Functional Electrical Stimulation for Foot Drop in Multiple Sclerosis: A Systematic Review and Meta-Analysis of the Effect on Gait Speed

Physical and occupational therapists' learning needs and preferences for education on functional electrical stimulation: A qualitative descriptive study

BACKGROUND

Functional electrical stimulation (FES) is an evidence-based intervention that is rarely used by Canadian physical therapists (PTs) and occupational therapists (OTs). A common barrier to FES implementation is a lack of knowledge and training. FES learning resources that meet therapists' learning needs and preferences may address this barrier.

OBJECTIVE

To explore OTs' and PTs' perspectives on the utility of FES e-learning resources, including whether the resources met their learning needs and preferences.

METHODS

Through this qualitative descriptive study, feedback on FES e-learning resources was solicited from 5 PTs and 18 OTs who work clinically, but do not use FES. Participants reviewed ≥3 prerecorded lectures on FES topics and then completed a semi-structured interview. Participants were asked about the lectures' content, delivery, ease of use and comprehensibility, and were asked to suggest modifications to facilitate self-directed learning about FES. Interviews were analyzed using conventional content analysis.

RESULTS

Three themes were identified. (1) Feedback on FES e-learning: the content and delivery of the prerecorded lectures facilitated participants' learning, although opportunities to improve content and delivery were identified. (2) Factors influencing FES learning needs and preferences: Participants identified internal (i.e., baseline knowledge, learning style) and external (i.e., learning with colleagues, practice setting) factors that affected learning. Themes 1 and 2 impacted (3) the effects of FES e-learning: Participants described the outcomes of their FES e-learning, including increases in FES knowledge, confidence, and use in clinical practice.

CONCLUSION

Therapists' perceived the FES e-learning resources to be useful and to address their learning needs and preferences.

Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review

Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.

Is functional electrical stimulation effective in improving walking in adults with lower limb impairment due to an upper motor neuron lesion? An umbrella review

PURPOSE

To conduct an umbrella review of systematic reviews on functional electrical stimulation (FES) to improve walking in adults with an upper motor neuron lesion.

METHODS

Five electronic databases were searched, focusing on the effect of FES on walking. The methodological quality of reviews was evaluated using AMSTAR2 and certainty of evidence was established through the GRADE approach.

RESULTS

The methodological quality of the 24 eligible reviews (stroke, n = 16; spinal cord injury (SCI), n = 5; multiple sclerosis (MS); n = 2; mixed population, n = 1) ranged from critically low to high. Stroke reviews concluded that FES improved walking speed through an orthotic (immediate) effect and had a therapeutic benefit (i.e., over time) compared to usual care (low certainty evidence). There was low-to-moderate certainty evidence that FES was no better or worse than an Ankle Foot Orthosis regarding walking speed post 6 months. MS reviews concluded that FES had an orthotic but no therapeutic effect on walking. SCI reviews concluded that FES with or without treadmill training improved speed but combined with an orthosis was no better than orthosis alone. FES may improve quality of life and reduce falls in MS and stroke populations.

CONCLUSION

FES has orthotic and therapeutic benefits. Certainty of evidence was low-to-moderate, mostly due to high risk of bias, low sample sizes, and wide variation in outcome measures. Future trials must be of higher quality, use agreed outcome measures, including measures other than walking speed, and examine the effects of FES for adults with cerebral palsy, traumatic and acquired brain injury, and Parkinson's disease.

Effects of non-pharmacological interventions on gait and balance of persons with Multiple Sclerosis: A narrative review

BACKGROUND

Multiple Sclerosis (MS) is among the most common reasons for disability in young adults. Mobility impairment, primarily related to gait and balance, is ranked as the preeminent concern among persons with MS (PwMS). Gait and balance dysfunction can directly affect the quality of life and activities of daily life in PwMS, hence the importance of effective treatment strategies. Previous studies have demonstrated the positive effect of various non-pharmacological rehabilitation methods, including physiotherapy and electrical stimulation, on gait and mobility in PwMS. Non-pharmacological methods can be tailored to the individual needs and abilities of each patient, allowing healthcare providers to create personalized training programs. Furthermore, these methods typically result in minimal or no side effects.

PURPOSE

This review provides a comprehensive overview of an array of non-pharmacological treatment approaches aimed at enhancing ambulatory performance in PwMS.

METHODS

We performed a narrative review of the original papers available in PubMed, investigating the effects of different nonmedical approaches on the gait and balance performance of the PwMS. Reviewed treatment approaches include "exercise, physical rehabilitation, dual-task (DT) rehabilitation, robot-assisted rehabilitation, virtual reality-assisted rehabilitation, game training, electrical stimulation devices, auditory stimulation, visual feedback, and shoe insoles".

RESULTS AND CONCLUSIONS

Eighty articles were meticulously reviewed. Our study highlights the positive effects of non-pharmacological interventions on patients' quality of life, reducing disability, fatigue, and muscle spasticity. While some methods, including exercise and physiotherapy, showed substantial promise, further research is needed to evaluate whether visual biofeedback and auditory stimulation are preferable over conventional approaches. Additionally, approaches such as functional electrical stimulation, non-invasive brain stimulation, and shoe insoles demonstrate substantial short-term benefits, prompting further investigation into their long-term effects. Non-pharmacological interventions can serve as a valuable complement to medication-based approaches.

Effects of Functional Electrical Stimulation on Gait Characteristics in Healthy Individuals: A Systematic Review

BACKGROUND

This systematic review aimed to provide a comprehensive overview of the effects of functional electrical stimulation (FES) on gait characteristics in healthy individuals.

METHODS

Six electronic databases (PubMed, Embase, Epistemonikos, PEDro, COCHRANE Library, and Scopus) were searched for studies evaluating the effects of FES on spatiotemporal, kinematic, and kinetic gait parameters in healthy individuals. Two examiners evaluated the eligibility and quality of the included studies using the PEDro scale.

RESULTS

A total of 15 studies met the inclusion criteria. The findings from the literature reveal that FES can be used to modify lower-limb joint kinematics, i.e., to increase or reduce the range of motion of the hip, knee, and ankle joints. In addition, FES can be used to alter kinetics parameters, including ground reaction forces, center of pressure trajectory, or knee joint reaction force. As a consequence of these kinetics and kinematics changes, FES can lead to changes in spatiotemporal gait parameters, such as gait speed, step cadence, and stance duration.

