[00:00:00] Dr. GG deFiebre: Hello and welcome to the SRNA “Ask the Expert” podcast series. My name is GG deFiebre and I moderated this episode called “FES 101.” SRNA is a nonprofit focused on support, education, and research of rare neuroimmune disorders. You can learn more about us on our website at wearesrna.org. “Ask the Expert” is sponsored in part by Amgen; Alexion, AstraZeneca Rare Disease; Genentech; and UCB.

[00:00:31] For this episode, I was pleased to be joined by Dr. Matthew Bellman. Dr. Bellman is a founder and the Chief Technology Officer for MYOLYN, Inc. You can view Dr. Bellman’s full bio in the podcast description. Thank you so much for joining me today to talk about functional electrical stimulation or FES. Do you mind just talking a little bit about what FES is and how it differs from other types of electrical stimulation or just kind of physical therapy more broadly?

[00:01:04] Dr. Matthew Bellman: Of course. And thanks for having me. It’s a pleasure to be able to share more about FES with people. So, FES, as you said, it’s functional electrical stimulation. There are many different types of electrical stimulation that are used in physical therapy and rehab. The thing that really separates functional electrical stimulation from the other types is the functional piece. So, throughout history, people have used electrical stimulation for various therapeutic purposes. You could go all the way back to the ancient Egyptians using electric eels to shock people for pain relief.

[00:01:46] But in more recent years, really starting with the sixties, seventies, 1960s and 70s, people began to experiment with using electrical stimulation during a functional activity to try to help somebody perform that activity better than they can without the stimulation. So that’s the functional piece. The first devices, the first FES use was for foot drop. Many people experience weakness in their lower leg and have difficulty picking their toes up as they’re walking. But you can stimulate the muscles on the front of the leg to lift the toe up when somebody takes a step to help them walk better.

[00:02:32] And that can be triggered very simply with a foot switch or some other device. And shortly after, foot drop stimulators were developed. Cycling with FES was developed as a therapeutic activity. And that’s similar in concept, but a little more complicated in the sense that you’re stimulating multiple muscle groups in the lower legs while somebody is trying to cycle to help them do that, either for recreation or really the therapeutic exercise.

[00:03:09] Other types of electrical stimulation are usually used in a context of you’re sitting still, maybe you’re causing a muscle to contract, but you’re not doing any work with it. Or you’re doing something else like pain relief or some other application that isn’t linked to a functional activity. So that’s what makes FES, FES.

[00:03:32] Dr. GG deFiebre: Got it. Thank you for that overview. And then how does FES work in the body, especially for people with impaired nerve signaling due to rare neuroimmune disorders. If someone doesn’t have any volitional movement in their legs, how does FES kind of work in the body with that context?

[00:03:51] Dr. Matthew Bellman: Yeah, great question. So, the way FES works in the body, generally speaking, is it can be applied either externally, non-invasively–you typically use the stick-on adhesive electrodes on the skin that apply electricity–and there are implanted systems. People get implants for spinal cord stimulation and pain control.

[00:04:17] There’re implants for stimulating the diaphragm to help with breathing, bowel and bladder functions, sexual function. But in any case, the way electrical stimulation works is when you apply electricity, it generates an electric field. That field kind of permeates your body and the tissues around where you’re stimulating. And that field actually moves ions, charged ions in your body. And that movement causes a voltage potential difference across your nerve cells.

[00:04:57] So, nerves are usually looking at what is the kind of state of my electrical charge. And when it wants to fire, when a nerve wants to fire and activate, there’s a complicated chemical process going on there that’s bringing ions in, bringing ions out to try to manage the charge and result in that activation. When you apply that electric field externally, it kind of tricks the neuron into thinking, “Oh, I should fire now.” Because it sees a little charge difference. And depending on where you stimulate, if there’s neurons in the area or axons, the arms and legs of the neurons, they will sense that change in currents and then respond.

[00:05:44] For somebody with a rare neuroimmune disorder, oftentimes what can happen is the neuron gets damaged to the point where it doesn’t actually respond to that change in charge. So, for some people, depending on the condition and how your nerves are affected, you may or may not respond to stimulation in the sense that the nerves may not fire when you try to stimulate them. But there are other processes that occur when you do stimulation.

