Electrical Stimulation for Paraplegia (Good News and Bad)

Muscle biopsies show that FES of denervated muscles reverses human muscle degeneration from permanent spinal motoneuron lesion. Kern H, Rossini K, Carraro U, Mayr W, Vogelauer M, Hoellwarth U, Hofer C.  J Rehabil Res Dev. 2005 May-Jun;42(3 Suppl 1):43-53.

Abstract
This paper presents biopsy analyses in support of the clinical evidence of muscle recovery induced by a new system of life-long functional-electrical-stimulation (FES) training in permanent spinal-motoneuron-denervated human muscle. Not earlier than 1 year after subjects experienced complete conus cauda lesion, their thigh muscles were electrically stimulated at home for several years with large skin surface electrodes and an expressly designed stimulator that delivered much longer impulses than those presently available for clinical use. The poor excitability of long-term denervated muscles was first improved by several months of twitch-contraction training. Then, the muscles were tetanically stimulated against progressively increased loads. Needle biopsies of vastus lateralis from long-term denervated subjects showed severe myofiber atrophy or lipodystrophy beginning 2 years after spinal cord injury (SCI). Muscle biopsies from a group of 3.6- to 13.5-year denervated subjects, who underwent 2.4 to 9.3 years of FES, show that this progressive training almost reverted long-term muscle atrophy/degeneration.

My comments
This paper is a bit of a follow up to my last one on using EMS for aerobic exercise, which I thought wasn’t particularly enjoyable for able bodied people, but might be just the ticket for those with injuries, particularly quadriplegia. I noted, however, that I did not expect the parameters used in that paper, or used in my own experiment, to work with paraplegia. The above paper however outlines the EMS parameters apparently being used successfully in ongoing experiments in Europe.

Classically, electrical muscle stimulation works well for upper motor neuron lesions typical of cervical spinal cord injury because the sensory and motor neurons between the muscles and the spinal cord is intact. What is missing is input from the brain turning on, or off in the case of clonus or spasticity, muscle contractions. Because the spinal cord ends at at ~L1-2, at which point spinal nerves exit the cord forming the cauda equina, an injury here disrupts the reflex arc between the leg muscles and the spinal cord. Since electric muscle stimulation (EMS) generally works by first activating the motor nerves, which then indirectly activate their respective muscles, and those nerves are damaged with lower motor neuron injuries, EMS is generally not effective for non-spastic paraplegia. NMES (neuromuscular electrical stimulation pays homage to the nerve-muscle distinction in it’s name. EMS seems to have won out in the terminology/popularity war. The presence of spasticity in the leg muscles, however, is an indication that those nerves are still intact and conventional EMS should then work. EMS with complete spinal cord injury has not been shown to restore function, but benefits do include preserving muscle health, increasing cardiovascular health, increasing bone mineral density, provide some muscle cushion to lessen risk of pressure ulcers. All are good things that would be great if they could be extended to those with lower motor neuron injuries.

So this group reportedly did it with four phases of treatment a custom made muscle stimulator with the following parameters used in each phase:
 
Phase 1: “Early Twitch Stimulation”

  • Waveform: biphasic rectangular
  • Pulse Duration: 150-200 ms (this is the MASSIVE difference) milliseconds (ms) rather than miroseconds (uS), 1 ms = 1000 uS and the strongest machine I know of available in the USA are the Globus units which top out at 450 uS. This machine in the same units has a pulse duration of 200,000 uS making it up to 444 times stronger.
  • Intensity: up to 200 mA (my Globus, that I love, tops out at 120 mA)
  • Rate: 2 Hz
  • Duty Cycle: 4 seconds on, 2 seconds off, progressed to 5 on 1 off with 3-5 min stimulation with 1-2 min rest
  • Treatment Length: 15 min per day
  • Training Frequency: 5 days per week
  • Training Length: few months
  • Electrodes: large 180 cm squared, per their 2010 paper

Phase 2: “Late Twitch Stimulation”

  • As above but with pulse duration shortened to 80-100 mS (still 80,000 to 100,000 uS)

Phase 3: “Burst Stimulation for Long-Term Spinal-Motor Neuron-Denervated Muscles”

  • Pulse shortened to 40 mS (40,000 uS), frequency increased to 20 Hz, for 2 seconds on 2 seconds off, 3-5 min stimulation with 1 min rest 3-5 times a session, twice a day, 5 days per week.