CONCLUSIONS

The findings of this review improve our understanding of the effects of FES on gait biomechanics in healthy individuals and highlight the potential of this technology as a training or assistive solution for improving gait performance in this population.

A systematic literature review of ankle-foot orthosis and functional electrical stimulation foot-drop treatments for persons with multiple sclerosis

Foot-drop is one of the most diagnosed and physically limiting symptoms persons with multiple sclerosis (pwMS) experience. Clinicians prescribe ankle-foot orthosis (AFO) and functional electrical stimulation (FES) devices to help alleviate the effects of foot drop, but it is unclear how their clinical and functional gait improvements compare given the user's level of disability, type of multiple sclerosis, walking environment, or desired physical activity. The research questions explored were what is the current state of AFO and FES research for pwMS? What are the prevailing research trends? What definitive clinical and functional device comparisons exist for pwMS? eight databases were systematically searched for relevant literature published between 2009 and 2021. The American Association of Orthotists and Prosthetists and Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines for systematic literature reviews were followed. A team of 3 researchers critically evaluated 17 articles that passed eligibility criteria. This review discusses the current state and trends of research, provides evidence statements on device effects, and recommends improvements for future studies. A meta-analysis would be informative, but study variability across the literature makes directly comparing AFO and FES device effects unreliable. This review contributes new and useful information to multiple sclerosis literature that can be used by both clinicians and researchers. Clinicians can use the provided insights to prescribe more effective, customized treatments, and other researchers can use them to evaluate and design future studies.

A case series in individuals with multiple sclerosis using direct current electrical stimulation to inhibit spasticity and improve functional outcomes

Background and Purpose

Multiple sclerosis (MS) has a high incidence of debilitating spasticity. Central Nervous System (CNS) intrafusal settings have an impact on spasticity level. Mechanoreceptors of the Peripheral Nervous System (PNS) communicate monosynaptically with the central nervous system (CNS). This case series assesses feasibility of multimodal treatment of individuals with MS using a direct current electrical stimulation (DC) to influence mechanoreceptors.

Case Description and Intervention

Seven MS diagnosed participants with Expanded Disability Status Scale (EDSS) = 6.0-8.0 completed 18 visits over 6 weeks of using DC combined with neuromuscular reeducation. Design included pre-, post- outcome measures of EDSS, 12-item MS Walking Scale (MSWS-12), Range of Motion (ROM), Manual Muscle Testing (MMT), Modified Ashworth Test (MAT), Timed 25-Foot walk (T25WT), Timed Up and Go (TUG) and the Multiple Sclerosis Impact Scale-29 (MSIS-29).

Outcome

125 out of a possible 126 visits were completed, demonstrating a high level of tolerance. Individual results included trends towards improvement in spasticity and agonists.

Discussion

This case series design of seven heterogenous subjects with MS is a low sample size for statistical analysis and should be considered a pilot. The study demonstrates a high level of feasibility and possible correlations to consider. Further research is warranted.

Gait analysis of leprosy patients with foot drop using principal component analysis

BACKGROUND

Peripheral nerve injury caused by leprosy can lead to foot drop, resulting in an altered gait pattern that has not been previously described using 3D gait analysis.

METHODS

Gait kinematics and dynamics were analyzed in 12 patients with unilateral foot drop caused by leprosy and in 15 healthy controls. Biomechanical data from patients' affected and unaffected limbs were compared with controls using inferential statistics and a standard distance, based on principal components analysis (PCA).

FINDINGS

Patients walked slower than controls (0.8 ± 0.2 vs. 1.1 ± 0.2 m/s, p = 0.003), with a reduced stance and increased swing percentage. The affected limb increased (p < 0.05) plantar flexion at the initial contact (-16.8^o ± 8.3), terminal stance (-29.1^o ± 11.5), and swing (-12.4^o ± 6.2) in the affected limb compared to unaffected (-6.6^o ± 10.3; -14.6^o ± 11.6; 2.4^o ± 7.6) and controls (-5.4^o ± 2.5; -18.8^o ± 5.8; -1.4^o ± 3.9). Increased pelvic tilt and knee adduction/abduction range, with lower hip adduction, were observed. The second peak of ground reaction force (98.6 ± 5.2 %BW), ankle torque (0.99 ± 0.33 Nm/kg), and net ankle work in stance (-0.03 ± 5.4 J/Kg) decreased in the affected limb compared to controls (104.1 ± 5.5 %BW; 1.24 ± 0.4 Nm/kg; -4.58 ± 5.19 J/kg; p < 0.05). There were decreasing multivariate standard distances in the affected limb compared with the unaffected and controls. PCA loading factors highlighted the major differences between groups.

INTERPRETATION

Leprosy patients with foot drop presented altered gait patterns in affected and unaffected limbs. There were remarkable differences in ankle kinematics and dynamics. Rehabilitation devices, such as ankle foot orthosis or tendon transfer surgeries to increase ankle dorsiflexion, could benefit these patients and reduce deviations from normal gait.

Electrical stimulation therapy for peripheral nerve injury

Peripheral nerve injury is common and frequently occurs in extremity trauma patients. The motor and sensory impairment caused by the injury will affect patients' daily life and social work. Surgical therapeutic approaches don't assure functional recovery, which may lead to neuronal atrophy and hinder accelerated regeneration. Rehabilitation is a necessary stage for patients to recover better. A meaningful role in non-pharmacological intervention is played by rehabilitation, through individualized electrical stimulation therapy. Clinical studies have shown that electrical stimulation enhances axon growth during nerve repair and accelerates sensorimotor recovery. According to different effects and parameters, electrical stimulation can be divided into neuromuscular, transcutaneous, and functional electrical stimulation. The therapeutic mechanism of electrical stimulation may be to reduce muscle atrophy and promote muscle reinnervation by increasing the expression of structural protective proteins and neurotrophic factors. Meanwhile, it can modulate sensory feedback and reduce neuralgia by inhibiting the descending pathway. However, there are not many summary clinical application parameters of electrical stimulation, and the long-term effectiveness and safety also need to be further explored. This article aims to explore application methodologies for effective electrical stimulation in the rehabilitation of peripheral nerve injury, with simultaneous consideration for fundamental principles of electrical stimulation and the latest technology. The highlight of this paper is to identify the most appropriate stimulation parameters (frequency, intensity, duration) to achieve efficacious electrical stimulation in the rehabilitation of peripheral nerve injury.

