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ELECTRICAL STIMULATION AND SPASTICITY
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Agarwal G.C., Gottlieb G.L.
(1977) Oscillation of the Human Ankle Joint in Response to Applied Sinusoidal
Torque on the Foot. J Physiol 268, 151-176.
Alfieri V. (1982) Electrical
treatment of spasticity. Scand J Rehab Med 14, 177-182.
Allum J.H.J, Mauritz K.H.
(1984) Compensation for Intrinsic Muscle Stiffness by Short-Latency Reflexes in
Human Triceps Surae Muscles. J Neurophysiol 52, 797-818.
Andrews B.J., Bajd T.,
Roxendale R.H. (1988): TENS treatment of spinal spasticity. Scand J Rehab Med
Suppl 17:155.
Apkarian J.A. and Naumann S.
(1991) Stretch reflex inhibition using electrical stimulation in normal subjects
and subjects with spasticity. J. Biomed. Eng 13, 67-73.
Abstract: The effect of electrically stimulating the tibialis anterior muscle on
the stretch reflex of the soleus muscle in normal subjects and subjects with
spasticity is investigated. Stimulation of the tibialis anterior just prior to
the onset of a mechanical disturbance, which causes a stretch in the soleus,
inhibits the stretch reflex of the soleus in normal subjects and may inhibit
clonus in subjects with spasticity
Ashby P., Burke D. (1971)
Stretch reflexes in the upper limb of spastic man. J Neurol Neurosurg
Psychiat 34, 765-771.
Ashby P., Mailis A., Hunter J.
(1987) The Evaluation of “Spasticity.” Can J Neurol Sci 14, 498-500.
Bajd T., Gregoric M., Vodovnik
L., and Benko H. (1985) Electrical stimulation in treating spasticity resulting
from spinal cord injury. Arch. Phys. Med. Rehabil. 66, 515-517.
Abstract: To study the efficacy of electrical stimulation in treating spasticity
of six spinal cord injured patients, transcutaneous electrical nerve stimulation
(TENS) was applied to the dermatomes belonging to the same spinal cord level as
the selected spastic muscle group. Spasticity was assessed in knee extensors by
a pendulum test in which the knee joint angle of a swinging lower leg was
recorded with an electrogoniometer. TENS was found to produce a noticeable
decrease of spasticity in three of the patients, but had little effect on the
others
Bajd T., Kralj A., Turk R.,
Benko H., and Sega J. (1989) Use of functional electrical stimulation in the
rehabilitation of patients with incomplete spinal cord injuries. J. Biomed. Eng
11, 96-102.
Abstract: When patients enter the Rehabilitation Centre a therapeutic electrical
stimulation programme is immediately initiated. Three groups of patients were
identified: (i) those in whom an improvement of both voluntary and stimulated
muscle force was observed, (ii) those with an increase in stimulation response
only, and (iii) patients in whom no effect of electrical stimulation training
could be recorded. Isometric measurement of voluntary and stimulated knee joint
torque revealed that in a great number of patients one leg was severely
paralysed while the other leg was under sufficient voluntary control. Unilateral
two- channel stimulation of knee extensors and the peroneal nerve was proposed
as an orthotic aid for this group of patients. Exaggerated extensor tone was
observed by assessment of spasticity around the knee joint. A two-channel
peroneal stimulator was found to be a useful approach in order to inhibit this
tone and thereby help the patients to initiate a step
Bajd T., Munih M., and Kralj A.
(1999) Problems associated with FES-standing in paraplegia. Technol. Health Care
7, 301-308.
Abstract: Prolonged immobilization, such as occurs after the spinal cord injury
(SCI), results in several physiological problems. It has been demonstrated that
the standing posture can ameliorate many of these problems. Standing exercise
can be efficiently performed by the help of functional electrical stimulation
(FES). The first application of FES to a paraplegic patient was reported by
Kantrowitz in 1963. It was later shown by our group that standing for
therapeutic purposes can be achieved by a minimum of two channels of FES
delivered to both knee extensors. The properties of the stimulated knee
extensors (maximal isometric joint torque, fatiguing, and spasticity) were not
found as sufficient conditions for efficient standing exercise. According to our
studies, the ankle joint torque during standing is the only parameter which is
well correlated to the duration of FES assisted standing. For good standing low
values of the ankle joint torque are required. To minimize the ankle joint
torque the lever belonging to the vertical reaction force must be decreased.
Adequate alignment of the posture appears to be the prerequisite for efficient
FES assisted and arm supported standing exercise. Some patients are able to
assume such posture by themselves, while many must be aided by additional
measures. At present, surface stimulation of knee extensors combined with some
appropriately "compliant shoes" looks to be adequate choice
Bajd T., Kralj A., Stefancic
M., and Lavrac N. (1999) Use of functional electrical stimulation in the lower
extremities of incomplete spinal cord injured patients. Artif. Organs 23,
403-409.
Abstract: After a program of therapeutic electrical stimulation, 3 groups of
incomplete spinal cord injured (SCI) patients were identified, those in whom an
improvement of both voluntary and stimulated muscle force was observed, those
with an increase in stimulation response only, and patients in whom no effect of
electrical stimulation training could be recorded. As it is difficult to predict
the outcome of the electrical stimulation rehabilitation process, a diagnostic
procedure was developed to predict soon after accidents which incomplete SCI
patients are candidates for permanent use of a functional electrical stimulation
(FES) orthotic aid. The candidates for chronic use of FES are patients with weak
ankle dorsiflexors and sufficiently strong knee extensors. These patients are
equipped with a single channel peroneal stimulator augmenting dorsiflexion and
knee and hip flexion in a total lower limb flexion response. By applying FES to
the ankle plantar flexors, the swing phase of walking can be significantly
shortened and faster walking obtained
Baker L.L., Yeh C., Wilson D.,
and Waters R.L. (1979) Electrical stimulation of wrist and fingers for
hemiplegic patients. Phys. Ther. 59, 1495-1499.
Abstract: Passive cyclical electrical stimulation was applied during a four-week
treatment program to the wrist and finger extensors of 16 hemiplegic patients
with flexor spasticity. The study noted the effects of this treatment on the
patients' sensation; spasticity; passive range of motion of the wrist,
metacarpophalangeal, and proximal interphalangeal joints; and strength in the
wrist extensor muscles. Patients were divided into chronic and subacute groups.
Both groups received electrical stimulation for three half-hour periods a day,
seven days a week, as a substitute for all other range-of-motion techniques.
Flexion contractures were prevented in the subacute group of patients at the
wrist, metacarpophalangeal, and proximal interphalangeal joints. A statistically
and clinically significant increase in wrist extension range occurred in the
chronic group that had wrist flexion contractures before the electrical
stimulation. Increased extension was noted at the metacarpophalangeal and
proximal interphalangeal joints of patients in the chronic group. Those patients
with some voluntary wrist extension before the treatment began were able to
increase their extension strength during stimulation. No changes in skin
sensation were noted and only a general trend in decreasing spasticity was
apparent
Baker L.L., Parker K., and
Sanderson D. (1983) Neuromuscular electrical stimulation for the head-injured
patient. Phys. Ther. 63, 1967-1974.
Abstract: Recent research has shown that electrical stimulation is effective in
treatment programs designed to maintain or gain range of motion, to facilitate
voluntary motor control, and to strengthen muscles weakened by disuse. All of
these treatment goals are relevant to the head- injured patient who frequently
demonstrates profound disuse atrophy, joint contractures with excessive muscle
tone, and decreased voluntary motor capabilities. As the cognitive status of the
head-injured patient improves, electrical stimulation can be incorporated into
traditional treatment programs to enhance their effectiveness. This article
discusses using neuromuscular electrical stimulation with programs aimed at
managing contractures, reducing spasticity, and facilitating voluntary motion.
The limitations of electrical stimulation in the head- injured patient
population are addressed
Bates J.A. (1978) Therapeutic
electrical stimulation. The transistorized placebo? Electroencephalogr. Clin.
Neurophysiol. Suppl 329-334.
Abstract: (1) Electrical stimulation therapy for patients suffering with labile
signs and symptoms, and these include all varieties of acute and chronic pains,
seizures and spasticity, has come into fashion and gone, and come again with
each new technological advance for the past two hundred years. (2) A proportion
of patients with chronic disease have their suffering made worse if they feel
deprived of the latest therapy and may be relieved if they are given it in the
right circumstances. In this group the relief will usually be temporary and the
limited supply of such reactors will promote the cycle of fashion. In a group of
126 patients with chronic pain associated with organic disease who were offered
transcutaneous stimulation, only 23 (18%) continued to use it one year after
they started. (3) The cycling of therapeutic fashion is assisted not only
because relief is often temporary, but also by the difficulty in establishing
the normal range of variability from which significant change can be assessed
and by the uncertain relationship between signs and symptoms and for the
functions of daily living. For these reasons there is an inevitable tendency to
temporary over- optimism and it seems impossible to counter this by the
execution of a satisfactory clinical trial, since the patient cannot be "blind"
and a significant variable is the enthusiasm with which a therapy is surrounded.
(4) Electrical stimulation by cutaneous devices or implants can give much
benefit to some patients in whom other methods have failed and there are
indications, not only from anecdote and clinical impression but also now from
experimental physiology, that it may benefit by mechanisms of interaction at the
first sensory synapse. It is, however, an over-simplification to regard any
therapy as either strictly physiological or simply fraudulent. Like other
so-called placebos, physical methods of therapy can presumably act on hormonal
systems associated with stress and the experience of pain
Barolat-Romana G., Myklebust
J.B., Hemmy D.C., Myklebust B., Wenninger W. (1985) Immediate effects of spinal
cord stimulation in spinal spasticity. J Neurosurg 62, 558-562.
Benecke R., Conrad B., Meinck
H.M., Hohne J (1983) Electromyographic Analysis of Bicycling on an Ergometer for
Evaluation of Spasticity of Lower Limbs in Man. In: Desmedt J.E. [Ed]: Motor
Control Mechanisms in Health and Disease. New York, Raven Press, pp
1035,1046.
Benzel E.C., Barolat-Romana G.,
and Larson S.J. (1988) Femoral obturator and sciatic neurectomy with iliacus and
psoas muscle section for spasticity following spinal cord injury. Spine 13,
905-908.
