International FES Centre®

There are only few studies available on functional improvement of the upper extremities. FES is a widespread and much used method in the rehabilitation of patients with a spinal cord injury with tetraplegia to improve hand and arm functions. EMG-triggered electrical stimulation is used, for example, to improve motor learning. The already investigated effects of FES become even more significant with regard to reconstructive arm and/or hand surgery in patients with tetraplegia. One possibility here could be to use FES to strengthen donor and recipient muscles before and after surgery. The motor learning process forms part of treatment before surgery, in particular. So far, there have been no investigations into whether the targeted use of FES before and after reconstructive surgery could improve results in terms of strength, motor learning and function. Initial clinical observations indicate a potentially positive effect of FES. A randomised controlled study aims to investigate the following points:

• Whether the use of FES before and after surgery can increase the strength of donor and recipient muscle and thus improve results in terms of strength and functionality
• Whether the use of FES with an EMG-triggered stimulator accelerates the motor learning process after surgery
• What level of patient satisfaction is achieved and how well patients are able to perform individually defined everyday movements
• Whether FES results in an increase in volume of the stimulated muscles
• How patients assess the applicability of FES relative to pre-treatment and post-treatment benefits

This study aims to investigate the effect on physical fitness of two different types of training of paralysed leg muscles using electrical stimulation. The effects of short, intensive training using electrical stimulation muscles will be compared to longer, low-intensity training of the leg muscles.

The study aims to investigate the effect of electrical stimulation on buttock muscle volume and pressure distribution when sitting. In addition, a questionnaire will be used to record the effect of electrical stimulation and the associated possible adaptations to buttocks on quality of life.

In this study, the effect of a 16-week period of NMES on the abdominal wall on defaecation time and bowel transit time is investigated. For this purpose, control assessments are conducted over a period of four weeks prior and after the stimulation period respectively. Other assessment timepoints take place at the beginning, after eight weeks and at the end of the NMES period. Participants document their defaecation times over the entire course of their study participation (24 weeks). At each of the five study appointments, the "International Standards to document remaining Autonomic Function after Spinal Cord Injury"(ISAFSCI), the "Qualiveen Short Form", the "Neurogenic Bowel Dysfunction Score" (NBDS) and the "Corn Test" are conducted. In the defaecation protocol, the participants note the defaecation times, the duration of stimulation as well as the stool consistency according to the Bristol scale.

The inclusion criteria are as follows:

• Traumatic/non-traumatic spinal cord injury; >1year ago
• Neurological level of injury: C2-L5
• ASIA A/B/C/D
• Age >18 years
• Need to decrease defaecation time

Study responsibility: Dr. Ines Bersch
The expected study conclusion is set to December 31^st, 2023.

People with tetraplegia have a more or less pronounced restriction of hand function depending on the extent of their paralysis. Hence, a decision to undergo a so-called ‘grip reconstruction’ during primary rehabilitation is not uncommon. Within this specific surgical procedure, one of the two parts of the extensor carpi radialis (ECR) muscle is transferred to the finger extensors. In this way, active hand opening can be guaranteed in case of sufficient muscle strength of the donor muscles. However, it often remains unclear whether the remaining part of the donor muscle, that has not been used for the transfer, can ensure a balanced movement of the wrist together with the remaining wrist extensors.

A non-invasive procedure, which allows to evaluate the innervation and activation potential of the various parts of the ECR, offers valuable information regarding further treatment indications. For this evaluation, motor point mapping using electrical stimulation is applied. A pen electrode is used to apply targeted stimulation to the motor point of the muscle. This method has already been validated for many muscles on the forearm. The aim of this study is to document the muscle contraction elicited through targeted stimulation by means of an ultrasound and a force measurement.

Medical rate

The outpatient consultation is carried out by a doctor and an FES therapist. The objective of these consultations is to be able to identify and test complex patient situations in an interdisciplinary team. The service is charged for at the following TARMED positions:

• Consultation (higher rate in the event of an external referring doctor for the initial findings)
• Medical consultation/follow-up (internal referring doctor)
• Medical service when the patient is present
• Charging for medical reports in accordance with TARMED specifications

Paramedical rate

A prescription for outpatient physiotherapy is required, on the basis of which the treatment can be charged for. The charging process uses a physiotherapeutic treatment rate with the addition of initial treatment at the first consultation.