Evaluating the validity of a functional electrical stimulation clinical decision making tool: A qualitative study

INTRODUCTION

Following central nervous system damage, the recovery of motor function is a priority. For some neurological populations, functional electrical stimulation (FES) is recommended in best practice guidelines for neurorehabilitation. However, limited resources exist to guide FES application, despite clinicians reporting that a lack of FES knowledge prevents use in clinical practice. The FES Clinical Decision Making Tool was developed to assist clinicians with FES application and translation into clinical practice. The purpose of this study was to evaluate the content validity of the Tool from the perspectives of Canadian physical and occupational therapists using FES in neurorehabilitation.

METHODS

Thirteen participants (twelve women, one man), aged 40.5 ± 10.3 years, participated in individual semi-structured interviews to explore their clinical decision making experiences when applying FES and to evaluate the content validity (i.e., appropriateness, comprehensibility, and comprehensiveness) of the Tool. Interviews were analyzed using a qualitative conventional content analysis following the DEPICT model.

RESULTS

Three themes were identified. 1) Clinician context influences FES usage. Participants' experiences with FES use varied and application was influenced by treatment goals. 2) Parameter selection in clinical practice. Participants identified decision-making strategies and the challenges of parameter selection. 3) With modifications, the Tool is a valid resource to inform FES applications. Participants discussed its strengths, limitations, and suggested changes. While the Tool is useful, a more extensive resource (e.g., appendix) for the Tool is warranted.

DISCUSSION

A revised Tool was created to improve its comprehensiveness and comprehensibility. Thus, the Tool is a valid resource for applying FES in neurorehabilitation.

The effects of orthotics device on the balance control in multiple sclerosis patients: A systematic review and meta-analysis

BACKGROUND

Multiple sclerosis refers to a progressive autoimmune inflammatory disease in the central nervous system usually accompanied by balance disorder. Our systematic review aimed to investigate the effects of orthotic devices on balance control of multiple sclerosis patients.

METHODS

The search procedure was according to the population, intervention, comparison, and outcome (PICO) strategy. We looked into PubMed, Embase, ISI Web of Knowledge, and Scopus databases and included all studies published since 1980. Two researchers did the searches separately and evaluated the selected papers' quality based on the physiotherapy evidence database (PEDro) scale and Cochrane risk of bias tool. We did a meta-analysis to evaluate the interventions' effects on the balance factors.

RESULTS

We found nine studies, of which seven studies with 162 participants were included in our meta-analysis. Four studies investigated the effect of foot orthoses, one evaluated the effect of shoe modifications and four evaluated the effect of ankle foot orthoses. There was no significant immediate difference between the insole and control groups in center of pressure velocity change, C7 displacement, in both open and closed eyes conditions. Also, there was no significant immediate difference between ankle foot orthosis' intervention and control groups in center of pressure velocity and displacement changes in antero-posterior and medio-lateral directions, in both open and closed eyes conditions. We could not do a meta-analysis for shoe modification.

CONCLUSION

Few studies have assessed the effects of orthoses on balance control in multiple sclerosis patients. Studies on ankle foot and foot orthoses show inconsistent results. According to our meta-analysis, orthotic interventions do not seem to improve the balance of people with multiple sclerosis.

Changes in Gait Characteristics During and Immediately After the 6-Minute Walk Test in Persons With Multiple Sclerosis: A Systematic Review

OBJECTIVE

There is limited information about gait patterns during prolonged walking in people with multiple sclerosis (PwMS). The aim of this review was to report on gait metrics during and immediately after the 6-Minute Walk Test (6MWT) in PwMS with different levels of disability.

METHODS

The systematic search was performed in 3 databases (PubMed, Web of Science, and SCOPUS) using keywords related to multiple sclerosis and 6MWT. Studies that reported on quantitative gait outcomes before and after the 6MWT or multiple time points during the 6MWT were included. The Hedges g effect size (ES) was calculated to determine the magnitude of change in each gait parameter.

RESULTS

Fourteen studies (n = 534 PwMS; n = 166 healthy controls) were eligible. Five studies investigated gait parameters prior to and immediately after the 6MWT. Nine studies collected gait measures during the 6MWT. Speed (ES = -0.43 to 0.19), cadence (ES = -0.46 to 0.16), step length (ES = -0.46 to 0.14), stability (ES = -0.35 to 0.33), and regularity (ES = -0.25 to -0.15) decreased in most studies. In the majority of included studies, step time (ES = 0 to 0.35), stance period (ES = 0.12 to 0.58), double support phase (ES = 0.03 to 0.62), variability (ES = -0.19 to 1.13), and asymmetry (ES = -0.79 to 0.62) increased following the 6MWT. The kinetic and kinematic (mainly in dorsiflexion angle [ES = -0.08 to -0.36]) features of gait were also negatively changed after 6 minutes of walking. Walking speed, cadence, step length, stride length, and stride time after 6MWT at a comfortable speed all increased. Changes in the majority of spatiotemporal parameters were more pronounced in PwMS with moderate-to-severe disability compared with PwMS with mild disability.

CONCLUSION

Most quantitative gait parameters deteriorated during the 6MWT, especially in PwMS with moderate-to-severe disability.

IMPACT

The deterioration of gait patterns should be considered when designing therapeutic interventions to increase sustained walking capacity.