Abstract: The treatment of severe refractory spasticity following spinal cord
injury may raise challenging therapeutic problems. Classical approaches involve
various types of myelotomies, rhizotomies and intrathecal injections of
neurolytic substances. Alternative approaches include percutaneous rhizotomies
and, more recently, the possible use of electrical stimulation of the spinal
cord. Certain cases, however, may not be amenable to commonly accepted
techniques. An operative technique is presented which involves a suprapubic
incision for an infraperitoneal approach to a femoral and obturator neurectomy
and an incision of the iliacus and psoas muscles bilaterally. This may be
followed, when indicated, by a bilateral infragluteal section of the sciatic
nerves. This technique offers a viable surgical alternative to the treatment of
spasticity following spinal cord injury in cases where other traditional methods
are contraindicated or have failed
Berg V., Bergmann S., Hovdal
H., Hunstad N., Johnsen H.J. (1982): The Value of Dorsal Column Stimulation in
Multiple Sclerosis. Scand J Rehab Med 14, 183-191.
Bhakta B.B. (2000) Management
of spasticity in stroke. Br. Med. Bull. 56, 476-485.
Abstract: Spasticity treatment must be considered in relation to other
impairments with functional goals defined prior to intervention. The effects of
muscle co-contraction and involuntary limb movement associated with exaggerated
cutaneous reflexes or effort as well as stretch reflex hyperexcitability need to
be considered. Exacerbating factors such as pain must be identified. Physical
therapy and conventional orthoses are the mainstays of spasticity management
during acute rehabilitation. Botulinum toxin shows promise but needs further
evaluation in the context of acute rehabilitation. Phenol chemodenervation can
produce good results in spasticity refractory to standard treatments. Muscle
strengthening exercises may be appropriate in chronic hemiparesis without
adversely affecting tone. Electrical stimulation may be a useful adjunct to
other spasticity treatments. Difficulty demonstrating functional benefit from
antispasticity treatment may imply that interventions directed at single motor
impairments whether weakness or spasticity are not likely to result in
functional benefit, but it is their combination that is important
Billian C. and Gorman P.H.
(1992) Upper extremity applications of functional neuromuscular stimulation.
Assist. Technol. 4, 31-39.
Abstract: Functional electrical stimulation (FES) has been used for increasing
muscle strength, decreasing spasticity, and controlling movement of limbs for
many years. Most of this work, however, has been done in a research setting.
Over the past decade, FES has moved slowly from the laboratory to the clinical
world through feasibility studies in groups of patients with spinal cord
injuries and strokes. Electrical stimulation has been shown to decrease spastic
tone both during and after the stimulation, allowing for better limb
positioning, decrease in contracture formation, and in some cases, improvement
of voluntary movement. Electrical stimulation as a motor prosthesis is now being
provided to small groups of spinal cord-injured patients (primarily C4, C5 and
C6 levels) to assist with hand positioning and to produce hand grasp. In these
settings, patients have attained greater independence in activities of daily
living and in work-related tasks. Distribution of this technology to multiple
centers is continuing through a technology transfer program
Bowman B.R., Bajd T. (1981)
Influence of electrical stimulation on skeletal muscle spasticity. Proc
International Symposium on External Control of Human Extremities, Belgrade,
Yugoslav Committee for Electronics and Automation, pp 561-576.
Bowman B.R., McNeal D.R. (1986)
Response of Single Alpha Motoneurons to High-Frequency Pulse Trains. Appl
Neurophysiol 49, 121-138.
Botte M.J., Bruffey J.D., Copp
S.N., and Colwell C.W. (2000) Surgical reconstruction of acquired spastic foot
and ankle deformity. Foot Ankle Clin. 5, 381-416.
Abstract: With the aging population and improved methods of emergency transport,
the number of surviving stroke and brain injury patients continues to increase.
Aggressive rehabilitation of appropriate candidates is justified. In the period
of spontaneous recovery, efforts are made to prevent fixed contractures using
passive mobilization, splinting, nerve blocks, and electrical stimulation. If
deformity persists and the patient is no longer recovering, operative management
can help alleviate the functional and hygiene problems associated with these
limb deformities
Braun Z., Mizrahi J., Najenson
T., and Graupe D. (1985) Activation of paraplegic patients by functional
electrical stimulation: training and biomechanical evaluation. Scand. J. Rehabil.
Med. Suppl 12, 93-101.
Abstract: A training method for the activation of the lower limb muscles of
paraplegics by functional electrical stimulation (FES) for standing and walking
is described. It consists of a daily program which does not interfere with the
normal routine of the patient. The treatment of four patients, paralysed form 7
to 30 years, is described. In these patients, a good standing position was
achieved by stimulating the quadriceps, sometimes supplemented by the gluteus
maximus or medius muscles. Gait was obtained by activation of the flexion reflex
in a single stimulation and by tilting the trunk. Difficulties during gait were
encountered due to the strong adduction of the legs. No mechanical support was
required for locking of the lower limb joints. However, to maintain the
equilibrium of the body, external support such as parallel bars, walker or
Canadian crutches were used. During treatment gait improved due to reduction of
spasticity and better stability of the body. Biomechanical measurements of
weight bearing on the legs indicated values ranging between 41 to 65% of the
body weight. During gait, a steady improvement of velocity was noted, with a
parallel decrease in stance and stride times
Brunelli G., Brunelli F. (1997)
Therapeutic electrical stimulation following selective posterior rhizotomy in
children with spastic diplegic cerebral palsy: a randomized clinical trial.
Dev Med Child Neurol 39, 515-520.
Burke D. (1988) Spasticity as
an Adaptation to Pyramidal Tract Injury. Adv Neurol 47:401-423.
Burke D., Andrews C.J., Gillies
J.D. (1971) The Reflex Response To Sinusoidal Stretching in Spastic Man.
Brain 94, 455-470.
Burridge J., Taylor P., Hagan
S., and Swain I. (1997) Experience of clinical use of the Odstock dropped foot
stimulator. Artif. Organs 21, 254-260.
Abstract: The Odstock dropped foot stimulator (ODFS) is a simple functional
electrical stimulation (FES) device for the correction of dropped foot. Improved
reliability, fine control of stimulation parameters, and careful application and
follow-up have let to 86% compliance. Data on 56 patients (50 patients with
hemiplegia, 5 patients with multiple sclerosis, and 1 patient with spinal cord
injury) who have used the system for between 6 and 18 months are presented and
show a statistically significant increase in walking speed with the stimulator
at 3 months of 14% (p < 0.001); decreased effort of walking, measured as
physiological cost index (PCI), of 37% (p < 0.001); and statistically
significant improvement in functional mobility tests and questionnaires. No
statistically significant carryover was seen although 3 patients had sufficient
improvement in active ankle control and gait parameters to no longer need the
stimulator. Six patients who used the stimulator all day every day had a problem
with skin irritation, which we have not yet been able to solve. Two patients
discontinued use after experiencing increased spasticity in the calf
Bussel B., Morin C.,
Pierrot-Deseilligny E. (1978) Mechanism of nonosynaptic reflex reinforcement
during Jendrassik manoeuvre in man. J Neurol Neurosurg & Psychiat 41,
40-44.
Caldwell C.B., Braun R.M.
(1974) Spasticity in the upper extremity. Clin Orthop 104, 80-91.
Campbell J.M., Waters R.L.,
Meadows P.M., Nakai R.J., Grek A.E. (1990) Electrical Stimulation and Spasticity:
The Challenge of Objective Documentation. Proc 13th RESNA Annual
Conference, Washington D.C., pp 369-370.
Campbell J.M., Waters R.L.,
Meadows P.M., Nakai R., Carter C.L., Grek A.E., Miller L., Gillim R. (1990)
Spasticity: Correlate of FES Motor Performance in Spinal Injury. Adv Ext
Control Human Extremities X, 601-613.
Campbell J.M., Meadows P.M.,
Waters R.L., Kashitani L., Oda S., Miller L. (1991) Spasticity in SCI:
Day-to-Day Variability in Response To Joint Movement and Electrical Stimulation.
Proc 14th RESNA Annual Conference, Kansas City, MO, pp
274-276.
Campbell J.M., Meadows P.M.
(1992) Therapeutic FES: From Rehabilitation to Neural Prosthetics. Assistive
Technology 4, 4-18.
Campbell J.M., Meadows P.M.,
Waters R.L., Wederich C., Jordan C. (1992) Improvement in Hemiplegic Gait with
Multichannel, Implanted ES System. Proc 14th Annual Intl
Conference of the IEEE EMBS, Paris, France, pp 1366-1368.
Campbell J.M., Meadows P.M.,
Monlux J., Waters R.L., Wederich C. (1994) FES in SCI: Comprehensive Management
of Muscle Performance in Complete and Incomplete Paralysis. Basic and Applied
Myology 4,187-194.
Campos R.J., Dimitrijevic M.M.,
Faganel J., and Sharkey P.C. (1981) Clinical evaluation of the effect of spinal
cord stimulation on motor performance in patients with upper motor neuron
lesions. Appl. Neurophysiol. 44, 141-151.
Abstract: The effect of chronic electrical stimulation of the spinal cord was
evaluated in a group of 24 patients with multiple sclerosis, spinal cord injury,
and degenerative disorders of the central nervous system. The systems for
stimulation had been implanted from 12 to 30 months prior to completion of
evaluation. At the time of completion of evaluation, 23 of the 24 patients still
had implanted systems, although 6 of them had not used spinal cord stimulation
because of no noticeable effect. In 3 patients stimulation had been disconnected
because of technical failure of the system. In 1 patient the system had been
removed 8 weeks after implantation because of inflammation in the under- skin
receiver pocket. The effects on motor performance of the remaining 14 patients
who had continuously active systems were improved bladder control, diminished
spasticity, improved movement coordination, and increased endurance
Carlsson C.A. and Fall M.
(1984) Electrical stimulation of the conus medullaris for bladder emptying in a
paraplegic. Paraplegia 22, 87-91.
Abstract: Nashold et al. (1972) have developed a surgically implantable system
for activating the micturition reflex in the paraplegic by electrical
stimulation of the spinal cord at the conus level. This communication describes
the long-term course in a paraplegic patient who has used conus stimulation to
achieve bladder emptying for 7 years. A 42-year- old man sustained a complete
transverse lesion at the C6 level. Ten months after the accident he developed
some spasticity in his legs but his urinary bladder remained completely flaccid.