[00:06:22] So even when somebody maybe doesn’t present immediately with a muscle contraction or something, a nerve activating. There are still benefits to doing that over time. And so, it’s essentially trying to activate a nerve anywhere in the body. And the results kind of depend on the stage, the status of your nerves. How healthy are they, how damaged are they, what kind of damage has been done. So, the responses vary widely with the condition of the patient really.

[00:06:56] Dr. GG deFiebre: Got it. And so earlier you mentioned the kind of different ways FES can be used, foot drop, and then also things like a bike. Can you share how FES is used specifically for those with spinal cord damage from rare neuroimmune disorders?

[00:07:12] Dr. Matthew Bellman: Yes. So, for example, the disorders that come to mind are like transverse myelitis or acute flaccid myelitis. And FES is used during physical therapy or rehabilitation to try to get the muscles that are weakened or paralyzed because of the nerve damage to fire so that they do work, so that they can do all the things that muscles are supposed to do. Help you move, put a load on your bones to strengthen the bones, put a demand on your cardiorespiratory system to get blood flowing and oxygen going.

[00:07:55] That all helps to…a lot of the benefits of FES for somebody, if we’re talking specifically about a person with spinal cord damage, typically that’s going to result in you not being able to move as well as you would like to, and a host of other problems associated with that amongst other things. So, the goal of using FES in that context is to try to help you move so that you can get the therapeutic exercise you need and or so that you can better perform some activities of daily life.

[00:08:31] Depending on the nature of the condition again and how your nerves are affected and how extensive is the damage, you may be doing FES for foot drop to correct gait while you’re walking, or you could stimulate other parts, other leg muscles, while somebody’s walking to try to help them walk better. For people who are non-ambulatory we typically would do cycling or some other, for example, rowing, stationary rowing on an ergometer is another activity that’s done in some places.

[00:09:10] And it’s really just trying to get as much of the body active and as much of the musculature active as possible because that is really what drives the benefits and can drive neuroplasticity, nerve regeneration. Those things can all help recovery. And of course, they can help mitigate the secondary health effects of the condition. Being immobile, being not active, those things alone have serious negative health effects. So, FES is using a variety of ways to try to assist and combat some of that.

[00:09:50] Dr. GG deFiebre: And then, are there certain symptoms that it’s helpful, especially helpful for? So, you mentioned it, you know, is it just to kind of strengthen muscles or are there any benefits for like spasticity or neuropathic pain or anything like that?

[00:10:03] Dr. Matthew Bellman: Yes. And as is the case with all neurological disorders, the results vary depending on the condition of that individual. So, the most commonly cited benefits of FES and things that it’s helpful for muscle atrophy that definitely can help rebuild and strengthen muscles. It can help with muscle spasticity, for example, for people with multiple sclerosis. We were actually surprised and the FES community in general, I think.

[00:10:43] A lot of the history of FES, the research was done on people with traumatic spinal cord injuries. But more recently, research has been done to see, investigate the benefits for people with MS and for other disorders. And for people with MS in particular, it was found that it can significantly reduce muscle spasticity in a way that helps somebody move more functionally because that spasticity is often fighting you while you’re trying to do something.

[00:11:13] So, activating a muscle, exercising it, getting it tired, stimulating other muscles, those can all help reduce spasticity. Although for some people it can make the muscle stronger. So maybe you have less frequent spasms, but the spasms you do have may be stronger. Blood flow and increased blood circulation is a major benefit, especially when you get a lot of muscles involved and actively working. That gets the blood flowing.

[00:11:43] Lots of benefits related to that. When FES is helping you move, it can help increase or maintain your joint range of motion, so you don’t end up with contractures or limited mobility in that sense. And the other major benefit that’s often cited is muscle reeducation or neuromuscular reeducation. So, if you have some, I put that into two categories, either you have no voluntary function and there’s an opportunity to regain some voluntary function, or you have some voluntary function and you are either weak, or your coordination is impaired.

