Home-based Functional Electrical Stimulation for long-term denervated human muscle: History, basics, results and perspectives of the Vienna Rehabilitation Strategy

We will here discuss the following points related to Home-based Functional Electrical Stimulation (h-b FES) as treatment for patients with permanently denervated muscles in their legs: 1. Upper (UMN) and lower motor neuron (LMN) damage to the lower spinal cord; 2. Muscle atrophy/hypertrophy versus processes of degeneration, regeneration, and recovery; 3. Recovery of twitch- and tetanic-contractility by h-b FES; 4. Clinical effects of h-b FES using the protocol of the “Vienna School”; 5. Limitations and perspectives. Arguments in favor of using the Vienna protocol include: 1. Increased muscle size in both legs; 2. Improved tetanic force production after 3-5 months of percutaneous stimulation using long stimulus pulses (> 100 msec) of high amplitude (> 80 mAmp), tolerated only in patients with no pain sensibility; 3. Histological and electron microscopic evidence that two years of h-b FES return muscle fibers to a state typical of two weeks denervated muscles with respect to atrophy, disrupted myofibrillar structure, and disorganized Excitation-Contraction Coupling (E-CC) structures; 4. The excitability never recovers to that typical of normal or reinnervated muscles where pulses less than 1 msec in duration and 25 mAmp in intensity excite axons and thereby muscle fibres. It is important to motivate these patients for chronic stimulation throughout life, preferably standing up against the load of the body weight rather than sitting. Only younger and low weight patients can expect to be able to stand-up and do some steps more or less independently. Some patients like to maintain the h-b FES training for decades. Limitations of the procedure are obvious, in part related to the use of multiple, large surface electrodes and the amount of time patients are willing to use for such muscle training

Optimal control problems with delays in state and control and mixed control-state constraints

Optimal control problems with delays in state and control variables are studied. Constraints are imposed as mixed control-state inequality constraints. Necessary optimality conditions in the form of Pontryagin's minimum principle are established. The proof proceeds by augmenting the delayed control problem to a nondelayed problem with mixed terminal boundary conditions to which Pontryagin's minimum principle is applicable. Discretization methods for the delayed control problem are discussed which amount to solving a large-scale nonlinear programming problem. It is shown that the Lagrange multipliers associated with the programming problem provide a consistent discretization of the advanced adjoint equation for the delayed control problem. An analytical example and two numerical examples from chemical engineering and economics illustrate the results

School-Class Co-Ethnic and Immigrant Density and Current Smoking among Immigrant Adolescents

Although the school-class is known to be an important setting for adolescent risk behavior, little is known about how the ethnic composition of a school-class impacts substance use among pupils with a migration background. Moreover, the few existing studies do not distinguish between co-ethnic density (i.e., the share of immigrants belonging to one’s own ethnic group) and immigrant density (the share of all immigrants). This is all the more surprising since a high co-ethnic density can be expected to protect against substance use by increasing levels of social support and decreasing acculturative stress, whereas a high immigrant density can be expected to do the opposite by facilitating inter-ethnic conflict and identity threat. This study analyses how co-ethnic density and immigrant density are correlated with smoking among pupils of Portuguese origin in Luxembourg. A multi-level analysis is used to analyze data from the Luxembourg Health Behavior in School-Aged Children study (N = 4268 pupils from 283 classes). High levels of co-ethnic density reduced current smoking. In contrast, high levels of immigrant density increased it. Thus, in research on the health of migrants, the distinction between co-ethnic density and immigrant density should be taken into account, as both may have opposite effects

