Functional Electrical Stimulation (FES): Clinical successes and failures to date

Gad Alon*

Published: 02 November, 2018 | Volume 2 - Issue 3 | Pages: 080-086

Non-invasive electrical stimulation in the form of neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES) has been documented as an optional assessment and treatment technology for decades. In contrast, translation of the robust clinical evidence supporting the effectiveness of FES’ enhancement of muscle force generation and adding to the recovery of motor control following damage to the brain appears limited. Furthermore, enabling many patients to regain locomotion ability though utilization of FES as a standard care option in rehabilitation medicine remains unmet. This perspective evolved over years of collaborative experience in clinical research, teaching, and patient care having a common goal of advancing patients’ rehabilitation outcomes. The clinical successes are supported by repeated evidence of FES utilization across the life span, from toddlers to elders, from hospitals’ critical care units to the home environment. The utilization include managing multiple deficits associated with the musculo-skeletal, neurological, cardio-pulmonary, or peripheral vascular systems. These successes were achieved in no small part because of the technological advancement leading to today’s wearable wireless FES systems that are being used throughout the continuum of rehabilitation care. However, failures to benefit from FES utilization are likewise numerous, collectively depriving most patients from using the technology to maximize their rehabilitation gains. The most critical failures are both clinical and technological. Whereas numerous barriers to NMES and FES utilization have been published, the focus of this perspective is on barriers not considered to date.

Read Full Article HTML DOI: 10.29328/journal.jnpr.1001022 Cite this Article Read Full Article PDF


  1. Wegrzyk J, Ranjeva JP, Fouré A, Kavounoudias A, Vilmen C, et al. Specific brain activation patterns associated with two neuromuscular electrical stimulation protocols. Sci Rep. 2017; 7: 27-42. Ref.: https://goo.gl/pvyyB2
  2. Gandolla M, Ward NS, Molteni F, Guanziroli E, Ferrigno G, et al. The Neural Correlates of Long-Term Carryover following Functional Electrical Stimulation for Stroke. Neural Plast. 2016; 2016: 4192718. Ref.: https://goo.gl/t7fX4q
  3. Sasaki K, Matsunaga T, Tomite T, Yoshikawa T, Shimada Y, et al. Effect of electrical stimulation therapy on upper extremity functional recovery and cerebral cortical changes in patients with chronic hemiplegia. Biomed Res. 2012; 33: 89-96. Ref.: https://goo.gl/uoSX3h
  4. Smith GV, Alon G, Roys SR, Gullapalli RP. Functional MRI determination of a dose-response relationship to lower extremity neuromuscular electrical stimulation in healthy subjects. Exp Brain Res. 2003; 150: 33-39. Ref.: https://goo.gl/5Qbt5X
  5. Alon G. Functional Electrical Stimulation (FES): Transforming Clinical Trials to Neuro-Rehabilitation Clinical Practice- A Forward Perspective. Journal of Novel Physiotherapies, 2013; 3: Ref.: https://goo.gl/1MDzkf
  6. Di Filippo ES, Mancinelli R, Marrone M, Doria C, Verratti V, et al. Neuromuscular electrical stimulation improves skeletal muscle regeneration through satellite cell fusion with myofibers in healthy elderly subjects. J Appl Physiol. (1985); 2017: 123: 501-512. Ref.: https://goo.gl/FnFqr3
  7. Kern H, Barberi L, Löfler S, Sbardella S, Burggraf S. et al. Electrical stimulation counteracts muscle decline in seniors. Front Aging Neurosci. 2014; 6: 189. Ref.: https://goo.gl/1C1iki
  8. Strasser EM, Stättner S, Karner J, Klimpfinger M, Freynhofer M, et al. Neuromuscular electrical stimulation reduces skeletal muscle protein degradation and stimulates insulin-like growth factors in an age- and current-dependent manner: a randomized, controlled clinical trial in major abdominal surgical patients. Ann Surg. 2009; 249: 738-743. Ref.: https://goo.gl/jGESDw
