Sleep Disordered Breathing After SCI

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Author: Sharon Jang | Reviewer: Viet Vu | Published: 10 March 2020 | Updated: ~

Sleep disordered breathing is common after a spinal cord injury (SCI). This page explains what sleep disordered breathing is, why it occurs, what factors influence it, and current management options.

Key Points

  • Sleep disordered breathing is a family of conditions (including sleep apnea) that involve the interruption of air flow during sleep.
  • Symptoms of sleep disordered breathing include feeling tired during the day, snoring, and choking or gasping for air in your sleep.
  • Sleep disordered breathing is prevalent after SCI, and can be attributed to the level of injury, weight, sleep position, and medications.
  • Lifestyle modifications and the use of continuous positive airway pressure (CPAP) machines are the most common management strategies.

Obstructive sleep apnea occurs when the throat muscles relax (highlighted by the red circle), resulting in a blockage of your airway.1

Sleep disordered breathing is an umbrella term for conditions that involve an interruption of breathing throughout the night. In research, sleep disordered breathing is evaluated through observing two key factors:

  • Apnea, or a loss of air flow for 10 seconds or more, and
  • Hypopnea, a partial blockage of an airway resulting in decreased air flow to the lungs and decreased oxygen in the blood.

When you sleep, the body normally goes into a state of hypoventilation, or a slow and shallow breathing. This results in a decrease in oxygen circulating in the blood. However, weak evidence suggests that after an SCI hypoventilation becomes more prevalent during sleep when compared to able-bodied people. Among those with SCI, hypoventilation occurs more often in individuals with tetraplegia versus paraplegia.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings

The two most common disorders under sleep disordered breathing include:

  • Obstructive sleep apnea, which occurs when the throat muscles relax and temporarily block your airway, and
  • Central sleep apnea, which occurs when the brain is unable to properly send signals to the breathing muscles. This occurs when your unconscious breathing stops.

Of the two types of sleep apneas, obstructive sleep apnea is more prevalent among individuals with SCI of all levels. However, central sleep apnea is more prevalent among individuals with cervical level injuries. Narcotic use can also increase the risk of central sleep apnea. It is important to note that some patients have mixed sleep apnea, a combination of obstructive and central sleep apnea.

The prevalence of sleep apnea in individuals with spinal cord injury is two to five times greater than that in the non-SCI population. In the SCI population, research has found that sleep apnea rates vary from 27-82%. A large variation in prevalence can be attributed to different diagnostic measures used in research studies (e.g., evaluating sleep apnea in a lab versus home setting) and the way each study defines sleep apnea.

A few hypotheses have been made by scientists as to why sleep apnea is prevalent in SCI. In general, sleep apnea is attributed to a complex interaction of a variety of factors:

Level of injury

Sleep disordered breathing is more prevalent in individuals with tetraplegia compared to those with paraplegia. Having a higher level of injury is usually associated with decreased muscle functioning and neural control over your organs. These impairments can create troubles with breathing, specifically with inhaling, exhaling, and the amount of air your lung can hold.

Refer to our article on Respiratory Changes After SCI for more information.

Changes in sensitivity to oxygen and carbon dioxide

After an SCI, your body becomes more sensitive to the amount of carbon dioxide circulating throughout your body. So, when there is a slight increase in carbon dioxide in the body, the brain senses it as a large change, which cues the body to hyperventilate, or rapidly breathe. However, since the change in carbon dioxide was small to start with, hyperventilation results in excess removal of carbon dioxide, resulting in very low carbon dioxide levels. During sleep, breathing is dependent on the amount of carbon dioxide circulating in the body. If this level drops below the level required for breathing, then central sleep apnea occurs. While some researchers believe this may be a cause of central sleep apnea, others note that there is currently only weak evidence to support this hypothesis.

Weight

Measures of body composition, including body mass index (BMI), neck circumference, and waist circumference, may be linked to the prevalence of sleep disordered breathing. Weak research evidence has suggested that a greater neck circumference or BMI can increase the odds of having sleep disordered breath. This is concerning for individuals with SCI, as 44-66% of this population are overweight or obese. However, other studies have found no relationship between BMI or neck circumference and sleep disordered breathing in SCI.

Sleeping on your back

There has been some research suggesting that your sleep position may relate to sleep disordered breathing. One weak evidence study has suggested that there is more than a 50% increase in apneic events that occur when you sleep on your stomach or on your back, rather than on your side. More specifically, tetraplegics who sleep on their backs experienced more apneas and hypopneas per hour compared to those who slept in other positions. Despite this evidence, other researchers found that sleeping on your back enhances overall breathing functions after SCI. More research is required to determine the optimal sleeping position for health benefits, keeping in mind that bed mobility and turns overnight also help to maintain skin health.

Medications

While factors such as level of injury and weight are primary contributors to sleep disordered breathing, common medications used by individuals with SCI can also impact breathing during sleep. These include: narcotics, baclofen, benzodiazepines (lorazepam, diazepam, clonazepam), testosterone, and heart medications to treat high blood pressures or arrhythmias. Although medications can cause sleep disordered breathing, they are not likely to be the main contributor to the issue.

Increased Nasal Resistance

Individuals with tetraplegia may find that it is harder for them to breathe in with their nose (i.e., nasal resistance). A common effect of a cervical injury on the nose includes swelling of the blood vessels and a thickening of the mucus in the nose. One moderate evidence study found that individuals with tetraplegia experienced greater nasal resistance in comparison with able-bodied individuals. Since increases in breathing resistance can cause the airways to collapse, some researchers believe that this may contribute to the higher prevalence of OSA in individuals with tetraplegia.

Some of the most common symptoms of sleep apnea in individuals with spinal cord injury include:

  • Snoring
  • Choking or gasping for air during sleep
  • Feeling fatigued during the day
  • Having a hard time concentrating when you are awake
  • Feeling unrefreshed after a night’s sleep
  • Difficulties falling asleep
  • Awakening multiple times throughout the night
  • Feeling sleepy during the day, as assessed by the Epworth Sleepiness Questionnaire in clinics

Although the above are symptoms of sleep apnea, it is important to note that these same symptoms can result from secondary complications from a spinal cord injury (e.g., pain, spasticity, posture).

Continuous positive airway pressure machines

A CPAP powered by a machine which regulates the flow of air. This machine is connected to a face mask that is worn via a tube.9

The first line of treatment for sleep disordered breathing generally includes lifestyle changes consisting of weight loss and the avoidance of alcohol and smoking. These lifestyle changes are normally done in conjunction with the use of a continuous positive airway pressure (CPAP) machine. CPAP machines act as a “pneumatic splint” that holds the airway open through a continuous pressure of air. To use a CPAP machine, an interface (nasal pillows or a mask is worn over the face/nose) overnight.

CPAP machines are commonly used to address sleep apnea, and their effectiveness for the SCI population is supported by some weak evidence research studies. However, strong evidence in the SCI population is lacking. Although CPAP machines can help with breathing, multiple weak evidence research articles report poor adherence in using CPAP machines. Some of these reasons include:

  • Difficulties putting on the mask, especially among individuals with limited hand function
  • Mask discomfort
  • Feelings of claustrophobia
  • Decreased sleep quality/hard time falling asleep with it on

Although CPAP machines have the potential to help with sleep disordered breathing, more research is required to determine how helpful CPAP machines are to individuals with SCI, and how we can improve adherence to this treatment.

Bilevel positive airway pressure machines

Bilevel positive airway pressure (BiPAP) machines operate similarly to CPAP machines in that air pressure is acts as a “pneumatic splint”. however, BiPAP machines do not deliver a constant pressure of air. Exhaling when using a CPAP machine may be difficult, as breathing against an inflow of air requires effort. The BiPAP machine is unique as the pressures it exerts varies with inhalation/exhalation. Normally, the BiPAP machine will be set to a higher pressure for inhalation, and to a reduced pressure during exhalation to facilitate this process. While there have been some thoughts that BiPAP machines may benefit the able-bodied population, more research is required to determine the effectiveness of BiPAP machines in an SCI population. It is worth a discussion with your doctor if you are not tolerating a CPAP machine to trial a BiPAP machine to treat sleep apnea.

Dental appliances

An example of a dental appliance. A gap exists between the teeth to help promote airflow when sleeping.10

Dental appliances are sometimes an alternative to CPAP if an individual exhibits mild sleep disordered breathing. Dental appliances fit in the mouth like a mouth guard, and help pull the jaw and the tongue forward to prevent obstructive sleep apnea by opening up the airway. Although there has been a lot of literature supporting the use of dental appliances in an able-bodied population, more research needs to be conducted in an SCI population.

Invasive interventions

In the UVPPP surgical procedure, extra tissue is removed from the roof of your mouth and/or from your throat.11

Surgical interventions for sleep disordered breathing are often the last resort, after CPAP or BiPAP fail to work. There are a variety of surgical procedures that are used to aid obstructive sleep apnea, many of which involve reducing or repositioning the soft tissue at the back of the throat. One of the most common surgical procedures is an uvulopalatopharyngoplasty (UVPPP), whereby the soft tissues at the back of your mouth and throat are reduced and removed. However, the success rate for this procedure is variable, and there is only weak evidence to support this technique in able-bodied populations. Moreover, sleep disordered breathing in SCI may result from complex interactions between a variety of factors including level of injury, weight, sleep position, and medications. Although obstructive sleep apnea is common in SCI, researchers are unsure whether it stems from the structure of the throat or changes accompanied by an SCI. The evidence for surgical procedures to aid obstructive sleep apnea after SCI is sparse and requires more research.

Sleep disordered breathing, or a lack of breathing during sleep, is two to five times more prevalent in the SCI population compared to the able-bodied population. This increase in prevalence is believed to be related to a variety of factors including weight, level of injury, sleep position, and medications. While there are a variety of non-invasive and invasive procedures to manage sleep disordered breathing, more research is required to determine which treatment is most effective in an SCI population.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

SCIRE Community. “Respiratory Changes After SCI”. Available from: https://community.scireproject.com/topics/respiratory-changes

SCIRE Community. “Spinal Cord Injury Basics”. Available from https://community.scireproject.com/topic/sci-basics/

Parts of this page have been adapted from the SCIRE Project “Respiratory management” Chapter:

Sheel AW, Welch J, Townson AF (2018). Respiratory Management Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, Sproule S, Querée M, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0. Vancouver: p. 1-72.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/respiratory-management/ 

 

Evidence for “What is sleep disordered breathing” is based on

Bascom, A. T., Sankari, A., Goshgarian, H. G., & Badr, M. S. (2015). Sleep onset hypoventilation in chronic spinal cord injury. Physiological Reports, 3(8), 1–10.

Castriotta, R. J., & Murthy, J. N. (2009). Hypoventilation after spinal cord injury. Seminars in Respiratory and Critical Care Medicine, 30(3), 330–338.

Chiodo, A. E., Sitrin, R. G., & Bauman, K. A. (2016). Sleep disordered breathing in spinal cord injury: A systematic review. Journal of Spinal Cord Medicine, 39(4), 374–382.

Fuller, D. ., Lee, K., & Tester, N. J. (2014). The impact of spinal cord injury on breathing during sleep, 27(4), 1–19.

Sankari, A., Vaughan, S., Bascom, A., Martin, J. L., & Badr, M. S. (2019). Sleep-Disordered Breathing and Spinal Cord Injury: A State-of-the-Art Review. Chest, 155(2), 438–445. Retrieved from https://doi.org/10.1016/j.chest.2018.10.002

Evidence for “Why is sleep disordered breathing common after SCI” is based on

Baydur A, Adkins RH, Milic-Emili J. (2001). Lung mechanics in individuals with spinal cord injury: effects of injury level and posture. Journal of applied physiology, 90, 405–411.

Berlowitz, D. J., Brown, D. J., Campbell, D. A., & Pierce, R. J. (2005). A longitudinal evaluation of sleep and breathing in the first year after cervical spinal cord injury. Archives of Physical Medicine and Rehabilitation, 86(6), 1193–1199.

Chiodo, A. E., Sitrin, R. G., & Bauman, K. A. (2016). Sleep disordered breathing in spinal cord injury: A systematic review. Journal of Spinal Cord Medicine, 39(4), 374–382.

