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Stimulating Technology for the Future: Proceedings of the Fifth Conference of the UK and Ireland Chapter of the International Functional Electrical Stimulation Society, Sheffield, UK, 8th – 9th May 2015

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Proceedings of the Fifth Conference of the UK and Ireland Chapter of the International Functional Electrical Stimulation Society (IFESSUKI), Sheffield, UK, 8th – 9th May 2015. Keynote Lectures: Functional Electrical Stimulation; Nair KPS. Magnetic Nerve Stimulation – reaching the parts other stimulators cannot reach; Barker AT. iCycle: electrical stimulation for motor recovery in spinal cord injury; Donaldson N. FES to Address Foot Drop: Impact of Functional Electrical Stimulation on Walking Speed, Clinically Meaningful Changes and Functional Walking Category for Multiple Sclerosis; Street T, Taylor P, Swain I. Effect of FES in patients with Hereditary Spastic Paraparesis; Chandy BR, Clarke A, McDermott CJ, Nair S. Impact of Functional Electrical Stimulation on Fear of Falling and Participation for people with Multiple Sclerosis and Stroke; Street T, Taylor P, Swain I. A service evaluation comparing the effectiveness of functional electrical stimulation compared to ankle foot orthosis for Multiple Sclerosis related dropped foot; Dimunge A, Taylor P, Street T, Wood D. The effect of dropped foot stimulation on walking speed for People with Multiple Sclerosis – a longitudinal study; Singleton C, Street T. Development of FES Services: A questionnaire study exploring the current use and non-use of functional electrical stimulation in spinal cord injury; Tedesco Triccas L, Donovan-Hall M, Burridge JH, Ellis-Hill C, Dibb B, Rushton D. Development of FES clinical commissioning guidelines: a case study; Tang K, Marchant S, Michael S. New Techniques for Delivering FES: Repetitive Control Based Tremor Suppression Using Electrical Stimulation; Copur EH, Freeman CT, Chu B, Laila DS. Sensory Barrage Stimulation is effective in reducing elbow spasticity: a crossover double blind randomized pilot trial; Slovak M, Chindo J, Nair S, Reeves ML, Heller B, Barker AT. Does Functional Electrical Stimulation improve stability as seen through plantar pressure measurement during stance phase of the gait cycle?; Ward S, Bowtell M, Shortland A, Tasker L. Correction of Dropped foot due to multiple sclerosis using the STIMuSTEP implanted Dropped foot Stimulator. Long term follow up.; Taylor P, Wilkinson I, Slade-Sharman D, Khan M. Two-channel stimulation for the correction of drop foot; Merson E, Swain ID, Taylor PN, Cobb JE. Comparing the effects of Functional Electrical Stimulation and Ankle Foot Orthosis to treat foot drop in people with MS. A non-randomised trial; Van der Linden M, Scott S, Hooper J, Cowan P, Weller B Mercer T. Using New Technology in the FES Setting: Novel methods of using accelerometry for upper limb FES control; Sun M, Howard D, Kenney LP, Smith CL, Waring K, Luckie H. Portable Brain Computer Interface and Functional Electrical Stimulation for Home-Based Sensorimotor Training; Al Taleb MK, Breslin S, Vuckovic A. Accelerometer-Triggered Functional Electrical Stimulation For Recovery of Upper Limb Function in Chronic Stroke Patients: A Randomised Trial; Taylor P, Mann G, Esnouf J, Luckie H, Waring K, McFadden C, Smith C, Kenney L. Upper limb electrical stimulation and robotic assisted therapy: A feasibility study; van der Walt A. Fabrication and Evaluation of Screen Printed Fabric Electrode Arrays; Yang K, Freeman CT, Torah R, Beeby S, Tudor J. Upper Limb Stroke Rehabilitation combining Electrode-Arrays with Low-cost Sensing and Advanced Control; Kutlu MC, Freeman CT, Hallewell E, Hughes AM, Laila DS. Novel Uses of FES: Functional Electrical Stimulation (FES): a potential method of Deep Vein Thrombosis (DVT) prevention in acute stroke patients?; Papworth NJ, Swain ID, Harris L. Home based therapeutic application of non-invasive posterior tibial nerve stimulation in the treatment of overactive bladder symptoms: a clinical trial; Slovak M, Hillary C, Barker AT, Chapple C. FES Cycling & Rowing: Power Generation during FES-Assisted Rowing in Spinal Cord Injury; McCarthy I, Gibbons R, Richards R, Andrews BJ. Short Term Effects of Functional Electrical Stimulation assisted cycling in People with Multiple Sclerosis – a pilot study; White M, Fryer IT, White HSF. Using FES for Exercise: Strength training with Neuromuscular Electrical Stimulation, Is the response similar in younger and older adults?; Griffiths L, Stewart C, Pandyan A. FES: A combined modality approach to support the rehabilitation in an adolescent with Transverse Myelitis; Hodgkinson K, Wright E. Case Study: Electrical Stimulation to the abdominals of a Stroke patient to improve walking; Turner-Smith T, Singleton C. Poster Presentations: Use of a Mobile Gait Analysis System to assess the Immediate and Long- term Effects of a Dropped Foot Stimulator on Walking in Stroke Patients; Whittaker M, Sabbaghan A, Holstrom L. Combined dropfoot treatment using dynamic splinting with FES: a case study; Lane RP, Chappell PH, Matthews MJA. A model to predict setup time for a novel upper limb FES system; Smith C, Kenney LP, Howard D, Hardiker N, Waring K, Sun M, Luckie H. Establishing an Outpatient Neuromuscular electrical stimulation (NMES) service: A review of early outcomes; Jones H, Bull K, Seary C, Steadman H, Farrell R. Control of Upper Limb FES Devices Using a Shoulder Position Sensor Based on an Inertial Measurement System; Venugopalan L, Swain ID, Cobb JE, Taylor PN. A systematic review of functional electrical stimulation for foot-drop of central neurological origin and its orthotic effect on walking; Prenton S, Hollands K, Kenney LPG. Functional Electrical Stimulation (FES) Service Patient Satisfaction Survey (n=138); Peace C, Singleton C. A comparison of Functional Electrical Stimulation and Ankle Foot Orthoses for the treatment of foot drop in Multiple Sclerosis; Miller L, Paul L, Rafferty D, Bowers R, Smith A, Mattison P. Quality of Life following the use of Functional Electrical Stimulation for Multiple Sclerosis; Street T, Taylor P, Swain I. A Clinically Meaningful Training Effect in Walking Speed using Functional Electrical Stimulation for Incomplete Spinal Cord Injury; Street T, Singleton C. Functional Electrical Stimulation, Impaired Gross Motor Control and Mobility Improvement; Bo KM. A practical, yet flexible functional electrical stimulation system for upper limb functional rehabilitation; Kenney L, Howard D, Smith C, Hardiker N, Williamson T, Taylor P, Finn S. Hospital and home-based feasibility study of iCycle for functional recovery after incomplete spinal cord injury (SCI); Al-Ahmary A, Burridge J, Donaldson N, Pearce J, Summers R, Gall A, Paddison S, Bulpitt S.
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Proceedings of the 5th Conference of IFESSUK&I, Sheffield,
2015
5th Conference of the
UK and Ireland Chapter
of the International
Functional Electrical
Stimulation Society
Sheffield, UK
8th 9th May 2015
Proceedings
Stimulating Technology for the Future
Photographs courtesy of Sheffield City Council
Stimulating Technology for the Future Introduction
IFESS UK&I Conference Sheffield 2015 1 Conference Proceedings
Proceedings of the Fifth Conference of the
UK and Ireland Chapter of the International
Functional Electrical Stimulation Society,
Sheffield, UK, 8th 9th May 2015
Editors
Mark L Reeves
Jill M van der Meulen
Organising Committee
Jill van der Meulen
Sheffield Teaching Hospitals
Mark Reeves
Sheffield Teaching Hospitals
Brigitte Kaviani
Sheffield Teaching Hospitals
Alison Clarke
Sheffield Teaching Hospitals
Ben Heller
Sheffield Hallam University
Chris Monk
Sheffield Teaching Hospitals
Amy Scarfe
Sheffield Teaching Hospitals
Scientific Committee
Paul Taylor
Salisbury NHS Foundation Trust
Christine Singleton
Birmingham Community Healthcare NHS Trust
Laurence Kenney
University of Salford
Nick Donaldson
University College London
Anand Pandyan
Keele University
Henrik Gollee
University of Glasgow
Stimulating Technology for the Future Introduction
IFESS UK&I Conference Sheffield 2015 2 Conference Proceedings
President’s Welcome
Welcome to the UK and Republic of Ireland chapter of the International FES Society’s fifth annual
scientific meeting.
The aim IFESSUKI is to provide a forum for interchange of ideas and opinions for all who have an
interest in use of electrical stimulation in the rehabilitation of people who have medical conditions.
IFESSUKI is multi-disciplinary and brings together clinical practitioners using FES in the clinic,
engineers developing and testing new applications and the basic scientists progressing our
understanding. We also welcome those who have a commercial interest in bringing FES to a wider
health care community and in particular thank the meeting sponsors. Please take some time to visit
their stands.
Please let us know if you have ideas for how UKRI-IFESS can better achieve its aims. We need your
support. I also urge you to become members of IFESS. Membership will enable you to keep up to
date with IFESS news through the new IFESS Newsletter and will also give a discount for future IFESS
meetings. You can find out more about membership at www.ifess.org.
Finally I would like to thank Dr Jill van der Meulen and the team in Sheffield for putting together
such a high quality meeting. I hope you enjoy the meeting and hope that through shared learning
and new contacts we may further the field of FES.
Paul Taylor
President of UKRI-IFESS
Stimulating Technology for the Future Introduction
IFESS UK&I Conference Sheffield 2015 3 Conference Proceedings
Conference Programme
08:30
Registration
09:30
Housekeeping and Welcome Address
(Jill van der Meulen and Paul Taylor)
09:40
Keynote Lecture: Functional Electrical Stimulation
(Dr Siva Nair, Sheffield Teaching Hospitals NHS Foundation Trust)
FES to Address Foot Drop
(Chair: Jill van der Meulen and Paul Taylor)
10:10
O1: Impact of Functional Electrical Stimulation on Walking Speed, Clinically Meaningful Changes and Functional Walking
Category for Multiple Sclerosis (Tamsyn Street, Salisbury Foundation Trust NHS)
10:30
O2: Effect of FES in patients with Hereditary Spastic Paraparesis
(Bobeena Chandy, Sheffield Teaching Hospitals NHS Foundation Trust)
10:50 Poster Teaser Session
11:20 Break
FES to Address Foot Drop
(Chair: Alison Clarke and Laurence Kenney)
11:40
O3: Impact of Functional Electrical Stimulation on Fear of Falling and Participation for people with Multiple Sclerosis and Stroke
(Tamsyn Street, Salisbury Foundation Trust NHS)
12:00
O4: A service evaluation comparing the effectiveness of functional electrical stimulation compared to ankle foot orthosis for
Multiple Sclerosis related dropped foot. (Agraja Dimunge, National Clinical FES Centre, Salisbury)
12:20
O5: The effect of dropped foot stimulation on walking speed for People with Multiple Sclerosis – a longitudinal study
(Christine Singleton, Birmingham Community Healthcare NHS Trust)
12:40
Sponsors: Biosense Medical, Cyclone, Odstock Medical, Ottobock, Trulife
13:00 Lunch & Poster Session
13:45 Panel Discussion: Commissioning FES Services
Development of FES Services
(Chair: Chris Monk and Tamsyn Street)
14:30
O6: A questionnaire study exploring the current use and non-use of functional electrical stimulation in spinal cord injury
(Lisa Tedesco Triccas, University of Southampton)
14:50
O7: Development of FES clinical commissioning guidelines: a case study
(Simon Marchant, Leeds Teaching Hospitals)
15:10 Break
New Techniques for Delivering FES
(Chair: Christine Singleton and Ben Heller)
15:30
O8: Repetitive Control Based Tremor Suppression Using Electrical Stimulation
(Engin Hasan Copur, University of Southampton)
15:50
O9: Sensory Barrage Stimulation is effective in reducing elbow spasticity: a crossover double blind randomized pilot trial
(Martin Slovak, Sheffield Teaching Hospitals NHS Foundation Trust)
16:10
O10: Does Functional Electrical Stimulation improve stability as seen through plantar pressure measurement during stance
phase of the gait cycle? (Sarah Ward, Morriston Hospital, Swansea)
16:30
O11: Correction of Dropped foot due to multiple sclerosis using the STIMuSTEP implanted Dropped foot Stimulator. Long term
follow up. (Paul Taylor, Salisbury District Hospital)
16:50
O12: Two-channel stimulation for the correction of drop foot
(Earl Merson, Bournemouth University)
17:10
O13: Comparing the effects of Functional Electrical Stimulation and Ankle Foot Orthosis to treat foot drop in people with MS. A
non-randomised trial. (Marietta van der Linden, Queen Margaret University)
17:30 Close
19:00
Drinks Reception at Cutlers' Hall
Cutlers' Hall, Church Street, Sheffield, S1 1HG. www.cutlershall.co.uk
19:30 Conference Dinner
Friday 8th May
Stimulating Technology for the Future Introduction
IFESS UK&I Conference Sheffield 2015 4 Conference Proceedings
Using New Technology in the FES Setting
(Chair: Jill van der Meulen and Laurence Kenney)
09:00
O14: Novel methods of using accelerometry for upper limb FES control
(Mingxu Sun, University of Salford)
09:20
O15: Portable Brain Computer Interface and Functional Electrical Stimulation for Home-Based Sensorimotor Training
(Manaf Al-Taleb, University of Glasgow)
09:40
O16: Accelerometer-Triggered Functional Electrical Stimulation For Recovery of Upper Limb Function in Chronic Stroke
Patients: A Randomised Trial (Paul Taylor, Salisbury NHS Foundation Trust)
10:00
O17: Upper limb electrical stimulation and robotic assisted therapy: A feasibility study
(Aisling van der Walt, The Wellington Hospital, London)
10:20
O18: Fabrication and Evaluation of Screen Printed Fabric Electrode Arrays
(Kai Yang, University of Southampton)
10:40
O19: Upper Limb Stroke Rehabilitation combining Electrode-Arrays with Low-cost Sensing and Advanced Control
(Mustafa Cagri Kutlu, University of Southampton)
11:00 Break
11:20
Keynote Lecture: Magnetic Nerve Stimulation - reaching the parts other stimulators cannot reach
(Prof Tony Barker)
Novel Uses of FES
(Chair: Chris Monk and Mark Reeves)
12:20
O20: Functional Electrical Stimulation (FES): a potential method of Deep Vein Thrombosis (DVT) prevention in acute stroke
patients? (Neil Papworth, Salisbury NHS Foundation Trust)
12:40
O21: Home based therapeutic application of non-invasive posterior tibial nerve stimulation in the treatment of overactive bladder
symptoms: a clinical trial (Martin Slovak, Sheffield Teaching Hospitals NHS Foundation Trust)
13:00 Lunch & Poster Session
14:00
Keynote Lecture: iCycle: electrical stimulation for motor recovery in spinal cord injury
(Prof Nick Donaldson, University College London)
FES Cycling and Rowing
(Chair: Ben Heller and Christine Singleton)
15:00
O22: Power Generation during FES-Assisted Rowing in Spinal Cord Injury
(Ian McCarthy, University College London)
15:20
O23: Short Term Effects of Functional Electrical Stimulation assisted cyc ling in People with Multiple Sclerosis – a pilot study
(Matt White, Cyclone Technologies Ltd, Ottringham)
15:40 Break
Using FES for Exercise
(Chair: Siva Nair and Alison Clarke)
16:00
O24:Strength training with Neuromuscular Electrical Stimulation, Is the response similar in younger and older adults?
(Anand Pandyan on behalf of Leanne Griffiths, St. Mary’s University, Twickenham)
16:20
O25: FES: A combined modality approach to support the rehabilitation in an adolescent with Transverse Myelitis
(Karen Hodgkinson, Birmingham Children’s Hospital)
16:40
O26: Case Study: Electrical Stimulation to the abdominals of a Stroke patient to improve walking
(Carla Peace, Birmingham Community Healthcare NHS Trust)
17:00 Close
Saturday 9th May
Stimulating Technology for the Future Introduction
IFESS UK&I Conference Sheffield 2015 5 Conference Proceedings
Sponsors
The organising committee would like to thank the sponsors for supporting the IFESSUKI 2015
conference in Sheffield.
Stimulating Technology for the Future Introduction
IFESS UK&I Conference Sheffield 2015 6 Conference Proceedings
Keynote Speakers
Dr K P S Nair
Siva Nair qualified in medicine from Kerala, India and trained at Rivermead Rehabilitation Centre,
Oxford. He is a consultant in Neurology with Sheffield Teaching Hospitals NHS Foundation Trust and
has held this post for over 10 years. His special interest is management of patients with disabilities
due to long term neurological conditions, especially Multiple sclerosis. His research interests include
functional electrical stimulation, spasticity and multiple sclerosis. He has 30 publications in various
peer reviewed journals including Medical Engineering and Physics, British Medical Journal and
Archives of Physical Medicine and Rehabilitation.
Professor A T Barker
Tony retired from the NHS earlier this year after 38 years in the Sheffield Department of Medical
Physics and Clinical Engineering. He has specialised in a number research areas during his NHS
career, including the effects of electromagnetic fields on the body (both detrimental and
therapeutic), electrical stimulation of nerves, Functional Electrical Stimulation and medical device
development. Tony led the group which invented the technique of Transcranial Magnetic
Stimulation, now widely used throughout the world for basic research, diagnosis and therapy, and
also the group which developed the first self-optimising, array based, FES stimulator for foot drop.
