Author: SCIRE Community Team | Reviewer: Susan Andrews | Published: 3 November 2017 | Updated: ~
- A pressure injury (or pressure ulcer, wound, or sore) is damage to the skin and underlying tissues caused by pressure, friction, or shear. Pressure injuries are common on weight-bearing areas of the body like the sit bones and tailbone.
- Pressure injuries are a common complication of SCI that can have serious consequences including reduced independence and life-threatening infections.
- People with SCI are at greater risk of developing pressure injuries because of changes to the body and how it is used after SCI.
- Preventing pressure injuries is very important and involves checking the skin regularly, pressure relief, staying healthy, and early treatment of potential injuries.
- The most important factor in treating a pressure injury is identifying and removing the cause of the injury.
- Pressure injuries are treated using several treatments, including wound care and dressings, medications, electrical and light stimulation, debridement, and surgery.
A pressure injury (also known as pressure wound, pressure ulcer or bed sore) is a breakdown of the skin and the tissues under the skin that is caused by pressure, friction, or shear.
Pressure injuries are a common complication of SCI that happens because of changes to the body and how it is used after the injury. Pressure injuries usually happen on areas of the body that bear weight in sitting or lying, such as the sit bones, tailbone, heels, back of the knees, elbows, and shoulder blades.
Pressure injuries are common
Pressure injuries are common after SCI. They can affect as many as one third of people with SCI each year and almost every person with an SCI experiences at least one pressure injury in their lifetime. The risk of pressure injuries increases over time when living with an SCI long-term.
Pressure injuries can have serious consequences
Pressure injuries can have serious consequences for health, function, and quality of life, including:
- Difficult and lengthy healing
- Infections, including severe infections that lead to a life-threatening condition called sepsis
- Long and costly hospital stays and re-hospitalizations
- Reduced independence and mobility during healing
- Inability to participate in work and school during healing
- Reduced life satisfaction and quality of life
- A greater need for assistance from caregivers and family during healing
Prevention is essential to reduce risk
The best management for pressure injuries is prevention. In fact, many pressure injuries are preventable through a combination of good self-care, staying healthy, and regular check-ins with your health team. It is essential to learn how to recognize, prevent, and treat pressure injuries as soon as possible after SCI to help reduce your risk.
Find out what advice Josh has on pressure sores and routines you can follow to avoid them.
Pressure injuries happen because of many different factors from both inside and outside the body. There are a number of changes to the body after SCI that make pressure injuries more likely. These factors, combined with forces like pressure, friction, and shear, can cause pressure injury.
Pressure injuries usually form on weight-bearing areas of the body that are in contact with supporting surfaces. This usually happens when sitting or lying in the same position for a long time or when positioned on a surface that does not support the weight properly (such as a hard chair).
Pressure usually happens in specific areas depending on the position, but most often affects the sit bones (ischial tuberosities), tailbone (sacrum and coccyx), heels, backs of the knees, elbows, back of the head, and shoulder blades.
Too much pressure can prevent blood from reaching the area, which is important for bringing oxygen and nutrients to the tissues. This can lead to skin damage or breakdown. Skin breakdown can happen quite quickly (in even 30 to 60 minutes) on a hard surface without changing positions regularly.
Friction and shear
Pressure injuries can also be caused by friction and shear. Friction can happen when the skin is rubbed on a course surface, such as sitting on an uneven wrinkle of clothing or rough surface. This can cause injury to the surface of the skin which can lead to skin breakdown.
Shear is a type of force where the skin goes one way and the body goes the opposite direction. This usually happens when the skin is caught on a surface while the body is moved. For example, when transferring in bed, the skin might be pulled along the bed while the person shifts positions, which causes shear. Shear strains and injures the tissues close to the bone.
There are many other factors from both inside and outside the body after SCI that make pressure injuries more likely to develop.
Other factors that contribute to pressure injuries
Changes to the skin
Spinal cord injury can affect the skin in various ways. The skin below the injury may become less elastic and weaker as a result of tissue changes caused by the SCI. In addition, people with injuries above T6 lose the ability to sweat below the injury, which means that body temperature is not regulated very well.
