Creative Evidence-Based Use of
Electrical Stimulation in Acquired
Brain Injury Rehabilitation
Amy Berryman, OTR, MSHSA
Denise O’Dell, PT, DScPT, NCS, MS
APTA Combined Sections
February 20, 2016
Introductions
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Convention…
adjective: conventional
1) based on or in accordance with what is generally done or believed:
"a conventional morality had dictated behavior"
synonyms: unoriginal · formulaic · predictable · stock · unadventurous · unremarkable
· humdrum · run-of-the-mill
2) (of
a person) concerned with what is generally held to be acceptable at the
expense of individuality and sincerity.
(of a work of art or literature) following traditional forms and genres:
"conventional love poetry"
synonyms: conservative · traditional · traditionalist · conformist · bourgeois · old-fashioned
· of the old school · small-town · suburban · straight · buttoned-down · square
· stick-in-the-mud · fuddy-duddy
Berryman and O'Dell 2016
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Question:
What is “conventional” E-Stim Use?
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Definition
Electrical Stimulation:
The use of electrical current applied through the skin
via the motor nerve to help produce a muscle
contraction.
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Wikipedia
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Neuromuscular Electrical Stimulation (NMES)
vs.
Functional Electrical Stimulation (FES)
• NMES: uses a device to send electrical impulses to nerves. This input causes
muscles to contract. The electrical stimulation can increase strength and range of
motion, and offset the effects of disuse. It is often used to “re-train” or “reeducate” a muscle to function and to build strength after a surgery or period
of disuse but is more truly routine exercise and strengthening.
• FES: refers to the use of (NMES) or electrical stimulation during a task.
This can include walking or using an arm to reach. Foot drop is a common
problem following a neurological injury which may result in decreased walking
speed, decreased step length, and tripping. When FES is applied to the muscles
that lift the foot at the correct time during the walking cycle it may not only
impact the ability to clear the foot and improve safety when walking but may
result in increased strength of those muscles and increased range of motion at
the ankle joint. FES can also improve safety, ease, and efficiency with walking.
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Wikipedia
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Learning Objectives
1. Discuss purpose and parameters for use of
FES for neuromuscular rehabilitation.
2. Summarize current literature for use of FES
for management of impairments.
3. Review clinical cases and videos for creative
treatment application of FES.
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E Stim Basics:
Contraindications/Precautions
•Cardiac Demand Pacemaker-need MD permission
•Hx of Congestive Heart Failure-need MD permission
•Recent Myocardial Infarction-need MD permission
•De-conditioned elderly patients- need MD permission
•Pregnancy (esp. 1st and 3rd trimesters)
•Protruding metal ( staples or external fixation)
•Incision sites
•Skin abrasions
•Do not shave the skin sooner than two days before
Estim is applied. Use scissors to cut hair.
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E Stim Basics: Parameters
Clinical Neurophysiology Systematic Review – 19 studies
Peripheral electrical stimulation to induce cortical plasticity: A systematic
review of stimulus parameters
Mar2011, Volume 122, Issue 3, Pages 456-463
L.S. Chipchase, S.M. Schabrun, P.W. Hodges
• This review provides an overview of the electrical stimulation parameters
needed to induce cortical plasticity in human subjects.
• current data indicate that stimulation intensity may be an important factor
in determining the direction of rapid plastic change. In particular, there
was a trend for stimulation above motor threshold to increase excitability
of the corticomotor pathway.
• Electrical stimulation in the clinical setting is a feasible and inexpensive
application. It has been widely used although its potential for inducing
plastic change has been realized only recently.
• How ES can be used to induce clinically meaningful plastic change in
movement related disorders needs to be addressed
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E Stim Basics: Parameter Adjustment
Goal of Adjusting Parameters:
1. To achieve the most beneficial and
appropriate muscular contraction and in the
case of our presentation to achieve function
2. To maintain maximum patient comfort
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E Stim Basics: Parameters
Pulse Amplitude (Intensity)
Duration
Pulse Rate (Frequency)
Waveform
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E Stim Basics: Pulse Amplitude
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E Stim Basics: Duration
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E Stim Basics: Pulse Rate
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E Stim Basics: Waveform
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E Stim Basics: Current Density
• Smaller electrode: Greater current density
(may be less comfortable, but able to achieve
more “robust” contraction if over motor
point).
• Larger electrode: Lesser current density (may
be more comfortable, but will get more
“spreading” out of the charge and may not be
able to isolate particular muscle group as
well).
