electronic stimulation

[galen]

when I got out of rehab I was using e-stem on my muscles below level of injury. I am now going to a different doctor who told me to stop because it could cause more damage to nerves. I am 19 months post injury and am still getting return at a very slow pace. Do not know what to believe. Also what causes electric type shocks on right leg ,inside above knee. Is strong at times. Galen

[Wise Young]

Galen,

There is no question that electrical stimulation can damage skin and perhaps even nerves, if very intense currents are used. On the other hand, most commercial stimulators do not provide sufficient current to do this, at least not to my knowledge.

Some doctors are in favor of functional electrical stimulation (FES) while others think that it is a waste of time. The decision to use FES depends not only on weighing the benefits and risks but whether there are other methods of achieving the same goals of reducing atrophy, placing stress on the bones to increase the strength of the bones, and activating your spinal cord.

FES clearly increases muscle bulk and strength when appropriately and consistently applied. It can be combined with an exercise cycle that allows convenient exercise of the legs in people. In my opinion, the risks are relatively low, if the stimulus is applied properly.

One recent study suggests caution in applying noxious levels of electical currents to the legs. Jim Grau at Texas A & M reported at the last Society for Neuroscience meeting that shocking the leg with electrical stimulation disrupted the walking reflexes in the spinal cord, often lasting for weeks. Many studies suggest that the spinal cord, even when bereft of connections to the brain, "remembers" experiences and particularly noxious experiences. Because people with spinal cord injury cannot feel the pain, they often crank up the stimulator to get maximal activation of their muscles, levels of stimulation that would be intolerable if the legs had sensation. The finding that noxious stimulation can produce long-lasting behavioral changes in the lower spinal cord suggests that we need to treat the paralyzed part of the body with respect and tenderness.

The question is whether other methods can be used to achieve the same goal as FES. The answer is yes.
• Spasticity and spams are very effective muscle activity and is very effective in maintaining muscle bulk. It is one of the reasons why I advise people not to take so much anti-spasticity drug that their legs are limp or flaccid and then try to use electrical stimulation to flog those drug-suppressed muscles to bulk up. It doesn't make sense.
• Standing is probably the most effective way of putting stress of the bones and exercising the tonic (slow) muscles that are essential for standing and postural maintainance. People with even the high cervical spinal cord injuries should be standing daily, in my opinion.
• Swimming. I recommend swimming to people. Standing in a poll is by far the most effective and cheapest way of putting weight on your legs, progressively going to the shallow end. Note that rhythmic activity of the cervical spinal cord will help drive motor centers in the lumbosacral spinal cord.
• Jumping. For those who are able to stand and take some steps, I recently saw quite an interesting presentation by Giselher Schalow in Switzerland (by the way, he is one of the most enthusiastic doctors that I know, devoted to rehabilitation of brain and spinal cord injury). He was having people with incomplete injuries jumping up and down on a board.
• Leg-arm cranks. Dr. Schalow also showed a wonderful device that has an arm and leg crank that is linked together. So, this way, the strongest limb can drive the others. This devices takes advantage of the ascending and descending connections between the lumbar and cervical spinal cord. For people who are very weak on all four limbs, somebody can help them at the beginning by manually helping the person through a cycle. It is low cost and based on sound physiological principles.
• Range of motion. For the longest time, I was not sure that range of motion really did all the much for muscles. Physical therapists, of course, have been doing ROM for many decades, perhaps even centuries. I thought that it was mostly to prevent contractures and to move the joints through their range. However, recent evidence suggest that stretching is very important in keeping the satellite cells in muscle alive. These cells are the ones that produce additional cells and nuclei to expand muscle bulk. Even in the most atrophied muscle, some satellite cells can be kept alive by regular stretching and movement of the muscle.

I can probably go on and on, and many people can chime in their particular approaches. FES is not the only approach to strengthening the muscle and bones. I believe that it does have an important place in exercising paralyzed muscles but it should be be considered the be-all and end-all of exercise. Many other approaches are very useful and effective.

