Advertisement

Functional Electrical Stimulation Therapy: Recovery of Function Following Spinal Cord Injury and Stroke

  • Milos R. Popovic
  • Kei Masani
  • Silvestro Micera
Chapter

Abstract

Functional electrical stimulation (FES) is a technology one can use to artificially generate body movements in individuals who have paralyzed muscles due to injury to the central nervous system. More specifically, FES can be used to generate functions such as grasping and walking in individuals with spinal cord injury (SCI), stroke, traumatic brain injury and other neurological disorders that do not affect lower motor neurons. This technology was originally used to develop neuroprostheses that were implemented to permanently substitute impaired functions such as bladder voiding, grasping, and walking. In other words, a consumer would use the device each time he/she wanted to generate a desired function. In recent years, FES technology has been used to deliver, therapies to retrain voluntary motor functions such as grasping, reaching and walking. In this application, FES is used as a short-term therapy, the objective of which is restoration of voluntary function and not lifelong dependence on the FES device, hence the name FES therapy or FET. The FET is used as a short-term intervention to help the central nervous system of the consumer to relearn how to execute impaired functions. In this chapter, we introduce recent findings and advances in the field of FET.

The findings to date clearly show that FET for reaching and grasping is a therapeutic modality that should be implemented in every rehabilitation institution that is treating patients with stroke and SCI. The results obtained in a number of randomized control trials to date clearly demonstrate that FET for upper limb should not be ignored any longer. There is also considerable evidence to support the use of FET as a therapeutic modality to treat drop foot problem in both stroke and incomplete SCI populations. Several commercial FES systems are available that can be used to deliver FET for drop foot and grasping, and physiotherapists and occupational therapists should take advantage of this technology.

Presently, few teams in the world are investigating the use of more complex FES systems (6–16 channels FES systems that stimulate muscles in one or both legs in a physiologically appropriate manner) for retraining voluntary walking function in stroke and incomplete SCI populations. Although comprehensive randomized control trials have not been completed yet with either patient population, preliminary findings are very encouraging.

As surface FES technology is continuously improving and delivery methods for FET are evolving due to system miniaturization, better stimulation electrodes, and better stimulation protocols, it is foreseeable that, in the next 10–15 years, FET will become one of the dominant interventions for upper and lower limb rehabilitation. Many neuroprostheses are already commercialized and many more are near in the process of being developed and/or commercialized. Thus, we feel very confident that FET field is only beginning to evolve, and that, in the future, it may become one of the key therapeutic interventions not only for patients with stroke and SCI but also for patients with other neuromuscular disorders.

Keywords

Functional electrical stimulation (FES) FES therapy Spinal cord injury Stroke Neuroprosthesis 

