Rehabilitation Matters

Young Transverse Myelitis Client Responds Well to FES Cycling

These notes refer to very pleasing progress with an FES Cycling Client - a 4 year old little boy with a neurological condition affecting motor function in his lower limbs.  It has a similar aetiology as transverse myelitis (TM). TM is a rare disease of the central nervous system involving inflammation of the spinal cord. This inflammation causes swelling which can block the nerve impulses that travel along the spinal cord.  It can also cause damage to the myelin sheath surrounding the axons in the spinal cord.

With this client not all muscle groups are affected and the weakest measles are his glutes and hamstrings.  He is able to mobilise independently holding onto furniture or walls for support. He has some spasms in his quads but are not problematic, sensory function is preserved.  The Client was supplied a RehaMove FES Cycling system, based on the Gracile model which is appropriately sized for children. The text here was originally produced by Andy Galbraith and edited by me.

Initial Setup visit
Starting Parameters: for RehaMove Gracile (Paediatric version of the RehaMove FES Cycling System)

• Motomed bike set to “direct” from “motivation”
• Initial gear start-up set to 1
• Passive cycling speed - default set at 20rpm
• Torque power set to 10

Stimulation Parameters:
All programmes set at 5mins warm up - 20mins stimulation - 5mins cool down
As client has preserved sensory function we set the stimulation to constant.

Programme 1 Ramp 5 Freq 20Hz Pulse width 150us (increased to 160us)
Involving quads and hamstrings of both legs
Ch1 - 35mA, Ch2 - 35mA, Ch5 - 35mA, Ch6 - 35mA

Programme 2 Ramp 5 Freq 20Hz Pulse width 150us (decreased to 130us)
Involving quads, hamstrings and gluteal muscles of both legs
Ch1 - 35mA, Ch2 - 35mA, Ch3 - 30mA, Ch5 - 35mA, Ch6 - 35mA, Ch7 - 30mA

Programme 3 Ramp 5 Freq 20Hz Pulse width 150us (decreased to 130us)
Involving quads, hamstrings, pretibial muscles and gastrocs of both legs
Ch1 - 35mA, Ch2 - 35mA, Ch3 - 25mA, Ch4 - 25mA, Ch5 - 35mA, Ch6 - 35mA, Ch7 - 20mA, Ch8 - 20mA

On muscle testing: all muscles reacted to stimulation, strongest contractions being felt in the quads, Client gave very good feedback for his age on the testing and we were also able to see contractions in the glutes, pre tibial and calf muscles, we reduced the current levels in response to his feedback being careful not to associate any discomfort with the stimulation.

Of course client attention span was limited, a diversionary video was playing which helped. When the client was paying attention and trying he was actively cycling well, this was limited to short bursts of approx. 15 to 20 seconds before "finding nemo" would be more important.

We belived that client will respond really well to the stimulation providing it is kept at low levels given his preserved sensation.  Reviewing in 6 weeks time, quick start with web support and fitness principles literature was left with mother.

Notes at FES Cycling 6 week follow up
Clients mother advised that Client has been using the FES Gracile system fairly regularly.  Apart from a family holiday for two weeks in August they have used the system for 20mins every other day, mostly on programmes 2 and 3. Client enjoys the sessions (providing he can watch TV) and remains motivated to use it.  It is believed the client has full sensation in his lower limbs and he has said the stimulation has been too painful from time to time, Mother has been reducing the Pulse width (down to 130us) to accommodate this, but this is not every time. At present the client does not tolerate any other physio intervention.

Checked Starting Parameters:

• Initial gear start-up 1
• Passive cycling speed - default at 20rpm
• Torque power at 10

Stimulation Parameters: at 6 weeks
All programmes set at 5mins warm up - 20mins stimulation - 5mins cool down, Mother feels 20mins is probably the maximum length of time the Client will tolerate the sessions at present.

As the Client has preserved sensory function we set the stimulation to constant and discussed with Mother the possibility of changing to adaptive stimulation protocols at a later stage. We have reduced the Frequency by 5Hz and planned to slightly increase the current and pulse widths to make the stimulation more tolerable.  The majority of the session was teaching Mother how to make the changes to the stimulator and reviewed position advice.

Programme 1 Ramp 5 Freq 15Hz Pulse width 150us
Ch1 - 35mA, Ch2 - 35mA, Ch5 - 35mA, Ch6 - 35mA

Programme 2 Ramp 5 Freq 15Hz Pulse width 150us
Ch1 - 35mA, Ch2 - 35mA, Ch3 - 30mA, Ch5 - 35mA, Ch6 - 35mA, Ch7 - 30mA

Programme 3 Ramp 5 Freq 15Hz Pulse width 150us
Ch1 - 35mA, Ch2 - 35mA, Ch3 - 25mA, Ch4 - 25mA, Ch5 - 35mA, Ch6 - 35mA, Ch7 - 20mA, Ch8 - 20mA

Good seating position was easily achieved with the use of a small wooden chair this time with a small cushion supporting Clients hips and lower back.  Much improved from the video clip viewed last week. As they had recently had a 2 week break from the set up procedure I think it was just down to them being a bit rusty and a bit of coaching was required with positioning.

Client's quadriceps muscle are his strongest muscles, he also has strong gastrocnemius muscles that spasm when he is excited or generally rushing (quite a lot of the time for a (now) 5year old) causing him to walk on his toes.  At present the client prefers to do this as he feels taller when he is doing it and should be able to modify this as he gets older which will have a positive impact on his gait . Mother informs me he can walk with his heels down when he is less excited. I did not see this when I was there but did note planter grade being achieved when using the bike.

