Posts Tagged Functional electrical stimulation

[VIDEO] Foot Drop and Functional Electrical Stimulation (FES)

PhysioFunction are recognised as international experts in the use of Functional Electrical Stimulation (FES). We ensure our clients receive the most clinically correct rehabilitation technology suited to their needs. Jon Graham, Clinical Director at PhysioFunction talks about Foot Drop and Functional Electrical Stimulation.


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[Abstract + References] EEG-controlled functional electrical stimulation rehabilitation for chronic stroke: system design and clinical application


Stroke is one of the most serious diseases that threaten human life and health. It is a major cause of death and disability in the clinic. New strategies for motor rehabilitation after stroke are undergoing exploration. We aimed to develop a novel artificial neural rehabilitation system, which integrates brain-computer interface (BCI) and functional electrical stimulation (FES) technologies, for limb motor function recovery after stroke. We conducted clinical trials (including controlled trials) in 32 patients with chronic stroke. Patients were randomly divided into the BCI-FES group and the neuromuscular electrical stimulation (NMES) group. The changes in outcome measures during intervention were compared between groups, and the trends of ERD values based on EEG were analyzed for BCI-FES group. Results showed that the increase in Fugl Meyer Assessment of the Upper Extremity (FMA-UE) and Kendall Manual Muscle Testing (Kendall MMT) scores of the BCI-FES group was significantly higher than that in the sham group, which indicated the practicality and superiority of the BCI-FES system in clinical practice. The change in the laterality coefficient (LC) values based on μ-ERD (ΔLCm-ERD) had high significant positive correlation with the change in FMA-UE(r = 0.6093, P = 0.012), which provides theoretical basis for exploring novel objective evaluation methods.


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[GUIDELINE] A Clinical Practice Guideline for the Use of Ankle-Foot Orthoses and Functional Electrical Stimulation Post-Stroke



Level of ambulation following stroke is a long-term predictor of participation and disability. Decreased lower extremity motor control can impact ambulation and overall mobility. The purpose of this clinical practice guideline (CPG) is to provide evidence to guide clinical decision-making for the use of either ankle-foot orthosis (AFO) or functional electrical stimulation (FES) as an intervention to improve body function and structure, activity, and participation as defined by the International Classification of Functioning, Disability and Health (ICF) for individuals with poststroke hemiplegia with decreased lower extremity motor control.


A review of literature published through November 2019 was performed across 7 databases for all studies involving stroke and AFO or FES. Data extracted included time post-stroke, participant characteristics, device types, outcomes assessed, and intervention parameters. Outcomes were examined upon initial application and after training. Recommendations were determined on the basis of the strength of the evidence and the potential benefits, harm, risks, or costs of providing AFO or FES.


One-hundred twenty-two meta-analyses, systematic reviews, randomized controlled trials, and cohort studies were included. Strong evidence exists that AFO and FES can each increase gait speed, mobility, and dynamic balance. Moderate evidence exists that AFO and FES increase quality of life, walking endurance, and muscle activation, and weak evidence exists for improving gait kinematics. AFO or FES should not be used to decrease plantarflexor spasticity. Studies that directly compare AFO and FES do not indicate overall superiority of one over the other. But evidence suggests that AFO may lead to more compensatory effects while FES may lead to more therapeutic effects. Due to the potential for gains at any phase post-stroke, the most appropriate device for an individual may change, and reassessments should be completed to ensure the device is meeting the individual’s needs.


This CPG cannot address the effects of one type of AFO over another for the majority of outcomes, as studies used a variety of AFO types and rarely differentiated effects. The recommendations also do not address the severity of hemiparesis, and most studies included participants with varied baseline ambulation ability.


This CPG suggests that AFO and FES both lead to improvements post-stroke. Future studies should examine timing of provision, device types, intervention duration and delivery, longer term follow-up, responders versus nonresponders, and individuals with greater impairments.


These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for people with poststroke hemiplegia who have decreased lower extremity motor control that impacts ambulation and overall mobility.