References

  1. 1.
    Reichel M, Breyer T, Mayr W, Rattay F. Simulation of the three-dimensional electrical field in the course of functional electrical stimulation. Artif Organs. 2002;26:252–5.PubMedCrossRefGoogle Scholar
  2. 2.
    Kern H, Hofer C, Mödlin M, Forstner C, Raschka-Högler D, Mayr W, et al. Denervated muscles in humans: limitations and problems of currently used functional electrical stimulation training protocols. Artif Organs. 2002;26:216–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Rushton D. Functional electrical stimulation and rehabilitation – an hypothesis. Med Eng Phys. 2003;25:75–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Kuhn A, Keller T, Micera S, Morari M. Array electrode design for transcutaneous electrical stimulation: a simulation study. Med Eng Phys. 2009;31:945–51.PubMedCrossRefGoogle Scholar
  5. 5.
    Micera S, Keller T, Lawrence M, Morari M, Popović DB. Wearable neural prostheses. Restoration of sensory-motor function by transcutaneous electrical stimulation. IEEE Eng Med Biol Mag. 2010;29:64–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Popović DB, Popović MB. Automatic determination of the optimal shape of a surface electrode: selective stimulation. J Neurosci Methods. 2009;178:174–81.PubMedCrossRefGoogle Scholar
  7. 7.
    Popovic MB, Popovic DB, Sinkjaer T, Stefanovic A, Schwirtlich L. Restitution of reaching and grasping promoted by functional electrical therapy. Artif Organs. 2002;26:271–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Waters RL. The enigma of “carry-over”. Int Rehabil Med. 1984;6:9–12.PubMedGoogle Scholar
  9. 9.
    Merletti R, Acimovic R, Grobelnik S, Cvilak G. Electrophysiological orthosis for the upper extremity in hemiplegia: feasibility study. Arch Phys Med Rehabil. 1975;56:507–13.PubMedGoogle Scholar
  10. 10.
    Taylor PN, Burridge JH, Dunkerley AL, Wood DE, Norton JA, Singleton C, et al. Clinical use of the Odstock dropped foot stimulator: its effect on the speed and effort of walking. Arch Phys Med Rehabil. 1999;80:1577–83.PubMedCrossRefGoogle Scholar
  11. 11.
    Stein RB, Everaert DG, Thompson AK, Chong SL, Whittaker M, Robertson J, et al. Long-term therapeutic and orthotic effects of a foot drop stimulator on walking performance in progressive and nonprogressive neurological disorders. Neurorehabil Neural Repair. 2010;24:152–67.PubMedCrossRefGoogle Scholar
  12. 12.
    Hausdorff JM, Ring H. Effects of a new radio frequency-controlled neuroprosthesis on gait symmetry and rhythmicity in patients with chronic hemiparesis. Am J Phys Med Rehabil. 2008;87:4–13.PubMedCrossRefGoogle Scholar
  13. 13.
    Burridge JH, Haugland M, Larsen B, Svaneborg N, Iversen HK, Christensen PB, et al. Patients’ perceptions of the benefits and problems of using the ActiGait implanted drop-foot stimulator. J Rehabil Med. 2008;40:873–5.PubMedGoogle Scholar
  14. 14.
    Kenney L, Bultstra G, Buschman R, Taylor P, Mann G, Hermens H, et al. An implantable two channel drop foot stimulator: initial clinical results. Artif Organs. 2002;26:267–70.PubMedCrossRefGoogle Scholar
  15. 15.
    van Swigchem R, Vloothuis J, den Boer J, Weerdesteyn V, Geurts ACH. Is transcutaneous peroneal stimulation beneficial to patients with chronic stroke using an ankle-foot orthosis? A within-subjects study of patients’ satisfaction, walking speed and physical activity level. J Rehabil Med. 2010;42:117–21.PubMedCrossRefGoogle Scholar
  16. 16.
    Daly JJ, Roenigk K, Holcomb J, Rogers JM, Butler K, Gansen J, et al. A randomized controlled trial of functional neuromuscular stimulation in chronic stroke subjects. Stroke. 2006;37:172–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Burridge JH, Taylor PN, Hagan SA, Wood DE, Swain ID. The effects of common peroneal stimulation on the effort and speed of walking: a randomized controlled trial with chronic hemiplegic patients. Clin Rehabil. 1997;11:201–10.PubMedCrossRefGoogle Scholar
  18. 18.
    Granat MH, Maxwell DJ, Ferguson AC, Lees KR, Barbenel JC. Peroneal stimulator; evaluation for the correction of spastic drop foot in hemiplegia. Arch Phys Med Rehabil. 1996;77:19–24.PubMedCrossRefGoogle Scholar
  19. 19.
