specially w/ curves of 20 - 45°

Back 97

Orthotic bracing for 16-23 hours per day

Front 98

Spasticity reduction can be treated by what?

Back 98

FES

Front 99

Documentation for FES

Waveform:

Waveform Parameters:

Electrode placement:

Patient position

Dosage:

Tx duration:

Impairment/Functional goal:

Back 99

Waveform: FES (asymetrical, BALANCED)

Waveform Parameters: Interrupted, 12-25 pps

Electrode placement:

-Square, 2 in, gel

- Bipolar, electrodes: L supraspinatus & posterior deltoid

Patient position: Seated

Dosage: Intensity Tetanic contraction to patient tolerance

Tx duration: 15-30 mins

-Impairment/Functional goal: Shd. pain due to subluxated shd.

-Increase function ROm & strength LUE

Front 100

Asymmetrical Biphasic Square is _____ the amplitude than ____ the duration

Back 100

Half and Twice

Front 101

Evidence for hand function

Two coupled motor recovery protocols are better than one

Back 101

EMG-triggered NMES & bilateral movements can help what

Front 102

What are the two set-ups for FES spasticity reduction?

Back 102

1) electrodes over the antagonists of spastic muscle to produce reciprocal inhibition

2) place electrodes over the spastic muscles to antidromically produce RENSHAW cell inhibition of motor neurons tot he spastic muscles