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Tuesday, 28 February 2017 14:16

The Benefits of FES-Cycling After a Stroke

Stroke (cerebrovascular accident or CVA) is a leading cause of death in the United States, killing more than 130,000 Americans every year [1]. Moreover, stroke is a leading cause of long-term disability, especially hemiparesis (weakness or paralysis on one side of the body). In fact, roughly 80% of stroke survivors have hemiparesis [2], which can cause difficult speaking, grasping objects, or walking. Therefore, rehabilitation following a stroke resulting in hemiparesis usually involves a combination of occupational therapy, speech therapy, and physical therapy. Independence in daily living, especially independent walking, is a priority for stroke survivors, so a major objective of rehabilitation post-stroke is to recover the ability to walk normally.

Recovery walking ability after a stroke is a complicated process, as walking function depends on motor control, muscular strength/power, cardiorespiratory fitness, and other factors [3]. There are many different therapeutic interventions aimed at improving walking function that address one or more of these factors. Recently, therapists have increased their use of task-specific training using bodyweight-supported treadmills or robotic gait trainers, but such systems are often complex, expensive, and difficult to use in a timely manner. Gait training is particularly difficult for patients with severely limited walking ability, limiting its effectiveness for the people who may need it most.

Stationary cycling is a tried and true means of exercise and rehabilitation, and it may be just as effective at improving gait as bodyweight-supported or robotic gait training devices [4]. Cycling is an effective therapeutic tool for improving walking post-stroke for a number of reasons:

  • it allows for continuous, repetitive motion involving symmetric, coordinated flexion and extension of the joints with agonist/antagonist muscle activation through a greater range of motion than that in walking
  • it can be used early post-stroke, when patients may not yet be able to participate in traditional gait training
  • it can easily be continued beyond rehab and incorporated into a healthy lifestyle, minimizing the risk for subsequent strokes
  • it may be safer than gait training, as balance isn’t required, minimizing the fear and risk of falling
  • cycling outcomes are easily quantifiable, and different training effects can be achieved by altering only a few parameters (e.g., muscular strength can be trained with low cadence and high resistance, while cardiorespiratory fitness can be trained with high cadence and low resistance)

When functional electrical stimulation (FES) is added to cycling (FES-cycling), the benefits of cycling for people post-stroke can be amplified. Several studies have demonstrated the benefits of FES-cycling for people post-stroke [5]-[9], including:

  • improved aerobic capacity and cardiopulmonary function;
  • improved symmetry and smoothness of cycling;
  • improved muscle strength, tone, and power output;
  • improved postural control and motor coordination;
  • reduced muscle spasticity; and
  • increased walking speed, step length, symmetry, and balance.

FES itself adds the benefits of preventing muscle atrophy, increasing blood flow, re-educating the muscles, and maintaining/increasing joint range of motion. FES-cycling may also provide afferent sensory input to the central nervous system that enhances brain plasticity and cortical motor output, which may further improve functional outcomes in a manner similar to the effect of FES-cycling for people with Parkinson’s disease.

Clearly, combining the benefits of cycling with the benefits of FES can dramatically improve the health and functional performance of people who have suffered a stroke. The MyoCycle is an FES bike that combines the benefits of cycling, isokinetic exercise, and FES into one affordable, easy-to-use system. If you or someone you love has had a stroke and is interested in FES-cycling, contact us today to learn how the MyoCycle can meet your needs!

