FES

(Functional Electrical Stimulation )

 Introduction
Externally powered orthotics and prostheses interface directly or
indirectly with the human neuromuscular system

Two approaches for the restoration of movements in humans with

paralysis are

1. Functional Electrical Stimulation (FES) or Functional Neuromuscular

Stimulation (FNS)

2. Hybrid Assistive System (HAS)

 Functional Electrical Stimulation (FES) or Functional
Neuromuscular Stimulation (FNS)

• It is a electrical stimulation of neuromuscular structures dedicated to

restore motor functions.
• It is a technique that uses electrical currents to activate nerves innervating
extremities affected by paralysis resulting from
– spinal cord injury,
– head injury
– stroke.

• The basic phenomenon of stimulation is a contraction of muscle due to the

controlled delivery of electric charge to neuromuscular structures.

• Hybrid Assistive System (HAS) is a combined usage of an FES and a

mechanical orthotics.
• FES components include an
– electronic stimulator,
– a feedback or control unit,
– leads, and electrodes
• Electrical stimulators can have one or multiple
channels (outputs), which are activated in unison or
in sequence to produce desired movements
 FES
• FES system have two Category of control mechanism
– Subject control
• joysticks,
• buttons,
• switches,
• joint positions sensors,
• heel switches,
• sip-and-puff devices,
• shoulder control,
• respiratory control,
• EMG electrodes,
• voice activation.
– Therapist control
• Switches
• Dials
• Subject-controlled FES can be open- or closed loop.
• In open-loop FES (Feed Forward), the electrical stimulator controls the
output.
• Closed-loop FES (Feed backward) employs joint or muscle position
sensors to facilitate greater responsiveness to muscle fatigue, or to
irregularities in the environment.

Block diagram of FES System

Schematic drawing of a functional electrical stimulation (FES) systems main components
and sequence of action (reprinted with permission from Downey and Darling's
Physiological Basis of Rehabilitation Medicine, Butterworth Heinemann 2001).
There are two main types of control systems:
•open-looped (or feed forward)
– It applies preprogrammed stimulation patterns to the target muscles and it does
not receive information about the actual state of the system.

– neither external (forces, obstacles) nor internal (muscle fatigue, spasms)

disturbances can be compensated.

•closed-looped control (or feedback)

– actual state of the system, for example forces or joint angles, is continuously
recorded by sensors, thus providing the corresponding feedback to the
controller.
– Based on the measured signals, the controller determines the adequate
stimulation pattern to fulfill the desired movement and reject disturbances such
as external forces, muscle fatigue and spasticity.
FES systems can restore
– Goal-oriented (hand and arm) movements
– Cyclic (walking and standing) movements
 Electrodes

In external system,
•Control unit and the stimulator are outside the body.
•Surface electrodes are attached to the skin above the muscle or
the peripheral nerve
In Percutaneous systems
•wire electrodes pierce the skin near the motor point of the
muscle.
In implanted system,
•the stimulator and the electrodes are inside the body.
 Restoration of Hand Functions

• Implantable electrodes can be inserted into

– the muscle (epimysial electrode),
– the nerve (epineural electrode)
– or surround the nerve (nerve cuff electrode).
• Implanted electrodes supply provide stronger, more
specific and more reliable responses.
Comparison between different types of electrodes
 Type of electrode Advantages Disadvantages
placement
Specific and selective
Implantable stimulation Cosmosis, Invasive
Convenience, No external
switches or body mounted
sensors
More selective than surface
Percutaneous electrodes , Easier to place Prone to infection
than implantable electrodes
• Only surface muscles
Surface Non-invasive, More used can be stimulated,
• difficulty positioning the
electrode accurately,
• Not practical and
convenient if number of
channels is large
 Handmaster NMS-1

• It is a neuroprosthesis for grasping with three surface

stimulation channels .
• It comprises a hinged wrist-forearm splint with a stimulator
box electrically connected to the splint via a cable.
• Electrodes inside the splint deliver stimulus to key muscle
points necessary for movement.
• The system is used to generate grasping function in tetraplegic
and stroke subjects
Handmaster NMS-1
 Handmaster NMS-1
This has three channels.
•First channel is used to stimulate the extensor
digitorum communis m. at the volar side of the forearm.
•The second channel stimulates the exor digitorum
profundus muscle. and the exor digitorum
supericialis m.