Have constructed the following programme to accommodate Glutes, Hamstings pretibial and gastroc muscles.

Programme 4 Ramp 5 Freq 15Hz Pulse width 150us

Ch1 - 30mA Right Gluteus Maximus Start Angle 120 Stop Angle 210
Ch2 - 35mA Right Hamstring Start Angle 220 Stop Angle 360
Ch3 - 25mA Right Tibialis Anterior Start Angle 330 Stop Angle 90
Ch4 - 25mA Right Gastrocnemius Start Angle 180 Stop Angle 280
Ch5 - 30mA Left Gluteus Maximus Start Angle 300 Stop Angle 30
Ch6 - 40mA Left Hamstring Start Angle 40 Stop Angle 180
Ch7 - 25mA Left Tibialis Anterior Start Angle 150 Stop Angle 270
Ch8 - 25mA Left Gastrocnemius Start Angle 0 Stop Angle 100

On muscle testing: all muscles reacted to stimulation Client gave very good feedback again and we were also able to see good contractions in the glutes and hamstrings with slightly reduced, softer contractions in the pre tibial and calf muscles.  Client was able to actively cycle and with the reduced frequency level did not report any discomfort.  Mother is now happy to change current and pulsewidth and will adjust over the coming weeks to get the optimum levels for the Client.

I have discussed with Mother the importance of not neglecting the quads and to monitor their strength in relation to his other muscles.  Client can actively cycle (20reps) in gear 1 using predominantly quads, Mother is constantly working on his exercise tolerance with this activity.

Since he has started using the Gracile and stimulator Client can now independently cycle his regular push bike with stabilisers to the park (approx. 400m) and back. He used to get very frustrated at not being able push over the top of the pedals. He proudly showed me his cycling today with no assistance, Mother did not think she would ever hear herself shout “that’s enough - not too far ahead” it was very impressive. Mother feels the Client has made great progress in a short period of time.

Sequence mode was successfully loaded onto the stimulator, demonstrated with Mother and explained set up. Not sure if the Client will tolerated the sequence mode at present as he needs the distraction of the bike or TV or even both when stimulation is on. I do feel Clients’s Gluteus medius will benefit most from sequence mode and have discussed this with Mother today.

Mother's Update at 10 Weeks
Client is continuing to make good progress with FES cycling. When we started, he could barely pedal it at all without the motor assistance.  The last 3 sessions, he has managed 8 minutes without the motor.  Speed  continues to be his aim so he is managing to get further each time. He was managing 0.7km last week in his 8 mins without the motor but over the weekend, it was 1.5 km without the motor in the same time period.  And I am quietly increasing the resistance levels too. We are up to level 6.

His legs are slowly starting to plump up, particularly at the tops. And his standing balance is much improved from 8 weeks ago. Walking is still poor but it's early days.
 All in all, a big success so far from our point of view. So thanks to you and Andy for your assistance.

Standing Start Showcase - A Great Success

This weekend's Standing Start Showcase in Cambridge focused on "Getting Fit for Life" following a spinal cord injury.  A mixture of presentation and demonstrations were used to successfully highlight the exercise techniques used at Standing Start. We also explored how FES Cycling and FES enhanced exercise could work to improve long term health for clients.

 

The format was quite novel as clients Mike and Harvey demonstrated the exercises with guidance from Standing Start staff Andy Galbraith and Natalie Dodson.  Moving around the room to observe different exercises definitely brought some variety from the usual "death by Powerpoint" scenario.  The remarkable thing was just how challenging some of the exercises were - and well beyond the expected abilities of persons with these levels of injury.

It clearly takes a leap of faith for many new clients to commit to these exercises. The likelyhood is that they have to be willing to work at developing some new abilities that they almost certainly they did not believe they could achieve.

After an introduction by myself and Peter Carr (Founder of Standing Start) the day kicked off with a contribution from Daniel Kuhn of the Bergamannstrost Kliniken Halle, Germany.  Daniel works with electrotherapy in the rehabilitation of spinal cord injured persons and in particular has a great deal of experience working with the RehaMove FES Cycling system manufactured in Germany by Hasomed GmbH and represented in the UK by Anatomical Concepts.  Daniel is currently working toward his PhD and looking at the clinical effectiveness of FES Cycling in the rehabilitation process.

I demonstrated the RehaMove FES Cycling system with the assistance of Katrin Bombitzki, Export Manager from Hasomed.  Katrin was able to give a brief overview of the many countries of the world nw using the RehaMove system and what to expect in the future.  I also showed the Stimulette den2x electrotherapy system for denervated muscles produced in Austria and now offered by Anatomical Concepts (UK) Ltd.

Left to right Natalie Dodson, "MJ" Perrier, Peter Carr (sitting), Daniel Kuhn, Katrin Bombitzki and Andrew "Iron Man" Galbraith.  (I hate having my picture taken so im behind the camera)

The final presentation or the day was from Marie-Josee Perrier.  MJ is a PhD student in Health and Sport Psychology at Queen's University in Kingston, Canada.  She talked about her research interests include the relationships between self-identity as an athlete and exercise/sport behaviour, motivation and planning for sport.  She is spending the next three months with Brett Smith at Loughborough University to learn a little more about qualitative research in the context of health and spinal cord injuries.