[00:12:25] The use of FES can help again strengthen the muscles, but it can also help improve your coordination, if the timing of the stimulation can help you retrain yourself and your nervous system, relearn how to really use the muscles in a way that’s beneficial. So those are the main usually cited benefits. You mentioned neuropathic pain. There has been a lot of research on stimulation and pain. We know that it can be beneficial. And FES in particular, there’s some good work being done, researching into neuropathic pain and finding that for some people it’s very helpful for neuropathic pain.

[00:13:08] Other people, their pain can be exacerbated by it. And it goes back to, it really depends on the individual, the state of their nerves, how extensive the damage is. So really for anybody who’s interested in any of the benefits of FES or electrical stimulation, it’s worth trying just because you never know. You may experience substantial benefits. You may not like it at all, but it’s something that’s usually worth trying out.

[00:13:38] Dr. GG deFiebre: Thank you for that overview. And so, you talked a bit about the kind of benefits of FES. What does the kind of current evidence say about FES benefits for people who don’t get a response or contraction right away? And then also kind of what are the secondary benefits of increased mobility you mentioned, like blood flow. Do they have anything to do with like skin issues or anything like that?

[00:14:03] Dr. Matthew Bellman: As far as evidence goes, there is a large body of literature on FES now. I did a literature review on FES cycling not too long ago and found over 300 publications that talked about the benefits for a wide variety of disorders. And in addition to those other benefits I mentioned. Those are kind of the. well established benefits. There’s been a lot of research to show particularly muscle health and those related benefits. So, atrophy, spasticity, blood flow, range of motion, muscle reeducation, those are all muscle related, and you can extrapolate some benefits from that.

[00:14:55] So, for example, if your muscles are getting stronger, you are probably more functional in your mobility, the mobility that you do have. Function is the same in terms of if you’re talking about performing a functional task, activity of daily life, getting dressed, transferring, getting about, reduced spasticity, range of motion. Those are all things that can help. In terms of blood flow, you mentioned skin health.

[00:15:30] We have seen lots of evidence and, in fact, I’ve been involved with some studies where we’ve done FES and directly measured blood flow by looking at the skin and found that just as you might expect when you’re being active, the muscles are doing work, blood flow is flowing and it’s definitely flowing to the regions that are active. So, if you have an area in your body that doesn’t have great circulation, for a lot of people that’s the lower leg, you can stimulate lower leg muscles or even upper leg muscles to drive blood in and out of the leg.

[00:16:12] And that can help bring nutrients to the skin, that can help prevent skin issues, that can help heal skin issues. There are actually types of stimulation that are focused on wound healing and are just directly targeting blood flow and the kind of the chemistry of the area with the stimulation. And then in terms of kind of overall benefits, quality of life, quality adjusted life years. I kind of like to boil the benefits of FES down to the benefits of physical activity because really what FES does is it enables somebody to be more active than they could without the stimulation.

[00:16:57] And if you’re talking about that physical activity, lack of physical activity is a major cause of chronic diseases. So, it’s very important that you get that activity just to preserve and maintain and improve your health. And then there are the applications I mentioned earlier that are more, say for example, diaphragm pacing. If you have difficulty breathing, that’s an absolutely critical thing that you need help with. And the quality of life between struggling to breathe and being able to breathe comfortably is enormous. You could say the same for bowel, bladder, sexual function. So, these are all things that can be improved, modulated, using stimulation, again, depending on your condition, really.

[00:17:47] Dr. GG deFiebre: And so, what does a typical FES session look like? And how accessible is it for people at home versus in the clinical setting?

[00:17:59] Dr. Matthew Bellman: So, a typical FES session in a clinical setting is…that’s usually where people first experience FES or stimulation. Usually, it’s going to begin with a clinician doing some kind of assessment to determine if you are appropriate for physical activity and for stimulation. There are contraindications to stimulation. Just as an example, extreme osteoporosis. For people who have really weak bones, activating the muscles, doing exercise, especially vigorous exercise. can lead to a bone fracture. If you have other implanted electronic devices, they may be interfered with by the stimulation. And there are other contraindications.

