Durable Medical Equipment Section - Electrical Stimulation Devices for Home Use

IMPORTANT REMINDER

Regence Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with contract terms. Benefit determinations are based in all cases on the applicable contract language. To the extent there may be any conflict between the Medical Policy and contract language, the contract language takes precedence.

PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that are considered investigational or cosmetic. Providers may bill members for services or procedures that are considered investigational or cosmetic. Providers are encouraged to inform members before rendering such services that the members are likely to be financially responsible for the cost of these services.

Description

Transcutaneous Electrical Nerve Stimulation Devices (TENS)

• Transcutaneous electrical nerve stimulator (TENS) consists of an electrical pulse generator connected by wire to two or more electrodes that apply electrical stimulation to the surface of the skin at the site of pain.  The stimulation of sensory nerves is intended to block pain signals and may also generate endorphins. TENS has been used to reduce chronic intractable pain, post-surgical pain, and pain associated with active or post-trauma injury unresponsive to other standard pain therapies. .

Neuromuscular Electrical Stimulation Devices (NMES)

• NMES, through multiple channels, attempts to stimulate motor nerves and alternately causes contraction and relaxation of muscles, unlike a TENS device which is intended to alter the perception of pain. NMES devices are used to prevent or retard disuse atrophy, relax muscle spasm, increase blood circulation, maintain or increase range-of-motion, and re-educate muscles.

Functional Neuromuscular Stimulation Devices (FNS or ENS)

• Functional neuromuscular stimulation (also called electrical neuromuscular stimulation, functional electrical stimulation and EMG-triggered neuromuscular stimulation) attempts to replace stimuli from destroyed nerve pathways with computer-controlled sequential electrical stimulation of muscles to enable spinal-cord-injured or stroke patients to function independently, or at least maintain healthy muscle tone and strength. Also used to stimulate quadriceps muscles following major knee surgeries to maintain and enhance strength during rehabilitation.
• Functional electrical stimulation cycle ergometer devices consist of motorized leg ergometer, optional motorized arm crank, and leg and optional arm electrical stimulation.  These devices allow patients with impaired function of the extremities to passively and actively undertake cycle ergometry. An example of a cycle ergometer that has 510k FDA approval is the RT300 (Restorative Therapies, Inc.) Rowing devices have also been devised.
• Functional electrical stimulation (FES) devices are also available for patients with foot drop or hand dysfunction secondary to neurological conditions such as stroke, traumatic brain injury, multiple sclerosis and cerebral palsy. An example of these devices are the NESS™ wireless FES devices (Ness-Neuromuscular Electrical Stimulation Systems). These devices are intended to facilitate a more normal gait or stronger grip, prevent disuse atrophy and maintain joint range of motion.

Note: A separate Regence Medical Policy, DME 56, addresses functional neuromuscular stimulation devices to provide ambulation.

Galvanic Stimulation Devices

• Galvanic stimulation is characterized by high voltage, pulsed stimulation and is used primarily for local edema reduction through muscle pumping and polarity effect. Edema is comprised of negatively charged plasma proteins, which leak into the interstitial space. The theory of galvanic stimulation is that by placing a negative electrode over the edematous site and a positive electrode at a distant site, the monophasic high voltage stimulus applies an electrical potential which disperses the negatively charged proteins away from the edematous site, thereby helping to reduce edema.

Microcurrent Stimulation Devices (MENS) including Alpha-Stim

• A microcurrent stimulation device is characterized by sub-sensory current that acts on the body’s naturally occurring electrical impulses to decrease pain and facilitate the healing process. MENS differs from TENS in that it uses a significantly reduced electrical stimulation. TENS blocks pain, while MENS acts on the naturally occurring electrical impulses to decrease pain by stimulating the healing process.  An example of a microcurrent electrical stimulation device used for pain management is the Alpha-Stim PPM (personal pain manager).  Additional AlphaStim devices for cranial electrostimulation therapy (CES) are addressed in Regence Medical Policy, DME, Policy No. 74, Cranial Electrostimulation Therapy.