    Kantrowitz A. A report of the maimonides hospital. Electronic Physiologic Aids. Publisher: New York, Brooklyn, 1960.Google Scholar
  20. 20.
    Strojnik P, Kralj A, Ursic I. Programmed six-channel electrical stimulator for complex stimulation of leg muscles during walking. IEEE Trans Biomed Eng. 1979;26:112–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Kralj A, Bajd T, Turk R. Enhancement of gait restoration in spinal injured patients by functional electrical stimulation. Clin Orthop Relat Res. 1988;223:34–43.Google Scholar
  22. 22.
    Graupe D, Kohn KH. Functional neuromuscular stimulator for short-distance ambulation by certain thoracic-level spinal-cord-injured paraplegics. Surg Neurol. 1998;50:202–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Graupe D, Davis R, Kordylewski H, Kohn K. Ambulation by traumatic T4–12 paraplegics using functional neuromuscular stimulation. Crit Rev Neurosurg. 1998;8:221–31.PubMedCrossRefGoogle Scholar
  24. 24.
    Popovic D, Tomović R, Schwirtlich L. Hybrid assistive system – the motor neuroprosthesis. IEEE Trans Biomed Eng. 1989;36:729–37.PubMedCrossRefGoogle Scholar
  25. 25.
    Solomonow M, Baratta R, Hirokawa S, Rightor N, Walker W, Beaudette P, et al. The RGO Generation II: muscle stimulation powered orthosis as a practical walking system for thoracic paraplegics. Orthopedics. 1989;12:1309–15.PubMedGoogle Scholar
  26. 26.
    Bailey SN, Hardin EC, Kobetic R, Boggs LM, Pinault G, Triolo RJ. Neurotherapeutic and neuroprosthetic effects of implanted functional electrical stimulation for ambulation after incomplete spinal cord injury. J Rehabil Res Dev. 2010;47:7–16.PubMedCrossRefGoogle Scholar
  27. 27.
    Davis JA, Triolo RJ, Uhlir JP, Bhadra N, Lissy DA, Nandurkar S, et al. Surgical technique for installing an eight-channel neuroprosthesis for standing. Clin Orthop Relat Res. 2001;385:237–52.PubMedCrossRefGoogle Scholar
  28. 28.
    Davis JA, Triolo RJ, Uhlir J, Bieri C, Rohde L, Lissy D, et al. Preliminary performance of a surgically implanted neuroprosthesis for standing and transfers – where do we stand? J Rehabil Res Dev. 2001;38:609–17.PubMedGoogle Scholar
  29. 29.
    Hardin E, Kobetic R, Murray L, Corado-Ahmed M, Pinault G, Sakai J, et al. Walking after incomplete spinal cord injury using an implanted FES system: a case report. J Rehabil Res Dev. 2007;44:333–46.PubMedCrossRefGoogle Scholar
  30. 30.
    Johnston TE, Betz RR, Smith BT, Benda BJ, Mulcahey MJ, Davis R, et al. Implantable FES system for upright mobility and bladder and bowel function for individuals with spinal cord injury. Spinal Cord. 2005;43:713–23.PubMedCrossRefGoogle Scholar
  31. 31.
    Popovic MR, Keller T. Modular transcutaneous functional electrical stimulation system. Med Eng Phys. 2005;27:81–92.PubMedCrossRefGoogle Scholar
  32. 32.
    Thrasher TA, Flett HM, Popovic MR. Gait training regimen for incomplete spinal cord injury using functional electrical stimulation. Spinal Cord. 2006;44:357–61.PubMedCrossRefGoogle Scholar
  33. 33.
    Pappas IP, Popovic MR, Keller T, Dietz V, Morari M. A reliable gait phase detection system. IEEE Trans Neural Syst Rehabil Eng. 2001;9:113–25.PubMedCrossRefGoogle Scholar
  34. 34.
    Bajd T, Kralj A, Stefancic M, Lavrac N. Use of functional electrical stimulation in the lower extremities of incomplete spinal cord injured patients. Artif Organs. 1999;23:403–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Wieler M, Stein R, Ladouceur M, Whittaker M, Smith A, Naaman S, et al. Multicenter evaluation of electrical stimulation systems for walking. Arch Phys Med Rehabil. 1999;80:495–500.PubMedCrossRefGoogle Scholar
  36. 36.
    Chae J, Harley M, Hisel T, Corrigan C, Demchak J, Wong Y-T, et al. Intramuscular electrical stimulation for upper limb recovery in chronic hemiparesis: an exploratory randomized clinical trial. Neurorehabil Neural Repair. 2009;23:569–78.PubMedCrossRefGoogle Scholar
  37. 37.
    Chae J, Hart R. Intramuscular hand neuroprosthesis for chronic stroke survivors. Neurorehabil Neural Repair. 2003;17:109–17.PubMedCrossRefGoogle Scholar
  38. 38.