Mason, M., Cj, C., & Smith, I. (2015). Effects of opioid, hypnotic and sedatingmedications on sleep- disordered breathing in adults with obstructive sleep apnoea (Review). Cochrane Database of Systematic Reviews, (7).

Fuller, D. ., Lee, K., & Tester, N. J. (2014). The impact of spinal cord injury on breathing during sleep, 27(4), 1–19.

McEvoy, R. D., Mykytyn, I., Sajkov, D., Flavell, H., Marshall, R., Antic, R., & Thornton, A. T. (1995). Sleep apnoea in patients with quadriplegia. Thorax, 50(6), 613–619.

Oksenberg, A., Silverberg, D. S., Arons, E., & Radwan, H. (1997). Positional vs nonpositional obstructive sleep apnea patients: Anthropomorphic, nocturnal polysomnographic, and multiple sleep latency test data. Chest, 112(3), 629–639.

Sankari, A., Vaughan, S., Bascom, A., Martin, J. L., & Badr, M. S. (2019). Sleep-Disordered Breathing and Spinal Cord Injury: A State-of-the-Art Review. Chest, 155(2), 438–445. Retrieved from https://doi.org/10.1016/j.chest.2018.10.002

Wijesuriya, N. S., Lewis, C., Butler, J. E., Lee, B. B., Jordan, A. S., Berlowitz, D. J., & Eckert, D. J. (2017). High nasal resistance is stable over time but poorly perceived in people with tetraplegia and obstructive sleep apnoea. Respiratory Physiology and Neurobiology, 235, 27–33. Retrieved from http://dx.doi.org/10.1016/j.resp.2016.09.014

Evidence for “What are the symptoms of sleep apnea” is based on

Chiodo, A. E., Sitrin, R. G., & Bauman, K. A. (2016). Sleep disordered breathing in spinal cord injury: A systematic review. Journal of Spinal Cord Medicine, 39(4), 374–382.

Fuller, D. ., Lee, K., & Tester, N. J. (2014). The impact of spinal cord injury on breathing during sleep, 27(4), 1–19.

Evidence for “What treatment is available for sleep disordered breathing” is based on

Burns, S. P., Little, J. W., Hussey, J. D., Lyman, P., & Lakshminarayanan, S. (2000). Sleep apnea syndrome in chronic spinal cord injury: Associated factors and treatment. Archives of Physical Medicine and Rehabilitation, 81(10), 1334–1339.

Burns, S. P., Rad, M. Y., Bryant, S., & Kapur, V. (2005). Long-term treatment of sleep apnea in persons with spinal cord injury. American Journal of Physical Medicine and Rehabilitation, 84(8), 620–626.

Fuller, D. ., Lee, K., & Tester, N. J. (2014). The impact of spinal cord injury on breathing during sleep, 27(4), 1–19.

Rotenberg, B. W., Vicini, C., Pang, E. B., & Pang, K. P. (2016). Reconsidering first-line treatment for obstructive sleep apnea: A systematic review of the literature. Journal of Otolaryngology – Head and Neck Surgery, 45(1), 1–9. Retrieved from http://dx.doi.org/10.1186/s40463-016-0136-4

Stockhammer, E., Tobon, A., Michel, F., Eser, P., Scheuler, W., Bauer, W., … Zach, G. A. (2002). Characteristics of sleep apnea syndrome in tetraplegic patients. Spinal Cord, 40, 286–294.

Tromans, A. M., Mecci, M., Barrett, F. H., Ward, T. A., & Grundy, D. J. (1998). The use of the BiPAP® biphasic positive airway pressure system in acute spinal cord injury. Spinal Cord, 36(7), 481–484.

Image credits
  1. Obstruction ventilation apnée sommeil © Habib M’henni, CC0 1.0
  2. Modified from Outlines. ©Servier Medical Art. CC BY 3.0
  3. visceral fat © Olena Panasovar, CC BY 3.0 US
  4. Bad breath © Mello, CC BY 3.0 US
  5. Sleeping on back © Sergio Filipe Cardoso Pires, CC BY 3.0 US
  6. Medication © Nikita Kozin, CC BY 3.0 US
  7. Nose © Rachel Healey, CC BY 3.0 US
  8. Black man sleeping at his desk cartoon vector ©Videoplasty, CC BY-SA 4.0
  9. CPAP © PruebasBMA, CC BY-SA 3.0
  10. Orthoapnea, oral appliance © Orthoapnea, CC BY-SA 3.0
  11. Modified from 4 figures. © Drcamachoent, CC BY-SA 4.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Dietary Fibre

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Authors: Vanessa MokDominik Zbogar | Reviewers: Janet ParkerGita Joshi | Published: 23 December 2019 | Updated: ~

Adequate fibre intake is important to ensure proper nutrition after spinal cord injury (SCI). This page outlines the current recommendations for dietary fibre and its role in managing conditions such as neurogenic bowel in SCI.

Key Points

  • Foods such as vegetables, fruits, legumes, and whole grains are great sources of dietary fibre.
  • Research in the general population shows that increasing dietary fibre reduces the risk for heart disease, obesity, diabetes, high blood pressure, and certain cancers.
  • Increasing dietary fibre in people with SCI may not have the same result as in the general population. It is important to continuously monitor how an increasing fibre intake affects you.
  • Increasing fibre in the diet should be done incrementally and may require increased fluid intake to prevent constipation.
  • An increased fibre intake may require a change in your bowel and bladder routine.

Dietary fibre is a kind of carbohydrate that is difficult for the body to break down, so it is not absorbed in the small intestines. Instead, it passes into the colon. Therefore, fibre supplies little to no calories.

Fibre can be classified into two types: soluble and insoluble. Both types of fibre play an important role in gut health and prevention of various health issues. Soluble fibre mixes with water in the intestine to form a gel-like substance that traps certain body wastes and moves them out of the body. Soluble fibre also decreases cholesterol, helps control blood sugar fluctuations, and feeds the good bacteria in the gut. Insoluble fibre absorbs and holds water, producing bulkier and uniform stool which helps with bowel movements, and it reduces the risk of colon cancer and diverticulitis among other benefits. Whole plant foods and fungi contain both types of fibre in varying amounts while animal food products contain no fibre.

Soluble fibre Insoluble fibre
  • Oatmeal/ oat bran
  • Seeds
  • Nuts
  • Legumes (e.g., beans, lentils, peas)
  • Fruits (e.g., oranges, blueberries)
  • Vegetables (e.g., broccoli)
  • Brown rice
  • Whole wheat bread
  • Whole grain cereal
  • Wheat bran
  • Fruits (e.g., bananas, avocados)
  • Vegetables (e.g., celery, carrots)Whole wheat bread, bananas, celery

 

A diagram of the digestive system showing the stomach, small intestine, large intestine, rectum, and anus.

Fibre aids in the proper movement of food through the intestines.7

When the spinal cord is injured, some or all of the nerve signals that would normally allow the brain and bowel (intestine or ‘gut’) to communicate are blocked. This can contribute to a number of bowel changes known as neurogenic bowel dysfunction. They include:

  • Reduced sensation
  • Slowed movement of stool through the bowel
  • Loss of bowel control

Depending on whether your injury is above or below T12, you may experience spastic bowel or flaccid bowel, respectively. Spastic bowel is characterized by increased muscle tone in the intestines and sphincters while flaccid bowel is characterized by decreased tone. This difference can play a role in how your body responds to changes in diet including increased fibre intake.

Dietary fibre is an important part of a bowel management program for neurogenic bowel. After a SCI, food moves through the bowels at a much slower pace. Slow movement means that food takes much longer to digest, which can lead to dry, hard stools and constipation. Too little fibre in the diet can worsen constipation, resulting in pain and difficulty when emptying the bowels. Fibre can increase bulk and soften stool. This stimulates bowel movements and makes stool easier to pass. Foods with high fibre content tend to be lower in calories too. As a result, diets that are low in fibre can contribute to uncontrolled weight gain and lead to less stable blood sugar levels after meals.

Line graph showing the relationship between risk of certain medical conditions (colorectal cancer, coronary heart disease, cardiovascular disease, stroke, and breast cancer) and dietary fibre intake.

Figure 1. In the general population, with increasing dietary fibre, the risk for various lifestyle diseases decreases in a dose-response manner.8

Research in the general population shows that adequate dietary fibre intake is associated with a decreased risk of developing numerous chronic diseases, including heart disease, high blood pressure, obesity, stroke, type 2 diabetes, and intestinal diseases (e.g. constipation, hemorrhoids).

As people with SCI are more prone to developing these health conditions due to factors including sedentary lifestyle and changes in metabolism, getting enough fibre in the diet may provide long-term health benefits.

Different species of gut bacteria

Examples of bacteria that can be found in the gut.9-12

There is emerging evidence suggesting that an imbalance of bacteria in the gut is linked to the progression of chronic conditions including diabetes, obesity, pain, and neurogenic bowel dysfunction. Additionally, recent studies have demonstrated that imbalances to the bacterial composition in the gut may result following SCI. Since fibre supports the growth of healthy bacteria in the gut, a fibre-rich diet may help to decrease these health risks in people with SCI.

Refer to our article on the Microbiome in SCI for more information!

Bar graph showing median fibre intake between females with SCI and males wih SCI in different age groups.

Figure 2. Graph showing median fibre intake in Canadians with SCI by gender and age group.13

A detailed look at fibre in the diet of individuals with SCI shows similarity between countries:

  • Canada (see the graph to the right): little variation between males and females or with age with values ranging from 15-23 g/day
  • Switzerland: people with acute SCI average 14.4 g/day and those with chronic SCI get 15.6 g/day
  • United States: 17.1 g/day
  • Iran:17.9 g/day
Individuals with SCI should not uniformly follow high fibre diets. For individuals with SCI, fibre should be increased slowly to avoid side effects and to assess tolerance. If symptoms of intolerance arise such as bloating or cramping, then one should try reducing or changing the type of fiber.

A box of All-Bran cerealIt is important to recognize that after a spinal cord injury, fibre can affect people differently and there is no agreed upon ideal amount of fibre for individuals with SCI. However, based on expert opinion, an initial diet containing no less than 15 g/day of fiber is recommended. One study (weak evidence) found that increasing dietary fibre from 25 g/day to 31 g/day with the addition of 40 g of “Kellogg’s All Bran” cereal a day to the diet worsened bowel function in 11 individuals with SCI. In fact, the higher fibre intake increased the time needed for food to move through the colon from 28 hours to 42 hours! While the Canadian recommendation for the general population is 25-38 grams per day, this study shows that individuals with SCI may respond differently to fibre. Further research is required on the effects of different types of fibre, as well as fluid intake on bowel function after an SCI.

For a review of what we mean by “expert opinion” or “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Increase fibre and increase water

Glass of waterDrinking enough water during the day is important for your health and may help prevent complications such as urinary tract infections. There is a temptation to keep water intake low to reduce catheterization frequency or other disruptions to your bladder/bowel routine. But, when you increase fibre intake it is important to also increase fluid intake to compensate. Fibre sources such as fruits and vegetables naturally contain lots of water with all the fibre they provide. However, fibre supplements, cereals, or dried fruit, nuts, ground flax seed, and the like should be accompanied by increased water consumption. It is important to strike a balance between increased fluid intake, increased fibre, and the potential impacts on your bowel and bladder routine.

 

Interestingly, little to no attention is given in guidelines to how the source of fibre may affect the bowel. In one study in the general population, it was shown that doubling stool output could be accomplished with 10 g of grain or vegetable fibre while such a doubling required 25 g of fruit fibre. The interaction of different types of dietary fibre in SCI requires investigation.

The effect of increased fibre in individuals with SCI may differ depending on whether one has spastic or flaccid bowel. One study (weak evidence) interviewing individuals about their bowel routines noted that more individuals with flaccid bowel reported benefits by modifying their diet with high fibre foods than those with spastic bowel.

Given the benefits of dietary fibre in reducing a number of diseases, it makes sense to want to increase how much you get in your diet. Individuals with SCI should increase fibre in their diet slowly to avoid side effects. In addition, for some people, high amounts of fibre may not be tolerated and fibre should be reduced if it worsens their bowel function.