[00:18:49] So, it’s important for a clinician to be in the loop to evaluate somebody to make sure it’s safe for them to try it. And then usually the next step is trying stimulation. And depending on the clinic and their resources, they’ll have some different devices for applying stimulation. You can go on Amazon and buy a stimulator for $20. It’ll be cheap and probably break soon, but it allows you to try that stimulation to see what your body does in response.

[00:19:22] So typically for say somebody who’s had spinal damage because of transverse myelitis, they would be applying stimulation to the muscles that are weak or paralyzed and looking for some response. Usually, you’re looking for visually you can see the muscle twitch or contract or you’re trying to feel you can physically palpate the muscle and try to feel for a contraction or the tendon itself. And if somebody does have a response or they don’t have a response, but there’s no negative effect. They’re not reporting pain.

[00:20:05] There are not any other kinds of negative sensations that are happening. They may take somebody through an FES session. And if there is a response, we would expect these kinds of benefits that we’re talking about. If there is not a response to the stimulation in terms of muscle contraction. Clinically, the really only course from that point forward is to continue applying stimulation in the hopes or expectation that something may change over time.

[00:20:44] And there has been some really interesting studies done on people who have had, say, transverse myelitis, have lower motor neuron damage, and that means that the typical FES response is not present. You apply a stimulation; you don’t see the muscle contract. But then they keep doing FES over months or even years, and people then report some spontaneous recovery of neurological function. And really what’s happening is even though the muscle’s not responding, the stimulation is still entering into the nervous system. You are still activating nearby neurons that may be not affected. It’s all one big network that all these neurons are connected to.

[00:21:31] So, they talk to each other and that activity supports neurogenesis and plasticity. And that can over time lead to improvements in voluntary function. Somebody may suddenly start responding to stimulation in the sense that their muscles will contract in response. And then clinically, once you get to this point of “I’ve seen how the patient responds. I have a sense for what kind of benefits they might expect from this.” Then a clinician will develop a program that incorporates the stimulation. So that may be a three times a week exercise program where you use stimulation to help, or it may be training in different activities with support from the stimulation.

[00:22:22] That’s all clinically. When somebody then needs to go home and they’re not going to be spending all their days in the rehab facility or the hospital. The first thing they’re going to need is some device that they can use at home. A clinician may talk to the patient about their options in terms of purchasing handheld devices or larger, more complex systems. And there’s some insurance coverage for this, but mostly it’s seen as experimental.

[00:22:53] We all know the struggles with insurance companies, so I won’t belabor that at this point. But if somebody can get access to a stimulation device that they can use at home, then that person can continue what they were doing in the clinic. They can try new things, kind of depending on your device and your condition and resources. A lot of people will consult with their clinician and say, “Hey, I got this thing. Can you help me make the most of it? Can you recommend settings or activities?”

[00:23:29] So, it’s definitely helpful to maintain contact with a clinician through this. But really, it’s in the home setting where people are going to gain the most benefit from stimulation, simply because it’s something that you can do on a daily basis. You don’t have to go to a facility to get access to it and do it. So just being able to be consistent, get a lot of time doing it. Just like physical activity, the more you do it, the more time you can spend doing it, the more benefit generally you’re going to receive. It’s the same with FES.

[00:24:06] Dr. GG deFiebre: Got it. And then are there any particular success stories or feedback you’ve heard from patients that you found to be especially meaningful in your experience with FES?

[00:24:17] Dr. Matthew Bellman: Yes. I personally have worked with a lot of patients to try FES in the form of FES cycling. So, we’ve had patients with spinal cord injury, multiple sclerosis, transverse myelitis, stroke, cerebral palsy, brain injury, a lot of different disorders, who have tried FES cycling and the benefits have been wide and diverse as we’ve already talked about. One story in particular comes to mind of a man with MS. He was a MD who had to retire because of his MS.

[00:25:04] And he was at the point where he was essentially presenting like an incomplete quadriplegic. He had some impairment in his upper extremities. Lower extremity, he had a lot of impairment. He was using the electric wheelchair, and he was at the point where if you helped him, he could stand up and maintain a standing posture with the walker. And then he could take one step with his good leg. But at that point you kind of get stuck and not really be able to move anymore or taking more steps.