Effects of brain-computer interface with functional electrical stimulation for gait rehabilitation in multiple sclerosis patients: preliminary findings in gait speed and event-related desynchronization onset latency

Objective.Brain-computer Interfaces (BCI) with functional electrical stimulation (FES) as a feedback device might promote neuroplasticity and hence improve motor function. Novel findings suggested that neuroplasticity could be possible in people with multiple sclerosis (pwMS). This preliminary study explores the effects of using a BCI-FES in therapeutic intervention, as an emerging methodology for gait rehabilitation in pwMS.Approach.People with relapsing-remitting, primary progressive or secondary progressive MS were evaluated with the inclusion criteria to enroll the nine participants required by the statistically computed sample size. Each patient trained with a BCI-FES during 24 sessions distributed in eight weeks. The effects were evaluated on gait speed (Timed 25 Foot Walk), walking ability (12-item Multiple Sclerosis Walking Scale), quality of life measures, the true positive rate as the BCI-FES performance metric and the event-related desynchronization (ERD) onset latency of the sensorimotor rhythms.Main results.Seven patients completed the therapeutic intervention. A statistically and clinically significant post-treatment improvement was observed in gait speed, as a result of a reduction in the time to walk 25 feet (-1.99 s,p= 0.018), and walking ability (-31.25 score points,p= 0.028). The true positive rate showed a statistically significant improvement (+15.87 score points,p= 0.018). An earlier ERD onset latency (-180 ms) after treatment was found.Significance.This is the first study that explored gait rehabilitation using BCI-FES in pwMS. The results showed improvement in gait which might have been promoted by changes in functional brain connections involved in sensorimotor rhythm modulation. Although more studies with a larger sample size and control group are required to validate the efficacy of this approach, these results suggest that BCI-FES technology could have a positive effect on MS gait rehabilitation.

[Rehabilitation of patients with multiple sclerosis]

Multiple sclerosis is a common cause of disability among young and middle-aged people. Despite the modern possibilities of diagnostics and therapy, over time, the disease acquires a secondary progressive character. Rehabilitation of patients at all stages of the disease plays an important role in improving well-being, improving the quality of life, adapting the patient and restoring motor skills. However, there is currently no clear recommendation for the application of specific techniques in each case. The aim of this work was to analyze the available methods of rehabilitation therapy, to highlight the most used and promising ones. Due to the progressive course of the disease, the benefits of rehabilitation measures are usually higher at the initial stages. Nevertheless, nowadays there is a large number of works devoted to rehabilitation measures in patients with moderate and high levels of disability. It has been shown that both inpatient and outpatient rehabilitation has a positive effect on the quality of life and improvement of clinical indicators. Our review describes the main techniques with recommendations for the scheme of application. A comprehensive assessment of the patient's health status, a multidisciplinary team and a personalized approach increase the quality and effectiveness of rehabilitation measures. We also describe our own experience in the treatment of spasticity in patients with a secondary progressive multiple sclerosis.

Development of clinical guidelines for service provision of functional electrical stimulation to support walking: mixed method exploration of stakeholder views

Background

Over the past 20 years Functional Electrical Stimulation (FES) has grown in clinical use to support walking in people with lower limb weakness or paralysis due to upper motor neuron lesions. Despite growing consensus regarding its benefits, provision across the UK and internationally is variable. This study aimed to explore stakeholder views relating to the value of a clinical guideline focusing on service provision of FES to support walking, how people might use it and what should be included.

Methods

A mixed methods exploration sought the views of key stakeholders. A pragmatic online survey (n = 223) focusing on the study aim was developed and distributed to the email distribution list of the UK Association for Chartered Physiotherapists Interested in Neurology (ACPIN). In parallel, a qualitative service evaluation and patient public involvement consultation was conducted. Two group, and seven individual interviews were conducted with: FES-users (n = 6), their family and carers (n = 3), physiotherapists (n = 4), service providers/developers (n = 2), researchers (n = 1) and distributors of FES (n = 1). Descriptive analysis of quantitative data and framework analysis of qualitative data were conducted.

Results

Support for clinical guideline development was clear in the qualitative interviews and the survey results. Survey respondents most strongly endorsed possible uses of the clinical guideline as ensuring best practice and supporting people seeking access to a FES service. Data analysis and synthesis provided clear areas for inclusion in the clinical guidelines, including current research evidence and consensus relating to who is most likely to benefit and optimal service provision as well as pathways to access this. Specific areas for further investigation were summarised for inclusion in the first stage of a Delphi consensus study.

Conclusions

Key stakeholders believe in the value of a clinical guideline that focuses on the different stages of service provision for FES to support walking. A Delphi consensus study is being planned based on the findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02299-1.

Triboelectric Nanogenerators for Therapeutic Electrical Stimulation

Current solutions developed for the purpose of in and on body (IOB) electrical stimulation (ES) lack autonomous qualities necessary for comfortable, practical, and self-dependent use. Consequently, recent focus has been placed on developing self-powered IOB therapeutic devices capable of generating therapeutic ES for human use. With the recent invention of the triboelectric nanogenerator (TENG), harnessing passive human biomechanical energy to develop self-powered systems has allowed for the introduction of novel therapeutic ES solutions. TENGs are especially effective at providing ES for IOB therapeutic systems given their bioconformability, low cost, simple manufacturability, and self-powering capabilities. Due to the key role of naturally induced electrical signals in many physiological functions, TENG-induced ES holds promise to provide a novel paradigm in therapeutic interventions. The aim here is to detail research on IOB TENG devices applied for ES-based therapy in the fields of regenerative medicine, neurology, rehabilitation, and pharmaceutical engineering. Furthermore, considering TENG-produced ES can be measured for sensing applications, this technology is paving the way to provide a fully autonomous personalized healthcare system, capable of IOB energy generation, sensing, and therapeutic intervention. Considering these grounds, it seems highly relevant to review TENG-ES research and applications, as they could constitute the foundation and future of personalized healthcare.

Functional electrical stimulation for foot drop in people with multiple sclerosis: The relevance and importance of addressing quality of movement

Impaired mobility is common in people with multiple sclerosis (MS). Changes in gait have different causes and require individualised gait rehabilitation. A common and often early cause of mobility impairment is footdrop, inability to lift the foot during the swing phase of gait, with increased risk of falls, effortful walking and fatigue. Using literature review, we have characterised published data on footdrop treatment in MS, specifically functional electrical stimulation (FES) to better understand the reported outcomes relevant to the user. We discuss the strengths and weaknesses of FES and how far it meets the needs of people with footdrop. Physiotherapy combined with FES may further enhance the benefits of FES. MS studies emphasise the value of maintaining activity levels in early MS but discussion on how to achieve this is lacking. We emphasise the value of qualitative measures to broaden our understanding and improve treatment and adherence and identify areas for further research. Supplementary video material illustrates key features of MS gait and its correction using FES and physiotherapy.

