The initial steps of functional
electrical stimulation in spinal cord injured patients were taken at our
Rehabilitation Institute of Ljubljana in 1979. For the first five years we had
mostly been doing scientific research work under the guidelines of professors
Kralj and Bajd. In 1984 FES became part of our daily physiotherapeutic routine.
It has been found that during rehabilitation programs about 60 % of patients
can receive FES as a means of therapy, 25 receive FES in order to improve or
perform certain functions and only about 10 % are provided with FES orthoses at
the concclusion of rehabilitation.
In order to evaluate the use of FES stimulators in the home
environment, a questionnaire was prepared and sent to all Slovenian patients to
whom FES as an orthotic aid has been prescribed at last ten years.
The questionnaire consisted of three parts (appendix 1). The first part
included questions about the stimulator and its use. The second part consisted
of statements about possible benefits and problems of FES. In the last section, the patients had to evaluate the
influence of FES on certain activities and give recommendations for the
improvement of the system.
The questionnaire was sent to 71 patients out of whome 35 were
tetraparetic (7 women, 28 men), 22 paraparetic (7 women, 15 men) and 14
paraplegic (1 voman, 13 men). 62 answers
to the questionnaire were received out of which 50 were complete. The remaining
patients had changed their address and were unavailable, did not accept the
letter for unknown reasons and one had died.
Three (3) out of 50 patients did not use FES any more. Among the other
patients,23 used a ubilateral or bilateral one channel stimulator and 24
used two channel stimulator.
32 patients used FES for walking, 11 for standing and 25 for muscle
strengthening.
They used stimulation from 40 minutes up to 12 hours par day, on
average between one to three hours.
21 patients agreed with the statement that FES enabled them to perform
activities that would be othewise
impossible.
27 were able to stand by means of FES and 33 to walk. 12 could also
climb stairs, 9 used FES for walking outdoors and 24 only at home.
The patients reported that they felt better after the use of FES (28),
that FES improved their quality of life (28) and dcreased spasticity (20). They
also reported improved digestion (15), less pain (13) and fewer urinary
infections (12).
The tehnical problems reported are that the batteries last too short a
period and that the electrodes and cables break too often. It is interesting
that in spite of the fact that the application of the electrodes takes only two to
three minutes, a considerable number of 21 patients complain that it is
too time consuming.
Discussion
A large majority of patients who received FES as an orthotic device was
found to be using it at home. FES enabled them to perform functions they would
not be able to do otherwise, such as walking, and it also had many other
positive effects. For most patients, a wheelchair is stil the main means of
transportation. Only 13 of the patients who answered our questionnaire agreed
with the statement that they could move faster and easier with a wheelchair
while eighteen patients disagreed. One fifth of the patients using FES were
able to walk to the nearest shop, twelwe were able to climb stairs and one
third were able to walk on uneven surfaces.
It was found that in male patients sexual activity was the most
frequent reason for the continuation of daily stimulation even when FES was not
used for walking. A ajority reported that the regular use of FES enabled
erection and two patient claimed that it enabled ejaculation.So far, there has
been no proof to support these statements, although the high percentage of
complete paraplegic patients who shared this opinion (90%) indicated a
possibility of its validity. In femal patients, the most frequent reason to use
FES was nicer appearance since stimulation prevents atrophy and contractures.
In all patients who have continued to use FES (for up to 19 years), no
contractures or skin problems were observed. Their bladder capacity increased,
bowel movements were alleviated and there were no major problems with kidneys.
The patients suggestion could be very informative for researchers and
designers of stimulators. Almost all of them were of technical nature. The most
frequent suggestions were to develop a wireless system, better electrodes, a
system that would be easier and faster to apply and batteries that would be
more durable.
It can be concluded that despite of many problems FES for home use improved functions and
quality of life.
Appendix 1 – the questionnaire
Encircle the appropriate answer concerning your
stimulator:
1. I have a one-channel stimulator for one side
2. I have a two-channel stimulator for one side
3. I have a one-channel stimulator for both sides
4. I have a two-channel stimulator for both sides
How many hours a day do you use FES? ___________h/day
I use
FES for:
1. Muscle strengthening
2. Standing
3. Walking
4. Other (please specify what)
5. I don't use it
I use FES:
2. 2 - 3-times a week
3. Once a week
4. 2 - 3-times a month
5. I don't use it
Which
aids do you use for walking in addition to FES?
1. A pair of crutches
2. A walker
3. Other (specify what)
How do you switch on (off) the stimulator?
1. By a heel switch
2. By a crutch or walker handle switch
3. Other (please specify)
Encircle whether the following statements apply to you or
not.
|
FES enables me to perform activities that would otherwise be impossible |
yes |
no |
|
FES enables me to stand |
yes |
no |
|
FES enables me to walk |
yes |
no |
|
FES enables me to walk up and down the stairs |
yes |
no |
|
I use FES only for walking at home |
yes |
no |
|
I use FES for walking outdoors |
yes |
no |
|
I can walk with FES on uneven surfaces (macadam, grass) |
yes |
no |
|
I can go to the nearest market |
yes |
no |
|
I feel better after using FES |
yes |
no |
|
When using FES, I feel less pain |
yes |
no |
|
When using FES, I have fewer urinary infections |
yes |
no |
|
When using FES, I have a better digestion |
yes |
no |
|
Using FES improves the quality of my life |
yes |
no |
|
Using FES decreases spasticity |
yes |
no |
Which are the problems that you have when using FES or
the problems that prevent you from using it?
|
Batteries empty too quickly |
yes |
no |
|
The application is time consuming |
yes |
no |
|
Cables are damaged too quickly |
yes |
no |
|
The stimulator breaks down too often |
yes |
no |
|
Electrodes wear out quickly |
yes |
no |
|
Cables hinder my movements when I walk |
yes |
no |
|
The function I get is not satisfactory |
yes |
no |
|
Unpleasant feeling |
yes |
no |
|
I have skin problems under the electrodes |
yes |
no |
|
I move faster and easier in the wheel-chair |
yes |
no |
|
Muscles fatigue appears too quickly |
yes |
no |
|
Mark the effect of EFS |
Deteriorates greatly |
Deteriorates slightly |
No effect |
Improves slightly |
Improves greatly |
|
I Independence in daily activities |
1 |
2 |
3 |
4 |
5 |
|
Valking |
1 |
2 |
3 |
4 |
5 |
|
Valking on stairs |
1 |
2 |
3 |
4 |
5 |
|
Quality of life |
1 |
2 |
3 |
4 |
5 |
|
Social life |
1 |
2 |
3 |
4 |
5 |
Make three suggestions
as to how the FES system that you use could be improved.