A prescription for an outpatient occupational therapy is required, on the basis of which the treatment can be charged for. The charging process uses an occupational therapy rate if the patient is present, and a 7602 rate if the patient is absent.

FES devices

The Swiss insurance system does not clearly regulate the assumption of costs for owned and leased equipment. Simulators for the area of functional electrical stimulation are not listed on the Mittel- und Gegenstandsliste (MiGel) (List of Media and Objects).

Outpatient documentation

BFollowing outpatient consultations, a chargeable report will be written upon request. Adaptations will be made according to the novel tariff structure as of 2025. Requests concerning health insurance coverage of electrical stimulation devices will be provided individually to the insurance in question. Based on all consultations by an external referring doctor, reports are written that include information about the testing and planned procedure. Progress reports are created for the GP and insurer one month before expiry of the assumption of costs. These include progress made to date, any further planned procedures, and a request to extend the assumption of costs.

Motor learning is a continuous change in the mastery of a skill resulting from practice or movement experience. "Motor learning" involves learning or relearning movements and functions, that have been affected by damage to the central and peripheral nervous systems, such as a spinal cord injury or stroke. Oftentimes, not everything can be relearned as areas that are too severely damaged are excluded from this process. Nevertheless, areas of the motor cortex that are affected by "learned disuse" are still activated.

The model of motor skill acquisition elaborated by Fitts and Posner serves as a foundation, where motor learning is divided into 3 phases:

FES Cycling is recommended as a cardiovascular training for prevention purposes. The leg muscles (M. quadriceps, Mm. ischiocrurales, M. glutaeus maximus, M. tibialis anterior, M. gastrocnemius) are stimulated in accordance to the cycling motion. This means that the bike is powered by the movement of the stimulated legs. Effects, such as greater oxygen uptake during exercise and increased fat burning through exercise, have been investigated and proven by clinical studies. Another effect is the improvement of physical fitness.

Perret et al. 2010, Gorgey et al. 2016, Hasnan et al. 2013

Arm cranking (hand/arm cycling) or rowing with FES can also be used as an alternative to FES cycling.

Patients with tetraplegia and paraplegia (Th2-Th5) lack voluntary activation of the abdominal muscles due to paralysis. The abdominal muscles, in turn, are essential for forced expiration. Forced expiration is necessary for a good ventilation of the lungs, coughing and a loud powerful speech. Usually, a person with tetraplegia needs assistance to provide manual support during cough. FES of the abdominal muscles constitutes an alternative. It strengthens the expiration and the forced cough. Coughing can thus be performed autonomously throughout the day. The electrodes are attached to the abdominal muscles in the morning. The stimulator is attached to the wheelchair with an appropriate switch control. The switch is activated when coughing is required so that the abdominal muscles contract and coughing can take place.

McCaughey et al. 2019

Patients with a damage to the primary breathing musculature (diaphragm), can improve its function by means of phrenic nerve stimulation. In this matter, the phrenic nerve is stimulated for inspiration and the abdominal muscles are stimulated during expiration. Keogh C et al, 2022 This type of stimulation can serve people with a high cervical spinal cord injury as a training or potentially as a preparation to the surgical implantation of a diaphragm stimulator.

FES can support or even replace partial functions of muscle groups or individual muscles in their function. The most commonly used system supports muscles of the lower extremity during walking, such as the ankle dorsiflexors (m. tibialis anterior) and/or the gluteal muscles. However, ES can be applied to support muscles of the trunk, muscles involved in locomotion as well as muscles of the upper extremities when grasping objects. An individual assessment is required to determine an effective and efficient functional support.