Clinical assessment, management, and rehabilitation of walking impairment in MS: an expert review

INTRODUCTION

One of the most common and life-altering consequences of Multiple Sclerosis (MS) is walking impairment. The distance, speed, and Gait pattern functions are components of the International Classification of Functioning, Disability, and Health (ICF) and are also predictors of dependency in terms of daily living activities in patients with MS (pwMS).

AREAS COVERED

This article provides an overview of walking impairment in pwMS, with focus on the assessment of gait and the rehabilitation approaches.

EXPERT OPINION

The authors recommend that pwMS undergo gait assessment integrating the ICF perspective using validated clinical outcome measures that cover spatiotemporal gait parameters. Moreover, assessment of walking speed with short walking capacity tests such as the timed 25-foot walk (T25FW) or the 10-m walk test (10 MWT) and tests for walking distance with middle distance tests such as the 2-min walk test (2MWT) and the 6-min walk test (6MWT). This review further highlights strategies that may restore walking function including pharmacological symptomatic treatment and non-pharmacological rehabilitation approaches such as exercise and task-specific training providing an appraisal of mobility targeted therapies to be considered when planning multidisciplinary comprehensive-care of pwMS. Finally, new and novel strategies such as motor imagery and rhythmic auditory stimulation have been developed to improve walking speed and distance in pwMS.

Movement Caused by Electrical Stimulation of the Lumbosacral Region in Standing Horses

Electrical stimulation is commonly used as a modality for physical therapy in human and veterinary medicine. However, studies measuring the movement generated by electrical stimulation in horses are rare. The present study therefore evaluates the range of movement provoked by a commercially available physical therapy unit (FES310) and contrasts it with the movement generated by manually induced pelvic inclination (back rounding). Ten horses were tested on three measurement days over one week. Electrical stimulation was applied via a back treatment pad (belonging to the FES310 system) containing six electrodes (three on either side of the spine) placed over the lumbosacral region. This system produced a pulsed, biphasic electrical stimulation in a rectangular waveform which was gradually increased to a maximum of 10 volts. Before and after electrical stimulation testing, manual pelvic inclination was achieved by pressure on two points lateral to the root of the tail. Muscle tone and lameness were evaluated before and after treatments. Skinfold thickness, body condition score, and body mass were measured to detect possible confounding factors. Using kinematics, the angle ranges during movement of ten three-dimensional angles of the trunk, the pelvis, and the hind limbs were further analyzed. Movement was produced with manual stimulation in every tested individual on all measurement days and with electrical stimulation on at least one measurement day. The electrical stimulation led to significantly (P < .05) smaller angle ranges which were 15 %-57 % of the median of the manually stimulated movement. Strong positive correlations between angle ranges of the electrically generated movement were found for the hind limbs implicating their involvement in the movement created. Correlations between skinfold thickness, body condition score, and body mass with the angle ranges were weak and not significant. Before and after electrical and manual stimulation, muscle tone and lameness were similar. In the present study, both electrical and manual stimulation were proven to produce significant trunk and hind limb movement. Within this study's electrical stimulation treatment protocol, the movement generated by electrical stimulation was significantly less than the movement caused by manual pelvic inclination. However, electrical stimulation could easily be applied over a longer period and in a higher frequency than it would be possible for manual pelvic inclination. This treatment shows potential for stabilization and or mobilization of the lumbosacral region, although its efficiency as a therapeutic tool and its effect on specific orthopedic problems and is to be evaluated in further research.

Randomized comparison of functional electric stimulation in posturally corrected position and motor program activating therapy: treating foot drop in people with multiple sclerosis

BACKGROUND

Functional electric stimulation (FES) is recommended for foot drop in multiple sclerosis, although little is known about its therapeutic effect.

AIM

The aim of this study is to evaluate a therapeutic effect immediately and two months after program termination (persistent and delayed effect) of a new approach using FES in combination with correcting the patients' postural system. More specifically, we evaluate the effects of this approach on the patients' clinical functions and compared it with individual physiotherapy.

DESIGN

Parallel randomized blind trial.

SETTING

Two-month-long treatments, functional electric stimulation in posturally corrected position (group 1) and neuroproprioceptive facilitation and inhibition physiotherapy called motor program activating therapy (group 2).

POPULATION

Forty-four subjects with multiple sclerosis.

METHODS

Primary outcomes: gait (the 2-Minute Walk Test; Timed 25-Foot Walk test; Multiple Sclerosis Walking Scale-12) and balance (by e.g. Berg Balance Scale [BBS], the Activities-Specific Balance Confidence Scale [ABC], Timed Up-and-Go Test [TUG]).

SECONDARY OUTCOMES

mobility, cognition, fatigue and subjects' perceptions (e.g. Multiple Sclerosis Impact Scale [MSIS], Euroqol-5 dimensions-5 levels [EQ-5D-5L]).

RESULTS

Group 1 showed immediate therapeutic effect in BBS (P=0.008), ABC (P=0.04) and EQ-5D-5L (self-care, P=0.019, mobility P=0.005). The improvement in EQ-5D-5L persisted and in TUG-cognitive we documented a delayed effect (P=0.005). Group 2 showed an immediate improvement in BBS (P=0.025), MSIS (P=0.043) and several aspects of daily life (the effect on health today was significantly higher than in group 1, significant difference between groups P=0.038).

CONCLUSIONS

FES in the posturally corrected position has an immediate therapeutic effect on balance and patients' perceptions comparable to motor program activating therapy, and higher persistent and even delayed therapeutic effect.

CLINICAL REHABILITATION IMPACT

The study results point to the importance of correcting the patients' posture when applying FES, the possibility to treat foot drop by individual physiotherapy and the activation of the patients' auto reparative processes.

