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25 YEARS OF CLINICAL EXPERIENCES IN USING FES BY HEMIPLEGIC PATIENT, PRACTICED IN THE LJUBLJANA REHABILITATION INSTITUTE

Ruza Aæimoviæ Janeziè, UroÆ Bogataj, UroÆ Staniè, Miroljub Kljajiæ, Nika Goljar, Bozena Lisatz,Rehabilitation Institute, Ljubljana Slovenia

ABSTRACT

25 years overview of clinical experiences using FES in 80% of treated patients with upper motor neuron lesion is given. On the basis of clinical evaluation the most suitable 1-channel, 2-channel and 6-channel stimulator for therapeutic and orthotic treatment were chosen. In recent years dual-channel stimulation of lower and upper extremity has been increased. In spite of technical and medical problems FES beside conventional rehabilitation methods has to be continued following by the biotechnical research.

INTRODUCTION

Electricity as a therapeutic agent was not reported as the use of heat, though the history of electro therapy is a very interesting field. Different devices were used more than a century ago. In 1747 Kratzenstein enabled a learned man, after a single electrification, to play the piano again with his two paralyzed fingers (1). Seiler 1860 reported improvement in cases of scoliosis, while the concept of iontophoresis was first claimed by De Luck in 1908 (1). Since W.T. Liberson 1961 proposed an FES peroneal brace for drop foot correction and L. Vodovnik started in 1965 his own design of the FES peroneal brace, routine application of FES treatment with hemiplegic patients in the Ljubljana Rehabilitation Institute has been introduced. Many different prototypes of stimulators have been researched and evaluated, but only few of them remain applicable for clinical practice. Comparing results obtained by different research centers in the USA and Europe, our experiences are similar (2).

THERAPEUTIC APPROACH

Impaired sensory motor functions in hemiplegic patients (stroke, brain injury, operated brain tumors) are typical persistent sequels after the onset in about 70% of cases. To prevent handicap rehabilitation treatment has to be provided for these patients who are candidates for the FES therapeutic procedure, beside conventional neurotherapeutic treatment. The main goal is to replace the lost central control of movement by artificial FES control, to achieve a functional selective response of stimulated muscle, to break synergistic movement and to reduce spasticity. From the early beginnings on the basis of technological development and evaluation different designs of the 1-channel peroneal brace in routine application are indicated and available in the market. Since the applicability of a 3-channel stimulator reported by Kralj in 1961 (3), few designs of multichannel stimulators with surface electrode have been developed. Finally, a 6-channel microprocessor stimulator for FES in institutional care has been used (4), mainly for research purposes. The results obtained in the research of multichannel electrical stimulation for the initiation of gait by patient with severe impairment have led to a prototype of a dual-channel device (5).

Beside those system surface stimulators, other surface stimulators have been used for the upper extremity stimulation.

ORTHOTIC APPROACH

Three different types of single channel peroneal surface stimulators, such as also in current use, have distinguishable properties of a typical orthosis. The implantable peroneal underknee stimulator can be excepted, as the most typical orthotic device for the correction of drop foot in patients with an upper motor neuron lesion (6). The dual-channel adapted clinical stimulation system for the control and analysis of gait has been designed in such a way that beside during the therapy it could be used as an orthotic aid. The system consists of two units: stimulator and programmer/stride analyzer. Programmer/stride analyzer is used by therapist for the programming of stimulation parameters in the stimulator unit. The statistical parameters of gait (stride time, left and right stand and swing times, symmetry of gait and number of steps) measured can also be displayed on the programme/stride analyzer (which is a big advantage of the system). Once programmed, the only thing the dual-channel unit requires for operation is turning on and setting the intensities on both channels. This can easily be performed by the patient himself. It enables surface stimulation of two different muscle groups. The stimulation timing can be adjusted for selected muscles and is synchronized automatically with the gait cycle.

RESULTS AND DISCUSSION

Table and Graph 1. Proportion of stroke patients with regard to the number of FES channels applied (over 200 patients per year).

