Artificial Organs
32(8):577–580, Wiley Periodicals, Inc.
© 2008, Copyright the Author
Journal compilation © 2008, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.
Clinical Practice of Functional Electrical Stimulation:
From “Yesterday” to “Today”
Milan R. Dimitrijevic
Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA; Foundation for
Movement Recovery, Oslo, Norway; and Ludwig Boltzmann Institute of Electrical Stimulation and Physical Rehabilitation,
Vienna, Austria
Abstract: Functional electrical stimulation (FES) is an
accepted treatment method for paresis or paralysis after
spinal cord and head injury as well as stroke and other
neurological upper motor neuron disorders. At the begin-
ning, FES worked like an electrophysiological brace for the
correction of drop foot of patients after a stroke. When
analyzing early accomplishments, it becomes evident that
FES was influenced rather by technological and biomedical
engineering development than by contemporary knowl-
edge on neurocontrol of movement in individuals with
upper motor neuron paralysis. Nevertheless, with better
understanding of pathophysiology of spasticity and neuro-
control of impaired movement, FES advanced from an
electrophysiological brace to a treatment modality for the
improvement of muscle control, neuroaugmentation of
residual movements, and supportive procedure for “spon-
taneous recovery” of motor control. In the present article
we shall illustrate barriers which delayed FES to be applied
FUNCTIONAL ELECTRICAL STIMULATION
(FES) OF “YESTERDAY”
The beginning of “Yesterday’s” FES was character-
ized by the effort to obtain an immediate functional
muscle movement in response to electrical stimu-
lation. It started with Giaimo as early as in 1951, by
the use of the so-called “faradic current” built from
coils and relays, even before portable transistorized
stimulators became available (1). The pioneering
doi:10.1111/j.1525-1594.2008.00604.x
Received May 2008.
Address correspondence and reprint requests to Dr. Milan R.
Dimitrijevic, Department of Physical Medicine and Rehabilita-
tion, Baylor College of Medicine, 6550, Houston, TX 77030, USA.
E-mail: naissus.milan@gmail.com
Presented in part at the 9th Vienna International Workshop on
Functional Electrical Stimulation held on September 19–22, 2007
in Krems, Austria.
577
in clinical practice of neuron rehabilitation from “Yester-
day” to “Today.” We shall discuss the importance to apply
FES early after the onset of neurological conditions to
prevent disuse of noninjured portions of the CNS. More-
over, FES can play a significant role in the supporting pro-
cesses of neuroplasticity in the subacute phase of upper
motor neuron dysfunction. Therefore, the electrophy-
siological brace of “Yesterday” provides “Today” a cor-
rection of missing neuromuscular function. At the same
time, it is an active external device for the correction of
motor deficits interacting with the somatosensory-motor
integration. Thus, “Yesterday” and “Today” of the same
technological approach can be very different, thanks to a
different understanding and assessment of “external” and
“internal” components of human motor control. Key
Words: Functional electrical stimulation clinical practice—
Upper motor neuron disorder—Human motor control.
work of the functional electrical therapy, later
renamed FES for the correction of upper motor
neuron motor deficits, was done by Wladimir T.
Liberson. He described in his autobiography how
critical for his pioneering work was his neurophy-
siological education gained from leading Russian
neuroscientists, and the opportunity to work with dis-
tinguished French neuroscientists in the field of elec-
trical stimulation (2). Additional factors were the
technological development of transistorized stimula-
tors and the availability of portable stimulators for
functional electrical stimulation in 1960.
Let us quote a description by Liberson of his dis-
covery of peroneal FES in 1960 from his autobio-
graphy: “With the help of Dr. Franklin Offner, a
manufacturer of EEG equipment, I was able to dem-
onstrate my idea on limited scale. I took for a model
the drop foot of a hemiplegic patient. I placed a
switch in the shoe. Each time the patient would lift his
578 M.R. DIMITRIJEVIC
leg from the floor a current would be initiated and
would stimulate the tibialis anticus and peroneal
muscles. The tibialis anticus elicits dorsiflexion of the
foot and its shoes. Thus a closed loop was created and
an automatic correction of the hemiplegic gait was
achieved (3).”