He has led numerous professional committees and currently is the long-standing chairman of the
Biological Effects of Low-Level Electromagnetic Fields Policy Advisory Group of the Institution of
Engineering and Technology. Tony has an active interest in the public understanding of science and
has given many public lectures including the Faraday lecture series, the Silvanus P Thomson series
and a Royal Institution Discourse.
Professor N Donaldson
Nick has led the Implanted Devices Group at University College London since 1992 and it the
Professor of Neuroprosthesis Engineering. Formally he was on Scientific Staff at the MRC
Neurological Prostheses Unit, working under Professor Giles Brindley. He has designed several
human implants, notably the Lumbar Anterior Root Stimulator, that was tested at Salisbury, and the
first neural signal telemeter that was used in Aalborg. His research interests are in FES, implant
technology, neuroprosthesis, nerve interfaces and neuroplasticity.
Stimulating Technology for the Future Abstracts
IFESS UK&I Conference Sheffield 2015 7 Conference Proceedings
Abstracts
Keynote Lectures
Functional Electrical Stimulation
Nair KPS 11
Magnetic Nerve Stimulation reaching the parts other stimulators cannot reach
Barker AT 12
iCycle: electrical stimulation for motor recovery in spinal cord injury
Donaldson N 13
FES to Address Foot Drop
Impact of Functional Electrical Stimulation on Walking Speed, Clinically Meaningful Changes and
Functional Walking Category for Multiple Sclerosis
Street T, Taylor P, Swain I 15
Effect of FES in patients with Hereditary Spastic Paraparesis
Chandy BR, Clarke A, McDermott CJ, Nair S 16
Impact of Functional Electrical Stimulation on Fear of Falling and Participation for people with
Multiple Sclerosis and Stroke
Street T, Taylor P, Swain I 18
A service evaluation comparing the effectiveness of functional electrical stimulation compared to
ankle foot orthosis for Multiple Sclerosis related dropped foot
Dimunge A, Taylor P, Street T, Wood D 20
The effect of dropped foot stimulation on walking speed for People with Multiple Sclerosis a
longitudinal study
Singleton C, Street T 22
Development of FES Services
A questionnaire study exploring the current use and non-use of functional electrical stimulation in
spinal cord injury
Tedesco Triccas L, Donovan-Hall M, Burridge JH, Ellis-Hill C, Dibb B, Rushton D 25
Development of FES clinical commissioning guidelines: a case study
Tang K, Marchant S, Michael S 27
New Techniques for Delivering FES
Repetitive Control Based Tremor Suppression Using Electrical Stimulation
Copur EH, Freeman CT, Chu B, Laila DS 29
Sensory Barrage Stimulation is effective in reducing elbow spasticity: a
crossover double blind randomized pilot trial
Slovak M, Chindo J, Nair S, Reeves ML, Heller B, Barker AT 30
Does Functional Electrical Stimulation improve stability as seen through plantar pressure
measurement during stance phase of the gait cycle?
Ward S, Bowtell M, Shortland A, Tasker L 32
Correction of Dropped foot due to multiple sclerosis using the STIMuSTEP implanted Dropped foot
Stimulator. Long term follow up.
Taylor P, Wilkinson I, Slade-Sharman D, Khan M 34
Stimulating Technology for the Future Abstracts
IFESS UK&I Conference Sheffield 2015 8 Conference Proceedings
Two-channel stimulation for the correction of drop foot
Merson E, Swain ID, Taylor PN, Cobb JE 35
Comparing the effects of Functional Electrical Stimulation and Ankle Foot Orthosis to treat foot
drop in people with MS. A non-randomised trial
Van der Linden M, Scott S, Hooper J, Cowan P, Weller B Mercer T. 36
Using New Technology in the FES Setting
Novel methods of using accelerometry for upper limb FES control
Sun M, Howard D, Kenney LP, Smith CL, Waring K, Luckie H 38
Portable Brain Computer Interface and Functional Electrical Stimulation for Home-Based
Sensorimotor Training
Al Taleb MK, Breslin S, Vuckovic A 39
Accelerometer-Triggered Functional Electrical Stimulation For Recovery of Upper Limb Function in
Chronic Stroke Patients: A Randomised Trial
Taylor P, Mann G, Esnouf J, Luckie H, Waring K, McFadden C, Smith C, Kenney L 40
Upper limb electrical stimulation and robotic assisted therapy: A feasibility study
van der Walt A 41
Fabrication and Evaluation of Screen Printed Fabric Electrode Arrays
Yang K, Freeman CT, Torah R, Beeby S, Tudor J 42
Upper Limb Stroke Rehabilitation combining Electrode-Arrays with Low-cost Sensing and
Advanced Control
Kutlu MC, Freeman CT, Hallewell E, Hughes AM, Laila DS 43
Novel Uses of FES
Functional Electrical Stimulation (FES): a potential method of Deep Vein Thrombosis (DVT)
prevention in acute stroke patients?
Papworth NJ, Swain ID, Harris L 45
Home based therapeutic application of non-invasive posterior tibial nerve stimulation in the
treatment of overactive bladder symptoms: a clinical trial
Slovak M, Hillary C, Barker AT, Chapple C 47
FES Cycling & Rowing
Power Generation during FES-Assisted Rowing in Spinal Cord Injury
McCarthy I, Gibbons R, Richards R, Andrews BJ 50
Short Term Effects of Functional Electrical Stimulation assisted cycling in People with Multiple
Sclerosis a pilot study
White M, Fryer IT, White HSF 51
Using FES for Exercise
Strength training with Neuromuscular Electrical Stimulation, Is the response similar in younger and
older adults?
Griffiths L, Stewart C, Pandyan A 54
FES: A combined modality approach to support the rehabilitation in an adolescent with Transverse
Myelitis
Hodgkinson K, Wright E 56
Case Study: Electrical Stimulation to the abdominals of a Stroke patient to improve walking
Stimulating Technology for the Future Abstracts
IFESS UK&I Conference Sheffield 2015 9 Conference Proceedings
Turner-Smith T, Singleton C 59
Poster Presentations
Use of a Mobile Gait Analysis System to assess the Immediate and Long- term Effects of a Dropped
Foot Stimulator on Walking in Stroke Patients
Whittaker M, Sabbaghan A, Holstrom L 62
Combined dropfoot treatment using dynamic splinting with FES: a case study
Lane RP, Chappell PH, Matthews MJA 64
A model to predict setup time for a novel upper limb FES system
Smith C, Kenney LP, Howard D, Hardiker N, Waring K, Sun M, Luckie H 65
Establishing an Outpatient Neuromuscular electrical stimulation (NMES) service: A review of early
outcomes
Jones H, Bull K, Seary C, Steadman H, Farrell R 66
Control of Upper Limb FES Devices Using a Shoulder Position Sensor Based on an Inertial
Measurement System
Venugopalan L, Swain ID, Cobb JE, Taylor PN 67
A systematic review of functional electrical stimulation for foot-drop of central neurological origin
and its orthotic effect on walking
Prenton S, Hollands K, Kenney LPG 68
Functional Electrical Stimulation (FES) Service Patient Satisfaction Survey (n=138)
Peace C, Singleton C 69
A comparison of Functional Electrical Stimulation and Ankle Foot Orthoses for the treatment of
foot drop in Multiple Sclerosis
Miller L, Paul L, Rafferty D, Bowers R, Smith A, Mattison P 71
Quality of Life following the use of Functional Electrical Stimulation for Multiple Sclerosis
Street T, Taylor P, Swain I 72
A Clinically Meaningful Training Effect in Walking Speed using Functional Electrical Stimulation for
Incomplete Spinal Cord Injury
Street T, Singleton C 74
Functional Electrical Stimulation, Impaired Gross Motor Control and Mobility Improvement
Bo KM 75
A practical, yet flexible functional electrical stimulation system for upper
limb functional rehabilitation
Kenney L, Howard D, Smith C, Hardiker N, Williamson T, Taylor P, Finn S 76
Hospital and home-based feasibility study of iCycle for functional recovery after incomplete spinal
cord injury (SCI)
Al-Ahmary A, Burridge J, Donaldson N, Pearce J, Summers R, Gall A, Paddison S, Bulpitt S 77
Author Index
Author Index 79
Stimulating Technology for the Future Keynote Lectures
IFESS UK&I Conference Sheffield 2015 10 Conference Proceedings
Keynote Lectures
Stimulating Technology for the Future Keynote Lectures
IFESS UK&I Conference Sheffield 2015 11 Conference Proceedings
Functional Electrical Stimulation
Nair KPS
Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust
The FES is becoming an established option for treatment of foot drop in people with disorders of
upper motor neuron. It is approved by NICE for correcting foot drop in upper motor neurone
conditions. In addition to improving the speed of walking the FES has the potential to improve the
safety of walking and to reduce falls. A reduction in falls improves patients’ confidence which in turn
increase their activity. Reducing the number of trips and falls reduces hospital admissions and
improves patient safety. Patients may require less support for mobility and the general activities of
daily living. Most of the studies on FES were done in gait laboratories and use measures like speed of
walking and energy expenditure as primary outcome measures. These measures may not reflect the
patients’ experience with the FES in the community.
There is pressure on the NHS to fund it. Some areas do fund it and some don’t; hence it is possible
that the NHS may be either wasting money or they may be denying an effective treatment. We need
studies of FES with patient reported outcome measures, quality of life and activities of daily living.
Given the potential for FES to improve mobility and provide a cost effective alternative to current
standard care i.e AFO; there is an urgent need for comprehensive multi centric randomised control
trials of this intervention.
There are other possible uses for the technology of FES. There are reports on its use in treatment of
Parkinson’s disease, weakness of upper limb and dysphagia. The electrical stimulation of the
peripheral nerves do have the capacity to modify the plasticity of the central nervous system. The
technology used in FES can be potentially used to facilitate neuronal recovery following insults such
as stroke or head injury. It could be used to treat conditions like spasticity and central neuropathic
pain. The avenues worth exploring include recovery of arm function following stroke and treatment
of neglect.
Questions for future research include
Is Functional Electrical more effective than standard orthotic interventions in the NHS
setting?
What is the cost effectiveness of FES?
Are there any factors which can predict whether a given patient respond to FES or AFO?
What is the role of FES in treatment of upper limb weakness?
Does FES facilitate recovery following stroke and head injury?
Does it have a role in treatment of conditions like spasticity and neglect?
What is the role of FES in Parkinson’s disease?
Stimulating Technology for the Future Keynote Lectures
IFESS UK&I Conference Sheffield 2015 12 Conference Proceedings
Magnetic Nerve Stimulation reaching the parts
other stimulators cannot reach
Barker AT
Electrical stimulation of nerves and muscles was first demonstrated in the 1790’s and is today widely
used in diagnosis and therapy. Whilst effective in many applications, it has some disadvantages. It
can be painful, it is difficult to non-invasively stimulate deep structures, and the human brain is
relatively inaccessible because the high electrical resistance of the skull which limits penetration of
applied currents.
An alternative method of neuronal stimulation is to induce currents in the body using a time-varying
magnetic field, based on the phenomenon of Electromagnetic Induction discovered by Michael
Faraday in 1831. In 1975 research started in the Sheffield department of Medical Physics on what
was to become a ten year ‘blue skies’ research project to investigate the practicality of stimulating
nerves with induced currents. We described supramaximal peripheral stimulation in 1982 and
widespread interest was generated by our first demonstration, of transcranial magnetic stimulation
(TMS) in 1985.
The technique has the advantage of being able to readily stimulate deep neural structures and, in
particular, the human brain. The skull presents no barrier because the magnetic fields pass through
it without attenuation. Stimulation is also relatively painless and this lack of discomfort enables the
technique to be readily used on both patients and volunteers.
Magnetic stimulation uses a brief but intense magnetic field pulse (up to 4 Tesla peak, dependent on
coil size, with a rise time of ~100μsec) to induce the required currents. The construction of magnetic
stimulators presents some engineering challenges. Voltages of up to 4kV and currents of up to 8kA
are delivered to the stimulating coil, but the technology continues to improve and commercial
devices that can stimulate at tens of pulses per second are now available, although electrical
inefficiencies still result in considerable power consumption and coil heating.
Stimuli delivered at relatively low repetition rates (~1Hz) have been shown to inhibit cortical
excitability and enhance it at higher frequencies (~10Hz). Recent work using stimuli in short trains
(for example ‘theta bursts’) rather than at a uniform repetition rate has been shown to appear to
produce longer-lasting effects than those produced by traditional protocols. It has been suggested
that such patterns of stimuli are more biologically potent and hence potentially more effective for
therapeutic purposes.
Magnetic stimulation is being used, or evaluated, in many applications. These include areas as
diverse as creating 'virtual lesions' in the human brain; treatment of depression and schizophrenia;
aiding the diagnosis of disease or mechanical damage in central and peripheral nerve pathways;
stimulating cortical plasticity as an adjunct to post-stroke rehabilitation; aphasia therapy; migraine
therapy; and, in the periphery, to produce more work and power from muscular contractions than is
achievable with conventional FES.
Since the advent of TMS in 1985 over 10000 papers have been published relating to the technique. It
seems likely that the range of clinical and research applications will continue to grow as more
effective delivery regimens are developed and stimulator hardware improves further.
Stimulating Technology for the Future Keynote Lectures
IFESS UK&I Conference Sheffield 2015 13 Conference Proceedings
iCycle: electrical stimulation for motor recovery in spinal cord injury
Donaldson N
Implanted Devices Group, Department of Medical Physics and Biomedical Engineering,
University College London
In the year 2000, we reported an accidental discovery: one man with an incomplete SCI had
recovered some normal walking function, apparently as a result of doing FES cycling for 15 months.
David Rushton proposed a hypothesis to explain this phenomenon, based on Hebbian learning, in
which the electrical stimulation combined with voluntary drive to the anterior horn cells caused
strengthening of synapses. To test this theory, I thought we needed a method to measure the
voluntary drive, and spent several fruitless years looking for a method using EMG. In 2011, Jane
Burridge & I invented a simple mechanical method and since then I have been developing FES
ergometers which may be used for applying electrotherapy treatment frequently at home. The
voluntary drive is measured and used as the speed input of a commercial virtual racing game. The
idea is that it will be useable by patients with a range of disability (ASIA C & D). The first prototype
has been tested with patients and the second prototype (‘iCycle’) in now ready to be tested in the
hospital. The machines will be described in this talk. A larger clinical trial will start soon. I will
comment on how electrotherapy and neuroprosthesis may be in future be used to treat spinal cord
injury.
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FES to Address Foot Drop
Stimulating Technology for the Future FES to Address Foot Drop
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Impact of Functional Electrical Stimulation on Walking Speed, Clinically
Meaningful Changes and Functional Walking Category for Multiple Sclerosis
Street T1, Taylor P1, Swain I1, 2
1 Salisbury Foundation Trust NHS,
2 Faculty of Science and Technology Computing, Bournemouth University, Poole, UK
Tamsyn.Street@salisburyfes.com
Introduction
A reduced ability to clear the foot in the swing phase of gait can lead to a decline in walking speed in
an attempt to mitigate an increased risk of falling. Functional electrical stimulation (FES) has been
found to be effective in improving walking speed in a clinically meaningful way that enables a change
in functional walking category.1 However, the studies conducted have all had relatively small sample
sizes. Therefore, the current study aimed to examine the viability of using FES on a large
representative sample using data from standard clinical practice.
Method
One hundred and eighty seven (117 females, 70 males, mean number of years since diagnosis 11.7,
range of years 1-56, age range 27-80, average age 55 years) patients with MS who have foot drop.
One hundred and sixty six were still using FES after 20 weeks with 153 patients completing the
follow up measures. Clinically meaningful changes (i.e. >0.05 ms-1 and >0.1ms-1) and functional
walking category were derived from 10 metre walking speed.
Results
An increase in walking speed was found to be highly significant (p<0.001), both initially where a
minimum clinically meaningful change was observed (0.07ms-1) and after 20 weeks with a
substantial clinically meaningful change (0.11ms-1). After 20 weeks participants displayed a 27%
average improvement in their walking speed. No significant training effect was found. Overall
functional walking category was maintained or improved in 95% of treatment responders.
Discussion
FES was associated with a statistically and clinically meaningful orthotic but not training effect in
walking speed. The lack of a significant training effect may be due to a reduced capacity for
neuroplasticity and gradual progression of multiple sclerosis. A substantial proportion of participants
also demonstrated improvements in their functional walking category. The highly significant effect
seen across all orthotic comparisons is consistent with the findings from smaller studies, suggesting
that FES is effective as a means of maintaining functional mobility for those with multiple sclerosis.
Conclusion
Peroneal nerve stimulation enables clinically meaningful changes in walking speed leading to
preserved or increased functional walking category for people with multiple sclerosis.
References
1. Taylor P, Humphreys L, Swain I. The long-term cost-effectiveness of the use of Functional
Electrical Stimulation for the correction of dropped foot due to upper motor neuron lesion. J
Rehabil Med. 2013;45(2):154-160. doi:10.2340/16501977-1090.
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Effect of FES in patients with Hereditary Spastic Paraparesis
Chandy BR, Clarke A, McDermott CJ, Nair S
Princess Royal Spinal Injuries Centre, Department of Neurology and * Gait Laboratory, Mobility and
Specialised Rehabilitation Centre, Sheffield Teaching Hospitals NHS Foundation Trust
Bobeena.chandy@sth.nhs.uk; Alison.clarke@sth.nhs.uk; Siva.nair@sth.nhs.uk
Introduction
Hereditary Spastic Paraparesis (HSP) is a heterogeneous group of neurodegenerative conditions
characterised by dying back axonal degeneration of neuronal tracts in spinal cord (McDermott et al
2000). Prevalence of HSP varies from 1.3 to 7.4 per 100,000 populations. (Brignolio et al 1986,
Erichsen et al 2009). It is most commonly inherited as an autosomal dominant trait, with recessive
and x-linked inheritance occurring less frequently. HSP is genetically diverse with 38 genetic loci for
HSP identified. In a study of over 50 patients with spastin mutation, the commonest cause of HSP,
the mean age at onset was 34 years (range: 2-65 years). (McDermott et al 2006) A walking aid was
required by 29% and a wheelchair was required by 12% of patients. There are currently no disease
modifying therapies for pwHSP. Treatment is therefore based on alleviating symptoms.
