Aetna considers functional electrical stimulation FES e. Aetna considers replacement of a FES for walking medically necessary if the original FES met criteria as medically necessary and is no longer under warranty and cannot be repaired. NMES are specifically contraindicated and considered unproven in persons with cardiac pacemakers. Tenga en cuenta lo siguiente :More than 2 hours of NMES per day is considered not medically necessary; protocols reported in the literature recommend no more than 2 hours of NMES treatment within a hour period. Aetna considers FES of the upper extremities e. Aetna considers FES and NMES experimental and investigational for all other indications, including any of the following because its effectiveness for indications other than the ones listed above as medically necessary has not been established:.
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Aetna considers functional electrical stimulation FES e. Aetna considers replacement of a FES for walking medically necessary if the original FES met criteria as medically necessary and is no longer under warranty and cannot be repaired. NMES are specifically contraindicated and considered unproven in persons with cardiac pacemakers.
Tenga en cuenta lo siguiente :More than 2 hours of NMES per day is considered not medically necessary; protocols reported in the literature recommend no more than 2 hours of NMES treatment within a hour period. Aetna considers FES of the upper extremities e.
Aetna considers FES and NMES experimental and investigational for all other indications, including any of the following because its effectiveness for indications other than the ones listed above as medically necessary has not been established:. Most Aetna plans exclude coverage of exercise equipment; please check benefit plan descriptions for details. Aetna considers a form-fitting conductive garment medically necessary DME only when it has been approved for marketing by the FDA, has been prescribed by a physician for use in delivering NMES that is considered medically necessary, and any of the following criteria is met:.
Aetna considers form-fitting conductive garments experimental and investigational for all other indications because its effectiveness for indications other than the ones listed above has not been established. For improvement of ventilatory function in stable, non-acute members with SCI when all of the following criteria are met:. Aetna considers electrical stimulation of the sacral anterior roots by means of an implanted stimulator, the Vocare Bladder System in conjunction with a posterior rhizotomy medically necessary for members who have clinically complete spinal cord lesions American Spinal Injury Association Classification with intact parasympathetic innervation of the bladder and who are skeletally mature and neurologically stable, to provide urination on demand and to reduce post-void residual volumes of urine.
The following selection criteria must be met:. Aetna considers threshold or therapeutic electrical stimulation experimental and investigational for the management of knee osteoarthritis, cerebral palsy and other motor disorders because its effectiveness for these indications has not been established.
Neuromuscular electrical stimulation NMES can be grouped into 2 categories: i stimulation of muscles to treat muscle atrophy, and ii enhancement of functional activity in neurologically impaired individuals.
These devices use electrical impulses to activate paralyzed or weak muscles in precise sequence and have been utilized to provide SCI patients with the ability to walk e. Neuromuscular electrical stimulation used in this manner is commonly known as functional electrical stimulation FES. The Parastep I System, a transcutaneous non-invasive and micro-computerized electrical stimulation system built into a battery-powered unit, is controlled by finger-touch buttons located on a walker's hand-bars for manual selection of stimulation menus.
The microcomputer shapes, controls, and distributes trains of stimulation signals that trigger action potentials in selected peripheral nerves. Walker support is used for balance. The patient can don the system in less than 10 minutes. At least 32 training sessions are required. The authors found that FES system generally provided equal or greater independence in seven mobility activities as compared with LLB, provided faster sit-to-stand times, and was preferred over LLB in a majority of cases.
Functional electrical stimulation has had some success in improving ventilatory function in adult patients with SCI Glenn et al, ; Carter et al, ; Glenn et al, Hunt et al reported that diaphragmatic pacing is also helpful for infants and children who need ventilatory support.
Candidates for diaphragmatic pacing should be stable and out of the acute phase of injury. The author stated that this approach of assisting ventilation in these patients resulted in psychological benefits to both the children and their families. Currently, bilateral stimulation at low frequency is more frequently used instead of stimulation of only one hemidiaphragm at a time, and adequate ventilation can be attained with 5 to 9 stimuli per minute.
Diaphragmatic pacing has also been used to treat patients with central alveolar hypoventilation syndrome. Yasuma and associates noted that the respiratory assistance by the diaphragm pacemaker or the use of a mechanical ventilator as a backup was highly useful for the home care of a patient with central alveolar hypoventilation.
The etiology was: 13 tetraplegia, 5 sequelae of surgical treatment of intracranial lesions, and 4 central alveolar hypoventilation.