Phase 4: “Force/Endurance Stimulation”

  • After 9-12 months of training, they started doing tetanic contractions (frequency not given but I would guess >50 Hz would start to work), pulse width and intensity not given, for leg extensions for 8-12 reps with 4-6 sets, 2 minutes rest, twice a week with cuff weights progressing up to 5 kg.

The authors did note that with the extreme high levels of electric stimulation that there were risks of “skin lesions,” particularly in the early phases of rehabilitation. The results certainly sound promising, which is the good news. The bad news is that I have yet to see an EMS machine capable of delivering anywhere close to the above parameters in the USA.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

18 thoughts on “Electrical Stimulation for Paraplegia (Good News and Bad)

  1. Hi Chad, I absolutely love the blog. I really like how you set up your articles, very easy to follow. My question is about the Globus EMS units that have denervation programs, do you believe they are effective for denervated muscle? All Globus units have pulse width cap of 450 uS I believe. Also, what are your thoughts on triangular and trapezoidal waveforms to isolate denervated muscle? Thanks for all you do, keep dropping knowledge

    • Hi Branden,

      Thanks for the kind words, you ask a good question. Could you give me a little more context as to the situation you are wanting to use the stimulation for? Quadriplegia with spasticity, paraplegia with or without spasticity in the legs, or perhaps partial/complete nerve damage of a peripheral nerve due to trauma or disease, like perhaps neuropathy? Does the person still have sensation?

  2. Thanks Chad..I had hip replacement a little over a year ago and have damage to my inferior gluteal nerve. I have glute max denervation, but the medius works fine. I’ve only tried Russian waveform, thinking it was the most powerful. Do you think 450 uS is enough pulse width and will the triangle/trapazoidal waves isolate my glute max. Thanks Chad, hope this is enough

    • OK, so I’ll take it you have a Globus stimulator already, one that has both Russian current and the denervated muscle programs, so it sounds like a higher level unit. When I first got seriously interested in EMS I was all hyped up on “Russian stimulation” too and bought this unit. I immediately returned it because the muscle contractions I got with it were so weak that I knew it wouldn’t work for anything. On the contrary Globus Genesy units are by far the best stimulators I have every tried, but when I put them on the “Russian” stimulation pattern they feel just as weak. There is a good (but in my opinion not perfect) write up on the EMS digest comparing Russian stimulation to biphasic square wave current and it concluded Russian stimulation was as strong as biphasic square wave with 200 uS. However when I try it on my Genesy 1100 it feels closer to maybe 50 mA. Plus only two channels work with Russian stim, instead of the Globus’ usual four, and you can only turn up the machine to 60 mA, vs 120 mA with biphasic square wave. So in short, I have yet to experience a Russian stimulation muscle contraction that feels remotely adequate.

      The denervated muscle feels much the same on myself, inadequate muscle contraction (just a twitch) but which is also quite painful. Also only two 2 channels work, and you can only go to 60 mA. That might be for the best because, as I mentioned, those twitches were sharply painful. Such that if you had no sensation, that would be fine, but if you can feel it, you probably won’t like it. So in your situation wouldn’t expect too much results from the triangle/trapazoidal waves.

      So hopefully your nerve is damaged and not obliterated. If that’s the case I would definitely try the Globus with the 450 uS biphasic square wave. The Globus units, depending on the model come with dozens and sometimes hundreds of prewritten EMS programs, and in all honesty I don’t use any of them, ever. I’m sure some of those programs are good, but most have warm-ups, cool downs that make the treatment last longer than I think it should, and the program names that are not particularly descriptive of what I think is going on. What the Globus Genesy models do have (THAT I LOVE and makes them cheap at any price) is the ability to write and save 15 or so of my own programs, exactly how I want them, based on any research I might read, or whatever I might want to try or test (up to the limit of 450 uS). FYI, though I have the Genesy 1100 at home, all my clinic units are 300s because the 300 is every bit as powerful, and is fully programmable. To me the only difference is the Genesy 300 has only 91 programs that I never use, while I think the 1100 has about 1000 programs, that I never use. The potential downside of the Genesy 300 vs the upper Genesy models is they don’t have the Russian or denervated muscle programs, but as stated, I don’t use them anyway, apparently except to try out and disparage.