Unfortunately only a few small clinical trials have been carried out evaluating treatments in HSP.
(Hecht et al 2008, Klebe et al 2006, Scheuer et al 2007).
Hereditary spastic Paraparesis causes foot drop due to weakness of dorsiflexors and spasticity of
plantar flexors of ankle. Foot drop reduces walking speed and increases risk of falls. Standard
interventions for foot drop are Ankle Foot Orthosis or foot up splint which mechanically support the
ankle. Another approach is Functional Electrical Stimulation (FES). A switch placed in the subject’s
footwear activates electrodes placed over the common peroneal nerve over head of fibula. This
contracts the dorsiflexors of the foot, correcting foot drop. Most studies of FES have been conducted
in patients with multiple sclerosis and stroke and did not include activities in community or patient
reported outcomes (NICE 2009). Persons with HSP (pwHSP) commonly have slowly progressive
stiffness and weakness of legs. Their gait differs from gait of people with stroke. Therefore FES, as in
post stroke patients, may benefit the patient to continue to help them remain mobile till the disease
progression affects independent ambulation.
Method
This is a retrospective study. 18 patients diagnosed to have HSP, under regular follow up with
neurology, and having had an FES clinic referral were included in the study. The study included 9
males and 9 females. The age group was in the range of 21-75 years with an average of 52.7 years.
All patients underwent an initial assessment with gait analysis and were given FES for the weaker
limb having difficulty in clearing the ground on walking. The speed of walking, step length and the
number of steps were recorded with and without the FES, were noted to use as an objective
measure of measuring improvement. The gait was reviewed 2 weeks after the initial assessment.
Results
Among the 18 patients who were assessed in the FES clinic and supplied with the equipment, 3 did
not attend the FES clinic. Of the remaining 15 patients, all attended the FES clinic for an initial
assessment. 14 patients followed up in 2 weeks for a second assessment, having used the FES for the
period. Of these 14 patients, 7 have continued to use the FES system till the last recorded follow up
in the clinic. 4 patients were lost to follow up, 2 patients returned the equipment due to difficulty in
coping with the equipment due to deteriorating physical and psychological issues. Another 2
patients discontinued the use of FES due to other health reasons. The gait analysis data from the
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initial assessment and the second assessment, did not show any significant improvement in the
speed of walking (0.07 m/s average) or increase in the number of steps and step length.
Discussion
Difficulty in walking is a common problem for pwHSP. A study of a small number of pwHSP found a
correlation between gait and spasticity (Klebe et al 2004). Brachinsky et al (2009) also reported that
in pwHSP walking is affected mainly due to spasticity. Gait problems in pwHSP are due to a
combination of spasticity of plantar flexors and weakness of the dorsiflexors of ankle.
Most evidence for FES relates to patients with stroke (NICE 2009, Burridge et al 1997, Pomeroy et al
2006). A meta-analysis showed that FES improved walking speed by 38% after stroke (Kottink et al
2004). There are few small studies on use of FES in few other conditions like multiple sclerosis,
cerebral palsy and spinal cord injury (Barrett etal 2009, Postans and Grant 2005, van der Salm et al
2005). People with HSP have unique gait characteristics that distinguish them from people with
stroke, multiple sclerosis or cerebral palsy . They experience excessive stiffness at knees and ankles
compared to people with cerebral palsy (Cimolin et al 2006, Wolf et al 2011). While people with
stroke largely require only a single FES, about a third of pwHSP reviewed in our gait laboratory
required bilateral FES. As gait in pwHSP are different from those of people with stroke, multiple
sclerosis or cerebral palsy, results from these studies should not be extrapolated to pwHSP. There is
only one small study on effect of FES on gait in pwHSP (Marsden et al 2012). This study included 11
long term users of FES with HSP and analysed the walking kinematics and muscle strength in the
laboratory. It demonstrated that FES reduced foot drop and improved walking speed. It did not
analyse walking in the community or compare FES with standard interventions. Our results:
Most studies on FES use speed of walking as the primary outcome measure. Speed of walking is
assessed in clinical settings, not in the community. FES not only speeds up walking, but also
improves the safety of walking by reducing trips and falls (Clarke et al 2013). NICE guidance on FES
(2009) recommended further studies on FES‘ specifically including patient reported outcome
measure, quality of life and activities of daily living’. Time spent walking is a good measure of activity
in community settings (Kozey-Keadle et al 2012).
Conclusion
In our study, we have noted that the speed of walking, number of steps taken and the step length
are not good predictors of improvement in gait with FES as is with post-stroke patients. As HSP is a
progressive condition usually involving both the lower limbs, it differs in the outcome in the
community setting. Patient reported outcome such as improvement in clearing the ground resulting
decrease in the frequency of trips and falls was seen as the main improvement. The patients, who
continued the use of FES after 2nd assessment, also reported that they felt more confident in walking
as they were more stable and the effort to walk was less. FES is a useful intervention in pwHSP,
however due to the progressive nature of the condition, the patients are unable to use it long term.
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Impact of Functional Electrical Stimulation on Fear of Falling and
Participation for people with Multiple Sclerosis and Stroke
Street T1, Taylor P1, Swain I1, 2
1 Salisbury Foundation Trust NHS,
2 Faculty of Science and Technology Computing, Bournemouth University, Poole, UK
Tamsyn.Street@salisburyfes.com
Introduction
Previous research has found a correlation between history of falling, static postural control and fear
of falling using the Falls Efficacy Scale International (FES-I).1 Therefore, fear of falling may be a
realistic appraisal of the risk of future falls, however it may also potentially increase the risk of
falling2 and have a detrimental impact on participation in everyday activities. Functional electrical
stimulation (FES) of the peroneal nerve has been found to reduce the frequency of falls.3 If
individuals have a reduced falls risk this may reduce fear of falling and increase participation. In a
recent study4, a significant reduction in the fear of falling following the use of FES was found,
however, this has not been confirmed using a validated scale. The current study explored the impact
of functional electrical stimulation on fear of falling using a validated scale and additionally explored
the frequency of participation in the 16 social and functional activities identified in the FES-I.
Method
Thirty-one patients with multiple sclerosis (mean age 53, range 44-70) and 16 stroke patients (mean
age 55, range 35-73) formed a referred sample for treatment between 2013 and 2014. The FES-I and
participation questionnaire were administered at baseline and after 18 weeks.
Results
A significant reduction in fear of falling (md 6, IQR 1-10) was found for multiple sclerosis (p<0.001),
with walking round the neighbourhood and managing stairs showing the greatest reduction.
Similarly, a significant reduction (md 7.5, IQR 1.75-17) was found for those with stroke (p<0.001)
with slippery surfaces and visiting people showing the largest change. For participation a significant
increase (md 4.5, IQR 1-9) in the frequency of participation was found for multiple sclerosis
(p<0.001). A significant increase in participation (md 5, IQR 1-15) was also found for stroke patients
(p=0.02).
Discussion
The findings indicate that in addition to a reduction in actual physical falls risk, FES is also associated
with a reduction in the fear of falling, enabling a greater confidence for individuals to participate in
social and functional activities.
Conclusion
FES can enable a reduction in fear of falling and increase in levels of participation for multiple
sclerosis and stroke patients which is likely to have an impact on quality of life and independence.
References
1. Kalron A, Achiron A. Postural control, falls and fear of falling in people with multiple sclerosis
without mobility aids. J Neurol Sci. 2013;335(12):186-190. doi:10.1016/j.jns.2013.09.029.
2. Young WR, Mark Williams A. How fear of falling can increase fall-risk in older adults: Applying
psychological theory to practical observations. Gait Posture. 2015;41(1):7-12.
doi:10.1016/j.gaitpost.2014.09.006.
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3. Taylor P, Barrett C, Mann G, Wareham W, Swain I. A Feasibility Study to Investigate the Effect of
Functional Electrical Stimulation and Physiotherapy Exercise on the Quality of Gait of People
With Multiple Sclerosis: FES for Dropped Foot and Hip Stability in MS. Neuromodulation Technol
Neural Interface. 2013:n/a - n/a. doi:10.1111/ner.12048.
4. Street T, Swain I, Taylor P. A comparison between ankle assisted orthotics and Functional
Electrical Stimulation: a feasibility study. Mult Scler J. 2014;20(7):1001.
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A service evaluation comparing the effectiveness of functional electrical
stimulation compared to ankle foot orthosis for Multiple Sclerosis related
dropped foot
Dimunge A1, 2, Taylor P1, Street T1, Wood D1
1 National clinical FES centre, Salisbury
2 King’s College London
a.dimunge@nhs.net
Introduction
Foot drop during swing is a common problem in people with Multiple Sclerosis (MS). Foot drop is
typically caused by weakness in ankle dorsiflexor muscles and spasticity in plantar flexor muscles. 1
Both Ankle Foot Orthosis (AFO) and Functional Electrical Stimulation was used to treat the MS
related dropped foot. Previous studies reports that both devices improve gait in people with MS.2
However, a review of the current evidence base found that there is a limited understanding of the
potential effects of either intervention on the quality of gait in terms of gait biomechanics.3 This
study aimed to compare the effectiveness of FES compared to AFO using clinical gait analysis and
other measurable outcomes.
Method
Four AFO users who have been referred to National clinical FES centre with a MS related foot drop
was recruited for this study. The Odstock dropped foot stimulator (ODFS) ® Pace was used for
electrical stimulation in this study. The effectiveness of FES was compared with AFO using the
changes in kinematics and kinetics using 3D motion capture, timed 10m walking speed, fear of falling
and quality of life. The participant gait was analysed before their FES set up appointment with their
AFO and at their FES day two and six week appointments with FES.
Results
The preliminary analysis of the kinematics profiles showed reduce plantar flexion at initial contact
and increase rate of dorsiflexion during stance in three participants at 6 week appointment
compared to no device and with an AFO. There was also reduced plantar flexion and presence of
eversion in swing with electrical stimulation. The stimulated walking speed was increased by on
average 20% in 3 participants. The fear of falling and the impact of MS were decreased in all four
participants and the impact of MS on gait was decreased on average 28% in three participants over
six weeks.
Discussion
The changes in ankle kinematics with FES shifted the profile towards the normals ankle kinematic
profile. Other kinematic profiles were variably affected by the device conditions. The small sample
size and the duration of the study, variability of ankle foot orthoses participants used in this study
and variability in impairment due to MS made it difficult to draw firm conclusions regarding the
device effectiveness. Further analysis including the collected kinetics and spatiotemporal data are
required before final conclusions.
Conclusion
The use of FES over six weeks had improved participant’s ankle kinematics, walking speed and
participant reported outcome measures compared to AFO and no device. Further studies with larger
sample size and longer data collection period are required to demonstrate the effectiveness of FES
and compared to AFO on quality of gait.
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References
1. Downing, A., Van Ryn, D., Fecko, A., Aiken, C., McGowan, S., Sawers, S., . . . Roger, H. (2014).
Effect of a 2-week trial of functional electrical stimulation on gait function and quality of life
in people with MS. International Journal of MS care, 146-152.
2. Wening, J., Ford, J., & Jouett, D. (2013). Orthotics and FES for maintenance of walking in
patients with MS. Disease - a - Month 59, 284-289.
3. Bowers, R., & Davidson, E. (2012). AFO and FES in MS - What's the evidence? 38th Academy
Annual Meeting and Scientific Symposium . American Academy of Orthotics and Prosthetics.
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The effect of dropped foot stimulation on walking speed for People with
Multiple Sclerosis a longitudinal study
Singleton C1, Street T2
1 Birmingham Community Healthcare NHS Trust
2 Salisbury NHS Foundation Trust
Christine.singleton@bhamcommunity.nhs.uk
Introduction
The Birmingham, UK Functional Electrical Stimulation (FES) Service has routinely collected data from
patients with upper motor neurone conditions receiving treatment. FES in the form of a dropped
foot stimulator has been shown to assist with mobility for patients with neurological conditions1
and improved quality of life for people with Multiple Sclerosis (PwMS) 2. The progressive nature of
Multiple Sclerosis (MS) usually results in a loss of mobility3 and increased risk of falls4. The data
collected from PwMS attending the service demonstrates the maintenance of mobility over four
years of continued use of a dropped foot stimulator. This longitudinal clinical study adds to the body
of evidence for the effective use of FES for mobility with this cohort of patients.
Method
In 2014 clinical data from PwMS attending the Birmingham (UK) FES Service was collated and filtered
for analysis. PwMS who had been successfully assessed and fitted with an Odstock dropped foot
stimulator using the clinical criteria for the service had a battery of outcome measures recorded.
Walking speed with stimulation (orthotic effect) and without the use of the stimulator (training
effect) was recorded at baseline, 6 months and annually for as long as PwMS continued to use the
stimulator. The data presented is preliminary analysis of patients after 6 months and 4 years of using
FES.
Results
For patients (n=257) an increase in walking speed was found to be highly significant (p<0.001) both
initially where a minimum clinically meaningful change was seen of 17% (0.07 m/s) and after 6
months where a 22% improvement in walking speed was found (0.09 m/s). No significant training
effect was found. A subset of patients (n=50) was examined over a period of 4 years. Walking speed
was found to be highly significant (p<0.001) at baseline with a substantially clinically meaningful
change of 19% (0.10m/s). No significant training effect was found instead there was a substantially
clinically meaningful decline in walking speed of 70% (-0.15m/s) over the 4 year period when not
walking with the stimulator which was highly significant (p<0.001). However a highly significant
(p<0.001) substantially clinically meaningful continuing orthotic effect was found of 40% (0.12m/s).
Discussion
Walking speed data shows the benefit of a dropped foot stimulator in increasing and maintaining
speed of mobility for PwMS over a 4 year period. An increase in speed may relate to a safer walking
pattern and improved confidence of mobility as shown in other studies5. The decline in walking
speed is likely to be a result of the progression of the disease process with demyelination resulting in
permanent axonal destruction6. Consistent use of the same outcome measures by a service provider
allows for longitudinal studies of medical device effectiveness and should be considered as standard
practice for clinical services in the National Health Service (NHS). The maintenance of safe mobility
has the potential to enhance quality of life for PwMS and reduce the cost of healthcare. Further
analysis of the data set is required to examine changes in functional walking category, impact on
quality of life, fear of falling, spasticity, effort and confidence of walking.
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Conclusion
The findings support the use of FES to provide a continued orthotic effect to maintain mobility for
the deteriorating condition of MS.
References
1. Taylor P, Humphreys L, Swain I (2013). The long term cost effectiveness of the use of Functional
Electrical Stimulation for the correction of dropped foot due to upper motor neuron lesion.
Journal of Rehabilitation in Medicine. 45 154-60
2. Barrett C & Taylor P (2009). The effects of the Odstock Drop Foot Stimulator on Perceived
Quality of Life for People with Stroke and Multiple Sclerosis. Neuromodulation 13(1), 58-64
3. Rejdak K, Jackson S, Giovannoni G (2010). Multiple Sclerosis. A practical overview for clinicians.
British Medical Bulletin. 95, 79-104
4. Peterson EW, Cho CC, von Koch L, Finlayson ML (2008). Injurious falls among middle aged and
older adults with multiple sclerosis. Archives of Physical and Medical Rehabilitation. 89, 1031-37
5. Matsuda P, Shumway-Cook A, Ciol M, Bombardier C et al (2012). Understanding Falls in Multiple
Sclerosis: Association of Mobility Status, Concerns about falling and accumulated impairments.
Physical therapy. 92(3), 407-15
6. Bjartmar C, Wujek JR, Trapp BD (2003), Axonal loss in the pathology of MS: consequences for
understanding the progressive phase of the disease. Journal of Neurological Science. 206, 165-
71
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Development of FES Services
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A questionnaire study exploring the current use and non-use of functional
electrical stimulation in spinal cord injury
Tedesco Triccas L1, Donovan-Hall M1, Burridge JH1, Ellis-Hill C2, Dibb B3, Rushton D4
1 Faculty of Health Sciences, University of Southampton
2 School of Health and Social Care, Bournemouth University
3 Department of Life Sciences, Brunel University London
4 King's College Hospital, Frank Cooksey Rehabilitation Unit, Denmark Hill, London
l.tedesco-triccas@uea.ac.uk
Introduction
Various rehabilitation assistive technologies, such as Functional Electrical Stimulation (FES), can
potentially be used in Spinal Cord Injury (SCI) clinical settings 1. A mixed methods research study was
carried out with people with SCI and Health Care Professionals (HCPs) to explore views regarding the
current and future use of FES 2. The first phase of the study using qualitative methods identified
several factors related to the facilitators and barriers of using FES. The aim of the second phase was
to use the qualitative findings to develop a range of questionnaires, to explore the extent to which
the views from phase one were held by the wider SCI community.
Method
Two main questionnaires were developed and piloted. The final versions of the questionnaires
consisted of open and closed questions and were administered to participants with SCI and HCPs.
The questionnaires were completed online, on paper or via telephone.
Results
A total of 263 questionnaires were completed (126 HCP and 137 SCI) (figure 1). Common views
between both groups identified were: (1) the beneficial use of FES were mainly to improve muscle
strength, upper limb movements and activities, mobility and psychosocial aspects (2) identification
that the therapist was the main person to suggest FES use and that National Health Service being the
main funding source and that (3) adequate support and training about FES application was provided.
FES was not being used effectively to avoid raising unrealistic hopes of recovery and because of lack
of staff time and funding. From the non-users of FES, 89.1% did not use it because it was not offered
to them and 63.1% felt that if they had the opportunity they would use it the future.