Sempere Á, Vera-Garcia FJ, Barbado D. Understanding the Deterioration of Gait, Postural Control, Lower Limb Strength and Perceived Fatigue Across the Disability Spectrum of People with Multiple Sclerosis

Disability progression is a prominent feature of multiple sclerosis (MS). However, little is known about the extent to which physical condition parameters and perceived fatigue evolve during the disease. We analyzed how strength, balance, core stability and perceived fatigue differ among different cohorts of people with MS (PwMS) with different disability degrees and how these contribute to patients' gait speed and functional mobility. Sixty-three PwMS divided into three groups according to the "Expanded Disability Status Scale" (MS1: EDSS ≤ 1.5; MS2: 2 ≤ EDSS ≤ 3.5; MS3: 4 ≤ EDSS ≤ 6) and 22 healthy controls (HC) participated in this study. MS1 showed lower balance and hip strength compared to HC. MS2 showed lower balance, core stability, gait speed, and functional mobility than MS1. MS3 showed lower gait speed, functional mobility, balance, and knee flexion strength than MS2. No between-group differences were observed in perceived fatigue. Relative weight analysis showed that strength, balance and core stability explained 60%-70% of the variance in gait speed and functional mobility. The decline of each parameter did not evolve at the same rate across the different stages of the disease, being knee flexion strength and balance the most influential factors in the disability progression. Overall, these results provide useful information to guide exercise prescription at different stages of MS.

Effect of remote ischaemic preconditioning on walking in people with multiple sclerosis: double-blind randomised controlled trial

Background

Remote ischaemic preconditioning (RIPC) is the exposure of body parts to brief periods of circulatory occlusion and reperfusion. Recent studies have also shown that RIPC can improve exercise performance in healthy individuals.

Objective

This study aimed to assess the effect of RIPC on walking in people with multiple sclerosis (MS).

Methods

This was a double-blind randomised controlled clinical trial. We used three cycles of RIPC delivered by occluding the upper arm with a blood pressure (BP) cuff inflated to a pressure of 30 mm Hg above the systolic BP. In patients in the sham intervention group, the BP cuff was inflated only to 30 mm Hg below diastolic BP. Outcome measures included the Six-Minute Walk Test (6MWT), gait speed, the Borg rate of perceived exertion (RPE) scale, the tolerability of the RIPC using a Numerical Rating Scale for discomfort from 0 to 10, and adverse events. We identified responders meeting the minimal clinically important difference (MCID) established in the literature in each group.

Results

Seventy-five participants completed the study (RIPC: 38 and Sham: 37). The distance walked during the 6MWT improved by 1.9% in the sham group and 5.7% in the RIPC group (p=0.012). The number of responders meeting MCID criteria in the RIPC group was significantly greater compared with the sham intervention group. No serious adverse events occurred.

Conclusion

Single cycle of RIPC resulted in immediate improvement in walking distances during 6MWT in people with MS.

Trial registration numbers

NCT03153553

Electrical Stimulation of Muscle: Electrophysiology and Rehabilitation

The generation of action potentials in intramuscular motor and sensory axons in response to an imposed external current source can evoke muscle contractions and elicit widespread responses throughout the nervous system that impact sensorimotor function. The benefits experienced by individuals exposed to several weeks of treatment with electrical stimulation of muscle suggest that the underlying adaptations involve several physiological systems, but little is known about the specific changes elicited by such interventions.

Evaluating the Effect of Functional Electrical Stimulation Used for Foot Drop on Aspects of Health-Related Quality of Life in People with Multiple Sclerosis: A Systematic Review

Background

Multiple sclerosis (MS) is a common degenerative neurologic condition resulting in walking difficulties. Foot drop is a common walking impairment in MS that can affect health-related quality of life (HRQOL). Functional electrical stimulation (FES) can improve walking in people with MS, but its effect on HRQOL is not well established. This review investigated the effect of FES used for foot drop on HRQOL in adults with MS.

Methods

A systematic search was performed using CINAHL, MEDLINE, Cochrane Library, PubMed, and PEDro online databases. Inclusion and exclusion criteria were applied to select eligible studies. Data were extracted, and two reviewers independently rated the quality of the studies using the Effective Public Health Practice Project assessment tool.

Results

Eight studies were eligible for review; seven were of moderate-to-strong methodological quality and one was weak. Seven studies demonstrated significant positive effects of FES on different aspects of HRQOL as measured by the 29-item Multiple Sclerosis Impact Scale, 36-item Short Form Health Status Survey, Canadian Occupational Performance Measure, and Psychosocial Impact of Assistive Devices Scale.

Conclusions

This review provides preliminary evidence that FES has a positive effect on aspects of HRQOL in people with MS; however, the variety of HRQOL outcomes used makes it difficult to determine definitive conclusions. Future larger-scale randomized studies with long-term follow-up are recommended to better understand the effect of FES on HRQOL. This will inform prescribing decisions and support compliance with FES over the longer-term.

Long-term outcomes of semi-implantable functional electrical stimulation for central drop foot

Background

Central drop foot is a common problem in patients with stroke or multiple sclerosis (MS). For decades, it has been treated with orthotic devices, keeping the ankle in a fixed position. It has been shown recently that semi-implantable functional electrical stimulation (siFES) of the peroneal nerve can lead to a greater gait velocity increase than orthotic devices immediately after being switched on. Little is known, however, about long-term outcomes over 12 months, and the relationship between quality of life (QoL) and gait speed using siFES has never been reported applying a validated tool. We provide here a report of short (3 months) and long-term (12 months) outcomes for gait speed and QoL.

Methods

Forty-five consecutive patients (91% chronic stroke, 9% MS) with central drop foot received siFES (Actigait®). A 10 m walking test was carried out on day 1 of stimulation (T1), in stimulation ON and OFF conditions, and repeated after 3 (T2) and 12 (T3) months. A 36-item Short Form questionnaire was applied at all three time points.