H-wave Stimulation Devices

• H-wave stimulation is a form of electrical stimulation that differs from other forms of electrical stimulation, such as transcutaneous electrical nerve stimulation (TENS), in terms of its waveform. While physiatrists, chiropractors, or podiatrists may perform H-wave stimulation, H-wave devices are also available for home use. H-wave stimulation has been used for the treatment of pain related to a variety of etiologies, such as diabetic neuropathy, muscle sprain’s, temporomandibular joint dysfunctions or reflex sympathetic dystrophy. H-wave stimulation has also been used to accelerate healing of wounds, such as diabetic ulcers. H-wave electrical stimulation must be distinguished from the H-waves that are a component of electromyography.

Note: This policy is not intended to address all electrical stimulation devices. Separate medical policies exist for the following services used in the home:

• Cranial Electrostimulation Therapy, Regence Medical Policy, DME 74
• Functional Neuromuscular Stimulation To Provide Ambulation, RegenceMedical Policy, DME 56
• Sympathetic Therapy for the Treatment of Pain, Regence Medical Policy DME 65
• Interferential Therapy, Regence Medical Policy, DME 66
• Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds, Regence Medical Policy, DME 67

Policy/Criteria

Note: Separate medical policies address the following electrical stimulation services in the home:

• Cranial Electrostimulation Therapy, Regence Medical Policy, DME 74
• Functional Neuromuscular Stimulation to Provide Ambulation, Regence Medical Policy, DME, Policy No. 56
• Sympathetic Therapy for the Treatment of Pain, Regence Medical Policy, DME, Policy No. 65
• Interferential Therapy, Regence Medical Policy, DME, Policy No. 66
• Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds, Regence Medical Policy, DME 6

Scientific Background

Transcutaneous Electrical Stimulation (TENS)

Treatment of pain is highly susceptible to placebo effect. Therefore, any clinical study of an electrical stimulation therapy device used as a treatment for pain should be placebo-controlled with random assignment. The optimal placebo control is use of a sham device.

The medical policy for TENS reflects the long-standing accepted standard of care within our medical communities. However, several published evidence-based assessments of TENS have found that evidence is lacking concerning the effectiveness of TENS in the treatment of chronic intractable pain and acute postoperative pain.

In 1996 the BlueCross and BlueShield Association TEC conducted an assessment of TENS for the treatment of chronic and postoperative pain. (2) The evidence did not clearly show that the effects of TENS exceed placebo effects. Subsequent updates to the 1996 TEC Assessment relied primarily on a comprehensive Cochrane Review of TENS for chronic pain (3), as well as literature searches. Review of the evidence produced since the 1996 TEC Assessment does not alter its conclusions.

The 1996 TEC Assessment and all subsequent updates of the literature used the following study selection criteria: the study contained original empirical data; the study design included a TENS treatment group and a control group; the study reported on a health outcome relevant to the pain condition treated; and the study used a random assignment, control design.

A search of the Cochrane Library identified several Cochrane Reviews of TENS. The most comprehensive Cochrane Review was completed by Carroll and colleagues (3), which was last amended in June 2000. It addressed chronic pain due to a variety of conditions. Reviewers searched five electronic databases, seeking randomized controlled comparisons of TENS, no treatment, alternative methods of TENS and sham TENS. Reviewers found 107 reports that were considered for inclusion in the Cochrane Review. A total of 19 randomized trials were judged as meeting study selection criteria. Reports were excluded if they were not randomized comparisons of active conventional TENS and sham TENS, used flawed methods of randomization, did not directly compare two forms of TENS, such as low frequency TENS (also known as microcurrent electrical stimulation or MENS) and high frequency TENS, did not use TENS as the exclusive analgesic treatment during the study period, or did not use subjective pain outcomes. The included studies varied considerably in design, outcome measures, chronic pain conditions, TENS methods, and study quality. Most studies selected patient samples. Reporting and study methods were generally poor. Adequate blinding was not rated as having been achieved in any of the studies. Variable methods of TENS were used, at various sites and for different durations. Due to heterogeneity of methods and inability to extract sufficient dichotomous pain outcome data, it was concluded that meta-analysis was not possible.