Assess how much dietary fibre you currently eatPen on top of a journal

  • Take a week-long diet history by writing down what and how much you eat and drink every day for a week. You can then calculate your fibre based on the foods you have eaten using an online fibre calculator.
  • At the same time, also record the effects of your current fibre intake on stool consistency (see the Bristol Stool Scale), frequency and duration of bowel movements.
  • With this information, you will know how much fibre you are currently getting and how it affects your bowel routine. Then, you may decide to stay where you are or to increase your fibre intake.

Increase dietary fibre slowly and continue to monitor your diet

  • If you decide to increase your fibre intake, proceed gradually and obtain fibre from a wide variety of sources as described in the beginning of this article.
  • Make one or two changes a week such as adding a daily serving of fruit or switching to whole grain pasta and continue to keep track of stool consistency, frequency of bowel movements, as well as any symptoms of intolerance. Keep track of how your body responds to more fibre, different sources of fibre-containing foods and more fluids to help you make informed decisions.
  • Recognize that some foods may not agree with you. These may be spicy foods that disrupt the digestive system or certain foods that cause more gas. Beans and cruciferous vegetables (like broccoli and Brussel sprouts) have a reputation for increasing flatulence, but this is usually temporary and your body adapts. Start off with small amounts of these foods and increase gradually. Recognize that you can develop a tolerance to certain foods.
  • Should symptoms of intolerance occur (e.g., bloating, cramping, and gas), reduce your dietary fibre intake or try a different source of fibre.
  • Balance the amount of water needed for optimal stool consistency with that needed for bladder management. Based on expert opinion, people with SCI should aim for a daily fluid intake of 500 mL more than the general population. This can be calculated by using the formula: 40 mL x body weight in kg + 500 mL.

To learn more, check out our article on Bowel Changes after SCI! 

Incorporating higher dietary fibre intake into your life

  • It is likely that increased dietary fibre and increased water in your diet will affect your bowel and bladder routine. Bowel movements may be required on a daily basis as opposed to every other day or less and more catheterizations may be required for the bladder.
  • These consequences of increased dietary fibre intake need to be weighed by you and your caregivers. If the changes are not acceptable, a new balance must be reached that works for your lifestyle.

Fruits and vegetables on half a plate, protein foods on a quarter of the plate, and whole grain foosd on the last quarter of the plate.

The main way to increase fibre is to make vegetables, fruit, whole grains, and plant-based protein foods the cornerstone of your diet, as per Canada’s Food Guide.

Eating a whole food plant-based diet to meet your fibre needs instead of supplements is preferred as whole foods provide nutritional benefits that fibre supplements do not. Indeed, studies which reduced the risk of disease with fibre used food and not supplements. It is not clear if fibre from supplements brings similar benefits. However, there may be situations where a fibre supplement is the best solution.

Below is an example from Dietitians of Canada of how a low fibre diet can be modified into a high fibre diet.

Chart comparing low and high fibre diet

Kombu seaweed

Kombu seaweed.22

Other simple ways to increase fibre in your diet include:

  • Choose whole fruit over fruit juices
  • Try a fruit or vegetable you’ve never heard of
  • Avoid peeling vegetables and fruits where appropriate
  • Add legumes such as lentils, beans, and peas to soups, salads, and other dishes
  • Add seaweed to soup
  • Switch white for 100% % whole grain bread, pasta and rice
    Ground flax seed

    Ground flax seed.23

  • Eat nuts and seeds as snacks or toppings to salads
  • Use whole grain flour when baking
  • Add ground flax seed to your morning oatmeal or smoothie
  • Read food nutrition labels and choose foods containing more fibre

 

Nutrition facts label on a box of crackersCalculating the percent daily value for fibre

A Daily Value meter showing 5% or less being a little and 15% or more being a lot.

The % Daily Value is found on the nutrition facts label on the packaging of many food products.25

The percent daily value (% DV) is a guideline to help you make informed food choices.

According to Canada’s Food Guide, food with 5% DV or less per serving size is considered little of a nutrient. On the other hand, food with 15% DV or more per serving size is considered a lot of a nutrient. To help reach the recommended amount of fibre in your diet, aim for food containing 15% DV or greater.

In Canada, the DV of fibre is 25 g/day. The box of crackers in the picture indicates that each serving size provides 2 g of fibre. The % DV would be calculated to be (2 g ÷ 25 g) x 100 = 8% DV.

Dietary fibre is an important part of a healthy bowel routine. Based on expert opinion, an initial diet containing at least 15 g/day of fiber is recommended in people with SCI. Increases in fibre should be individualized and done gradually. General population fibre guidelines may not be appropriate for people after SCI, and in some cases may worsen their bowel function.

Research in the general population shows that increasing fibre in the diet reduces the risk of many lifestyle diseases that individuals with SCI are at a higher risk of developing. If you are interested in increasing your dietary fibre, adding fibre requires an individualized approach.

The recommended individualized approach is to track your diet for a week before and then during the process of increasing fibre. With the information in the food journal, you can see out how much fibre and fluids you are getting on an average day and how increased fibre and fluids affect your bowel and bladder routine. Increases in dietary fibre should be progressed slowly and monitored closely by the individual and their health care provider.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Parts of this page has been adapted from SCIRE Project (Professional) “Bowel Dysfunction and Management” Chapters:

Coggrave M, Mills P, Williams R, Eng JJ, (2014). Bowel Dysfunction and Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-48.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bowel-dysfunction-and-management/

 

Evidence for “Why is fibre important in spinal cord injury?” is based on:

Lockyer, S., Spiro, A., & Stanner, S. (2016). Dietary fibre and the prevention of chronic disease – should health professionals be doing more to raise awareness? Nutrition Bulletin, 41(3), 214–231. https://doi.org/10.1111/nbu.12212

Slavin, J. L. (2008). Position of the American Dietetic Association: health implications of dietary fiber. Journal of the American Dietetic Association, 108(10), 1716–1731. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18953766

Gungor, B., Adiguzel, E., Gursel, I., Yilmaz, B., & Gursel, M. (2016). Intestinal Microbiota in Patients with Spinal Cord Injury. PLOS ONE, 11(1), e0145878. https://doi.org/10.1371/journal.pone.0145878

Zhang, C., Zhang, W., Zhang, J., Jing, Y., Yang, M., Du, L., … Li, J. (2018). Gut microbiota dysbiosis in male patients with chronic traumatic complete spinal cord injury. Journal of Translational Medicine, 16(1), 353. https://doi.org/10.1186/s12967-018-1735-9

Data for Figure 1 “Risk of chronic diseases with dietary fibre intake” is based on:

Aune, D., Chan, D. S. M., Lau, R., Vieira, R., Greenwood, D. C., Kampman, E., & Norat, T. (2011). Dietary fibre, whole grains, and risk of colorectal cancer: Systematic review and dose-response meta-analysis of prospective studies. BMJ (Online). http://doi.org/10.1136/bmj.d6617

Threapleton, D. E., Greenwood, D. C., Evans, C. E. L., Cleghorn, C. L., Nykjaer, C., Woodhead, C., … Burley, V. J. (2013). Dietary fibre intake and risk of cardiovascular disease: systematic review and meta-analysis. BMJ (Clinical Research Ed.), 347, f6879. http://doi.org/10.1136/bmj.f6879

Threapleton, D. E., Greenwood, D. C., Evans, C. E. L., Cleghorn, C. L., Nykjaer, C., Woodhead, C., … Burley, V. J. (2013). Dietary Fiber Intake and Risk of First Stroke. Stroke, 44(5), 1360–1368. http://doi.org/10.1161/STROKEAHA.111.000151

Aune, D., Chan, D. S. M., Greenwood, D. C., Vieira, A. R., Navarro Rosenblatt, D. A., Vieira, R., & Norat, T. (2012). Dietary fiber and breast cancer risk: A systematic review and meta-analysis of prospective studies. Annals of Oncology. http://doi.org/10.1093/annonc/mdr589

Evidence for “How much fibre do we get?” is based on:

Walters, J. L., Buchholz, A. C., Martin Ginis, K. A., & SHAPE-SCI Research Group. (2009). Evidence of dietary inadequacy in adults with chronic spinal cord injury. Spinal Cord, 47(4), 318–322. https://doi.org/10.1038/sc.2008.134

Perret, C., & Stoffel-Kurt, N. (2011). Comparison of nutritional intake between individuals with acute and chronic spinal cord injury. The Journal of Spinal Cord Medicine, 34(6), 569–575. https://doi.org/10.1179/2045772311Y.0000000026

Tomey, K. M., Chen, D. M., Wang, X., & Braunschweig, C. L. (2005). Dietary intake and nutritional status of urban community-dwelling men with paraplegia. Archives of Physical Medicine and Rehabilitation, 86(4), 664–671. https://doi.org/10.1016/j.apmr.2004.10.023

Sabour, H., Javidan, A. N., Vafa, M. R., Shidfar, F., Nazari, M., Saberi, H., … Emami Razavi, H. (2012). Calorie and macronutrients intake in people with spinal cord injuries: An analysis by sex and injury-related variables. Nutrition, 28(2), 143–147. https://doi.org/10.1016/j.nut.2011.04.007

Data for Figure 2 “Median fibre intake in people with SCI” is based on:

Walters, J. L., Buchholz, A. C., Martin Ginis, K. A., & SHAPE-SCI Research Group. (2009). Evidence of dietary inadequacy in adults with chronic spinal cord injury. Spinal Cord, 47(4), 318–322. https://doi.org/10.1038/sc.2008.134

Evidence for “How much fibre should you get?” is based on:

Health Canada. (2019). Fibre. Retrieved January 2, 2019, from https://www.canada.ca/en/health-canada/services/nutrients/fibre.html

Consortium for Spinal Cord Medicine. (1998). Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury. Retrieved from http://www.pva.org/media/pdf/cpg_neurogenic bowel.pdf

Cameron, K. J., Nyulasi, I. B., Collier, G. R., & Brown, D. J. (1996). Assessment of the effect of increased dietary fibre intake on bowel function in patients with spinal cord injury. Spinal Cord, 34(5), 277–283. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8963975

de Vries, J., Birkett, A., Hulshof, T., Verbeke, K., & Gibes, K. (2016). Effects of Cereal, Fruit and Vegetable Fibers on Human Fecal Weight and Transit Time: A Comprehensive Review of Intervention Trials. Nutrients, 8(3), 130. https://doi.org/10.3390/nu8030130

Yim, S. Y., Yoon, S. H. S., Lee, I. Y., Rah, E. W., & Moon, H. W. (2001). A comparison of bowel care patterns in patients with spinal cord injury: Upper motor neuron bowel vs lower motor neuron bowel. Spinal Cord, 39(4), 204–207. https://doi.org/10.1038/sj.sc.3101131

Evidence for “How do you choose the right foods?” is based on:

Threapleton, D. E., Greenwood, D. C., Evans, C. E. L., Cleghorn, C. L., Nykjaer, C., Woodhead, C., … Burley, V. J. (2013). Dietary fibre intake and risk of cardiovascular disease: systematic review and meta-analysis. BMJ (Clinical Research Ed.), 347, f6879. https://doi.org/10.1136/bmj.f6879

Hartley, L., May, M. D., Loveman, E., Colquitt, J. L., & Rees, K. (2016). Dietary fibre for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews, (1), CD011472. https://doi.org/10.1002/14651858.CD011472.pub2

Dietitians of Canada. (2014). Healthy Eating Guidelines for Increasing your Fibre Intake. Retrieved from www.dietitians.ca

Health Canada. (2019). Percent daily value. Retrieved January 31, 2019, from https://www.canada.ca/en/health-canada/services/understanding-food-labels/percent-daily-value.html

Image credits

  1. Top view walnuts texture horizontal ©8photo, CC BY 2.0
  2. Almond almonds brazil nut – Credit to https://homegets.com/ ©David Stewart, CC BY 2.0
  3. Mr Beans ©Kenneth Leung, CC BY 2.0
  4. Vegan Nine Grain Whole Wheat Bread ©Veganbaking.net, CC BY-SA 2.0
  5. Banana © kimwang yip, CC0 1.0
  6. IMG_8230 1 ©Dennis Amith, CC BY-NC 2.0
  7. Modified from: Stomach Colon Rectum Diagram ©William Crochot, CC BY-SA 4.0
  8. Image by SCIRE Community Team
  9. Modified from: Lactobacillus casei ©AJC1, CC BY-SA 2.0
  10. Modified from: Campylobacter bacteria ©Microbe World, CC BY-NC-SA 2.0
  11. Modified from: Koli Bacteria ©geralt geralt / 18959 images, CC0 1.0
  12. Modified from: jpg ©Lamiot, CC0 1.0
  13. Image by SCIRE Community Team
  14. Kellogg’s Cereals #2 ©Like_the_Grand_Canyon, CC BY-NC 2.0
  15. Water ©rawpixel, CC0 1.0
  16. Image by SCIRE Community Team
  17. Canada’s Food Guide ©Health Canada. All Rights Reserved. Adapted and reproduced with permission from the Minister of Health, 2019.
  18. sun ©Maxim Kulikov, CC BY 3.0 US
  19. sun ©johartcamp, CC BY 3.0 US
  20. sunset ©ruliani, CC BY 3.0 US
  21. Moon ©Three Six Five, CC BY 3.0 US
  22. Kombu ©Alice Wiegand, CC BY-SA 3.0
  23. Modified from: Ground flax seed ©Veganbaking.net, CC BY-SA 2.0
  24. Image by SCIRE Community Team
  25. Daily Value meter ©Health Canada. All Rights Reserved. Adapted and reproduced with permission from the Minister of Health, 2019.