A Video Abstract is available as supplemental digital content from the authors (available at:



Levels of Evidence and Grades of Recommendations … 117

Summary of Action Statements … 118

Introduction … 119

Methods … 121

Action Statements and Research Recommendations … 128

Action Statement 1: Quality of Life … 128

Action Statement 2: Gait Speed … 129

Action Statement 3: Other Mobility … 135

Action Statement 4: Dynamic Balance … 139

Action Statement 5: Walking Endurance … 143

Action Statement 6: Plantarflexor Spasticity … 147

Action Statement 7: Muscle Activation … 149

Action Statement 8: Gait Kinematics … 152

Overall CPG Clinical Recommendations … 156

Summary of Research Recommendations … 157

Limitations … 158

Guideline Implementation Recommendations … 159


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[Abstract] A Robotic System with EMG-Triggered Functional Eletrical Stimulation for Restoring Arm Functions in Stroke Survivors



Robotic systems combined with Functional Electrical Stimulation (FES) showed promising results on upper-limb motor recovery after stroke, but adequately-sized randomized controlled trials (RCTs) are still missing.


To evaluate whether arm training supported by RETRAINER, a passive exoskeleton integrated with electromyograph-triggered functional electrical stimulation, is superior to advanced conventional therapy (ACT) of equal intensity in the recovery of arm functions, dexterity, strength, activities of daily living, and quality of life after stroke.


A single-blind RCT recruiting 72 patients was conducted. Patients, randomly allocated to 2 groups, were trained for 9 weeks, 3 times per week: the experimental group performed task-oriented exercises assisted by RETRAINER for 30 minutes plus ACT (60 minutes), whereas the control group performed only ACT (90 minutes). Patients were assessed before, soon after, and 1 month after the end of the intervention. Outcome measures were as follows: Action Research Arm Test (ARAT), Motricity Index, Motor Activity Log, Box and Blocks Test (BBT), Stroke Specific Quality of Life Scale (SSQoL), and Muscle Research Council.


All outcomes but SSQoL significantly improved over time in both groups (P < .001); a significant interaction effect in favor of the experimental group was found for ARAT and BBT. ARAT showed a between-group change of 11.5 points (P = .010) at the end of the intervention, which increased to 13.6 points 1 month after. Patients considered RETRAINER moderately usable (System Usability Score of 61.5 ± 22.8).


Hybrid robotic systems, allowing to perform personalized, intensive, and task-oriented training, with an enriched sensory feedback, was superior to ACT in improving arm functions and dexterity after stroke.


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[VIDEO] Hand-wrist orthosis + Functional Electrical Stimulation – YouTube

Hand-wrist orthosis and functional electrical stimulation can be used in association, so that the wrist and the palm of the hand are fixed in an optimal position, while the electrodes stimulate the extrinsic muscles to flex and extend the fingers.

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[VIDEO] Functional Electrical Stimulation Performed by OT Zubair Abdulgafar – YouTube

Functional electrical stimulation is a technique that uses low-energy electrical pulses to artificially generate body movements in individuals who have been paralyzed due to injury to the central nervous system.

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[ARTICLE] Functional Electrical Stimulation Therapy for Retraining Reaching and Grasping After Spinal Cord Injury and Stroke – Full Text

Neurological conditions like hemiplegia following stroke or tetraplegia following spinal cord injury, result in a massive compromise in motor function. Each of the two conditions can leave individuals dependent on caregivers for the rest of their lives. Once medically stable, rehabilitation is the main stay of treatment. This article will address rehabilitation of upper extremity function. It is long known that moving the affected limb is crucial to recovery following any kind of injury. Overtime, it has also been established that just moving the affected extremities does not suffice, and that the movements have to involve patient’s participation, be as close to physiologic movements as possible, and should ideally stimulate the entire neuromuscular circuitry involved in producing the desired movement. For over four decades now, functional electrical stimulation (FES) is being used to either replace or retrain function. The FES therapy discussed in this article has been used to retrain upper extremity function for over 15 years. Published data of pilot studies and randomized control trials show that FES therapy produces significant changes in arm and hand function. There are specific principles of the FES therapy as applied in our studies: (i) stimulation is applied using surface stimulation electrodes, (ii) there is minimum to virtually no pain during application, (iii) each session lasts no more than 45–60 min, (iv) the technology is quite robust and can make up for specificity to a certain extent, and (v) fine motor function like two finger precision grip can be trained (i.e., thumb and index finger tip to tip pinch). The FES therapy protocols can be successfully applied to individuals with paralysis resulting from stroke or spinal cord injury.


