APTA Parametros FES

8/13/2019 APTA Parametros FES

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Functional Electrical Stimulation Programs

for People with SCI: Clinician and Consumer

Perspectives for Clinic and Home

January 22, 2013

Property of French, Johnston, Lombardo &Tefertiller, not to be copied without permission 1

Functional Electrical

Stimulation Programs forPeople with SCIClinician and the Consumer Perspectives

for Clinic and Home

Moderator: Jennifer French, MBA, Neurotech Network

Speakers:

!Therese E. Johnston, PT, PhD, MBA, Jefferson School of Health Professions!Candy Tefertiller, PT, DPT, ATP, NCS, Craig Hospital!Lisa Lombardo, PT, MPT, Cleveland FES Center

APTA Combined Sections Meeting 2013

San Diego, CAJanuary 22, 2013, 8:00-10:00am

Course Objectives1. Discuss the current evidence for the use of FES for people with SCI2. Discuss FES parameter applications and modifications to achieve

optimal outcomes in individuals with neurologic disabilities

3. Discuss the opportunities and challenges of implementing FES in theclinical setting.

4. Understand multiple uses of FES from the perspectives of theconsumer and clinician.

5. Assess practical applications for successful implementation in theclinic and the home environment for FES

6. Discuss lower cost alternatives to commercially available FEStechnologies and the financial implications of FES programs andtechnologies

7. Explore current technology surrounding implantable FES systemsand current functional applications for implantable FES systems

Introductions Parameters and Evidence for Common FES

Applications: Therese Johnston

Implementing a Clinical Program for FES:Candy Tefertiller

Short Session Break Implantable FES Systems: Lisa Lombardo Consumer & Clinical Perspectives: Panel

Question & Answer

Course Agenda Priorities of Individuals with SCI

Anderson, K.D. (2004) J. Neurotrauma, 21: 1371-1383.

FES Parameters and

Evidence for FES in SCI

Therese E. Johnston, PT, PhD, MBA

Thomas Jefferson University

Philadelphia, PA

Parameters used in Clinical FES

Important to understand parameters To understand how units differ To make best decisions for the intervention

Read the booklets that come with theequipment!


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January 22, 2013


Current (I)

Rateof movementof charged particlesin a conductor

Involves transfer ofenergythat causesphysiologicalchange

Directly related tothe voltage

Measured in amperes Our applications:milliamps (mA)

On e-stim machines,often is the intensitydial

Resistance

Defines the ease ofmovement withinthe conductor

Measured in Ohms

Ohms LawI = V/RV = I x R

Therefore, as Rincreases, V needs toincrease to maintain aconstant I

Resistance in our Applications

Use of gels, sponges, & wet gauzedecrease the resistance

Lotions, oils, dry skin, & callus increaseresistance

Alternating Current

Uninterrupted bi-directional flow ofparticles

Polarity reverses aselectrons move in

one direction & then

reverse

+

-

+

-

Pulsed Current

Each pulse is anisolated electrical

event -

+

-

+

-

+

Biphasic Pulsed Current

Pulse & Pulse duration

Pulse= isolatedelectrical event

Can be uni or bi-directional

Pulse duration= timeto complete onepulse

Our applications:usually inmicroseconds (sec)

-

+

Pulse duration


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January 22, 2013


Other Terms

*Interpulseinterval= timebetweenpulses

*Period=pulse duration+ interpulseintervalduration

Interpulse

interval

-

+

-

+

-

+

Period

-

+

-

+

-

+

*Frequency

The number of pulses each second Important in fatigue

1 sec-

+

-

+

-

+

0

This would represent 3 pulses per second (pps)

*Balance of Charge

A waveform isbalanced

when:

The area

under the

negative

phase = the

area under the

positive phase

Balanced

Unbalanced

This unbalanced waveform gives you a

net positive charge for the pulse

Amplitude Characteristics

Peak Amplitude Peak to peak amp RMS amp: takes the

shape of waveforminto account. Isabout 70% of peakamp for a truesinusoidal wave

Peak amp

Peak to

peak amp

*Ramp Up & Ramp Down Times

Ramp Up: Timeacrosssuccessivepulses to reach

peak amplitude(usually inseconds)

Ramp Down:Returning tobaseline

-+

-+

-

+

-

+

-

+

-

+

Clinical Stimulators

Primary Parameters Pulse duration: usually less than 400 secAmplitude: up to 100 mA Frequency: up to 100 pps