[00:25:43] He got into FES cycling and he had gotten a FES cycling system for use at home. And he started doing that at home on a regular basis. He was doing it about an hour a day, five or six days a week. And after about eight weeks, I heard this story about his wife was on a video call with his mother and he walked across the background of the video frame and his mother said, “Who is, who was that? Who’s over at your house right now?” And the man’s wife was like, “Well, that’s your son.” He just walked across the back of the frame and mother burst into tears.

[00:26:27] His wife burst into tears. It was a big moment for everybody because she hadn’t seen her son walk in a long time. And really for him, it was that benefit of the FES really reduced his spasticity. So, him trying to stand on his own, was his muscles getting stiff on him that were preventing that, it was preventing him from taking steps. After that period of use, he was able to take about 10 steps in his walker, and that was enough to get him across the room.

[00:26:57] And he could also stand on his own at that point. And that makes a huge difference in quality of life. And we’ve seen similar stories with people with MS. I can think of another gentleman. He actually started doing FES cycling and taking dalfampridine at the same time and dramatically improved his walking performance. From not being able to go more than a hundred feet to really walking all about in his community and walking at normal walking speeds and really getting a lot of benefit.

[00:27:32] For people who are non-ambulatory, we’ve had a lot of people with spinal cord injury, complete injuries, no voluntary function. And for a lot of those people, they’ve had issues with the muscle atrophy and self-image. There’s blood flow and skin issues. I hear a lot about spasticity and sleep. So even for people with spinal cord injury, knocking out those spasms, helps people sleep better at night. People with improved self-image, people who have significantly regained some strength and are just able to do more and get about better.

[00:28:17] So, we’ve seen a lot of benefits, real benefits reported by people. There are a lot of other anecdotal benefits that people report talking about, say like urinary tract infections being reduced, pressure sores, not having them. Those are all anecdotal. We don’t have a whole lot of published data to show that. But in my experience, generally, if somebody responds to the stimulation, they get a muscle contraction or they don’t have any negative response to it, and then it’s something that they do consistently, you can guarantee that there will be some kind of benefits realized. And again, mostly related to the physical activity and getting the nervous system going. But we’ve seen, we’ve heard lots of reports from a lot of different people reporting those benefits.

[00:29:17] Dr. GG deFiebre: Yeah, those stories are great to hear and also, I think speak to the wide range of benefits that FES can have. So, given that this is, you know, there’s benefits to this, what are the biggest barriers you see to using FES? Is it insurance coverage? Is it cost? Providers that are aware of FES? What have you found?

[00:29:41] Dr. Matthew Bellman: Yes, so to really benefit from FES, you’d have to acquire an FES device, and you need to learn how to use it effectively and you need to be able to use it consistently. So those are kind of the three barriers. The first one, acquiring an FES device. Yes, you must

[00:30:01] first become aware that FES is something that is an option for you. So, if you’ve done your own research and came across it, that’s great. If a clinician told you about it, recommended it to you, excellent. There are a lot of clinicians out there that have no idea that FES is an option for people. That’s always a priority for the FES community is just educating people so that they come aware of it. Once somebody becomes aware, there’s a lot of different devices out there that they can research and look at. Again, maybe they get recommended one or it’s something they tried in therapy.

[00:30:40] So, they had a little bit more insight into the device and will it work for them. Once you’ve selected a device, now you need to buy it, I mentioned insurance earlier. Stimulation devices and FES devices range in price from, again, you can get something very cheap and limited functionality on Amazon or online. And then there are FES devices that cost tens of thousands of dollars. And the story with insurance is generally insurance sees this as an experimental investigational type treatment.

[00:31:24] And that’s really unfortunate because there is so much evidence for the benefits. The problem with, I think, insurance companies and kind of accepting those benefits is just the diversity of neurological disorders and injuries. And it’s really hard to do large studies that recruit people who have all in the exact same type of condition so that you can really get a high statistical significance that will convince an insurance company to pay. But they do pay on case-by-case basis.

[00:31:58] So, if you have enough evidence to support, you can present that to the insurance company. Maybe 20% of the time, they will cover something to some extent, even though their policy maybe says that they wouldn’t cover it. And there are also a lot of grants options out there. A lot of people do fund raising. So, there’s different financial resources that are available to people to help with some of these things. Once you get it, we mentioned the best place to use it is probably at home because that’s where you can get the most usage out of it.