Application of functional electrical stimulation (FES) for therapeutic purposes in rehabilitation settings dates back to the 1960’s when Liberson et al. (1961) used an FES system to stimulate the peroneal nerve to correct foot drop by triggering a foot switch, a single-channel electrical stimulation device stimulated the common peroneal nerve via a surface electrode, producing ankle dorsiflexion during the swing phase of gait (Liberson et al., 1961). This led to the first commercially available FES system with surface stimulation electrodes. Since then FES technology has been researched extensively to evaluate its benefits in diverse neurological conditions, and using an array of application techniques (Baldi et al., 1998Field-Fote, 2001Popovic et al., 2005201120122016Yan et al., 2005Frotzler et al., 2008Griffin et al., 2009Daly et al., 2011Kapadia et al., 201120132014aGiangregorio et al., 2012Malešević et al., 2012Martin et al., 2012Kawashima et al., 2013Lee et al., 2013Sadowsky et al., 2013Ho et al., 2014Kapadia N. et al., 2014Popović, 2014Sharif et al., 2014Bauer et al., 2015Howlett et al., 2015Vafadar et al., 2015Buick et al., 2016Cuesta-Gómez et al., 2017Fu et al., 2019Straudi et al., 2020). The two common uses of FES are to replace function (i.e., as an orthotic device) and to retrain function (i.e., as a therapeutic device). In this article we will limit ourselves to the therapeutic application of FES.

In the therapeutic application (FES therapy), FES is used as a short-term treatment modality. The expectation is that, after training with the FES system, the patients will be able to voluntarily perform the trained activities without FES (i.e., patients are expected to regain voluntary function). To date, a few high-quality randomized controlled trials have been performed, proving the efficacy of FES therapy over other rehabilitation techniques (Sharififar et al., 2018Yen et al., 2019). This paucity in multicenter randomized controlled trials and the limited access to systems that can properly deliver FES therapy might have affected its uptake in clinical settings (Ho et al., 2014Auchstaetter et al., 2016). Fortunately, both these issues are being addressed as new FES systems that are specifically developed for FES therapy are being introduced, as well as large scale multicenter randomized controlled trials are being planned to further confirm the efficacy of this rehabilitation modality. This article will provide readers with the details on how transcutaneous multichannel FES therapy for the upper extremity can be applied in clinical trials and as such the same methodology can be used in clinical practice by physiotherapists and occupational therapists.

The FES methodology discussed here has been developed with the intent to be user friendly, robust and to be able to produce better functional gains than the presently available best-practice rehabilitation techniques. The FES system used in our laboratory is a surface stimulation system with up to 4 stimulation channels that can produce gross motor function as well as precision grips such as two finger pinch grip. However, the methodology of FES application discussed here is pertinent to any multichannel transcutaneous FES device. We have used transcutaneous FES to retrain reaching and grasping in individuals with both spinal cord injury and stroke (Thrasher et al., 2008Kapadia and Popovic, 2011Kapadia et al., 20112013Popovic et al., 2012Hebert et al., 2017). The results obtained in both patient populations indicate functional improvements after 8–14 weeks of therapy (20–48 h of stimulation). Patients showed reduced dependency on caregivers, and some even became independent in their activities of daily living.