These 3 parameters together are allimportant in how strong the electrical

stimulus is & what effects it can create


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January 22, 2013


Effects of Increasing

Parameters

Amplitude Increases force production Pulse Duration

Increases force production (& pain over 400sec) Frequency

Increases firing rate Increases force Increases fatigue

FES Applications

This talk will include Walking Cycling

FES as a Dorsiflexion Assist during

Gait

Electrodes are typicallyplaced on the anterior

tibialis and the peroneal

nerve

Triggered by a footswitch or external

trigger

Considered an orthoticsubstitute

(Diagram: Robinson, Snyder-Mackler pg 178)

Parameters from the Literature

Pulse duration: 200-400 sec

Frequency: To obtain tetany

Amplitude: To create a 3- to 3+/5

On/off time: Times with persons gait Need a control source

Possible Stimulators

Portable stimulator that can use a trigger Foot/heel switch Hand trigger

Single application devices on the market WalkAid Bioness Odstock (UK only)

Portable Stimulator

Programmableparameters

Pre-set Custom allows wide range

Remote heel switch


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January 22, 2013


WalkAid

One-channel stimulator Uses a Tilt or Heel Sensor

to control stimulation

Parameters 25-300 !sec 16.7- 33 pps Up to 200 mA Up to 3 sec on time (for

exercise)

Bioness L300

Gait Sensor In shoe and attachedto shoe

Detects speed &surface changes

Parameters 200 !sec 30 pps 30-35 mA

Parastep Walking System

Muscles stimulated by surface stim quadriceps, peroneal reflex for

stepping, and the gluteal muscles

Parameters: 24Hz, pulse width 150!sec, & intensity up to 300mA

The user can chose from sit/stand, stand/sit, right step & left

step, and can increase or decreasethe stim intensity while walking

Parastep, Sigmedics, Fairborn, OH

Evidence for Walking with FES

Parastep

Series of 5 papers from Miami Projectpublished on its effects (1997, Arch Phys Med Rehabil)

16 subjects, trained 32 sessions Outcomes

"walking distance, standing duration, & pace "thigh and calf girth

No change in BMD !self-concept and "depression !blood flow "time to fatigue, "workload, "VO2 during UE

ergometry

Papers by Guest et al., Jacobs et al., Klose et al., Nash et al, Needham-Shropshire et a

FES: Incomplete SCI

Field-Fote et al. 2011 FES to peroneal nerve "walking speed & distance across groups (FES/OG,

TM/manual A, TM/FES, TM/robotics)

Distance "greatest in OG group who used FES Ladouceur et al. 2000

FES for peroneal nerve (swing) & quadriceps (stance) With FES, saw

"functional mobility "maximal overground walking speed


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January 22, 2013


FES: Incomplete SCI

Kim et al. 2004 FES: surface peroneal nerve stimulator Results: Gait speed best with FES/hinged AFO

combo, Best foot clearance with FES

Postans et al. 2004Acute SCI: FES to many muscles on TM Greater "in overground walking distance after

FES and TM training

No difference in walking speed gains

FES Cycling

Parameters of FES Cycles

Ergys 0-140 mA; 400-1000 !sec; 30, 40, 50, 60 pps

RT300 0-140mA, 100-1000 !sec, 10-100 pps

Motomed/Hasomed 0-126 mA, 20-500 !sec, up to 180 pps (using

doublets)

Common Intervention Times

From the literature Most studies have subjects cycle for 30 mins

3x/week

More recent studies have made changes tothis

Some increased duration to 1 hour Some increased frequency to 5x/week

In practice See 30-60 minutes 3-5x/week

Evidence for FES Cycling

Bone Lauer et al. 2011 (peds): hip BMD !more than in kids

without SCI

Lai et al. 2010 (acute): "loss of bone in distal femur Bloomfield et al., 1996: Bone !only if cycling at >18W Chen et al. 2005: "in distal femur, proximal tibia Frotzler et al. 2008 (higher intensity): "in trabecular

& total BMD and CSA in distal femoral epiphysis


Muscle Demchak et al. 2005 (acute): less muscle loss Johnston et al., 2011 (peds): !quadriceps

volume & stimulated strength

Scremin et al. 1999 (chronic): !CSA ofquadriceps, adductor magnus,!muscle to

adipose ratio

Duffell et al. 2008 (chronic): !stimulatedquadriceps torque,!quadriceps fatigue

resistance


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January 22, 2013



Cardiorespiratory Hettinga, et al., 2008 (review): average VO2increase of 1.05L/min (n=264) while cycling

Johnston et al., 2011 (peds): "greater than kidswith typical development

Janssen et al., 2008 (chronic): Modified FES: !VO2, HR, cardiac output, blood lactate