    Chae J, Bethoux F, Bohine T, Dobos L, Davis T, Friedl A. Neuromuscular stimulation for upper extremity motor and functional recovery in acute hemiplegia. Stroke. 1998;29:975–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Francisco G, Chae J, Chawla H, Kirshblum S, Zorowitz R, Lewis G, et al. Electromyogram-triggered neuromuscular stimulation for improving the arm function of acute stroke survivors: a randomized pilot study. Arch Phys Med Rehabil. 1998;79:570–5.PubMedCrossRefGoogle Scholar
  40. 40.
    Hendricks HT, IJzerman MJ, de Kroon JR, in’t Groen FA, Zilvold G. Functional electrical stimulation by means of the ‘Ness Handmaster Orthosis’ in chronic stroke patients: an exploratory study. Clin Rehabil. 2001;15:217–20.PubMedCrossRefGoogle Scholar
  41. 41.
    Kowalczewski J, Gritsenko V, Ashworth N, Ellaway P, Prochazka A. Upper-extremity functional electric stimulation-assisted exercises on a workstation in the subacute phase of stroke recovery. Arch Phys Med Rehabil. 2007;88:833–9.PubMedCrossRefGoogle Scholar
  42. 42.
    Popovic D, Popovic M, Sinkjaer T, Stefanovic A, Schwirtlich L. Therapy of paretic arm in hemiplegic subjects augmented with a neural prosthesis: a cross-over study. Can J Physiol Pharmacol. 2004;82:749–56.PubMedCrossRefGoogle Scholar
  43. 43.
    Popović D, Stojanović A, Pjanović A, Radosavljević S, Popović M, Jović S, et al. Clinical evaluation of the bionic glove. Arch Phys Med Rehabil. 1999;80:299–304.PubMedCrossRefGoogle Scholar
  44. 44.
    Prochazka A, Gauthier M, Wieler M, Kenwell Z. The bionic glove: an electrical stimulator garment that provides controlled grasp and hand opening in quadriplegia. Arch Phys Med Rehabil. 1997;78:608–14.PubMedCrossRefGoogle Scholar
  45. 45.
    Rebersek S, Vodovnik L. Proportionally controlled functional electrical stimulation of hand. Arch Phys Med Rehabil. 1973;54:378–82.PubMedGoogle Scholar
  46. 46.
    Sullivan JE, Hedman LD. Effects of home-based sensory and motor amplitude electrical stimulation on arm dysfunction in chronic stroke. Clin Rehabil. 2007;21:142–50.PubMedCrossRefGoogle Scholar
  47. 47.
    Sullivan JE, Hedman LD. A home program of sensory and neuromuscular electrical stimulation with upper-limb task practice in a patient 5 years after a stroke. Phys Ther. 2004;84:1045–54.PubMedGoogle Scholar
  48. 48.
    Popovic MR, Thrasher TA, Zivanovic P, Takaki M, Hajek P. Neuroprosthesis for retraining reaching and grasping functions in severe hemiplegic patients. Neuromodulation. 2005;8:58–72.PubMedCrossRefGoogle Scholar
  49. 49.
    Popović MB. Control of neural prostheses for grasping and reaching. Med Eng Phys. 2003;25:41–50.PubMedCrossRefGoogle Scholar
  50. 50.
    Thrasher TA, Zivanovic V, McIlroy W, Popovic MR. Rehabilitation of reaching and grasping function in severe hemiplegic patients using functional electrical stimulation therapy. Neurorehabil Neural Repair. 2008;22:706–14.PubMedCrossRefGoogle Scholar
  51. 51.
    Smith B, Tang Z, Johnson MW, Pourmehdi S, Gazdik MM, Buckett JR, et al. An externally powered, multichannel, implantable stimulator-telemeter for control of paralyzed muscle. IEEE Trans Biomed Eng. 1998;45:463–75.PubMedCrossRefGoogle Scholar
  52. 52.
    Gritsenko V, Prochazka A. A functional electric stimulation-assisted exercise therapy system for hemiplegic hand function. Arch Phys Med Rehabil. 2004;85:881–5.PubMedCrossRefGoogle Scholar
  53. 53.
    Popovic MR, Keller T, Pappas IP, Dietz V, Morari M. Surface-stimulation technology for grasping and walking neuroprosthesis. IEEE Eng Med Biol Mag. 2001;20:82–93.PubMedCrossRefGoogle Scholar
  54. 54.
    Glanz M, Klawansky S, Stason W, Berkey C, Chalmers TC. Functional electrostimulation in poststroke rehabilitation: a meta-analysis of the randomized controlled trials. Arch Phys Med Rehabil. 1996;77:549–53.PubMedCrossRefGoogle Scholar
  55. 55.
    Cauraugh JH, Kim S. Two coupled motor recovery protocols are better than one: electromyogram-triggered neuromuscular stimulation and bilateral movements. Stroke. 2002;33:1589–94.PubMedCrossRefGoogle Scholar
  56. 56.
    Ring H, Rosenthal N. Controlled study of neuroprosthetic functional electrical stimulation in sub-acute post-stroke rehabilitation. J Rehabil Med. 2005;37:32–6.PubMedCrossRefGoogle Scholar