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Supported Standing

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Author: SCIRE Community Team | Reviewer: Darryl Caves | Published: 17 January 2018 | Updated: ~

Standing with supportive equipment is a therapy option after spinal cord injury (SCI). This page outlines basic information about the use of supported standing after SCI.

Key Points

  • Passive standing using supportive equipment is a therapy option for people who do not stand as part of their everyday mobility.
  • Passive standing involves using equipment such as standing frames, tilt tables, orthoses or standing wheelchairs to support an upright position for a period of time.
  • Standing involves a change in posture that challenges the circulatory system, loads the legs, and provides different sensory stimulation.
  • Research evidence suggests that standing may improve blood pressure control and spasticity management. There is conflicting evidence about whether passive standing helps with bone density or bowel and bladder health.
  • Further research is needed to better understand the benefits of standing after SCI and how long standing should be done for to achieve those benefits.
Running shoes

Standing is a therapy option following SCI.1

Standing is an important part of functional movement in humans. Standing is needed for walking, and also provides a challenge to the circulatory system, bones, and muscles in ways that cannot be achieved in sitting or lying.

Passive standing (standing with support instead of by muscle activation) may have treatment benefits after SCI, even when the recovery of walking and standing abilities is unlikely. Standing may have benefits in treating health conditions associated with SCI, such as conditions involving the musculoskeletal, circulatory, breathing, bowel and bladder systems. It remains a key treatment tool used in rehabilitation.

Supported standing involves the use of special equipment to support an upright posture. The type of equipment used depends on the person’s unique characteristics and abilities (such as the amount of muscle control in the arms, legs and trunk), the equipment that is available, and other medical concerns like joint contractures, spasticity and osteoporosis. Equipment used for standing may include a wide range of different devices such as:

Tilt tables

Illustration showing a person lying on a tilt table and secured with a band around the waist. There is an arrow showing that the tilt table is moving to an upright position.

Tilt tables can be moved from a horizontal to a vertical position.2

Tilt tables are flat surfaces that can be tilted from a horizontal position into a vertical standing position. The person is strapped securely to the table while in a horizontal lying position and the table can be tilted vertically. Tilt tables are typically the first devices that are used to work towards standing because the table can be gradually increased by degrees. This is often needed because it may take some time to tolerate being upright and maintaining a safe blood pressure. It is also a good device to test a person’s physical tolerance and safety for standing.

Standing frames

Standing frames are simple frames that have padding at the joints to support a standing position. There are many different types of standing frames. The frame needs to be fitted to the person’s unique physical abilities and body type and minimize areas of excess pressure.

Standing wheelchairs

Photograph of a person using a standing frame with cushions behind and in front of the legs to help align them. The person is resting their arms on a small desk that is attached to the frame.

Standing using a standing frame.3

Standing wheelchairs are wheelchairs that can extend from a sitting position into standing. There are many different types of standing wheelchairs, from manual devices to motorized systems. However, standing wheelchairs are expensive and not commonly available.

Body weight-supported treadmill training

Suspension body weight support systems involve a harness system that is suspended from above to support a percentage of body weight while standing. These systems are typically used while walking on a treadmill (body weight-supported treadmill training) or sometimes while walking over ground. This type of system is usually used for people with incomplete injuries that may work towards standing or stepping independently.

See our article on Body Weight Supported Treadmill Training.

Robotic exoskeletons

Robotic exoskeletons are a relatively new and emerging technology that is typically used for walking and walking training, but may also have benefits related to standing. However, this equipment is costly and not available in most settings.

Walkers, crutches or canes may be used by people with incomplete SCI and good strength in the arms who need only minimal support in standing.

Orthroses

Orthoses and braces may be used to brace the hip, knee and/or ankle joints to keep them from bending. This can help to support the person in an upright standing posture with training and rehabilitation. Orthoses and braces are typically custom-made and usually used by people with paraplegia who have good upper body strength and hip flexibility. Orthoses and braces used for standing may include:

  • Knee Ankle Foot Orthoses (KAFOs) provide support at the knee, ankle and foot.
  • Reciprocating Gait Orthoses (RGOs) are more complex orthoses that are made of a left and right KAFO that are linked together with a rigid brace at the pelvis or abdomen. The brace has hip joints that are built with an alternating stepping mechanism. When one leg is extended, the other flexes forward, providing assistance for stepping. Although normally used for walking, reciprocating gait orthoses can also be used to help support a standing position.

     

    Functional electrical stimulation

    A person walking between parallel bars with FES applied to their legs and two other people supporting the feet.

    FES can be applied to the leg muscles during assisted walking.4

    Functional electrical stimulation (FES) involves the use of electrical stimulation to activate muscles that are weak or paralyzed after an SCI during a purposeful activity. FES over the trunk or leg muscles may be used while standing with equipment for added benefits.

     

     

    See our article on Functional Electrical Stimulation (FES) for more information.

     

    Standing equipment may be expensive and sometimes requires repeated visits to healthcare facilities, which can sometimes be a barrier to regular standing. It is important for the individual to work with their health providers to find appropriate equipment that is safe and suitable.

Once appropriate equipment and strategies for standing are selected with assistance from a health provider, standing is gradually introduced over time. The amount of time spent standing, the amount of load that is taken through the legs, and the final standing position will be adjusted until a suitable standing position can be maintained. During these first several sessions, health providers will monitor for any adverse effects related to the treatment.

A person walking between parallel bars with his wheelchair behind him. A heathcare provider on the side watches him.

Standing and stepping activities may be combined to optimize therapy.5

Current research findings are unable to tell us how long or how often standing should be done to have benefits. Studies have used standing for 20 to 60 minutes, three to four times per week to study the effects of this treatment. It will be different for everyone. The standing prescription will be based on the person’s unique situation.

Depending on the treatment goals, standing may also involve:

  • Adding extra weight while standing
  • Using standing together with functional electrical stimulation (FES) to activate the muscles of the legs and/or trunk
  • Weight-shifting, balance or stepping activities

Supported standing is considered to be a relatively safe treatment for use after SCI. However, there are some situations in which standing may not be appropriate and some possible risks. This is not a complete list; please consult a health provider for further safety information.

Standing should not be used in the following situations:

  • By people with recent broken bones (fractures) or a high risk of fractures (such as people with severe osteoporosis)
    Diagram comparing bone with normal bone mineral density to bone with osteoporosis.

    People with osteoporosis have weaker bones which can pose a risk during supported standing.6

  • Where the standing equipment places excess pressure on areas where there are injuries, sores, and wounds; or areas of skin prone to pressure injuries
  • By individuals whose limbs cannot be brought into a good standing position due to other conditions like joint contractures, spasticity, or heterotopic ossification
  • By people with medical conditions where heart rate or blood pressure are uncontrolled, such as those who are unable to stay upright without a major drop in blood pressure (severe orthostatic hypotension)
  • By people with muscle or joint injuries or other conditions that may be worsened by standing

Risks of standing may include:

  • Pressure injuries if the position and equipment used for standing creates too much pressure or shear while standing – it is essential that the equipment used for standing is appropriately fitted to prevent skin damage
  • Blood pooling in the legs may lead to feelings of light-headedness, dizziness or fainting (orthostatic hypotension)
  • Broken bones (fractures) are possible in weight-bearing positions in people with osteoporosis
  • Increased spasticity or autonomic dysreflexia in some people
  • Pain in the standing position

For more information on these topics, see our articles on: Pressure Injuries, Orthrostatic Hypotension, Osteoporosis, Spasticity, and Autonomic Dysreflexia

If using electrical stimulation, the safety precautions and risks associated with use of functional electrical stimulation (FES) also apply.

Bone health

It is not clear if standing helps to maintain or increase bone density in the legs after SCI. Current research evidence is inconclusive and further studies are needed.

Blood pressure and circulationA person taking a blood pressure reading of another person wearing a blood pressure cuff

Another proposed use of standing after SCI is in helping with blood pressure control. One study provides weak evidence that standing with a harness and assistance from health providers helps to increase resting blood pressure and reduce drops in blood pressure when standing (orthostatic hypotension) in people with cervical SCI.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Spasticity

There is weak evidence that standing may help to reduce spasticity short term in people with SCI. There are also surveys that report that many people with SCI report that regular standing helped to reduce their spasticity.

Bowel problems

There is not enough evidence to determine whether standing can also improve bowel function. Further research in this area is needed.

Supported standing serves as a therapy option for people such as individuals with SCI as they do not normally stand as part of their everyday mobility. This therapy involves equipment such as standing frames, tilt tables, orthoses, or standing wheelchairs to support an upright position for a designated period of time. While there is research supporting the benefits of supported standing, conflicting evidence is still apparent. Further research is needed to better understand the benefits of supported standing after SCI.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Parts of this page have been adapted from the SCIRE Project “Bone Health”, “Orthostatic Hypotension”, “Spasticity”, and “Bowel Dysfunction and Management”  Chapters:

Craven C, Lynch CL, Eng JJ (2014). Bone Health Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 37.

Available from: http://scireproject.com/evidence/rehabilitation-evidence/bone-health/

Krassioukov A, Wecht JM, Teasell RW, Eng JJ (2014). Orthostatic Hypotension Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p. 1-26.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/orthostatic-hypotension/

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.

Available from: http://scireproject.com/evidence/rehabilitation-evidence/spasticity/

Coggrave M, Mills P, Willms R, Eng JJ, (2014). Bowel Dysfunction and Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 48.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bowel-dysfunction-and-management/

 

Evidence for “Does standing work for treating the symptoms of SCI?” is based on the following studies:

Bone health

[1] Dudley-Javoroski S, Saha PK, Liang G, Li C, Gao Z, and Shields RK. High dose compressive loads attenuate bone mineral loss in humans with spinal cord injury. Osteoporos Int 2012; 23:2335-2346.

[2] Goktepe A, Tugco I, Alaca, R, Gunduz S, Nikent M. Does standing protect bone density in patients with chronic spinal cord injury? JSCM 2008;31:197-201.

[3] Needham-Shropshire BM, Broton JG, Klose KJ, Lebwohl N, Guest RS, Jacobs PL. Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 3. Lack of effect on bone mineral density.  Arch Phys Med Rehabil 1997;78:799-803.

[4] Kunkel CF, Scremin AM, Eisenberg B, Garcia JF, Roberts S, Martinez S. Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males. Arch Phys Med Rehabil 1993;74:73-78.

[5] Kaplan PE, Roden W, Gilbert E, Richards L, Goldschmidt JW. Reduction of hypercalciuria in tetraplegia after weight-bearing and strengthening exercises. Paraplegia 1981;19:289-293.

[6] Ben M, Harvey L, Denis S, et al.  Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries? Aust J Physiother. 2005;51:251-256.

[7] de Bruin ED, Frey-Rindova P, Herzog RE, Dietz V, Dambacher MA, Stussi E. Changes of tibia bone properties after spinal cord injury: effects of early intervention. Arch Phys Med Rehabil 1999;80:214-220.

[8] Dudley-Javoroski S, and Shields RK. Active-resisted stance modulates regional bone mineral density in humans with spinal cord injury. Journal of Spinal Cord Medicine 2013; 36: 191-199.