Loss of sensation
Sensation is important because it allows us to recognize discomfort and provides a cue to change position regularly. When sensation is reduced or absent, these cues are not present and we may sit in an uncomfortable position where there is too much pressure for too long.
Loss of movement
Loss of movement also contributes to pressure injuries. People with reduced movement often use a wheelchair as their main method of mobility, which may lead to long periods of sitting in one position. It may also be more difficulty to reposition in sitting or lying so pressure may be placed in one area for too long. As well, when the muscles are not used regularly, they shrink (called muscle atrophy), which means there is less padding between the skin and bone.
Hear Peter speak about his difficulties with not having sensation to his elbows.
Moisture makes the skin more vulnerable to injury and bacteria. Moisture may be present because of bladder or bowel problems after an SCI or in warm and humid climates.
Changes to body weight, either being too thin or overweight, can increase the risk of pressure injuries. When a person is underweight, there is less padding between the skin and bone. When a person is overweight, the body is heavier, which creates more pressure in weight-bearing and can also make transfers more difficult, which may result in more shearing and friction.
The characteristics of surfaces that support the body in regular positions are very important for distributing pressure. This includes wheelchair cushions, mattresses, couch cushions, car seats, commode or toilet seats, sports equipment, and any other surface that is regularly used for supporting the body. Hard or unsupportive surfaces can contribute to developing pressure injuries. It is important to also consider surfaces in unfamiliar settings, such as when travelling or when a hospital visit is needed. Airplane seats and hospital stretchers do not often provide enough protection for your skin following SCI and you may need a lightweight travel cushion when travelling or to request a specialized surface if you need to visit a hospital.
- Reduced ability to fight infections (reduced immune function)
- Other medical conditions like infections, blood clots, spasticity and contractures
- Poor nutrition (especially if there is not enough calories or protein)
- Reduced physical activity
- Long periods of bed rest
- The sit bones (ischial tuberosities) may become flatter over time
- Higher level of injury and complete SCI
- Reduced ability to perform behaviours that reduce risk, such as regular pressure relief, good skin care, and skin inspections
Pressure injuries are classified by how severe they are as “stages” of injury. These stages can range from just a small amount of redness on the skin to a wound that travels all the way down to the bone. Determining which stage a pressure injury is can help you and your health team to measure the extent of wounds and figure out how to treat it.
Stages of Pressure Injury (National Pressure Injury Advisory Panel)2
To identify a pressure injury early you need to check your skin once or twice daily using a mirror or with the help of a care provider.
The main way that pressure injuries are diagnosed is with a visual skin check. Checking by feel is not enough, because it only identifies open areas that can be felt. Early pressure injury can be as simple as red or purple discoloration to the skin.
If there is an open wound you may need to be seen by a physician and referred to a nurse for a wound assessment. This may involve starting a treatment plan that should include trying to identify the cause of the pressure injury.
The nurse will observe the wound and take note of its appearance (such as its edges, colour, and shape) and look for signs of inflammation or infection. The nurse may take measurements of the length, width, and depth of the wound. These can help determine the stage of the wound and be used as a comparison as it heals. Sometimes, the nurse may take photos for assessment purposes. A swab of the pressure sore is only taken if infection is suspected. Infection is suspected if there has been increased redness, odour or drainage or if pain has increased if you have sensation.
It is often helpful to have an occupational therapist or physiotherapist involved to help figure out the cause of tissue damage.
Listen to Josh describe his experience of having a pressure sore he wasn’t aware of and how he overcame it with the help of a specialist.
- Blood tests may be used to identify if there is an infection.
- Ultrasound is an imaging technique that may be used in some facilities. Ultrasound imaging uses sound waves to detect injuries deep within the skin. It may be used to detect suspected pressure injuries that are not easily seen.
The most important part of managing pressure injuries is preventing them from happening in the first place. Many different techniques may be used to prevent pressure injuries. Some of these are a part of self-care and others involve working together with your health team.