Results

We found a main effect of stimulation on both maximum (p < 0.001) and comfortable gait velocity (p < 0.001) and a main effect of time (p = 0.015) only on maximum gait velocity. There were no significant interactions. Mean maximum gait velocity across the three assessment time points was 0.13 m/s greater with stimulation ON than OFF, and mean comfortable gait velocity was 0.083 m/s faster with stimulation ON than OFF. The increase in maximum gait velocity over time was 0.096 m/s, with post hoc testing revealing a significant increase from T1 to T2 (p = 0.012), which was maintained but not significantly further increased at T3. QoL scores showed a main effect of time (p < 0.001), with post hoc testing revealing an increase from T1 to T2 (p < 0.001), which was maintained at T3 (p < 0.001). Finally, overall absolute QoL scores correlated with the absolute maximum and comfortable gait speeds at T2 and T3, and the increase in overall QoL scores correlated with the increase in comfortable gait velocity from T1 to T3. Pain was reduced at T2 (p < 0.001) and was independent of gait speed but correlated with overall QoL (p < 0.001).

Conclusions

Peroneal siFES increased maximal and comfortable gait velocity and QoL, with the greatest increase in both over the first three months, which was maintained at one year, suggesting that 3 months is an adequate follow-up time. Pain after 3 months correlated with QoL and was independent of gait velocity, suggesting pain as an independent outcome measure in siFES for drop foot.

The clinical- and cost-effectiveness of functional electrical stimulation and ankle-foot orthoses for foot drop in Multiple Sclerosis: a multicentre randomized trial

OBJECTIVE

To compare the clinical- and cost-effectiveness of ankle-foot orthoses (AFOs) and functional electrical stimulation (FES) over 12 months in people with Multiple Sclerosis with foot drop.

DESIGN

Multicentre, powered, non-blinded, randomized trial.

SETTING

Seven Multiple Sclerosis outpatient centres across Scotland.

SUBJECTS

Eighty-five treatment-naïve people with Multiple Sclerosis with persistent (>three months) foot drop.

INTERVENTIONS

Participants randomized to receive a custom-made, AFO (n = 43) or FES device (n = 42).

OUTCOME MEASURES

Assessed at 0, 3, 6 and 12 months; 5-minute self-selected walk test (primary), Timed 25 Foot Walk, oxygen cost of walking, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, Modified Fatigue Impact Scale, Euroqol five-dimension five-level questionnaire, Activities-specific Balance and Confidence Scale, Psychological Impact of Assistive Devices Score, and equipment and National Health Service staff time costs of interventions.

RESULTS

Groups were similar for age (AFO, 51.4 (11.2); FES, 50.4(10.4) years) and baseline walking speed (AFO, 0.62 (0.21); FES 0.73 (0.27) m/s). In all, 38% dropped out by 12 months (AFO, n = 21; FES, n = 11). Both groups walked faster at 12 months with device (P < 0.001; AFO, 0.73 (0.24); FES, 0.79 (0.24) m/s) but no difference between groups. Significantly higher Psychological Impact of Assistive Devices Scores were found for FES for Competence (P = 0.016; AFO, 0.85(1.05); FES, 1.53(1.05)), Adaptability (P = 0.001; AFO, 0.38(0.97); FES 1.53 (0.98)) and Self-Esteem (P = 0.006; AFO, 0.45 (0.67); FES 1 (0.68)). Effects were comparable for other measures. FES may offer value for money alternative to usual care.

CONCLUSION

AFOs and FES have comparable effects on walking performance and patient-reported outcomes; however, high drop-outs introduces uncertainty.

A cohort study of functional electrical stimulation in people with multiple sclerosis demonstrating improvements in quality of life and cost-effectiveness

OBJECTIVE

The objective of this study was to determine the impact on health-related quality of life of functional electrical stimulation used to improve walking in people with multiple sclerosis and to explore cost-effectiveness.

DESIGN

A retrospective analysis of patient records was conducted.

SETTING

This study used outpatient therapy service as the study setting.

SUBJECTS

Data from 82 consecutive patients with multiple sclerosis attending for set up with functional electrical stimulation were analysed.

INTERVENTIONS

Patients were seen at baseline, three and six months for support in use of functional electrical stimulation, and data were collected at baseline and six months.

MAIN MEASURES

The EQ-5D-5L and walking speed were collected at baseline and six months after using functional electrical stimulation. The Psychosocial Impact of Assistive Device Scale was collected at six months. EQ-5D-3L utilities were derived and cost-effectiveness analysis was completed utilizing a five-year time horizon and methodology published by National Institute for Health and Care Excellence.

RESULTS

Significant differences (P < 0.001) were seen in walking speed (baseline 0.670 m/s; with stimulation 0.768 m/s) and maintained over six months (0.772 m/s with stimulation). EQ-5D data significantly improved over six months (baseline 0.486, six months 0.596, P < 0.001) and meaningful mean scores were seen in all aspects of the Psychosocial Impact of Assistive Device Scale. However, there were no correlations between measures. In the cost utility analysis, compared to standard care, functional electrical stimulation was more expensive and more effective with an incremental cost-effectiveness ratio of £6137.

CONCLUSION

Functional electrical stimulation is a cost-effective treatment to improve walking speed and health-related quality of life in people with multiple sclerosis.

An exploration of the experiences and utility of functional electrical stimulation for foot drop in people with multiple sclerosis

Purpose: Functional electrical stimulation (FES) is effective in improving walking in people with multiple sclerosis (MS) with foot drop. There is limited research exploring people's experiences of using this device. This study aims to explore the utility, efficacy, acceptability, and impact on daily life of the device in people with MS.Methods: An interpretative phenomenological approach was employed. Ten participants who had used FES for 12 months were interviewed. Transcripts were analysed, and emergent themes identified.Results: Nine participants continued to use the device. Three relevant super-ordinate themes were identified; impact of functional electrical stimulation, sticking with functional electrical stimulation, and autonomy and control. Participants reported challenges using the device; however, all reported positive physical and psychological benefits. Intrinsic and external influences such as; access to professional help, the influence of others, an individual's ability to adapt, and experiences using the device, influenced their decisions to continue with the device. A thematic model of these factors was developed.Conclusions: This study has contributed to our understanding of people with MS experiences of using the device and will help inform prescribing decisions and support the continued, appropriate use of FES over the longer term.Implications for RehabilitationPeople with multiple sclerosis using functional electrical stimulation report benefits in many aspects of walking, improved psychological well-being and increased engagement in valued activities.A number of challenges impact on functional electrical stimulation use. Factors such as; a positive experience using the device, access to professional help, the influence of others, a strong sense of personal autonomy and an individual's ability to adapt, influence an individual's decision to continue using functional electrical stimulation.Clinicians prescribing functional electrical stimulation should be aware of these factors so that the right support and guidance can be provided to people with multiple sclerosis, thus improving outcomes and compliance over the long term.