This article will extensively detail how FES was applied in these previously successful clinical trials to retrain reaching and grasping functions in individuals who sustained a spinal cord injury or a stroke.[…]


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[ARTICLE] Functional electrical stimulation therapy for restoration of motor function after spinal cord injury and stroke: a review – Full Text


Functional electrical stimulation is a technique to produce functional movements after paralysis. Electrical discharges are applied to a person’s muscles making them contract in a sequence that allows performing tasks such as grasping a key, holding a toothbrush, standing, and walking. The technology was developed in the sixties, during which initial clinical use started, emphasizing its potential as an assistive device. Since then, functional electrical stimulation has evolved into an important therapeutic intervention that clinicians can use to help individuals who have had a stroke or a spinal cord injury regain their ability to stand, walk, reach, and grasp. With an expected growth in the aging population, it is likely that this technology will undergo important changes to increase its efficacy as well as its widespread adoption. We present here a series of functional electrical stimulation systems to illustrate the fundamentals of the technology and its applications. Most of the concepts continue to be in use today by modern day devices. A brief description of the potential future of the technology is presented, including its integration with brain–computer interfaces and wearable (garment) technology.


Losing the ability to move voluntarily can have devastating consequences for the independence and quality of life of a person. Stroke and spinal cord injury (SCI) are two important causes of paralysis which affect thousands of individuals around the world. Extraordinary efforts have been made in an attempt to mitigate the effects of paralysis. In recent years, rehabilitation of voluntary movement has been enriched by the constant integration of new neurophysiological knowledge about the mechanisms behind motor function recovery. One central concept that has improved neurorehabilitation significantly is neuroplasticity, the ability of the central nervous system to reorganize itself during the acquisition, retention, and consolidation of motor skills [1]. In this document, we present one of the interventions that has flourished as a consequence of our increased understanding of the plasticity of the nervous system: functional electrical stimulation therapy or FEST. The document, which is not a systematic review, is intended to describe early work that played an important historical role in the development of this field, while providing a general understanding of the technology and applications that continue to be used today. Readers interested in systematic reviews of functional electrical simulation (FES) are directed to other sources (e.g., [2,3,4]).[…]


Textile-based neuroprostheses. a Finger extension produced using a shirt designed for implementing a neuroprosthesis for reaching and grasping. The garment includes rectangular areas (dark grey patches) made of conductive yarn that function as electrodes. b Forward reaching. Details can be found in [65]

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[ARTICLE] Automated functional electrical stimulation training system for upper-limb function recovery in poststroke patients – Full Text


• We developed an accelerometry system to detect the motion intention of poststroke patients for triggering FES.

• A visual game module was combined with this automated FES training system.

• This system can reduce variability in compound movements produced by poststroke patients and FES.

• An optimal threshold of triggering can defined for each patient for specific tasks.



This paper describes the design and test of an automated functional electrical stimulation (FES) system for poststroke rehabilitation training. The aim of automated FES is to synchronize electrically induced movements to assist residual movements of patients.


In the design of the FES system, an accelerometry module detected movement initiation and movement performed by post-stroke patients. The desired movement was displayed in visual game module. Synergy-based FES patterns were formulated using a normal pattern of muscle synergies from a healthy subject. Experiment 1 evaluated how different levels of trigger threshold or timing affected the variability of compound movements for forward reaching (FR) and lateral reaching (LR). Experiment 2 explored the effect of FES duration on compound movements.


Synchronizing FES-assisted movements with residual voluntary movements produced more consistent compound movements. Matching the duration of synergy-based FES to that of patients could assist slower movements of patients with reduced RMS errors.


Evidence indicated that synchronization and matching duration with residual voluntary movements of patients could improve the consistency of FES assisted movements. Automated FES training can reduce the burden of therapists to monitor the training process, which may encourage patients to complete the training.

1. Introduction

Hemiplegia is a common sequela experienced by stroke survivors; it leads to dysfunction in the upper and lower limbs. Various rehabilitation strategies have been adopted to help patients recover limb motor functions [1,2]. The methods of rehabilitation training currently adopted in clinic for poststroke patients are generally high-intensity, repetitive task-oriented paradigms that are practiced daily with outcome feedback [1]. Information on movement kinematics and muscle activation is often used to adjust the training strategy and to ensure that recovery progresses in the desired direction [3,4]. An inappropriate regimen in rehabilitation training may result in abnormal activation of muscles [4] and may lead to reduced effectiveness in motor functional recovery or even increased risk of muscle contracture and spasticity [5,6].