Learning how to prevent pressure injuries
Early on in your care, your health providers will speak to you about how to prevent pressure injuries. This may be a part of one-on-one care or as a part of a group education class. Prevention education is a very important part of reducing risk. You will learn how to identify skin concerns early on and the best techniques for you to keep your skin healthy.
Maintaining good skin care
Regular skin care is an important part of preventing pressure injuries. Many of these techniques you will learn as a part of skincare education.
Regular skin checks
Checking the skin for changes in color and texture is important to recognize areas of risk and to identify any changes early. The main areas to check are bony areas, like the sit bones, tail bone, side of the hips, and heels. A mirror or assistance from a caregiver may be needed to check some areas. Any areas of redness, bruising, or injury should be discussed with your health providers immediately. Skin checks are recommended once or twice daily or after activities like prolonged bed rest or trying new equipment.
Listen to Peter describe how he regularly checks his elbows to maintain good skin health.
Keeping the skin healthy
Regular skin care should be done using a gentle pH-balanced skin cleanser and moisturizer. The skin should always be treated gently and not rubbed or massaged forcefully The skin should be kept dry using loose fitting clothes made of light weight fabrics and protecting the skin from excess moisture. Avoid clothing with thick seams or pockets like denim that can contribute to tissue damage.
Regular pressure relief
Pressure relief techniques are positions and movements that remove pressure and give the tissues a chance to regain proper blood flow. You should discuss with your health providers about which positions are best for you and how often and for how long they should be done for. Keep in mind that moving into pressure relieving positions should not involve pulling or shearing of the skin while re-positioning.
Depending on your level of in, some people are able to re-position themselves or need a small amount of assistance. People with higher level SCI can use the functions of their wheelchairs or equipment to weight shift or may rely more on caregivers and family to provide assistance.
Pressure relief is usually recommended every 15 to 30 minutes to replenish blood flow to vulnerable areas of the skin and held for at least 1 to 2 minutes.
Using appropriate equipment and seating
Appropriately fitted equipment like wheelchairs, cushions, and bedding can help to maintain healthy skin. During rehabilitation, you may work with your health providers or attend a special clinic where you receive advice on selecting equipment and the correct use of the equipment.
The team will recommend seat cushions, backrests, commodes, and mattresses to help manage pressure in at-risk areas. Regular check-ins at the clinic may also be needed. Most equipment needs to be reviewed and replaced periodically. For example a padded raised toilet seat that has rips or is worn out can be a cause of a pressure injury.
Keeping a healthy lifestyle
Adopting a healthy diet, exercising regularly, and avoiding smoking are simple steps to help maintain healthy skin.
A healthy diet with enough fluids, calories, and protein provides the nutrients and vitamins needed to maintain healthy skin. It also helps in maintaining a healthy body weight. A dietician can help you learn how to eat well to prevent pressure injuries and can advise you on the nutrition you need for healing should you develop a pressure injury.
Exercise helps to increase circulation (which carries oxygen and nutrients throughout the body) and maintain overall health. Exercise may also help to maintain muscle bulk which creates padding between the skin and bone.
Although it may seem strange, electrical stimulation is a treatment which may help to prevent pressure injuries. Electrical stimulation on its own can help to increase blood flow and oxygen supply to the body tissues. Electrical stimulation during exercise (functional electrical stimulation) may help to maintain muscle mass that pads areas under the skin.
Many people avoid doing regular pressure injury prevention because it can be time-consuming and difficult. If you are having trouble finding the time to fit these techniques in, it may be time to get support. Speak to your health providers about this issue and see if you can work together to come up with ways that you can make pressure relief and skin care a part of your daily activities so you have enough time to participate in everything that is important to you. Some people find the following tips helpful:
- Make skin care a regular part of your routine, just like brushing your teeth – have everything you needs (a mirror, skin care supplies) easily available where you can use them each day and do your routine at the same time every day
- Ask for help from caregivers and family for help with techniques or reminders to maintain good skin care
- Put a timer on your phone or watch to remind you to shift positions regularly.
Discover how Peter manages pressure sores with his wound care nurse.