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E Stim Basics:
Algorithm for FES
Parameter
Adjustment
-Candy Tefertiller
PT, DPT
Estim
On/Off time Ex: 10:10
Phase Dep: Switch
Frequency 30-45 Hz
Pulse Width LE’s:300 ms
UE’s: 100-200ms
Contraction thru
Full Range?
YES
NO
Assess available ROM
And provide AAROM
Thru full range
↓Freq as low as
Possible w/ quality
contraction
If painful, ↑ pulse width
to highest comfortable
Then ↑ freq. up to 35 Hz
If no overflow, ↑
Freq up to 35 Hz and
 Amp to Reach tetany
If not painful, ↑ pulse
width up to 500ms and
Check for overflow
If overflow,  pulse
100ms,  Freq up to
35 Hz &  amp to tetany
E-Stim Basics: Dosage
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Principles to Enhance Neural Plasticity
 Use it or Lose it
 Time Matters
 Use it and Improve it
 Salience Matters
 Specificity Matters
 Age Matters
 Repetition Matters
 Transference
 Intensity Matters
 Interference
Kleim & Jones 2008; Hornby et al 2011
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E-stim Basics: Preparatory Methods
To optimize the quality of practice:
Overall Treatment Planning
• Evaluate and adjust for/treat:
ROM, Spasticity, Sensation
• Manage spasticity
– Tone reduction techniques,
meds, splinting/casting
• Postural interventions
• Assess Learning needs/best
environment for practice
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E-stim Basics: Preparatory Methods
To optimize the quality of practice:
Immediately before FES Practice
• Prepare ROM
– Stretching, PROM/AROM activities
• Reduce Spasticity
– Weightbearing, closed chain/modified
closed chain, heat/ice
• Adjust posture to match the task
– Consider props or other tools
• Adjust to learning needs of patient
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UnconINTERVENTIONS:
1.
2.
3.
4.
Muscle activation
Sensory awareness
Co-contraction
Paired with robotics
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Facilitating weight shift
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Parameters Used
•
•
•
•
•
•
•
Placement: right glutes
Pulse Rate: 35 pps
Pulse Width: 350 microseconds
Waveform: Symmetrical
Cycle: N/A: Single Channel
Amplitude: To motor contraction
Timing Characteristics: Left heel switch
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Facilitating weight shift while walking
• Case example:
• 26 yo male, s/p brain tumor rupture, 6 mos
post injury (outpatient)
• L hemiparesis with severe loss of
sensation/proprioception
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Facilitating weight shift
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Parameters Used
•
•
•
•
•
•
•
Placement: left tricep, left lower trapezius
Pulse Rate: 35 pps
Pulse Width: 350 microseconds
Waveform: Asymmetrical
Cycle: Simultaneous
Amplitude: To motor contraction
Timing Characteristics: 20 seconds on, 2
seconds off with 2 second ramp time
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Facilitating weight shift
• 45 yo female, s/p CVA
with right hemiparesis,
severe inattention and
proprioceptive loss, 1 yr
post injury (outpatient)
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Parameters Used
•
•
•
•
•
•
•
Placement: right triceps and right wrist extensors
Pulse Rate: 35 pps
Pulse Width: 350 microseconds
Waveform: Symmetrical
Cycle: Simultateous
Amplitude: To muscle contraction
Timing Characteristics: Heel switch under left
(uninvolved) foot, when pt shifts weight to
involved side, estim is triggered to the right
triceps and wrist extensors to stabilize lettuce
while cutting
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Shoulder Subluxation
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Parameters Used
• Placement: right supraspinatus, anterior
deltoid, infraspinatus, and middle deltoid
• Pulse Rate: 35 pps
• Pulse Width: 350 microseconds
• Waveform: Symmetrical
• Cycle: Simultaneous
• Amplitude: To muscle contraction
• Timing Characteristics: Used either 1:1 or 1:2
ratio, example 10 on, 10 off or 10 on, 20 off
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Functional Activity: Wheelchair Propulsion
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Parameters Used
•
•
•
•
•
•
•
Placement: left wrist extensors and triceps
Pulse Rate: 50 pps (for comfort)
Pulse Width: 300 microseconds
Waveform: Asymmetrical
Cycle: Simultaneous
Amplitude: To muscle contraction
Timing Characteristics: Hand switch to time
with activity
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Functional Activity: Handwriting
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Lip Closure for Swallowing
• 30s male, s/p TBI, 1 yr
post injury
(outpatient)
• Goal is to close lips
while swallowing, stop
drooling
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Parameters Used
•
•
•
•
•
•
•
Placement: Orbicularis oris
Pulse Rate: *
Pulse Width: *
Waveform: *
Cycle: Simultaneous
Amplitude: To muscle contraction
Timing Characteristics: 12 seconds on, 8 seconds
off
*Used parameters in the Vital Stim manual, co-tx
with speech therapist to set up home estim unit
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Using other tools to supplement
Using orthosis to keep fingers
straight while working on wrist
extension (pts fingers were
curling, negatively reinforcing a
“tenodesis” effect, which could
increase flexor tightness)
Using buddy strapping to
positively reinforce appropriate
grasp pattern with e-stim on
wrist/finger flexors
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Optimizing Practice
Wrist/finger extension practice,
note the bending of middle finger
Wrist/finger extension practice,
taping to middle finger to assist
with full extension
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Sensory Awareness
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Sensory level stim as a treatment option:
• Sensory level stim can be more beneficial than none
– Yan T, Hui-Chan CWY, Li LSW. Functional Electrical Stimulation Improves Motor
Recovery of the Lower Extremity and Walking Ability of Subjects With First Acute
Stroke A Randomized Placebo-Controlled Trial. Stroke 2005;36(1):80-85.
