Electrical Stimulation in the Management of Spasticity:

A Review
Joyce M. Campbell, Member, IFESS

Abstract Despite the proliferation of studies in

Despite successful reports of spasticity the past 20 years, this body of knowledge has
management by electrical stimulation [ES] over been ignored by many clinicians. In many
the past 246 years, this potentially effective and centers, medications are the first treatment of
economical tool is often overlooked in clinical choice and intrathecal drug administration is
practice in favor of oral medications with commonly employed. Surgical intervention,
serious side-effects, intrathecal drug including phenol nerve block and tendon
administration, or surgical procedures including lengthening is recommended without prior trials
tendon lengthening and long-term muscle of electrical stimulation. It is time to consider
denervation. The body of literature on ES and the development of criteria for the use of
spasticity provides a rationale for critical review electrical stimulation in concert with, or as an
of the relative merits of all strategies employed alternative to medications and surgery.
to manage spasticity as well as for the
development of criteria to use these available Consensus of Results in Peripheral Nerve
tools in concert for optimal patient outcomes. Stimulation
Study protocols, using objective
Index terms: Spasticity; Electrical Stimulation; measures of spasticity, ranging from single
Stroke; Brain Injury; Spinal Cord Injury; assessment to two year follow-up have
Cerebral Palsy; Multiple Sclerosis; Amyotrophic demonstrated statistically significant reduction
Lateral Sclerosis. in spasticity as a result of peripheral nerve
stimulation. [5-16] Cutaneous electrodes,
Historical Perspective implanted electrodes and implanted neural
Electrical stimulation has been used prosthetic systems have led to reduced
therapeutically for over 2,000 years. It has been interference from spastic muscles,
employed to manage spasticity for 246 years, or improvements in volitional control and positive
more. In 1752, Benjamin Franklin wrote a case changes in the energy demand of walking. [11-
report describing his use of electricity to manage 12] Carry-over effects ranged from 30 minutes
involuntary muscle contractions in a young to 24 hours, or more. Functional outcomes were
patient. In 1871, Duchenne used electrical realized when ES was combined with goal
stimulation [ES] to inhibit spastic antagonist directed physical therapy. [7-8,17-18]
muscles that interfered with function. [1-2]
Following the interest in the Results of Cerebellar and Spinal Cord
neurophysiological mechanisms underlying Stimulation
spasticity in the early 1900's, practical electrical Cerebellar ES in cerebral palsy and
stimulation devices became available in the multiple sclerosis resulted in reduced spasticity
1960's. Success with cutaneous, or skin, in the majority of subjects along with
electrodes was replicated when implanted improvement in bladder function, respiratory
electrodes were employed. function, volitional control, active and passive
Cerebellar and spinal cord stimulation movement and mood state. [3] Spinal cord ES
studies in the early 1970's appeared to reduce outcomes were similar with carry-over effects
spasticity and improve the lives of the patients lasting up to 24 hours.[4] Functional test scores
implanted, but the statistical outcomes were not in many of the studies did not reflect the other
universally rewarding. [3-4] improvements observed. [3-4]
 neurological dysfunction and treatment must be
Problems in Study Design tailored to each individual.
Among the problems in some study It must be recognized that ES alone is
designs have been small subject samples with usually not an encompassing treatment for
extremely varied diagnoses and severity of spasticity. ES can "unmask" residual control and
disability. Objective measures of spasticity have result in early recovery of selected functional
not been uniformly employed. Gross functional movement. In most instances when the patient
scales have been used as the primary is in the phase of "neural recovery" after insult
measurement tool and the statistical significance to the CNS, reduction of spasticity with ES is
criteria imposed would have required relatively only the first step. ES can then be employed to
miraculous changes in function in order to be improve muscle recruitment and performance
considered efficacious. In addition, many final [force, work, power, and fatigue resistance] as
publications have disregarded reports of well as enhance timing of recruitment for
improvement from patients, families and function. When recovery is incomplete, ES may
physicians. [2-4] be used as a neural prosthetic for maintained
daily function.
Critical Concepts Goals must be individualized and small
Confusion exists in terminology, achievements that result in even minimal
selection of assessment tools, methods of improvements in function and quality of life
patient evaluation and the importance of must be delineated. Whether the goal is
specificity in goal setting, treatment and improved sitting position and tolerance resulting
outcome evaluations. Terms such as "muscle in less frequent repositioning by an attendant or
tone" and "muscle spasm" are not objectively the ability to bring the body weight forward
measurable and should be replaced by over the base of support in order to allow a
"spasticity" which can be measured. reasonable contralateral step length, improved
Spasticity must be assessed in the safety in walking, increased free pace velocity
upright or most functional position if and reduced energy demand, objective