Half of the included studies addressed single applications of TENS. The reviewers made the critical observation that such a design fails to address the long-term use and effectiveness of TENS for chronic pain. Most of the reviewed studies do not address how TENS is intended to be used in actual patient care. Of fifteen studies that compared single applications of active TENS with inactive control treatment, ten found an effect favoring active TENS. However, of seven studies that addressed multiple applications of TENS, only three found results favoring active TENS over inactive treatment. Carroll and colleagues summarized by stating that the evidence on use of TENS for chronic pain is inconclusive. They noted that trials do not indicate which stimulation parameters are responsible for any pain relief and that the crucial question of long term effectiveness has been inadequately addressed.

A search of the literature aimed at identifying articles published since the last update of the Cochrane Review found an article on TENS for knee osteoarthritis by Yutkuran and Kocagil. (4) While this study found that TENS achieved better pain relief than placebo, it did not address long-term effectiveness and it is unclear whether the study was adequately blinded. Thus, based on the Cochrane Review and additional literature search, the conclusions of the 1996 TEC Assessment of TENS for chronic pain do not change.

In addition to the comprehensive Cochrane Reviews of TENS for chronic pain, the Cochrane Library also contains five other Cochrane Reviews of TENS for specific pain conditions. Three of these Cochrane Reviews reach the same conclusions as the review by Carroll and colleagues. Cochrane Reviews by the following reviewers agreed with Carroll and colleagues: Milne and colleagues (5) on chronic low back pain; Pelland and colleagues (6) on rheumatoid arthritis; and Price and colleagues (7) on post-stroke shoulder pain. Cochrane Reviews on knee osteoarthritis by Osiri and colleagues (8) and primary dysmenorrhea by Proctor and colleagues (9) concluded that a small number of studies for each condition show TENS to be more effective than sham TENS. Both of these reviews failed to address the key issue of long-term effectiveness and thoroughly examine the potential influence of study quality, thus the Cochrane Review by Carroll and colleagues should be viewed as most relevant.

The 1996 TEC Assessment addressed both chronic pain and postoperative pain. While the Cochrane Review by Carroll and colleagues focused on chronic pain no Cochrane Review has focused on postoperative pain. The literature search for studies appearing since 1996 identified one randomized trial comparing active TENS with sham TENS among patients undergoing lower abdominal gynecologic surgery. (10) Hamza and colleagues found that three different TENS techniques reduced the need for postoperative opioids, compared with sham TENS. The report does not clearly state whether patients or investigators were adequately blinded, nor does it mention whether patients withdrew from the study and how many withdrawals were handled in the data analysis. A March 2005 updated search of the literature did not reveal any clinical trial evidence that addresses above concerns. Given these flaws, the recent evidence does not alter conclusions of the 1996 TEC Assessment.

In a 2006 literature review update, two additional Cochrane Reviews (11,12) were identified along with several randomized controlled trials (RCTs) on the use of TENS (13-18).  Neither of the Cochrane Reviews nor any of the RCTs identified were sufficient to alter the conclusions reached above.  In the Cochrane Review of TENS for the treatment of rheumatoid arthritis of the hand, Brosseau and colleagues found conflicting results and determined that further study is still needed. (11) In the other Cochrane Review, Cameron and colleagues reviewed the use of TENS for treatment of dementia. (12) The authors concluded that the evidence was inadequate to draw conclusions about the effects of TENS on dementia.

Two new systematic Cochrane reviews have been initiated to assess the use of TENS for cancer pain and acute pain. Factors that may influence efficacy, such as the type of pain, the type of TENS used, duration of treatment, and whether the study measures acute or chronic outcomes, will be addressed. Recent literature suggests that TENS may alleviate acute pain. For example, one double-blind randomized sham-controlled trial found that during emergency transport of 101 patients, TENS reduced posttraumatic hip pain with a change in visual analog scale (VAS) from 89 to 59, whereas the sham stimulated group remained relatively unchanged (86 to 79). (37) Confirmation of these results is needed.

