International FES Centre®
International FES Centre® – Functional Electrical Stimulation
In 2018 we opened the International FES Centre® for inpatients and outpatients in the area of neurological and musculoskeletal rehabilitation.
FES at the Swiss Paraplegic Centre (SPC)
Functional Electrical Stimulation (FES) was introduced as a treatment method at the SPC in 1992. Since then, it has become an integral component in the rehabilitation of both inpatients and outpatients. All requirements for functional electrical stimulation in the musculoskeletal area are met, as listed in the guidelines issued by the International Functional Electrical Stimulation Society (IFESS).
This also includes integration of the latest technologies in the area of functional electrical stimulation, various robotics including exoskeletons with integrated FES, and combination treatments such as stimulation following injection of botulinum toxin.
We already conduct research projects which further refine and verify the evidence of this methodology.
What is “functional electrical stimulation”?
Functional electrical stimulation is a treatment method that acts on muscles using electrical pulses rather than neural stimuli, and which results in the contraction of one or multiple muscles. Electrical stimulation can have a supportive effect in order to achieve a new level of functional balance, i.e. to support or replace functions.
When using electrical stimulation, electrodes are placed on the skin and then used to create an electrical field. Under the influence of this electrical field, the activation of nerve and muscle tissue is artificially stimulated, and the muscle contracts. Electrical stimulation is used below the lesion to stimulate the nerves in patients with damage to the upper motor neurones, and it is used to directly stimulate the affected muscles in patients with damage to the lower motor neurones.
Inpatient care for patients receiving FES is provided by the treating therapists, specialists, and therapeutic experts in the FES area.
Care for outpatient referrals, including follow-up care.
Care for all post-inpatient patients with functional electrical stimulation is provided on a prescription basis and via a subscription system.
The outpatient consultation is carried out by a doctor and an FES therapist The objective of these consultations is to be able to identify and test complex patient situations in an interdisciplinary team. The service is charged for at the following TARMED positions:
- Consultation (higher tariff in the event of an external referring doctor for the initial findings)
- Medical consultation/follow-up (internal referring doctor)
- Medical service when the patient is present
- Charging for medical reports in accordance with TARMED specifications
A prescription for outpatient physiotherapy is required, on the basis of which the treatment can be charged for. The charging process uses a physiotherapy tariff with the addition of initial treatment at the first consultation.
A prescription for outpatient occupation therapy is required, on the basis of which the treatment can be charged for. The charging process uses an occupational therapy tariff if the patient is present, and a 7602 tariff if the patient is absent.
The Swiss insurance system does not clearly regulate the assumption of costs for owned and leased equipment. Simulators for the area of functional electrical stimulation are not listed on the Mittel- und Gegenstandsliste (MiGel) (List of Media and Objects).
Based on all consultations by an external referring doctor, reports are written that include information about the testing and planned procedure. Progress reports are created for the GP and insurer one month before expiry of the assumption of costs. These include progress made to date, any further planned procedures, and a request to extend the assumption of costs.
FES services / treatment methods
FES represents a multifaceted treatment method that is ideally combined with occupational therapy and/or physiotherapy. The stimulation programmes and relevant parameters should, however, be selected on a case-by-case basis. As a rule, the use of standard programmes has not provided promising results.
Motor learning is a permanent change in the mastery of a skill in response to practice or movement experience. “Motor learning” therefore includes learning or relearning movements and functions that have been impaired by neurological damage such as a spinal cord injury or a stroke. Not everything can be relearned as areas that have been too severely damaged are excluded from this process. However, areas of the motor cerebral cortex affected by the “learned lack of use” can be activated. This is also possible in the case of a chronic spinal cord injury.
Popovic et al 2011
FES cycling is a recommended form of cardiovascular training for the purpose of prevention. In FES cycling, the leg muscles (m. quadriceps, hamstring muscles, m. gluteus maximus, m. tibialis anterior, and m. gastrocnemius) are electrically stimulated while performing the cycling movement. This means that the patient drives the bike forward by moving their stimulated legs. Effects such as greater oxygen uptake during training and increased fat burning due to the training have been investigated and proven. An improvement in physical fitness is an additional benefit. Perret et al 2010, Gorgey et al 2016, Hasnan et al 2013.
Breathing – coughing
Patients with tetraplegia and paraplegia (TH2-TH5) exhibit a lack of voluntary activity in the stomach muscles because of paralysis. This in turn has a significant effect on forced exhalation. Forced exhalation is necessary for good ventilation of the lungs, coughing and loud, powerful speech. Tetraplegic patients usually require someone to manually assist them when coughing up. FES to the stomach muscles offers an alternative option, strengthening exhalation and coughing.
Function replacement and support for movement
FES can support and even replace sub-functions of muscle groups or individual muscles. The system is used most frequently to support muscles in the lower extremities when walking, such as the dorsal flexor and/or buttock muscles. However, it’s also possible to support or replace muscle function in the torso, in muscles used for locomotion, and those in the upper extremities when gripping objects. An individual assessment is necessary to facilitate effective and efficient functional replacement.