year 1987 1994
one channel 60% 29%
two channels 30% 58%
more ch. 10% 13%

In the recent years the electrical stimulation is being applied in 80% of hospitalized patients and outpatients (7). As initiation of gait and mobility are achieved in a relatively short time (three weeks of radical therapy with a 6-channel stimulator), the hospitalization period is growing shorter (8-10 days) per patient. Due to therapeutic effect the number of channels can be reduced (from 6 to 2 or 1-channel), so the prescription of FES orthoses is on a decrease. The dual channel stimulator and programmer/stride analyzer can be used at home mostly with the help of relatives. Selfmanagement of the system depends on the group of stimulated muscles and upper extremity function. The positioning of surface electrodes to the m. quadriceps and common peroneal nerve is easier than the positioning to the m. gluteus maximus or m. triceps brachii. The first research results in 1993 and 1994 obtained in a group of 1 CP, 11 CVI, 4 TBI patients 568 +- 450 days after the onset, 44 +-13 years of age, showed, that only 8 of them were capable of using the system at home. The same system can also be used for the stimulation of two muscle groups of the upper extremity (agonist - antagonist, deltoid muscle - extensor of the wrist). From Table and Graph 1 increased number of patients treated with the dual-channel stimulator in the year 1994 is evident. After 20 years of clinical experience with the orthotic implantable 1-channel peroneal stimulator, problems on displacement of subcutaneus electrodes due to a fibrous capsule and undesirable not-selective excitation of the deep branch of common peroneal nerve are evident (50 implantations, including 9 reimplantations) (8). The problems of surgical techniques, biocompatible materials, design of a complex nerve electrode and also the problems of surface electrodes have remained the same as before.

CONCLUSION

In our case the first step will be a clinical evaluation of a new generation of simple embodiments of one and dual channel electrical stimulators with electrodes for better selectivity of movement will be done. In spite of many persisting problems the application of FES as an additive method is doubtlessly justified in rehabilitation programs on patients with upper motor lesions. Concerning the long-lasting experiences, technological, biological and biomedical research, especially for implantable systems, has to be carried on. Namely, optimal results can only be obtained by following some general principles developed in practice over the years to comply with patients' and special trained staff's requirements.

REFERENCES

1. Wakim, K.G., F.H. Drusen, The Influence of electrical stimulation on the work output and endurance of denervated muscle. Arch. Phys. Med. Rehabil. 32: 523, 1951.

2. Kralj, A., T. Bajd, L. Vodovnik. FES for mobility: The lesson learned in 30 years. In: 5th Vienna International Workshop on Functional Electrostimulation: Basis, technology, clinical application. Proceedings, Wienna, August 17-19, 1995. Wienna: Dept. of Biomedical engineering and physics, University of Vienna, 13-20, 1995.

3. Kralj, A., A. Trnkoczy, R. Aæimoviæ. Improvement of locomotion in hemiplegic patients with multichannel electrical stimulation. Human locomotor engineering, Sussex, England, 60-68, 1971.

4. Bogataj, U., N. Gros, M. Kljajiæ, R. Aæimoviæ, M. Maleziè. The rehabilitation of gait in patients with hemiplegia: A comparison between conventional therapy and multichannel functional electrical stimulation therapy. Phys. Ther., Vol. 75, 6: 40/490-52/502, 1995.

5. Maleziè, M., U. Bogataj, N. Gros, I. Deèman, P. Vrtaènik, M. Kljajiæ, R. Aæimoviæ Janeziè. Application of programmable dual channel adaptive electrical stimulation system for control and analysis of gait. Journal of Rehabilitation Research and Development, Vol. 29, 4: 41-53, 1992.

6. Staniè, U., R. Aæimoviæ Janeziè, N. Gros, M. Kljajiæ, M. Maleziè, U. Bogataj, J. Rozman. Functional electrical stimulation in lower extremity orthoses in hemiplegia. J. Neuro. Rehab., Vol.#, No.#: 1-14, 1991.

7. Aæimoviæ Janeziè, R. Verwendung von FES bei Hemiplegia. Physic und technik in der Traumatologie, Intensivmedizin und Rehabilitazion. 14. Jahrestagung der Österreichischen Gesellschaft für BME. Wissenschaftliche Berichte, Klosterneuburg bei Wien: 255-258, 1989.

8. Kljajiæ, M., M. Maleziè, R. Aæimoviæ, E. Vavken, U. Staniè, B. PangrÆiè, J. Rozman. Gait evaluation in hemiplegic patients using subcutaneus peroneal electrical stimulator. Scand. J. Rehab. Med., 24: 121-126, 1992.

ACKNOWLEDGMENT

The authors would like to acknowledge the support from the Republic Slovenia Ministry for Science and Technology. The authors are also acknowledging the National Institute for Disability and Rehabilitation Research, Washington, USA, for the past support.

Prim. RuÆa Aæimoviæ JaneÆiè, MD Rehabilitation Institute 61000 Ljubljana, Linhartova 51 Slovenia

Fax: (+386) 61 13 72 070 E-mail: jozica.zrim(ir-rs.si

USING FES BY HEMIPLEGIC PATIENT