Microcurrent Electrical Stimulation (MENS)

A search of the literature returned one randomized clinical study designed to compare the efficacy of microcurrent stimulation to mid-laser and laser placebo treatment of 48 patients with temporomandibular joint (TMJ) pain. (19) There was a difference in pain and functional outcomes between laser and MENS with laser being slightly higher; however, the difference was not statistically significant.  There was no data to suggest whether the effect was durable and whether the effects continued with repeated use.  Two clinical studies have focused on the effect of microcurrent stimulation on exercise-induced muscle soreness in healthy subjects. (20, 21)

There has been interest in using microcurrent electrical stimulation therapy in the treatment of migraine headaches.  A search of the MEDLINE database returned studies setting forth the theoretical physiologic basis for the possible effect of electrical stimulation in treatment of migraine.  However, there were no double-blinded, randomized controlled clinical trials of microcurrent stimulation in the treatment of migraine.  A search of the manufacturer’s Web site for the Alpha-Stim microcurrent device lists a number of references that address the use of microcurrent electrical stimulation in the treatment of a wide range of conditions.  None of the studies listed are large double-blinded, randomized controlled clinical trials designed to test the effectiveness of microcurrent stimulation against a placebo microcurrent stimulation device.  Therefore, none of the studies provide sufficient evidence to draw conclusions about the effects of microcurrent stimulation on conditions such as migraine headache, dementia, dyslexia and attention deficit disorder, insomnia, depression, anxiety, pain, cognitive dysfunction, multiple sclerosis, and fibromyalgia that are addressed in the various articles and case series.

The Cochrane Reviews summarized in the above discussion of TENS also included microcurrent stimulation devices. (5-9, 11, 12) The Cochrane evidence-based conclusions apply to both TENS and MENS therapies.

Based on the available evidence conclusions cannot be reached concerning the effect of MENS on pain management and cognitive and behavioral conditions.

A February 2007 updated search of the medical literature did not return any new clinical trial information that addresses the concerns regarding the effectiveness of microcurrent electrical stimulation in the unsupervised home setting.

H-Wave Stimulation

Clinical trials of H-wave stimulation therapy in the peer-reviewed literature that use random assignment and placebo control are limited to one group of investigators. Kumar and Marshall compared active H-wave electrical stimulation with sham stimulation for treatment of diabetic peripheral neuropathy. (22) The authors selected 31 patients with type 2 diabetes and painful peripheral neuropathy in both lower extremities lasting at least 2 months. Patients were excluded if they had vascular insufficiency of the legs or feet, or specified cardiac conditions. Patients were randomly assigned to the active group (n=18) or the sham group (n=13). Both groups were instructed to use their devices 30 minutes daily for 4 weeks. The device used in the sham group had inactive electrodes. Outcomes were assessed using a pain grading scale ranging from 0 to 5. Both groups experienced significant declines in pain and the post-treatment mean grade for the active group was significantly lower than the mean grade for the sham group. This study did not state whether patients and/or investigators were blinded and did not state whether any patients withdrew from the study. Another study, published by the same group of investigators compared active H-wave electrical stimulation with sham stimulation among patients treated initially with tricyclic antidepressants. (23) The authors enrolled 26 patients with type 2 diabetes and painful peripheral neuropathy persisting for 2 months or more. Exclusion criteria were similar to those used in the earlier study. Amitriptyline was administered for 4 weeks initially and those who had a partial response or no response were later randomized to the 2 groups. After excluding 3 amitriptyline responders, the active stimulation group included 14 patients and the sham stimulation included 9 patients. Sham devices had inactive output terminals. Stimulation therapy lasted 12 weeks. As in the earlier study, mean pain grade in both groups improved significantly, but the difference between groups after treatment significantly favored active H-wave stimulation. Results on an analog scale were similar. It is unclear if patients were blinded to the type of device and the report does not note whether withdrawals from the study occurred. A later report from this group described a case series of 34 patients who continued H-wave electrical stimulation for over 1 year and achieved a 44% reduction in symptoms (24) While the 2 small controlled trials provide suggestive evidence, their results are insufficient to permit conclusions about the effectiveness of H-wave electrical stimulation for diabetic neuropathy. Additional sham-controlled studies are needed from other investigators; preferably studies that are clearly blinded, specify the handling of any withdrawals, and provide long-term, follow-up data.