Wise.

[galen]

I am now going to a gym every 2 days. I am riding a exersize bike 15 minutes. I walk with a walker. I have no feeling below my knees. From your responce Dr.Young I will keep doing what I am doing and leave the EFS alne for now. Should I push myself as far as being in the walker for nerve stimulation. It is so hard because I am so close to walking on my own ,but it seems like I am having trouble getting past that one point. I have very lousy insureance so I am trying to do this recovery part on my own. I honestly do not know what exersizes to do daily. My injury is L1 burst from a 21 ft. fall.The cord was flat I was told, not cut. Bowel and bladder problems I know I will have to live with. Any help on exrsizes or help getting signals going again is appreciated. Thank you. Galen

[Chris Chappell]

You mentoned leg - arm crank machines.

Do you or anyone else have additional information on the products available to do this?

Thanks.

Onward and Upward!

[etexley]

Recently I've been using my stim unit to assist me in assuming a standing position with a walker. I find that if I put my weight over my legs, they will remain locked throughout the off cycle.

Recently I've read that there are methods of stimulating a muscle directly, bypassing the spinal cord reflex arc which involves peripheral nerves...."Galvanic electircal stimulation." I don't understand this...a muscle contraction is caused the proper potential difference at the neuromuscular juntions. This triggers a chemical change. Would this be effective to prevent the atrophy of denervated muscles?

Eric Texley

[Wise Young]

Eric, most electrical stimulation does what you describe. It is not that different. Usually, electrical stimulation not only activates the muscle directly but stimulates the nerves going to the muscle and activates them to release their neurotransmitters to produce muscle contraction. As I described earlier, atrophic muscles were traditionally thought to be non-responsive to electrical stimulation. This is because the muscle is usually so degenerated that electrical stimulation cannot activate the remaining myofibers in the muscle. However, a recent study, that was reported in Brescia, suggests that if very large electrical currents are used and over long periods of time, even atrophic muscles can be restored and maintained with electrical stimulation. Likewise, physical therapy which stretches the muscles can also maintain denervated muscles. Both of these findings contradict the dogma that most clinicians adhere to, i.e. atrophic muscles cannot be restored.

Wise.

[Wise Young]

Chris, I don't know the name of the unit or who manufactures it. I have written to Dr. Giselher Schalow (Switzerland) who presented the work to see if he can provide some information. Wise.

[etexley]

What is the effect of electrical stimulation of a smooth muscle?

For instance, the urinary sphincter...what would be the effect of a faradic stimulation of the urethral sphincter?

Why is it necessary to stimulate the sacral nerve root rather than just applying a stimulation to the peripheral nerves which innervate the muscle? And if the muscle is too deep, why not just create a magnetic field using a toroidal coil?

Why do we still catheterize? I would think it something from the dark ages... I'm sick to death of the thread of strictures and UTIs...it's hell on the body as well as the spirit. There needs to be a cheap, inexpensive, alternative to using catheters.

Eric Texley

[etexley]

Why is it not possible to stimulate the urethral sphincter to relax through the use of transcutaneous electrodes?

Eric Texley

[FellowHawkeye]

At least for females, but maybe males, too. I discovered this FDA-approved e-stim device for strengthening the pelvic wall, which then helps eliminate stress/urge incontinence in 60 to 80 percent of patients. I ordered it by doctor's prescription from SRS Medical and have yet to use it because my female aide refused to help me with it. I've also got a firm hymen so will have to have the doctor's help the first time. Email me at janjanjan@aol.com for details.

Jan

[etexley]

I'm gonna try an FMS therapy next week. Maybe I can get control of my bladder, maybe not. But there needs to be a cheap, easy way to empty the bladder without catheterizing...NOW. Not in 15 years when the FDA gets ready to approve it.