  9. Huang SC, Wong AM, Chuang YF, Liu YC, Tsai WL, et al. Effects of neuromuscular electrical stimulation on arterial hemodynamic properties and body composition in paretic upper extremities of patients with subacute stroke. Biomed J. 2014; 37: 205-210. Ref.: https://goo.gl/qrbCW8
  10. Vieira PJ, Chiappa AM, Cipriano G Jr, Umpierre D, Arena R, et al. Neuromuscular electrical stimulation improves clinical and physiological function in COPD patients. Respir Med. 2014; 108: 609-620. Ref.: https://goo.gl/T9zE9y
  11. Yoshida Y, Ikuno K, Shomoto K. Comparison of the effect of sensory-level and conventional motor-level neuromuscular electrical stimulation on quadriceps strength after total knee arthroplasty: a prospective randomized single-blind trial. Arch Phys Med Rehabil. 2017; 98: 2364-2370. Ref.: https://goo.gl/qKnSyj
  12. Matsuse H, Hashida R, Takano Y, Omoto M, Nago T, et al. Walking Exercise Simultaneously Combined With Neuromuscular Electrical Stimulation of Antagonists Resistance Improved Muscle Strength, Physical Function, and Knee Pain in Symptomatic Knee Osteoarthritis: A Single-Arm Study. J Strength Cond Res. 2017; 31: 171-180. Ref.: https://goo.gl/UbLNDy
  13. Brüggemann AK, Mello CL, Dal Pont T, Hizume Kunzler D, Martins DF, et al. Effects of Neuromuscular Electrical Stimulation during Hemodialysis on Peripheral Muscle Strength and Exercise Capacity: A Randomized Clinical Trial. Arch Phys Med Rehabil, 2017; 98: 822-831 e1. Ref.: https://goo.gl/npkC4h
  14. Grosset JF, Canon F, Pérot C, Lambertz D. Changes in contractile and elastic properties of the triceps surae muscle induced by neuromuscular electrical stimulation training. Eur J Appl Physiol. 2014; 114: 1403-1411. Ref.: https://goo.gl/NDGdNx
  15. Ambrosini E, Ferrante S, Pedrocchi A, Ferrigno G, Molteni F. Cycling induced by electrical stimulation improves motor recovery in postacute hemiparetic patients: a randomized controlled trial. Stroke, 2011; 42: 1068-1073. Ref.: https://goo.gl/vW2ibP
  16. Embrey DG, Alon G, Brandsma BA, Vladimir F, Silva A, et al. Functional electrical stimulation improves quality of life by reducing intermittent claudication. Int J Cardiol, 2017; 243: 454-459. Ref.: https://goo.gl/wmU6Lq
  17. Williams KJ, Moore HM, Davies AH. Haemodynamic changes with the use of neuromuscular electrical stimulation compared to intermittent pneumatic compression. Phlebology. 2015; 30: 365-372. Ref.: https://goo.gl/e77JCG
  18. Mifsud M, Cassar K. The Use of Transcutaneous Electrical Stimulation of the Calf in Patients Undergoing Infrainguinal Bypass Surgery. Ann Vasc Surg. 2015; 29: 1524-1532. Ref.: https://goo.gl/CRmxHk
  19. Tucker AT, Maass A, Bain DS, Chen LH, Azzam M, et al. Augmentation of venous, arterial and microvascular blood supply in the leg by isometric neuromuscular stimulation via the peroneal nerve. Int J Angiol. 2010; 19: e31-37. Ref.: https://goo.gl/VkWUVb
  20. Sampson P, Freeman C, Coote S, Demain S, Feys P, et al. Using Functional Electrical Stimulation Mediated by Iterative Learning Control and Robotics to Improve Arm Movement for People with Multiple Sclerosis. IEEE Trans Neural Syst Rehabil Eng. 2016; 24: 235-248. Ref.: https://goo.gl/74xRX2
  21. Knutson JS, Gunzler DD, Wilson RD, Chae J. Contralaterally Controlled Functional Electrical Stimulation Improves Hand Dexterity in Chronic Hemiparesis: A Randomized Trial. Stroke, 2016; 47: 2596-2602. Ref.: https://goo.gl/ctDk7D
  22. Springer S, Khamis S, Laufer Y. Improved ankle and knee control with a dual-channel functional electrical stimulation system in chronic hemiplegia. A case report. Eur J Phys Rehabil Med. 2014; 50: 189-195. Ref.: https://goo.gl/ojVNwV
  23. Pool D, Blackmore AM, Bear N, Valentine J. Effects of short-term daily community walk aide use on children with unilateral spastic cerebral palsy. Pediatr Phys Ther. 2014; 26: 308-317. Ref.: https://goo.gl/bTWPKJ
  24. O'Dell MW, Dunning K, Kluding P, Wu SS, Feld J, et al. Response and prediction of improvement in gait speed from functional electrical stimulation in persons with poststroke drop foot. PM R. 2014; 6: 587-601. Ref.: https://goo.gl/6pyZxQ