interference is to be accurately defined. It must documentation of goal achievement is
be recognized that interfering muscle activity [ie invaluable. It is not necessary to change from
in walking or transfers] may be the result of a bedridden to walking independently to show
spastic response to voluntary use of antagonist efficacy of ES in the modulation of spasticity.
muscles or it may be that the inappropriate
muscle is being recruited in the wrong phase of Common Misconceptions
movement. In the latter case, spasticity is not the There are a variety of misconceptions in
culprit and we have no evidence that therapy the treatment of spasticity. One serious pitfall
will alter the cortical recruitment pattern. relates to the amount of ES required per day to
Surgical relocation of the muscle's action to its reduce spasticity and the need for immediate ES
functioning phase would then be appropriate. treatment when spastic episodes occur. There is
[19-20] agreement among researchers that 1-2 hours of
The only way to determine if ES per day will suppress spasticity on a 24
inappropriate muscle activity is responsible hour/day basis. In addition, the ES may be
[spastic or out of phase, or both] is to do administered at any time, including nighttime.
intramuscular electromyography [EMG] Even cutaneous, or sub-motor, intensities of ES
recordings during movement such as walking or result in 24 hour/day suppression of interfering
grasp and release. Cutaneous EMG recordings spasticity. [15-16]
are contaminated by volume conduction from One of the biggest impediments to the
all muscles in the limb and are useless for use of spasticity is the misconception that ES for
diagnostic purposes of this nature. [21-22] It spasticity modulation is expensive or esoteric.
must be recognized that each patient has his or There are a variety of ES devices available
her own "neurological fingerprint" of through wholesale vendors for less than the cost
of a single physician or therapy clinical visit [ie potential for recurrence of spasticity associated
less than $45-100.00, US currency]. Despite the with rhizotomy, ES is very safe. [25] In
body of literature and the inexpensive cost of comparison with the muscle weakness or even
ES devices, a relatively recent publication states complete denervation associated with botulinum
that there is no basic research and there have toxin and phenol nerve block, ES is a preferred
been no multicenter trials on the use of ES to initial treatment. [19-20,26-27]
control spasticity, and the clinical availability of
ES systems for this purpose in the U.S.A. is Summary of Clinical Suggestions
limited. [23] The survey results reported in this Individual patient care can be improved
publication indicate that of 105 "FES" centers, through clarity of terminology [ie omission of
only 4 centers listed spasticity management terms like tone and spasm and replacement with
among their services [Public Hospital in Lonato, spasticity when applicable] and the use of
Italy; National University Hospital in Reykjavik, objective measurements [ie measurable
Iceland; "Shake-A-Leg" FES Research Program, resistance to passive joint movement, available
University of Sydney, Australia; and the joint range of motion, sitting tolerance, specific
Cleveland Clinic, Ohio]. These four centers hand function assessment, manual muscle test
state that they charge from approximately or instrumented assessment of force, work,
$1,000.00 to $20,000.00 to treat spasticity. [23] power and fatigue, and mechanical as well as
ES can be used anywhere in the world metabolic characteristics of gait].
to modulate spasticity for a minimum cost Attention to specific changes in function
[$45.00 to $100.00 and the cost of 1-3 physical is critical. It is not necessary to improve from
therapy visits]. The lack of recognition of this bedridden to independent ambulation, for
opportunity by clinicians and publishers of example, to realize the benefits of reduced
consumer education materials is revealing of the spasticity. Careful documentation of ES
lack of understanding of the clinical needs of protocols is important. For example, the use of
patients and the ES research and clinical a comfortable, balanced pulse duration [ie 300
outcome reports available in the literature. usec] and a long ramp in intensity [2 seconds or
more] along with a minimal intensity will
Considerations of Risk minimize the potential for aggravation of
ES for spasticity modulation is relatively spasticity in the early days of an ES protocol.
risk free. Although it is possible that spasticity When prospective data collection is
may be temporarily exacerbated, especially if planned, categorization of patients by diagnosis,
abrupt muscle contraction is generated, any severity and specific goals will improve
adverse effect is significantly reduced or absent outcome evaluation and statistical analyses.
within 30-60 minutes. If the patient uses
spasticity to allow standing, transfers or limited Suggestions For Future Spasticity Studies
stepping, the reduction of spasticity by ES may There are many options for successful
reduce function until ES control of muscle or use of ES to modulate spasticity and accomplish
ES facilitation of muscle recruitment can be reasonable, efficacious goals for the patient.
instituted. When ES is applied as one When ES alone is not adequate to resolve the
component of an integrated rehabilitation penalties of severe spasticity, it may offer a first
protocol, this is not a problem. line of evaluation as well as an adjunct to the
In comparison to the muscle weakness, overall rehabilitation outcomes. [28-29]
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