Discussion
There seems to be an agreement between views of the current use of FES by HCPs and people with
SCI. HCPs and SCI users agreed that FES can be beneficial for physical and psychosocial problems.
However, half of the representative SCI population are not using FES. This could be due to lack of
funding, staff time and education as was identified from the previous qualitative research2.
Conclusion
FES can be recommended for SCI rehabilitation programmes however, there are still some barriers
with funding, resources and education. Future research should focus on the effectiveness of FES
education programmes within spinal units and community rehabilitation settings in United Kingdom.
References
1. Martin R, Sadowsky C, Obst K, Meyer B, McDonald J. Functional electrical stimulation in
spinal cord injury: from theory to practice. Topics in spinal cord injury rehabilitation.
2012;18(1):28-33.
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2. DonovanHall MK, Burridge J, Dibb B, EllisHill C, Rushton D. The views of people with spinal
cord injury about the use of functional electrical stimulation. Artificial organs.
2011;35(3):204-211.
Figure 1: A bar chart displaying % users and non-users of FES
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Development of FES clinical commissioning guidelines: a case study
Tang K1, Marchant S1, Michael S1
1 Medical Physics & Engineering, Leeds Teaching Hospitals, Lincoln Wing, St James’ University
Hospital
shona.michael@nhs.net
Introduction
Functional electrical stimulation (FES) has seen rapid commercial expansion in recent years, and a
range of products are now available in the UK. No literature currently exists to compare similar
devices from different manufacturers. Leeds MPE were asked to evaluate alternative devices and
propose local commissioning guidelines - this study shows the findings.
Method
A review of the relevant literature was conducted. The technical specifications of commercially
available surface-stimulation FES devices were compared, and devices were tested on volunteers.
From this information, it is planned that a commissioning decision framework will be developed,
based on the minimum-cost option for the greatest clinical benefit.
Results
Existing literature demonstrates the clinical efficacy of FES used for foot-drop, and shows that it is
equivalent to ankle-foot orthosis use (Kim, Eng, & Whittaker, 2004; Kluding et al., 2013). Available
specifications for devices currently on the market show broadly similar modes of operation for all
devices, the differences being mainly practical and aesthetic.
Discussion
It is interesting to note the large differences in price of devices, considering that the fundamental
technology used is largely identical and has been available for over a decade. Currently, no literature
compares similar devices from different manufacturers, and a possible avenue for future studies
could be a multi-centre, randomised trial examining the clinical outcomes for different FES devices.
Conclusion
Our evaluation supports the use of FES generally, and found some practical differences between
devices which may support the use of alternative devices in some specific cases. We hope to present
a decision framework for local clinical commissioning at the conference.
References
Kim, C. M., Eng, J. J., & Whittaker, M. W. (2004). Effects of a simple functional electric system and/or
a hinged ankle-foot orthosis on walking in persons with incomplete spinal cord injury. Archives
of physical medicine and rehabilitation, 85(10), 171823.
Kluding, P. M., Dunning, K., O’Dell, M. W., Wu, S. S., Ginosian, J., Feld, J., & McBride, K. (2013). Foot
drop stimulation versus ankle foot orthosis after stroke: 30-week outcomes. Stroke; a journal of
cerebral circulation, 44(6), 16609.
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New Techniques for Delivering FES
Stimulating Technology for the Future New Techniques for Delivering FES
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Repetitive Control Based Tremor Suppression Using Electrical Stimulation
Copur EH, Freeman CT, Chu B, Laila DS
University of Southampton, University Road, Southampton, UK, SO16 1BJ
ehc1g12@ecs.soton.ac.uk
Introduction
Multiple sclerosis (MS) affects around 100,000 people in the UK, and between 25% and 40% of MS
patients suffer from tremor. Tremor is an involuntary, approximately rhythmic and roughly
sinusoidal movement and makes performing daily activities difficult, degrading quality of life and
contributing to feelings of isolation. Functional electrical stimulation (FES) is a potential approach to
suppress tremor that provides a noninvasive method that does not entail the bulky or expensive
equipment, as an alternative to the commonly applied invasive methods. The aim of this research
programme is to develop novel controllers to address the poor performance of existing FES control
schemes that have been applied to suppress tremor.
Method
An innovative approach to FES-based tremor suppression, called Repetitive Control (RC) was applied.
RC is a technique used in industrial automation to control robots operating in a periodic/repetitive
manner. By modelling the tremor as a periodic disturbance signal with a frequency in a specified
range, RC employs an underlying model of the limb dynamics in order to cancel this external
disturbance. Procedures were developed to identify an accurate model of the relevant joint
dynamics. The proposed model comprises horizontal plane-flexion and extension wrist dynamics in
response to FES applied to the Flexor Carpi Radialis (FCR) and Extensor Carpi Radialis (ECR) muscles,
as well as oscillatory movement due to tremor. An optimisation procedure was then developed to
identify the unknown parameters using tests that are suitable for application to people with MS.
Following identification, the models are used within RC structures.
Results
Four male unimpaired participants were recruited for testing. A validated instrumented wrist rig was
used to perform the tests. Tremor was simulated using a DC motor operating with closed-loop
torque control, applying a sinusoidal disturbance of 1 Nm across a range of frequencies. Positional
data were collected during application of FES to FCR and ECR muscles during both identification and
RC tests.
Discussion
Experimental results have confirmed satisfactory modelling accuracy, with cross-validation tests
giving rise to a fitting accuracy of over 70% in all participants tested. Results have also showed that
RC enables tremor to be suppressed more sufficiently than filter-based methods.
Conclusion
This study provides the first thorough assessment of RC for tremor, to establish feasibility and
performance advantages compared to the filter-based methods that have so far been employed.
Clinical feasibility tests will commence in early 2015 with five MS patients diagnosed with intention
tremor in order to evaluate the efficacy of the approach.
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Sensory Barrage Stimulation is effective in reducing elbow spasticity: a
crossover double blind randomized pilot trial
Slovak M1, Chindo J2, Nair S3, Reeves ML1, Heller B4, Barker AT1
1 Department of Medical Physics & Clinical Engineering, Royal Hallamshire Hospital, Sheffield
Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield, S10 2JF, United Kingdom
2 Department of Neuroscience, 385A Glossop Road, Sheffield, S10 2HQ, United Kingdom
3 Department of Neurology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS
Foundation Trust, Glossop Road, Sheffield, S10 2JF, United Kingdom
4 Faculty of Health and Wellbeing, Sheffield Hallam University, A129 Collegiate Hall, Collegiate
Crescent, Sheffield, S10 2BP, United Kingdom
m.slovak@sheffield.ac.uk
Introduction
Spasticity is a disorder of sensorimotor control, resulting from an upper motor neurone (UMN)
lesion and presenting as intermittent or sustained involuntary activation of muscles [1]. Spasticity is
difficult to treat. Current pharmacological agents are often not well tolerated due to their side
effects [1]. Non-pharmacological approaches have insufficient evidence to justify their use[2]. We
have created a novel form of multi-channel electrical stimulation, termed Sensory Barrage
Stimulation (SBS) with an aim of enhancing its treatment efficacy. The goal of this pilot trial was to
assess the feasibility of using SBS for the treatment of spasticity affecting the elbow flexor muscles
and to compare this with conventional TENS stimulation applied between two electrodes.
Method
A heterogeneous group of 10 patients with spasticity of the flexor muscles of the elbow-of grade 2
or above on the Modified Ashworth Scale (MAS) received two intervention sessions (TENS and SBS),
one week apart in a randomised order. Both SBS (delivered as a spatio-temporal pattern
mimicking physical stroking using 64 electrodes) and TENS (100Hz constant frequency stimuli,
applied using 2 electrodes) were delivered with a 50% on/off period. The 60 minute stimulation
was applied over the triceps brachii on the affected arm. Spasticity was measured using the MAS [3].
Secondary outcome measures were self-reported change in spasticity, measured on a visual
analogue scale (VAS), and therapist-rated power of elbow extension (PEE) and flexion (PEF). A
reduction of at least one grade combined with at least 30% decrease of spasticity categorised the
participant as responders to the intervention. The measures were taken immediately before each
intervention was applied, immediately after and one hour after the intervention.
Results
Immediately after the stimulation finished spasticity showed significant reduction on the MAS and
VAS for both TENS and SBS. At one hour post-stimulation SBS still showed significant reductions in
MAS and VAS but TENS only for MAS. Altogether seven subjects were categorised as SBS responders,
in comparison to four in the TENS group.
Discussion
This novel concept of stimulation allows us to deliver stimuli at multiple sites and with spatio-
temporal patterns which give the sensation that the stimuli are moving over the skin, both of which
may aid in producing a greater subjective sensory input. Although this pilot trial did not use a
placebo stimulus its promising results indicate a reduction in spasticity immediately after stimulation
that persists for at least one hour with better results being obtained for SBS.
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IFESS UK&I Conference Sheffield 2015 31 Conference Proceedings
Conclusion
This study demonstrated the feasibility and practicality of using the SBS. Further investigation of
optimal stimulation parameters followed by larger and longer-term placebo controlled trials are
required before further conclusions can be made about the clinical value of the technique.
References
1. Kheder, A. and K.P. Nair, Spasticity: pathophysiology, evaluation and management. Pract
Neurol, 2012. 12(5): p. 289-98.
2. Amatya, B., F. Khan, L. La Mantia, M. Demetrios, and D.T. Wade, Non pharmacological
interventions for spasticity in multiple sclerosis. Cochrane Database Syst Rev, 2013. 2: p.
CD009974.
3. Pandyan, A.D., G.R. Johnson, C.I. Price, R.H. Curless, M.P. Barnes, and H. Rodgers, A review of
the properties and limitations of the Ashworth and modified Ashworth Scales as measures of
spasticity. Clin Rehabil, 1999. 13(5): p. 373-83.
Stimulating Technology for the Future New Techniques for Delivering FES
IFESS UK&I Conference Sheffield 2015 32 Conference Proceedings
Does Functional Electrical Stimulation improve stability as seen through
plantar pressure measurement during stance phase of the gait cycle?
Ward S1, Bowtell M1, Shortland A2, Tasker L1
1 Rehabilitation Engineering Unit, Medical Physics & Clinical Engineering, Specialist Rehabilitation
Centre, Morriston Hospital, Swansea, SA6 6NL
2 One Small Step Gait Laboratory, Guy's Hospital, London
Sarah.ward2@wales.nhs.uk
Introduction
The ability of FES to improve impaired gait has been well documented. However, studies primarily
focus on the ability of FES to improve outcome measures such as speed and effort of walking (1, 2).
Some mention ground clearance in swing phase(3), but little information is available regarding the
often perceived benefit of improved stability during stance phase; extended stimulation enables
eccentric contraction of the anterior tibialis, not only to control weight acceptance, but provide
eversion for stability of the ankle joint (4). This study evaluates the effects of FES on eversion and
loading rate of the foot through plantar pressure measurement. Centre of pressure (COP) deviation
was used as a measure for stability, as with other studies (5, 6).
Method
Ten volunteers, eight with multiple sclerosis and two post stroke, who were FES users (≥3 months)
took part. Participants performed a series of twelve randomised walks, for comparative analysis with
and without FES. Stride length and walking speed were recorded using Siliconcoach P&O Clinical
Movement Data software. Plantar pressure data were captured at 150 Hz using a RS Scan platform
(7) set within a raised walkway. Data was compared to data obtained for nine non-pathological
participants.
Results
A measure of “Most Lateral CoP” demonstrated a significant change (p=0.015), with the application
of FES promoting a more medial CoP position which was more comparable to the normal group.
Application of FES did not show a significant effect (p=0.222) on time from initial contact to
metatarsal contact.
Discussion
This study has shown that the application of FES can alter the foot-floor interaction in patients with
dropped foot due to MS and Stroke. The application of FES showed a medial shift in CoP inferring
reduced inversion and thus improved stability. This observed benefit of FES was not concurrent with
improvements of speed and stride length. These findings indicate FES is more than a swing phase
intervention and highlight the need of measures in addition to walking speed and stride length to
objectively assess an individual’s benefits from use of FES. Here, the potential of plantar pressure
measurement for this purpose has been shown. Further work is required to explore the effect of
extended stimulation through stance on transition time to forefoot contact during stance.
Conclusion
The application of FES to the dorsiflexors, in patients with dropped foot, produces a medial shift in
CoP, promoting a position more comparable to a typically developing population. Plantar pressure is
an informative tool to objectively measure improved stability during stance when FES is applied and
may be useful clinically to assess individual patient benefits of this intervention.
Stimulating Technology for the Future New Techniques for Delivering FES
IFESS UK&I Conference Sheffield 2015 33 Conference Proceedings
References
1. Street T,et al. The Effectiveness of Functional Electrical Stimulation on Walking Speed,
Functional Walking Category and Clinically Meaningful Changes for People with Multiple Sclerosis.
Archives of Physical Medicine and Rehabilitation. 2014(0).
2. Taylor PN, et al. Clinical use of the odstock dropped foot stimulator: Its effect on the speed
and effort of walking. Archives of Physical Medicine and Rehabilitation. 1999;80(12):1577-83.
3. Van der Linden ML, et al. Gait kinematics of people with Multiple Sclerosis and the acute
application of Functional Electrical Stimulation. Gait & Posture. 2014;39(4):1092-6.
4. Odstock Medical Ltd. Clinicians Instruction Manual Odstock Dropped Foot Stimulator.
Salisbury District Hospital2008.
5. Valentini FA, et al. Repeatability and variability of baropodometric and spatio-temporal gait
parameters Results in healthy subjects and in stroke patients. Neurophysiologie Clinique/Clinical
Neurophysiology. 2011;41(4):181-9.
6. Granat MH, et al. Peroneal stimulator: Evaluation for the correction of spastic drop foot in
hemiplegia. Archives of Physical Medicine and Rehabilitation. 1996;77(1):19-24.
7. RS Scan International . Footscan entry level USB2 system. 2008.
Stimulating Technology for the Future New Techniques for Delivering FES
IFESS UK&I Conference Sheffield 2015 34 Conference Proceedings
Correction of Dropped foot due to multiple sclerosis using the STIMuSTEP
implanted Dropped foot Stimulator. Long term follow up.
Taylor P, Wilkinson I, Slade-Sharman D, Khan M
Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ, UK.
p.taylor@salisburyfes.com
Background
While FES has been shown to significantly aid walking following dropped foot due to Multiple
Sclerosis (MS), some device users experience difficulties using external FES that may be addressed by
an implanted device. This study compares the effect of external and implanted FES devices.
Method
External FES was used for a minimum of 6 months prior to implantation. Walking was assessed using
10m walking speed, 3 minute walking distance, physiological cost index (PCI) and health (SF36
Short Form 36) and device related quality of life (PIADS psychosocial impact of assisted device
scale) and device use questionnaire. Assessments were made with external FES prior to
implantation and 20 weeks post-surgery with additional walking speed measurements at 3 years.
The change in walking speed without FES was compared to the Miller modal for decline in walking
speed over time.
Results
23 people received the implant with a mean time use of 4.2 years (1.0 8.4 as of January 2015). The
reasons for choosing to receive the implant were; difficulty placing external electrodes 11, skin
irritation under the external electrodes 9 and improved convenience 3. All device recipients
achieved effective correction of dropped foot with the device. Two people have discontinued device
use due to determination of their MS symptoms (after 2.1 & 4.3 years, both bilateral STIMuSTEP)
and one device user died due to a non-related causes after 3.5 years of device use. Both devices
caused clinically & statically meaningful increases in median walking speed (external 0.125 ms-1,
implant 0.13ms-1) and 3 min walking distance (external 27m, implant 28m) with a strong trend to
reduced PCI indicating walking was less effort. The number of device users who reduced their
unassisted walking speed by greater than a clinically meaningful threshold (16.67%), n=5 was less
than that predicted by the Miller Modal, n=7.
Both devices improved device related quality of life. Despite progression of MS, walking speed gain
with FES was maintained at 3 years. Three implants failed following falls and a 4th with no known
cause. All four were successfully replaced. Two cases of pain in response to stimulation with the
implant were recorded. One was associated with neuropraxia and resolved after 6 months. The
second case was due to external pressure on the nerve from the external controller and leg strap
which resolved after modification of the external components. The implant was used more days per
week and was quicker to put on each day than the external FES. More people used the implant at
work than the external device.
Conclusion
The STIMuSTEP implanted dropped foot stimulator is an effective long term device for correction of
dropped foot. The surgical procedure does not appear to adversely affect the progression of MS.
There is a risk of short term neuropraxia and implant failure which have been successfully clinically
managed.
Stimulating Technology for the Future New Techniques for Delivering FES
IFESS UK&I Conference Sheffield 2015 35 Conference Proceedings
Two-channel stimulation for the correction of drop foot
Merson E1,2, Swain ID1,2, Taylor PN2, Cobb JE1
1 Bournemouth University, Bournemouth, UK
2 Odstock Medical, Salisbury, UK
emerson@bournemouth.ac.uk
Introduction
Functional Electrical Stimulation (FES) is used for the correction of drop foot. The ability to gain a
functional and safe foot posture (i.e. dorsiflexed and mildly everted) is dependent on recruiting the
deep and superficial branches of the common peroneal nerve in suitable proportion. Implanted
stimulators require an invasive operation, while traditional single-channel surface stimulation
systems require careful manual placement of surface electrodes (which may be difficult for FES
users). Cuff systems are simple to apply but are bulky and may suffer from slight misalignments.
Electrode arrays may be able to adapt for changes in response, but are complex to manufacture. The
approach presented here uses two channels of stimulation (lateral and medial), altering the inter-
channel bias to influence the degree of eversion and dorsiflexion. The hypothesis was that
inaccuracy in the positioning of the electrodes could be accommodated by adjusting the bias point
to maintain a safe and functional foot posture.