A device for electrical stimulation of the conus was implanted. This enabled the
patient to empty his bladder without significant residual urine. His bladder
remained flaccid. Seven years after the implant he developed reflex micturition
and he is no longer dependent upon electrical stimulation
Carmick J. (1995) Managing
equinus in children with cerebral palsy: electrical stimulation to strengthen
the triceps surae muscle. Dev. Med. Child Neurol. 37, 965-975.
Abstract: A new therapeutic proposal for the management of equinus in children
with cerebral palsy is to strengthen the calf muscles instead of weakening them
surgically. Prior research indicates that in children with cerebral palsy the
triceps surae muscle is weak and needs strengthening. Neuromuscular electrical
stimulation (NMES) was used as an adjunct to physical therapy. A portable NMES
unit with a hand-held remote switch stimulated an active muscle gait cycle.
Results are discussed for four children, who showed improved gait, balance,
posture, active and passive ankle range of motion, and foot alignment. The toe
walkers became plantigrade and the equinovalgus posture of the foot decreased.
Spasticity did not increase
Carmick J. (1997) Use of
neuromuscular electrical stimulation and [corrected] dorsal wrist splint to
improve the hand function of a child with spastic hemiparesis. Phys. Ther. 77,
661-671.
Abstract: This case report describes a program for a child with spastic
hemiparesis who had previously received physical therapy with neuromuscular
electrical stimulation (NMES). After a year without physical therapy, he
returned to continue to receive NMES to strengthen muscles, increase sensory
awareness, and improve hand function. The child quickly regained his previous
level of functioning and made additional progress. After 38 sessions, he still
lacked adequate wrist stability for independent hand function. A dorsal wrist
splint was used to stabilize the wrist while NMES facilitated muscle activity of
the hand and wrist. While wearing the splint, the child could use his hand
independently without adult interference or "assistance," thus allowing motor
learning to occur. After 24 additional sessions (i.e., 9 months of using the
splint), the child could use the hand for activities such as tying his shoelaces
without the splint. No increase in spasticity was seen in spite of strengthening
the spastic finger flexors
Carnstam B., Larsson L.E., and
Prevec T.S. (1977) Improvement of gait following functional electrical
stimulation. I. Investigations on changes in voluntary strength and
proprioceptive reflexes. Scand. J. Rehabil. Med. 9, 7-13.
Abstract: Patients with central spastic paresis and equipped with peroneal
stimulators sometimes experience an improvement in their gait, even when the
stimulator has been switched off. The object of the present investigation was to
reach a better understanding of the mechanisms operating in such cases. 7
patients were investigated on repeated occasions. It was found that some of
these patients got a clear increase in isometric strength of foot dorsiflexion
following 10 min of peroneal stimulation. In other cases the increase was only
slight. There was an inverse relation between the increase and the strength
before stimulation. The increase of strength was due, at least partly, to an
increased ability to activate the foot dorsiflectors, since there was a
simultaneous increase in the EMG from the anterior tibial muscle. Evidence was
also obtained suggesting that the increase in strength involved not only foot
dorsiflexion but also plantarflexion of the foot end extension of the knee.
Following peroneal stimulation there was also a decrease of the achilles reflex
and in some cases possibly also the patellar reflex. There was an inverse
relation between the decrease in the achilles reflex and its strength before
stimulation. It is probable that the changes in voluntary strength and reflex
activity reflect conditions which can be of importance in explaining the gait
improvement which is sometimes observed in patients equippped with peroneal
stimulators
Cooper I.S. [Ed] (1978)
Cerebellar Stimulation in Man. New York, Raven Press.
Cooper I.S., Upton A.R., and
Amin I. (1982) Chronic cerebellar stimulation (CCS) and deep brain stimulation
(DBS) in involuntary movement disorders. Appl. Neurophysiol. 45, 209-217.
Abstract: Motor disorders of disinhibition may be modified by prosthetic
mobilization of CNS inhibitory mechanisms by chronic electrical stimulation of
the cerebellar cortex (CCS) and by deep brain stimulation of the thalamus and
internal capsule (DBS). Reduction in spasticity, abnormal movements, intractable
epilepsy and aggressive behavior has been reported after CCS, although negative
results in human and animal studies have been published. No adverse neurologic,
psychologic or intellectual effects of stimulation have occurred after 7 years
of CCS, although subclinical histological changes may occur in the cerebellar
cortex under the electrodes. CCS has been shown to produce physiological changes
in evoked potentials, motoneurone excitability, epileptic discharges in the EEG
and quantitative changes in movement. Surface and deep thalamic recordings have
shown reduced amplitudes of somatosensory responses after CCS. Over the last 2
years we have employed chronic deep brain stimulation (DBS) in 49 patients with
clinically useful results in half the patients. The technique allows reversible
modification of movement disorders, and the technique can be used on the second
side after a previous thalamectomy. Physiological testing, direct thalamic
recordings and quantitative analysis of movement have allowed assessment of
optimal rate and voltage of stimulation. For some intractable movement disorders
DBS has effected significant therapeutic results when all other therapeutic
techniques have failed
Cope T.C., Bodine S.C.,
Fournier M., Edgerton R.V. (1986) Soleus Motor Units in Chronic Spinal
Transected Cats: Physiological and Morphological Alterations. J Neurophysiol
55, 1202-1220.
Corcos D.M., Gottlieb G.L.,
Penn R.D., Myklebust B., Agarwal G.C. (1986) Movement Deficits Caused By
Hyperexcitable Stretch Reflexes in Spastic Humans. Brain 109, 1043-1058.
Daly J.J., Marsolais E.B.,
Mendell L.M., Rymer W.Z., Stefanovska A., Wolpaw J.R., and Kantor C. (1996)
Therapeutic neural effects of electrical stimulation. IEEE Trans. Rehabil. Eng
4, 218-230.
Abstract: The use of a functional neuromuscular stimulation (FNS) device can
have therapeutic effects that persist when the device is not in use. Clinicians
have reported changes in both voluntary and electrically assisted neuromuscular
function and improvements in the condition of soft tissue. Motor recovery has
been observed in people with incomplete spinal cord injury, stroke, or traumatic
brain injury after the use of motor prostheses. Improvement in voluntary
dorsiflexion and overall gait pattern has been reported both in the short term
(several hours) and permanently. Electrical stimulation of skin over flexor
muscles in the upper limb produced substantial reductions for up to 1 h in the
severity of spasticity in brain-injured subjects, as measured by the change in
torque generation during ramp-and-hold muscle stretch. There was typically an
aggravation of the severity of spasticity when surface stimulation reached
intensities sufficient to also excite muscle. Animals were trained to alter the
size of the H-reflex to obtain a reward. The plasticity that underlies this
operantly conditioned H- reflex change includes changes in the spinal cord
itself. Comparable changes appear to occur with acquisition of certain motor
skills. Current studies are exploring such changes in humans and animals with
spinal cord injuries with the goal of using conditioning methods to assess
function after injury and to promote and guide recovery of function. A better
understanding of the mechanisms of neural plasticity, achieved through human and
animal studies, may help us to design and implement FNS systems that have the
potential to produce beneficial changes in the subject's central nervous systems
Davis R. and Gesink J.W. (1974)
Evaluation of electrical stimulation as a treatment for the reduction of
spasticity. Bull. Prosthet. Res. 302-309.
Davis R., Bloedel J.R. [Eds]
(1985) Cerebellar Stimulation for Spasticity and Seizures. Boca Raton,
CRC Press.
Davis R., Gray E., Ryan T.,
Schulman J. (1985) Bioengineering changes in spastic cerebral palsy groups
following cerebellar stimulation. Appl Neurophysiol 48, 111-116.
Davis R., Kondraske G.V.,
Tourtellotte W.W., Syndulko K. [Eds] (1989) Quantifying Neurologic Performance.
Phys Med and Rehabil: State of the Art Reviews 3.
Delwaide P.J., Young R.R. [Eds]
(1985) Clinical Neurophysiology in Spasticity [Restorative Neurology, Vol 1].
Amsterdam, Elsevier.
Dewald J.P., Given J.D., and
Rymer W.Z. (1996) Long-lasting reductions of spasticity induced by skin
electrical stimulation. IEEE Trans. Rehabil. Eng 4, 231-242.
Abstract: We studied the effects of electrical stimulation of the skin on upper
extremity spasticity in nine hemiparetic stroke subjects. The effects were
quantified by comparing reflex torque responses elicited during ramp and hold
angular perturbations of the elbow recorded before and after low-intensity skin
stimulation. Electrical stimulation was applied to skin over the biceps muscle
for a period of ten minutes at a 20 Hz frequency, pulse duration 0.1 ms, with an
intensity level below motor threshold but above sensory threshold. In seven of
the nine subjects, stimulation of skin over spastic muscle reduced peak torque
responses in both flexors and extensors for at least 30 min. In these seven
subjects there were significant increases in mean threshold angle for the onset
of reflex torque so that a greater angular rotation was required to initiate the
stretch reflex response. This shift occurred without change in reflex impedance.
The origins of these long-term changes in reflex torque are unclear, but may
reflect synaptic plasticity of spinal circuitry outside the stretch reflex loop
Dimitrijevic M.R., Sherwood
A.M. (1980) Spasticity: medical and surgical treatment. Neurol 30, 19-27.
Dimitrijevic M.R. (1987)
Neurophysiology in Spinal Cord Injury. Paraplegia 25, 205-208.
Dimitrijevic M.M. and Soroker
N. (1994) Mesh-glove. 2. Modulation of residual upper limb motor control after
stroke with whole-hand electric stimulation. Scand. J. Rehabil. Med. 26,
187-190.
Abstract: The effects of whole-hand electrical stimulation via a wired
mesh-glove upon the residual motor control of the upper extremity are described.
Clinical observations were made in 2 patients with nonfunctional upper limbs, 4
and 2 years after stroke, who had been enrolled in the home mesh-glove program
for 6 and 4 months, respectively. The stimulation paradigm is novel and the
target of stimulation is the hand. Preliminary results indicate beneficial
effects such as reduction in muscle hypertonia and facilitation of isolated hand
movements
Dimitrijevic M.R. and Sherwood
A.M. (1980) Spasticity: medical and surgical treatment. Neurology 30, 19-27.