Muscle pathology in lower motor neuron paraplegia and h-b FES

After complete Spinal Cord Injury (SCI), causing complete disconnection between the muscle fibers and the nervous system, the denervated muscles become unexcitable with commercial electrical stimulators within several months and undergo severe atrophy and disorganization of contractile apparatus after 1-3 years. Years after the injury the surviving and regenerated myofibers are substituted with adipocytes and collagen. To counteract the progressive changes transforming muscle into an unexcitable tissue, we developed a novel therapy concept for paraplegic patients with complete lower motor neuron (LMN) denervation of the lower extremities. The new stimulators for home-based functional electrical stimulation (h-b FES) have been designed to reverse longstanding and severe atrophy of LMN denervated muscles by delivering high-intensity (up to 2,4 J) and long-duration impulses (up to 150 ms) able to elicit contractions of denervated skeletal muscle fibers in absence of nerve. Concurrent to the development of the stimulation equipment, specific clinical assessments and training strategies were developed at the Wilhelminenspital Wien, Austria. Main results of our clinical study on 20 patients, which completed a 2 years h-b FES program are: 1. significant +33% increase of muscle size and +75% of the mean diameter of muscle fibers, with striking improvements of the ultra-structural organization of contractile material; 2. recovery of the tetanic contractility with significant increase in muscle force output during electrical stimulation; 3. five subjects performed FES-assisted stand-up and stepping-in-place exercises;. 4. data from ultrastructural analyses indicating that the shorter the time span between SCI and the beginning of h-b FES, the larger were the number and the size of recovered fibers. The study demonstrates that h-b FES of permanent LMN denervated muscle is an effective home therapy that results in rescue of muscle mass, function and perfusion. Additional important benefits for the patients are the improved cosmetic appearance of lower extremities and the enhanced cushioning effect for seating

Strength training in elderly people improves static balance

Aim of this study was to investigate the effects of two different types of strength training programs on static balance in elderly subjects. Subjects older than 65 years of age were enrolled and assigned to control group (CG, n =19), electrical stimulation group (ES, n = 27) or leg press group (LP, n = 28). Subjects in both the training groups were exposed to training (2-3x/week) for a period of 9 weeks. In the ES group the subjects received neuromuscular electrical stimulation of the anterior thigh muscles. In the LP group the subjects performed strength training on a computer-controlled leg press machine. Before and after the training period, static balance of the subject was tested using a quiet stance task. Average velocity, amplitude and frequency of the center-of-pressure (CoP) were calculated from the acquired force plate signal. The data was statistically tested with analysis of (co)variance and t-tests. The three groups of subjects showed statistically significant differences (p < 0.05) regarding the pre-training vs. post-training changes in CoP velocity, amplitude and frequency. The differences were more pronounced for CoP velocity and amplitude, while they were less evident in case of mean frequency. The mean improvements were higher in the LP group than in the ES group. Our results provide supportive evidence to the existence of the strength-balance relationship. Additionally, results indicate the role of recruiting central processes and activation of functional kinetic chains for the better end effec

Medical image analysis and 3-d modeling to quantify changes and functional restoration in denervated muscle undergoing electrical stimulation treatment

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Reliability of novel postural sway task test

The purpose of this study was to examine the reliability of parameters obtained from a novel postural sway task test based on body movements controlled by visual feedback. Fifty-nine volunteers were divided into two groups. The first group consisted of young (n = 32, 16 females and 16 males, age: 25.2 3.4 years) and the second group of elderly individuals (n = 27, 17 females and 10 males, age: 75.7 6.9 years). Participants stood in parallel on a computer based stabilographic platform with the feet approximately a shoulder width apart, the toes slightly pointing outwards, the hands placed on the hips. The computer screen was placed approximately 1.5 meter from the platform at a height of subjects eyes. An instantaneous visual feedback of participants centre of pressure (COP) was given in a form of a blue cross visible on the screen. Participants were instructed to keep the blue cross driven by movements of their hips as close as possible to a predefined curve flowing on the screen. Out of the 6 parameters studied, only the average distance of COP from the curve line and the sum of the COP crossings through the curve line showed high reliability. Correlation between these two highly reliable parameters was -0.89. There was also a statistical difference (p<0.001) between young and elderly in both the average distance of COP from the curve line and the sum of the COP crossings through the curve. To conclude, the novel postural sway task provides a simple tool with relatively low time burden needed for testing. The suggested output parameters measured are highly reliable and easy to interpre