The Potential Benefits of Functional Electrical Stimulation for Motor Return with Patients with Incomplete Spinal Cord Injury

Lukas Sand, SPT, MS, ATC

Background:

During one of my PT rotations, my clinical instructor (CI) and I were working with a patient with an incomplete spinal cord injury who demonstrated significant weakness in the dorsiflexor muscle group and knee extensor muscle group in his right lower extremity. We had tried a variety of treatment strategies to address this weakness, but nothing seemed to affect outcomes or manual muscle test scores. So, I began to wonder if Functional Electrical Stimulation (FES) would be an effective tool for improving these scores. I found research that supported its use with patients with incomplete spinal cord injury, so my CI and I decided to implement it into that patient’s treatment plan. After consistent application over a week and a half, the patient’s outcome measures improved. Surprisingly, it was a treatment tool that not many clinicians used at that clinical site. So, I figured it could be something that I should find more research for and contribute to the treatment team at some point in the future. As fall approached, I decided to focus my critically appraised topic (CAT) on whether or not incorporating FES into gait training could improve outcomes more than standard gait training. When completing my CAT, I found mixed results regarding the potential results FES can have on outcomes. In the process, I also became curious and wanted to investigate whether the use of FES during the acute stage of recovery was as effective as its use with a chronic condition. So, I decided that this would be a good capstone topic. Furthermore, I figured I should share my findings with future students that may be unaware of this treatment strategy. Considering I had clinical experience using FES when working with a patient in the acute stage of recovery, and that patient was willing to participate in the project, there was room for potential clinical application of my findings.

Project Overview and Purpose:

This past year, it is estimated that there were 17,700 new cases of patients having a spinal cord injury.¹ Of these, 47.2% initially present as incomplete tetraplegia, and 20.4% present as incomplete paraplegia.¹ Given these statistics, it is important to be aware of the different gait training, transfer training, and strength training strategies that can be used to treat patients with incomplete spinal cord injury. Although there are many options, FES is a treatment tool that may be able to improve strength scores and some gait-related outcomes.^2–5 However, there are certain precautions and contraindications to consider when applying it.⁶ A few aims of the project were to identify those safety considerations, describe how to use FES properly, and show examples of what exercises can be performed with it. It also explains that FES can be applied when working with patients in the acute or chronic stage of recovery, with patients in the acute stage seeing better improvements than those in the chronic stage.⁷ Finally, the VoiceThread module incorporates a case study, research, multiple pictures and videos, and clinically oriented questions. Therefore, the purpose of this multimodal approach is to foster classroom learning and clinical reasoning with regards to the application of FES with patients with incomplete spinal cord injury.

Statement of Need:

This project was created to provide second or third year physical therapy students with information regarding when it is appropriate to use this treatment when working with patients with incomplete spinal cord injury. In Neuro II, we learn about incomplete spinal cord injuries and are provided with a few different ways to treat patients that have them. However, there is little information shared on implementation of FES when treating patients with this type of injury, and not many case examples. Also, on my outpatient and inpatient rehabilitation clinical rotations, there were not many clinicians that were aware of the use of FES when working with patients with incomplete spinal cord injury. This suggests that this module could be shared with students, and could also be shared with clinicians who are unaware of the clinical implications of FES when working with patients with this injury.

Products:

The VoiceThread in this project includes an educational component, a case study, and videos of patients participating in treatment with FES. Together, these can allow students to see this treatment being used in a clinical setting, and understand why it is being used. In addition, the attached evidence table and literature review will provide students or clinicians with a comprehensive educational module that describes the evidence addressing the potential effects FES has on outcome measures. This module will help students learn when to apply FES, how to apply it, and what functional activities it can facilitate. Furthermore, the practice questions written in the supplemental VoiceThread can promote clinical reasoning with the information that is learned in the main VoiceThread.

Evaluation:

My primary method of evaluation and feedback came from communication with my committee members, Prue Plummer, PT, PhD, Vicki Mercer, PT, PhD, and Mike Stine, PT, DPT. Dr. Plummer was my capstone advisor and offered initial feedback at the beginning of the semester to help guide the success of the project. Dr. Mercer provided initial feedback that would help me mold the VoiceThread and literature review to ensure that it fit the curriculum for the Neuro II class that she co-instructs. Throughout the remainder of the semester, all three members provide constructive feedback on my products and were able to answer any questions that I had throughout the semester.