  1. https://www.cdc.gov/stroke/facts.htm
  2. http://www.stroke.org/we-can-help/survivors/stroke-recovery/post-stroke-conditions/physical/hemiparesis
  3. Bowden, M. G.; Embry, A. E.; and Gregory, C. M. 2011. Physical Therapy Adjuvants to Promote Optimization of Walking Recovery After Stroke. Stroke Research and Treatment.
  4. Barbosa, D.; Santos, C. P.; and Martins, M. 2015. The Application of Cycling and Cycling Combined with Feedback in the Rehabilitation of Stroke Patients: A Review. Journal of Stroke and Cerebrovascular Disease. 24(2):253-273.
  5. Peng, C.-W. et al. 2011. Review. Clinical Benefits of Functional Electrical Stimulation Cycling Exercise for Subjects with Central Neurological Impairments. Journal of Medical and Biological Engineering. 31(1):1-11.
  6. Lee, S. Y. et al. 2013. The effects of assisted ergometer training with a functional electrical stimulation on exercise capacity and functional ability in sub-acute stroke patients. Ann Rehabil Med. 37:619.
  7. Ambrosini, E. et al. 2011. Cycling induced by electrical stimulation improves motor recovery in postacute hemiparetic patients: a randomized controlled trial. Stroke. 42:1068-1073.
  8. Lo, H.-C. et al. 2012. Cycling exercise with functional electrical stimulation improves postural control in stroke patients. Gait Posture. 35:506-510.
  9. Ambrosini, E. et al. 2012. Cycling induced by electrical stimulation improves muscle activation and symmetry during pedaling in hemiparetic patients. IEEE Trans Neural Syst Rehabil Eng. 20:320-330.
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Parkinson’s disease (PD) is a progressive neurological disorder that can have a profound impact on the way people move. Damage to brain cells inhibits the brains' ability to produce dopamine – a neurotransmitter necessary for communication between different parts of the brain. Without enough dopamine, the symptoms of Parkinson’s disease appear, which may include tremor, slow movements (bradykinesia), stiff muscles, weakness, loss of coordination, and other effects on movement.

Exercise is medicine, and exercise is especially therapeutic for people with PD [1]. The leading theory is that exercise triggers the release of neurotrophic factors in the brain, which help to protect the brain cells from further degeneration. Exercise may even improve the brain’s ability to produce dopamine, further slowing the degenerative effects of PD. This would explain the success of programs like Pedaling for Parkinson’s. Researchers have discovered that forced exercise, as opposed to voluntary exercise, can have an even greater therapeutic effect for people with PD [2].

Forced exercise usually involves a tandem bicycle with fixed gears, upon which an able-bodied person and a person with PD sit. The able-bodied person pedals faster than the person with Parkinson's can pedal on their own (usually around 90 rpm), effectively forcing the person with PD to pedal faster. This same effect can be achieved with a motorized exercise bike [3]. It has been demonstrated that forced exercise has a positive effect on PD symptoms, likely because both the quantity (pedaling faster) and quality (pedaling smoother) of the exercise is enhanced in forced pedaling when compared to voluntary pedaling by people with PD. Cueing (e.g., auditory cueing like a metronome) can have a similar effect by helping someone with Parkinson's improve the quality of their movements [1].

To summarize, Parkinson's causes stiffness, weakness, loss of coordination, tremors, and other effects on movement that can be treated by motor-assisted cycling, especially if cueing is provided.

It makes perfect sense, then, that motor-assisted cycling with functional electrical stimulation (FES-cycling) would be a great therapy option for people with PD. However, surprisingly, only MYOLYN’s co-founder, Matthew Bellman, PhD, together with Chris Hass, PhD, have investigated the potential benefits of FES-cycling for people with Parkinson's [4]. Their pilot data suggests that a person with Parkinson's can pedal faster and more smoothly when assisted by FES, likely because the added FES can enhance muscle force production and provide cueing via the sensation of the stimulation during cycling.

Therefore, FES-cycling, especially isokinetic FES-cycling with electric motor assistance, can provide a person with PD all the benefits of forced exercise, in addition to the traditional benefits of FES, which are:

  • Relaxation of muscle spasms
  • Prevention or retardation of disuse atrophy
  • Increasing local blood circulation
  • Muscle re-education
  • Maintaining or increasing range of motion

MYOLYN is working to understand further the potential benefits of FES-cycling for people with PD. If you or someone you love has Parkinson's and is interested in FES-cycling, contact us today to learn how the MyoCycle Home can meet your needs!

References

[1] Earhart, G. M. and Falvo, M. J. 2013. Parkinson Disease and Exercise. Comprehensive Physiology. 3:833–848.

