### Steering group

Julia Bott (Chair), support to Section 6, Consultant Physiotherapist, Surrey PCT NW Locality

Sheric Ellum, support to Section 5, Consultant Physiotherapist, Guy's & St Thomas' NHS Trust, London

Dr Rachel Garrod, support to Section 1, Reader, School of Physiotherapy, Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London.

Dr Jennifer Pryor, support to Sections 3 and 4, Senior Research Fellow in Physiotherapy, Royal Brompton & Harefield NHS Trust

Dr Lesley Rimington, support to Section 2, Lecturer School of Health and Rehabilitation, Keele University

### Section 1—COPD

Sharon Baines, Clinical Specialist Physiotherapist, Chronic Lung Disease Service, NHS Central Lancashire

Amanda Dryer, Physiotherapy Clinical Lead in Respiratory Care, Central Manchester and Manchester Children's University Hospital

Robert Goddard, Superintendent Physiotherapist, County Durham and Darlington NHS Foundation Trust

Catherine Thompson, Senior Lecturer, York St John University

Dr John White (Chair), Respiratory Physician, York Hospitals NHS Trust

### Section 2—Asthma and disordered breathing

Caroline Falconer (Co-Chair), Senior Physiotherapist, Papworth Hospital NHS Foundation Trust

Lianne Jongepier, Respiratory Specialist Physiotherapist, Service Lead COPD Team, Primary Care Centre, Colchester

Melanie Lincoln (Co-Chair), Team Leader Physiotherapist, Papworth Hospital NHS Foundation Trust

Christine Mikelsons, Consultant Respiratory Physiotherapist, Royal Free Hospital

Dr Mike Thomas, General Practitioner, Asthma UK Senior Research Fellow, University of Aberdeen

Jo Williams, Senior Pulmonary Rehabilitation Specialist Glenfield Hospital, University Hospitals of Leicester NHS Trust

### Section 3—Cystic fibrosis

On behalf of the Association of Chartered Physiotherapists in Cystic Fibrosis

Penny Agent, Service Lead Physiotherapist, Royal Brompton & Harefield NHS Trust

Gillian Davie, Senior I Physiotherapist, Cystic Fibrosis Team, Aberdeen Royal Infirmary

Mary Dodd, Consultant Physiotherapist in Cystic Fibrosis, University Hospital of South Manchester NHS Foundation Trust

Dr Sarah Elkin, Respiratory Physician, St Mary's Hospital, London

Tracey Hughes (Chair), Senior I Physiotherapist, Leeds Regional Adult Cystic Fibrosis Unit, Leeds Teaching Hospitals NHS Trust

Margaret MacLeod, Senior I Physiotherapist, Cystic Fibrosis Team, Aberdeen Royal Infirmary

Nicola …

/pdf/guidelines-for-the-physiotherapy-management-of-the-adult-9g87sbxufz.pdf

Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient

The authors review recent efforts to design stimulus waveforms for selective electrical stimulation of the nervous system. Two types of selectivity are considered. Fiber diameter selectivity refers to the ability to activate one group of nerve fibers having a common diameter without activating nerve fibers having different diameters. Spatial selectivity refers to the ability to activate nerve fibers in a localized region without activating nerve fibers in neighboring regions. The fundamental principles governing the response of excitable nerve fibers to imposed stimuli are reviewed and used to design waveforms. The emphasis of the presentation is on excitation of peripheral myelinated nerve fibers, The underlying principles, however, are broadly applicable to all excitable membranes. >

Stimulus waveforms for selective neural stimulation

Analysis of standing up and sitting down in humans : definitions and normative data presentation

A computer simulation of functional neuromuscular stimulation (FNS)-assisted bipedal gait shows that it is difficult, but possible, to attain undisturbed, level gait at normal speeds provided the electrically stimulated ankle plantarflexors exhibit near-normal strengths or are augmented by an orthosis, and at least seven muscle groups in each leg are stimulated. A combination of dynamic programming and an open-loop, trial-and-error adjustment process was used to find a suboptimal set of discretely varying muscle stimulation patterns needed for a 3-D, 8 degree-of-freedom dynamic model to sustain a step. An ankle-foot orthosis was found to be especially useful, as it helped to stabilize the stance leg and simplified the task of controlling the foot during swing. It is believed that the process of simulating natural gait with this model will serve to highlight difficulties to be expected during laboratory and clinical trials. >

/pdf/restoring-unassisted-natural-gait-to-paraplegics-via-2vgren92gf.pdf

Restoring unassisted natural gait to paraplegics via functional neuromuscular stimulation: a computer simulation study

Tapping into spinal circuits to restore motor function.