FES can be used to prevent muscle atrophy arising from lack of use or denervation (Gordon et al 1994). The strength of the musculature (Crameri et al 2004), power (Haapala et al 2008) and endurance (Sabatier et al 2005) can all be improved. FES can stimulate an increase in the cross-sectional area of the muscles (Martin et al 1992, Scremin et al 1999) and an increase in muscle mass (Scremin et al 1999). The function of individual muscles or muscle groups may also be strengthened.
Tone (spasticity, spasms)
Using FES has a regulating effect on tone – that is, spasticity and spasms. This can be seen briefly after the first treatment, though a longer-lasting effect can only be achieved after several weeks to months of treatment.
Subluxation prophylaxis using FES
The risk of the humeral head being incorrectly positioned in relation to the acromion commonly affects people with tetraplegia who have insufficient musculature surrounding the shoulder due to paralysis. Subluxation in the shoulder joint may result in pain and movement restrictions. FES represents a treatment method which can counteract this. Ideally, FES is combined with targeted physiotherapy.
Treating the torso muscles using FES
Structural changes can occur in the area of stasis and torso musculature due to scoliotic malposition, scoliosis resulting from paralysis, asymmetries in the torso due to spasticity or voluntary motor function, or – in children with spinal cord injury – during growth. FES, in combination with targeted physiotherapeutic treatment of posture as well as simultaneous wheelchair adaptation, offers a treatment method.
Contracture prophylaxis using FES
FES can be used to avoid and treat joint restrictions, provided that their causes are muscular. It can be used on the upper and lower extremity. In the area of hand and finger joints, it is possible to treat muscular shortening which results, for example, from an imbalance between the hand and finger benders and flexors. In the lower extremity, drop foot can be treated using FES. In this regard, combination treatment involving the injection of botulinum toxin and subsequent FES is possible following medical assessment.
Ongoing studies at the SPC
Effect of electrical stimulation on the muscle structure of paretic muscles in the hand and forearm
The study aims to investigate the effect of electrical stimulation on paretic muscles in the forearm and hand, notably the effect of electrical stimulation on muscle structure and muscle thickness. The study is being carried out on people with tetraplegia who have paresis of the extensor carpi muscle, the abductor pollicis brevis muscle, or the first dorsal interosseous muscle. Stimulation of a paretic muscle results in a return of its ability to contract. Maintaining the muscle in this way has a positive effect on its structure. It may be possible to avoid or improve misalignments of the wrist, for example. Other treatment options such as nerve transfers to achieve functional improvement could also be discussed, where applicable.
Sustainable effects of transcutaneous spinal cord stimulation on spasticity and mobility with repeated application in the case of incomplete spinal cord inju-ry
Spasticity is a common side effect of spinal cord injuries. It often causes severe impairments in everyday life and can make any remaining ability to move more difficult. Current treatment methods comprise physiotherapy or drug therapy. Over recent years, a method known as transcutaneous spinal cord stimulation has been developed where the spinal cord is electrically stimulated by self-adhesive electrodes on the skin. Pilot studies have shown that a single half-hour application of this stimulation technology can provide effective control of spasticity for several hours. This study therefore aims to investigate whether repeated application of transcutaneous spinal cord stimulation over a six-week period can provide sustainable (i.e. beyond the duration of application) control of spasticity in patients with an incomplete spinal cord injury.
The effect of functional electrical stimulation (FES) in reconstructive arm and hand surgery in the case of tetraplegia
There are only few studies available on functional improvement of the upper extremities. FES is a widespread and much used method in the rehabilitation of patients with a spinal cord injury with tetraplegia to improve hand and arm functions. EMG-triggered electrical stimulation is used, for example, to improve motor learning. The already investigated effects of FES become even more significant with regard to reconstructive arm and/or hand surgery in patients with tetraplegia. One possibility here could be to use FES to strengthen donor and recipient muscles before and after surgery. The motor learning process forms part of treatment before surgery, in particular. So far, there have been no investigations into whether the targeted use of FES before and after reconstructive surgery could improve results in terms of strength, motor learning and function. Initial clinical observations indicate a potentially positive effect of FES. A randomised controlled study aims to investigate the following points:
- Whether the use of FES before and after surgery can increase the strength of donor and recipient muscle and thus improve results in terms of strength and functionality
- Whether the use of FES with an EMG-triggered stimulator accelerates the motor learning process after surgery
- What level of patient satisfaction is achieved and how well patients are able to perform individually defined everyday movements
- Whether FES results in an increase in volume of the stimulated muscles
- How patients assess the applicability of FES relative to pre-treatment and post-treatment benefits
Effect on physical fitness of training leg muscles using electrical stimulation after a spinal cord injury
This study aims to investigate the effect on physical fitness of two different types of training of paralysed leg muscles using electrical stimulation. The effects of short, intensive training using electrical stimulation muscles will be compared to longer, low-intensity training of the leg muscles.
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