Abstract: Electromyographic (EMG) recordings from multiple muscle groups with
surface electrodes during systematic evaluation of phasic and tonic stretch
reflexes, cutaneomuscular reflexes, long loop reflexes, postural reflexes, and
volitional activation have been used to provide a neurophysiologic basis for
selection of the appropriate treatment for spasticity, and to gain further
insights into the general mechanisms of spasticity. Pharmacologic methods are
useful as a temporary measure. Hypertonia of a single muscle can be effectively
treated with 40% alcohol injections to the motor points and hypertonia of a
muscle group with partial denervation through 6% phenol in water injected into
the nerve trunk. Hypertonia of several muscle groups can be treated by chemical
or surgical rhizotomy or myelotomy. Generalized hypertonia involving limb and
trunk muscles can be modified through chronic epidural stimulation of the spinal
cord. Modification of reciprocal antagonistic muscle activity may be achieved
through electrical stimulation of the involved nerve trunks
Dimitrijevic M.R. (1988)
Residual motor functions in spinal cord injury. Adv Neurol 47, 139-155.
Dooley D.M. and Sharkey J.
(1981) Electrical stimulation of the spinal cord in patients with demyelinating
and degenerative diseases of the central nervous system. Appl. Neurophysiol. 44,
218-224.
Dooley D.M. and Nisonson I.
(1981) Treatment of patients with degenerative diseases of the central nervous
system by electrical stimulation of the spinal cord. Appl. Neurophysiol. 44,
71-76.
Abstract: Patients with dystonia, spinocerebellar and cerebellar ataxia and
spasmodic torticollis have a reasonable chance of being significantly aided in
their control of motor function and neurogenic bladder by electrical stimulation
of the cervical or thoracic spinal cord. This mode of therapy has the advantages
that it is not destructive of neurological tissue, effects can be varied by
altering the intensity and rate of the stimulus and preliminary testing with
externalization of the electrodes is predictive of the effects of chronic
stimulation
Eccles S.J., Dimitrijevic M.R.
(1985) Recent Achievements in Restorative Neurology: 1. Upper Motor Neuron
Functions and Dysfunctions. Basel, Karger.
Etnyre B.R., Abraham L.D.
(1988) Antagonist muscle activity during stretching: a paradox reassessed.
Med Sci Sports Exerc 20, 285-289.
Feldman R.G., Young R.R.,
Koella W.P. (1980) Spasticity: Disordered Motor Control. Chicago, Year
Book Publishers.
Franek A., Turczynski B., and
Opara J. (1988) Treatment of spinal spasticity by electrical stimulation. J.
Biomed. Eng 10, 266-270.
Abstract: We present the results and the methodology of trials using
transcutaneous electrical stimulation. The aim of our work was to decrease
spasticity in 44 patients with traumatic damage to the spinal cord; 35
non-electrically stimulated spastics were used as controls. Both groups were
randomly selected from inpatients in the Paraplegic Department at the Hospital
Rehabilitation Centre. This electrical stimulation procedure leads to a
long-lasting reduction in spasticity, an increased range of passive and active
movements, the facilitation of lost functions, an improvement in breathing, an
increase in pulmonary capacity, the reappearance of some neurological reflexes,
and a diminution of supersensitivity to skin irritation. Blood pressure and
neurogenic bladder functions were restored to normal. In addition to clinical
observations, we investigated muscle force and the electromyogram; other
measurements used in the trials involved the use of a specially adapted
neurological hammer, a pendulum test, spirometry, cystometry, sphincterometry
and biochemical estimations
Friedman M., Toriumi D.M.,
Grybauskas V.T., and Applebaum E.L. (1989) Implantation of a recurrent laryngeal
nerve stimulator for the treatment of spastic dysphonia. Ann. Otol. Rhinol.
Laryngol. 98, 130-134.
Abstract: Spastic dysphonia, a rare speech disorder, is characterized by
strained phonation with excessively adducted vocal cords. Recurrent laryngeal
nerve section, botulinum toxin injection into the vocalis- thyroarytenoid muscle
complex, and other techniques have been used to treat this disorder. We have
used percutaneous electrical stimulation of the recurrent laryngeal nerve with
good results. Previous dog studies demonstrated the relative safety of an
implantable recurrent laryngeal nerve stimulator. In this study, we directly
stimulated the recurrent laryngeal nerve and vagus nerve in a dog without change
in cardiorespiratory status. A Medtronic peripheral nerve stimulator was
implanted in a patient with abductor spastic dysphonia. The cuff electrode was
positioned around the recurrent laryngeal nerve and stimulation resulted in
improvement in her voice. Extensive cardiopulmonary monitoring did not reveal
any adverse response to stimulation and there was no discomfort to the patient.
On the basis of the good results of this preliminary study, further study with
long- term follow-up is under way
Gaebler-Spira D.J., Richman D.,
Selber P., Dias L. (1995) Therapeutic Electrical Stimulation Effect on Gait in
Children with Cerebral Palsy. Arch Phys Med Rehabil 76, 1038.
Given J.D., Dewald J.P.A.
(1991) Changes in stretch reflex threshold in spastic muscle as a result of
electrical stimulation. Soc Neurosci Abstr 17, 1033.
Glenn M.B. (1994) Nerve Blocks
for the Treatment of Spasticity. Phys Med Rehabil: State of the Art Reviews
8, 481-505.
Godec C., Cass A.S., and Ayala
G.F. (1975) Bladder inhibition with functional electrical stimulation. Urology
6, 663-666.
Abstract: Spastic or hyperreflex bladder dysfunction can cause frequency,
urgency, and incontinence. Detrusor activity was inhibited by FES (functional
electrical stimulation) applied to the anal sphincter causing decreased bladder
spasticity and increased bladder capacity. FES is indicated for incontinence not
only because of weakness of the pelvic floor but also because of hyperreflex
bladder
Gottlieb G.L., Agarwal G.C.,
Penn R. (1978) Sinusoidal oscillation of the ankle as a means of evaluating the
spastic patient. J Neurol Neurosurg and Psychiat 41, 32-39.
Gottlieb G.L., Myklebust B.M.,
Stefoski D., Groth K., Kroin J., and Penn R.D. (1985) Evaluation of cervical
stimulation for chronic treatment of spasticity. Neurology 35, 699-704.
Abstract: Electrical stimulation of the spinal cord (SCS) to reduce spasticity
was evaluated in seven patients who, along with their physicians, perceived
significant and prompt benefit from stimulation. In two 24- hour test periods,
on or off stimulation, we used two independent methods of evaluation:
quantitative measures of joint compliance and stretch reflexes, and a
standardized neurologic examination. Neither method did better than chance in
determining whether SCS was actually being received. Problems with the
experimental protocol are discussed, but the results cannot be interpreted as
supporting the efficacy of SCS as a treatment for spasticity
Goulet C., Arsenault A.B.,
Bourbonnais D., Laramee M.T., Lepage Y. (1996) Effects of Transcutaneous
Electrical Nerve Stimulation on H-Reflex and Spinal Spasticity. Scand J Rehab
Med 28, 169-176.
Gracanin F. (1978) Functional
electrical stimulation in control of motor output and movements.
Electroencephalogr. Clin. Neurophysiol. Suppl 355-368.
Abstract: In patient with damaged upper motor neurones we show the therapeutic
effect of electrical stimulation (called FES) of peripheral mixed nerves on the
restoration of motor activity and movements. The results of neurophysiological,
kinesiological and clinical observations are presented. We discuss the possible
mechanisms, especially the spinal ones, which are fundamental for such a
rhythmic activity as gait. We discuss them also from the point of view of
activation of proprioceptive feedback mechanisms and of achieved sensory
reinforcement influencing the spinal reflex mechanisms as well as the preserved
supraspinal integrated activity which contributes to the long- term FES effect.
The stimulation modes, the control of stimuli in relation to the needs of
individual patients (hemiplegia in adults, paraparesis, cerebral palsy in
children and multiple sclerosis) as well as the motor deficit are discussed. We
conclude that the electronic system used for this purpose represents a
functionally active orthotic aid with therapeutic effects
Granat M.H., Ferguson A.C.,
Andrews B.J., and Delargy M. (1993) The role of functional electrical
stimulation in the rehabilitation of patients with incomplete spinal cord
injury--observed benefits during gait studies. Paraplegia 31, 207-215.
Abstract: The benefits of a functional electrical stimulation (FES) gait
programme were assessed in a group of 6 incomplete spinal cord injured subjects.
Measurements were made of quadriceps spasticity, lower limb muscle strength,
postural stability in standing, spatial and temporal values of gait,
physiological cost of gait and independence in activities of daily living. The
subjects were assessed before commencement of the programme and after a period
of gait training using FES. The benefits derived as a result of the FES gait
programme included a reduction in quadriceps tone, an increase in voluntary
muscle strength, a decrease in the physiological cost of gait and an increase in
stride length
Graupe D. and Kohn K.H. (1998)
Functional neuromuscular stimulator for short-distance ambulation by certain
thoracic-level spinal-cord-injured paraplegics. Surg. Neurol. 50, 202-207.
Abstract: BACKGROUND: Functional Neuromuscular Stimulation (FNS) for unbraced
short-distance ambulation by traumatic complete/near-complete T4 to T12
paraplegics is based on work by Graupe et al (1982), Kralj et al (1980),
Liberson et al (1961), and others. This paper discusses methodology,
performance, training, admissibility criteria, and medical observations for
FNS-ambulation using the Parastep-I system, which is the first and only such
system to have received FDA approval (1994) and which emanated from these
previous works. METHOD: The Parastep system is a transcutaneous non-invasive and
microcomputerized electrical stimulation system built into a Walkman-size unit
powered by eight AA batteries that is controlled by finger-touch buttons located
on a walker's handbars for manual selection of stimulation menus. The
microcomputer shapes, controls, and distributes trains of stimulation signals
that trigger action potentials in selected peripheral nerves. Walker support is
used for balance. The patient can don the system in under 10 minutes. At least
32 training sessions are required. RESULTS: Approximately 400 patients have used
the Parastep system, essentially all achieving standing and at least 30 feet of
ambulation, with a few reaching as much as 1 mile at a time. Recent literature
presents data on the medical benefits of using the Parastep system-beyond the
exercise benefits of short distance ambulation at will-such as increased blood
flow to the lower extremities, lower HR at subpeak work intensities, increased
peak work capability, reduced spasticity, and psychological benefits.