  25. Kamel DM, Yousif AM. Neuromuscular Electrical Stimulation and Strength Recovery of Postnatal Diastasis Recti Abdominis Muscles. Ann Rehabil Med. 2017; 41: 465-474. Ref.: https://goo.gl/QsDds4
  26. Porcari JP, Miller J, Cornwell K, Foster C, Gibson M, et al. The effects of neuromuscular electrical stimulation training on abdominal strength, endurance, and selected anthropometric measures. J Sports Sci Med. 2005; 4: 66-75. Ref.: https://goo.gl/knwCPu
  27. Taylor P, Humphreys L, Swain I. The long-term cost-effectiveness of the use of Functional Electrical Stimulation for the correction of dropped foot due to upper motor neuron lesion. J Rehabil Med. 2013; 45: 154-160. Ref.: https://goo.gl/4m73Me
  28. Alon G, Embrey DG, Brandsma BA, Stonestreet J. Comparing four electrical stimulators with different pulses properties and their effect on the discomfort and elicited Dorsiflexion. International J Physiotherapy Res. 2013; 1: 122-129. Ref.: https://goo.gl/3Juzv6
  29. Springer S, Vatine JJ, Wolf A, Laufer Y. The effects of dual-channel functional electrical stimulation on stance phase sagittal kinematics in patients with hemiparesis. J Electromyogr Kinesiol, 2013; 23: 476-482. Ref.: https://goo.gl/2s3Ddc
  30. Kluding PM, Dunning K, O'Dell MW, Wu SS, Ginosian J, et al. Foot drop stimulation versus ankle foot orthosis after stroke: 30-week outcomes. Stroke. 2013; 44: 1660-1669. Ref.: https://goo.gl/pnPDvu
  31. Springer S, Vatine JJ, Wolf A, Laufer Y. The effects of dual-channel functional electrical stimulation on stance phase sagittal kinematics in patients with hemiparesis. J Electromyogr Kinesiol. 2013; 23: 476-482. Ref.: https://goo.gl/AyoGMq
  32. Alon G, Levitt AF, McCarthy PA. Functional electrical stimulation (FES) may modify the poor prognosis of stroke survivors with severe motor loss of the upper extremity: a preliminary study. Am J Phys Med Rehabil. 2008; 87: 627-636. Ref.: https://goo.gl/34BWwZ 
  33. Alon G, Levitt AF, McCarthy PA. Functional electrical stimulation enhancement of upper extremity functional recovery during stroke rehabilitation: a pilot study. Neurorehabil Neural Repair. 2007; 21: 207-215. Ref.: https://goo.gl/jD2aog
  34. Auchstaetter N, Luc J, Lukye S, Lynd K, Schemenauer S, et al. Physical Therapists' Use of Functional Electrical Stimulation for Clients With Stroke: Frequency, Barriers, and Facilitators. Phys Ther. 2016; 96: 995-1005. Ref.: https://goo.gl/Pvz8aJ
  35. Fabbrini S, Casati G, Bonaiuti D. Is CIMT a rehabilitative practice for everyone? Predictive factors and feasibility. Eur J Phys Rehabil Med. 2014; 50: 505-514. Ref.: https://goo.gl/nhaHJn
  36. Dobkin BH. Confounders in rehabilitation trials of task-oriented training: lessons from the designs of the EXCITE and SCILT multicenter trials. Neurorehabil Neural Repair. 2007; 21: 3-13. Ref.: https://goo.gl/Rs5YpG
  37. Raffin E, Hummel FC. Restoring Motor Functions after Stroke: Multiple Approaches and Opportunities. Neuroscientist. 2017; 24: 400-416. Ref.: https://goo.gl/Dccszc
  38. van der Linden ML, Hooper JE, Cowan P, Weller BB, Mercer TH. Habitual functional electrical stimulation therapy improves gait kinematics and walking performance, but not patient-reported functional outcomes, of people with multiple sclerosis who present with foot-drop. PLoS One. 2014; 9: e103368. https://goo.gl/9ijXVb
  39. Kutlu M, Freeman CT, Hallewell E, Hughes AM, Laila DS. Upper-limb stroke rehabilitation using electrode-array based functional electrical stimulation with sensing and control innovations. Med Eng Phys. 2016; 38: 366-379. Ref.: https://goo.gl/H7on2Q
  40. Freeman C, Exell T, Meadmore K, Hallewell E, Hughes AM. Computational models of upper-limb motion during functional reaching tasks for application in FES-based stroke rehabilitation. Biomed Tech (Berl). 2015; 60: 179-191. Ref.: https://goo.gl/zsEvKW
  41. El-Gohary M, McNames J. Human Joint Angle Estimation with Inertial Sensors and Validation with a Robot Arm. IEEE Trans Biomed Eng. 2015; 62: 1759-1767. Ref.: https://goo.gl/f9E6fT