An updated search of the medical literature through March 24, 2008 did not return any new clinical trial evidence concerning the use of H-wave stimulation therapy.

Functional Neuromuscular Stimulation

The scientific evidence related to electromyography (EMG)-triggered electrical stimulation therapy continues to evolve, and this therapy appears to be useful in a supervised physical therapy setting to rehabilitate atrophied upper extremity muscles following stroke and as part of a comprehensive PT program. However, there is minimal information regarding the outcomes of treatment in the unsupervised home setting. Cauraugh, and colleagues randomized 11 patients to supervised EMG-triggered electrical stimulation or sham electrical stimulation. All patients had chronic upper extremity paresis for at least one year following stroke; all had received standard stroke rehabilitation. (25) Using a standard motor assessment scale and sustained muscle contraction tasks for assessment of outcomes, the EMG-triggered treatment group showed statistically significant improvement over the sham treated group. Kraft, and colleagues documented sustained improvement at 9 months following EMG-triggered therapy in 13 patients. (26) Fields studied outcomes of EMG-triggered stimulation in 69 stroke patients who had not recovered satisfactory use of the affected upper extremity. (27) Patients received supervised EMG therapy in an outpatient PT setting and experienced a 90% improvement in functional movement. EMG-triggered therapy was found useful in a therapist-supervised program for the rehabilitation of wrist extensor, finger extensor and ankle dorsiflexor muscles.

Kimberley and colleagues studied the effects of home treatment with EMG-triggered NMES compared with a sham treatment, applied to the extensor muscles of the hemiplegic forearm to facilitate hand opening in sixteen stroke subjects. (28) The study protocol called for 60 hours of EMG-triggered stimulation for three weeks. Following treatment, NMES subjects improved on measures of grasp and release, isometric finger extension strength, and self-rated Motor Activity Log. The sham subjects did not improve on any grasp and release measure or self-rated scale, but did improve on isometric finger extension strength. Due to the few number of patients in the study and the lack of long term outcomes, conclusions cannot be reached concerning the effectiveness of EMG-triggered stimulation in an unsupervised home setting.

More recently there has been interest in EMG-triggered functional neuromuscular stimulation to treat lower extremity paresis.  The available studies are all non-randomized patient series, the largest of which enrolled 44 subjects. (29-36) The studies address the intermediate physiologic effects of EMG-triggered cycling. The studies appear to indicate a consistent impact of EMG-triggered NMES plus cycling for the following measures: (1) increased quadriceps muscle mass (validated by MRI in one study), (Calf girth did not increase significantly); (2) increased ability to perform a 30 minute work-out; (3) increased oxygen uptake during cycling exercise from 1.20 to 1.43 liters/min; (4) biopsy proven muscle atrophy normalized following one year of therapy; (5) increased pre-tibial bone mineral density following 1 year of therapy (no increase in BMD in lumbar spine or femoral neck); (6) increased tidal volume; (7) and, decreased spasticity in quadriceps muscles.  The intermediate outcomes confirm what is well-established and that is that exercise is physiologically beneficial.  Long term, health related outcomes and impact on quality of life for paraplegics are not measured.  The studies do not indicate that FES plus cycling affect paraplegia in any way by decreasing paralysis or allowing the patient to better function independently.  Also, it appears that the beneficial effects continue as long as patients continue at least 3, 30 minute sessions each week.  When sessions decrease in frequency the improvement in intermediate outcomes is reduced.

None of the published clinical data are from randomized trials.  It is not clear that the benefits accomplished with EMG-triggered NMES plus cycling cannot be realized through standard passive range of motion exercise.  Based on the available published evidence, the technology evaluation criteria for EMG-triggered NMES plus cycling are not met.