CONCLUSIONS: We believe that the Parastep FNS system, which is presently
commercially available by prescription, is easily usable for independent
short-distance ambulation. We believe that its exercise benefits and its other
medical and psychological benefits, as discussed, make it an important option
for thoracic-level traumatic paraplegics
Gregoric M., Stefanovska A.,
Vodovnik L., Rebersek S., and Gros N. (1988) Rigidity in parkinsonism:
characteristics and influences of passive exercise and electrical nerve
stimulation. Funct. Neurol. 3, 55-68.
Abstract: Rigidity was measured during sinusoidal passive movements of the ankle
joint in 7 patients with parkinsonism. Velocity-dependent changes were observed,
less marked than in spasticity and expressed in a different way in flexor and
extensor muscles: a mild decrease in resistive torques at faster stretching of
dorsal flexors and an increase in resistance on stretching of plantar flexors.
Dorsal flexors also frequently showed shortening reactions. Passive exercises
and electrical stimulation of the peroneal nerve resulted in decreased
electromyographic responses to stretch, smoother passive movements and in
improved voluntary contraction
Halstead L.S., Seager S.W.J.,
Houston J.M., Whitesell K., Dennis M., Nance P.W. (1993) Relief of spasticity in
SCI men and women using rectal probe electrostimulation. Paraplegia 31,
715-721.
Han J.S., Chen X.H., Yuan Y.,
and Yan S.C. (1994) Transcutaneous electrical nerve stimulation for treatment of
spinal spasticity. Chin Med. J. (Engl. ) 107, 6-11.
Abstract: Thirty-two patients with spinally originated muscle spasticity were
treated with a transcutaneous electrical nerve stimulator, the Han's acupoint
nerve stimulator (HANS) via skin electrodes placed over the acupoints on the
hand and leg. High frequency (100 Hz), but not the low frequency (2 Hz),
stimulation was effective in ameliorating muscle spasticity. While the
therapeutic effect lasted for only 10 minutes in the first treatment, it became
consolidated after consecutive daily treatment for 3 months. The anti-spastic
effect induced by high frequency electrical stimulation can be partially
reversed by a high dose of naloxone. The results suggest that the anti-spastic
effect elicited by peripheral electrical stimulation is mediated, at least in
part, by the endogenous opioid ligand interacting with the kappa opiate
receptors, most probably dynorphin, in the central nervous system
Handa I., Matsushita N., Ihashi
K., Yagi R., Mochizuki R., Mochizuki H., Abe Y., Shiga Y., Hoshimiya N., Itoyama
Y., Handa Y. (1995) A Clinical Trial of Therapeutic Electrical Stimulation for
Amyotrophic Lateral Sclerosis. Tohoku J Exp Med 175, 123-134.
Hazelwood M.E., Brown J.K.,
Rowe P.J., Salter P.M. (1994) The use of therapeutic electrical stimulation in
the treatment of hemiplegic cerebral palsy. Dev Med Child Neurol 36,
661-673.
Herman R. (1970) The Myotatic
Reflex – Clinico-physiological Aspects of Spasticity and Contracture. Brain
93, 273-312.
Herman R., Freedman W., Mayer
N. (1974) Neurophysiologic Mechanisms of Hemiplegic and Paraplegic Spasticity:
Implications for Therapy. Arch Phys Med Rehabil 55, 338-343.
Hermans H.J., Migchelbrink J.H.,
Rutten W.L.C., Postema K. (1987) Quantification of Spasticity Using Repetitive
Movements. Adv External Control of Human Extremities IX, 375-383.
Hesse S., Jahnke M.T., Luecke
D., and Mauritz K.H. (1995) Short-term electrical stimulation enhances the
effectiveness of Botulinum toxin in the treatment of lower limb spasticity in
hemiparetic patients. Neurosci. Lett. 201, 37-40.
Abstract: The study tested the spasmolytic effect of Botulinum toxin A in two
groups of hemiparetic patients with lower limb spasticity: in the first group (n
= 5) 2000 U Dysport were injected into the soleus, tibialis posterior and both
heads of gastrocnemius muscles alone; the second (n = 5) received additional
repetitive alternating electrical stimulation of M. tibialis anterior and
plantar flexors for 30 min six times per day during the 3 days following the
injection. Muscle tone, rated by the Ashworth spasticity score, and gait
analysis including recording of vertical ground reaction forces, were assessed
before and 4 weeks after injection. The combined treatment proved to be more
effective with respect to the clinically assessed reduction of muscle tone, gait
velocity, stride length, st
Hesse S., Reiter F., Konrad M.,
and Jahnke M.T. (1998) Botulinum toxin type A and short-term electrical
stimulation in the treatment of upper limb flexor spasticity after stroke: a
randomized, double-blind, placebo-controlled trial. Clin. Rehabil. 12, 381-388.
Abstract: OBJECTIVE: To investigate whether the combined approach of botulinum
toxin type A (BtxA) and electrical stimulation was more effective than the toxin
alone in the treatment of chronic upper limb spasticity after stroke. DESIGN:
Randomized, placebo-controlled study with four treatment groups: 1000 units BtxA
(Dysport) + electrical stimulation (A), 1000 units BtxA (B), placebo +
electrical stimulation (C) and placebo (D). SETTING: A neurological
rehabilitation clinic. SUBJECTS: Twenty-four stroke patients with chronic upper
limb spasticity after stroke, six patients in each treatment group.
INTERVENTIONS: Intramuscular injection of either toxin or placebo into six upper
imb flexor muscles. In group A and C additional electrical stimulation of the
injected muscles with surface electrodes, three times half an hour each day for
three days. MAIN OUTCOME MEASURES: Muscle tone rated with the modified Ashworth
score, limb position at rest and difficulties encountered during three upper
limb motor tasks assessed before and 2, 6 and 12 weeks after injection. RESULTS:
Most improvements were observed in patients of group A. Cleaning the palm (p =
0.004) differed across groups. Pairwise comparison for this target variable
showed that group A differed from group B and D (p <0.01), but not from C.
Indicative across-group differences were obtained for elbow spasticity reduction
(p = 0.011), and improvement of putting the arm through a sleeve (p = 0.020).
CONCLUSIONS: The placebo-controlled trial favours the concept that electrical
stimulation enhances the effectiveness of BtxA in the treatment of chronic upper
limb flexor spasticity after stroke
Hines A.E., Crago P.E., and
Billian C. (1993) Functional electrical stimulation for the reduction of
spasticity in the hemiplegic hand. Biomed. Sci. Instrum. 29, 259-266.
Abstract: Functional electrical stimulation can be used to provide hand opening
in hemiplegics with spastic finger flexor muscles through stimulation of the
extensor digitorum communis (EDC) muscle and the ulnar nerve. Stimulation of the
finger extensor muscles in both hemiplegics and nonneurologically impaired
individuals does not appear to cause significant reciprocal inhibition of finger
flexor muscles. Thus stimulation of the EDC and ulnar nerve may not decrease
finger flexor spasticity in the hemiplegic subjects, yet functional hand opening
can still be obtained through a direct mechanical effect of the extensor
stimulation
Hoffer M.M., Perry J.,
Melkonian D.V.M. (1979) Dynamic electromyography and decision-making for surgery
in the upper extremity of patients with cerebral palsy. J Hand Surg 4,
424-431.
Hugenholtz H., Humphreys P.,
McIntyre W.M.J., Spasoff R.A., Steel K. (1988) Cervical Spinal Cord Stimulation
for Spasticity in Cerebral Palsy. Neurosurg 22, 707-714.
Hummelsheim H., Maier-Loth M.L.,
and Eickhof C. (1997) The functional value of electrical muscle stimulation for
the rehabilitation of the hand in stroke patients. Scand. J. Rehabil. Med. 29,
3-10.
Abstract: The influence of suprathreshold electrical stimulation of the extensor
and flexor carpi radialis muscles on biomechanical and functional movement
parameters is compared with the effect of a standardized active repetitive
training of hand and fingers. Twelve patients suffering from ischaemic lesions
in the territory of the middle cerebral artery participated in the study, which
was conducted using a multiple baseline design. Following a baseline phase that
lasted between one and three weeks all patients received electrical muscle
stimulation for 20 minutes twice daily. In a third phase the repetitive training
of hand and fingers was conducted for 20 minutes twice daily. Both interventions
were applied in addition to conventional occupational therapy and physiotherapy.
With the exception of spasticity in hand and finger flexors, repetitive
electrical muscle stimulation does not improve biomechanical or functional motor
parameters of the centrally paretic hand and arm. The repetitive motor training,
however, is appropriate to improve biomechanical and functional movement
parameters significantly. Apart from a possible effect on the muscle cell
itself, the electrical muscle stimulation is thought to represent a mainly
sensory, i.e. proprioceptive, and cutaneous intervention, whereas the active
motor training is characterized by a continuous sensorimotor coupling within
motor centres of the brain. The underlying neurophysiological mechanisms as well
as basic principles concerning the role of afferent input for motor learning and
recovery are discussed
Illis I.S., Sedgwik E.M.,
Tallis R.C. (1980) Spinal cord stimulation in multiple sclerosis: clinical
results. J Neurol, Neurosurg & Psychiat 43, 1-14.
Illis L.S. (1982)
Rehabilitation following brain damage: some neurophysiological mechanisms. The
effects of repetitive stimulation in recovery from damage to the central nervous
system. Int. Rehabil. Med. 4, 178-184.
Abstract: There is a growing body of evidence that the central nervous system
(CNS), even in the adult animal, is capable of adaptation and reorganization not
only as a result of partial damage to the CNS but also in response to
stimulation. Environmental stimulation produces changes including expansion of
visual cortex, increases in dendritic branching, glia and cholinesterase.