[2] Ridgel, A. L.; Vitek, J. L.; and Alberts, J. L. 2009. Forced, Not Voluntary, Exercise Improves Motor Function in Parkinson’s Disease Patients. Neurorehabilitation and Neural Repair. 23(6):600-608.

[3] Ridgel, A. L. et al. 2012. Active-Assisted Cycling Improves Tremor and Bradykinesia in Parkinson’s Disease. Archives of Physical Medicine and Rehabilitation. 93(11):2049-2054.

[4] Bellman, M. J. et al. 2016. Switched Control of Cadence During Stationary Cycling Induced by Functional Electrical Stimulation. IEEE Transactions on Neural Systems and Rehabilitation Engineering. 24(12):1373-1383.

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Stationary cycling combined with electrical stimulation applied to the leg muscles (FES-cycling) is commonly used by people with spinal cord injury to maintain good health of their paralyzed limbs. Recent studies have highlighted the fact that FES-cycling is beneficial for people with other neurological disorders, especially stroke and multiple sclerosis (MS). An upcoming post will discuss the benefits for people with stroke, while this post will focus on the benefits for people with MS.

A recent pilot study conducted by Deborah Backus, PhD, PT, and her team at the Shepherd Center assessed the effects of FES-cycling on outcomes for people with MS [1]. Previous studies on the outcomes of FES-cycling training for ambulatory people with MS have demonstrated improvements in strength, walking endurance and speed, and even mental health and quality of life [2]. However, the effects of FES-cycling training for non-ambulatory people with MS haven’t been adequately studied, so Backus and her team set out to do just that.

Fourteen people (8 men and 6 women) with MS participated in the study. Participants ranged from 31 to 70 years old, and had been diagnosed with MS from 3 to 28 years ago. Only non-ambulatory people with MS could participate, meaning that they had to be unable to walk more than 70 feet at a time and has to use a wheelchair outside their homes. Participants completed 12 30-minute FES-cycling sessions over four weeks.

The results of the FES-cycling training indicate that not only is FES-cycling safe for non-ambulatory people with MS, but also that such training provides physical benefits and improved quality of life to people with moderate to severe MS. All the participants were able to increase their cycling time and/or resistance over the course of the training, suggesting that their ability to cycle improved as a result of the FES-cycling training. While the training had little effect on muscle strength or spasticity, the study participants reported that transfers and walking at home were easier after the FES-cycling training, suggesting that the training had functional benefits for the study participants. Perhaps most importantly, the participants reported that the social aspects of their life had improved as a result of the study, suggesting that the FES-cycling training had a positive effect on the participants’ quality of life.

Despite the fact that this was only a 4-week pilot study, the outcomes are promising for people with moderate to severe MS. More in-depth research is needed to learn more about the potential benefits of FES-cycling training for people with MS. To that end, a team of researchers at the University of Illinois at Urbana-Champaign is embarking on a 6 month clinical study to examine the effects of FES-cycling training on walking performance and physiological function among people with severe MS [3]. Based on the pilot data from the Shepherd Center, the results of this longer study are expected to be positive.

While FES-cycling is typically associated with spinal cord injury, its benefits extend to people with other neurological disorders, especially stroke and MS. These benefits include:

  • Improved walking and cycling ability
  • Increased muscle strength
  • Improved physical, mental, and social well-being
  • Better quality of life

Exciting research into the benefits of FES-cycling for people with MS is being conducted at places like the Shepherd Center and the University of Illinois at Urbana-Champaign. If you or someone you love has MS and is interested in FES-cycling, contact us today to learn how the MyoCycle Home can meet your needs!

References

[1] Deborah Backus, Blake Burdett, Laura Hawkins, Christine Manella, Kevin K. McCully, and Mark Sweatman (2016) Pilot Study of Outcomes After Functional Electrical Stimulation Cycle Training in Individuals with Multiple Sclerosis Who Are Nonambulatory. International Journal of MS Care.

[2] John N. Ratchford, Wendy Shore, Edward R. Hammond, Gregory J. Rose, Robert Rifkin, Pingting Nie, Kevin Tan, Megan E. Quigg, Barbara J. de Lateur, and Douglas A. Kerr (2010) A pilot study of functional electrical stimulation cycling in progressive multiple sclerosis. NeuroRehabilitation.

