Functional Electrical Stimulation in Neurorehabilitation

This following is an edited transcript from a live course titled, Functional Electrical Stimulation in Neurorehabilitation, by Jill Seale, PT, PhD, NCS.  It is recommended to follow along with course handout to thoroughly understand course material.  Jill Seale: Learning Objectives ·       Define functional electrical stimulation (FES)·       Identify the possible mechanisms for therapeutic benefit from FES·       Identify the common uses for FES in neurological rehabilitationo   FES for shoulder subluxationo   FES for upper extremity functiono   FES for ambulationo   FES for exercise·       Appraise the current best evidence for the use of FES in persons with neurological diagnosis·       Develop treatment plans for use of FES in actual patient cases (paper and video)  My goal today is to do a quick review of what functional electrical stimulation is, how it is different from just neuromuscular electrical stimulation, the basics of how we are going to use it in terms of contraindications, parameters, etc., but more specifically focus on who we use it on, when do we use it and how we make those clinical decisions. The second part of the course will focus on what types of patients we would use this intervention for and how we would use this as an augment to our treatment, not just as the treatment.  Those are the goals that I have for this course. Functional Electrical Stimulation What is functional electrical stimulation?  Everyone probably knows this already as you learn this in your basic undergraduate curriculum.  It is the use of neuromuscular electrical stimulation, but specifically to enhance the control of movement.  It is used to replace, assist, or substitute for someone's voluntary movement when motor function has been impaired such that there is some motor dysfunction.  The goal is to improve performance of an activity or a better phrase would be to improve function.  Performance implies that we are talking about something that is short term, and we really want to improve overall function.  You can even go a step further to add there that the goal is to improve motor learning.  We are familiar with the common diagnoses, but we can use this with patients with stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, or many other neurological diagnoses.  The four that are l mentioned are the ones we will focus on today. One of the things we sometimes struggle with, with our patients with stroke or other diagnoses (I will reference stroke frequently as it is the most common thing that we see by the sheer number of people that have it), is how we can make that little bit of movement that they have intact into a bigger, stronger, more functional movement.  I think that idea of replacing or assisting a person's voluntary movement when motor function is impaired is something that we all struggle with.  One of the ways we can use functional electrical stimulation, or FES, is to help them reconnect.  It is not that the nerve is not there and working.  The nerve is there and intact, but we are helping them be able to find that connection, strengthen that connection, and then attach that connection into a functional task.  Keep in mind that when we are talking about functional electrical stimulation in the context that we are talking about in this course, we are talking about neurological diagnoses that involve an upper motor neuron lesion.  All of the things we are talking about in this course refer to diagnoses that are upper motor neuron in nature.  The peripheral nerve needs to be intact.  Difference Between NMES vs FES We need to distinguish what is different between FES and what we would consider just traditional or normal neuromuscular electrical stimulation.  They both substitute for or augment voluntary contractions and used for strengthening of hypertrophy.  Both of these interventions can be used for those common purposes.  The difference is for traditional NMES, it is part of a training program that we are doing with the goal of increasing strength.  You might have a consequential goal of increasing some function, but the goal of the protocol is to increase strength, whereas with FES, the goal is to use that electrical stimulation to promote a functional activity.  We are putting it into a functional task.  Sometimes I think an oversimplified way that you can think about the differences between an NMES and FES is that an NMES for the most part is going to be passive versus FES is going to be active.  You might also think of FES as being a goal directed activity and this becomes important because if you think back to what we know about motor learning being goal directed or goal oriented, it is very important and a necessary component in order to have motor learning occur.  Active involvement of the participant of the patient is also necessary in order for motor learning to occur.   These are important distinctions between an NMES and FES.  Benefits of NMES To summarize the benefits of NMES, there is evidence that shows that NMES increases voluntary strength in all of those diagnoses, but there is no evidence and not a real clear picture whether or not those translate into changes in function.  NMES is better than no intervention, but we are not really sure that it is better than progressive resistive training for strengthening.  We are also not sure if it has an additive benefit on to traditional training.  What seems to be missing is that connection or that improvement in function.  There is a lack of functional improvement, despite that there may be an increase in strength.  This makes sense if you really think again back to motor learning.  There is more than just one component of relearning and rehabbing a task.  I will say a benefit of NMES is it is a way to get more repetition of muscle contraction. It is a way to get more repetition of muscle contraction without skilled intervention.  Once you have set up the patient and given them a portable device (if they can set up the equipment themselves or have a caregiver), it is...