Environmental stimulation also produces behavioural changes. Experimental
electrical stimulation produces changes in synapse size, synaptic vesicle
change, dendritic branching and changes in synaptic transmission. In man,
repetitive electrical stimulation via epidural electrodes increases plasma
levels of norepinephrine, epinephrine, and dopamine, and CSF levels of
norepinephrine. Repetitive electrical stimulation in man dates back to 1967 and
has been used for the control of pain, to improve spasticity, bladder control,
motor deficit and the autonomic hyperreflexia of spinal cord injury. In
addition, improvement has been reported in epilepsy, cerebral palsy, torticollis
and peripheral vascular diseases. The best controlled studies are in multiple
sclerosis and peripheral vascular disease, and these results will be presented
in more detail
Isakov E., Mizrahi J., Graupe
D., Becker E., and Najenson T. (1985) Energy cost and physiological reactions to
effort during activation of paraplegics by functional electrical stimulation.
Scand. J. Rehabil. Med. Suppl 12, 102-107.
Abstract: In this study, the aim was to evaluate the influence on the
cardiopulmonary system of muscular contractions of the paralyzed limbs in
paraplegia, activated by FES during treatment, and the energy cost of standing
and walking while using FES as an orthotic aid. Three traumatic spastic
paraplegics were selected for the measurements. At the end of a 6 month training
program heart rate and oxygen consumption of the patients were evaluated as
follows: at rest; following 30 minutes of FES in the sitting position; following
15 minutes of standing; and during ambulation. Lactic acid level during maximal
effort was evaluated as well. The results indicated a low energy cost of FES in
the sitting position and during usage of FES as an orthotic device for standing,
confirming the beneficial effect of FES for spastic paraplegics. However, effort
invested during ambulation by means of FES was found exhaustive and FES is
therefore advisable for young subjects mainly
Izzo K.L. and Aravabhumi S.
(1989) Cerebrovascular accidents. Clin. Podiatr. Med. Surg. 6, 745-759.
Abstract: CVA comprises a large number of clinical entities, depending on the
site of infarction in the brain. Accurate evaluation of deficits in the
patient's sensory and/or motor systems and the patient's intellectual status are
paramount in establishing realistic rehabilitation goals. With respect to the
motor system, two types of voluntary movement may occur. These include
synergistic or pattern movement and selective movement. Spasticity in the
affected lower extremity may result in a variety of lower-extremity deformities
and contractures. Those most commonly encountered include hip flexion and
adduction contracture, inadequate knee flexion and knee flexion contracture, and
ankle equinus, varus, and equinovarus. Correct evaluation of deformities may be
aided by the use of poly-EMG analysis and evaluation after nerve block or motor
point blocks. In hemiplegic gait dysfunction, the basic requirements for
functional ambulation include (1) ability to maintain standing balance; (2)
voluntary hip flexion; (3) leg stability; and (4) ability to follow instructions
and adequate motivation. Often a hemiplegic patient can be trained to ambulate
if an adequate extensor synergy pattern develops, since mass extension can
provide stability of the leg for weight bearing. Medical rehabilitative
management of the CVA patient includes early mobilization, restorative exercises
(including neuromuscular facilitation techniques), measures to prevent or
correct contractures, the use of AFOs, and occasionally functional electrical
stimulation. Orthopedic management of deformities in CVA is indicated where
conservative measures fail. Surgical procedures seek to alter the forces causing
shortening of the muscles and tendons. Hence, the most commonly performed
surgical procedures include (1) tendon lengthening or release; (2) soft-tissue
release; and (3) tendon transfer. Surgery for hip contractures is not common;
however, occasional release of hip flexors is indicated when hip flexion
contracture impedes ambulation or prone lying. Inadequate knee flexion, caused
by dysphasic quadriceps contraction, can be corrected by release of the vastus
medialis and rectus femoris muscles. Distal hamstring tendon release with or
without knee joint capsule release is the surgical procedure of choice for
severe knee flexion contractures. Surgical correction of an equinus deformity is
by TAL, with or without neurectomy of tibial nerve branches to the gastrocsoleus
muscles. Severe ankle varus may require a SPLATT procedure. Surgery for
equinovarus includes the combined surgery for both equinus and varus (that is,
TAL and SPLATT procedures). Toe curling is corrected by toe flexor
releases.(ABSTRACT TRUNCATED AT 400 WORDS)
Kanaka T.S., Kumar M.S. (1990)
Neural Stimulation for Spinal Spasticity. Paraplegia 28, 399-405.
Katz R.T., Rymer W.Z. (1989)
Spastic Hypertonia: Mechanisms and Measurement. Arch Phys Med Rehabil 70,
144-155.
Katz R.T., Campagnolo D.I.
(1994) Pharmacologic Management of Spasticity. Phys Med Rehabil: State of the
Art Reviews 8, 473-480.
Kawamura J., Ise M., Matsuya
M., Tagami M., Ezaki S., Nishihara K. (1987) Clinical Use of Electrical
Stimulation For Reducing Spasticity. Adv External Control of Human
Extremities IX, 353-362.
Keenan M.A., Kozin A., Berlet
A.C. (1993) Manual of Orthopaedic Surgery for Spasticity. New York, Raven
Press.
Khalili A.A., Betts H.B. (1970)
Management of Spasticity with Phenol Nerve Block. Dept HE&W Final Report
RD-2529-M, December.
Kimura J. (1983) Recurrent
Inhibition of Motoneurons During the Silent Period in Man. In: Desmedt J.E.
[Ed]: Motor Control Mechanisms in Health and Disease. New York, Raven
Press, pp 459-465.
King T.I. (1996) The Effect of
Neuromuscular Electrical Stimulation in Reducing Tone. AJOTA 50, 62-64.
Klingler D. and Kepplinger B.
(1982) Quantification of the effect of epidural spinal electrostimulation (ESES)
in central motor disorders. Appl. Neurophysiol. 45, 221-224.
Abstract: The importance of film documentation for objective and quantitative
assessment of the results of epidural spinal electrical stimulation (ESES) was
shown. Our experience is based on 25 patients with central motor disorders,
predominantly of spinal origin. 17 were selected for internalization of a
receiver system. By means of description and clinical registration of spasticity,
reduced mobility, motor strength, dexterity, etc., or by means of
electrophysiological tests, complex motor performance such as standing, sitting,
dressing and undressing, eating and writing cannot be sufficiently evaluated.
Short scenes of these activities when demonstrated by motion picture enable the
therapist to compare better the condition of the patient before and with ESES,
and thereby facilitate the selection of patients for internalization of receiver
systems
Knutsson E., Martenson A.,
(1980) Dynamic motor capacity in spastic paresis and its relation to prime mover
dysfunction, spastic reflexes and antagonistic co-activation. Scand J Rehabil
Med 12, 93-106.
Knutsson E. (1983) Analysis of
Gait and Isokinetic Movements for Evaluation of Antispastic Drugs or Physical
Therapies. Arch Neurol 39, 1013-1034.
Kostov A., Hansen M., Haugland
M., and Sinkjaer T. (1999) Adaptive restriction rules provide functional and
safe stimulation pattern for foot drop correction. Artif. Organs 23, 443-446.
Abstract: We report on our advances in sensory feedback data processing and
control system design for functional electrical stimulation (FES) assisted
correction of foot drop. We have applied 2 methods of signal purification on the
bin integrated electroneurogram (i.e., optimized low pass filtering and wavelet
denoising) before training adaptive logic networks (ALN). ALN generated
stimulation control pulses, which correspond to the swing phase of the impaired
leg when dorsal flexion of the foot is necessary to provide safe ground
clearance. However, the obtained control signal contained sporadic stimulation
spikes in the stance phase, which can collapse the subject, and infrequent
broken stimulation pulses in the swing phase, which can result in unpredictable
consequences. In this study, we have introduced adaptive restriction rules (ARR),
which are initially used as previously reported and then dynamically adapted
during the use of the system. Our results suggest that ARR provide a safer and
more reliable stimulation pattern than fixed restriction rules
Kralj A., Bajd T., Turk R.,
Krajnik J., and Benko H. (1983) Gait restoration in paraplegic patients: a
feasibility demonstration using multichannel surface electrode FES. J. Rehabil.
R. D. 20, 3-20.
Abstract: Recent advances in science have aided research toward the restoration
of biped gait in paraplegic patients by means of functional electrical
stimulation (FES). In this paper it is shown how FES-restrengthened muscles of
paraplegic patients have been used for simple FES-assisted standing. Those
experiments subsequently led to biped gait-initializing experiments and to
simple forms of biped gait synthesis. The purpose of this paper is to show the
feasibility of using FES for standing and for restoring biped gait in many
paraplegic patients--to present the past achievements, focus on problems, and
highlight directions for future research. The results of gait obtained in three
complete spinal cord injured patients (out of a series of 17) are shown, using
four to six channels of FES. It is also shown how preserved reflex mechanisms of
the transected spinal cord can be incorporated and employed for obtaining
improved function while at the same time simplifying the FES hardware. Of the
three patients reported on in detail here, two patients have managed to walk in
parallel bars while the third patient has mastered independent unassisted
walking over shorter distances with the aid of a roller walker. The
biomechanical and control problems of this last patient's gait are presented in
detail
Lance J.W., Burke D. (1974)
Mechanisms of Spasticity. Arch Phys Med Rehabil 55, 332-337.
Landau W.M. (1974) Spasticity:
The Fable of a Neurological Demon and the Emperor’s New Therapy. Arch Neurol
31, 217-219.
Landau W.M. (1980) Spasticity:
what is it? What is it not? In: Feldman R.G., Young R.R., Koella W.P. [Eds]:
Spasticity: Disordered Motor Control. Chicago, Year Book Publishers, p 17.
Lee W.J., McGovern J.P., Duvall
E.N. (1950) Continuous tetanizing (low voltage) currents for relief of spasm.
Arch Phys Med Rehabil 31, 766-771.
Lehmann J.F., Price R.,
deLateur B.J., Hinderer S., Traynor C. (1989) Spasticity: Quantitative Measures
as a Basis for Assessing Effectiveness of Therapeutic Intervention. Arch Phys
Med Rehabil 70, 6-15.
Levine M.G., Knott M., Kabat H.
(1952) Relaxation of Spasticity by Electrical Stimulation of Antagonist Muscles.
Arch Phys Med Rehabil 33, 668-673.
Levine M.F., Hui-Chan C.W.Y.