• Sensory level stim can improve hand/arm kinematics
– Koesler IBM et al. Electrical somatosensory stimulation improves movement
kinematics of the affected hand following stroke. Journal of Neurology,
Neurosurgery, and Psychiatry 2008.
• Sensory level stim on the arm can improve visual inattention
– Harding, P, Riddoch, MJ. Functional Electrical Stimulation (FES) of the upper limb
alleviates unilateral neglect: A case series analysis. Neuropsychological
Rehabilitation 2009, 19 (1), 41 –63.
• Sensory level stim can improve arousal in disorders of
consciousness
– Cooper EB et al. Electrical treatment of reduced consciousness: experience with
coma and Alzheimer’s disease. Neuropsychological Rehabilitation 2005, 15:289405.
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• Discussion on parameters for sensory
Look at NRN ???
High rate, low width -- Amy
35 rate – traditional pulse to point of muscle
contraction and back off.
Lower – would that trigger more awareness?
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Sensory Awareness
• Case example:
– 33 yo male s/p TBI, 1 year post injury, at Craig for
1 week re-evaluation, resolving right hemiparesis
– Has full active range of motion and can reach in all
planes against gravity, abnormal proprioception in
right hand
– Goal: increase right UE coordination
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Sensory Awareness
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Parameters Used
• Placement: Channel 1: Posterior forearm and
back of hand, Channel 2: Anterior forearm
• Pulse Rate: 65 pps
• Pulse Width: 250 microseconds
• Waveform: asymmetrical
• Cycle: simultaneous
• Amplitude: sensory level only
• Timing Characteristics: 20 seconds on, 2 seconds
off, with 2 second ramp
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Sensory Awareness – BITS
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Parameters Used
• Placement: left forearm (2 channels) OR left
wrist extensors and left scapula stabilizers
• Pulse Rate: 50 pps
• Pulse Width: 300 microseconds
• Waveform: symmetrical
• Cycle: simultaneous
• Amplitude: sensory level only, pt unable to feel
so took it to motor and went right below motor
threshold
• Timing Characteristics: Continuous for the task
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Sensory Awareness - Vision
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Parameters Used
• Placement: Right/left cheek OR right/left
upper neck and back
• Pulse Rate: 80 pps
• Pulse Width: 250 microseconds
• Waveform: asymmetrical
• Cycle: alternating
• Amplitude: sensory level only
• Timing Characteristics: 2-5 seconds
alternating
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Sensory Awareness: “Neglect”
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Parameters Used
•
•
•
•
•
•
•
Placement: Left arm
Pulse Rate: 50 pps
Pulse Width: 250 microseconds
Waveform: symmetrical
Cycle: simultaneous
Amplitude: sensory level and/or motor level
Timing Characteristics: 20 seconds on, 2
seconds off, 2 seconds ramp
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Comparing Sensory Parameters
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Co-contraction in Ataxia
Reference: Neuromuscular
electrical stimulation of the
median nerve facilitates low
motor cortex excitability in
patients with
spinocerebellar ataxia.