An updated search of the medical literature through March 24, 2008 did not return any new clinical trial information that addresses the concerns regarding the effectiveness of EMG-triggered electrical stimulation in the unsupervised home setting.

References

1. BlueCross and BlueShield Association Medical Policy Reference Manual, Policy Nos.1.01.09 and 1.01.13
2. 1996 TEC Assessment, Transcutaneous Electrical Stimulation, Tab. 21
3. Carroll D, Moore RA, McQuay HJ et al. Transcutaneous electrical nerve stimulation (TENS) for chronic pain (Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software
4. Yurtkuran M, Kocagil T. TENS, electroacupuncture and ice massage: comparison of treatment for osteoarthritis of the knee. Am J Acupunct 1999;27(3-4):133-40
5. Milne S. Welch V, Brosseau L et al. Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain (Cochrane Review). In: The Cochrane Library, Issue 3, 2002
6. Pelland L, Brousseau L, Casimiro L et al. Electrical stimulation for the treatment of rheumatoid arthritis (Cochrane Review). In: The Cochrane Library, Issue 3, 2002
7. Price CIM, Pandyan AD. Electrical stimulation for preventing and treating post-stroke shoulder pain (Cochrane Review). In: The Cochrane Library, Issue 3, 2002
8. Osiri M, Welch V, Brousseau L et al. Transcutaneous electrical nerve stimulation for knee osteoarthritis (Cochrane Review). In: The Cochrane Library, Issue 3, 2002
9. Proctor ML, Smith CA, Farquhar CM et al. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhea (Cochrane Review). In: The Cochrane Library, Issue 3, 2002
10. Hamza MA, White PF, Ahmed HE et al. Effect of the frequency of transcutaneous electrical nerve stimulation on the postoperative opioid analgesic requirement and recovery profile. Anesthesiology 1999;91(5):1232-8
11. Brosseau L,Yonge KA, Robinson V et al. Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand. Cochrane Database Syst Rev 2003; (3): CD004287
12. Cameron M, Longergan E, Lee H. Transcutaneous electrical nerve stimulation (TENS) for dementia. Cochrane Database Syst Rev 2003; (3): CD004032
13. Limoges MF, Rickabaugh B. Evaluation of TENS during screening flexible sigmoidoscopy. Gastroenterol Nurs 2004; 27(2): 61-8
14. Ng MM, Leung MC, Poon DM. The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: a randomized controlled trial with follow-up evaluation. Altern Complement Med 2003; 9(5): 641-9
15. Rakel B, Frantz R. Effectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement. J Pain 2003; 4(8): 455-64
16. De Angelis C, Perrone G, Santoro G et al. Suppression of pelvic pain during hysteroscopy with a transcutaneous electrical nerve stimulation device. Fertil Steril 2003; 79(6): 1422-7
17. Cheing GL, Tsui AY, Lo SK et al. Optimal stimulation duration of TENS in the management of osteoarthritic knee pain. J Rehabil Med 2003; 35(2):62-8
18. Cheing GL, Hui-Chan CW, Chan KM. Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritic knee pain? Clin Rehabil 2002; 16(7):749-60
19. Bertolucci LE, Grey T. Clinical comparative study of microcurrent electrical stimulation to mid-laser and placebo treatment in degenerative joint disease of the temporomandibular joint. Physical Therapy 1995;13(2):116-120
20. Lambert MI, Marcus P, Burgess T et al. Electro-membrane microcurrent therapy reduces signs and symptoms of muscle damage. Med Science Sports & Ex 2002; 602-607
21. Weber MD, Servedio FJ, Woodall WR. The effects of three modalities on delayed onset muscle soreness. J Orthop Sports Phys Ther 1994 Nov;20(5):236-42
22. Kumar D, Marshall HJ. Diabetic peripheral neuropathy: amelioration of pain with transcutaneous electrostimulation. Diabetes Care 1997;20(11):1702-5