[3] Lara A. Pilutti, Robert W. Motl, Thomas A. Edwards, and Kenneth R. Wilund (2016) Rationale and design of a randomized controlled clinical trial of functional electrical stimulation cycling in persons with severe multiple sclerosis. Contemporary Clinical Trials Communications.

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Electrical stimulation is an incredible technology with the potential to dramatically change the way we restore and enhance the human body. Unfortunately, despite centuries of research on electrical stimulation, we still have yet to see the practical use of electrical stimulation reach its full potential.

Gad Alon, in his lecture at the APTA’s NEXT 2015 conference, said that one barrier to the acceptance of electrical stimulation as a standard of care is the “name game,” or, “the absence of consensus on generic meaningful terminology and the prevailing promotion of erroneous and misleading jargon.”

A quick Google search for electrical stimulation will lead you to discover a lot of names, abbreviations, and acronyms, including:

  1. Electrical muscle stimulation (EMS)
  2. Russian electrical stimulation
  3. Neuromuscular electrical stimulation (NMES)
  4. Functional electrical stimulation (FES)
  5. Transcutaneous electrical nerve stimulation (TENS)
  6. and many more…

All of these names refer to the same basic thing – applying electricity to the body to increase or decrease activity in the nervous system. The different names come from applying the current in different ways, to different parts of the body, or for different reasons. Part of the problem that Gad Alon referred to is the fact that people will say they use a particular kind of electrical stimulation, like Russian electrical stimulation, without ever explaining what it really means.

electrical stimulations

Generally speaking, the different names reflect either the intended use of the electrical stimulation or the characteristics of the stimulation itself. For example, EMS and Russian electrical stimulation are both generally intended for athletic training, but Russian stimulation uses high frequency sinusoidal waveforms, whereas EMS typically uses lower frequency rectangular waveforms. As another example, TENS units are typically used for pain relief, while NMES units are used to retrain muscles after an injury, even though both TENS and NMES use similar stimulation waveforms.

Instead of trying to solve the problem of the name game, this post provides a brief explanation of the most common types of electrical stimulation and how they are used in therapy. Hopefully, this information will help you to avoid the pitfalls of the name game and choose the right therapeutic modality for your purposes.

  • Transcutaneous electrical nerve stimulation (TENS)
    • Intended for temporary pain relief in sore and aching muscles or for symptomatic relief of chronic pain
    • Most pervasive type of electrical stimulation (a search for “TENS units” on Amazon.com brings up over 60,000 results)
    • Typically limited in functionality, but cheap as a result
    • Example: TENS 7000 unit
  • Interferential current (IFC) electrical stimulation
    • Intended for symptomatic relief of acute, chronic, and post-traumatic or post-surgical pain
    • Similar to TENS, but generally more effective and powerful
    • Much less common than TENS, but more functional and more expensive
    • Example: Amrex Z-Stim IF150
  • Electrical muscle stimulation (EMS)
    • Intended for strengthening muscles, increasing muscle size, improving muscular endurance, and accelerating muscle recovery
    • Also similar to TENS, but designed to make the muscles contract strongly
    • Typically used by athletes, especially for muscle recovery
    • Example: Compex Sport Elite
  • Russian stimulation
    • Intended for strengthening muscles, increasing muscle size, improving muscular endurance, and accelerating muscle recovery
    • Similar to EMS, but uses high frequency, sinusoidal stimulation waveforms
    • Popularized in the 1970s when Russian researchers used EMS to enhance the training of Olympic athletes
    • Example: RS 2500 Russian Stimulator
  • Neuromuscular electrical stimulation (NMES)
    • Intended for relaxing muscle spasms, preventing muscle atrophy, increasing blood circulation, maintaining or increasing range of motion, and especially for re-educating the neuromuscular system
    • Essentially the same as EMS, but typically focused on therapeutic use (rehab) instead of athletic use (training)
    • Example: Intelect NMES Digital Unit
  • Functional electrical stimulation (FES)
    • Intended for relaxing muscle spasms, preventing muscle atrophy, increasing blood circulation, maintaining or increasing range of motion, and especially for re-educating the neuromuscular system
    • Essentially the same as NMES, but especially effective for neurological rehabilitation, as the stimulation is automatically controlled to turn muscle contractions into functional movements
    • Usually incorporated into an exercise or bracing device to maximize functionality
    • Example: the MyoCycle Home, MyoCycle Pro, and MyoCycle Mobile

If you’d like to know more about the applications of electrical stimulation or the benefits of FES-cycling, check out earlier blog posts. Have questions about electrical stimulation? Leave a comment below or contact us to learn more!