Before Liberson discovered “FES for correction
of the drop foot,” he worked in the laboratory of
Nikolai Wedensky (1852–1922), a Russian neuro-
physiologist at the end of the 19th century. He was
introduced to electrodiagnosis by Lapicque and
Bourguignon while working in Salpêtrière, Paris.
Liberson’s educational and research path and his
physician practice supported by technological elec-
tronic development clearly illustrates the develop-
ment of “Yesterday’s” FES toward new solutions for
medical problems by integrating contemporary neu-
rophysiology and technology. Liberson developed
consequently other systems for the improvement of
locomotion: an electromechanical brace for the
stimulation of soleus and gluteus maximus activities
in 1966 and “reflex walking” in paraplegic patients in
1973 (2).
Let us bring to our attention Dr. Liberson’s find-
ing following his work with an “electromechanical
brace” in the 1960s in patients with drop foot after
stroke—that some of them walked with an improved
gait, even hours after cessation of stimulation (2,3).
From 1963 onwards, new groups appeared in addi-
tion to Liberson’s pioneering work on clinical appli-
cation of FES. These groups were oriented more
toward medical and biological engineering, technol-
ogy, and cybernetics than toward neurophysiology. In
their publications we can read about (i) information
processing in the central nervous system; (ii) propor-
tionally controlled FES of the hand; (iii) information
content of myo-control signals for orthotic and pros-
thetic systems; (iv) indirect and direct effects of elec-
trical currents on pathological neuromuscular
systems; (v) the effect of stimulation parameters on
the modification of spinal spasticity; (vi) rigidity in
the Parkinsonism characteristics and influences of
passive exercise and electrical stimulation; (vii)
improved motor response due to electrical simula-
tion of the denervated tibialis anterior muscle in
humans; and (viii) muscle force recovery after con-
tinuous direct current stimulation of a crushed nerve.
Thus, FES research and clinical practice interests
moved on to a variety of dysfunctions of upper and
lower motor neurons from the previous restricted
interests in the development of functional move-
ments by electrical stimulation of the corresponding
nerve trunk of paralyzed or paretic muscle groups
(4). However, in this period from 1963 to 1999,
Artif Organs, Vol. 32, No. 8, 2008
further technological and clinical improvements of
single and multisite FES systems for upper and lower
limbs with surface and implanted electrodes contin-
ued to be the area of ongoing projects in Vienna,
Ljubljana, Cleveland, and some less defined but
active laboratories in Sweden, Poland, the USA, The
Netherlands, Yugoslavia, and Denmark.
This was a brief outline of “Yesterday’s” FES with
its characteristic origin in the early development of
electrophysiology at the end of the 19th century and
the beginning of the 20th century, making FES
become a clinical reality, thanks to new technologies
of transistorized stimulators. After this success, FES
advanced to a more sophisticated clinical system
together with studies of upper and lower motor
neuron properties of trophic and increased excitabil-
ity conditions in the 1960s and 1970s. Let us conclude
where we have been with “Yesterday’s” FES and
what we have been expecting from “Today’s” FES by
using another quotation of Liberson from his autobi-
ography:“Whatever will be accomplished now will be
little in comparison with the progress to be expected
in the future. So my younger colleagues will have a
great deal to expect during their scientific lifetime.”
FES OF “TODAY”
Where are we today and how different is the
progress achieved in comparison to FES from “Yes-
terday?” When reviewing programs of recent inter-
national FES congresses, symposia, and workshops,
common topics are the following: (i) denervated
muscles; (ii) paraplegia, upper motor neuron lesion;
(iii) FES cycling; (iv) implant technology and appli-
cation; (v) command and feedback signals, stimula-
tion parameters; (vi) stimulation and closed-loop
control; (vii) drop foot, functional restoration; (viii)
drop foot stimulators; and (ix) upper extremity, func-
tional restoration. All these examples are taken from
the Vienna FES workshop series (5). In a way, we are
“Today” giving priority to new developments of FES
systems to solve problems of the FES clinical practice
from “Yesterday” and expend the clinical practice of
FES.