Method
Volunteer FES users were set up with two channels of stimulation. The lateral electrode (3x5 or
5x5cm, depending on leg size) was on or slightly posterior to the head of fibula, and the medial
electrode was slightly anterior; the common indifferent electrode (5x5cm) was on the tibialis
anterior. Placement and current levels were adjusted by trial and error to provoke a range of
eversion with dorsiflexion. The response to stimulation pulse trains (ankle dorsiflexion and eversion)
was recorded both in sitting and while walking on smooth level ground, while the current bias was
shifted between the channels. This was repeated after all electrodes were translated 10mm laterally,
medially, proximally and distally.
Results
Careful electrode positioning was required to avoid either inversion or eversion dominating. In
nearly all cases the level of eversion increased as the current was biased to the lateral electrode. The
effect varied notably between individuals. Moving the electrodes by 10mm often produced a
markedly different response, which could only be partially compensated for by changing the current
bias.
Conclusion
This approach did not avoid the need to position the electrodes accurately. However, in most cases
there was some influence over eversion. The technique may have utility as part of a cuff system, to
fine-tune the response once the electrodes are positioned appropriately.
Stimulating Technology for the Future New Techniques for Delivering FES
IFESS UK&I Conference Sheffield 2015 36 Conference Proceedings
Comparing the effects of Functional Electrical Stimulation and Ankle Foot
Orthosis to treat foot drop in people with MS. A non-randomised trial
Van der Linden M1, Scott S1, Hooper J2, Cowan P3, Weller B2 Mercer T1.
1 Rehabilitation Sciences, Queen Margaret University UK
2 NHS Lothian UK3NHS Lanarkshire
Introduction
Both Functional Electrical Stimulation (FES) and Ankle Foot Orthoses (AFOs) are prescribed to people
with Multiple Sclerosis (pwMS) who present with foot drop. The aim of this study was to compare
the relative effects of these assistive devices on the gait of pwMS who present with foot drop.
Method
The assistive device was prescribed by a specialist physiotherapist, using clinical guidelines. PwMS,
(FES (n=9, and ,AFO (n=8), mean age 53 and 57 resp.), EDSS 2-4, were assessed (gait analysis and
timed walk tests), at baseline (prior to AFO/FES habitual use), and after 6 and 12 wks. Repeated
measures ANOVA was performed for the FES and AFO groups separately. Cohen’s effect size d was
calculated for the orthotic gain at 12 wks i.e. no device at baseline vs. with device at 12 wks.
Results
Fig 1 Speed (m/s) in 2minWT Fig 2 Dorsiflexion in swing (degrees)
Statistical analysis revealed a significant condition effect (with vs without) for both 2minWT and
dorsiflexion in swing for the FES group alone. Cohen’s d was 0.41 and 0.37 for 2minWT and DFswing
(FES group) and 0.28 and 0.19 for 2minWT and DFswing (AFO group).
Discussion
Although effect sizes were modest, the results of this pilot non-randomised trial indicated that the
FES group showed more improvements in gait compared to the AFO group.
Conclusion
Further appropriately powered studies, conducted with a longer follow-up period, are needed to
confirm whether the observed changes persist and favourably affect ADL-related functional capacity.
0.75
0.80
0.85
0.90
0.95
FESBL
FES6w
AFOBL
AFO6w
AFO12w
Without
With
0
2
4
6
8
FESBL
FES6w
AFOBL
AFO6w
AFO12w
Without
with
Stimulating Technology for the Future Using New Technology in the FES Setting
IFESS UK&I Conference Sheffield 2015 37 Conference Proceedings
Using New Technology in the FES Setting
Stimulating Technology for the Future Using New Technology in the FES Setting
IFESS UK&I Conference Sheffield 2015 38 Conference Proceedings
Novel methods of using accelerometry for upper limb FES control
Sun M, Howard D, Kenney LP, Smith CL, Waring K, Luckie H
University of Salford, Salford, UK.
m.sun@salford.ac.uk
Introduction
Accelerometry offers a low cost, low power solution to measuring body segment angle (BSA) relative
to the gravity vector under quasi-static conditions. BSA may be used as an input to a state-machine
based, upper limb functional electrical stimulation (FES) system [1]. However, existing methods to
obtain angle from the vertical all suffer from poor sensitivity when the sensitive axis approaches the
vertical. This paper reports on two alternative methods (uncalibrated and calibrated) that use 3-axis
accelerometer data to track body segment angle with respect to gravity.
Methods
The uncalibrated method calculates the angle between the accelerometer x-axis and the gravity
vector. The calibrated method uses a calibration rotation to define the measurement plane and the
positive rotation direction. This method then calculates the component of rotation that is in the
same plane as the calibration rotation. Both methods use an algorithm that switches between using
sine and cosine, depending on the measured angle, which overcomes the poor sensitivity problem
seen in previous methods.
Results
A protractor system was used to test the accuracy of the algorithms. During the test, the protractor
was moved from to 180°, with short pauses at 30°, 60°, 90° and 150°. Maximum mean error for
the uncalibrated method was 2.5° when the angle was near 0°. However, when testing the calibrated
method, significant errors were observed when the measured angle was <30° or >150°.
Discussion
The uncalibrated method is insensitive to rotation about the x-axis, a feature which could be
advantageous for controlling upper limb FES if, for example, stimulation is to be triggered by lift of
the forearm, but not as a result of pronation-supination. To do this, the x-axis of the accelerometer
would be simply aligned with the long axis of the forearm. The calibrated method has the advantage
that it can provide the sign of the angle change.
Conclusion
Two novel methods for calculating BSA from 3-axis accelerometer data have been presented. The
performance of the uncalibrated method led to it being incorporated into a flexible state-machine
controller for the real-time control of FES during upper limb rehabilitation [2].
References
1. Tresadern P. et al. IEEE Pervasive Comp, 2008; 7(2): 62-69. 2. Sun M. (2014). A functional
electrical stimulation (FES) control system for upper limb rehabilitation. PhD thesis. University of
Salford, UK
This is a summary of independent research funded by the National Institute for Health Research
(NIHR)’s NEAT Programme (Grant Reference Number L030). The views expressed are those of the
author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Stimulating Technology for the Future Using New Technology in the FES Setting
IFESS UK&I Conference Sheffield 2015 39 Conference Proceedings
Portable Brain Computer Interface and Functional Electrical Stimulation for
Home-Based Sensorimotor Training
Al Taleb MK1,2, Breslin S1, Vuckovic A1
1 University of Glasgow, UK
2 Wasit University, Iraq
m.al-taleb.1@research.gla.ac.uk, shinyi.breslin@gmail.com, Aleksandra.Vuckovic@glasgow.ac.uk
Introduction
Brain Computer Interface (BCI) controlled Function Electrical Stimulation (FES) has been proposed in
literature for rehabilitation of spinal cord injured (SCI) and stroke patients1. However, suggested
solutions typically rely on costly equipment, limiting its application to the hospital environment.
Patients, however, have prolonged period of rehabilitation and would benefit from extended home-
based therapy with an inexpensive, user-friendly device. Here we propose a portable BCI system
consisting of wireless multichannel headset (Epoch, Emotive, USA) and a tablet, combined with
multichannel FES (Rehastim, Hasomed, Germany).
Methods
Six naive participants took part in this study (30.5±5.08) (3M, 3F). The FES simulator controlled the
right hand extensor muscles. The electroencephalography (EEG) signal was recorded bipolarly at
FC3-CP3 (sampling frequency 128 Hz). A controlled parameter was the relative power of the sensory-
motor rhythm (SMR, 8-12 Hz), calculated online by band pass filtering the signal, squaring,
smoothing and averaging over 0.5 s window. The algorithm was based on time-controlled switch
algorithm1 with the time set to 1s and SMR threshold set individually. Following an audio cue,
subjects were instructed to imagine moving their right hand, supported by a visual feedback. They
had 10s to accomplish the tasks; otherwise, the trial was considered unsuccessful. Each participant
attempted 2 sessions of 30 trials each. The wireless connection between the Epoch and a tablet
(ASUS Win 8.1) was performed using a proprietary software and Bluetooth technology. EEG data
recording, processing, visualization and control of FES device was performed using a custom made
applications developed under Visual Studio C++.
Results
Average success rate was 76.2% in Session 1 and increased to 85.7% Session 2 (Table 1). This shows
fast improvement of BCI performances in naïve participants due to training.
Table 1 . Success rate
Subjects
1
2
3
4
5
6
Session1 Success rate%
70
67
93
80
80
67
Avg. 76.2
Session2 Success rate%
87
87
100
83
80
77
Avg.85.7
Discussion and Conclusion
This study demonstrates the technical feasibility of the design of a portable, inexpensive BCI-FES
system. Experiments on patients in the home environment are necessary to establish a long-term
reliability and user friendliness of the system.
References
1. Vuckovic A, Wallace L, Allan DB. (2015). J Neurol Phys Ther, 39(1), 314.
Acknowledgements: This work has been supported by The Higher committee for educational
development in Iraq and by IAA EPSRC grant 67150/1
Stimulating Technology for the Future Using New Technology in the FES Setting
IFESS UK&I Conference Sheffield 2015 40 Conference Proceedings
Accelerometer-Triggered Functional Electrical Stimulation For Recovery of
Upper Limb Function in Chronic Stroke Patients: A Randomised Trial
Taylor P1, Mann G1, Esnouf J1, Luckie H2, Waring K2, McFadden C2, Smith C2, Kenney L2
1 National Clinical FES Centre, Dept. Clinical Sciences and Engineering, Salisbury NHS Foundation
Trust, Salisbury, SP2 8BJ.
2 Centre for Health Sciences, University of Salford, Greater Manchester, M6 6PU
h.m.luckie@salford.ac.uk
Introduction
The aim of this trial was to evaluate accelerometer-triggered FES device as a rehabilitation tool for
the upper limb following stroke.
Method
Following a 6-week baseline, participants were randomised into FES and exercise, and exercise only
groups. The FES group participated at home in 2 weeks of cyclic stimulation then accelerometer-
triggered stimulation for another 10 weeks. Both groups practised functional tasks and were
assessed at week’s -6, 0, 12 and 24.
Results
57 participants were recruited and 44 data completed the protocol. There was a statistically
significant increase in total Action Research Arm Test (ARAT) scores in the exercise group at 12
weeks, which was maintained at week 24. No significant change was seen in the FES group, except
with FES turned on, and there was no significant difference in the change in scores between groups.
Both groups showed significant improvement in impairment level by Fugl-Meyer (FM) test at 12
weeks, but there was no significance between groups. A small but statistically significant
improvement was measured in both groups using the Canadian Occupational Performance Measure,
no difference between groups. Both groups received similar improvements in quality of life score.
User satisfaction was overall positive but reports of difficulties suggest device improvements are
needed to make it adequately reliable and more user friendly. Long term follow performed 12
months after the intervention has ended, has been performed and will be available by the
conference.
Conclusion
There were no significant differences between the groups in almost all outcome measures, changes
were significantly less than in the pilot. Participants did report benefits from the device, however
improvements in the reliability of the device are required.
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IFESS UK&I Conference Sheffield 2015 41 Conference Proceedings
Upper limb electrical stimulation and robotic assisted therapy: A feasibility
study
van der Walt A
The Wellington Hospital, Wellington Place, St Johns Wood, London, NW8 9LE
aislingjoy@hotmail.com
Introduction
Electrical stimulation and robotic assisted therapy are each strongly supported by research for
rehabilitation of the neurologically impaired upper limb (Thrasher et al, 2008). However, the
combined use of these interventions has been given little consideration in the literature. This study
sought to establish the feasibility of using electrical stimulation in conjunction with robotic assisted
therapy for upper limb rehabilitation.
Method
An inpatient at The Wellington Hospital Neurological Rehabilitation Unit with hemiparesis was
selected as appropriate. Hypertonicity when using the ARMEO prevented finger extension, therefore
electrical stimulation was considered. Approval was gained from the clinical research and
development lead for this study and patient consent was gained. Electrodes were placed on the
finger extensors, the patient was set up in the robotic device (ARMEO) and the therapist controlled
finger extension using a trigger-activated device during therapy games.
Results
The electrical stimulation was found to work well with the ARMEO to facilitate finger extension
during grasp and release games. The patient achieved more active finger extension with stimulation
than without.
Discussion
Potential benefits of this approach include increased patient participation in electric stimulation
through games, more accurate simulation of functional tasks when using electrical stimulation with a
hemiparetic arm, and improved use of clinician’s time by combining approaches.
Conclusion
The clinical benefits of combined electrical stimulation and robotics should be explored further by
occupational therapists in research in a multi-centre randomized control trial. Occupational
therapists in neurorehabilitation should use their own clinical reasoning in the meantime to consider
if their patients would benefit from this approach.
References
Thrasher, T.A., Zivanovic, V., McIlroy, W., & Popovic, M.R. (2008). Rehabilitation of reaching and
grasping function in severe hemiplegic patients using functional electrical stimulation therapy.
Neurorehabilitation & Neural Repair, 22 (6), p. 706-714.
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IFESS UK&I Conference Sheffield 2015 42 Conference Proceedings
Fabrication and Evaluation of Screen Printed Fabric Electrode Arrays
Yang K, Freeman CT, Torah R, Beeby S, Tudor J
Electronics and Computer Science, University of Southampton, Southampton, UK, SO16 1BJ
ky2@ecs.soton.ac.uk
Introduction
The recent emergence of electrode arrays for functional electrical stimulation (FES) of nerves using
electrical currents has been shown to enable greater muscle selectivity and reduced fatigue
compared with use of large individual surface electrode pads. However, existing fabrication
techniques are expensive and have flexibility constraints which limit patient uptake and scope for
clothing-based wearable application.
Method
In this work a flexible and breathable fabric electrode array (FEA) is developed, fabricated entirely by
screen printing the active electrode array directly onto standard fabric. The printed FEA has required
the development of bespoke polymer based screen printable pastes, and consists of four printed
functional layers: an interface layer, a conductive silver layer, an encapsulation layer and a carbon
loaded silicone rubber layer. The FEA materials have been cytotoxicity tested to confirm they are
biocompatible. The dry carbon loaded rubber contact yields improved comfort and lifespan
compared to a standard conductive hydrogel.
Results
Tests have shown that the FEA can provide highly accurate assistance of movement. The FEA can
produce over 90% of the angular joint movement generated by the leading alternative which is a
flexible PCB array on polycarbonate with a hydrogel layer. Furthermore, joint movement has greater
repeatability on FEA compared to the PCB plastic electrode array. Different reference postures
(‘pointing’, ‘pinch’ and ‘open hand’) have been achieved by stimulating an optimised selection of
elements.
Discussion
The feasibility of manufacturing fabric electrode arrays using low temperature screen printable
materials has been demonstrated which establishes the potential for wearable FES technology with
a high level of breathability and flexibility. Fabric surface roughness has been reduced significantly
by using an interface layer between the conductor and the rough fabric. Printing a single deposit of
silver on the fabric interface layer has achieved better conductivity than on Kapton (a flexible
polyimide film used widely in printed electronics) when the interface layer was used on the fabric.
Conclusion
The FEA has potential for wide medical application for assistance and rehabilitation in both clinical
and home environments.
Stimulating Technology for the Future Using New Technology in the FES Setting
IFESS UK&I Conference Sheffield 2015 43 Conference Proceedings
Upper Limb Stroke Rehabilitation combining Electrode-Arrays with Low-cost
Sensing and Advanced Control
Kutlu MC, Freeman CT, Hallewell E, Hughes AM, Laila DS
University of Southampton, University Road, Southampton, UK, SO16 1BJ
mck1e12@ecs.soton.ac.uk
Introduction
Functional electrical stimulation (FES) has shown effectiveness in restoring upper limb movement
post-stroke when applied to assist patients’ voluntary intention during repeated, motivating tasks.
Recent clinical trials at Southampton have employed advanced controllers that precisely adjust the
stimulation applied to three muscle groups in the upper limb in order to assist functional reach and
grasp tasks, giving rise to statistically significant reduction in impairment.
Method
A novel system is developed that advances the state-of-the-art by integrating: (i) an FES electrode
array to activate wrist/finger extensors together with single pad electrodes to activate the anterior
deltoid and triceps, (ii) PrimeSense and Kinect sensors to record the arm, hand, and wrist positions
for use in real-time feedback control, (iii) an interactive touch table to present motivating virtual
reality tasks, (iv) a SaeboMAS arm support. An advanced model-based iterative learning controller
uses position data from previous attempts at each task to update the FES applied to each muscle on
the subsequent trial. This facilitates accurate task completion while encouraging voluntary effort.
Results
Stroke participants (N=4) undertook seventeen intervention sessions, each of one hour duration.
During each session FES was applied to assist participants in performing functional tasks comprising:
1) pressing low or high light switches, 2) closing a drawer, 3) grasping-replacing-releasing an object.
Participants completed clinical assessments (Fugl-Meyer and Action Research Arm Test) pre- and
post-intervention, as well as FES-unassisted tasks during each intervention session.
Discussion
Statistically significant improvements were observed in FES-unassisted tasks over the course of the
intervention. In particular, range of movement (ROM) increased at the shoulder, elbow, wrist and
index finger joints over a range of tasks; the high light switch demonstrated the most significant gain
in shoulder flexion ROM, the contralateral reach in elbow extension ROM, the near reach in wrist
extension ROM and the far reach in index finger extension ROM.
Conclusion
The feasibility of applying precisely controlled FES to multiple muscle groups in the upper limb using
advanced sensors, controllers and array hardware was demonstrated. This technology is expected to
lead to significant reductions in upper-limb impairment following chronic stroke. This compact low-
cost rehabilitation technology also has potential for future transfer to patients’ homes.