  57. 57.
    Popovic MR, Thrasher TA. Neuroprostheses. In: Wnek GE, Bowlin GL, editors. Encyclopedia of biomaterials and biomedical engineering. New York: Marcel Dekker, Inc; 2004. p. 1056–65.Google Scholar
  58. 58.
    Mangold S, Keller T, Curt A, Dietz V. Transcutaneous functional electrical stimulation for grasping in subjects with cervical spinal cord injury. Spinal Cord. 2005;43:1–13.PubMedCrossRefGoogle Scholar
  59. 59.
    Popovic MR, Thrasher TA, Adams ME, Takes V, Zivanovic V, Tonack MI. Functional electrical therapy: retraining grasping in spinal cord injury. Spinal Cord. 2006;44:143–51.PubMedCrossRefGoogle Scholar
  60. 60.
    Popovic M, Kapadia N, Zivanovic V, Furlan J, Craven C, McGillivray C. Functional electrical stimulation therapy for restoring voluntary grasping function in patients with sub-acute incomplete tetraplegia: a randomized single-blind clinical trial. Neurorehabilitation and Neural Repair. 2011;25:433–42.Google Scholar
  61. 61.
    Kapadia NM, Zivanovic V, Furlan J, Craven BC, McGillivray C, Popovic MR. Toronto Rehabilitation Institute’s functional electrical stimulation therapy for grasping in traumatic incomplete spinal cord injury: randomized control trial. Artificial Organs. 2011;35: 212-6.Google Scholar
  62. 62.
    Tomovic R, Popovic D, Stein RB. Nonanalytical methods for motor control. Singapore: World Sci Publ; 1995.CrossRefGoogle Scholar
  63. 63.
    Andrews BJ, Baxendale RH, Barnett R, Phillips GF, Yamazaki T, Paul JP, et al. Hybrid FES orthosis incorporating closed loop control and sensory feedback. J Biomed Eng. 1988;10:189–95.PubMedCrossRefGoogle Scholar
  64. 64.
    Solomonow M. Biomechanics and physiology of a practical powered walking orthosis for paraplegics. In: Stein RB, Peckham P, Popovic D, editors. Neural prostheses: replacing motor function after disease or disability. New York: Oxford University Press; 1992. p. 202–32.Google Scholar
  65. 65.
    Freeman C, Hughes A, Burridge J, Chappell P, Lewin P, Rogers E. Iterative learning control of FES applied to the upper extremity for rehabilitation. Control Eng Pract. 2009;17:368–81.CrossRefGoogle Scholar
  66. 66.
    Stauffer Y, Allemand Y, Bouri M, Fournier J, Clavel R, Metrailler P, et al. The WalkTrainer – a new generation of walking reeducation device combining orthoses and muscle stimulation. IEEE Trans Neural Syst Rehabil Eng. 2009;17:38–45.PubMedCrossRefGoogle Scholar
  67. 67.
    Granat MH, Ferguson AC, Andrews BJ, Delargy M. The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury – observed benefits during gait studies. Paraplegia. 1993;31:207–15.PubMedCrossRefGoogle Scholar
  68. 68.
    Weiller C, Ramsay SC, Wise RJ, Friston KJ, Frackowiak RS. Individual patterns of functional reorganization in the human cerebral cortex after capsular infarction. Ann Neurol. 1993;33:181–9.PubMedCrossRefGoogle Scholar
  69. 69.
    Ridding MC, Brouwer B, Miles TS, Pitcher JB, Thompson PD. Changes in muscle responses to stimulation of the motor cortex induced by peripheral nerve stimulation in human subjects. Exp Brain Res. 2000;131:135–43.PubMedCrossRefGoogle Scholar
  70. 70.
    Chae J, Yu D. Neuromuscular stimulation for motor relearning in hemiplegia. Crit Rev Phys Rehabil Med. 1999;11:208–29.Google Scholar
  71. 71.
    Thompson A, Doran B, Stein R. Short-term effects of functional electrical stimulation on spinal excitatory and inhibitory reflexes in ankle extensor and flexor muscles. Exp Brain Res. 2006;170:216–26.PubMedCrossRefGoogle Scholar
  72. 72.
    Thompson AK, Stein R. Short-term effects of functional electrical stimulation on motor-evoked potentials in ankle flexor and extensor muscles. Exp Brain Res. 2004;159:491–500.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

  • Milos R. Popovic
    • 1
  • Kei Masani
    • 2
  • Silvestro Micera
    • 3
  1. 1.Institute of Biomterials and Biomedical EngineeringUniversity of TorontoTorontoCanada
  2. 2.Lyndhurst CentreToronto Rehabilitation InstituteTorontoCanada
  3. 3.Neuroprosthesis Control Group, Department of Information Technology and Electrical EngineeringSwiss Federal Institute of TechnologyZurichSwitzerland

Personalised recommendations