Blood Pressure and Circulation

[1] Harkema SJ, Ferreira CK, van den Brand RJ, Krassioukov AV. Improvements in orthostatic instability with stand locomotor training in individuals with spinal cord injury. J Neurotrauma 2008;25:1467-1475.

Spasticity

[1] Odeen I, Knutsson E. Evaluation of the effects of muscle stretch and weight load in patients with spastic paraplegia. Scand J Rehabil Med 1981;13:117-21.

[2] Bohannon R. Tilt table standing for reducing spasticity after spinal cord injury. Arch Phys Med Rehabil 1993;74:1121-2.

[3] Kunkel C, Scremin A, Eisenberg B, Garcia J, Roberts S, Martinez S. Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males. Arch Phys Med Rehabil 1993;74:73-8.

[4] Dunn R, Walter J, Lucero Y, Weaver F, Langbein E, Fehr L, et al. Follow-up assessment of standing mobility device users. Assist Technol 1998;10:84-93.

[5] Eng JJ, Levins S, Townson A, Mah-Jones D, Bremner J, Huston G. Use of prolonged standing for individuals with spinal cord injuries. Phys Ther 2001;81:1392-9.

[6] Shields R & Dudley-Javoroski S. Monitoring standing wheelchair use after spinal cord injury: a case report. Disabil Rehabil 2005;27:142-6.

Bowel problems

[1] Hoenig H, Murphy T, Galbraith J, Zolkewitz M. Case study to evaluate a standing table for managing constipation. SCI Nursing 2001;18:74-7.

Other references

Dunn RB, Walter JS, Lucero Y, Weaver F, Langbein E, Fehr L, Johnson P, Riedy L. Follow-up assessment of standing mobility device users. Assist Technol. 1998;10(2):84-93.

Glickman LB, Geigle PR, Paleg GS. A systematic review of supported standing programs. J Pediatr Rehabil Med. 2010; 3(3),197-213.

Sadeghi M, McLvor J, Finlayson H, Sawatzky B. Static standing, dynamic standing and spasticity in individuals with spinal cord injury. Spinal Cord 2016;54:376-82.

Spinal Cord Injury Centre Physiotherapy Lead Clinicians. Clinical guideline for standing adults following spinal cord injury. 2013 Apr. Available from: https://www.mascip.co.uk/wp-content/uploads/2015/05/Clinical-Guidelines-for-Standing-Adults-Following-Spinal-Cord-Injury.pdf. Accessed Dec 1, 2017.

Image credits

  1. 58/365 ©John Lustig, CC BY 2.0
  2. Image by SCIRE Community Team
  3. Standing frame ©Memasa, CC BY-SA 3.0
  4. Functional Electrical Stimulation Therapy for walking ©MilosRPopovic, CC BY-SA 4.0
  5. Image by SCIRE Community Team
  6. Modified from: oesteoporosis_eng ©go elsewhere…, CC BY-NC 2.0
  7. KRT LIFE HEALTH-BLOOD-PRESSURE PG ©Fort George G. Meade Public Affairs Office, CC BY 2.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Body Weight Supported Treadmill Training

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Author: SCIRE Community Team | Reviewer: Tania Lam and Shannon Sproule | Published: 29 November 2017 | Updated: ~

Body weight supported treadmill training is a therapy that can be used to support walking training after spinal cord injury (SCI). This page outlines basic information about the use of body weight supported treadmill training after SCI.

Key Points

  • Body weight supported treadmill training is a therapy modality in which part of a person’s body weight is supported while walking on a treadmill.
  • It is usually used to work on walking ability, walking speed, and fitness in people with some control of movement in their legs after SCI (usually people with incomplete SCI).
  • Research evidence supports that body weight supported treadmill training is effective to help improve walking in people with incomplete SCI. It may also have benefits for fitness, reducing spasticity, and overall wellness.
  • The relationship between body weight supported treadmill training and stepping movements after complete SCI is not well understood. Further research is needed to understand whether body weight supported treadmill training has potential treatment benefits on walking (locomotor) function for people with complete injuries.

Body weight supported treadmill training is a therapy modality in which part of a person’s body weight is supported while walking on a treadmill. It is usually done using an overhead suspension system attached to a harness that supports part of a person’s body weight over a treadmill. While supported, the person walks with or without assistance from health providers on a treadmill.

Illustration showing a person walking on a treadmill supported by a harness around their pelvis and waste attached to an overhead suspension system by straps. Suspension system is behind the treadmill and on the other side has an off-weighting system labelled 'weight' and a height adjustable winch.

Body weight supported treadmill training is usually done using an overhead suspension system and harness that supports the body over a treadmill

Body weight supported treadmill training is usually used to work on walking in people with some control of movement in their legs after SCI (usually people with incomplete SCI).

The goals of treatment with body weight supported treadmill training may include:

To practice walking and standing

Body weight supported treadmill training is usually used to work on walking and standing skills after incomplete SCI. Because the body weight is partially supported, walking can be practiced even when a person cannot stand or walk independently. This may also allow for walking training to begin earlier after injury.

To work on walking quality and speed

Body weight supported treadmill training may be used to practice better walking patterns and prevent unwanted movement compensations that can happen during unsupported walking. It may also allow a person to safely practice walking at faster speeds. This may provide important feedback to the nervous system to help with learning.

To train fitness and health

Standing upright and walking may have benefits for cardiovascular fitness and overall health. It may also have other benefits, such as improving spasticity and feelings of wellness.

Body weight supported treadmill training usually involves the use of an overhead harness and suspension system that supports the person in standing over a treadmill. There are other forms of body weight support training, such as underwater treadmills, anti-gravity treadmills and robotic assisted systems, although these are less common in standard clinical settings.

The amount of body weight that is supported will be different for each person depending on the characteristics of their SCI (such as the level of injury), the level of support provided by the health providers, and the person’s experience with the training.

Equipment

Body weight supported treadmill training may involve the use of several different pieces of equipment, depending on the type of support provided. The most common type of harness and suspension system may involve a variety of pieces of equipment such as:

  • A harness
  • Groin and abdominal straps and padding
  • An overhead suspension system
  • A treadmill with adjustable speeds
  • A ramp up to the treadmill
  • Additional tubing or strapping
  • Parallel bars
  • Braces and orthoses
Photograph of a treadmill with handrails and equipment at the back of the treadmill supporting a harness that is placed above the treadmill.

Equipment for a suspension type system includes a treadmill, overhead suspension system, and harness1

Some body weight supported treadmill training systems may also involve the use of computer systems which control the training and/or robotic systems which guide movement of the legs.

Procedures

The exact procedures depend on the type of equipment used and the person’s physical abilities. General procedures for use of a standard harness and overhead suspension system may include the following steps:

  • In order to ensure this treatment is safe for you, your health providers will measure your heart rate, blood pressure, and assess your risk of fractures before beginning this treatment.
    Female clinician adjusting the harness on a man sitting up out of his wheelchair

    Female clinician adjusting the harness, preparing a man for the treadmill

  • Your health providers with help you put the harness and groin straps on in a lying or standing position. The harness is then tightened so it does not slide up when weight is supported.
  • The harness is then securely connected to the overhead suspension over the treadmill and you are lifted up using a mechanical lift to support some weight. There are usually bars on the side to hold on to for balance.
  • Once you are standing upright, your health provider will then turn on the treadmill and gradually increase the speed of the treadmill. Depending on your needs and abilities, hands-on assistance or braces may be used to help move the legs or control the trunk and pelvis.

Training usually begins with maximum body weight support at a slow speed. The amount of support is usually between 35% and 50% of body weight, but depends on your ability to stand on one leg without it buckling. As you get used to the training, the amount of support provided is reduced and the speed or time spent on the treadmill can be increased. It is important to maintain a good quality walking pattern to practice normal movement patterns.

Man supported with harness walks on a treadmill with a female clinician standing beside him

Man engages in body weight supported treadmill training

Amount of training

Your health provider will determine how long the training will last, depending on you and your training goals, as well as the availability of equipment and staff. Body weight supported treadmill training is often done for 15 to 30 minutes two to five times per week. However, we do not know what the optimal amount of training is.

Additional therapies

Body weight supported treadmill training is just one of many different walking therapies for people with SCI. It is often accompanied by other forms of walking training such as:

  • Walking overground (off the treadmill) with or without an assistive device, such as a walker. This may be used to help reinforce walking after treadmill training in a form that is more realistic to everyday movement.
    A leg with two electrodes on the thigh for functional electrical stimulation execise therapy

    FES training can also strengthen muscles used for walking

  • Functional electrical stimulation (FES) can be applied to the muscles of the legs and trunk during treadmill training to stimulate muscle activity. This may help to create stronger muscle contractions in weakened muscles when walking. Special FES systems (such as foot control systems that raise the toes up with each step) may be used to help with coordination when stepping.

It is important to speak with a health provider about body weight supported treadmill training to make sure it is safe and suitable for you and to learn how to use the equipment correctly.

There are some situations in which body weight supported treadmill training may be unsafe to use. This not a complete list, speak to a health provider about whether this treatment is safe and appropriate for you.

Body weight supported treadmill training should not be used in the following situations:

  • By people with medical conditions where heart rate, blood pressure, or seizures are uncontrolled
  • By individuals who are unable to stay upright for 5-10 minutes without a major drop in blood pressure
  • By people at risk of broken bones (fractures), such as people with severe osteoporosis or recent fractures
  • By people with joint limitations (such as contractures) which limit walking, weight-bearing, or standing
  • In areas where the harness may put pressure on open wounds or areas at risk of pressure sores
  • By people using mechanical ventilation

Body weight supported treadmill training should be used with caution in the following situations:

  • When there are tubes or lines attached to the body, such as a feeding tube or indwelling catheter
  • By people with severe and uncontrolled spasticity
  • By people with blood clots or a history of blood clots
  • By people with other major medical conditions or injuries
  • By people prone to autonomic dysreflexia

There are some risks and side effects that should be discussed before participating in body weight supported treadmill training. This is not a complete list; ask your health providers for more detail.

Risks and side effects of body weight supported treadmill training may include:

  • Groin discomfort or pain around the harness
  • Skin irritation near where skin or clothes are shearing against the harness
  • Abdominal discomfort or difficulty breathing if the harness is too tight
  • Broken bones (fractures)
  • Muscle strain, soreness, or injuries
  • Worsening of muscle spasms
  • Autonomic dysreflexia
  • Changes in blood pressure that may cause light-headedness and dizziness

In addition to the risks and side effects of body weight supported treadmill training, there are also practical limitations its use, including:

  • It is challenging to use and sometimes requires assistance from up to four people
  • The equipment and staff time needed for body weight supported treadmill training can be very costly
  • Many facilities do not have the staff or equipment to use body weight supported treadmill training in their day to day programs

Walking

Research studies have found that body weight supported treadmill training may help to:

  • Improve walking ability in people with chronic incomplete SCI (weak evidence)
  • Improve walking to a similar degree as walking off the treadmill at a similar intensity in people with recent incomplete SCI (moderate evidence)
  • Improve functional walking in people with incomplete SCI when used together with functional electrical stimulation (FES) of the leg muscles (moderate evidence)

Man walking while holding parallel bars

However, the benefits for walking do not appear to be unique to this type of training. Most walking strategies which involve weight-bearing (including walking overground, treadmill walking, and walking with FES) appear to be equally effective at improving walking after incomplete SCI.

Cardiovascular fitness

Several studies have looked at the effects of body weight supported treadmill training on different aspects of cardiovascular fitness after SCI. Taken altogether, these studies provide early evidence that body weight supported treadmill training helps to improve many aspects of cardiovascular fitness and health in people with complete and incomplete tetraplegia and paraplegia.

Other effects

In addition to benefits for walking and fitness, body weight supported treadmill training may also have other effects after SCI.

  • Body weight supported treadmill training may help to improve spasticity (weak evidence)
  • Body weight supported treadmill training may lead to greater life satisfaction and well-being (weak evidence)
  • Body weight supported treadmill training has been thought to improve bone density after SCI, however, early research suggests that it may not help to prevent bone loss after SCI (weak evidence).

Although we tend to think about walking as being entirely voluntary, the ability to step and walk is actually related to both conscious and unconscious (automatic) processes. Some of the automatic walking processes are thought to be controlled within the spinal cord by networks of nerve cells known as central pattern generators or CPGs.