[00:32:39] So, you’ll need to learn how to use it effectively at home. Not all devices are created equally. Some are much more difficult to use than others. So that’s a factor. And depending on who you’re getting it from, you may need some degree of training and education on how to make the most out of it. That should probably be a part of your plan anyways, because it’s an investment and time and money and you want to get the most out of it. And then once you’ve kind of learned the ropes of how to really make the most of it, then it’s just a matter of, like exercise, doing it consistently on a regular basis so that you can gain the benefits. And if you stop, you’ll see those benefits start to go away. So, consistency is key.

[00:33:28] Dr. GG deFiebre: And are there any new developments in FES technology or research that you’re particularly excited about?

[00:33:36] Dr. Matthew Bellman: Yes. I think the thing that I’m most excited about with new technology and development in the FES space is the kind of impact of AI on the field. My background, I have done some work in the AI space and have long thought about applying it to the problem of FES. The human body is just so complicated that for a person to try to wrap their mind around all of the different people out there and designing a device for them to control their own muscles in a way that is optimal and beneficial, it’s not an easy thing to do.

[00:34:22] You can’t sit there with a remote control and just press buttons and activate somebody’s muscles and puppeteer them to walk well or something like that. Muscle from second to second to the way your body responds to stimulation can change from day to day with hydration levels. There are so many different factors that go into it. It is a problem that’s actually really well suited for a large computational model that can take all of those factors into consideration and then output something that will be tailored and optimized for that individual.

[00:35:05] But you need a lot of information about their body and about how the human body works in general. But there are people who are doing research on this and this concept of a digital twin where I can take your body, model it in a computer, simulate how it would respond to stimulation. Do that millions or billions of times, and then select from those different stimulation programs, say that it implemented, which one had the best benefit for your digital self. Now let’s try that in the real world.

[00:35:41] And hopefully if we did a good job in modeling you digitally, then the transition to the real world will be effective and smooth. That’s something that we’re seeing right now with robots, humanoid robots and others. The difference between a humanoid robot and a human is the human is way more complicated, even though they’re both doing very similar tasks. So, it will be a while before we get there, but that to me is the most exciting development because then we can really custom tailor stimulation for each person and do that in a way that’s going to help them optimally in the best way possible.

[00:36:27] Dr. GG deFiebre: Yeah, that’s very interesting. I mean, we’ve seen such a growth in the availability of AI for kind of like the general public. So, it will be interesting to see what happens in the rehab space. So yeah, thank you for answering my questions. Any other kind of final thoughts or anything you want to leave our listeners with?

[00:36:46] Dr. Matthew Bellman: Yeah, so I know that the listeners out there are people interested in rare neuroimmune disorders and how best can we address the problems associated with them, actively prevent them, cure them, treat them. FES is not going to prevent any of those disorders, and it certainly isn’t going to cure any of them except to some extent in a functional capacity. Really the benefit of FES is in treating the secondary conditions and kind of managing the impact of the condition.

[00:37:27] Long-term we may see more evidence for some of that neurological recovery and functional recovery. And that’s something to stay tuned to. And there are a lot of new developments in that direction. So, there’s a lot of hope to be had, a lot of things to look forward to. As I alluded to earlier, I think it all kind of boils down to you have to try it for yourself. If you are working with a clinician, talk to them about it.

[00:38:04] See if they know anything about FES. Ask if it might be something that’s worth trying for yourself. Certainly, do your own research and see what is available in your area or maybe you go on Amazon and buy a little stimulator and try it if you’ve never experienced that before. So, I just want to, I think, leave people with a bit of a message of hope in that. There are people like me and others out here who are dedicating our lives to developing technologies and treatments that will try to help improve your quality of life as best as we can. So, bear with us and stay tuned and we’ll keep working on it.

[00:38:44] Dr. GG deFiebre: Great. Thank you so much for answering all my questions. I thought this was a really great overview of FES and I hope it was helpful for those listening. So, thank you.

[00:38:53] Dr. Matthew Bellman: Yes, thank you.

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