The delivery of such a function-improving system takes place under the supervision of a specialist from the International FES Centre^®. The muscles to be stimulated must be systematically trained in order to be able to use function-improving systems permanently in everyday life. Testing phases with regular check-ups, in which the stimulation parameters are adjusted, are part of the delivery and permanent follow-up care. At the International FES Centre^®, we primarily work with the FESIA Walk system, which allows for stimulation of the ankle dorsiflexors and plantar flexors, both being of equal importance in gait.

FES can prevent muscle atrophy that is due to disuse or denervation (Gordon et al 1994). Muscle strength (Crameri et al 2004), power (Haapala et al 2008) and endurance (Sabatier et al 2005) can be improved. There is an increase in the cross-sectional area of the muscles (Martin et al 1992, Scremin et al 1999) and an increase in muscle mass (Scremin et al 1999). Individual muscles or muscle groups can be strengthened in a functional way.

The use of FES has an effect on muscle tone (i.e. regulation of spasticity and spasms). Short-term effects already set in after the first treatment. However, a longer lasting effect is only achieved after a few weeks or months of stimulation. Good methods for the regulation of muscle tone are FES cycling, FES-supported arm cranking and FES rowing. The idea is to support voluntary movement through stimulation of the respective muscles in all three methods.

Transcutaneous spinal cord stimulation (lumbar and cervical) may be used for the regulation of muscle tone and to treat neuropathic pain.

Through activation of proprioceptive fibres, responsible for spatial orientation, signals are being sent to the motoneurons.

Grau et al, 2020; Inanici et al, 2021

It is known that the spinal cord not only possesses a capacity to memorize but that it is also well capable to learn. Thereby, inactive functions can be reactivated.

Wolpaw, 2010

The danger of a malposition of the head of the humerus towards the acromion affects people with tetraplegia or stroke, in whom the muscles surrounding the shoulder joint are not sufficiently supporting due to paralysis. The consequences of a subluxation position in the shoulder joint can be pain and restricted movement. NMES is a treatment method that is able to counteract this pathological pattern. Optimally, targeted physiotherapeutic treatment is combine with NMES.

Structural changes in the trunk musculature have consequences for the statics in standing and sitting. The consequences can be scoliotic Structural changes in the trunk musculature have consequences for the statics in standing and sitting. The consequences can be scoliotic malpositions, paralysis-related scolioses and asymmetries in the trunk. Neuronal changes in muscle tone such as spasticity or asymmetrical innervation of the trunk are also causes of static deviations in the vertebral column. In children and adolescents without previous neurological disease, the term "idiopathic scoliosis" is used. NMES in combination with targeted physiotherapeutic treatment of posture, as well as simultaneous adjustment of the wheelchair, represents a possible treatment method. For children and adolescents with idiopathic scoliosis, treatment methods such as Lehnert-Schrot and Gocht-Gessner can very well be combined with NMES.

FES can be used to prevent and treat joint restrictions originating from muscular dysfunction. This can be done in the upper as well as in the lower extremity. Muscular shortening in the hand and finger joints, e.g. caused by an imbalance between the hand and finger flexors and extensors, can be treated. In the lower extremity, equinovarus foot can be treated with FES. In this case, a combination treatment with injection of botulinum toxin and subsequent FES is recommended after medical evaluation.

The goals for the use of FES in the prevention of skin injuries of various origins are the reduction and prevention of atrophy and/or denervation atrophy. It is also intended to improve nourishment of the tissue by promoting skin perfusion.

When using ES in patients with paraplegia, it is important to distinguish between two groups: those with an upper motor neuron (UMN) lesion and those with a lower motor neuron (LMN) lesion. The stimulation parameters differ between the two types of lesions. In the case of an UMN damage, the muscle is stimulated via its nerve with a pulse duration lying within the microsecond (μs)-range; whereas in the case of a LMN damage, the muscle is stimulated directly with a pulse duration within the millisecond (ms)-range (direct muscle stimulation). In both cases, the aim is to achieve hypertrophy of the gluteal muscles in order to reach a sufficient cushioning effect on the sitting surface.

The application can be carried out in the clinical but also in the home setting. In addition, this preventive treatment is a way to avoid or shorten hospitalizations and reduce health care costs.