A comparison of the initial orthotic effects of functional electrical stimulation and ankle-foot orthoses on the speed and oxygen cost of gait in multiple sclerosis

Background

Foot drop affects walking in people with multiple sclerosis (pwMS). This study compares the initial orthotic effects of two treatments for foot drop: ankle-foot orthoses (AFO) and functional electrical stimulation (FES), on the speed and oxygen cost of walking in MS.

Method and materials

Seventy-eight pwMS were randomised to receive AFO or FES (ODFS PACE (OML, Salisbury, UK)). Participants completed the 25-ft walk test (25ftWT) and 5-min self-selected walk test (5minSSWT), from which oxygen cost was determined, with and without their device. Between-, within- and sub-group analyses (based on baseline walking speed of <0.8 m/s (slow) or ≥0.8 m/s (fast)) were undertaken.

Results

No significant differences between baseline measures were observed. The AFO group walked significantly slower than the FES group (5minSSWT, p = 0.037, 0.11 m/s). The AFO group walked significantly slower with than without AFO (25ftWT, p = 0.037), particularly in the fast-walking group ( p = 0.011). The slow-walking FES group walked significantly faster with FES than without (25ftWT; p = 0.029, 5minSSWT; p = 0.037). There were no differences in the fast-walking FES group or in the oxygen cost for either device.

Conclusion

AFO reduced walking speed, particularly in fast walkers. FES increased walking speed in slow, but not fast walkers.

The Effects of Aerobic Exercise on the Recovery of Walking Ability and Neuroplasticity in People with Multiple Sclerosis: A Systematic Review of Animal and Clinical Studies

INTRODUCTION

Walking is of high priority for people with multiple sclerosis (PwMS). It remains unclear whether aerobic exercise can improve walking ability and upregulate neurotrophins. This review aims to consolidate evidence to develop optimal aerobic training parameters to enhance walking outcomes and neuroplasticity in PwMS.

METHODS

Clinical studies examining aerobic exercise for ≥3 weeks, having outcomes on walking with or without neurotrophic markers, were included. Studies utilizing animal models of MS were included if they employed aerobic exercise with outcomes on neurological recovery and neurotrophins. From a total of 1783 articles, 12 clinical and 5 animal studies were included.

RESULTS

Eleven clinical studies reported improvements in walking ability. Only two clinical studies evaluated both walking and neurotrophins, and neither found an increase in neurotrophins despite improvements in walking. Patients with significant walking impairments were underrepresented. Long-term follow-up revealed mixed results. Two animal studies reported a positive change in both neurological recovery and neurotrophins.

CONCLUSION

Aerobic exercise improves walking ability in PwMS. Gains are not consistently maintained at 2- to 9-month follow-up. Studies examining levels of neurotrophins are inconclusive, necessitating further research. Aerobic exercise enhances both neurological recovery and neurotrophins in animal studies when started 2 weeks before induction of MS.

Management of the symptoms of multiple sclerosis using functional electrical stimulation and exercise

Previously, it was believed that exercise-related activity was likely to lead to the symptoms of multiple sclerosis (MS) becoming worse. More recently, it has been acknowledged that the consequences of not exercising are detrimental and may exacerbate symptoms of MS. In addition, it has been recognized that some of the disability that occurs after MS is likely to be due to deconditioning from a reduction in physical activity. The current paper will explore the potential role of functional electrical stimulation of the peroneal nerve, for facilitating neurorehabilitation, through increasing mobility and overcoming barriers to accessing exercise. The paper will also examine the impact of using exercise-related activity to manage the symptoms of MS along with the potential neuroprotective effects.

Effects of a multimodal intervention on gait and balance of subjects with progressive multiple sclerosis: a prospective longitudinal pilot study

PURPOSE

To investigate the effects of a multimodal intervention including a modified Paleolithic diet, nutritional supplements, stretching, strengthening exercises with electrical stimulation of trunk and lower limb muscles, meditation and massage on walking performance and balance of subjects with progressive multiple sclerosis (MS).

MATERIALS AND METHODS

Twenty subjects with mean (standard deviation) age of 51.7 (6.4) years and Expanded Disability Status Scale score of 6.2 (1) participated in a 12-month study. Assessments were completed at baseline, 3, 6, 9, and 12 months.

RESULTS

The entire cohort did not show significant changes in any of the assessments over 12 months except higher speed of walking toward the 10 feet mark during timed up and go (TUG) test at 6 months compared with baseline (mean change 7.9 cm/s [95% confidence interval {CI}]: 0.3, 15.2; p=0.041). Sub-group analysis revealed that 50% subjects (n=10) showed decrease in TUG time from baseline to at least 3 of 4 time-points post-intervention and were considered as responders (TUG-Res), the remaining 10 subjects were considered as nonresponders (TUG-NRes). Over 12 months, TUG-Res showed decreased mean TUG time by 31% (95% CI: -52%, -2%), increased median Berg Balance Scale scores (42 to 47), 30% increase in mean timed 25-foot walk speed (>20% considered clinically significant) and increased speed of walk toward 10 feet mark during TUG by 11.6 cm/s (95% CI: -3.0, 25.9) associated with increases in step lengths and decrease in step duration. TUG-NRes showed deterioration in walking ability over 12 months. Comparison of TUG-Res and TUG-NRes showed no significant differences in adherence to intervention but better stride duration and longer step length at baseline for TUG-Res than for TUG-NRes (p<0.05).

CONCLUSION

A multimodal lifestyle intervention may improve walking performance and balance in subjects with progressive MS who have mild-to-moderate gait impairment, whereas subjects with severe gait impairments may not respond to this intervention. Future trials should assess effects of this intervention in subjects with MS during early stages of the disease.