Monday, 1 September 2014

Foot drop treatment

Are you have problems accessing FES? #MSBlog #MSResearch

"The pilot study below is very small and hence we can't extrapolate the findings to everyone. What it does show, however, is that MSers with foot drop benefit from functional electrical stimulation (RES) with regard to an improvement in walking, but the latter was not evident in the PROMS (patient related outcome measures). This disconnect between objective (measured) and subjective (MSer perceived) outcome measures tells us that FES did not improve the perceived function nor quality of life of MSers. This has not been my experience with FES; when patients are carefully selected and the FES works it can have major impact on day-to-day functioning."

"What is not covered in this study is the impact of FES on falls. MSers with a dropped foot are at increased risk of falls; the dropped foot often catches on steps and raised edges and is associated with tripping and falls. The FES stops the foot dropping and hence prevents the foot catching on raised edges and prevents MSers tripping, falling and sustaining fractures. The latter cannot be overemphasised as a positive outcome as it is so important when assessing the cost-effectiveness of interventions. Fractures cause a lot of suffering and cost the NHS a lot of money."

"Post-code prescribing! FES is the one intervention that is subject to massive post-code prescribing in the UK. When I was at MS Life in Manchester earlier this year I was surprised how many MSers who needed a FES assessment could not get one as their local Clinical Commissioning Group (CCG) were not covering the cost of FES. In comparison most of London's CCGs do; this is one of many examples of a disparity in access to care across the country. Despite access to FES, we do have a waiting list for patients to be assessed in the walking clinic, but if the patients are eligible they get a trial of FES and if successful they get the device. Although FES is relatively expensive it is not exorbitant and substantially less the an admission for a fractured femur. Prevention is better than cure!"

"May be someone needs to come up with a better designed and more flexible FES system? May be a wireless system that runs from a Smartphone is possible?"


van der Linden et al. Habitual Functional Electrical Stimulation Therapy Improves Gait Kinematics and Walking Performance, but Not Patient-Reported Functional Outcomes, of People with Multiple Sclerosiswho Present with Foot-Drop. PLoS One. 2014 Aug 18;9(8):e103368. doi: 10.1371/journal.pone.0103368. eCollection 2014.

BACKGROUND: MSers often experience a disturbed gait function such as foot-drop. The objective of this pilot study was to investigate the medium term effects of using Functional Electrical Stimulation (FES) to treat foot-drop over a period 12 weeks on gait and patient reported outcomes of MSers

METHODS AND FINDINGS: Nine MSers aged 35 to 64 (2 males, 7 females) were assessed on four occasions; four weeks before baseline, at baseline and after six weeks and twelve weeks of FES use. Joint kinematics and performance on the 10 meter and 2 minute walk tests (10WT, 2 minWT) were assessed with and without FES. Participants also completed the MS walking Scale (MSWS), MS impact scale (MSIS29), Fatigue Severity Score (FSS) and wore an activity monitor for seven days after each assessment. Compared to unassisted walking, FES resulted in statistically significant improvements in peak dorsiflexion in swing (p = 0.006), 10MWT (p = 0.006) and 2 minWT (p = 0.002). Effect sizes for the training effect, defined as the change from unassisted walking at baseline to that at 12 weeks, indicated improved ankle angle at initial contact (2.6°, 95% CI -1° to 4°, d = 0.78), and a decrease in perceived exertion over the 2 min walking tests (-1.2 points, 95% CI -5.7 to 3.4, d = -0.86). Five participants exceeded the Minimally Detectable Change (MDC) for a training effect on the 10mWT, but only two did so for the 2 minWT. No effects of the use of FES for 12 weeks were found for MSWS, MSIS29, FSS or step count.

CONCLUSION: Although FES to treat foot-drop appears to offer the potential for a medium term training effect on ankle kinematics and walking speed, this was not reflected in the patient reported outcomes. This observed lack of relationship between objective walking performance and patient reported outcomes warrants further investigation.

4 comments:

  1. Agreed it would be good if technology could be improved for these devices. I was lucky to be provided with one on the NHS but ended up returning it as the constant switching on and off, the little audible signal etc was not practical for everyday use in an office environment. Thee must be a better way for them to work, a better user interface? See what the Apple designers would make of it?!

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  2. I have used a wired FES device for three years now, and I am told that a wireless version has been developed. The audible signal is switched on during my yearly visits to the FES clinic, and switched off again before I leave, so it is only used by the clinic staff to verify correct operation of the device.

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  3. I went to the local Gait Analysis unit today and was recommended to be fitted with two fes units. Grateful, not bragging, for being recommended, yet regret needing it. Read the advert in the MSsociety magazine 6-7 years ago but didn't think I'd need any thing like this for decades. NHS tech still looks a bit clunky, but I'd put up with anything that meant that I don't need a claw hammer to get my toes off the floor at times.

    Smarter, sleeker tech is available for those willing to pay. Certainly won't be competing in any round the block races, but I'd be grateful to be able to use my rollator and walking poles more effectively.

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  4. The whole FES process is a complicated one but I certainly found it beneficial. TBH, no other medical professionals have ever shown that much interest in the day-to-day business of managing impairment. Appointments were typically 1.5 hours - that's a good slice of time devoted to the minutiae of how you put one foot in front of another! When my knee finally gave up after years of misuse, it was the FES team who suggested the orthotic to stop the hyperextension... their (innovative) recommendation hadn't even been heard of by my hospital's orthotic clinic. I'll always be grateful for that.

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