“Despite the high promise of functional electro-
therapy and functional electro-stimulation for
improving walking of hemiplegic and paraplegic
people it is still unusual to see plegic patients walking
around with stimulators instead of walkers and other
mechanical prosthesis, even in the nineties.” This
observation of Liberson is still holding in the first
decennium of the 21st century.
What shall we do “Today” to bring FES closer to
the clinical practice of the so-called “electrophysi-
 CLINICAL PRACTICE OF FES
ological bracing” of impaired movement? I think we
are already on the right track by the beginning of
modest industrial interests for new technological
systems and by teaching professionals involved in the
rehabilitation medicine programs. Nevertheless, we
should not forget that the majority of users of FES
systems expect ultimately an improvement of their
control and force of otherwise weak movements, and
after some time of regular use of electrophysiological
bracing they replace them with classical mechanical
braces. Therefore, we shall move the application of
FES clinical protocols to the early onset, early phase
of upper motor neuron disorders (as well as in some
conditions of the lower motor neuron) in order to
prevent effects of disuse and to support neuroplastic-
ity and recovery processes.
Finally, we should ask ourselves, where neuro-
physiology of the electrical stimulation is now at the
beginning of the 21st century in comparison to the
one at the end of the 19th century, which contributed
so significantly to the early development of FES clini-
cal practice, the FES of “Yesterday?” In this first
decennium of the 21st century, the knowledge about
the generation of movements and control, the motor
control of volitional, automatic, and reflex activity
becomes a part of our practice of FES “Today.”
Advancements in the conduction and processing of
nervous system mechanisms are available not only
in scientific publications but also in laboratories for
studies of motor control in humans by application of
noninvasive neurophysiological methods.
It might be of interest to show two documents, one
from the middle of the 20th century, and the other
from the first decade of the 21st century.
FIG. 1. Schematic drawing showing the principle of the so-called
H reflex, that is, the reflex response of the muscle following
electrical stimulation of sensory nerve fibers (6).
579
FIG. 2. Effect of H reflex up-conditioning on the step-cycle. (A)
Right and left soleus bursts (rectified electromyographic activity)
from an HRup rat (rat exposed to H reflex up-conditioning proto-
col) for the first (i.e., before up-conditioning) treadmill session and
the second (i.e., after up-conditioning) session. (B) Time from
right to left soleus burst onset in control and H reflex
up-conditioned rats. Adapted from Chen et al. (7).
In my article, “Physiological Mechanisms in the
Electrical Control of Paralyzed Extremities” (6), I
used Fig. 1 showing the principle of H reflexes. At
that time, I asked why we do not add also sensory
nerve fibers to motor nerve stimulation in order to
develop electrical stimulation of movement through
the activation of reflex centers and processing mecha-
nisms of spinal cord and brain structures (6).
The other document is from Dr. Jonathan R.
Wolpaw’s group from the Laboratory of Nervous
System Disorders, Wadsworth Center, New York
State, Albany, NY, USA, on “Operant Conditioning
of H-Reflex Can Correct a Locomotor Abnormality
after Spinal Cord Injury in Rats” (7) (Fig. 2). Dr.
Wolpaw and his colleagues conclude, on the basis of
their studies in spinal cord injured rats, that selected
reflex conditioning protocols might improve func-
tions also in people with partial spinal cord injuries.
Recently, during the January 2008 meeting of the
New York Academy of Sciences, “New York State
Spinal Cord Injury Research Program Symposium:
From the Bench to the Bedside, the Latest Discover-
ies in SCI Research” (8), Wolpaw and his group dem-
onstrated first results on ambulatory spinal cord
injured patients.
Shall we ask why the pace of advancements of
clinical practice of FES from “Yesterday” to “Today”
is so slow in the past 50 years? Is it because the
development depends on so many different pro-
fessions and expertise and we did not learn how
to integrate necessary knowledge, sciences, and
technologies toward one common achievable goal?
Acknowledgments: The author would like to
acknowledge the support of the Foundation for
Artif Organs, Vol. 32, No. 8, 2008
580 M.R. DIMITRIJEVIC
Movement Recovery, Oslo, Norway, and the Wings
for Life Spinal Cord Research Foundation, Salzburg,
Austria.
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