(1992) Relief of hemiparetic spasticity by TENS is associated with improvement
in reflex and voluntary motor functions. Electroenceph & Clin Neurophys
85, 131-142.
Maiman D.J., Myklebust J.B.,
Barolat-Romana G. (1987) Spinal Cord Stimulation for Amelioration of Spasticity:
Experimental Results. Neurosurgery 21, 331-333.
McLellan D.L., Selwyn M.,
Cooper I.S. (1978) Time course of clinical and physiological effects of
stimulation of the cerebellar surface in patients with spasticity. J Neurol
Neurosurg & Psychiat 41, 150-160.
McNeal D.R. (1977) Two thousand
years of electrical stimulation. In: Hambrecht F.T., Reswick J.B. [Eds]:
Functional electrical stimulation, application in neural prostheses. New
York, Marcel Dekker, 3-25.
McNeal D.R., Wilemon W.K.
(1971) Treatment of Spasticity Through Functional Electrical Stimulation. In:
Reynolds D.V., Siebert A.E. [Eds]: Neuroelectric Research. Springfield,
Charles C. Thomas.
Merletti R., Andina A., Galante
M., and Furlan I. (1979) Clinical experience of electronic peroneal stimulators
in 50 hemiparetic patients. Scand. J. Rehabil. Med. 11, 111-121.
Abstract: Fifty hemiparetic subjects were selected from a population of 250
patients according to criteria forsuitable candidates for peroneal stimulation.
The patients received from 10 to 120 hours of treatment during 2--5 weeks. The
therapeutic results obtained were classified into four groups, ranging from none
to excellent improvement of voluntary movement and reduction of spasticity. The
clinical results were correlated to different variables where time from lesion,
spasticity, and extent of treatment appeared to be the most important ones. The
percentage of excellent results decreased with increasing time from lesion and
spasticity, and increased with increasing treatment. Orthotic validity (i.e. the
beneficial effect of the orthosis) was observed in 76% of the selected cases and
in most of them it was very significant. Preliminary tests performed on 9
subjects showed that in cases with orthotic validity the peroneal brace slightly
reduces the oxygen consumption of patients and improves their motivation. This
work gives a more quantitative perspective of the validity of functional
peroneal stimulation and a better indication of criteria for patient selection.
The overall validity of an electronic peroneal brace appears to apply to 15% of
the total ambulatory hemiparetic population and its therapeutic value is
relevant in two- thirds of such cases if sufficient treatment is provided.
Application of functional electrical stimulation to non-ambulatory subjects in
the acute phase may however lead to a higher percentage of cases of therapeutic
validity
Miyazaki M.H., Lourencao M.I.,
Ribeiro Sobrinho J.B., and Battistella L.R. (1992) [Functional electric
stimulation (FES) in cerebral palsy]. Rev. Hosp. Clin. Fac. Med. Sao Paulo 47,
28-30.
Abstract: Our study concerns a patient with cerebral palsy, submitted to
conventional occupational therapy and functional electrical stimulation. The
results as to manual ability, spasticity, sensibility and synkinesis were
satisfactory
Mooney V., Wileman E., McNeal
D.R. (1964) Stimulator reduces spastic activity. JAMA 207, 2199-2200.
Nakamura M. and Sakurai T.
(1984) Bladder inhibition by penile electrical stimulation. Br. J. Urol. 56,
413-415.
Abstract: Transcutaneous electrical stimulation was applied to the penis in 22
patients complaining of frequency, urgency and/or urge incontinence. Detrusor
activity was suppressed with this stimulation, causing decreased bladder
spasticity and/or increased cystometric capacity in 10 of 22 patients. Clinical
success was noted in four patients with a portable stimulator
Nashold B.S., Jr., Grimes J.,
Friedman H., Semans J., and Avery R. (1977) Electrical stimulation of the conus
medullaris in the paraplegic. A 5- year review. Appl. Neurophysiol. 40, 192-207.
Abstract: In 1970 we carried out the first electrode implantation of the conus
medullaris of a 17-year-old male paraplegic to control the emptying of his
paralyzed bladder. Our patient has used electromicturition for 6 years to
successfully empty his bladder and prevent urinary infection. To date, a total
of 11 paraplegic patients have been implanted (6 males, 5 females). The cause of
the paraplegia was the result of trauma, and the implants were performed from 16
days to 15 years postinjury. All the patients had experienced numerous urinary
infections and required constant catheter drainage, and it was the opinion of
our urologic associate that current methods of control of the bladder problem
were of no avail. The bladder was considered to be atonic in 7 patients and
spastic in 4. The results indicate that after a follow-up of 1--6 years, 8
patients have complete control of voiding by electrical stimulation (4 female, 4
male). 2 of the males required partial sphincterotomy to improve emptying, but
none of the females experienced sphincter interference. One male quadriparetic
patient died 7 months postimplantation of pneumonia and hepatitis. There have
been no infections related to the implantable device; however, 1 female broke
the connecting wires to the spinal cord electrode during a paraplegic basketball
game. In addition to the induced electrical contraction of the bladder, we have
observed increased autonomic activity below the level of the spinal cord
transection, improved defecation, reduction of spasticity in the paralyzed legs,
penile erection in males, and reduction of decalcification of the long bones.
This group of patients represents the longest use of an implantable electronic
device to control bladder function
Nashold B.S., Jr., Friedman H.,
and Grimes J. (1981) Electrical stimulation of the conus medullaris to control
the bladder in the paraplegic patient. A 10-year review. Appl. Neurophysiol. 44,
225-232.
Nickel V.L., Botte M.J. (1992)
Orthopaedic Rehabilitation. New York, Churchill Livingstone.
Norton B.J., Bomze H.A.,
Chaplin H. (1972) An Approach to the Objective Measurement of Spasticity.
Phys Ther 52, 15-24.
O'Brien C.F. (1997) Injection
techniques for botulinum toxin using electromyography and electrical
stimulation. Muscle Nerve Suppl 6, S176-S180.
Abstract: Increasing data supports the use of botulinum toxin injection as a
therapeutic intervention in the management of spasticity. The avid binding of
botulinum toxin (BTX) to presynaptic neuron terminals and the diffusion
characteristics of the medication allow relative ease of administration. For
many clinical applications, efficacy may be improved, and adverse effects
reduced, by more precise targeting of the muscles to be injected.
Electromyographic guidance (EMG) is commonly used to confirm appropriate
localization of the injection needle in specific muscles immediately before
injection. Electrical stimulation (ES) may be more useful in patients who are
unresponsive or sedated. Equipment options and technical aspects of EMG and ES
are discussed, including some adjunctive imaging methods for injecting
difficult-to- localize muscles
Odeen I., Knutsson E. (1981)
Evaluation of the Effects of Muscle Stretch and Weight Load in Patients with
Spastic Paraplegia. Scand J Rehab Med 13, 117-121.
Okawa Y., Ueda S. (1988) The
development of a testing device for the quantitative evaluation of muscle tone
and strength. Scand J Rehab Med Suppl 17, 163.
Pease W.S. (1998) Therapeutic
electrical stimulation for spasticity: quantitative gait analysis. Am. J. Phys.
Med. Rehabil. 77, 351-355.
Abstract: Improvement in motor function following electrical stimulation is
related to strengthening of the stimulated spastic muscle and inhibition of the
antagonist. A 26-year-old man with familial spastic paraparesis presented with
gait dysfunction and bilateral lower limb spastic muscle tone. Clinically,
muscle strength and sensation were normal. He was considered appropriate for a
trial of therapeutic electrical stimulation following failed trials of physical
therapy and baclofen. No other treatment was used concurrent with the electrical
stimulation. Before treatment, quantitative gait analysis revealed 63% of normal
velocity and a crouched gait pattern, associated with excessive
electromyographic activity in the hamstrings and gastrocnemius muscles. Based on
these findings, bilateral stimulation of the quadriceps and anterior compartment
musculature was performed two to three times per week for three months. Repeat
gait analysis was conducted three weeks after the cessation of stimulation
treatment. A 27% increase in velocity was noted associated with an increase in
both cadence and right step length. Right hip and bilateral knee stance motion
returned to normal (rather than "crouched"). No change in the timing of dynamic
electromyographic activity was seen. These findings suggest a role for the use
of electrical stimulation for rehabilitation of spasticity. The specific
mechanism of this improvement remains uncertain
Pedersen E. (1974) Clinical
Assessment and Pharmacologic Therapy of Spasticity. Arch Phys Med Rehabil
55, 344-354.
Perell K., Scremin A., Scremin
O., Kunkel P. (1996) Quantifying muscle tone in spinal cord injury patients
using isokinetic dynamometric techniques. Paraplegia 34, 46-53.
Perry J., Gronley J.K.,
Lunsford T. (1981) Rocker Shoe as Walking Aid in Multiple Sclerosis. Arch
Phys Med Rehabil 62, 59-65.
Perry J., Keenan M.A. (1989)
Rehabilitation of the
Perry J., Waters R.L. (1975)
Orthopaedic evaluation and treatment of the stroke patient. AAOS Instr Course
Lect 24, 40-44.
Pinter M.M., Gerstenbrand F.,
and Dimitrijevic M.R. (2000) Epidural electrical stimulation of posterior
structures of the human lumbosacral cord: 3. Control Of spasticity. Spinal Cord.
38, 524-531.
Abstract: OBJECTIVES: The purpose of this study was to evaluate the effect of
spinal cord stimulation (SCS) on severe spasticity of the lower limbs in
patients with traumatic spinal cord injury (SCI) under close scrutiny of the
site and parameters of stimulation. MATERIALS AND METHODS: Eight SCI patients
(four women, four men) were included in the study. Levels of spasticity before
and during stimulation were compared according to a clinical rating scale and by
surface electrode polyelectromyography (pEMG) during passive flexion and
extension of the knee, supplemented by a pendulum test with the stimulating
device switched either on or off over an appropriate period. RESULTS: Both the
clinical and the experimental parameters clearly demonstrated that SCS, when
correctly handled, is a highly effective approach to controlling spasticity in
spinal cord injury subjects. The success of this type of treatment hinges on
four factors: (1) the epidural electrode must be located over the upper lumbar
cord segment (L1, L2, L3); (2) the train frequency of stimulation must be in the
range of 50 - 100 Hz, the amplitude within 2 - 7 V and the stimulus width of 210
micross; (3) the stimulus parameters must be optimized by clinically assessing
the effect of arbitrary combinations of the four contacts of the quadripolar
electrode; and (4) amplitudes of stimulation must be adjusted to different body
positions. CONCLUSIONS: Severe muscle hypertonia affecting the lower extremities
of patients with chronic spinal cord injuries can be effectively suppressed via
stimulation of the upper lumbar cord segment
Popovic D., Stein R.B.,
Oguztoreli N., Lebiedowska M., and Jonic S. (1999) Optimal control of walking
with functional electrical stimulation: a computer simulation study. IEEE Trans.