      So if I were you, and your Globus model is programmable, I’d write a program and call it “10-50-10,” for which I would program as follows:

      Stimulation Type: EMS
      Number of phases: 1
      Phase duration: 10
      Type of stimulation: Intermittent
      Type of modulation: Constant
      Workout frequency: 120
      Workout pulse width: 450 uS
      Ramp up duration: 1500 mS
      Workout duration: 10s
      Ramp down duration: 500 mS
      Rest stimulation type: Constant
      Rest frequency: 1 Hz (this doesn’t matter because I turn it down to zero or close anyway when in use)
      Rest duration: 50

      That’s my ‘go to’ program that I use on myself and with my patients more than 90% of the time. If you have read about Russian stimulation you might notice I am taking Yakov Kotz’s 10 second contraction, 50 second rest, 10 times duty cycle and programmed it into my Genesy with a modern biphasic square wave current that is pretty much maxed out. Intensity of muscle contraction is then controlled from light to stronger than most humans can take but increasing the mA as you go.

      Also I think the electrodes you chose matter a lot. Usually (more than 90% of the time) I use one’s like this, and here is why.

      I hope that helps. Let me know if you have any other questions, and if the EMS seems to work or doesn’t. Somewhere on my site I there are diagrams of where where I would place the electrodes for glute max/hip strength so if you want, let me know and I’ll ask my staff where they are and how to link them.

  3. Wow! Thank a million Chad, above and beyond. I ordered a globus genesy 600 and it should be here any day now, so thanks for the parameters. I notice in the user manual, that the denervation mode has a rectangular waveform. Do you know how that would be different from the normal square biphasic? I did notice that Compex puts out 2 units with 1ms pulse width in denervation mode (Compex 3 & physio 5). It just seems like a wide pulse width is the key. I did order some of your caebon rubber electrodes and straps, can’t wait 2 get away from the gel pads for good.

    • Cool, the Genesy 600 should be a great machine and you can program about anything you want, though for someone with paraplegia without spasticity type denervation I don’t think it would work. Per the manual for the denervated settings the triangular pulses are 1000 mS, while the rectangular and trapezoidal currents are 500 mS. I have been unable to get any definitive information regarding if it is monophasic or biphasic, but it stings like a monophasic current, which is just one reason I like the biphasic symmetric square wave currents A LOT better. With your machine you’ll be able to try both and see what works better for you. My instincts are that parameters I listed above with the 10-50-10 program to work better. If the muscle is 100% denervated then it won’t work but if it’s partial and recovering I’d expect the biphasic wave with 10 on 50 off to be considerably more powerful.

      Interesting info about the Compex units. On paper they sound great, and I’m sure they are good quality. However, from what I can tell, none of the one’s available in the USA are programmable, the given programs were limited, and the max pulse width and amplitude was less than the Globus on the USA models. If you get your hands on one of the new one’s I’d love to hear what you think. If your Genesy 600 is able to activate your muscles with the biphasic square wave, I expect it will be CONSIDERABLY MORE than adequate. Definitely let us know how it works out because I have never treated anyone with your exact type of injury.

  4. Thanks again Chad for taking the time out of your day to respond. I honestly don’t think its gonna be the answer either, but its my starting point. There is a machine made by Anatomical Solutions, called the stimulette Den2X I believe. Its the only unit capable of treating lower motor injuries to my knowledge. I’m gonna be flying to the UK to check it out if nothing else works. I’m a little obsessed about healing my injury, and its nice to know that we’re just scratching the surface with EMS in rehab settings. Thanks for being a pioneer in research of EMS, all of your theories are field tested, and frankly its really hard to find anyone with any sort of actual knowledge of parameters and such.

  5. Hi Chad
    I have been reading your posts with great interest and fascination. I have partial nerve damage of my suprascapular nerve that is caused by a large paralabral cyst. I have a labral tear of my left shoulder with the fluid leaked from the shoulder joint forming a large cyst. I have been fighting atrophy of my infraspinatus muscle aggressively using EMS and external rotation exercises everyday for the last 2.5 months. So far it responds well to EMS stimulations regaining strength for external rotation but I still have another 7 weeks of waiting before my nerve decompression and labral repair key hole surgery. I have been weight lifting for the last 30 years.

    I still have noticeable atrophy of my infraspinatus muscle.

