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Latest MS research update - Could functional electrical stimulation (FES) and robotic support improve arm movement in people with MS? - 15 April 2015

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This week's highlighted research...

Could functional electrical stimulation (FES) and robotic support improve arm movement in people with MS?

Research by topic areas...

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Co-existing conditions
Disease modifying treatments
Drugs in development
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Paediatric MS
Pathophysiology
Physical activity
Psychological aspects
Rehabilitation
Symptoms and symptom management


Could functional electrical stimulation (FES) and robotic support improve arm movement in people with MS?

Summary

Difficulties with movement and strength of the upper body, including the arms and hands can be found in people with MS, these can make everyday tasks more difficult. Currently there are very few available treatments for upper limb difficulties. Functional electrical stimulation (FES) is known to many people with MS as a treatment that can help with foot drop. The device applies small electrical impulses directly to the nerves in the affected leg muscles and forces movement, helping with walking. However to date no study has looked to see if FES could also help with similar problems in the arms. This small study tested the feasibility of a system that uses FES in conjunction with a robotic exoskeleton, as a treatment for arm problems in people with MS.

Five women with MS took part in the study which was conducted in Southampton. Each participant identified their most impaired arm. They could control the intensity of the FES, so they could find a setting that was comfortable and also helped them to produce a movement. They performed several tasks with their hand and arm, within a virtual reality environment, both with the FES turned on and off.

The study found that after the period of using the system participants has less difficulties with their arm, they could do movements more accurately both with and without FES input. All the participants reported that they were more aware of their affected arm and after using the system they could reach out more easily and could do two handed task such as folding clothes or using a knife and fork more easily than they could before.

The authors concluded that using the system to improve arm movement for people with MS was feasible and appeared to be safe and effective. This was only a proof of concept study, so a larger study with a control group would be needed to further investigate the potential benefits of using the system for people with MS.


Background

Difficulties with movement and strength of the upper body, including the arms and hands can be found in people with MS. This can have an impact on many daily activities such as lifting or holding an item. Some people may have less grip strength, some may struggle with fine dexterity and others may use more force or effort to hold onto or move things. This will use more energy and can increase fatigue and muscle tiredness and make everyday tasks much more difficult.

Currently there are very few available treatments for upper limb difficulties, and finding something that could improve hand and arm function could help people remain as independent as possible, for a longer period. Functional electrical stimulation (FES) is known to many people with MS as a treatment that can help with foot drop. The device applies small electrical impulses directly to the nerves in the affected leg muscles and forces movement, helping with walking. However to date no study has looked to see if FES could also help with similar problems in the arms. This study looks at a system that combines FES with a robotic exoskeleton to see if it could help people with MS. The system has previously been used in people who have had a stroke and has been shown to improve arm function. This study was an initial test to involving a small number of people with MS to see if it is feasible to use the system to help with arm difficulties in MS.


How this study was carried out

Five women with MS took part in the study which was conducted in Southampton. One had relapsing remitting MS, one primary progressive MS and three secondary progressive MS and they had various levels of disability.

To be included in the study all had to have an impairment in one of their arms that meant they could not lift their arm to be out in front of them or hold it in this position (90° shoulder flexion), for most of the participants this was due to weakness.

The study used the SAIL (Stimulation Assisted by Iterative Learning) system. This is made up of several components:

  • A FES device with the pads attached the front of the shoulder and triceps.
  • The participant's arm is placed within a robotic exoskeleton, which supports their arm while it does movement, but as it is a passive device so it does not move their arm for them.
  • These are linked into a computer system that learns from the participant's attempts at movement, so assistance from the FES is provided to precisely coincide the participant's intention to move.
  • Tasks with their hand and arm are performed within a virtual reality environment, so the participant can see the progress of their movement to the target on a screen.

Each participant identified their most impaired arm. They could control the intensity of the FES, so they could find a setting that was comfortable and also helped them to produce a movement. They first took part in a pilot session so they could get used to the device and the appropriate settings could be found. They then took part in 18 intervention sessions where they performed several tasks within the virtual reality environment. As the participants progressed through the interventions the support of the robot exoskeleton arm was decreased, so they were supporting more of their own arm weight while trying to do the movement. The participants arm movements were also tested without the FES at the beginning and end of each intervention session.

Before participants used the SAIL system and then one week after the treatment period they also performed several tests of arm and hand function, including the nine hole peg test (9HPT) and also completed a questionnaire at the end of the study which explored how effective and easy to use they thought the system had been.


What was found

The study found that after the period of using the system participants has less difficulties with their arm, they could do movements more accurately both with and without FES input. All the participants reported that they were more aware of their affected arm and after using the system they could reach out more easily and could do two handed task such as folding clothes or using a knife and fork more easily than they could before.


What does it mean?

The authors concluded that using the SAIL system to improve arm movement for people with MS was feasible and appeared to be safe and effective. This was only a proof of concept study, so a larger study with a control group would be needed to further investigate the potential benefits of using the system for people with MS.


Sampson P, Freeman C, Coote S, et al.
Using functional electrical stimulation mediated by iterative learning control and robotics to improve arm movement for people with multiple sclerosis..
IEEE Trans Neural Syst Rehabil Eng. 2015 Mar 24. [Epub ahead of print]
abstract

More about upper body strength and function in MS

Many people are probably already aware that people with MS may have difficulties with their walking. However many of the symptoms that can make walking more difficult, such as weakness, spasm, spasticity (muscle stiffness) and sensory changes, can also affect the upper body as well, making things like lifting, holding and feeling more difficult. Other MS symptoms can also have a large impact on upper body strength and function, such as difficulties with pain, tremor and visual problems. For example, vision that is double, blurred or has altered depth perception can make it difficult to judge where cup of tea is on the table and make it difficult to pick it up safely.

If you are experiencing difficulties with your arms, hands or upper body, you can speak to your MS nurse or GP who may refer you to physiotherapy or occupational therapy services. The best way forward depends on what is causing the difficulties. Treatment may involve physiotherapy or drug treatments to alleviate specific underlying symptoms such as spasticity or pain.

Muscle weakness and fatigue can also affect the upper body. Muscles that are not used regularly become weakened and require more energy to do tasks leading to increased fatigue. This can lead to a cycle of decline, as an already weak muscle that is not used will become weakened further. As muscle weakness in MS is due to problems with getting messages along the nerves rather than within the muscle itself, expending a great deal of energy by exercising to the point of exhaustion doesn't help the problem and can make fatigue and weakness worse. Exercise that works on building up endurance and strength in muscles without increasing fatigue is considered beneficial.

You can view or download some arm and hand exercises and strength exercises for people with MS, or you can watch our exercise videos online or order the free DVD.

If you are concerned about fatigue, you might like to read Living with fatigue which gives tips on managing fatigue and maximising energy.

Keep up to date

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You can also sign up for our News alerts which cover reports about MS on our news page and in the media.

Open Door, the MS Trust's free quarterly newsletter is available both by post and by email. It contains information on all the publications and support that the MS Trust provides, articles on a wide range of topics written by health professionals and people with MS as well as news about MS and recent research. Sign up for Open Door here or call us on 0800 032 38 39 or 01462 476700

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Miller L, Rafferty D, Paul L, et al.
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