If the peripheral nervous system is damaged, the stimulation parameters must be adjusted in order to achieve effective stimulation. Long pulses are usually used because muscle fibres are slower to be excited than nerve fibres. Since more charge has to be transmitted through the skin, stimulation is done with sponge electrodes or safety electrodes using salt-free gel.

Under these conditions, the stimulation is very effective and can be used for motor learning, but also for structural change and strength training purposes.

Another area of application is before and after muscle tendon and nerve transfers to improve function in the upper extremity. Here, the donor and recipient muscles can be identified and specifically treated with appropriate stimulation parameters.

Bersch et al 2020, Fridén et al 2021

Furthermore, it is possible for outpatients to pursue treatment supported by physical and occupational therapists from different departments allowing to combine and integrate methods and technologies that rely on electrical stimulation.

People, who wish to make use of this offer through self-payment, may contact our administration office without preliminary outpatient referral.

These services will be charged according to the following list and will apply until December 31^st, 2025:

• 1^st evaluation, 60 minutes: CHF 264.-
• 1^st evaluation with medical doctor, 60 minutes: CHF 346.-
• Outpatient evaluation, 30 minutes: CHF 114.-
• Outpatient evaluation, 60 minutes: CHF 228.-

Ines Bersch: Therapeutic Applications of Electrical Stimulation in Spinal Cord Injury. Kapitel 11. S. 253-279 In: Gernot Müller-Putz, Rüdiger Rupp: Neuroprosthetics and Brain-Computer Interfaces in Spinal Cord Injury.  Springer-Verlag, 2021

Jan Friden, Ines Bersch, Fabrizio Fiumedinisi , Silvia Schibli, Sabrina Koch-Borner.Surgical rehabilitation across countries: A model for planning in telerehabilitation. Kapitel 25, In: Elsevier Verlag. 2021

Ines Bersch. Upper and Lower Motoneuron Lesions in Tetraplegia – Diagnostic and Therapeutic Implications of Electrical Stimulation. 2019. University of Gothenburg, Schweden.

Thomas Schick (Hrsg.). Funktionelle Elektrostimulation in der Neurorehabilitation. Synergieeffekte von Therapie und Technologie. 2021. Springer-Verlag Berlin Heidelberg.