Find out how Josh learns how to take care of his pressure sores at home with his wound care nurse.
There are a number of different treatments for pressure injuries. Treatments may be used to reduce pressure or shearing to the wound, keep the wound clean and protected to reduce the risk of infection, and aid circulation and healing. Treatment for pressure sores is the responsibility of the whole health team, so you may work with many different professionals.
Wound dressings help to protect the wound, absorb drainage from the wound, and prevent bacteria from entering while also allowing it to breathe. There are many different types of dressings that may be used for pressure sores. Your nurse will help to decide which dressings to use and how often they need to be changed.
Antibiotics are used as needed to treat infections in the soft tissues or when osteomyelitis (bone infection) is present. Topical antimicrobial treatments are sometimes applied to the wound to reduce bacteria to try to prevent infection and support healing.
A number of different energy-based therapies may also be used to treat pressure injuries. These treatments are done to help increase circulation, kill bacteria, and promote healing.
Electrical stimulation may be applied to pressure injuries through electrodes connected to a small device. Studies suggest that electrical stimulation works to help with healing of severe wounds (stage 3 and 4) after SCI.
Ultraviolet C light
Ultraviolet C light may be applied to a wound using special light bulbs and equipment. Ultraviolet C light has antibacterial effects on wounds. Research suggests that Ultraviolet C is effective for helping treat pressure injuries after SCI.
Debridement is a method of removing dead tissue and debris from wounds. There are several methods used to debride wounds and your wound care nurse or physician will choose the method that is right for you. Types of debridement may include:
Surgical debridement by a surgeon under anesthesia
- Sharp debridement using sterile scissors performed by a wound care nurse
- Maggot therapy, which involves using maggots to selectively remove only the dead tissue
- Enzymatic debridement, which involves using enzymes to help dissolve the dead tissue
- Autolytic debridement, when moisture is added to the wound as needed to help the dead tissue debride from the wound
Debridement is only needed if there is slough or unhealthy yellow black tissue in the wound base and should only be done when there is enough circulation for healing to occur.
Flap reconstruction surgery
Surgery may be an option if the wound does not improve with other treatments. This is typically only used for stage 3 or stage 4 injuries. The procedure for closing these wounds is called flap reconstruction surgery. Flap reconstruction involves removing the wound and surrounding tissue and covering it with other nearby tissues, such as muscles and skin. After this type of surgery, careful procedures must be followed before you can get up and moving safely.
Amputation may sometimes be necessary if a wound gets severely infected and the infection moves into nearby tissues. This is more commonly seen in legs and feet.
Negative pressure treatments
Negative pressure wound treatments involve the use of a vacuum which applies suction to a wound that is covered with a wound dressing. This helps to manage drainage and increase circulation. A negative pressure dressing should only be used when the wound is clean and pink healthy tissue and when the cause of the pressure injury has been addressed.
Other pressure injury treatments
There are many other medical, alternative, and physical treatments that may be used in the treatment of pressure injuries. Speak to your wound care team about any treatments you are considering trying.
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- Reprinted with permission of the copyright holder, Gordian Medical, Inc. dba American Medical Technologies (courtesy of National Pressure Ulcer Advisory Panel)
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Pressure mapping is a clinical technique that is used to help prevent pressure sores after spinal cord injury (SCI). This page outlines how pressure mapping is used after SCI.
- Pressure mapping is a technique that involves the use of a pressure-sensitive mat and computer system to measure the amount of pressure between a person’s body and a supporting surface.
- Pressure mapping is used to help identify areas of excess pressure that may contribute to pressure sores. This can be used to help make decisions about surface options (like wheelchair cushions and bedding) and find out how effective a person’s pressure relief techniques are.
- This technique involves the use of a flexible mat containing pressure sensors that is placed on the surface being tested and then the person is positioned on the mat. The mat is connected to a computer system that creates a color-coded diagram showing areas of pressure.
- Pressure mapping is considered to be a useful tool for making decisions about reducing pressure that is used as a decision-making and educational tool. There is a lack of research on whether pressure mapping directly helps to reduce pressure sores after SCI.
