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:


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.


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

Journal Club February 2017: Return to the Primary Acute Care Service Among Patients With Multiple Myeloma on an Acute Inpatient Rehabilitation Unit

Article Title: Return to the Primary Acute Care Service Among Patients With Multiple Myeloma on an Acute Inpatient Rehabilitation Unit

Author: Jack B. Fu, MD, Jay Lee, PhD, Ben C. Shin, MD, Julie K. Silver, MD, Dennis W. Smith, PhD, Jatin J. Shah, MD, Eduardo Bruera, MD

Journal: PM R. 2017 Jan 8. pii: S1934-1482(17)30021-7. doi: 10.1016/j.pmrj.2016.12.007.

Patients with multiple myeloma often require inpatient rehabilitation service due to unexpected medical complications related to their cancer and treatment, which include infection, bone pain, fractures and spinal cord compression. Although there have been several studies on return to the primary acute care service among patients with lymphoma, leukemia, and hematopoietic stem cell undergoing inpatient rehabilitation, no previous study has evaluated risk factors for return to the primary acute care inpatient service of multiple myeloma patient population.

The purpose of this study is two-fold: (1) to identify the percentage of multiple myeloma patients under treatment, who transferred to the primary acute care inpatient service from inpatient rehabilitation for unplanned reasons, and (2) to identify risk factors associated with unplanned transfers of patients with multiple myeloma from inpatient rehabilitation to the primary acute care service.

Thirty-two of the 122 total patients (26%) transferred back to the primary acute care service for unplanned reasons, such as infection, cardiac, renal, neurologic, gastrointestinal bleed, pulmonary, and orthopedic. Those with planned transfers, such as planned chemotherapy, were not included in the study group.

Unplanned return to the primary acute care service had statistically significant associations with elevated Bence Jones protein and a lower platelet count as well as male gender, presence of Foley catheter, IV antifungal agent, antiviral agent, IV

Multiple myeloma is a cancer that begins in plasma cells. The cause of multiple myeloma is currently unknown. This cancer usually occurs in people older than 60 years of age. It is slightly more common in men than in women.

antibiotic, history of stem cell transplant, and being deceased as of June 1, 2015. However, after a multivariate logistic regression analysis, only two of these factors continued to be significant: (1) male gender and (2) thrombocytopenia (less than 140,000/mL). Survival time for patients who returned to the primary acute care service was significantly shorter (median 180 days), compared to those who did not return to the primary acute care service (median 550 days).

Identifying such high-risk patients would be desirable and clinically important. Closer supervision by oncologists can help prevent possible complications and transfers back to the primary acute care service among people with increased risk. By understanding and addressing those identified risk factors, consulting physiatrists involved in care of high-risk groups would be able to plan the most appropriate and safest inpatient rehabilitation program for the patients.

Discussion Author: Lanah Koh, OMS-II, Touro College of Osteopathic Medicine

Discussion Points:

  1. What is the goal of rehab for patients with multiple myeloma?

  2. What role does a physiatrist play in the medical care of patients with

    multiple myeloma?

  3. What are some of the risk factors of multiple myeloma?

  4. Was the sample size adequate enough to fulfill the objectives of the study?

    How might a bigger sample size have affected the study result?

  5. How would this study be designed differently if Functional Independence

    Measure scores and staging of multiple myeloma were known?

  6. What comorbidity measures in patients with multiple myeloma could have

    been included in the analysis?

  7. What would be the possible explanation for higher mortality in patients

    who transferred back to the primary acute care service for unplanned


  8. How could the inpatient rehabilitation therapy be modified based on the

    patient’s subjective history and findings documented in this study?

LEARN MORE by downloading the article:

Journal Article Summary and Discussion Questions Feb 2017

Journal Article Feb 2017


Journal Club January 2017: Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study

Article Title: Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study

Author: Yetsa A. Tuakli-Wosornu, MD, MPH Alon Terry, MD, Kwadwo Boachie-Adjei, BS, CPH, Julian R. Harrison, BS, Caitlin K. Gribbin, BA, Elizabeth E. LaSalle, BS, Joseph T Nguyen, MPH, Jennifer L. Solomon, MD, Gregory E Lutz, MD

Journal: PM R. 2016 Jan;8(1):1-10; quiz 10. doi: 10.1016/j.pmrj.2015.08.010. Epub 2015 Aug 24.


Musculoskeletal complaints are the second most common cause for doctor visits in the United States. The overwhelming odds indicate that these complaints are of low back pain (LBP). In fact, more than 80% of American adults experience at least one episode of LBP during their lifetime. Various structures within the human body can cause LBP and the intervertebral disk (IVD) accounts for more than 40% of cases of chronic LBP. Being the largest avascular structure in the human body, the IVD has poor inherent healing potential. Therefore, it is necessary to develop a recipe for a healing cascade to address the numerous pathologies associated with the IVD. Platelet Rich Plasma (PRP) can provide the essential ingredients for the body to address these pathoanatomic processes and help treat LBP.

PRP is thought to provide the necessary growth factors that are lacking at injurious sites, especially ones with a scarcity of vasculature like the IVD. Placing a high concentration of growth factors (PDGF, VEGF, TGF-Beta, IGF etc.) directly at the site of collagen injury or degeneration can help restore the integrity of the structures via a healing response. In addition, the cytokines in PRP act as humoral mediators to induce the natural healing cascade. In comparison to surgery, PRP is readily available and cost-effective.

In this study, Tuakli-Wosornu et al 2016 investigated whether a single intradiskal injection of PRP delivered to symptomatic degenerative IVD(s), would be clinically beneficial for individuals with chronic diskogenic LBP. This was a prospective, double-blind, randomized controlled trial. A single independent observer randomized 47 participants into two treatment groups (29 in the treatment and 18 in the control). PRP or contrast agent was used under standardized protocol as the injectate for either group. Only disk levels that elicited pain with evidence of incomplete annular disruption were injected. Four internationally validated surveys were used as outcome measures over the 8 weeks of follow-up: the FRI, the NRS, the SF-36, and the modified NASS Outcome Questionnaire.

Participants who received intradiskal PRP injections experienced significantly greater improvements in FRI, NRS-Best Pain, and NASS satisfaction scores compared with those who received contrast agent alone over 8 weeks. Moreover, the improvement in FRI scores lasted for up to 1 year or more for the PRP group. Consequently, this study highlights that intradiskal PRP can be considered a viable option to alleviate pain and restore function for a universally common complaint of low back pain.

Discussion Author: Altamash Raja, OMS-IV, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

Discussion Points:

  1. What are the most common causes of chronic low back pain? Which causes are more prevalent in the various age groups? Young adults (18-35)? Middle aged (35-60)? Elderly (>60)?
  2. What therapeutic objectives should techniques for diskogenic low back pain aim to achieve?
  3. Describe some of the current limitations regarding PRP injections.
  4. How does PRP compare to other interventional treatment options such as facet joint injections, epidural steroid injections etc.? What are the pros? Cons?
  5. What other orthobiologics can be utilized for treatment of musculoskeletal complaints? Where does the future go?
  6. What are some osteopathic techniques for the treatment of low back pain that should be explored further?
  7. When is surgery the preferred treatment option, even in the eyes of a non-operative expert?

LEARN MORE by downloading the article:

Journal Article Summary and Discussion Questions January 2017

Journal Article January 2017