What are central pattern generators (CPGs)?

Central pattern generators (CPGs or spinal pattern generators) are networks of nerve cells in the spinal cord that generate rhythmic movement patterns. These networks do not require signals from the brain or sensation to keep going once they are activated.

CPGs were discovered when researchers found that animals with complete SCI demonstrated stepping movements when they were supported over a treadmill. These animals could not start the movement themselves, but once it was triggered (typically by electrical stimulation, application of certain drugs, or sensory stimulation to an area between the pubic bone and sacrum called the perineum), the stepping movements continued in a rhythmic pattern which resembled walking.

These networks of nerve connections are thought to be located within the spinal cord itself and exist to allow repetitive movements to continue without the need to think about each step.

Evidence for central pattern generators in humans with complete SCI

A diagram showing how the pathway of locomotor CPG is cut short by a complete SCI

Generation of rhythmic movement through the CPG is debatable in people with SCI2

Researchers are still unsure about whether central pattern generators can be activated after complete SCI in humans. Researchers have suggested several observations that may show evidence of central pattern generators after complete SCI in humans, including:

  • Spontaneous rhythmic movements below the level of injury;
  • Stepping-like movements when electrical stimulation is applied through an electrode implanted over the spinal cord (epidural stimulation); and
  • Rhythmic muscle contractions that can be induced through treatment with certain drugs.

However, there is debate among researchers about whether these findings really show evidence of central pattern generators or not. It is also not clear if central pattern generators are activated during body weight supported treadmill training after SCI.

Automatic stepping is not walking

It is also important to consider that automatic stepping is not walking. Walking is much more complex, involving many other components, such as strength to support the body weight, balance to stay upright and shift weight, and sensation and voluntary control to adapt to the environment and situation. For these reasons, even if central pattern generators are activated after complete SCI, we do not know whether this will help a person regain walking ability or have any other benefits for functional walking.

Further research is needed to better understand central pattern generators after complete SCI. At this time, body weight supported treadmill training continues to be used clinically as a treatment for people with incomplete SCI who retain some movement in the legs.

The bottom line

Overall, the research evidence suggests that body weight supported treadmill training has positive effects on walking after incomplete SCI that are similar to other forms of walking training. It may also have benefits for fitness, spasticity, and wellness after SCI, although more high quality research is needed to confirm.

Body weight supported treadmill training appears to be relatively safe when used appropriately, however the equipment and support needed for this treatment may not be commonly available for regular use. If you are interested in this treatment, discuss your options with your health providers to find out if it is suitable to you.

For a list of included studies, please see the Reference List.


Parts of this page have been adapted from the SCIRE Project (Professional) “Lower Limb”, “Cardiovascular Health and Exercise”, “Bone Health”, “Depression after SCI” and “Spasticity”. chapters:

Lam T, Wolfe DL, Domingo A, Eng JJ, Sproule S (2014). Lower Limb Rehabilitation Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-74.

Available from: http://scireproject.com/evidence/rehabilitation-evidence/lower-limb/

Warburton DER, Krassioukov A, Sproule S, Eng JJ (2014). Cardiovascular Health and Exercise Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-48.

Available from: http://scireproject.com/evidence/rehabilitation-evidence/cardiovascular-health-and-exercise/

Craven C, Lynch CL, Eng JJ (2014). Bone Health Following Spinal Cord Injury, In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-37.

Available from: http://scireproject.com/evidence/rehabilitation-evidence/bone-health/

Orenczuk S, Mehta S, Slivinski J, Teasell RW (20140). Depression Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-35.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/depression-following-spinal-cord-injury/

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/spasticity/.

Evidence for ‘Does body weight supported treadmill training improve walking after incomplete SCI?’ is based on the following studies:

Walking

[1] Behrman AL, Ardolino E, VanHiel LR, Kern M, Atkinson D, Lorenz DJ, Harkema SJ. Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury. Arch Phys Med Rehabil 2012;93:1518-29.

[2] Buehner JJ, Forrest GF, Schmidt-Read M, White S, Tansey K, Basso DM. Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program. Arch Phys Med Rehabil 2012;93:1530-40.

[3] Lorenz DJ, Datta S, and Harkema SJ. Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation. Arch Phys Med Rehabil 2012;93:1541-52.

[4] Winchester P, Smith P, Foreman N, Mosby J, Pacheco F, Querry R, and Tansey K. A prediction model for determining over ground walking speed after locomotor training in persons with motor incomplete spinal cord injury. J of Spinal Cord Med 2009;32:63-71.

[5] Hicks AL, Adams MM, Martin Ginis K, Giangregorio L, Latimer A, Phillips SM, and McCartney N. Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: effects on functional walking ability and measures of subjective well-being. Spinal Cord 2005;43:291-298.

[6] Wirz M, Zemon DH, Rupp R, Scheel A, Colombo G, Dietz V, and Hornby TG. Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: A multicenter trial. Arch Phys Med Rehabil 2005;86:672-680.

[7] Thomas SL, Gorassini MA. Increases in corticospinal tract function by treadmill training after incomplete spinal cord injury. J Neurophysiol 2005;94:2844-2855.

[8] Protas EJ, Holmes SA, Qureshy H, Johnson A, Lee D, and Sherwood AM. Supported treadmill ambulation training after spinal cord injury: a pilot study. Arch Phys Med Rehabil 2001;82:825-831.

[9] Wernig A, Nanassy A, and Muller S. Maintenance of locomotor abilities following Laufband (treadmill) therapy in para- and tetraplegic persons: follow-up studies. Spinal Cord 1998;36:744-749.

[10] Field-Fote EC, Roach KE. Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: A randomized clinical trial. Physical Therapy 2011;91:48-60.

[11] Dobkin B, Apple D, Barbeau H, Basso M, Behrman A, Deforge D, Ditunno J, Dudley G, Elashoff R, Fugate L, Harkema S, Saulino M, and Scott M. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology 2006;66:484-493.

[12] Hitzig SL, Craven BC, Panjwani A, Kapadia N, Giangregorio LM, Richards K, Masani K, and Popovic MR. Randomized trial of functional electrical stimulation therapy for walking in incomplete spinal cord injury: effects on quality of life and community participation. Top Spinal Cord Inj Rehabil 2013;19(4):245-58.

[13] Field-Fote EC, Lindley SD, and Sherman AL. Locomotor training approaches for individuals with spinal cord injury: a preliminary report of walking-related outcomes. J Neurol Phys Ther 2005;29:127-137.

[14] Field-Fote EC, Tepavac D. Improved intralimb coordination in people with incomplete spinal cord injury following training with body weight support and electrical stimulation. Phys Ther 2002;82:707-715.

[15] Field-Fote EC. Combined use of body weight support, functional electric stimulation, and treadmill training to improve walking ability in individuals with chronic incomplete spinal cord injury. Arch Phys Med Rehabil 2001;82:818-824.

[16] Hesse S, Werner C, and Bardeleben A. Electromechanical gait training with functional electrical stimulation: case studies in spinal cord injury. Spinal Cord 2004;42:346-352.

Cardiovascular fitness

[1] Miller PJ, Rakobowchuk M, Adams MM, Hicks AL, McCartney N, Macdonald MJ. Effects of short-term training on heart rate dynamics in individuals with spinal cord injury. Auton Neurosci 2009;150(1-2):116-21.

[2] Jack LP, Allan DB, Hunt KJ. Cardiopulmonary exercise testing during body weight supported treadmill exercise in incomplete spinal cord injury: a feasibility study. Technol Health Care 2009; 17(1):13-23.

[3] Soyupek F, Savas S, Ozturk O, Ilgun E, Bircan A, Akkaya A.E ffects of body weight supported treadmill training on cardiac and pulmonary functions in the patients with incomplete spinal cord injury. J Back Musculoskelet Rehabil 2009; 22(4):213-8.

[4] Ditor DS, Macdonald MJ, Kamath MV, Bugaresti J, Adams M, McCartney N, et al. The effects of body-weight supported treadmill training on cardiovascular regulation in individuals with motor-complete SCI. Spinal Cord 2005b;43(11):664-73.

Other effects

[1] Giangregorio LM, Hicks AL, Webber CE, Phillips SM, Craven BC, Bugaresti JM, et al. Body weight supported treadmill training in acute spinal cord injury: impact on muscle and bone. Spinal Cord 2005;43:649-657.

[2] Hicks AL, Adams MM, Martin GK, Giangregorio L, Latimer A, Phillips SM, McCartney N. Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: Effects on functional walking ability and measures of subjective well-being. Spinal Cord 2005;43:291-8.

[3] Adams M, Hicks A. Comparison of the effects of body-weight-supported treadmill training and tilt-table standing on spasticity in individuals with chronic spinal cord injury. J Spinal Cord Med 2011;34:488-94.

Evidence for ‘Can body weight supported treadmill training cause stepping after complete SCI?’ is based on the following studies:

[1] Minassian K, Hofstoetter US, Dzeladini F, Guertin PA, Ijspeert A. The Human Central Pattern Generator for Locomotion. Neuroscientist. 2017 Mar 1:1073858417699790. doi: 10.1177/1073858417699790. [Epub ahead of print]
[2] Kern H, McKay WB, Dimitrijevic MM, Dimitrijevic MR. Motor control in the human spinal cord and the repair of cord function. Curr Pharm Des. 2005;11:1429-1439.

[3] Dietz V, Muller R, Colombo G. Locomotor activity in spinal man: significance of afferent input from joint and load receptors. Brain. 2002;125:2626-2634.

[4] Guertin PA. Central pattern generator for locomotion: anatomical, physiological, and pathophysiological considerations. Front Neurol. 2013 Feb 8;3:183.

[5] Yang JF, Gorassini M. Spinal and brain control of human walking: implications for retraining of walking. Neuroscientist. 2006 Oct;12(5):379-89.

[6] Illis LS. Is there a central pattern generator in man? Paraplegia. 1995 May;33(5):239-40.

Other references:

Body Weight Support Treadmill Training. Summary by: Lisa Taipalus BScPT, NEO Regional Stroke Best Practice Consultant for Physiotherapy, December 2009 (updated June 2011).

Duncan PW, Sullivan KJ, Behrman AL, Azen SP, Wu SS, Nadeau SE, et al. Body-weight-supported treadmill rehabilitation after stroke. N Engl J Med 2011;364(21):2026-2036.

Senthilvelkumar T, Magimairaj H, Fletcher J, Tharion G, George J. Comparison of body weight-supported treadmill training versus body weight-supported overground training in people with incomplete tetraplegia: a pilot randomized trial. Clin Rehabil 2015; 29(1):42-49.

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.

Hicks AL, Ginis KA. Treadmill training after spinal cord injury: it’s not just about the walking. J Rehabil Res Dev 2008; 45(2):241-218.

Image credits:

  1. Image by SCIRE Community Team
  2. ‘Figure 1. Device for body weight support (LINAK, Silkeborg, Denmark) and treadmill (FITEX T-5050; Fitex, Gwangju, Korea) and treadmill’ from: Joon Lee B, Lee HJ, Lee, WH. The effects of intensive gait training with body weight support treadmill training on gait and balance in stroke disability patients: a randomized controlled trial. Phys Ther Rehabil Sci. 2013;2(2),104-110.
  3. Image by SCIRE Community Team
  4. Image by SCIRE Community Team
  5. Image by SCIRE Community Team
  6. Image by SCIRE Community Team
  7. ‘Figure 3 `Central’ tonic input, external train of electrical stimulation, delivered by SCS can induce stepping movements’ from: Pinter, M. M., & Dimitrijevic, M. R. (1999). Gait after spinal cord injury and the central pattern generator for locomotion. Spinal cord, 37(8), 531.

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Functional Electrical Stimulation (FES)

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Author: SCIRE Community Team | Reviewer: Shannon Sproule | Published: 10 October 2017 | Updated: ~

Functional electrical stimulation is a treatment that activates muscles below the spinal cord injury (SCI) during exercise and activity. This page outlines basic information about functional electrical stimulation and its use for movement and strength after SCI.