Functional electrical stimulation (FES) may potentially increase the effectiveness of rehabilitation training. It uses electrical stimulation to assist patients in producing physical movements [7] and to facilitate the training of patients’ voluntary muscle contraction [8]. Several studies have reported that FES improves the plasticity of the cerebral cortex and can be easily performed by therapists because it does not require extensive manual operations [9][10][11][12]. Evidence suggests that FES is a useful modality for rehabilitation training with explainable neural mechanisms.

Progress has been made in FES applications to aid the recovery of motor functions in patients poststroke [13], and novel technologies have been integrated into FES paradigms, including gaming [14] and intelligence applications [15][16][17]. However, even though many control strategies have been developed to generate electrical stimulation patterns, these control strategies have not been widely translated into routine clinical uses [18][19][20][21][22] due to the controller is too complex, or needs to be adjusted according to the patient’s condition. Notably, a recent development in neuromotor control theory focusing on the modular organization of multiple muscle activations has led to the formulation of synergy-based FES strategies [23][24][25]. This approach provides a feasible solution for multi-channel FES control using residual muscle activities from the patient [23,[25][26][27][28]]; and it leverages the idea that normal movement kinematics can be generated out of muscle synergies [23].

We have evaluated the synergy-based FES training paradigm in a short-term clinical intervention study. A five day of intervention using synergy-based FES was carried out in poststroke patients. The outcome of the short-term intervention was measured by changes in Fugl-Meyer scores and movement kinematics. Results of evaluations prior to and post intervention showed improvements in both Fugl-Meyer scores and movement kinematics [25]. In a subsequent analysis, synergy-based FES training demonstrated evidence in reorganizing neural circuits in the brain, which led to repairing of impaired muscle activation pattern towards the normal pattern [29].

In this study, we present a design and verification of an autotriggered FES system with a synergy-based stimulation strategy and used RMS errors to analyze the movement process of the patients for each trial by using acceleration. This automated FES training system is designed to continuously integrate with FES clinical protocol therapeutic intervention in stroke rehabilitation [30].

The automated FES training system with a gaming interface and accelerometer triggered generation of multiple channels of electrical stimulations to a group of targeted muscles. In this automated FES training system, we anticipated improved consistency of patient movements during rehabilitative training. If successful, the study will provide a training protocol that induces smaller RMS errors across movement trials.

2. Methods and materials

2.1. Design of the automated FES system

Fig. 1 presents a schematic of the components and experimental environment of the automated trigger FES system. The system was composed of a gaming device, an elbow cast including a radiofrequency identification (RFID) reader and an accelerometer, a multichannel FES system, and a computer. The software for the development of the training game (named Picking Apples) was created using Unity (version 2018.1.3f1, Unity Technologies Inc., CA, USA). For ease of operation, the RFID device and the Li-ion battery were mounted in the elbow cast. The RFID information and accelerometer data were transmitted wirelessly by Bluetooth (Fig. 1A).

Fig 1
Fig. 1. Illustration of the FES system. (A) The automated trigger FES system operation. (B) The experimental setup with the automated trigger FES system. The experiment was performed using the affected upper limb of the subject, which was fixed in a golden yellow plastic elbow cast. Stimulation electrodes were placed on the seven target muscles. A pair of electrodes (4 cm × 4  cm) was placed on each muscle: the red electrode represented the positive pole and the black the negative. The initial and target points are circles with a diameter of 2.5 cm.


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[ARTICLE] Functional Electrical Stimulation Controlled by Motor Imagery Brain-Computer Interface for Rehabilitation – Full Text HTML