Zgobar et al., 2008 (chronic): !small arterycompliance

Berry et al., 2008 (chronic): !peak power output,!peak VO2

Conclusions

Understand parameters needed andrationale for decision making Some evidence exists for the use of FES

applications in SCI

Implementing a Clinical Program

of

Functional Electrical Stimulation

Candy Tefertiller, PT, DPT, ATP, NCS

Director of Physical Therapy at Craig Hospital

Intensive Activity Based Therapy

Focus on recovery vs. compensation Retraining the neuromuscular system below

the LOI for task execution

Development and implementation of newtechnologies and interventions to facilitate

repetition and task specificity

Improvement in neuromuscular function seeneven years after neurologic injury

Electrical Stimulation and FES may offer animportant avenue to facilitate movement in aninjured musculoskeletal system and facilitateimproved function via.

**Neuroplasticity

and/or

**Improved Compensation

FES Research

Daly 2011: !gait coordination; effects X 6 months Kesar 2011: !AGRF, trailing limb angle, knee flexion (swing) Kesar 2010: !muscle performance with VFTs vs. CFTs Forssberg et al. 1977: phase dependent modulation Fung et al 1994: !H-Reflex Perez et al 2003: "spasticity Bajd et al 1997: !vertical swing Barbeau et al 2002: Therapeutic Effect Field-Fote et al 2005, 2011 (RCTs): !OG speed Thompson 2012: SCI !CST activity with 30 min PNS


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January 22, 2013


FES in the Clinic/Home

Available Technologies: Foot Drop Systems

Bioness L300 Walkaide

Foot/Thigh Control Bioness L300 Plus

FES Cycles Restorative Therapies (UE and LE cycles) Motomed (UE and LE cycles) Ergys

FES Elliptical Restorative Therapies

FES Cycling Classes:

Inpatient and WellnessClasses 4-5 clients/hour 1PT; 1 Tech; 1-2

Volunteers

Creates competitiveand motivatingenvironment

Peer Support Transition to upright

posture whenappropriate

ABT Program: Cycling#Elliptical

Evaluate:SpasticityIsolated MovementTrunk ControlTransition:FES Bike#RT600

Neuroprosthetics

Nerve stimulation devices designed to replace or improve

function of an impaired nervous system

Commercially available for home and clinical use

FES in the Clinic:

Combined with OG training Common Peroneal/TA Gastroc/soleus Hip flexors/extensors Trunk extensors Knee flexors/extensors Foot sensors reversed to control stance vs. swing phase Strength training (TA vs. Gastroc/soleus) for clonic activity Initiate stepping prior voluntary initiation

Combined with developmental sequencing Combined with manually assisted BWS LTing

FES in the Clinic

Developmental Sequencing Over ground training Core Strengthening


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January 22, 2013


FES in

the Clinic

FESNo FES

Step withoutassist and no

Clonus in stance

StepWithout assist

StepRequires assist

FES

>1 on anySynergy patterns

Or >2 on MA

!1 on all 3Synergy patterns

Or !2 on MA

Over GroundTraining

Manual TreadmillTraining

AssessOver Ground

Manual Treadmill

SpasticitySCATS or MA

unilateral

Step RequiresAssist and/or

Clonus in stance

FES

SpasticitySCATS or MA

unilateral

FES Training Algorithm

1. Assess unilaterally for all tasks2. As patient continues to progress,

discharge FES unilaterally whenstandard is met.

AIS C and D, BI orCVA

FESNo FES

>1 on anySynergy pattern

Or >2 on MA

!1 on all 3Synergy patterns

Or !2 on MA

FES and Locomotor Training

Easily combined Manual Assist Over ground

Reduces staff fatigue May reduce clonic activity May allow training at higher speeds including

running Spinal Cord Assessment Tool for Spasticity

(SCATS) Modified Ashworth

Conclusion

Clinical Decision Making is the Key Lots of wonderful new technology in rehab to

enhance our treatment plans

They are simply the Tools.. we need todetermine when, how and with whom to improvelong term outcomes

No one modality will work for everyone Use EBM to guide clinical decision making

Lisa Lombardo, MPTCleveland FES Center

Implantable FES Systems

Applications of FES for SCI

Learning Objectives

Discuss implanted FES research applicationsfor spinal cord injury

Provide benefits and limitations for each ofthe applications

Discuss recommendations for the future


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January 22, 2013


Cleveland FES CenterAdvancing Technology, Enhancing Life

Developing technology that improves the quality of life

of individuals with disabilities through the use ofFunctional Electrical Stimulation and enabling the

transfer of the technology into clinical deployment.