Chih-Chung Chen, Yu-Fen
Chuang, Hsiao-Chu Yang,
Miao-Ju Hsu, Ying-Zu Huang,
Ya-Ju Chang. Journal of
Electromyography and
Kinesiology. 2014
Case Example
2 years s/p GSW
Trunk & Limb Ataxia
Goal – Sustained upright
posture for balance &
function
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Co-Contraction in Ataxia
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Co-Contraction in Ataxia
Estim coming off
Estim turning on and sustained
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Sit to Stand in Ataxia
No estim and left lean
4 channels estim on trunk, note
upright head and posture
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STANDING Ataxia
No estim and left lean
4 channels estim on trunk, note
upright head and posture
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Parameters Used
•
•
•
•
•
•
•
Placement: 2 estim units: abs and erectors
Pulse Rate: 35 pps
Pulse Width: 350 microseconds
Waveform: Symmetrical
Cycle: Simultaneous
Amplitude: To motor contraction
Timing Characteristics: With hand switch to
time with task
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Sit to Stand in Ataxia: 1 year later
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Parameters Used
• Placement: 2 estim units: left abs and
erectors, left glutes
• Pulse Rate: 35 pps
• Pulse Width: 350 microseconds
• Waveform: Symmetrical
• Cycle: Simultaneous
• Amplitude: To motor contraction
• Timing Characteristics: With hand switch to
time with task
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Robotics/High-Tech
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FES Bike: RT300
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Alter G with Bioness
Case Example:
• Alter G
– Body weight support treadmill
• Bioness – with foot sensor
– L300 (anterior tib / peroneal stim)
– L300 plus (hamstring for this case – can be quads)
• 44 year old male, 6 months s/p L CVA, right
hemiparesis with apraxia
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Alter G with Bioness
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Erigo
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Armeo Power
• Inpatient Rehab s/p CVA
• Flaccid Right UE with
sublux
• Estim at sensory level
• Full robotic assist with
augmentative feedback
using ARMEO
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Future Applications
SAGE 6 channels per unit - simultaneous stim for all channels
Future Goal is remote and patterned
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Translation Into Your Practice
• Low cost options for home and clinic use
• Patient and family independent in use to
maximize neuroplasticity
• Remember to integrate neuroplasticity
principles and appropriate preparatory
methods
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Translation into your Practice
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Questions/Discussion
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References
1.
L.S. Chipchase, S.M. Schabrun, P.W. Hodges. Peripheral electrical stimulation to induce cortical plasticity: A systematic
review of stimulus parameters. Clin Electrophysiology. 2011; 122(3):456-463.
2. Yan T, Hui-Chan CWY, Li LSW. Functional Electrical Stimulation Improves Motor Recovery of the Lower Extremity and
Walking Ability of Subjects With First Acute Stroke A Randomized Placebo-Controlled Trial. Stroke 2005;36(1):80-85.
3. Koesler IBM, Dafotakis M, Ameli M, Fink GR, Nowalk DA. Electrical somatosensory stimulation improves movement
kinematics of the affected hand following stroke. J Neurol Neurosurg Psychiatry 2009;80:614-619.
4. Cooper EB, Scherder EJA, Cooper JB. Electrical treatment of reduced consciousness: experience with coma and
Alzheimer’s disease. Neuropsychological Rehab 2005;15:289-405.
5. Harding, P, Riddoch, MJ. Functional Electrical Stimulation (FES) of the upper limb alleviates unilateral neglect: A case
series analysis. Neuropsychological Rehab 2009;19 (1):41 –63.
6. Chih-Chung Chen, Yu-Fen Chuang, Hsiao-Chu Yang, Miao-Ju Hsu, Ying-Zu Huang, Ya-Ju Chang. Neuromuscular
electrical stimulation of the median nerve facilitates low motor cortex excitability in patients with spinocerebellar ataxia. J of
Electromyography Kinesiol.. 2015;25(1):143-150.
7. Tefertiller C, Pharo B, Evans N, Winchester P. Efficacy of rehabilitation robotics for walking training in neurological
disorders: a review. J Rehabil Res Dev. 2011;48(4):387-416.
8. Bethoux F, Rogers HL, Nolan KJ, Abrams GM, Annaswamy T, Brandstater M, Browne B, Burnfield JM, Feng W, Freed MJ,
Geis C, Greenberg J, Gudesblatt M, Ikramuddin F, Jayaraman A, Kautz SA, Lutsep HL, Madhavan S, Meilahn J, Pease WS,
Rao N, Seetharama S, Sethi P, Turk MA, Wallis RA, Kufta C. Long-Term Follow-up to a Randomized Controlled Trial
Comparing Peroneal Nerve Functional Electrical Stimulation to an Ankle Foot Orthosis for Patients With Chronic Stroke.
Neurorehabil Neural Repair. 2015 Feb 4. pii: 1545968315570325. [Epub ahead of print].Additional references will be utilized,
this is just a synopsis.
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