Key Points

  • Electrical stimulation can be used to activate muscles that are weak or paralyzed after an SCI.
  • Functional electrical stimulation (FES) involves stimulating the muscles during an activity like exercise or movement.
  • FES is relatively safe and widely available treatment option for improving muscle strength and fitness after SCI.
  • Overall, the research evidence suggests that FES is most likely effective for improving muscle strength after SCI. It may also improve fitness, walking skills, bone density and other symptoms, although more high quality research is needed to confirm.

Functional electrical stimulation (FES) is a type of neuromodulation where electrical stimulation is applied to the nerves located outside the spinal cord and brain. This stimulation causes the muscles to contract and can assist with purposeful or functional movement in weak or paralyzed muscles.

FES is delivered using a variety of handheld or specialized commercial electrical therapy machines connected to electrodes that are placed on the skin surface. Systems are also available with implanted electrodes in the muscles, although this is very specialized and not widely available.

FES electrodes are placed on the leg muscles to be used during stationary cycling.1

Muscle stimulation is used for several reasons after SCI:

To promote movement and strength in weak or paralyzed muscles: Muscles stimulation is used early in rehabilitation to promote movement in muscles that are not moving or only producing a flicker of movement. It may promote recovery of movement function by assisting with normal movements and with repetition of movements.

To improve fitness and health: When FES is used as part of a rhythmic exercise like cycling, walking, or rowing, it can help to maintain health of the heart, lungs, and circulation. It may also help to maintain healthy bones.

To assist with functional movement activities like stepping, getting up to standing, and grasping: FES can be used to assist with purposeful movements by improving muscle contractions (for weakened muscles), mobility or range of movement as well as possibly decreasing spasticity.

To maintain muscle mass below the SCI: Regular use of FES may help to prevent muscle loss that happens when the muscles that are paralyzed are not used. Unless neurological return occurs this improvement will stop if the FES is discontinued.

To control the muscles of breathing and bladder function: This includes the use of surgically implanted diaphragmatic pacers (FES systems that create muscle contractions in the diaphragm to stimulate regular breaths) and bladder control systems (FES systems that stimulate the muscles of urination). However, this page will focus on FES used for movement and strength after SCI.

Other names for FES of muscles

You may hear other names for FES such as ‘neuromuscular electrical stimulation’ (NMES) or simply ‘electrical stimulation’ (ES). These terms are often used to refer to electrical stimulation of the muscles during more passive activities (like lying down or sitting), while ‘FES’ usually describes stimulation during purposeful activities like cycling or walking. However, in practice these terms are often used interchangeably to describe similar or related treatments and the goals of all are to promote strength, movement and function and decrease pain and spasticity.

There are a number of other neuromodulation techniques that are used for various purposes in SCI, including transcutaneous electrical nerve stimulation, sacral nerve stimulation, and intrathecal Baclofen, described in other SCIRE Community articles.

It is important to speak with a health provider about using FES to make sure it is safe and suitable for you and to learn how to use the equipment correctly.

FES is usually applied through electrodes that are placed on the surface of the skin, although electrodes can also be implanted into the muscles. Electrodes are placed over nerves or part of the muscles below the SCI that respond well to electrical stimulation. The electrodes are then attached to an adjustable machine that generates the stimulation. Your health provider will determine the settings that are used for the treatment and how long it will last for.

The electrical stimulation is then gradually turned up until the muscles begin to tense or contract. Depending on your sensation, as the machine is turned up, you may feel pins and needles or other unusual sensations, which may take some time to get used to. The aim is to create a forceful but tolerable muscle contraction.

FES is applied through electrodes on the leg muscles during assisted walking.2

If the electrical stimulation goes well, it is then combined with a movement task. This may be as simple as lifting a wrist or ankle or more complex such as cycling on a stationary bike, rowing on a rowing machine, grasping, or stepping in parallel bars or a body weight support treadmill system.

The length of each session will vary depending on the goals of the treatment. Time may be required to enable your muscles to tolerate longer sessions as the muscles may fatigue quickly. Sessions are usually done several times per week for several weeks to gain training benefits.

Your health provider will monitor your response to the treatment and inspect the skin for any redness or irritation after the treatment has ended. Once you have learned to use FES safely, you may be able to use it on your own.

Our bodies naturally use electrical signals as part of the nervous system. When we move, the brain generates and sends electrical impulses along the spinal cord and nerves to tell the muscles to move.

Spinal cord injury can interrupt this pathway, preventing electrical impulses from passing through the spinal cord to reach the muscles. However, if the nerves and muscles below the injury are not damaged, they can still respond to electrical signals.

A leg with two electrodes on the thigh for functional electrical stimulation execise therapy

FES electrodes are placed over nerves or over electrically-sensitive parts of the muscles below the SCI. The specific type of electrical stimulation used with FES can trigger the nerve cells of movement (motor neurons) to send signals that cause muscle movement. An intact peripheral nerve and healthy muscle tissue is required to enable the external source of electricity to facilitate the muscle contraction.

FES does not work for nerve injuries outside the spinal cord

FES can only be used for muscle weakness or paralysis caused by injuries to the spinal cord, but not injuries to the conus medullaris, cauda equina, or the nerves outside of the spinal cord. The nerve cells in these structures (called lower motor neurons) must to be intact for FES to work.

 

Like exercise, regular treatment with FES is usually needed to maintain the effects of the treatment. For people with complete injuries, when FES treatments are stopped, the treatment effects will usually go away over time. For people with incomplete injuries, the goal is for some carryover of strength and movement be retained after the treatment is stopped.

A cartoon pen and clipboard with check marks and x marksThere are some situations in which FES may be unsafe to use. This not a complete list, speak to a health provider about your health history and whether FES is safe for you.

FES should not be used in the following situations:

  • Near implanted medical devices like heart pacemakers
  • On areas of active cancer, or by people with bleeding disorders or other major medical conditions
  • On areas with blood clots, bleeding, damaged skin, infection, or poor circulation
  • By pregnant women
  • Electrodes should not be placed over the eyes, through the head, through the chest or abdomen, or on the front of the neck or genitals
  • By people with recent broken bones
  • By people with damage to the nerves or muscles near the area where FES is used

FES should be used with caution in the following situations:

FES is often used with the following conditions after SCI but should be monitored closely. Speak to your health provider for more information.

FES is generally well tolerated by people who can use it safely (see above for when FES may be unsafe). Serious medical complications from FES are rare. However, there are risks and side effects that should be discussed with a health provider before using FES.

More common risks and side effects of FES include:

Other less common risks and side effects of FES include:

  • Mild electrical burns near the electrodes
  • Skin breakdown near the electrodes
  • Fainting
  • Worsening of muscle spasms (spasticity)
  • Muscle and joint injuries, such as joint swelling or muscle strains
  • Broken bones
  • Mild electrical shocks (from improper use or faulty equipment)

In some cases, risks and side effects may be caused by improper use of the equipment. It is essential to learn to use the equipment from a health provider and to only use FES according to their direction and with the settings that they recommend.

For some people, side effects of FES may be stronger at first, but as their body gets used to FES with repeated treatments, their physical reactions may reduce over time.

Several studies have shown that FES helps to improve strength and fitness after SCI.

Strength

Cartoon of a flexed armStudies have shown that both FES arm exercise and FES cycling helps to maintain or improve strength after SCI. However, FES cycling may be more effective for maintaining strength after injury than improving strength that has already been lost. This is supported by moderate evidence from five studies.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Cardiovascular fitness

Heart with a barbellFifteen studies have looked at FES for improving many different aspects of fitness after SCI. Taken altogether, these studies provide weak evidence that FES training done at least 3 days per week for 2 months helps to improve many aspects of cardiovascular fitness after SCI.

Walking

A person walking between parallel bars with his wheelchair behind him. A heathcare provider on the side watches him.Studies show that FES improves walking speed and distance in people with both incomplete and complete SCI. Some of these studies also showed that regular use of FES carried over to improve walking even without FES. This is supported by weak evidence from eight studies.

The effects of FES treatment may also help to prevent complications of SCI like pressure sores, bone loss, spasticity, and orthostatic hypotension. These benefits may accompany gains in strength or fitness related to FES treatment.

Pressure sores

A woman lifting up her buttocks off her wheelchair by straightening her armsAlthough it is commonly thought that increased muscle bulk from FES will reduce the risk of pressure sores, there are not very many studies which have looked at whether this actually happens. One study provides weak evidence that FES cycling for 2 years reduced the number of pressure ulcers that occurred after SCI. Another study showed that regular FES cycling showed a trend towards reducing seat pressures.

Bone health

Silhouette of a fractured boneResearch studies show that FES cycling does not prevent bone loss after SCI (moderate evidence from two studies). However, it may help to increase bone density that has already been lost, although the evidence for this is conflicting (based on six studies). It is not clear whether any gains in bone density last long-term or if continued FES treatment is needed for them to be maintained.

For more information on bone density, read our article Osteoporosis After Spinal Cord Injury.

Spasticity

It is not clear what effects FES has on spasticity after SCI. There is conflicting evidence from three studies about whether FES cycling can help to reduce spasticity after SCI.

Click here for our article on Spasticity.

Orthostatic hypotension

Three studies provide moderate evidence that FES of the legs during a single change in position reduced orthostatic hypotension. However, this only shows that FES prevents orthostatic hypotension while it is applied, and further research is needed to look at what benefits this could have to people living with SCI.

Click here for our article on Orthrostatic Hypotension.

Overall, the research evidence suggests that FES is most likely effective for improving muscle strength after SCI. It may also have effects on fitness, walking skills, bone density, skin health, spasticity, and orthostatic hypotension, although more high quality research is needed to confirm. FES appears to be safe when used appropriately and is widely available in most rehabilitation settings. Discuss this treatment with your health providers to find out if it is a suitable treatment option for you.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Parts of this page have been adapted from the SCIRE Project (Professional) “Lower Limb”, “Upper Limb”, “Bone Health”, “Cardiovascular Health and Exercise”, “Orthostatic Hypotension”, “Pressure Ulcers”, and “Spasticity” chapters:

Lam T, Wolfe DL, Domingo A, Eng JJ, Sproule S (2014). Lower Limb Rehabilitation Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-74.

Available from: http://scireproject.com/evidence/rehabilitation-evidence/lower-limb/

Connolly SJ, McIntyre A, Mehta, S, Foulon BL, Teasell RW. (2014). Upper Limb Rehabilitation Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-77.

Available from: http://scireproject.com/evidence/rehabilitation-evidence/upper-limb/

Craven C, Lynch CL, Eng JJ (2014). Bone Health Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 37.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bone-health/

Warburton DER, Krassioukov A, Sproule S, Eng JJ (2014). Cardiovascular Health and Exercise Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p. 1-48.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/cardiovascular-health-and-exercise/

Krassioukov A, Wecht JM, Teasell RW, Eng JJ (2014). Orthostatic Hypotension Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p. 1-26.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/orthostatic-hypotension/

Hsieh J, McIntyre A, Wolfe D, Lala D, Titus L, Campbell K, Teasell R. (2014). Pressure Ulcers Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. 1-90.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/skin-integrity-pressure-injuries/

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/spasticity/

 

Evidence for “Strength” is based on the following studies:

[1] Baldi JC, Jackson RD, Moraille R, and Mysiw WJ. Muscle atrophy is prevented in patients with acute spinal cord injury using functional electrical stimulation. Spinal Cord 1998;36:463-469.

[2] Scremin AM, Kurta L, Gentili A, Wiseman B, Perell K, Kunkel C, and Scremin OU. Increasing muscle mass in spinal cord injured persons with a functional electrical stimulation exercise program. Arch Phys Med Rehabil 1999;80:1531-1536.

[3] Crameri RM, Weston A, Climstein M, Davis GM, and Sutton JR. Effects of electrical stimulation-induced leg training on skeletal muscle adaptability in spinal cord injury. Scand J Med Sci Sports 2002;12:316-322.

[4] Gerrits HL, de Haan A, Sargeant AJ, Dallmeijer A, and Hopman MT. Altered contractile properties of the quadriceps muscle in people with spinal cord injury following functional electrical stimulated cycle training. Spinal Cord 2000;38:214-223.

[5] Needham-Shropshire BM, Broton JG, Cameron TL, Klose J. Improved motor function in tetraplegics following neuromuscular stimulation-assisted arm ergometry. J Spinal Cord Med 1997;20:49-55.

[6] Cameron T, Broton JG, Needham-Shropshire B, Klose KJ. An upper body exercise system incorporating resistive exercise and neuromuscular electrical stimulation (nms). J Spinal Cord Med 1998;21:1-6.