Once I had received feedback from all committee members at the final update, and modified my products accordingly, I presented the products to students during a Lunch and Learn to receive their feedback on how I could modify the module to ensure that they are able to effectively learn the content. All of their feedback was positive and constructive, and the only recommendation I received from a few students was to include more videos of patient cases. Unfortunately, I am unable to add new videos at this time, but that is an idea to incorporate into future versions of the presentation. Attached is the feedback form they filled out after the presentation. They also suggested that I make slight changes to some of the practice questions in the supplemental VoiceThread to make them easier to understand.

Self-Reflection:

Completing this capstone was a rewarding process. I invested a significant amount of time into it because of my personal interest in the topic and am satisfied with my ability to provide a thorough product for educating students on the use of FES. Although I found limited research on the topic in the fall, I was able to find a substantial amount of evidence on the use of FES with patients with incomplete spinal cord injury this semester due to broadening my search parameters. With feedback from of my committee, I was able to synthesize the information I found last fall and this spring in the forms of a presentation, evidence table, and literature review.

In another opportunity to improve the educational capacity of my capstone, I was able to take video footage of a patient working with FES in the clinic and incorporate it with prior footage of a former patient I had seen that had benefitted from FES. After receiving feedback from fellow students, I wish I had the opportunity to incorporate more video footage of patients using FES, however, it wasn’t a possibility with the timeframe, unfortunately.

Overall, I am pleased with the work I put in. All of this information will be beneficial for future students that are working with patients that are appropriate for FES. Most importantly, completing this capstone helped me become more knowledgeable in the application of this treatment modality, especially when working with patients with incomplete spinal cord injury.

Acknowledgements:

I would like to thank my capstone advisor, Prue Plummer, PT, PhD. Dr. Plummer was very helpful in advising me on how set up my capstone, answering all of my questions, and providing feedback to ensure my presentation would be appropriate for future students.

I would like to thank my committee members Vicki Mercer, PT, PhD, and Mike Stine, PT, DPT. Dr. Mercer provided me with insight on how to begin filming patients at the CRC, gave important feedback on all of my capstone materials, and helped me mold my presentation to foster effective learning.

Mike Stine was an outstanding CI who was instrumental in piquing my initial interest in FES. He was supportive of my decision to use it when treating a patient, and offered feedback on different ways to incorporate it into treatment. He was also able to provide feedback on this capstone to help it become appropriate for potential use with clinicians.

I would like to thank Edelle Field-Fote, PT, PhD, FAPTA for providing invaluable insight to this project. Dr. Field-Fote discussed her past research with me regarding the combination of FES with body weight supported treadmill training vs. over ground gait training with patients with incomplete spinal cord injury. This substantially helped with the practical and research-based components of my capstone.

I would like to thank Karen McCulloch, PT, PhD, NCS, FAPTA for assisting me with the proper way to incorporate video into my presentation and for sharing the VoiceThreads on the our capstone site on how to construct an effective PowerPoint.

Finally, I would like to thank Audrey Osinski, PT, DPT for assisting with filming during her treatment sessions.

 

References

1. Spinal Cord Injury Facts and Figures at a Glance. National Spinal Cord Injury Statistical Center. 2018. Available at: https://www.nscisc.uab.edu/Public/Facts%20and%20Figures%20-%202018.pdf. Accessed April 17, 2019.
2. Morawietz C, Moffat F. Effects of locomotor training after incomplete spinal cord injury: a systematic review. Arch. Phys. Med. Rehabil. 2013;94(11):2297-2308. doi:10.1016/j.apmr.2013.06.023.
3. Zhou R, Alvarado L, Ogilvie R, Chong SL, Shaw O, Mushahwar VK. Non-gait-specific intervention for the rehabilitation of walking after SCI: role of the arms. J. Neurophysiol. 2018;119(6):2194-2211. doi:10.1152/jn.00569.2017.
4. Mehrholz J, Kugler J, Pohl M. Locomotor training for walking after spinal cord injury. Cochrane Database Syst. Rev. 2012;11:CD006676. doi:10.1002/14651858.CD006676.pub3.
5. Field-Fote EC, Lindley SD, Sherman AL. Locomotor training approaches for individuals with spinal cord injury: a preliminary report of walking-related outcomes. J Neurol Phys Ther 2005;29(3):127-137.
6. Electrophysical Agents – Contraindications And Precautions: An Evidence-Based Approach To Clinical Decision Making In Physical Therapy. Physiother. Can. 2010;62(5):1-80. doi:10.3138/ptc.62.5.
7. Lam T, Noonan VK, Eng JJ, SCIRE Research Team. A systematic review of functional ambulation outcome measures in spinal cord injury. Spinal Cord 2008;46(4):246-254. doi:10.1038/sj.sc.3102134.