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FES Cycling A New Approach to Tailored Exercise for MS Multiple Sclerosis can restrict exercise participation and lead to a reduction in fitness. Along with this restriction goes a higher risk of health complications and i"ness in the longer term. It's understandable that many people with Multiple Sclerosis steer clear of regular exercise because they're afraid it might increase their fatigue or because they feel they simply aren't up to it. You may have heard the mottos "stretch till it hurts" or "feel the burn," but those approaches are counterproductive for people with Multiple Sclerosis. If you overdo it you can end up straining an already compromised muscular system, increasing pain and causing your body and mind to become overstressed, overworked, and overtired. But with a properly managed regime, always taking into account a person's individual limitations, exercise is a good thing both physically and mentally. We know that exercise helps increase mobility, build up muscle strength and strengthens the heart. Importantly regular exercise has been shown to release “happy chemicals” in the brain, known as endorphins, so can help combat depression or emotional problems brought on by living with Multiple Sclerosis. We are looking to apply a new exercise approach to the challenge of enhancing fitness in Multiple Sclerosis. This approach relies on combining FES (Functional Electrical Stimulation) with a motorised exercise cycle. We have a great deal of experience applying this FES Cycling technology in Spinal Cord Injury and new work ongoing in Germany with Multiple Sclerosis has encouraged us to apply the knowledge and skills we have developed in this direction too.

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A new way.. Exercise aided by Functional Electrical Stimulation The latest multi-center trials based on FES Cycling programmes with Spinal Cord Injury show important improvements in cardiopulmonary (heart and lung) fitness, bone density (resistance to fractures), circulatory function and muscle bulk and strength can be expected through regular exercise. In clinical terms there are some aspects of FES Cycling that will transfer directly to Multiple Sclerosis from what we have already learned with Spinal Cord Injury. As you already know, it is difficult to perform controlled research trials with Multiple Sclerosis but there is an emerging clinical consensus in Germany that supports the value of FES Cycling. The Process In Germany the process is as follows: • A client with Multiple Sclerosis is tested to determine their individual exercise performance limits. • Clients train under supervision for up to 2 hours per session, depending on their individual performance capability. • This session is repeated every 2 weeks to see if there is a confirmed medical benefit. • After a few weeks training with confirmed positive benefits clients may continue at home or at a Centre without direct supervision In Munich, this test training is free of charge and participants who apply via their health insurance are able to purchase equipment for home use. Outcomes In Munich they recommend FES Cycling for clients who have leg weakness and/or spasticity. These individuals are showing positive effects however researchers have not found an explanation for this. It seems to work but the reasons are not scientifically confirmed. Many of the clients report a benefit in reducing spasticity and researchers are suggesting that this is because of a change in nerve structures. However there is no evidence or suggestion that FES can make nerves grow again. This is potentially an important finding as it is known that a spasticity is highly prevalent and

Innovative, clinically effective, healthcare solutions - 8-10 Dunrobin Court, Clydebank G81 2QP Scotland t: +44(0)141-952-2323 f:+44(0)141-952-3434

associated with a reduced level of functional independence. (See Barnes et al)

Benefits • Improved cardiovascular health • Increased muscle strength in the muscles of the legs • Increased bone density in the lower limbs • Reduction of spasticity • Lowered risk of pressure sores. • Improved feelings of wellbeing • Reduced risk of DVT

Some participants commencing exercise had hyperesthesia, or oversensitivity to touch although the researchers suggest that participants have adjusted quickly to the stimulation and reported improvements - although again there is no known reason for this.

How does it work?

FES Cycling You may have already heard of FES because it is being widely using used to assist with muscle weakness causing drop foot in Multiple Sclerosis. This technology is well established and FES Cycling is a more sophisticated application of the same principles. FES has decades of research behind it although it is only in recent years that this has started to be routinely applied in therapy situations. RehaMove To use the system, sticky pads (electrodes) are placed over leg muscles - up to four muscle groups on each leg are exercised at one time. A sophisticated control system delivers precisely controlled stimulation to the muscles of the legs in the right sequence to allow the muscles to contract and generate power. At the push of a button the cycle pedals starts to rotate, the system detects the position of the crank arms, calculates the time at which each muscle

Contra Indications - Do not use if You use a cardiac pacemakers You have epilepsy Have known allergies to electrode gel Have metal implants underneath or near the muscle groups which are to be stimulated. Pregnant women should desist from using stimulation because the possible adverse effects are unknown and have not yet been rigourously investigated.

needs to work and sends the correct stimulation impulses to the electrodes. Thus it creates a fluent cycling movement. Over time, as the condition of the muscles improve, they can take a greater share of the effort required to work against resistance - producing a training effect. The system automatically senses the contribution that a users muscles can make from moment to moment and adjusts how hard the user is working – making up the difference with motor

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power. Any time a user wishes a break or if the muscles start to fatigue, the built-in motor takes over and passively moves the users legs. By adjusting the stimulation, the user can easily set exercise targets to work progressively against resistance.