Evidence for “Cardiovascular Fitness” based on:

[1] Berry HR, Kakebeeke TH, Donaldson N, Perret C, Hunt KJ. Energetics of paraplegic cycling: adaptation to 12 months of high volume training. Technology and Health Care 2012; 20: 73-84.

[2] Griffin L, Decker MJ, Hwang JY, Wang B, Kitchen K, Ding Z, et al. Functional electrical stimulation cycling improves body composition, metabolic and neural factors in persons with spinal cord injury. J Electromyogr Kinesiol 2009;19(4):614-22.

[3] Zbogar D, Eng JJ, Krassioukov AV, Scott JM, Esch BT, Warburton DE. The effects of functional electrical stimulation leg cycle ergometry training on arterial compliance in individuals with spinal cord injury. Spinal Cord 2008;46(11):722-6.

[4] Crameri RM, Cooper P, Sinclair PJ, Bryant G, Weston A. Effect of load during electrical stimulation training in spinal cord injury. Muscle Nerve 2004;29(1):104-11.

[5] Hjeltnes N, Aksnes AK, Birkeland KI, Johansen J, Lannem A, Wallberg-Henriksson H. Improved body composition after 8 wk of electrically stimulated leg cycling in tetraplegic patients. Am J Physiol 1997;273(3 Pt 2):R1072-9.

[6] Mohr T, Andersen JL, Biering-Sorensen F, Galbo H, Bangsbo J, Wagner A, et al. Long-term adaptation to electrically induced cycle training in severe spinal cord injured individuals. Spinal Cord 1997;35(1):1-16.

[7] Barstow TJ, Scremin AM, Mutton DL, Kunkel CF, Cagle TG, Whipp BJ. Changes in gas exchange kinetics with training in patients with spinal cord injury. Med Sci Sports Exerc 1996;28(10):1221-8.

[8] Faghri PD, Glaser RM, Figoni SF. Functional electrical stimulation leg cycle ergometer exercise: training effects on cardiorespiratory responses of spinal cord injured subjects at rest and during submaximal exercise. Arch Phys Med Rehabil 1992;73(11):1085-93.

[9] Hooker SP, Figoni SF, Rodgers MM, Glaser RM, Mathews T, Suryaprasad AG, et al. Physiologic effects of electrical stimulation leg cycle exercise training in spinal cord injured persons. Arch Phys Med Rehabil 1992;73(5):470-6.

[10] Gerrits HL, de Haan A, Sargeant AJ, van Langen H, Hopman MT. Peripheral vascular changes after electrically stimulated cycle training in people with spinal cord injury. Arch Phys Med Rehabil 2001;82(6):832-9.

[11] Ragnarsson KT, Pollack S, O’Daniel W, Jr., Edgar R, Petrofsky J, Nash MS. Clinical evaluation of computerized functional electrical stimulation after spinal cord injury: a multicenter pilot study. Arch Phys Med Rehabil 1988;69(9):672-7.

[12] Taylor JA, Picard G, Widrick JJ. Aerobic capacity with hybrid FES rowing in spinal cord injury: comparison with arms-only exercise and preliminary findings with regular training. PM R 2011;3(9):817-24.

[13] Kahn NN, Feldman SP, Bauman WA. Lower-extremity functional electrical stimulation decreases platelet aggregation and blood coagulation in persons with chronic spinal cord injury: a pilot study. J Spinal Cord Med 2010;33(2): 150-8.

[14] Hakansson NA, Hull ML. Can the efficacy of electrically stimulating pedaling using a commercially available ergometer be improved by minimizing the muscle stress-time integral? Muscle Nerve 2012; 45:393-402.

Evidence for “Walking” is based on the following studies:

[1] Thrasher TA, Flett HM, and Popovic MR. Gait training regimen for incomplete spinal cord injury using functional electrical stimulation. Spinal Cord 2006;44:357-361.

[2] Ladouceur M, and Barbeau H. Functional electrical stimulation-assisted walking for persons with incomplete spinal injuries: changes in the kinematics and physiological cost of overground walking. Scand J Rehabil Med 2000a;32:72-79.

[3] Ladouceur M, and Barbeau H. Functional electrical stimulation-assisted walking for persons with incomplete spinal injuries: longitudinal changes in maximal overground walking speed. Scand J Rehabil Med 2000b;32:28-36.

[4] Wieler M, Stein RB, Ladouceur M, Whittaker M, Smith AW, Naaman S, Barbeau H, Bugaresti J, and Aimone E. Multicenter evaluation of electrical stimulation systems for walking. Arch Phys Med Rehabil 1999;80:495-500.

[5] Klose KJ, Jacobs PL, Broton JG, Guest RS, Needham-Shropshire BM, Lebwohl N, Nash MS, and Green BA. Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 1. Ambulation performance and anthropometric measures. Arch Phys Med Rehabil 1997;78:789-793.

[6] Granat MH, Ferguson AC, Andrews BJ, and Delargy M. The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury–observed benefits during gait studies. Paraplegia 1993;31:207-215.

[7] Stein RB, Belanger M, Wheeler G, Wieler M, Popovic DB, Prochazka A, and Davis LA. Electrical systems for improving locomotion after incomplete spinal cord injury: an assessment. Arch Phys Med Rehabil 1993;74:954-959.

[8] Granat M, Keating JF, Smith AC, Delargy M, and Andrews BJ. The use of functional electrical stimulation to assist gait in patients with incomplete spinal cord injury. Disabil Rehabil 1992;14:93-97.

Evidence for “Bone health” is based on the following studies:

[1] Eser P, de Bruin ED, Telley I, Lechner HE, Knecht H, Stussi E. Effect of electrical stimulation-induced cycling on bone mineral density in spinal cord-injured patients. Eur J Clin Invest 2003;33:412-419.

[2] Lai CH, Chang WHS, Chan WP, Peng CW, Shen LK, Chen JJJ, Chen SC. Effects of Functional Electrical Stimulation Cycling Exercise on Bone Mineral Density Loss in the Early Stages of Spinal Cord Injury. J Rehabil Med 2010; 42:150-154.

[3] Mohr T, Podenphant J, Biering-Sorensen F, Galbo H, Thamsborg G, Kjaer M. Increased bone mineral density after prolonged electrically induced cycle training of paralyzed limbs in spinal cord injured man. Calcif Tissue Int 1997;61:22-25.

[4] Chen SC, Lai CH, Chan WP, Huang MH, Tsai HW, Chen JJ. Increases in bone mineral density after functional electrical stimulation cycling exercises in spinal cord injured patients. Disabil Rehabil 2005;27:1337-1341.

[5] Frotzler A, Coupaud S, Perret C, Kakebeeke TH, Hunt KJ, Donaldson Nde N, Eser P. High-volume FES-cycling partially reverses bone loss in people with chronic spinal cord injury. Bone. 2008 Jul;43(1):169-76. Epub 2008 Mar 20.

[6] Pacy PJ, Hesp R, Halliday DA, Katz D, Cameron G, Reeve J. Muscle and bone in paraplegic patients, and the effect of functional electrical stimulation. Clin Sci (Lond) 1988;75:481-487.

[7]  Leeds EM, Klose J, Ganz W, Serafini A, Green BA. Bone mineral density after bicycle ergometry training. Archives of Physical Medicine and Rehabilitation 1990;71:207-9.

[8] BeDell KK, Scremin AM, Perell KL, Kunkel CF. Effects of functional electrical stimulation-induced lower extremity cycling on bone density of spinal cord-injured patients. Am J Phys Med Rehabil 1996;75:29-34.

Evidence for “Pressure Ulcers” is based on the following studies:

[1] Dolbow DR, Gorgey AS, Dolbow JD, Gater DR. Seat pressure changes after eight weeks of functional electrical stimulation cycling: a pilot study. Top Spinal Cord Inj Rehabil. 2013 Summer;19(3):222-8.

[2] Petrofsky JS. Functional electrical stimulation, a two year study. J Rehabil. 1992;58(3):29–34

Evidence for “Spasticity” is based on the following studies:

[1] Kapadia N, Masani K, Craven B, et al. A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on walking competency. J Spinal Cord Med 2014;37:511-24.

[2] Manella K & Field-Fote E. Modulatory effects of locomotor training on extensor spasticity in individuals with motor-incomplete spinal cord injury. Restor Neurol Neurosci 2013;31:633-46.

[3] Ralston K, Harvey L, Batty J, et al. Functional electrical stimulation cycling has no clear effect on urine output, lower limb swelling, and spasticity in people with spinal cord injury: A randomised cross-over trial. J Physiother 2013;59:237-43.

[4] Kuhn D, Leichtfried V, Schobersberger W. Four weeks of functional electrical stimulated cycling after spinal cord injury: a clinical cohort study. Inter J Rehabil Res 2014;37:243-50.

[5] Mazzoleni S, Stampacchia G, Gerini A, Tombini T, Carrozza M. FES-cycling training in spinal cord injured patients. Eng Med Biol Soc 2013:5339-41.

[6] Sadowsky C, Hammond E, Strohl A, et al. Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury. J Spinal Cord Med 2013;36:623-31.

[7] Reichenfelser W, Hackl H, Hufgard J, Kastner J, Gstaltner K, Gföhler M. Monitoring of spasticity and functional ability in individuals with incomplete spinal cord injury with a functional electrical stimulation cycling system. J Rehabil Med 2012;44:444-9.

[8] Krause P, Szecsi J, Straube A. Changes in spastic muscle tone increase in patients with spinal cord injury using functional electrical stimulation and passive leg movements. Clin Rehabil 2008;22:627-34.

[9] Mirbagheri M, Ladouceur M, Barbeau H, Kearney R. The effects of long-term FES-assisted walking on intrinsic and reflex dynamic stiffness in spastic spinal-cord-injured

[10] Granat M, Ferguson A, Andrews B, Delargy M. The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury–observed benefits during gait studies. Paraplegia 1993;31:207-15.

[11] Thoumie P, Le C, Beillot J, Dassonville J, Chevalier T, Perrouin-Verbe B et al. Restoration of functional gait in paraplegic patients with the RGO-II hybrid orthosis. A multicenter controlled study. II: Physiological evaluation. Paraplegia 1995;33:654-9.

Evidence for “Orthostatic Hypotension” is based on the following studies:

[1] Faghri PD, Yount J. Electrically induced and voluntary activation of physiologic muscle pump: a comparison between spinal cord-injured and able-bodied individuals. Clin Rehabil 2002;16:878-885.

[2] Elokda AS, Nielsen DH, Shields RK. Effect of functional neuromuscular stimulation on postural related orthostatic stress in individuals with acute spinal cord injury. J Rehabil Res Dev 2000;37:535-542.

[3] Sampson EE, Burnham RS, Andrews BJ. Functional electrical stimulation effect on orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil 2000; 81: 139-143.

Other references:

Electrophysical Agents – Contraindications And Precautions: An Evidence-Based Approach To Clinical Decision Making In Physical Therapy. Physiother Can. 2010 Fall;62(5):1-80.

Gibbons RS, Shave RE, Gall A, Andrews BJ. FES-rowing in tetraplegia: a preliminary report. Spinal Cord. 2014 Dec;52(12):880-6.

Martin R, Sadowsky C, Obst K, Meyer B, McDonald J. Functional electrical stimulation in spinal cord injury: from theory to practice. Top Spinal Cord Inj Rehabil. 2012 Winter;18(1):28-33.

Warms CA, Backus D, Rajan S, Bombardier CH, Schomer KG, Burns SP. Adverse events in cardiovascular-related training programs in people with spinal cord injury: a systematic review. J Spinal Cord Med. 2014 Nov;37(6):672-92.

Image credits

  1. E-Stim Therapy ©Rankn Jordan, CC BY-NC-SA 2.0
  2. Functional electrical stimulation ©MilosRPopovic, CC BY-SA 4.0
  3. Image by SCIRE Community Team
  4. Checklist ©lastspark,CC BY 3.0 US
  5. Muscle © Smalllike, CC BY 3.0 US
  6. cardio ©emma Mitchell, CC BY 3.0 US
  7. Image by SCIRE Team.
  8. Image by SCIRE Team.
  9. fracture ©fahmionline, CC BY 3.0 US

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.