Stimulating Technology for the Future Novel Uses of FES
IFESS UK&I Conference Sheffield 2015 44 Conference Proceedings
Novel Uses of FES
Stimulating Technology for the Future Novel Uses of FES
IFESS UK&I Conference Sheffield 2015 45 Conference Proceedings
Functional Electrical Stimulation (FES): a potential method of Deep Vein
Thrombosis (DVT) prevention in acute stroke patients?
Papworth NJ1, Swain ID1,2,3, Harris L1
1 Salisbury NHS Foundation Trust, 2 Odstock Medical Ltd,
3 Faculty of Science and Technology, Bournemouth University
neil.papworth@salisbury.nhs.uk
Introduction
Acute stroke patients are at high risk of DVT due to immobility. Due to increased bleeding risk, use of
prophylactic anticoagulation is contraindicated for most such patients, whether their stroke is
haemorrhagic or ischaemic1. Instead IPC is used as the current gold standard for DVT prevention in
acute stroke2. This work aims to assess whether FES has the potential to be as effective as
intermittent pneumatic compression garments (IPC) in preventing DVT in acute stroke patients.
Electrical stimulation of the foot dorsiflexors via the common peroneal nerve is an established
method of correcting foot drop in individuals with a range of neurological conditions. Contraction of
the dorsiflexors has the effect of compressing the calf against the tibia, activating the calf muscle
pump and aiding venous return. This has the potential to reduce DVT risk by reducing venous stasis,
and may be more tolerable to patients than IPC3,4. Trials using a simple FES-like device (called a
GekoTM) have shown that this device significantly increases venous blood flow in the lower limbs
when compared to IPC5. This work will show how Odstock Medical’s FES compares with both IPC and
the GekoTM in increasing venous flow in the lower limbs. The question of whether patients will be
able to tolerate the sensation of FES is highly relevant to future applications of the technology in
DVT prevention, so discomfort caused by FES was also evaluated.
Method
12 healthy volunteers were recruited, and each had venous blood flow measurements taken while
using IPC, the GekoTM device and FES. Venous blood flow in the lower limbs was measured using
duplex ultrasonography, and the primary outcome measures used were peak velocity and flow
volume over 1 minute, measured at the superficial femoral vein. Discomfort was measured by visual
analogue scale and verbal response scale.
Results
Odstock Medical’s FES enhanced venous return in healthy subjects, achieving a statistically
significant augmentation in venous flow volume from resting baseline (p = 0.003), and a statistically
significant increase in flow volume compared to IPC (p = 0.006). All 3 technologies (IPC, GekoTM and
FES) achieved a significant augmentation in peak flow velocity from resting baseline (p = 0.003, 0.004
and 0.003 respectively), with both IPC and FES giving a statistically significant advantage in peak
velocity over GekoTM (p = 0.038). All 3 technologies were well tolerated.
Discussion
Our results in healthy volunteers would indicate that FES is at least as effective as IPC in reducing
venous stasis in the lower limbs, and may well have some advantage in the volume of flow achieved.
The literature does not entirely agree as to which flow parameter (flow volume or peak velocity) is
most important in DVT prevention, although there is evidence that extremely high velocities may
potentially damage venous endothelium and predispose to thrombus formation6. Therefore a
technology that achieves a significant augmentation in flow volumes over IPC with comparable peak
velocities would seem worthy of further investigation. Several authors have theorised that FES may
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ultimately prove superior to IPC in DVT prevention, as FES gives a physiological contraction of the
lower leg muscles (as opposed to the external compression of muscles by IPC), which more
effectively empties the deep veins in which DVTs most commonly form7,8.
The target patient group (acute stroke patients) will differ from study participants in age and co-
morbidities, and may well have existing vascular disease (such as valvular incompetence in the veins
of the lower limb) that may alter the response to FES. Hence further studies in patients are indicated
before FES can be used in practice.
Conclusion
The results suggest that FES has a potential use in the prevention of DVT in acute stroke patients.
References
1. Sandercock PAG, Counsell C, Kamal AK. Anticoagulants for acute ischaemic stroke. Cochrane
Database of Systematic Reviews 2008, Issue 4.
2. Venous thromboembolism: reducing the risk: Reducing the risk of venous thromboembolism
(deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. NICE guidelines
[CG92] Published January 2010.
3. Tucker AT, Maass, A, Bain DS et al. Augmentation of venous, arterial and microvascular blood
supply in the leg by isometric neuromuscular stimulation via the peroneal nerve. Int J Angiol. 2010
Spring; 19(1): e31e37.
4. Izumi M, Ikeuchi M, Mitani T et al. Prevention of venous stasis in the lower limb by transcutaneous
electrical nerve stimulation. European Journal of Vascular and Endovascular Surgery; 2010 May; 39
(5): 642-645.
5. The geko device for reducing the risk of venous thromboembolism. NICE medical technology
guidance [MTG19] Published June 2014.
6. Proctor MC, Greenfield LJ, Wakefield TW, Zajkowski PJ. A clinical comparison of pneumatic
compression devices: the basis for selection. J Vasc Surg. 2001 Sep;34(3):459-63; discussion 463-4.
7. Faghri PD, Van Meerdervort HF, Glaser RM, Figoni SF. Electrical stimulation induced contraction to
reduce blood stasis during arthroplasty IEEE Trans Rehabil Eng. 1997 Mar;5(1):62-9.
8. Laverick MD, McGivern RC, Crone MD, Mollan RAB. A comparison of the effects of electrical calf
muscle stimulation and the venous foot pump on venous blood flow in the lower leg. Phlebology.
1990 Dec;5(4) 285-290
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Home based therapeutic application of non-invasive posterior tibial nerve
stimulation in the treatment of overactive bladder symptoms: a clinical trial
Slovak M1,2, Hillary C2, Barker AT1, Chapple C2
1 NIHR Healthcare Technology Co-operative, Devices for Dignity, Royal Hallamshire Hospital,
Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield, S10 2JF, United
Kingdom
2 Department of Medical Physics & Clinical Engineering, Royal Hallamshire Hospital, Sheffield
Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield, S10 2JF, United Kingdom
3 Department of Urology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation
Trust, Glossop Road, Sheffield, S10 2JF, United Kingdom
m.slovak@sheffield.ac.uk
Introduction
Urgency is the pivotal symptom of overactive bladder (OAB) symptom complex and is presented in
almost all of the sufferers by this condition , which is accompanied by urinary frequency and often
by nocturia [1]. One third of patients are also severely bothered by urinary incontinence [2].
Currently, the commercially-available technique of posterior tibial nerve stimulation (PTNS) using a
stimulator plus needle is invasive and requires patients to perform this at clinics, which is time
consuming and expensive. An alternative option is to stimulate posterior tibial nerve using a
conventionally available TENS machine, but this approach has a very limited evidence.
Method
19 patients with OAB symptoms who could not tolerate (due to side effects) or have not responded
to a conventional drug therapy, were randomized and completed one of three non-invasive forms of
PTNS, either bilateral (n=6), unilateral (n=7), or sham stimulation (applied to shoulder, n=6). Self-
administered 40 min stimulation was applied every day over a 4 week period using a conventional
TENS machine and a pair of surface electrodes. Patients were assessed using standardised OAB
questionnaires and a 3-day bladder diary: at baseline; after the first week; after four weeks of
stimulation; and four weeks after stimulation ended. Urinary frequency, urgency and incontinence
episodes were recorded and treatment response was defined as a combination of a >30% reduction
in total daily voids and/or urgency episodes as compared to baseline and a subjective improvement
of their condition.
Results
Mean number of voids per 24h decreased by 2.8 (95% CI -6.7 to 1.1) in the bilateral treatment
group, 1.7 (9 to 3.7) episodes in the unilateral treatment group and 0.7 (-2.1 to 6.3) in the sham
stimulation group. 3/7 participants in the unilateral stimulation group, 2/6 in the bilateral
stimulation group and 1/6 patients in the sham group were reported as responders to treatment.
Discussion
Currently neither type of PTNS is recommended by the National Institute of Clinical Excellence (NICE)
guideline due to their insufficient evidence of efficacy. This pilot trial demonstrates that there are
patients who may benefit from this non-invasive type of therapy. Although the effects do not seem
to be large, they are comparable to the success rates observed in the latest OAB drug trials [3].
Furthermore, the non-invasive stimulation has no significant side effects, is low cost and easy to
administer and offers a potentially useful additional treatment option for patients with OAB.
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Conclusion
Although the sample size is small in this study, there is clearly some benefit provided by non-invasive
PTNS. This form of treatment would be particularly useful in those patients who suffer side effects
with medications or do not wish to undergo invasive procedures for their condition. Larger clinical
trials that would have sufficient power to investigate the effects of PTNS in detail would be both
costly and labour-intensive. Recruitment rates are often limited by attempts to obtain homogeneity
in the investigated group and overactive bladder symptoms are often accompanied by various
pathological conditions which preclude many of these patients from participating. Therefore, in view
of the relatively low cost and absence of side effects, NHS Trusts and patient care organisations may
wish to consider deploying this technique using a standard evaluation protocol to allow its benefits
to be evaluated locally and, retrospectively on a wider scale using meta-analyses.
References
1. Abrams, P., L. Cardozo, M. Fall, D. Griffiths, P. Rosier, U. Ulmsten, P. Van Kerrebroeck, A.
Victor, and A. Wein, The standardisation of terminology in lower urinary tract function:
report from the standardisation sub-committee of the International Continence Society.
Urology, 2003. 61(1): p. 37-49.
2. Chapple, C.R., W. Artibani, L.D. Cardozo, D. Castro-Diaz, M. Craggs, F. Haab, V. Khullar, and E.
Versi, The role of urinary urgency and its measurement in the overactive bladder symptom
syndrome: current concepts and future prospects. BJU Int, 2005. 95(3): p. 335-40.
3. Khullar, V., G. Amarenco, J.C. Angulo, J. Cambronero, K. Hoye, I. Milsom, P. Radziszewski, T.
Rechberger, P. Boerrigter, T. Drogendijk, M. Wooning, and C. Chapple, Efficacy and
tolerability of mirabegron, a beta(3)-adrenoceptor agonist, in patients with overactive
bladder: results from a randomised European-Australian phase 3 trial. Eur Urol, 2013. 63(2):
p. 283-95.
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FES Cycling & Rowing
Stimulating Technology for the Future FES Cycling & Rowing
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Power Generation during FES-Assisted Rowing in Spinal Cord Injury
McCarthy I1, Gibbons R2, Richards R3, Andrews BJ4
1 Pedestrian Accessibility and Movement Environment Laboratory, University College London; 2
College of Health and Life Sciences, Brunel University London; 3 Royal National Orthopaedic Hospital,
London; 4 Cybernetics Group, University of Reading, Nuffield Department of Surgical Science, Oxford
University and Toronto Rehabilitation Institute, University of Toronto
i.mccarthy@ucl.ac.uk
Introduction
Individuals with spinal cord injury (SCI) are at the low end of the activity spectrum with high risk of
cardiovascular disease, diabetes, obesity, and osteoporosis. Exercises for the upper body have low
metabolic demand because of the small muscle mass being exercised, and do not apply the
necessary mechanical loading to the lower limbs for maintaining bone mass. Ergometer rowing,
where the upper limb actions are concurrent with Functional Electrical Stimulation (FES) induced
muscle actions in the lower limbs, has the potential to increase metabolic demand by exercising a
larger muscle mass, in addition to loading the bones of the lower limbs. Cyclical activation of the leg
muscles also partially restores the ‘muscle pump’ that may enable the upper body to engage in a
greater intensity and volume of work and delays the onset of upper limb fatigue. We hypothesize
that FES-rowing can improve musculoskeletal and cardio-respiratory health in the SCI population.
Methods
We have recruited four subjects (Male, 58, T4, AIS A; Female, 34, T10, AIS A; Female, 32, T6, AIS A;
Male, 26, C4, AIS A). A Concept 2 rowing ergometer was adapted so individuals with SCI could row
much like their non-SCI counterparts. The rowing action was achieved by alternative activation of
quadriceps and hamstrings using a momentary action switch to change between the two muscle
groups. The ergometer was instrumented by connecting the foot stretchers of the ergometer to
force plates, and attaching a load cell to the handle. Infra-red markers were placed on the
participants to define the foot, shank, thigh and pelvis; in addition markers were placed on the
handle and seat of the ergometer. Participants warmed up at a self-selected power output. Once the
participants had reached a steady state exercise intensity, foot and handle forces were recorded and
measurement of the rowing action was taken using an optical motion capture system.
Results
Power recorded by the ergometer during rowing ranged from 10W to 75W. Peak foot forces were
comparable, ranging from 180 to 220 N; handle forces varied far more, ranging from 120N to 600 N.
Calculated power from the movement and force in the handle agreed reasonably with power
recorded by the ergometer. For the three participants with thoracic level injury, the legs provided
around 20% of the power required to pull against the resistance of the ergometer. For the subject
with the C4 level injury, the legs contributed 50% to the overall power. In addition, power is required
to accelerate the mass of the rower, and raise the weight of the rower up the incline of the
monorail; this power must be provided by the legs, and peak power for these processes is about 90%
of peak leg power developed in overcoming the resistance of the ergometer.
Discussion
FES-assisted rowing has the potential to provide an intense workout to maximize cardiovascular
health in participants with SCI whilst providing sufficient osteogenic lower limb loading. Quantitative
analysis of the rowing action can help determine the potential cardiorespiratory and skeletal health
benefits from this activity. Our data show that legs develop the initial rowing force and as such,
contribute to power generated during FES rowing training.
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Short Term Effects of Functional Electrical Stimulation assisted cycling in
People with Multiple Sclerosis a pilot study
White M1, Fryer IT1, White HSF2
1 Cyclone Plus, Cyclone Technologies, Orchard House, Sunk Island Road, Ottringham, HU12 0DX
2 Department of Sport Health and Exercise Science, University of Hull, Hull, East Yorkshire, HU6 7RX,
matt@cyclonemobility.com
Introduction
Exercise in People with Multiple Sclerosis (PwMS) is a safe and effective method of maintaining and
enhancing functional ability, and maximising quality of life1. Functional Electrical Stimulation (F.E.S.)
assisted cycling is a long established treatment modality for spinal cord injury that now has a
growing research base in PwMS2-5. Our pilot study investigated functional and psychological
outcomes of a one month F.E.S. assisted cycling programme in a small sample of PwMS.
Method
Nine participants volunteered to attend our clinic where a Physiotherapy suitability assessment and
F.E.S familiarisation session was undertaken. Of these participants, six were diagnosed with
Relapsing Remitting MS (3 male, 3 female, age range 26 -67 years, diagnosed between 6 and 11
years previously), two with Secondary Progressive MS (2 females aged 55 and 64 years, diagnosed
for 17and 46 years) and one with Primary Progressive MS (male, aged 59, diagnosed for 1 year). Six
participants were able to self-ambulate, and three were full time wheelchair users. The outcome
measures used for this pilot study were a timed up and go (TUG) test which was performed in those
participants capable (n = 6), F.E.S cycling power output (Watts/hour) (n = 9) and psychological
questionnaires including the Satisfaction with Life (SWLS) Scale, the Hospital Anxiety and Depression
Scale (HADS) and a truncated three item quality of life questionnaire (QoL) for the participants who
were full-time wheelchair users (n = 3). All participants completed a one month programme of F.E.S.
assisted cycling and the outcome measures were repeated after the one month period. Three groups
of subjects (all n = 3) were determined based upon the number of sessions performed in the month.
Group one contained participants who could self-ambulate and attended for F.E.S therapy once a
week (0.92-1.45 sessions/week; 4-5 sessions), group two contained participants who could self-
ambulate but attended twice per week (1.84-2.30 sessions/week; 8-10 sessions), and group three
contained the full time wheelchair users (1.38-1.84 sessions/week; 6-8 sessions).
Results
In all three groups the average power recorded in the F.E.S. session increased, group one displayed a
123% improvement, group two a 109% improvement and group three a 49% improvement. In
groups one and two the TUG test showed considerable improvement, group two decreased their
time by 22% and group one by 11%. Group three also demonstrated improvements in all of the
questionnaire outcome measures (QoL increased from 8.3/21 to 18.3/21, SWLS increased from
16.3/35 to 21.3/35, HADS Depression reduced from 9/21 to 6.3/21, HADS Anxiety reduced from 8/21
to 4.7/21).
Discussion
The results of this pilot study support those of Ratchford et al. (2010) and suggest that F.E.S. assisted
cycling can produce both physical and psychological benefits in PwMS. In our outcome measures it
was apparent that the greatest improvements in power output were in those capable of self
ambulation, in functional performance (TUG) more sessions of F.E.S cycling therapy appeared to be
associated with greater magnitude of improvement.
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Conclusion
Our pilot study suggested that F.E.S. cycling was associated with improved functional and quality of
life in PwMS, irrespective of MS diagnosis, time since diagnosis or functional capability.
References
1. Dalgas, U., Ingemann-Hansen, T., Stenager, E. Physical Exercise and MS Recommendations.
International MS Journal, 16(1): pp 5-11.
2. Fornusek, C. and Hoang, P. (2014). Neuromuscular electrical stimulation cycling exercise for
persons with advanced multiple sclerosis. J. Rehabil Med, 46; Epub ahead of Print
3. Krause, P., Szecsi, J. and Straube, A. (2007). FES Cycling Reduces Spastic Muscle Tone in a Patient
with Multiple Sclerosis: Case Report. Neurorehabilitation, 22; 335-337.
4. Ratchford, J.N., Shore, W., Hammond, E.R., Rose, J.G., Rifkin, R., Nie, P., Tan, K., Quigg, M.E., de
Lateur, B.J. and Kerr, D.A. (2010). A Pilot Study of Functional Electrical Stimulation Cycling in
Progressive Multiple Sclerosis. Neurorehabilitation, 27; 1-8.