Eighteen patients Five patients died Two cases were considered failures: 1 patient had transitory neurapraxia lasting 80 days, and the other had an ischemic spinal cord syndrome with progressive deterioration of the left-side response to stimulation. One patient had right phrenic nerve entrapment by scar tissue and 4 suffered infections.
These results demonstrated that complete stable ventilation can be achieved using diaphragmatic pacing and that it improves the prognosis and life quality of patients with severe chronic respiratory failure.
Girsch et al noted that ventilatory insufficiency due to central hypoventilation syndrome and SCI can be treated even in children with diaphragm pacing, provided the indication for implantation, containing medical and social aspects, was made correctly. Additionally, Flageole et al stated that pediatric surgeons should be aware of congenital central hypoventilation syndrome CCHS because it may be treated with surgically implanted electrodes that allow for pacing of the diaphragm.
The technique has an acceptable complication rate, and it can greatly decrease the impact of the disease on the lifestyle and activity of the patient. Shaul et al stated that diaphragmatic pacing can provide chronic ventilatory support for children who suffer from CCHS or cervical SCI. Chen and Keens reported that all patients with CCHS require lifelong ventilatory support during sleep but some will be able to maintain adequate ventilation without assistance while awake once past infancy. Modalities of home mechanical-assisted ventilation include positive pressure ventilation via tracheostomy, non-invasive positive pressure ventilation bi-level ventilation , negative pressure ventilation and diaphragmatic pacers.
Furthermore, Creasey et al reported that electrical stimulation has been used for over 25 years to restore breathing to patients with high quadriplegia causing respiratory paralysis and patients with central alveolar hypoventilation. Three groups have developed electrical pacing systems for long-term support of respiration in humans. These systems consist of electrodes implanted on the phrenic nerves, connected by leads to a stimulator implanted under the skin, and powered and controlled from a battery-powered transmitter outside the body.
The systems differ principally in the electrode design and stimulation waveform. Approximately 1, people worldwide have received one of the three phrenic pacing devices, most with strongly positive results: reduced risk of tracheal problems and chronic infection, the ability to speak and smell more normally, reduced risk of accidental interruption of respiration, greater independence, and reduced costs and time for ventilatory care.
For patients with partial lesions of the phrenic nerves, intercostal muscle stimulation may supplement respiration. Neuromuscular respiratory failure is the cause of death in the majority of patients with amyotrophic lateral sclerosis ALS. Respiratory muscle dysfunction impacts on quality of life and survival. Yun and associates noted that closed loop systems may facilitate the implementation of diaphragmatic pacing for the treatment of many indications.
They may allow for wider adoption of ventilatory support in central sleep apnea and improve quality of life in diseases of chronic hypoventilation, such as ALS. Onders and colleagues a summarized the complete worldwide multi-center experience with diaphragm pacing stimulation DPS to maintain and provide diaphragm function in ventilator-dependent SCI patients and respiratory-compromised patients with ALS.
It high-lighted the surgical experiences and the differences in diaphragm function in these 2 groups of patients. In prospective Food and Drug Administration FDA trials, patients underwent laparoscopic diaphragm motor point mapping with intra-muscular electrode implantation. Age of patients at implantation ranged from 18 to 74 years.
Time from SCI to implantation ranged from 3 months to 27 years. In 87 patients the diaphragm motor point was mapped with successful implantation of electrodes with the only failure the second SCI patient who had a false-positive phrenic nerve study. Patients with ALS had much weaker diaphragms identified surgically, requiring trains of stimulation during mapping to identify the motor point at times.
There was no cardiac involvement from diaphragm pacing even when analyzed in 10 patients who had pre-existing cardiac pacemakers.
No infections occurred even with simultaneous gastrostomy tube placements for ALS patients. The authors concluded that this multi-center experience has shown that laparoscopic diaphragm motor point mapping, electrode implantation, and pacing can be safely performed both in SCI and in ALS.
In SCI patients it allows freedom from ventilator and in ALS patients it delays the need for ventilators, increasing survival. The overall strategy outlined includes the use of rapidly reversible short-acting analgesic and amnestic agents with no neuromuscular relaxants. A total of 51 patients were implanted from March to March at 2 sites. On pre-operative blood gases, Pco 2 was as high as Using this protocol, there were no failures to extubate or day mortalities.