    I am looking into buying an EMS with denervated programs.

    My options are:

    Globus Genesy 600 (£500)
    Compex 3 Professional 3 (£1190 here in the UK)

    The Compex 3 has denervated current of pulse width 10ms-1000ms (Compensated, rectangular or triangular) and dedicated carbon electrodes for the denervated current.

    Unfortunately I have already spent a fortune on EMS machines. Currently I have four EMS machines: Globus Premier 400, Compex Sp 4.0, Neutrac Sport XL and Everyway Premier combo Plus which none of them have denervated programs. I have used EMS efffcetively to replace my weight training program and so far I have maintained the same muscle mass for 2.5 months after stop lifting heavy weights. I have experimented with many different settings and customised programmes and different types of electrodes. I am very familiar with the program settings used by Compex and Globus.

    Globus web site only states that the Globus Genesy 600 has:

    Triangular (low denervation level)
    Trapezoidal (intermediate denervation level)
    Rectangular (high denervation level

    Where did you get the information of “Per the manual for the denervated settings the triangular pulses are 1000 mS, while the rectangular and trapezoidal currents are 500 mS” from? I cannot find any online manual for the Globus 600.

    I would definitely go for the Globus 600 if it can do what Compex 3 does with the denervated current. Here I can get 20% discount for the Globus. Compex is too pricy.

    In addtion, I also interested in trying out biofeedback EMG+EMT+ EMS machine:

    Neutrac Myoplus (£310)

    I have seen a few research papers on the use of biofeedback for the rehab of infraspinatus muscle.

    • Hi Sing,

      I think you are probably doing the best you can do already.

      I have a Globus Genesy 1100, which has the same software as the 1200 that they sell in Europe. I think in the manual for it is where I found the parameters for denervation program. I wouldn’t go so far as to say those programs don’t work, but they sure felt weak too me (like I could hardly any muscle contraction, just stinging), while I think the contractions with the parameters in the study this blog is about I have to imagine on me would be IMMENSE! So if I were you I wouldn’t buy either the Genesy 600 or that Compex unless you could try it out first, or return it if you aren’t impressed. I think the Globus Premier 400 you already have is a great machine and it’s programmable, so if it were me I’d write up a custom program with 10 seconds on 50 seconds off, or 5 on 15 off, with a 2.5 second ramp, 120 hz (heck maybe max it at 150 hz) for 10 minutes duration and call it good. I have been writing all my EMS programs lately with 5 hz during the rest period, which if you turned that up as much as tolerated would improve circulation to the muscles at the same time you are strengthening. I just have this feeling that if you get either of the new machines with the denervation programs you’ll be disappointed. However, if you do try one and it works noticeably better than biphasic square wave, please post here to say.

      Biofeedback I think is lame. You already lift weights so should have a good feel for if your muscle is working or not, and you can put your other hand over the muscle and feel if it’s thickening/firming up during contractions (a sort of poor man’s biofeedback).

  6. Hello Chad, three months ago and due to an intramuscular injection in my quadriceps, I had the end of the vastus lateralis totally atrophied, a hole a hole, from where I put the injection diagonally until the end of the quadricep I have gone to various specialists and me Speak of damage to the femoral nerve in its most distal part, I would like to know if it is possible to reinerve that nerve with the help of electrostimulation and if possible the hypertrophy in that part, I am weightlifter and I need to match both legs, I can buy globus 600 or 1500 the one you tell me thanks for your patience and answer has this message (I fell my English is bad)

    • Hi Alfonso,

      Of the two stimulators available I would go with the Globus 600. It’s definitely worth trying and I would program mine using a biphasic square wave current, using the longest pulse width possible (450 uS), 120 hz, 10 seconds on 50 seconds off for 10 minutes. I’d probably give it a 2.5 second ramp up and a 0.5 second ramp off. Oh, and I’ve been setting up my stimulators with 5 hz during the rest period to improve circulation at the same time as you are working on strength. I’m not sure if the combination stimulation helps or hurts, but it’s what I have been doing with mine in my office.

      With peripheral nerve injuries I don’t think you can ever know if the nerve will grow back or not, but they sometimes do and with EMS I think you are giving yourself the best shot at recovery. Unfortunately it’s a poorly researched area. Oh, and large rubber carbon electrodes work better than the sticky one’s that come with your machine. I hope that helps.