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Thursday, 05 January 2017 16:10

Make FES a Standard of Care

Less clinical research, more personal care

Should we base the standards of care for physical therapy on clinical research, or do we need a different model to speed adoption of new treatment approaches such as functional electrical stimulation (FES) for physical injuries?
That’s the controversial question posed by Gad Alon, PT, PhD, Emeritus Associate Professor at the University of Maryland School of Medicine, Department of Physical Therapy and Rehabilitation Science.

At the NEXT conference of the American Physical Therapy Association last summer in Nashville, TN, Dr. Alon made a case for adopting FES as a standard of care based on a new model for making standards of care for people with physical limitations.

The controversy stems from the clinical research model that has long been used in clinical practice. The current legacy approach advises physical therapists to only use treatment modalities that have "statistically significant and clinically meaningful findings." However, achieving such results often takes years of academic or clinical research, with many more years of commercial development following before a useful product reaches the market. Still worse, the current model makes it so that product is only used for patients who are like the patients in the original research studies.

 

Let’s look at an example. Suppose a therapist treats patients who have hemiparesis after a stroke. The clinic also treats patients with multiple sclerosis, traumatic brain injury, and other neurological disorders. In an effort to better treat these patients, the therapist uses the clinical research model by doing some research on treatment options. The therapist finds a lot of research papers about how FES has a statistically significant and clinically meaningful effect on upper extremity function for patients after a stroke, and so the therapist starts using FES with the patients who have had a stroke and need help with upper extremity function. The therapist does not find as many papers about FES for lower extremity function or for other disorder groups, so those patients are never offered FES, even though many of them would probably benefit greatly from FES treatment.

This is the legacy approach that Dr. Alon criticizes, because patients are highly varied in types and levels of impairments and functional limitations. In other words, the functional goals of one patient with a physical impairment may be very different from another person with the same impairment. It doesn’t make sense for both patients to wait for years for a study of a device or regimen to enroll enough participants and reach some predefined outcome over years of testing before they can have access to an intervention that may or may not meet their individual goals.

To counter this limitation of the current model, Dr. Alon advocates adopting a different model for physical rehabilitation based on "personalized rehabilitation programs." He proposes that such a model seeks to address each individual’s functional goals with a focus on determining which treatment approaches are most likely to advance that person’s goals.

He stresses that no single intervention can maximize functional outcomes, and the goal should not be “normal” movement, but “visibly better” performance.

To that end, Dr. Alon advocates for adopting functional electrical stimulation or FES combined with task-specific interventions to reach best possible outcomes as the standard of care for patients who are candidates for FES.

Dr. Alon also pointed to a pair of additional obstacles to the adoption of FES as a standard of care.  One is the difficulty of using the devices by clinicians and the second is the high cost of the technology both for physical therapy clinics and for home use.

Two of MYOLYN’s guiding principles are to make its FES technology easy-to-use and affordable both for in-clinic and home use.

  • The MyoCycle Pro provides patients with a great workout using MYOLYN’s state of the art technology that automatically tailors the electrical stimulation to the individual patient. The result is a device that makes managing patients and patient load easier while providing fun, efficient therapy.
  • The MyoCycle Home automatically customizes muscle stimulation to meet your individual needs. It is easy to use and effective.
  • The MyoCycle Mobile is a one-of-a-kind product that gives people the ability to enjoy a bike ride with their friends and family despite their disability.

Join our waiting list today to be one of the first to experience the benefits of the MyoCycle and contribute to making FES a standard of care.

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