The DPS system increase the respiratory system compliance by decreasing posterior lobe atelectasis and can stimulate respirations at the end of each case.
The authors concluded that laparoscopic surgery with general anesthesia can be safely performed in patients with ALS undergoing DPS. It has not been consistently shown that spasticity decreases with long-term FES. Yarkony et al claimed that no definitive statement can be made regarding the type, the magnitude, or even the direction of the effect of electrical stimulation on the spasticity of patients with SCI. Current management strategy for this condition ranges from rehabilitative physical therapy, re-education therapeutic exercise, oral medications such as Dantrium, Valium, and Lioresal baclofen , intra-thecal infusion of baclofen, motor point blocks or nerve blocks, to destructive neurosurgical procedures Merritt Estos investigadores sugirieron que los estudios futuros deben incluir un grupo control con placebo.
Se ha utilizado para administrar la contractura de las articulaciones, mantener ROM, facilitar el control motor voluntario, y reducir la espasticidad. In a review on the clinical applications of FES, Kumar et al stated that advances in electrode technology and control and command sources activation systems as well as development of close-loop systems are needed if wide patient acceptance of this modality FES is to be ensured.
Furthermore, Hummelsheim et al reported that repetitive electrical muscle stimulation did not improve biomechanical or functional motor parameters of the centrally paretic hand and arm of stroke patients. In a randomized controlled study, Yan and colleagues evaluated whether FES was more effective in promoting motor recovery of the lower extremity and walking ability than standard rehabilitation alone.
A total of 46 patients were assigned randomly to one of three groups receiving standard rehabilitation with FES or placebo stimulation or alone control.
Outcome measurements included composite spasticity score, maximum isometric voluntary contraction of ankle dorsi-flexors and planter-flexors, and walking ability. All patients in the FES group were able to walk after treatment, and However, these authors stated that generalization of the results from this study should be performed with caution because of subject selection criteria, which did not cover all stroke categories or subjects aged younger than 45 or older than 85 years.
Further studies are now needed to see whether FES can work with a wide range of stroke patients. Although a number of studies suggested that electrical stimulation may be effective for reducing shoulder pain and subluxation or improving the function of wrist and finger extensors following stroke Chantraine et al, ; Wang et al, ; and Yozbatrian et al, , more research is needed to validate these findings.
Chantraine et al reported that FES program was significantly effective in reducing the severity of subluxation and pain and possibly may have facilitated recovery of the shoulder function in hemiplegic patients. However, they noted that more research addressing the mechanism of the actions of FES on pain and subluxation of the hemiplegic shoulder is needed. Three distinct applications were reviewed in the areas of motor relearning, shoulder dysfunction, and neuroprostheses.
Assessment of clinical effectiveness and recommendations on clinical implementation were based on the weight of published scientific evidence. With respect to motor relearning, evidence supports the use of NMES to facilitate recovery of muscle strength and coordination in hemiplegia. However, effects on physical disability are uncertain.
With respect to shoulder dysfunction, NMES decreases shoulder subluxation, at least in the short term. However, effects on shoulder pain and disability are also uncertain.
With respect to neuroprosthesis systems, clinically deployable upper extremity systems must await the development of more sophisticated control methods and greater fundamental understanding of motor dysfunction in hemiplegia. The evidence for clinical feasibility of lower extremity neuroprostheses is stronger, and investigations on clinical effectiveness should be pursued. These investigators concluded that the evidence from randomized controlled studies so far does not confirm or refute that ES around the shoulder after stroke influences reports of pain, but there do appear to be benefits for passive humeral lateral rotation.
A possible mechanism is through the reduction of glenohumeral subluxation. The authors stated that further studies are needed. Management should vary accordingly; each presentation requiring different approaches to handling, support and intervention. In the "flaccid" stage, the shoulder is prone to inferior subluxation and vulnerable to soft-tissue damage. The arm should be supported at all times and FES may reduce subluxation and enhance return of muscle activity. In the "spastic" stage, movement is often severely limited.
A menudo no se han probado completamente en humanos y no siempre se han demostrado su seguridad y eficacia. Se han sometido a prueba los siguientes usos en humanos o animales. La seguridad y eficacia de los mismos no siempre se han demostrado. Se necesita estudios de alta calidad y comparaciones con placebo para confirmar estos hallazgos. Los resultados son inciertos.
Puntos motores musculares. Cupping Therapy. Massage Therapy. Acupuncture Points. Trigger Points. Massage Techniques.
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