•The third stimulation channel generates the thumb

opposition
 Handmaster NMS-1
• It is controlled with a push button that triggers the hand opening and
closing functions.
• Two switches are connected in parallel, one mounted at the stimulator box
and the other at the plastic orthosis that houses the electrodes.
• By pressing the push button the stimulator turns on and after a short time
delay extends the subject’s fingers for a short period of time followed by
the thumb and finger flexion.
• The fingers and thumb remain flexed until the subject presses the push
button for the second time.
• The consecutive activation of the push button generates finger extension
that lasts a predetermined period of time followed by switching off of the
stimulator.
 Handmaster NMS-1

• An additional sliding resistor, which is built into the control box, allows
the subject to regulate the intensity of the thumb opposition stimulation.
• This feature helps the subject to adjust the grasp to the size and the shape
of the object he/she wants to grasp.
• The subject can increase or decrease the grasping force using two
additional push buttons on the control box.
• One of the advantages of the Handmaster is that it is easy to don and doff.
• One of the disadvantages of the Handmaster is that it does not provide the
user with sufficient flexibility to vary the position of the stimulation
electrodes.
• Another limitation of the Handmaster is the subject cannot perform full
supination when he/she wears the system.
 Bionic Glove

• It is a fingerless flexible garment with a built-in stimulator or

electrode contacts.
• It is designed to rehabilitate hand muscles in

– C5-6 spinal-cord-injured people and for

– persons with tetraplegia and a
– small percentage of hemiplegic people who have some
active wrist movement.
Bionic Glove

Bionic glove for restoration of

grasping in persons with
tetraplegia. The upper panel
shows electrodes, stimulator,
and the glove, while the bottom
panel shows the glove
mounted and ready for use.
 Bionic Glove

• The user places self-adhesive electrodes over certain muscles

and puts the glove on over the electrodes.
• Tightening the glove causes internal panels to make electrical
contact with metal studs on the backs of the electrodes.
• A sensor is used to detect wrist movement, and trigger
opening and closing of the hand.
• A microcomputer is built into the battery operated stimulation
unit, which detects movements and controls three channels to
stimulate thumb extension and flexion, and finger flexors.
 FES implantation grasping devices

• FES implantation grasping devices include the following

1. Implantable Functional Neuromuscular Stimulator or

Freehand System
2. Myoelectrically-Controlled System
3. Case Western Reserve University (CWRU) fully implantable
system
4. STIMuGRIP System
 Implantable Functional Neuromuscular Stimulator or
Freehand System

• It was implanted in individuals with C4-C5 injuries

• a joystick-like device placed on the left shoulder is controlled through
shoulder movement, which, in turn, sends electrical signals to a nearby
external controller.
• controller then sends signals to a transmitting coil which is relayed to a
receiver-stimulator that has been implanted near the right shoulder.
• Finally, movement-generating impulse signals are sent to eight electrodes
implanted on the muscles of the right arm and hand that are used for
grasping.
• To further augment hand function, various surgical procedures are often
carried out in conjunction with the implantation of components, such as
tendon transfers and joint fusions.
Implantable Functional Neuromuscular Stimulator or Freehand
System
First-generation
implantable FES
system for upper
limbs (reprinted
with permission
from Keith MW,
Peckham PH,
Thrope GB et al.
(1988). Functional
neuromuscular
stimulation,
Neuroprosthesis
for the tetraplegic
hand. Clin
Orthopaedics 233:
25–33).
 Myoelectrically-Controlled System
• powerful, less cumbersome, second-generation device has
been developed .
• This device eliminates the need to wear a shoulder joystick as
required with the Freehand.
• With 12 stimulation electrodes, this system can activate 12
muscles compared , allowing more refined hand function,
forearm rotational movement, and elbow extension.
• In addition to the stimulation electrodes, two recording
electrodes are implanted near muscles in which the individual
can still voluntarily control.
 Myoelectrically-Controlled System
• one recording electrode is implanted on the muscle furthest
down the arm that still has some voluntary control, and the other
is implanted in the neck or shoulder region.
• When the individual contracts the targeted voluntary muscles, the
recording electrodes pick up the electrical signals (i.e.,
myoelectrical) the muscles generate and transmit them out of the
body to an external control unit.
• This unit transforms these signals and relays them back into the
body to the 12 electrodes that stimulate the desired hand and arm
function.
• The voluntary movement of controllable muscles send signals
through the device that stimulate paralysis-affected muscles.
Myoelectrically-Controlled System
 STIMuGRIP System