  42. Wang HP, Bi ZY, Zhou Y, Zhou YX, Wang ZG, et al. Real-time and wearable functional electrical stimulation system for volitional hand motor function control using the electromyography bridge method. Neural Regen Res. 2017; 12: 133-142. Ref.: https://goo.gl/PkSefP
  43. Li Z, Guiraud D, Andreu D, Gelis A, Fattal C, et al. Real-Time Closed-Loop Functional Electrical Stimulation Control of Muscle Activation with Evoked Electromyography Feedback for Spinal Cord Injured Patients. Int J Neural Syst. 2017; 1750063. Ref.: https://goo.gl/FnRhnV
  44. Seel T, Werner C, Schauer T. The adaptive drop foot stimulator - Multivariable learning control of foot pitch and roll motion in paretic gait. Med Eng Phys. 2016; 38: 1205-1213. Ref.: https://goo.gl/iYKN65
  45. Zhang Q, Hayashibe M, Azevedo-Coste C. Evoked electromyography-based closed-loop torque control in functional electrical stimulation. IEEE Trans Biomed Eng. 2013; 60: 2299-2307. Ref.: https://goo.gl/dvMwQW
  46. Jovic J, Fraisse P, Coste CA, Bonnet V, Fattal C, et al. Improving valid and deficient body segment coordination to improve FES-assisted sit-to-stand in paraplegic subjects. IEEE Int Conf Rehabil Robot. 2011; 2011: 5975369. Ref.: https://goo.gl/1RT6aj
  47. Ethier C, Acuna D, Solla SA, Miller LE. Adaptive neuron-to-EMG decoder training for FES neuroprostheses. J Neural Eng. 2016; 13: 046009. Ref.: https://goo.gl/qVvVds
  48. Rocon E, Gallego JA, Barrios L, Victoria AR, Ibanez J, et al. Multimodal BCI-mediated FES suppression of pathological tremor. Conf Proc IEEE Eng Med Biol Soc. 2010; 2010: 3337-3340. Ref.: https://goo.gl/jWw7j7
  49. Li Z, Guiraud D, Andreu D, Benoussaad M, Fattal C, et al. Real-time estimation of FES-induced joint torque with evoked EMG : Application to spinal cord injured patients. J Neuroeng Rehabil. 2016; 13: 60. Ref.: https://goo.gl/KVt7Ak
  50. Rueterbories J, Spaich EG, Andersen OK. Gait event detection for use in FES rehabilitation by radial and tangential foot accelerations. Med Eng Phys. 2014; 36: 502-508. Ref.: https://goo.gl/psSPX3
  51. Mann G, Taylor P, Lane R. Accelerometer-triggered electrical stimulation for reach and grasp in chronic stroke patients: a pilot study. Neurorehabil Neural Repair. 2011; 25: 774-780. Ref.: https://goo.gl/7F1LZy
  52. Sun M, Kenney L, Smith C, Waring K, Luckie H, et al. A novel method of using accelerometry for upper limb FES control. Med Eng Phys. 2016; 38: 1244-1250. Ref.: https://goo.gl/WdK2ic
  53. Ha KH, Murray SA, Goldfarb M. An Approach for the Cooperative Control of FES With a Powered Exoskeleton During Level Walking for Persons With Paraplegia. IEEE Trans Neural Syst Rehabil Eng. 2016; 24: 455-466. Ref.: https://goo.gl/vgHEa9
  54. Salchow C, Valtin M, Seel T, TSchauer T. A New Semi-Automatic Approach to Find Suitable Virtual Electrodes in Arrays Using an Interpolation Strategy. Eur J Transl Myol. 2016; 26: 6029. Ref.: https://goo.gl/7JVufT
  55. Biasiucci A, Leeb R, Iturrate I, Perdikis S, Al-Khodairy A, et al. Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke. Nat Commun. 2018; 9: 2421. Ref.: https://goo.gl/eVVzqr
  56. Carda S, Biasiucci A, Maesani A, Ionta S, Moncharmont J, et al. Electrically Assisted Movement Therapy in Chronic Stroke Patients with Severe Upper Limb Paresis: A Pilot, Single-Blind, Randomized Crossover Study. Arch Phys Med Rehabil. 2017; 98: 1628-1635 e2. Ref.: https://goo.gl/iM2Nck
  57. Anaya F, Thangavel P, Yu H. Hybrid FES–robotic gait rehabilitation technologies: a review on mechanical design, actuation, and control strategies. International Journal of Intelligent Robotics and Applications. 2018; 2: 1-28. Ref.: https://goo.gl/Kd9dkH
  58. Heller BW, Clarke AJ, Good TR, Healey TJ, Nair S, et al. Automated setup of functional electrical stimulation for drop foot using a novel 64 channel prototype stimulator and electrode array: results from a gait-lab based study. Med Eng Phys. 2013; 35: 74-81. Ref.: https://goo.gl/UYQshM

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