23. Kumar D, Alvaro MS, Julka IS et al. Diabetic peripheral neuropathy. Effectiveness of electrotherapy and amitriptyline for symptomatic relief. Diabetes Care 1998;21(8):1322-5
24. Julka IS, Alvaro M, Kumar D. Beneficial effects of electrical stimulation on neuropathic symptoms in diabetes patients. J Foot Ankle Surg 1998;37(3):191-4
25. Cauraugh et al. Chronic motor dysfunction after stroke, recovering wrist and finger extension by electromyography-triggered neuromuscular stimulation. Stroke 2000; 31:1360-64
26. Kraft et al. Techniques to improve functions of the arm and hand in chronic hemiplegia. Arch Phys Med Rehabil 1992; 73:220-7
27. Fields, R. Wayne. Electromyographically triggered electric muscle stimulation for chronic hemiplegia. Arch Phys Med Rehabil 1997; 98:407-14
28. Kimberley TJ, Lewis SM, Auerbach EJ et al. Electrical stimulation driving functional improvements and cortical changes in subjects with stroke. Exp Brain Res 2003 Nov 15 (Epub ahead of print)
29. Mohr T Andersen JL Biering-Sorensen F et al. Long-term adaptation to electrically induced cycle training in severe spinal cord injured individuals Spinal Cord 1997; 35(1):1-16
30. Mohr T Podenphant J Biering-Sorensen F et al. Increased bone mineral density after prolonged electrically induced cycle training of paralyzed limbs in spinal cord injured man. Calcif Tissue Int 1997; 61(1):22-5
31. Ragnarsson KT. Physiologic effects of functional electrical stimulation-induced exercises in spinal cord-injured individuals. Clin Orthop 1988; 233:53-63
32. Arnold PB McVey PP Farrell WJ et al. Functional electric stimulation: its efficacy and safety in improving pulmonary function and musculoskeletal fitness. Arch Phys Med Rehabil 1992; 73(7): 665-8
33. Figoni SF Rodgers MM Glaser RM et al. Physiologic responses of paraplegics and quadriplegics to passive and active leg cycle ergometry. J Am Paraplegia Soc 1990;13(3):33-9
34. Bremner LA Sloan KE Day RE et al. A clinical exercise system for paraplegics. Paraplegia 1992; 30(9):647-55
35. Baldi JC Jackson RD Moraille R et al. Muscle atrophy is prevented in patients with acute spinal cord injury using functional electrical stimulation; Spinal Cord 1998; 36(7):463-9
36. Hooker SP Figoni SF Rodgers MM et al. Physiologic effects of electrical stimulation leg cycle exercise training in spinal cord injured persons. Arch Phys Med Rehabil 1992; 73(5):470-6
37. Lang T, Barker R, Steinlechner B et al. TENS relieves acute posttraumatic hip pain during emergency transport. J Trauma 2007; 62(1):184-8

Cross References

Pelvic Floor Stimulation as a Treatment of Urinary Incontinence, Regence Medical Policy Manual, Allied Health, Policy No. 4

Electrical Bone Growth Stimulators (Osteogenic Stimulation), Regence Medical Policy Manual, DME, Policy No. 10

Functional Neuromuscular Stimulation to Provide Ambulation, Regence Medical Policy Manual, DME, Policy No. 56

Threshold Electrical Stimulation as a Treatment of Motor Disorders, Regence Medical Policy Manual, DME, Policy No. 57

Sympathetic Therapy for the Treatment of Pain, Regence Medical Policy Manual, DME, Policy No. 65

Interferential Stimulation, Regence Medical Policy Manual, DME, Policy No. 66

Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds in the Home Setting, Regence Medical Policy Manual, DME, Policy No. 67

Cranial Electrostimulation Therapy (CES), Regence Medical Policy Manual, DME, Policy No. 74

Percutaneous Neuromodulation Therapy (PNT), Regence Medical Policy Manual, Surgery, Policy No. 44

Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction, Regence Medical Policy Manual, Surgery, Policy No. 134

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