Recent advances in science have aided research toward the restoration of biped gait in paraplegic patients by means of functional electrical stimulation (FES). In this paper it is shown how FES-restrengthened muscles of paraplegic patients have been used for simple FES-assisted standing. Those experiments subsequently led to biped gait-initializing experiments and to simple forms of biped gait synthesis. The purpose of this paper is to show the feasibility of using FES for standing and for restoring biped gait in many paraplegic patients--to present the past achievements, focus on problems, and highlight directions for future research. The results of gait obtained in three complete spinal cord injured patients (out of a series of 17) are shown, using four to six channels of FES. It is also shown how preserved reflex mechanisms of the transected spinal cord can be incorporated and employed for obtaining improved function while at the same time simplifying the FES hardware. Of the three patients reported on in detail here, two patients have managed to walk in parallel bars while the third patient has mastered independent unassisted walking over shorter distances with the aid of a roller walker. The biomechanical and control problems of this last patient's gait are presented in detail.

Gait restoration in paraplegic patients: a feasibility demonstration using multichannel surface electrode FES.

Use of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injuries.

The presently employed posture for Functional Electrical Stimulation (FES) assisted standing in spinal cord injury (SCI) patients utilises the active locking of knee joints by tetanically stimulating the quadriceps muscle. The hip joints are in hyper extension and the ankle joints remain free. The upper limbs are used for balancing. This posture requires minimal corrective forces exerted by the hands, the weight is transferred across the legs, while very limited forward-backward sway is permitted. Knee jack-knifing may occur in the instance when the gravity knee bending moment exceeds the moment generated by the quadriceps muscle. Because of these effects and fatiguing of the M. quadriceps the standing time is short, lasting from several minutes up to an hour, depending on the condition of the patient's muscles. Cyclical FES with a duty cycle of 10-20 seconds (onjoff) fatigues muscle considerably less. The use of different postures for standing requiring activation of different muscles permits the application of cyclical FES. The cyclic FES results in prolonging standing times by a factor of two to five. Utilising this improvement some patients can stand for up to five hours at a time. This functional achievement is comparable to the standing time of a normal man. The incorporation of the principle of posture switching also prolongs standing in patients with weak muscles, because of the possibility of cyclical coactivation of different synergistic muscle assemblies. It is shown that posture switching can be carried out automatically and that patients adapt quickly to it. In addition using co-contraction of two or three muscles with posture switching does further expand the range of suitable patients and improves standing with an increased permissible range of body sway. Also, the FES antigravity action obtained raises hopes for substantially improving FES induced reciprocal gait.

/pdf/posture-switching-for-prolonging-functional-electrical-454s9wtxcy.pdf

Posture switching for prolonging functional electrical stimulation standing in paraplegic patients

Thirteen tetraplegic patients were included in the study of the effects of respiratory muscle training and of electrical stimulation of the abdominal muscles on their respiratory capabilities. Each patient was subjected for three 1 month lasting periods of the study: for inspiratory muscle training, expiratory muscle training and for a period without training. The sequence of these three periods was random for each patient. Respiratory tests (RT) measuring forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were conducted before and following each monthly period. Measurements were taken under four sets of conditions: the patients' unassisted efforts, their efforts combined with pressure manually applied by a therapist to the upper part of their abdomen, and their efforts accompanied by electrical stimulation (ES) of the abdominal muscles during the early phase of expirium, once triggered by the therapist and once by the patients themselves. RT values were increasing following respiratory muscle training and inspiratory training apparently had a slightly greater effect than its expiratory counterpart. The increments of values of RT were statistically significant (P < 0.05) after the inspiratory muscle training. RT measurements were greater when the patient's voluntary effort was combined with ES of abdominal muscles than when it was not. This study concludes that respiratory muscle training is a potentially effective approach and that ES of the abdominal muscles has potentials to improve coughing in tetraplegic patients.

/pdf/effects-of-respiratory-muscle-training-and-electrical-3nkkep6t5y.pdf

H Benko

Papers

Gait restoration in paraplegic patients: a feasibility demonstration using multichannel surface electrode FES.

Use of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injuries.

Posture switching for prolonging functional electrical stimulation standing in paraplegic patients

Effects of respiratory muscle training and electrical stimulation of abdominal muscles on respiratory capabilities in tetraplegic patients.

Neurophysiological background of the use of functional electrical stimulation in paraplegia.