Functional Electrical Stimulation (FES) is the application of

electrical stimulation to restore function. FES can be applied

for therapeutic purposes or for replacement of lost function.

Neural Prosthesis:A device that connects directly with

the nervous system and uses FES to replace or

supplement function.

www.FEScenter.org

Email: [email protected]

Enabling technology

Implanted Stimulator-Telemeter (IST)Pacemaker for thebody

12 - 16 stimulus channels up to 2 biosignal

sensing (EMG) channels

Intramuscular electrode Multicontact spiral cuffs Universal External

Control Unit (UECU)

Clinical Applications for SCI

Trunk Control & Posture Pressure Sore Prevention Wheelchair Propulsion

Standing Transfers Balance

Stepping

Inclusion C6-T12 SCI > 6 months post-injury Intact lower motor neurons Absence of psychiatric

problems

No untreated orthopaedicproblems

No acute medical problems Adequate social support Willingness to comply w/ follow-

up procedures

Exclusion Pacemaker Cardiac arrythmia Pregnancy Contractures Seizure disorder Obesity Untreated substance

abuse

Immunodeficiency Frequent UTIs Pressure sores

FES Lower Extremity Research

Trunk Control & PosturePressure Sore Prevention Trunk Control & Posture

Wheelchair Propulsion


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January 22, 2013


Standing SystemTransfer & Balance

Stepping System

Lower Extremity FES Summary

Controlling posture and balance may be feasible andclinically relevant

Implanted systems for standing after SCI areclinically viable

Nerve cuffs can improve system performance Standing balance can be addressed in new ways FES with EMG control can enhance walking ability

after incomplete SCI

Cleveland FES Center Programs

Spinal Cord Injury

Hand Grasp Arm & Shoulder Movement Pressure Sore Prevention Trunk Control & Posture Restoration of Cough Urology/Pelvic Health Pain & Spasticity Standing & Transfer Walking

Stroke

Shoulder Pain Reduction Pain & Spasticity Mental Image/Upper Body Hand, Implanted System Hand, Functional Control Foot Drop Walking Stability Swallowing Assistance

Acknowledgements

ALL RESEARCH VOLUNTEERS & THEIR FAMILIES

Website: www.fescenter.org

Department of Veterans Affairs; Rehabilitation Research and Development Service

National Institutes of Health: National Institute on Child Health and Human Development,National Center for Medical Rehab ilitation Research, National Institute of Neurological Disorders

and Stroke, National Institute of Biomedical Imaging and BioEngineering, National Institute ofDiabetes and Digestive and Kidney Diseases, National Institute on Deafness and OtherCommunication Disorders, National Institute on Disability and Rehabilitation Re search

U.S. Department of Education

State of Ohio: Third Frontier Program

Department of Defense: Army, Telemedicine and Advanced Technology Research Center (TATRC)

Craig H. Neilsen Foundation, Davis Phinney Fo undation, Lincy Foundation, MedtronicFoundation, Michael J. Fox Foundation, NDI Medical Inc, Case Western Reserve University,

Cleveland Clinic Foundation, Paralyzed Veterans of America, SPR Therapeutics,ThomasJefferson University, Wallace H. Coulter Foundation, Wiegand Family Foundation

Consumer & Clinician

Perspectives

Panel Question & Answer


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January 22, 2013


Considerations to Participating in any

FES program

Not all programs are appropriate for all populations Implanted vs. external Commitments of self, family/caregiver

Time Out of pocket cost and/or reimbursement

Potentially dangerous if not used properly use Peripheral nerve damage or skin damage Infections Over-stress or fatigue the stimulated muscles

Resources to Learn More

for you and your clients

Electrotherapeutic Terminology in Physical Therapy: APTA Sectionon Clinical Electrophysiology. Published in 2000. Available through

the APTA on line store

International Functional Electrical Stimulation Society EducationSection. Website: http://www.ifess.org/cedu_consumereducation

Neurotech Network Spinal Cord Injury Fact Sheet. Website:http://www.neurotechnetwork.org/educate_spinal_cord_injury.htm

Also available on Spinal Cord Central: http://www.spinalcord.org Cleveland FES Center: http://www.fescenter.org

References1. Behrman AL, Harkema SJ. Physical rehabilitation as an agent for recovery after spinal cord

injury. Phys Med Rehabil Clin N Am. May 2007;18(2):183-202, v.