  7. Hello Chad, I already have the 600, first of all thank you for your free information and your attention. I have programmed the Globus just as you told me now I only have a few small questions, how many times a day and a week? And I can alternate it with some other program of denervation (triangular, rectangular or trapezoidal), I am involved with the placement of the electrodes, if I put them distally at the beginning of the vast lateral the negative and the positive at the end (in the atrophied part) I notice a large contraction but only in the unaffected part. If I put them almost together right at the denervated point I can augment until 60ma without problem noticing just a little contraction since it is just the denervated part, where do you advise me to put them? In this last part to stimulate only the end of the vast atrophied lateral?

    Thank you very much for this support, I am from Spain but I do not have the slightest problem of realizing some economic income if it is necessary I am a bodybuilder and this has stopped my career, I am desperate

    • Hi Alfonso,

      Nobody knows how many days per week but I would think for hard EMS do it maybe once a day at most, though every other day might be just as good. Every other day for strength of normal muscle is just as good as every day, but it’s hard to say if that translates to your situation. Maybe do my program every other day and try the denervation programs in between. I don’t don’t think the denervation programs actually work but the shouldn’t hurt anything. As for pad placement I would put them where you notice the best contraction of the atrophied muscle. I don’t think positive or negative electrode placement matters. At least with the symmetric biphasic square wave programs I like, the current is alternating so each electrode is equally both positive and negative.

      I might think about writing a program that’s just aerobic to increase circulation to the area, 30 minutes at 5hz like I talk about in the aerobic EMS blog. I would still think it a good idea to put the electrodes where you notice the most contraction of the affected muscle fibers if possible. Otherwise I would put the electrodes to such as to get a contraction right near the affected muscles. Don’t worry about payment, just tell me what you notice works or not.

  8. Hi Chad,

    Great info!! I’m a paraplegic, and would like to stop at least., but preferably reverse it. These Globus products are quite expensive. For people looking for a EMS that can probably build muscle, and don’t want to spend $1000+, what more affordable reliable products could get the job done. I don’t need all the bells and whistles. Could you recommend at least one affordable option, that is strong enough to build muscle USF used properly. I noticed you mentioned this unit in one of your posts: https://www.absolutept.com/product/pads-straps-kit/

    Is this an option that can do what I’m looking for? Other recommendations would be great as well.
    Thank you so much for all this great info!

    Justin

    • Hi Justin,

      If your SCI level or severity is such that you have muscle spasms then EMS like the Globus Triathlon I’m using now, with the good electrodes should work and I would think would be ideal. If it’s a lower motor neuron injury (usually at or below L1-L2) such that you don’t have leg muscle spasms then it probably wouldn’t work.

      The cheaper machines you linked I think are mostly too low in power, and if they only have two channels you would have to apply the stimulation more times to target all the important muscles. The Compex machine you link too is supposed to be pretty good, not as powerful as the Globus but close, however, it isn’t programmable, so you would have to take what you get with it, and I haven’t worked with one to know if I would like the presets. If you have spasms, and you think the EMS would work on you, check out my blog on EMS aerobic conditioning, for which I think EMS with SCI would be ideal along with a 10-50-10 for muscle strength. I like the combination enough that I have been programming my Globus machines to do both at the same time.

  9. Hi Chad
    I have weakness in my left muscle leg and started using complex EMS with the rehab program. They insist the muscle be contracted isometrically in specific positions for each muscle. The programs are already given and produce strong stimulation. Do yo you have an idea about ?

    • Hello Hind,

      Do you mean a “Compex” machine? If so it should be a decently strong machine. I don’t think muscle rehabilitative protocols are different from sports conditioning programs except for marketing purposes. There is something to be said for training the muscle over various muscle lengths but with EMS nobody has quantified how much that matters. Based on my experience it only matters a little bit and I’ll usually set people up in what I think will be their most comfortable position with the EMS. I don’t try and contract my muscles isometrically while the EMS is going. I think to be optimally effective the EMS should be so strong as to drown out any active input you have to give. So I mostly tell people to just “brace themselves” for the EMS blast, which I want to be as powerful as possible. In other words the EMS should be strongly isometric all by itself.

      Usually I’ll do active exercise to the weakened muscle first, training it over a full range of motion, then doing the EMS afterwards. I hope that helps.

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