• It restores control of wrist extension and hand

opening actions to the following users
– Stroke,
– Spinal Cord Injury,
– Cerebral Palsy,
– Multiple Sclerosis.
• The system comprises two key parts
– Implant
– External Controller (worn over the site of the implant)
 STIMuGRIP System
• The external controller is positioned over the site of the
implant.
• This implant comprises epimysial electrodes, Cooper cables
and a receiver-stimulator.
• The user selects one of the pre-programmed stimulation
routines or the exercise program.
• The exercise program cycles are rest, opening the hand,
closing the hand and relaxing the wrist.
• The External Controller transmits power and control signals,
when triggered, through the skin, to the Implant Receiver.
 STIMuGRIP System

• The Implant Receiver converts the received signals

into stimulation impulses which are delivered to the
nerves/muscles at the electrodes, thereby causing the
muscle to contract.
• The programs can use many different triggers to start
and stop the stimulation giving a wide range of
activities that can be undertaken.
STIMuGRIP System
 RESTORATION OF STANDING AND
WALKING

• FES is applied for restoration of gait.

• FES systems can be single channel or multi-channel
stimulation.
• The simplest one, from a technical point, is a single-
channel stimulation system.
Single-channel stimulation system
• is applicable to stroke patients
• special group of patients with incomplete spinal cord
injury who can perform limited walking with assistance of
the upper extremities but the walking is impaired or
modified.
•The FES in these humans is used to activate a single
muscle group.
• The stimulation is applied to ankle dorsiflexors so the
“foot-drop” can be eliminated.
• Single channel correcting foot-drop is now a regular
clinical treatment in some rehabilitation institutions
Multichannel FES system
• with at least four channels;
• oriented to patients with complete spinal cord injury
• stimulation of the quadriceps muscle locks the knee during
standing. Swing phase – by movement of the upper part of the
body and using of rolling walker;
•hand- or foot switches are used for flexion-extension alternation.
•Stimulation of quadriceps stimulation causes leg flexion,
peroneal nerve causes hip flexion and gluteal muscle for trunk
stability.
•For a patient with a complete motor injury of lower extremities
and preserved balance and upper body motor control a
multichannel system with a minimum of four channels of FES is
required for ambulation.
Parastep Functional Electrical Stimulation System
• It is a microcomputer controlled functional neuromuscular
stimulation (FNS) system that enables standing and walking.
• Users hold on to a front wheeled walker fitted with a keypad
wired to a microprocessor worn on the belt.
• Surface electrodes are placed on the quadriceps, the gluteal
muscles and the peroneal nerve.
•The user initiates stepping by firing muscles in the proper
sequence.
• Stimulation of quadriceps causes a contraction that results in
knee flexion, enables the user to stand.
• Stimulation of peroneal nerve initiates a contraction to flex the
hip, knee and ankle, this lifts the foot off the floor as quadriceps
stimulation then cycles on to extend the knee for taking a step.
• Hand or foot switches can provide the flexion–extension
alternation needed for a slow forward or backward progression.
• Sufficient arm strength must be available to provide balance in
parallel bars (clinical application), and with a rolling walker or
crutches (daily use of FES).
Parastep system
factors that limit the effectiveness of FES systems are
•muscle fatigue,
• reduced joint torques generated through FES in comparison to CNS
activated torques in healthy subjects,
• modified reflex activities,
•spasticity, (there is altered skeletal muscle performance and a lack
of inhibition from the CNS results in excessive contraction of the
muscles)
• joint contractures (Stiffness of the joints that prevents full
extension),
•osteoporosis,
•stress fractures .