Pressure mapping is a technique that is used to identify areas of pressure between a person’s body and a supporting surface like a cushion or chair. A thin, pressure-sensitive mat and computer system are used to develop a map showing areas of pressure where the body contacts the surface. This technique is most often used to identify areas of high pressure associated with wheelchair seating that could contribute to the development of pressure sores.
Pressure mapping is also used on other such as mattresses, toilet seats, car seats, sports equipment, or any other surface a person sits or lies on for periods of time that may influence their skin health.
People with spinal cord injuries have an increased risk of developing skin lesions called pressure sores. Pressure sores occur for many reasons, including increased pressure on vulnerable areas of the skin. Bony areas that come into contact with support surfaces, like the sit bones and tailbone in sitting, are highly vulnerable to increased pressure.
Pressure mapping is used to determine areas of increased pressure in certain postures on specific surfaces. It may be used to assess areas of pressure on various surfaces, such as chairs, beds, sofas, car seats, and toilet seats. This information can be used to develop strategies to reduce pressure and improve comfort in these situations.
Pressure mapping may be used as a tool to aid decision-making when selecting support surfaces and equipment, such as assessing which wheelchair cushions provide the best pressure relief for you. Pressure mapping is also used to assess the effectiveness of pressure relief techniques like weight-shifting by providing real-time feedback about the pressure during the performance of these techniques.
A flexible mat containing pressure sensors is placed on the surface to be tested. The person being assessed then sits on the mat. Information about pressure between their body and the seat is picked up by sensors in the mat and sent to a computer, where it is translated into a color coded diagram.
The diagram displays the pressure recorded at each sensor in the mat by number and displays areas of high and low pressure with different colors. A clinician then determines the corresponding areas on the body through a hands-on physical examination. This technique is used together with other assessments of pressure sore risk to make recommendations for reducing areas of high pressure. There may be variation in the procedures used for pressure mapping in different settings.
Pressure mapping can be influenced by many aspects of how the procedure is done. For example, how the person positions themselves at the time of the reading and how long the person sits on the mat before the readings are taken can change the findings. There are also different types of systems that collect information about pressure differently. These factors and other concerns have led to disagreement among experts about how to best understand and interpret the results of pressure mapping for clinical use.
In addition, pressure is just one factor that contributes to pressure sores. Friction, moisture, age, body composition, time spent sitting, and many other factors also contribute to pressure sores. These factors cannot be detected by pressure mapping, which limits the use of pressure mapping as a stand-alone tool.
Pressure mapping also requires special equipment and trained health providers which may not be available in settings outside of major rehabilitation centers.
Pressure mapping is considered by experts to be a useful tool for understanding pressure and making decisions about pressure relief. At this time, most of the research that has been done on whether pressure mapping is effective for preventing pressure sores has been done in populations outside of SCI. We do not know if pressure mapping is effective for preventing of pressure sores in people with SCI.
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- Veterans wheelchair games 2009 ©U.S. Air Force photo/Staff Sgt. Desiree N. Palacios, CC0 1.0
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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.
- 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.
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.
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.
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.
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.
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.
There 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.
- By people who have had seizures
- By people prone to severe autonomic dysreflexia (people with cervical and thoracic injuries)
- By people with uncontrolled spasticity
- By people with severe osteoporosis
- In areas where heterotopic ossification causes restricted movement
- In areas with reduced or absent sensation (below the level of injury)
- By people who are unable to follow instructions or provide accurate feedback
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:
- Discomfort or pain
- Skin redness or irritation
- Nausea, light-headedness, or autonomic dysreflexia
Other less common risks and side effects of FES include:
- Mild electrical burns near the electrodes
- Skin breakdown near the electrodes
- 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.
Studies 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.
Fifteen 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.
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.
Although 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.
Research 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.
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.
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.
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.
Evidence for “Strength” is based on the following studies:
 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.
 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.
 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.
 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.
 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.
 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:
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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:
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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:
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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:
 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.
 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:
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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
 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.
 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:
 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.
 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.
 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.
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