Journal Club April 2017: Effects of Functional Electrical Stimulation on Reducing Falls and Improving Gait Parameters in Multiple Sclerosis and Stroke

Article: Effects of Functional Electrical Stimulation on Reducing Falls and Improving Gait Parameters in Multiple Sclerosis and Stroke

Authors: Elisa Gervasoni, Riccardo Parelli, Marcin Uszynski, Alessandro Crippa, Alberto Marzegan, Angelo Montesano, Davide Cattaneo

Journal: PM&R Nov 2016. doi: http://dx.doi.org/10.1016/j.pmrj.2016.10.019

Discussion:

Multiple sclerosis and stroke have detrimental effects on patients’ health. In particular neuromuscular control may be impaired from potential damage to the motor cortex or corticospinal tract. These conditions often result in decreased motor control, such as significant weakness at the ankle joint. This results in an inefficient gait pattern and increases the likelihood of falling. Falls in these patients have been associated with fractures, increased care utilization, decreased capacity to perform activities of daily living, and diminished overall quality of life. Ankle foot orthotics have been used to support the ankle joint during the swing phase of the gait cycle, however, functional electrical stimulation (FES) have been developed as an alternative treatment modality to decrease foot drop and improve the gait pattern in these patients.

FES devices utilize low-energy electrical pulses to artificially generate contractions in paralyzed muscles. Prior studies related to FES have demonstrated improved dorsiflexion at the ankle and reduced foot drop, which subsequently improves the quality of the gait; however, little data is available on FES effects on reducing falls, and resultant kinematic changes in the lower extremities related to foot clearance and energy recovery.

This prospective longitudinal study by Gervasoni, et al. investigated the effectiveness of functional electrical stimulation in 24 subjects with known upper motor neuron lesions. The subjects, 10 with multiple sclerosis and 10 with stroke, were followed for 8 weeks and measurements were made via instrumental gait analysis and clinical assessment at baseline, 4 weeks, and at 8 weeks. The main outcomes of this study were to assess: the effectiveness of FES on reducing falls, the effectiveness of FES on improving foot clearance and lower limbs kinematics, and the effectiveness of FES on promoting energy recovery.

The researchers determined that there is indeed an improvement in gait mechanics in the study subjects via increased foot clearance, and a resultant decrease in number of falls after 8 weeks of FES use. In conclusion, FES should be considered by a consulting rehabilitation team in mitigating falls, and their negative sequelae, in multiple sclerosis and stroke patients with motor control impairment in their lower extremities.

Discussion Author: Juan R. Querubin, OMS-III (Lincoln Memorial University – DeBusk College of Osteopathic Medicine)

Discussion Points:

  1. Was the sample size adequate? What are the study’s strengths/weakness?
  2. What are the different disease patterns of progression in multiple sclerosis?
  3. What role does a physiatrist play in the care of patients with multiple sclerosis/ stroke?
  4. What other medical conditions would the application of FES be appropriate for?
  5. Under what circumstance(s) would an ankle foot orthotic (AFO) be a better treatment choice for foot drop as opposed to FES, and vice versa?

Learn More by downloading the article here:

Journal Club Discussion April 2017

Journal Club Article April 2017

Journal Club March 2017: The importance of rehabilitation concerning upper extremity amputees: A Systematic Review

Article Title: The importance of rehabilitation concerning upper extremity amputees: A Systematic Review

Author: Kardem Soyer, Banu Unver, Seval Tamer, Ozlem Ulger

Journal: Pak J Med Sci. 2016;32(5):1312-1319.

Discussion:

This systematic review looked at 620 studies done in the past 10 years, but found that only 9 of the studies pertained to specifically to rehabilitation in upper extremity amputees. These 9 studies focused on functional impairment, activities for daily living, sensory function, and pain reduction in these subjects. In all, 116 individuals with upper limb amputations were assessed. Of these, 58 were above the elbow amputees and 49 were below the elbow amputees. Note that 9 of the subjects’ amputation level was not specified in the studies.

The upper extremity is one of the most important parts of the body largely in part due to the roles it plays in a person’s ability to perform daily activities such as bathing, cleaning, dressing oneself, and eating. This does not even take into consideration more advanced skills such as writing, typing, driving or playing sports. These everyday tasks can become overwhelming challenges in the event of losing one’s nondominant upper limb, let alone a person’s dominant limb.

This is where the role of prostheses and prosthetic training come into the picture. It is important to target patient therapy and rehabilitation from a holistic point of view. Patients need to be educated on how to use and acclimate the prosthesis into everyday life in order to help increase a person’s overall level of function and quality of life. Prosthetic rehabilitation facilitates independence and improvement in a person’s functional capacity. Among upper limb prosthetic rehabilitation modalities are general exercise programs, phantom exercises, muscle training system, edema control, neuromuscular re-education techniques, virtual images, and virtual reality exercises.

Overall, prosthetic rehabilitation seems to be effective and beneficial for the upper limb amputees. However, one key limitation that this review points out is that many of the studies that were involved implemented subjective responses from subjects and/or the researchers to assess benefit and improvement in pain and function. In addition, only 1 of the 9 studies was a randomized control trial. Moving forward, this area of rehabilitation would be well served if more physiatrists and researchers performed quality studies involving upper extremity amputees so that these patients can benefit and potentially improve their quality of life.

Discussion Author: Kumail S. Kazim, OMS-IV (Rowan University - School of Osteopathic Medicine)


Discussion Points:

  1. In patients who have undergone limb amputations, should the primary goal of rehabilitation be functional recovery or pain management?
  2. What are some management options for phantom limb pain?
  3. How would you imagine above the elbow amputation rehabilitation differs from below the elbow amputation rehabilitation?
  4. Do you think there is a role for prosthetic rehabilitation in lower extremity amputation?
  5. What studies need to be done in order to establish stronger support in favor or against prosthetic rehabilitation?

Learn More by downloading the article here:

Journal Club Article March 2017

Journal Club Discussion March 2017