1. Alberty M, Mayr W, Bersch I. Electrical Stimulation for Preventing Skin Injuries in Denervated Gluteal Muscles – Promising Perspective from a Case Series and Narrative Review, Diagnostics, 2023; 13(2):219.
2. Bersch, I. & Mayr, W. Electrical stimulation in lower motoneuron lesions, from scientific evidence to clinical practice: a successful transition. Eur. J. Transl. Myol. (2023) doi:10.4081/ejtm.2023.11230.
3. Zampieri, S., Bersch, I., Kern, H., Sarabon, N., Rosati, R., LeBrasseur, N.K., Leeuwenburgh, C., Carraro, U.  2023 Padua Days of Muscle and Mobility Medicine: post meeting book of abstracts. Eur. J. Transl. Myol. 33, 11427 (2023).
4. Koch-Borner, S. Bersch, U., Grether, S., Fridén, J., Schibli, S., Bersch, I. Different thumb positions in the tetraplegic hand. Arch. Phys. Med. Rehabilitation (2023) doi:10.1016/j.apmr.2023.06.014.
5. Dolbow, D. R., Gorgey, A. S., Johnston, T. E. & Bersch, I. Electrical Stimulation Exercise for People with Spinal Cord Injury: A Healthcare Provider Perspective. J Clin Medicine 12, 3150 (2023).
6. Harder M, Baumberger M, Pannek J, Decker J, Bersch I. [Rehabilitation after Spinal Cord Injury : Current trends and principles]. Unfallchirurgie (Heidelb). Oct;126(10):764-773. (2023).
7. Zampieri S, Bersch I, Smeriglio P, Barbieri E, Ganassi M, Leeuwenburg C, Rosati R, Gargiulo P, Pond A, Sweeney HL, Carraro U. Five Padua days on muscle and mobility medicine (2024Pdm3) 27 February - 2 March, 2024 at Hotel Petrarca, Thermae of Euganean Hills, Padua, and San Luca Hall, Prato della Valle, Padua, Italy. Eur J Transl Myol. Dec 18;33(4). (2023).
8. Bersch I, Krebs J, Fridén J. A Prediction Model for Various Treatment Pathways of Upper Extremity in Tetraplegia. Front Rehabil Sci. 2022 Jun 30;3:889577. doi: 10.3389/fresc.2022.889577.
9. Bersch I, Alberty M, Fridén J. Robot-assisted training with functional electrical stimulation enhances lower extremity function after spinal cord injury. Artif Organs. 2022 Oct;46(10):2009-2014. doi: 10.1111/aor.14386.
10. Bersch I, Fridén J. Long-term effect of task-oriented functional electrical stimulation in chronic Guillain Barré syndrome-a single-subject study. Spinal Cord Ser Cases. 2021 Jun 28;7(1):53.  doi: 10.1038/s41394-021-00419-0.
11. Bersch I. Einsatz der Funktionellen Elektrostimulation (FES) in der Neurorehabilitation – ein Überblick. Orthopädietechnik. Verlag Orthopädie Technik. Dortmund. 72. Jahrgang. 10/ 2021. S. 28—35.
12. Bersch I, Friden J. Electrical stimulation alters muscle morphological properties in denervated upper limb muscles. EBioMedicine, published by LANCET. 2021 Dec 9;74:103737. doi: 10.1016/j.ebiom.2021.103737. 
13. Chandrasekaran S, Davis J, Bersch I, Goldberg G, Gorgey AS. Electrical stimulation and denervated muscles after spinal cord injury. Neural Regen Res. 2020 Aug;15(8):1397-1407.
14. Bersch I, Fridén J. Upper and lower motor neuron lesions in tetraplegia: implications for surgical nerve transfer to restore hand function. J Appl Physiol (1985). 2020 Nov 1;129(5):1214-1219.
15. Bersch I, Koch-Borner S, Fridén J. Motor Point Topography of Fundamental Grip Actuators in Tetraplegia: Implications in Nerve Transfer Surgery. J Neurotrauma. 2020 Feb 1;37(3):441-447.
16. Bersch I, Koch-Borner S, Fridén J.(2018). Electrical stimulation-a mapping system for hand dysfunction in tetraplegia, Spinal Cord 56(5):516-522.
17. Lampart P, Gemperli A, Baumberger M, Bersch I, Prodinger B, Schmitt K, Scheel-Sailer A. Administration of assessment instruments during the first rehabilitation of patients with spinal cord injury: a retrospective chart analysis. Spinal Cord. 2018 Apr;56(4):322-331.
18. Laubacher M, Aksöz EA, Bersch I, Hunt KJ. (2017)  The road to Cybathlon 2016- Functional electrical stimulation cycling Team IRPT/SPZ Eur J Transl Myol. 6;27(4).
19. Bersch I, Fridén J. (2016). Role of Functional Electrical Stimulation in Tetraplegia Hand Surgery, Arch Phys Med Rehabil. 97(6 Suppl):S 154-9.
20. Bersch I, Tesini S, Bersch U, Frotzler A. (2015). Functional Electrical Stimulation in Spinal Cord Injury: Clinical Evidence versus Daily Practice, Artif. Organs 39(10):849-54.
21. Mueller G, Bersch-Porada I, Koch-Borner S, Raab AM, Jonker M, Baumberger M, Michel F. (2014). Laboratory evaluation of four different devices for secretion mobilization: Acapella choice, green and blue versus water bottle. Respir Care. 59(5):673-7.
22. Tesini S, Frotzler A, Bersch I, Tobón A. (2013). Prevention of Orthostatic Hypotension with Electric Stimulation in Persons with Acute Spinal Cord Injury, Biomed Tech(Berl).58.
23. Bersch I, Frotzler A, Baumberger M. Functional Electrical Stimulation in Spinal Cord Injury: Clinical Evidence versus Daily Practice. Biomed Tech (Berl). 2013 Aug;58 Suppl 1.