Sensorimotor rhythm (SMR)-based brain–computer interface (BCI) controlled Functional Electrical Stimulation (FES) has gained importance in recent years for the rehabilitation of motor deficits. However, there still remain many research questions to be addressed, such as unstructured Motor Imagery (MI) training procedures; a lack of methods to classify different MI tasks in a single hand, such as grasping and opening; and difficulty in decoding voluntary MI-evoked SMRs compared to FES-driven passive-movement-evoked SMRs. To address these issues, a study that is composed of two phases was conducted to develop and validate an SMR-based BCI-FES system with 2-class MI tasks in a single hand (Phase 1), and investigate the feasibility of the system with stroke and traumatic brain injury (TBI) patients (Phase 2). The results of Phase 1 showed that the accuracy of classifying 2-class MIs (approximately 71.25%) was significantly higher than the true chance level, while that of distinguishing voluntary and passive SMRs was not. In Phase 2, where the patients performed goal-oriented tasks in a semi-asynchronous mode, the effects of the FES existence type and adaptive learning on task performance were evaluated. The results showed that adaptive learning significantly increased the accuracy, and the accuracy after applying adaptive learning under the No-FES condition (61.9%) was significantly higher than the true chance level. The outcomes of the present research would provide insight into SMR-based BCI-controlled FES systems that can connect those with motor disabilities (e.g., stroke and TBI patients) to other people by greatly improving their quality of life. Recommendations for future work with a larger sample size and kinesthetic MI were also presented.

1. Introduction

Healthy individuals whose brains and neuromuscular systems enable normal motor functions can naturally perform Activities of Daily Living (ADLs). Nonetheless, for some people who have disabilities in these functions due to injury or disease, simple tasks become very difficult or impossible to do. To assist this population, researchers in many fields, from physical therapy to engineering, have developed various rehabilitation technologies that help them perform ADLs [1,2]. One such technology, Functional Electrical Stimulation (FES), delivers electrical impulses to either paralyzed or impaired limbs to generate artificial muscle contraction [3,4]. In this way, FES helps disabled people perform ADLs such as walking, reaching, and grasping [5,6]. Some FES devices are controlled by brain–computer interfaces (BCIs), sometimes called brain–machine interfaces.
In general, BCIs can help people communicate and control devices and applications without using peripheral nerves and muscle pathways [7]. BCIs are also a potential method to promote the independence of physically disabled people by means of the BCI’s ability to bypass non-functional neural pathways [8]. A sensorimotor rhythm (SMR)-based BCI-controlled FES system is a novel technology that combines the advantages of FES and BCI systems, and allows severely disabled patients to restore motor functions through the FES system by translating voluntary Motor Imagery (MI) to physical action [9]. There are many potential benefits of combining SMR-based BCIs and FES systems, such as the promotion of neuroplasticity [10], the restoration of motor functions by using voluntary motor intentions [9,11], and providing proprioceptive sensory feedback as a result of their intentions [12].
Although SMR-based BCI-controlled FES methods seem promising, current studies still have central issues: (1) ambiguous instruction of MI tasks during training under SMR-based BCI systems, and (2) difficulties in classifying voluntary MI-evoked SMRs and FES-driven passive-movement-evoked SMRs when FES is activated. Moreover, (3) only a few studies have examined the feasibility of classifying two different MI tasks of a single hand, such as grasping and opening, and (4) few studies have examined human factors and ergonomics (HF/E) perspectives such as subjective mental workload and user satisfaction in the use of SMR-based BCI-controlled FES systems. This research that is composed of two phases was conducted to address these issues by developing a new SMR-based BCI system with visual guidance during training to classify a 2-class MI task in a single hand, as well as voluntary and passive SMRs (Phase 1), and evaluating the feasibility of the proposed BCI-controlled FES system by performing sequential goal-oriented tasks with stroke and TBI patients (Phase 2).
The remainder of this article consists of five more sections (this introduction being Section 1): Section 2 describes a survey of current SMR-based BCI studies for FES systems to identify the limitations of current research and clarifies the current state of BCI-controlled FES technologies. Section 3 presents Phase 1, where an SMR-based BCI system to control FES was developed and validated to address the issues on current research studies. Section 4 describes Phase 2, which assessed the feasibility of the proposed BCI-FES system by conducting a sequential task with fixed order under a semi-asynchronous mode. Section 5 discusses the findings of the present research along with implications and future directions.[…]

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Figure 1. Schematic illustration of the experiment procedure. Text in the blue box indicates the auditory cue that played at the beginning of each period, and INI is an abbreviation of the Functional Electrical Stimulation (FES) initiation period. MI: Motor Imagery.


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