How is this better than using a motion-trainer alone? One component of the RehaMove system is the popular Reck MOTOMed Viva2 motion trainer. Many people with Multiple Sclerosis already use such a trainer to keep their legs moving at home. Reck’s partner company, Hasomed GmbH , developed the stimulator unit and the sophisticated software that made RehaMove possible. Although, in theory each user of a motion trainer can use it to exercise their legs, in practice the precise control and quality of muscle contraction, makes FES Cycling with RehaMove a much more eective form of exercise. The stimulator unit is programmed through an intuitive touch screen interface ensuring control of exercise.

The close cooperation between Reck and Hasomed means that it is possible to add FES to an existing MOTOmedmotion trainer. precise

Does the system need maintenance? In an institutional setting we generally expect to work with that organisation via a contract to ensure that the system is inspected regularly because of the likely high frequency of usage. For home users we suggest that the stimulator unit is returned to us after two years for routine safety testing. There are no particular maintenance requirements other than following our guidance on keeping the equipment clean. Care needs to be taken with the electrode cables to keep them clear of the cycle pedals.

What ongoing costs are there? Electrodes are the only consumable cost. Electrodes we provide are good quality, reusable ones that last between 15 and 25 sessions before replacement. Each user needs their own electrode set.

Support? We provide professional training and support to clients or clinicians. We can also provide specialist personal training services with individuals knowledgeable in exercise science as well as Multiple Sclerosis.

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Who are Anatomical Concepts? Established in 1996, Anatomical Concepts (UK) Ltd was founded by clinicians, engineers and business professionals. As part of a group of three long-established companies in related areas of rehabilitation, we are well placed to serve clients with diverse and complex needs. The company designs, develops and distributes innovative and clinically effective healthcare solutions on an international basis. The core products we offer are widely used in rehabilitation - whether in a hospital or home environment. Based in Clydebank Scotland, Anatomical Concepts works with distribution partners throughout Europe and directly with hospitals, other care providers and private individuals. The products and services we offer aim to improve the quality of life of people affected by conditions such as stroke, diabetes, spinal cord injury, arthritis and multiple sclerosis. The company works closely with clinicians such as orthotists, surgeons, therapists, podiatrists and nurse specialists to ensure that our products are effective and refined in practice. Crossappointments with University and research organisations allow us to maintain awareness of emerging technologies and concepts. We are represented at conferences and seminars around the world and recognised for our own research and educational expertise. With respect to FES Cycling, Anatomical Concepts represents the products of Hasomed GmbH, based in Magdeburg, Germany. The Scottish National Spinal Injuries Unit at the Southern General Hospital introduced Anatomical Concepts to Hasomed to lead the commercialisation of these products developed in part with research at the Unit and at the University of Glasgow under the leadership of Professor Ken Hunt. FES Cycling is now frequently recommended by spinal injury consultants as standard. For further information contact

Derek Jones PhD, MBA Director

ANATOMICAL CONCEPTS (UK) LTD Innovative, clinically effective, healthcare solutions - 8-10 Dunrobin Court, Clydebank G81 2QP Scotland t: +44(0)141-952-2323 f:+44(0)141-952-3434

References ‘Management of MS Related Fatigue’. Expert Opinion Paper, Medical Advisory Board of the National Multiple Sclerosis Society. (2002) Mostert, S. & Kesselring, J. (2002). ‘Effects of a short term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with MS’ Mult Scler. 2002 Apr; 8(2):161-168. Department of Neurology, Rehabilitation Centre, CH-7317 Valens, Switzerland. Petajan, J.H.; Gappmaier, E.; White, A.T.; Spencer, M.K.; Mino, L. & Hicks, R.W. (1996). ‘Impact of aerobic training on fitness and quality of life in multiple sclerosis.’ Ann Neurol. 1996 Apr; 39(4):432-41. Department of Neurology, University of Utah, Salt Lake City 84112, USA. Stui'ergen, A.K. (1997). ‘Physical activity and perceived health status in persons with multiple sclerosis.’ J Neurosci Nurs. 1997 Aug; 29(4):238-243. University of Texas at Austin, School of Nursing 78701, USA. Rehab Center for Physical Medicine, Ichenhausen, Germany – Reduction of spasm using movement trainers, a report for Medicamedizintechnik, Hochdorf, Germany. Barnes, M. P.; Kent, R. M.; Semlyen, J. K. & McMullen, K. M. (2003). ‘Spasticity in Multiple Sclerosis’. Neurorehabilitation and Neural Repair, 2003 März; Vol. 17, No. 1, 66-70. Krause, P.; Szecsi, J. & Straube, A. (2007). ‘FES cycling reduces spastic muscle tone in a patient with multiple sclerosis’. In: Neurorehabilitation 22 (4), 335-337. Department of Neurology, University of Munich, Germany.

Note based on the approach of :Prof. Dr. A. Straube, Prof. Dr. Dr. h.c. T. Brandt Forschungshaus Neurologische Klinik und Poliklinik Klinikum der Universität München Marchioninistr. 23 D-81377 München

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