Is it really necessary to get one's sacral nerves cut??? I would think that as a general rule, the least invasive therapy would be used to "cure" a condition. Clearly making people urinate without the need for catheters should be a prime directive for the SCI community. To live without the fear of UTI would be a wonderul thing.

"...the non-binding guideline, to be issued March 23 by the U.S. Agency for Health Care Policy and Research, calls for doctors generally to use surgery as a last resort. It emphasizes informing patients about and using the full range of treatment options, including bladder retraining, pelvic muscle exercises and medication."

Eric Texley

[This message was edited by Eric Texley on Apr 21, 2002 at 09:15 PM.]

[This message was edited by Eric Texley on Apr 21, 2002 at 09:16 PM.]

[FellowHawkeye]

Oh no, you don't want to do that. I wish this 4-Conti Stimulator was for men, but doesn't look like it. I'd email SRS Medical Systems to ask how men's incontinence can be controlled through e-stim.

Jan

[etexley]

Actually, I bet it is possible to measure innvervation for the urethral sphincter for men or women with a probe... Male or female, the muscle is in the same place.

I would think the kegel exercises whether they are induced through signal from my head or through FES would help incontinence in the very least.

But there needs to be an inexpensive, portable FES solution for emptying the bladder available...NOW. Not in 15 or 20 years. And it doesn't make restoring voluntary control of the bladder for everyone with SCI any less urgent...

We live in the 21st centruy...why are we using a method of emptying the bladder that was developed in the 1700s...or BEFORE...GESSH

To quote Scotty..."What is this, the dark ages?" For Spinal Cord Injury, it sure is

Eric Texley

[FellowHawkeye]

You just want to empty the bladder? Try a simple vibrator. That would surely stimulate the muscle and nerves.

Jan

[antiquity]

E. Tex. I share your frustration there and believe that B/B control should be the first goal for curative therapies as well.

Jan, what kind of vibrator?

[annettekaip]

My son has been using e-stim with much success, but now is developing contact dermatitis. Does anybody now about a barrier cream that has been used successfully?

[annettekaip]

my son has been using e-stim very successfuly, but now has contact dermatitis from the electrodes. Is anybody out there using a barrier cream that works well?

[gcblarsen]

Dr. Wise,

My daughter is T-12 (functional level L-1). She isn't getting very little or no muscle contractions using FES or with our e-stim unit. I was told it is still benefical as it sends the electric current to stimulant the cord. Her poor legs are wasting away even though we are doing other therapies.

Could you explain why she wouldn't be getting contractions when others at her level of injury do. I got the idea that she injuried her reflex or that her injury is lower than her reflex. I don't really understand.

[chesmo]

Does FES build muscle when the user is complete ie no control or return? My wifes doctor says FES is a waste as it won't build muscle. He prefers just a motobike for range of motion. Does anyone have info on the hand and leg crank bike Wise was referring to?

[Leo]

Does FES build muscle when the user is complete ie no control or return? My wifes doctor says FES is a waste as it won't build muscle. He prefers just a motobike for range of motion. Does anyone have info on the hand and leg crank bike Wise was referring to?

As I understand it your doctor is wrong. Sue Maus is c5 some thing and complete and loves it.

I have another friend who's a para and with the FES his leg muscles are bulkier than before injury.

So maybe do more research, good luck.

BTW. If I could get one I'd go for it, c4/5 complete

[bhukari]

Check out these links. My sister has one of the Giger units, purchased used. She's only used it a few times, so no good beta--positive or negative--yet. She does like the "feeling" of using it & it seems to relax her...the first three times she tried it (right before bed) she was falling asleep in mid-pedal, which is very unusual for her.
I spoke with several PT's before buying it...heard only positive feedback. The theory seems sound...remains to be seen if theory manifests into results.

http://www.gigermd.com/md_e.htm

http://www.centerforscirecovery.org/?id=207&sid=3

[tarheelandy]

I use the FES bike and my legs look almost the same as before. I don't expect them to be just like before.