5. Szecsi, J., Schlick, C., Schiller, M., Pollman, W., Koenig, N. and Straube, A. (2009). Functional
Electrical Stimulation-Assisted Cycling of Patients with Multiple Sclerosis: Biomechanical and
Functional Outcome A Pilot Study. Journal of Rehabilitation Medicine, 41; 674-680.
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Using FES for Exercise
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Strength training with Neuromuscular Electrical Stimulation, Is the response
similar in younger and older adults?
Griffiths L1, Stewart C2, Pandyan A3
1 School of Sport, Health and Applied Physics, St. Mary’s University, Twickenham
2 ORLAU, RJAH Orthopaedic Hospital Foundation Trust
3 School of Health and Rehabilitation, Keele University
Leannemgriffiths1@gmail.com
Introduction
The population of frail elderly individuals is increasing, which is concurrent with an increase in
muscle atrophy (Mackenbach, Slobbe et al. 2012). Literature is emerging to suggest that the frail
elderly can benefit from a resistance training programme (Fahlman 2011), however it fails to take
into account that some individuals are unable to contract their muscles to an intensity sufficient to
perform rehabilitation. Much of the NMES literature has focused on improving sporting
performance, and has therefore used a young population (Maffiuletti, Cometti et al. 2000). Research
that has been conducted on an older population is often inconclusive and contains inconsistencies in
application (Elboim-Gabyzon, Rozen et al. 2013); limiting the ability of NMES to be integrated into a
clinical setting (Giggins, Fullen et al. 2012). This study aimed to establish whether the use of NMES
for muscle strength training in a younger population is similar to that of an older population.
Method
This study adopted an unblinded RCT with stratification based on age. Twenty healthy participants
were recruited: 10 in the under-30 age category (5 treatment 5 control), and 10 in the over-60
category (5 treatment, 5 control). Participants were positioned in a specially designed and developed
Leg Measurement Device which was capable of measuring moments about the knee and ankle
joints. Participants underwent 6 weeks of NMES training (3 sessions per week) with the following
parameters: 50Hz, 450µs, 3 seconds on, 10 seconds off, 0.5 seconds ramp times and maximal
tolerated intensity. Outcome measures were tested at baseline and 6 weeks. Outcome measures
included: Maximal Isometric Force Production (MIFP), Maximal Electrically Stimulated Force
Production (MFP-ES) and Pennation Angle.
Results
Nineteen participants completed the 6 week training period, no adverse events were reported. The
under-30 treatment group increased MIFP by 13.7Nm more than the over-60 treatment group,
however both showed statistical significance on paired T-testing (P<0.05). Both control groups
demonstrated a small rise in MIFP. Variation between groups was evident. Pennation angle
increased in treatment participants of both groups compared to control participants (2.2° under-30,
2.4° over-60). Under-30 participants produced a mean MFP-ES which was 72.6Nm higher than the
over-60 group (mean rate of improvement of 18.22 Nm (P=0.004)). Both groups showed a steady
rise of MFP-ES over the 6-week intervention. Variation was greater in under-30 participants.
Discussion
Both treatment groups demonstrated improvement in MIFP, indicating that the 6-week intervention
was sufficient to cause advances in muscular strength. The corresponding increase in pennation
angle indicates that treatment with NMES caused muscular hypertrophy, rather than neuromuscular
adaptation to treatment. Participants also demonstrated adaptation to the stimulation, highlighting
the need to modify stimulation intensity in response to muscular output. The under-30 group
demonstrated greater improvement and variation of all three outcome measures, indicating more
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adaptability within the muscle. However the over-60 demonstrated a clear improvement in outcome
measures tested.
Conclusion
This study indicates that NMES could be delivered as an adjunct to a Physiotherapy programme in
both an older and younger population to reduce rates of muscle atrophy and to allow shorter
rehabilitation times. NMES can activate a muscle to a level sufficient to cause muscle hypertrophy,
which may have profound effects on reducing the rate of functional decline in an elderly population.
These results need verifying with a greater sample size and pathological population.
References
ELBOIM-GABYZON, M., ROZEN, N. and LAUFER, Y., 2013. Does neuromuscular electrical stimulation
enhance the effectiveness of an exercise programme in subjects with knee osteoarthritis? A
randomized controlled trial. Clinical rehabilitation, 27(3), pp. 246-257.
EVANS, W.J., 2010. Skeletal muscle loss: cachexia, sarcopenia, and inactivity. The American Journal of
Clinical Nutrition, 91(4), pp. 1123S-1127S.
FAHLMAN, M., 2011. Effects of resistance training on functional ability in elderly individuals.
American journal of health promotion, 25(4), pp. 237-243.
GIGGINS, O., FULLEN, B. and COUGHLAN, G., 2012. Neuromuscular electrical stimulation in the
treatment of knee osteoarthritis: a systematic review and meta-analysis. Clinical rehabilitation,
26(10), pp. 867-881.
MACKENBACH, J., SLOBBE, L., LOOMAN, C., VAN DER HEIDE, A., POLDER, J. and GARSSON, J., 2012.
Sharp upturn of life expectancy in the netherlands: effect of more health care for the elderly?
European journal of epidemiology, 26(12), pp. 903-914.
MAFFIULETTI, N., COMETTI, G., AMIRIDIS, I., MARTIN, A., POUSSON, M. and CHATARD, J., 2000. The
effects of electromyostimulation training and basketball practice on muscle strength and jumping
ability. International journal of sports medicine, 21(6), pp. 437-443.
SCHUHFRIED, O., CREVENNA, R., FIALKA-MOSER, V. and PATERNOSTRO-SLUGA, T., 2012. Non-
invasive neuromuscular electrical stimulation in patients with central nervous system lesions: an
educational review. Journal of Rehabilitation Medicine, 44(2), pp. 99-105.
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FES: A combined modality approach to support the rehabilitation in an
adolescent with Transverse Myelitis
Hodgkinson K1, Wright E1
1 Physiotherapy Department, Birmingham Children’s Hospital
Karen.hodgkinson@bch.nhs.uk, Elizabeth.wright@bch.nhs.uk
Introduction
This case study follows the journey of a 14 year old boy admitted to Birmingham Children’s Hospital
with a diagnosis of Transverse myelitis(TM) and discusses how Functional Electrical Stimulation
(FES) was used to support his rehabilitation.
TM is caused by a inflammatory process across both sides of one level or segment of the spinal cord.
The inflammation can damage or destroy myelin, the fatty insulating substance that covers the
nerve cell fibres within the spinal cord and causes disruption to the passage of nerve impulses
between the spinal cord and the rest of the body. About one-third of people affected with
transverse myelitis experience good or full recovery from their symptoms. Another one-third show
fair recovery and are left with deficits such as spastic gait, sensory dysfunction, and prominent
urinary urgency or incontinence. The remaining one-third show no recovery at all, using wheelchairs,
perhaps with marked dependence on others for basic functions of daily living ( National Institute of
Neurological Disorders and Stroke (NINDS), Transverse Myelitis Association).
Rehabilitation is defined as the process of assisting someone to improve or recover lost function
after an event, illness or injury that has caused functional limitations (Sadowsky et al 2011).
Conventional therapeutic methodologies aim to impact on the impairment, e.g. range of movement
(ROM), increase strength and improve tone. Functional electrical stimulation (FES) in conjunction
with conventional therapy has been shown to be an effective management strategy for individuals
recovering from TM and has been postulated to promote peripheral and central nervous system
repair following injury (Sadowsky et al 2011).
Despite a growing evidence base the use of FES, access to FES stimulation in the acute paediatric
setting is not common place. There are studies published and an evidence base to look at the
benefits of FES cycling for patients who have presented with a spinal cord injury in both adults and
paediatrics.
Aims
This case study aims to demonstrate how the addition of FES alongside traditional methods of
physiotherapy assisted this patient’s engagement and recovery.
Method
Early rehabilitation began from physiotherapy as part of the multidisciplinary team, but during the
intial weeks very little changes were seen in his presentation and at this time the consultant team
felt a poor prognosis was to be expected.
The aims of physiotherapy were to
maintain range of passive movement,
prevent development of contractures,
strengthen weak muscles
maximise functional ability and independence with activities of daily living
Conventional physiotherapy rehabilitation was continued throughout his stay. Patient R initially
presented with complete paralysis in his legs and poor upper limb strength, however the latter
improved quickly.
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During his rehabilitation journey patient R accessed FES cycling, beginning at week 4, abdominal
stimulation and use of FES as an orthotic for facilitation of gait re-education and exercise stimulation
for dorsiflexion strengthening and reduction in spasticity
For the first month initial conventional management concentrated on prevention of contractures, on
maintenance of joint range of motion (ROM) in his legs, strengthening for arms, work to gain
independent sitting balance and transfers into and out of wheelchair.
FES cycling using a RT 300 was commenced in week 4 post onset of paralysis with stimulation of his
quadriceps and hamstrings. At this time flickers of movement were present in his right leg during
sleep, but no isolated volitional active movement was present. FES cycling continued over the
subsequent weeks with tibilais anterior stimulation during cycling also added and with increases to
the time, speed and resistance during this journey. See table 1 for details of FES stimulation
progression.
As patient R progressed he began transferring and walking within therapy with a zimmer frame.
Although activation of his abdominal muscles improved during static exercises, patient R found it
very difficult to recruit abdominal activity whilst being challenged in a sitting or standing position.
Stimulation using a Microstim to his abdominals was found to be beneficial.
Odstock device with a foot switch was used to facilitate heel strike and clearance of toes for gait re-
education and a microstim was encouraged for daily exercise stimulation to facilitate dorsiflexion.
Results
Table 1- Timeline
Timeline
from onset
ASIA/LL power
FES modality
Function
Right
Left
Week 1
0/25
0/25
Nil
Complete dependence
Week 5
0/25
0/25
FES cycle ergometry 100%
Standing in tilt table. Unable to sit
independently.
Sliding transfer with assistance of 2
Week 6
11/25
0/25
FES cycle ergometry 100%
As above
Week 8
14/25
12/25
Programme of FES altered to 15
minutes supported by motor
Resistance 1.85
Perceived effort 8/10
Independent sliding transfers
Standing in parallel bars
Floor exercise/ Core Weak
abdominals
Week 14
16/25
12/25
Increase resistance 1.99
15 minutes active movement/
unsupported
Perceived effort 8/10
Standing transfers
Gait re-education on parallel bars
Floor exercise/ Core Poor
abdominals
Week 18
16/25
12/25
Interval training commence on
FES cycle
Increased resistance
Floor exercise/ Core
Week 20
21/25
17/25
Began abdominal stimulation
during exercise and gait re-
education
E stim exercise for Tibialis
anterior
Continue with interval training
on FES cycle
Floor exercise/ Core
GAITRite assessment
With and without abdominal
stimulation
( see table below)
Week 28
23/25
20/25
Odstock for gait re education
E stim exercise for Left Tibialis
anterior
Walking with crutches
Treadmill
Floor exercises
Beginning to reintegrate into school
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Outcome Measures:
A variety of outcome measures were used to chart this patient’s progress through rehabilitation.
These included the American Spinal Injury Association (ASIA) assessment, Oxford scale for muscle
power in lower limbs, GAITRite walking assessment and the Edinburgh Visual Gait Scale.
Discussion
Patient R achieved a level of recovery that was not anticipated by his medical team based on the
information from scans and his progress over the first month of his hospital stay. It is not possible,
nor appropriate to attribute this recovery solely to the additional use of FES. However, it was noted
that this young man made a significant improvement in his muscle powers and functional abilities
quickly after commencing FES. He progressed from needing support in sitting to being able to stand
for transfers within 3 weeks and by week 14 gait re-education was commenced.
FES provides a patient with the means to build or maintain their muscle strength when this is not
possible through their own nerve innervations and gives the opportunity to practice patterns of
movement with a level of repetition that would otherwise not be possible with conventional
physiotherapy treatment. This has a direct impact on reducing the length of hospital stay.
The patient and his family engaged well with the FES adjuncts throughout the rehabilitation journey.
This was particularly true of the FES cycling which was clearly the element of his rehabilitation that
was enjoyed the most. Technology is very much part of young people’s lives as they grow up and
the use of technology within rehabilitation in this case was readily accepted.
The use of abdominal stimulation was added as treatment strategy to augment manual therapy
whilst engaging in core exercise and gait re-education. The improvement in gait pattern was clearly
evident through the Edinburgh Visual Gait Score and data captured on the Gait rite system. With the
stimulation on, a better control of his pelvis was evident allowing a longer step length and more
fluid gait pattern. The stimulation provides good proprioceptive information which appeared
sufficient to encourage activity through this muscle group.
The use of FES as an orthotic is well documented and is advocated with the NICE guideline for FES.
Within the acute setting, patient’s may have a changing presentation and orthotic need. The
addition of a walking device at this time may offer a cost effective solution that allows for easy
adjustment to meet the patient’s needs.
It is recognised that there are gaps within the outcome measures that were used to demonstrate
this patents progress. During this patient’s journey the full ASIA scale was not completed regularly,
with the motors components only being completed. In hindsight this may have shown some
interesting correlation.
Conclusion
This case study demonstrates how FES modalities can be used to support standard physiotherapy
treatment within the acute rehabilitation setting. The addition of FES to this young man’s
programme was completed without the need for additional physiotherapy time/ sessions.
It is recognised that access to FES cycling is not possible throughout the majority of acute centres,
however, the addition of FES stimulation to isolated muscle groups may be possible and should be
considered. It is the opinion of the authors that FES stimulation has a much wider role to play to
support the rehabilitation of children within the acute hospital as an adjunct to physiotherapy.
Through the exploration of this and sharing as case studies or larger trials greater engagement can
be encouraged.
References
Sadowsky, C. et al (2011) Rehabilitation in Transverse Myelitis. Continuum Lifelong learning
Neurology 17(4):816-830.
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Case Study: Electrical Stimulation to the abdominals of a Stroke patient to
improve walking
Turner-Smith T, Singleton C
Birmingham Community Healthcare NHS Trust
Christine.singleton@Bhamcommunity.nhs.uk
Introduction
Electrical stimulation for exercise of muscles to facilitate movement has been shown to assist with
the rehabilitation of patients with neurological conditions including stroke (Yan et al 20051, Chae et
al 20082, Swain & Taylor 20043, Baker et al, 20004). A 28 year old female had a left pontine and
cerebellar stroke in March 2013. Prior to her stroke she lived independently in her own second floor
flat and worked full time. Post stroke symptoms included ataxia, reduced co-ordination, memory
deficits, fatigue, nausea and dizziness. Rehabilitation consisted of daily multiple disciplinary team
(MDT) input on a Stroke ward including 5 days per week Physiotherapy sessions. Progress was slow
and after 10 weeks discharge plans to her parent’s home with a zimmer frame were being arranged.
An extension of rehabilitation was agreed to allow for electrical stimulation of patient’s abdomen
and back extensors for core stability and improved mobility to possibly enable independent living.
ES treatment was introduced following attendance by patient’s treating Physiotherapist at a
continual professional development session.
Method
Two Microstim MS2 electrical stimulators from Odstock Medical Ltd were used on the internal and
external obliques and back extensors for 1 hour twice a day in the reclined position. Rectangular 5 x
3 cm Pals Plus electrodes were used. Output 5, frequency 40Hz and mode 1 for long up and down
ramping were the most comfortable and effective parameters. Baseline measures of 10 metre
walking speed with appropriate walking aids, timed stepping, timed up and go, timed ascent and
descent using rehabilitation stairs in Physio gym were recorded at weekly intervals prior to her
discharge 6 weeks after starting ES treatment. Repeat measures were recorded at 2 x 2 month
intervals post discharge. On discharge the electrical stimulators were replaced with a Slendertone
belt for daily treatment.
Results
Timed up and go with zimmer frame initially and progression to elbow crutches significantly
improved from 4.17 minutes to 34 seconds over 12 weeks. Ascent and descent of stairs significantly
improved from 10.30minutes to 1.10 minutes over 5 weeks. Timed stepping onto a lower step
improved from 6.21 minutes to 38 seconds in 12 weeks. The patient’s goal to be discharged to her
own second floor flat using elbow crutches was achieved 6 weeks after commencing ES treatment.
Progress continued at home and patient is now an independent walker and has returned to full time
employment. She completed a half marathon in September 2014 in 4 hours 12 minutes.
Discussion
The rehabilitation journey for stroke patients is many and varied in time and outcome. Access to
treatment options, pathological, physical and psychological factors all influence stroke rehabilitation.
Progress with conventional rehabilitation treatment had plateaux after 10 weeks prior to
commencement of ES treatment. ES may have had a role in the continued rehabilitation of this
patient towards independence and improved mobility. A single case study does not give sufficient
evidence for treatment options but it can inform for future studies. There are no known studies
describing this technique to improve mobility.
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Conclusion
The use of ES in this case study was beneficial in enabling the patient to return to independent living.
Further studies are required to provide evidence of the benefits of this form of ES treatment for
stroke patients.
References
1. 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 randomised
placebo-controlled trial. Stroke 2005;36(1):80-5
2. Chae J, Sheffler LR, Knutson JS. Neuromuscular electrical stimulation for motor restoration in
hemiplegia. Topics in Stroke Rehabilitation. 2008;15(5):41-26
3. Swain I, Taylor P. The clinical use of functional electrical stimulation in neurological
rehabilitation. Harizons in medicine, vol.16. Royal College of Physicians, London 2004:315-22
4. Baker L, Wederich C, McNeal D, Newsam C, Waters R. Neuro Muscular Electrical Stimulation
A Practical Guide, 4th Edition.