Rehabil. Eng 7, 69-79.
Abstract: Bipedal locomotion was simulated to generate a pattern of activating
muscles for walking using electrical stimulation in persons with spinal cord
injury (SCI) or stroke. The simulation presented in this study starts from a
model of the body determined with user-specific parameters, individualized with
respect to the lengths, masses, inertia, muscle and joint properties. The
trajectory used for simulation was recorded from an able-bodied subject while
walking with ankle-foot orthoses. A discrete mathematical model and dynamic
programming were used to determine the optimal control. A cost function was
selected as the sum of the squares of the tracking errors from the desired
trajectories, and the weighted sum of the squares of agonist and antagonist
activations of the muscle groups acting around the hip and knee joints. The aim
of the simulation was to study plausible trajectories keeping in mind the
limitations imposed by the spinal cord injury or stroke (e.g., spasticity,
decreased range of movements in some joints, limited strength of paralyzed,
externally activated muscles). If the muscles were capable of generating the
movements required and the trajectory was achieved, then the simulation provided
two kinds of information: 1) timing of the onset and offset of muscle
activations with respect to the various gait events and 2) patterns of
activation with respect to the maximum activation. These results are important
for synthesizing a rule-based controller
Potisk K.P., Gregoric M., and
Vodovnik L. (1995) Effects of transcutaneous electrical nerve stimulation (TENS)
on spasticity in patients with hemiplegia. Scand. J. Rehabil. Med. 27, 169-174.
Abstract: The effect of afferent cutaneous electrical stimulation on the
spasticity of leg muscles was studied in 20 patients with chronic hemiplegia
after stroke. Stimulation electrodes were placed over the sural nerve of the
affected limb. The standard method of cutaneous stimulation, TENS with impulse
frequency of 100 Hz, was applied. The tonus of the leg muscles was measured by
means of an electrohydraulic measuring brace. The EMG stretch reflex activity of
the tibialis anterior and triceps surae muscles was detected by surface
electrodes and recorded simultaneously with the measured biomechanical
parameters. In 18 out of 20 patients, a mild but statistically significant
decrease in resistive torques at all frequencies of passive ankle movements was
recorded following 20 min of TENS application. The decrease in resistive torque
was often (but not always) accompanied by a decrease in reflex EMG activity.
This effect of TENS persisted up to 45 min after the end of TENS. The results of
the study support the hypothesis that TENS applied to the sural nerve may induce
short-term post- stimulation inhibitory effects on the abnormally enhanced
stretch reflex activity in spasticity of cerebral origin
Price C.I. and Pandyan A.D.
(2000) Electrical stimulation for preventing and treating post-stroke shoulder
pain (Cochrane Review). Cochrane. Database. Syst. Rev. CD001698.
Abstract: BACKGROUND: Shoulder pain after stroke is common and disabling. The
optimal management is uncertain, but electrical stimulation (ES) is often used
to treat and prevent pain. OBJECTIVES: The objective of this review was to
determine the efficacy of any form of surface ES in the prevention and / or
treatment of pain around the shoulder at any time after stroke. SEARCH STRATEGY:
We searched the Cochrane Stroke Review Group trials register and undertook
further searches of MEDLINE, EMBASE and CINAHL. Contact was established with
equipment manufacturers and centres that have published on the topic of ES.
SELECTION CRITERIA: We considered all randomised trials that assessed any
surface ES technique (functional electrical stimulation (FES), transcutaneous
electrical nerve stimulation (TENS) or other), applied at any time since stroke
for the purpose of prevention or treatment of shoulder pain. DATA COLLECTION AND
ANALYSIS: Two reviewers independently selected trials for inclusion, assessed
trial quality and extracted the data. MAIN RESULTS: Four trials (a total of 170
subjects) fitted the inclusion criteria. Study design and ES technique varied
considerably, often precluding the combination of studies. Population numbers
were small. There was no significant change in pain incidence (Odds Ratio (OR)
0.64; 95% CI 0.19 to 2.14) or change in pain intensity (Standardised Mean
Difference (SMD) 0.13; 95% CI -1.0 to 1.25) after ES treatment compared to
control. There was a significant treatment effect in favour of ES for
improvement in pain-free range of passive humeral lateral rotation (Weighted
Mean Difference (WMD) 9.17; 95% CI 1.43 to 16.91). In these studies ES reduced
the severity of glenohumeral subluxation (SMD -1.13; 95% CI -1.66 to -0.60), but
there was no significant effect on upper limb motor recovery (SMD 0.24; 95% CI
-0.14 to 0.62) or upper limb spasticity (WMD 0.05; 95% CI -0.28 to 0.37). There
did not appear to be any negative effects of electrical stimulation at the
shoulder. REVIEWER'S CONCLUSIONS: The evidence from randomised controlled trials
so far does not confirm or refute that ES around the shoulder after stroke
influences reports of pain, but there do appear to be benefits for passive
humeral lateral rotation. A possible mechanism is through the reduction of
glenohumeral subluxation. Further studies are required
Price C.I. and Pandyan A.D.
(2001) Electrical stimulation for preventing and treating post-stroke shoulder
pain: a systematic Cochrane review. Clin. Rehabil. 15, 5-19.
Abstract: BACKGROUND: Shoulder pain after stroke is common and disabling. The
optimal management is uncertain, but electrical stimulation (ES) is often used
to treat and prevent pain. OBJECTIVES: The objective of this review was to
determine the efficacy of any form of surface ES in the prevention and/or
treatment of pain around the shoulder at any time after stroke. SEARCH STRATEGY:
We searched the Cochrane Stroke Review Group trials register and undertook
further searches of Medline, Embase and CINAHL. Contact was established with
equipment manufacturers and centres that have published on the topic of ES.
SELECTION CRITERIA: We considered all randomized trials that assessed any
surface ES technique (functional electrical stimulation (FES), transcutaneous
electrical nerve stimulation (TENS) or other), applied at any time since stroke
for the purpose of prevention or treatment of shoulder pain. DATA COLLECTION AND
ANALYSIS: Two reviewers independently selected trials for inclusion, assessed
trial quality and extracted the data. MAIN RESULTS: Four trials (a total of 170
subjects) fitted the inclusion criteria. Study design and ES technique varied
considerably, often precluding the combination of studies. Population numbers
were small. There was no significant change in pain incidence (odds ratio (OR)
0.64; 95% CI 0.19-2.14) or change in pain intensity (standardized mean
difference (SMD) 0.13; 95% CI -1.0-1.25) after ES treatment compared with
control. There was a significant treatment effect in favour of ES for
improvement in pain-free range of passive humeral lateral rotation (weighted
mean difference (WMD) 9.17; 95% CI 1.43-16.91). In these studies ES reduced the
severity of glenohumeral subluxation (SMD -1.13; 95% CI -1.66 to -0.60), but
there was no significant effect on upper limb motor recovery (SMD 0.24; 95% CI
-0.14-0.62) or upper limb spasticity (WMD 0.05; 95% CI -0.28-0.37). There did
not appear to be any negative effects of electrical stimulation at the
shoulder.REVIEWERS' CONCLUSIONS: The evidence from randomized controlled trials
so far does not confirm or refute that ES around the shoulder after stroke
influences reports of pain, but there do appear to be benefits for passive
humeral lateral rotation. A possible mechanism is through the reduction of
glenohumeral subluxation. Further studies are required
Ragnarsson K.T. (1992)
Functional electrical stimulation and suppression of spasticity following spinal
cord injury. Bull. N. Y. Acad. Med. 68, 351-364.
Rebersek S., Stefanovska A.,
Gros N., Vodovnik L. (1982) The Influence of Electrical Stimulation and Passive
Movements on Spastic Ankle Joint in Hemiplegia. Proc 5th Annual
RESNA Conference, Houston, TX, 56.
Rebersek S., Stefanovska A.,
Vodovnik L., Gros N. (1986) Some properties of spastic ankle joint muscles in
hemiplegia. Med & Biol Eng & Comput 24, 19-26.
Remy-Neris O., Barbeau H.,
Daniel O., Boiteau F., and Bussel B. (1999) Effects of intrathecal clonidine
injection on spinal reflexes and human locomotion in incomplete paraplegic
subjects. Exp. Brain Res. 129, 433-440.
Abstract: We studied the effect of the intrathecal (i.t.) injection of clonidine
(30, 60 and 90 microg) on the polysynaptic spinal reflexes (PSR) elicited by
electrical stimulation of flexor reflex afferents (FRA), monosynaptic reflex and
gait of 11 subjects with spinal cord injuries. The effect of clonidine
administration on gait velocity, stride amplitude and duration was measured in
eight subjects who were able to walk. Five subjects were able to walk after
intrathecal injection of clonidine and three were not able to stand up. Three
subjects improved their gait velocity after clonidine administration; one (S6)
increased his stride amplitude; the two others decreased their cycle durations.
The tibialis anterior seemed to be more regularly activated during gait.
Spasticity was reduced dramatically (P<0.0001) after i.t. clonidine injection,
but there was no statistically significant difference in the soleus H reflex (no
effect on Hmax/Mmax). Clonidine administration decreased the amplitude of the
early PSR (90-120 ms, N=4) and the threshold and maximal integrated EMG
corresponding to the late response (140-450 ms, N=7). This effect was dose
dependent (30, 60 and 90 microg). Placebo injection (N=4) caused no change. The
changes in spinal reflexes, with a large reduction in spasticity, no change in
motoneurone excitability and a large decrease in PSR, suggest that clonidine
acts at a premotoneuronal level, possibly by presynaptic inhibition of group II
fibres. The increase in gait velocity in three subjects could have been due to
reduced spasticity or activation of spina |