2. Beekhuizen KS, Field-Fote EC. Sensory stimulation aug ments the effects of massed practicetraining in persons with tetraplegia.Arch Phys Med Rehabil. Apr 2008;89(4):602-608.

3. Hoffman JR, Ratamess NA, Cooper JJ, Kang J, Chilakos A, Faigenbaum AD. Comparison ofloaded and unloaded jump squat training on strength/power performance in college footballplayers.J Strength Cond Res. Nov 2005;19(4):810-815.

4. Dobkin B, Apple D, Barbeau H, et al. Weight-supported treadmill vs over-ground training forwalking after acute incomplete SCI.Neurology. Feb 28 2006;66(4):484-493.

5. Field-Fote EC, Lindley SD, Sherman AL. Locomotor training approaches for individuals withspinal cord injury: a preliminary report of walking-related outcomes.J Neurol Phys Ther. Sep

2005;29(3):127-137.

6. Lam T, Eng J, Wolfe D, Hsieh J, Whattaker M. A systematic review of the Efficacy of GaitRehabilitation Strategies for spinal cord injury. Topics in Spinal Cord. Injury Rehabilitation: Apr2007 13(1):32-57.

7. Backus D, Tefertiller C. Incorporating manual and robotic locomotor training into clinicalpractice: Suggestions for Clinical Decision Making. Topics in Spinal Cord. InjuryRehabilitation: 2008 14(1):23-33.

8. Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. A physiologically based clinicalmeasure for spastic reflexes in spinal cord injury. Arch Phys Med Rehabil. Jan 200 5;86(1):52-59.

9. Barbeau H, Ladouceur M, Mirbagheri MM, Kearney RE. The effect of locomotor trainingcombined with functional electrical stimulation in chronic spinal cord injured subjects:walking and reflex studies. Brain Res Brain Res Rev. Oct 2002;40(1-3):274-291.

10. Fung J, Barbeau H. Effects of conditioning cutaneomuscular stimulation on the soleus H-reflex in normal and spastic paretic subjects during wa lking and standing. J Neurophysiol.Nov 1994;72(5):2090-2104.

11. Perez M, Field-Fote C. Impaired posture-dependen t modulation of disynaptic reciprocal Iainhibition in individuals with incomplete spinal cord injury. Neuroscience Letters. 341(2003): 225-228.

12. Field-Fote EC. Electrical stimulation modifies spinal and cortical ne ural circuitry. ExercSport Sci Rev. Oct 2004;32(4):155-160.

13. Musselman KE. Clinical significant testing in rehabilitation research: what, why and how?Phys Ther Rev. 2007; 12: 287-296

14. Baily, SN, Hardin EC, Kobetic R, Boggs LM, Pinault G, Triolo, RJ. Neurotherapeutic andneuroprosthetic effects of implanted functional electrical stimulation for ambulation afterincomplete spinal cord injury. J Rehabil Res Dev. 2010; 47(1): 7-16. PMD: 20437323

15. Dutta A, Kobetic R, Triolo RJ. Gait initiation with electromyographically triggered electricalstimulation in people with partial paralysis. J Biomech Eng. 2009 Aug 131(8):081002.

PubMed PMID: 19604014.

References

16. Lambrecht JM, Audu ML, Triolo RJ, Kirsch RF. Musculoskeletal model of trunk and hips fordevelopment of seated-posture-control neuroprosthesis. J Rehabil Res Dev. 2009;46(4):

515-28. PubMed PMID: 19882486.

17. Johnson T, G. Nemunaitis, J. Nagy, M. Boulet, L. Boggs, M. Miller, J. Anderson, H. Hoyen,M. Keith, K. Nicolackis, L. Murray, R. Triolo Trunk muscle neuromuscular stimulation: A

case study of the effects on spinal alignment and respiratory function in a tetraplegic,American Spinal Injury Association (ASIA) meeting, June 19-22, 2008.

18. Nataraj R, Audu ML, Kirsch RF, Triolo RJ. Comprehensive joint feedback control forstanding by functional neuromuscular stimulation-a simulation study. IEEE Trans NeuralSyst Rehabil Eng. 2010 Dec;18(6):646-57. Epub 2010 Oct 4. PMID: 20923741

19. Triolo RJ, Boggs L, Miller ME, Nemuna itis G, Nagy J, Bailey SN. Implanted electricalstimulation of the trunk for seated postural stability and function after cervical spinal cordinjury: a single case study. Arch Phys Med Rehabil. 2009 Feb;90(2):340-7. PubMed PMID:

19236990; PubMed Central PMCID: PMC2648134.

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References

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