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Poster Presentations
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Use of a Mobile Gait Analysis System to assess the Immediate and Long- term
Effects of a Dropped Foot Stimulator on Walking in Stroke Patients
Whittaker M1, Sabbaghan A2, Holstrom L3
1 FES Mobility, West Vancouver, BC, Canada
2 Simon Fraser University, Burnaby, BC, Canada
3 APDM, Portland, Oregon, USA
maurawhittaker@gmail.com
Introduction
Measuring gait changes when fitting a dropped foot stimulator (DFS) is an essential but often
difficult task for clinicians. Methods of assessing gait comprise, among others, qualitative kinematic
analysis involving observation and rating of gait deviations, video analysis, gait speed assessment
using a stop watch and more sophisticated three dimensional kinematic assessments using Vicon
Motion and similar systems. Observational gait analysis such as the Wisconsin Gait Scale is simple
and inexpensive to perform, can be repeated as needed but is subjective and influenced by the
experience of the observer as low inter and intra test reliability with observational gait analysis has
been reported. Measuring gait speed change provides useful evidence of progress with a DFS but
does not provide detail on specific gait parameters. Kinematic assessments in a gait lab can be
expensive, require patients to attend for lengthy appointments and are generally not available to
clinicians in regular practice.
Mobility Lab (APDM Inc.,) is a portable, instrumented gait and balance mobility assessment system
designed for use in the clinic setting. It uses wireless, body worn inertial movement monitors to
track each foot during gait. Both the positional trajectory through space and the orientation of each
foot is measured 128 times per second. Mobility Lab can be set up in any location and offers fast
collection of a range of gait data.
A study is underway utilizing Mobility Lab to collect gait data on stroke patients with & without the
Odstock Dropped Foot Stimulator (ODFS). Study aims include: assessing the immediate orthotic
effect of the ODFS on patients not previously fitted with a device; collecting longitudinal data on
patients currently fitted with a device and comparing results from Mobility Lab to previously
published kinematic studies on gait with and without FES.
Method
Initial assessment with the ODFS is undertaken to check for stimulation response and ability to walk
with the device. At a second appointment, subjects are instrumented with Mobility Lab sensors and
perform 5 consecutive walks, as follows: 1st walk: no stimulation; 2nd, 3rd 4thwalk with stimulation;
5th walk: no stimulation. Subjects walk for a maximum of 2 minutes/walk, generally over a 10 metre
course.
Results
Early trials of Mobility Lab testing on subjects set up with a DFS show that gait data can be extracted
that would not be possible with observation alone. Key walking parameters - speed, cadence, double
support time, stance & swing phase, stride length, pitch of the foot at heel strike & toe off, lateral
step & step variability can be measured in both the paretic & non paretic limb. See Table I for sample
of parameters.
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Parameter
No FES
With FES
% Change
Cadence
61
73
Inc 19%
Gait Cycle (s)
1.96
1.64
Dec 16%
Speed (m/s)
.18
.328
Inc 83%
Dbl Support
(% GCT)
67%
58%
Dec 12%
Stance (%GCT)
80/85%
73/84%
Dec 9%
Stride
(metres)
.4/.4
.5/.6
Inc 23/31%
Table I: Mobility Lab test data; 48 y/o stroke Figure 1: Mobility Lab
Discussion/Conclusion
Use of a portable, quick set up gait analysis system that provides objective, quantitative gait data can
assist the clinician in identifying the effects of dropped foot stimulation in hemiplegic patients. The
ability to easily track progress with use of a stimulator provides additional support to the clinician in
the management of the patient. Long term data can also be collected to support use of FES in
neurologic conditions.
Mobility Lab provides a level of gait data not previously available to clinicians in daily practice. It
makes it possible now to fully assess the orthotic, total orthotic and carry over effect of a dropped
foot stimulator.
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Combined dropfoot treatment using dynamic splinting with FES: a case study
Lane RP, Chappell PH, Matthews MJA
ECS, Zepler Building, Highfield Campus, University of Southampton SO17 1BJ
rodlane@soton.ac.uk
Introduction
There are a number of problems associated with the use of FES for the treatment of dropfoot when
used with children and young people. These include: daily accurate electrode positioning; hygiene
and skin irritation; and potential developmental effects of inappropriate foot positioning. This paper
describes a compound solution that has been developed to address these issues, by combining
dynamic elastomeric splinting to provide passive ankle joint support with FES for additional active
dorsiflexion. A further innovation was the use of a newly developed trans-conductive polymer layer
(EPSRC funded) that enables the stimulation electrodes to be permanently placed externally on the
splint, while the internal surface against the skin can be easily cleaned daily. The solution addresses
the daily problems of accurate electrode positioning and skin hygiene. A final benefit is improved
foot position at heel strike. Conventional dropfoot systems are normally setup to produce eversion
of the foot along with dorsiflexion to ensure stability of the ankle at heel strike. This is opposite to
normal gait where the foot lands partially inverted, rolling into eversion during stance. Landing on
an everted foot produces abnormal loading on the inside of the knee joint and an abnormal gait
pattern. By using dynamic elastomeric splinting to stabilise the ankle, the FES can produce
dorsiflexion alone, promoting a more normal gait pattern with consequential benefits on developing
limbs.
Method
A standard dorsiflexion sock made by DM Orthotics Ltd. was modified to include a panel of trans-
conductive polymer. The material is inert against the skin but allows conduction of FES stimulation
from the outer surface. The subject was a 17 y.o. female, CP with left-hemi. Measurements were
taken during walking: without intervention; with the splint without FES; and with both splint and
FES. Data were captured for 3 concurrent, timed 10m walks with the steps counted and the
physiological cost index (PCI) calculated.
Results
Averaged over the 3 walks
Speed m/s
Stride cm
Cadence steps/min
PCI
No intervention
1.20
115
124.47
0.49
Splint alone
1.18
118
120.38
0.35
Splint + FES
1.21
123
118.59
0.30
Discussion
The intervention had little influence upon walking speed but improved stride length. From
observation the additional dorsiflexion increased the step length on the affected side accounting for
the 3cm improvement (splint alone) and a further 5cm with FES. The improved PCI indicated that
changes to the gait (improved cadence) made a large difference to the effort required to walk, the
subject reported at the time that she much preferred the ease of walking with the splint.
Conclusion
This single case study has produced positive results that warrant further investigations into this
combined intervention.
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A model to predict setup time for a novel upper limb FES system
Smith C, Kenney LP, Howard D, Hardiker N, Waring K, Sun M, Luckie H
University of Salford, Salford, UK
c.smith1@salford.ac.uk
Introduction
Despite the evidence supporting high intensity therapy, stroke patients receive little upper limb
therapy during their in-patient stay [1]. Rehabilitation technologies may offer increased intensity of
therapy without increasing the demand on therapists’ time, but uptake remains limited [2]. One of
the reported barriers to uptake is the time needed to set up the technologies [3], yet setup time has
received very little attention in the literature. In this paper we report on the development of a
model to predict setup time of a new upper limb FES system which allows therapists to define a
state-machine based FES controller specific to both the patient and the chosen functional task. As
therapists typically have fixed time for each patient session, prediction of setup time would allow
the therapist to make informed decisions on the selection of FES-assisted task(s) for a given patient.
Method
We hypothesised that two factors would influence setup time, task complexity and patient
impairment; the more complex a task, the more phases would be needed in a state machine
controller; the more impaired the patient, the greater the number of stimulation channels would be
needed to support movement. Patient impairment was characterised using Fugl-Meyer test and task
complexity was characterised using a measure developed during the study, based on changes in joint
status. Six subjects (mean age 60, mean time since stroke 9.8 years, mean FM 31) were recruited to
the study. For each of the subjects a single experienced therapist used the new system to set up a
number of different tasks, each of which was assigned a task complexity score. Setup times for each
task with each patient were recorded using a stopwatch.
Results
Upper limb impairment and task complexity scores statistically significantly predicted setup time,
F(2,21) = 12.782, p<0.000234, adj.R2 = 0.506
Discussion and conclusion
Our model was able to predict 51% of the variability in observed setup time. Further work is
required to explore the influence of other factors, including training and experience of the therapists
on setup time, before generalisation to other clinical environments. A similar approach could be
adapted to other types of rehabilitation technology.
References
1. McHugh G et al. Disabil Rehabil 2014;36(11):925-31.
2. Hughes A. et al. BMC Health Services Research 2014, 14:124
3. Hochstenbach-Waelen A et al. J Neuroeng Rehabil. 2012; 9:52
This is a summary of independent research funded by the National Institute for Health Research
(NIHR)’s NEAT Programme (Grant Reference Number L030). The views expressed are those of the
author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
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Establishing an Outpatient Neuromuscular electrical stimulation
(NMES) service: A review of early outcomes
Jones H, Bull K, Seary C, Steadman H, Farrell R
National Hospital for Neurology and Neurosurgery
Helen.jones@uclh.nhs.uk
Introduction
This is a poster to illustrate early subjective findings in a newly established upper limb electrical
stimulation (NMES) service for patients with neurological conditions, which started in January 2013.
A total of 36 patients have been assessed in a consultant led clinic and set up with NMES. Here we
present our initial subjective findings, reflections and plans for future progression of service.
Method
(Pathway diagrammatically represented on poster) Patients are referred via consultant or GP.
Referral criteria are wide with a variety of neurological conditions and functional ability. An in-depth
assessment, trial of stimulation and goal setting occurs at initial assessment. If appropriate the
patient attends 2 set up appointment with a Physiotherapist where outcome measures are
completed and they are taught how to integrate the device into their home based upper limb
management program. They are then reviewed at 6 weeks and 3 months when their outcome
measures are repeated.
Data has been collected for all patients who have completed at least 3 months using NMES. This will
be analysed retrospectively in order to describe demographics of patients seen in the service to
date. Categorical analysis of each patients self-identified patient’s ‘main problem’ and goals will also
be completed.
Results
On initial review of the data, categories chosen for main problems are defined as: Stiffness,
Weakness, Pain and Function. Patient’s goals have been categorised into: Range of movement,
Reach, Grasp, Stabilising and Functional activities.
The pre- treatment and post- treatment subjective data will also be analysed and presented in graph
format. The subjective measure used was the Arm activity measure sections A and B (ARM A, ARM
B). The results show that 39% of patients reported improvement in the passive care pf their arm.
33% reported improvements in functional use (ARM B). With regards to goal achievement, 39%
didn’t achieve their goals, 39% partially achieved and 22% achieved their goals.
Discussion/ Conclusion
Initial analysis of outcomes following implementation of a specialist neurological NMES service
demonstrate significant variability in patient function and compliance. Physiotherapists have
reflected that patients may have benefitted from more physiotherapy treatment sessions alongside
NMES to improve goal achievement. In some cases, patient goals were not specific or easy to
measure, which made determining goal achievement difficult. Some data was incomplete due to
problems with patient attendance at follow up and staff changes. Identification of NMES treatment
pathways dependent on presentation may provide added benefits to patient outcomes.
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Control of Upper Limb FES Devices Using a Shoulder Position Sensor Based on
an Inertial Measurement System
Venugopalan L1, 2, Swain ID1, 2, Cobb JE2, Taylor PN1
1 The National Clinical FES Centre, Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ
2 The Faculty of Science and Technology, Bournemouth University, Poole, BH12 5BB
lvenugopalan@bournemouth.ac.uk
Introduction
Functional Electrical Stimulation (FES) has helped people with tetraplegia in partially regaining their
upper limb functions, enabling them to perform some of their activities of daily living (ADL)
independently1. The user activates a man-machine interface (MMI) to generate the command signal
which is interpreted by the FES device. The most commonly used MMIs are push buttons and
myoelectric signals. The possibility of using commercially available Inertial Measurement Units
(IMUs) like the Xsens MTx as a possible MMI for upper limb FES devices has also been explored2. The
main disadvantages of using the Xsens module are the size of the sensor and the cost. Hence the
possibility of using an inexpensive commercially available IMU as a shoulder position sensor is
explored in this paper. The specifications for an IMU based shoulder positions sensor are: it should
be able to detect the shoulder movement; it should be compact so that it can be strapped across the
upper arm as close to the shoulder as possible and it should be cost effective.
Method
The two possible shoulder position sensors are: the Xsens MTx, which is the gold standard for IMUs
and the Flyduino Nanowii flight controller. In order to select the better sensor, two experiments
were performed. In the first experiment, the sensor was strapped rigidly across the volunteer’s
shoulder and they were asked to perform shoulder elevation, protraction and retraction in a given
sequence. In the second experiment, the volunteers performed the shoulder elevation protraction
and retraction in random sequence for a longer duration of time.
Results
In the first experiment, the cross correlation between the signals obtained from the two sensors
ranged between 0.7086 and 0.9907. From the data obtained from the second experiment, the
sequence of the shoulder movement was identified.
Discussion
The axes of the sensors were aligned as closely as possible while strapping it across the volunteer’s
shoulder and the sampling frequency of the Flyduino Nanowii was downsampled to match that of
the Xsens Module. There was however a slight frequency mismatch which affected the cross
correlation calculations. Hence the signals were post processed in order to remove the lag and then
the cross correlation values were evaluated.
Conclusion
Based on the results obtained from both the experiments, it can be concluded that the Flyduino
Nanowii flight controller can be used as a shoulder position sensor to control an upper limb FES
device.
References
1. Pancrazio JJ, Hunter Peckham P. Neuroprosthetic devices: How far are we from recovering
movement in paralyzed patients? Expert review of neurotherapeutics. 2009
2. Tresadern P, Thies S, Kenney L, Howard D, Goulermas JY. Artificial Neural Network Prediction
Using Accelerometers to Control Upper Limb FES During Reaching and Grasping Following Stroke. In:
; 2006. p. 29162919.
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A systematic review of functional electrical stimulation for foot-drop of
central neurological origin and its orthotic effect on walking
Prenton S1, Hollands K2, Kenney LP2
1 University of Huddersfield, Queensgate, Huddersfield, West Yorkshire, HD1 3DH
2 University of Salford, Frederick Road, Salford, Greater Manchester, M6 6PU
S.Prenton@hud.ac.uk
Introduction
Functional electrical stimulation (FES) is recognised as an effective treatment for foot-drop of central
neurological origin. However recommendations and previous reviews have been based, in part, on
non-randomized controlled trials (RCTs). Recently, several more RCTs in this area have been
published. This presented an opportunity to review RCT evidence focussing specifically on what is
known as the total orthotic effect, which compares walking at baseline with no stimulation to
walking after a period of use with stimulation. The objectives were to investigate: (i) the total
orthotic effect of foot-drop FES on improving walking (spanning all domains of the WHO ICF); (ii)
whether foot-drop FES has a greater total orthotic effect on walking than the usual management
approach of ankle foot orthoses (AFO).
Method
Comprehensive searches of MEDLINE (Ovid), CINAHL (EBSCO), AMED (Ovid), CENTRAL, Scopus
(Elsevier), REHABDATA, PEDro, NIHR Centre for Reviews & Dissemination & clinicaltrials.gov
databases plus reference lists, citations, key authors and journals was completed using a priori
strategy. Screening was performed by 2 reviewers independently, data was extracted using a pre-
piloted proforma and quality was assessed using the Cochrane risk of bias assessment tool (by the
same 2 reviewers). Narrative and meta-analysis was conducted to meet the review’s objectives.
Results
8 studies were eligible for inclusion. 2 of these reported outcomes from the same study so were
considered together, resulting in 7 studies which underwent quality assessment. Meta-analysis
considered activity and participation measures; body function and structures (BFS) measures were
used infrequently so could not be considered. The results of the data extraction, quality assessment,
narrative and meta-analysis will be presented at the conference.
Discussion
At this point in time a definitive conclusion regarding the orthotic effect cannot be provided as the
meta-analysis is yet to be completed. However, it is already clear there is a continued lack of high
quality RCTs in this area, a tendency to overly focus on measures of activity, and poor descriptions of
the specific effects of FES being studied.
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Functional Electrical Stimulation (FES) Service Patient Satisfaction Survey
(n=138)
Peace C, Singleton C
Birmingham Community Healthcare NHS Trust
Carla.Peace@Bhamcommunity.nhs.uk, Christine.singleton@Bhamcommunity.nhs.uk
Introduction
Patient Surveys enable Service Providers to have valuable information from their Service Users.
Service evaluation and recommendations for improvements as well as evidence of patient
satisfaction inform Services for future development. The FES Service in Birmingham, UK, conducted
an independent survey with the assistance of the Trust’s Patient Experience Team between
December 2012 and March 2013. An analysis of the 138 completed forms provided information for
the Service to use with Commissioners to help secure funding for the FES Service in 2014
Method
Patients attending the FES Clinic between December 2012 and March 2013 were independently
asked by the Trust’s Patient Experience Team to complete a Patient Survey following their
appointment. The survey comprised 24 closed questions with either a Yes/No or Likert response and
3 open questions for subjective comments. The closed questions related to environment,
communication, available information, administration, dignity, respect, privacy, quality of care and
experience with staff. A further 5 questions provided standard information on Equalities
Monitoring. The Patient Experience Team compiled, analysed and reported on the outcome of 138
completed surveys.
Results
The first 22 closed questions provided 91% positive responses. The overall satisfaction rating of good
to excellent was recorded by 100% of patients. The Net Promoter Question (Q24) asking how likely
they are to recommend the service to Friends and Family reported 97.8% responding ‘highly likely’.
This question is a benchmark for all NHS Trusts.
There were 87 comments from the open question asking What difference, if any, has the F.E.S
made to your quality of life? Responses included comments on quality of life, gaining of
independence and safety of mobility eg: It has improved my life, by enabling me to walk without
tripping and given me confidence to go out and made walking easier.
The second open question Was there anything particularly good about your visit to the West
Midland Rehabilitation Centre(WMRC)?” provided 60 responses relating to staff, environment , care
by staff and information provided eg: “Clean, bright and welcoming free parking”, “Excellent Physio
she was very caring and explained everything really well”.
The third open question asked for “Any other comments”. Responses related to appointment times,
extra services, satisfaction with the service despite distance travelled eg: “we need to get in to
appointment on time”, “toilets in need of updating”, “I was very pleased with my visit although my
round trip is 140 miles it is well worth it”.
The negative themes related to appointment start times and lack of information relating to wait
times.