Surface-applied functional electrical stimulation for orthotic and therapeutic treatment of drop-foot after stroke – a systematic review

Abstract

Objectives: Drop-foot when incurred as a deficit post-stroke significantly contributes to the development of physical disability and social restriction. The condition is most commonly treated using a custom moulded ankle foot orthosis (AFO) or functional electrical stimulation (FES). No previous systematic review has assessed the evidence for both an orthotic (while the device is still on) and therapeutic (when the device is no longer worn) effect of FES, including all types of methodology and outcome measure. This is certainly a gap in the literature in terms of informing the practising clinician. Methods: A systematic search was conducted to identify all articles published between 1990 and 2008 relating to the effectiveness of FES for the treatment of drop-foot post-stroke using strict inclusion/exclusion criteria. Included literature was quality-appraised according to the Guidelines for Cochrane reviewers. Results: Thirty studies were analysed (264 excluded) and results support the conclusion that FES can have a positive orthotic effect particularly for gait speed and physiological cost index (PCI), in chronic post-stroke patients. Research supporting a therapeutic effect of FES post-stroke is less conclusive. Some support exists for FES in combination with 'conventional rehabilitation' or treadmill training or for increasing the effectiveness of Botulinum toxin injections. Discussion: While more evidence exists to support an orthotic than therapeutic effect of FES, further research is needed to define the extent of a therapeutic effect (particularly in acute patients) and compare the efficacy of FES with an AFO. More standardisation of protocols and a more collaborative approach between engineers, researchers, clinicians and users is required.Post-stroke drop-foot results when the normal interplay between tibialis anterior and triceps surae muscle is disturbed as a result of spasticity in the posterior muscle group (exacerbated by tendon shortening over time) and a weakness of the tibialis anterior and the peroneii muscles. 1 Drop-foot contributes significantly to the residual disabilities incurred as a result of stroke and publications have quoted a conservative estimate of between 18 and 20% as a residual deficit. 2,3 Functional electrical stimulation (FES) is designed to deliver goal-orientated, active repetitive movement training without the constant need for direct therapist input. It is therefore ideally placed to facilitate the neuroscientific principle of motor relearning (in having a carry-over effect) whilst providing an

A feasibility study to investigate the clinical application of functional electrical stimulation (FES), for dropped foot, during the sub-acute phase of stroke – A randomized controlled trial

“…Future studies should consider screening for these issues to assess their impact on the use of FES. Roche, Laighin and Coote, 2009 highlighted the need for further evidence to inform the selection of candidates for FES at this stage of recovery and this study contributes further knowledge which could be explored in more depth in larger studies.…”

“…Some authors have highlighted the potential of FES to influence neuroplasticity [Burridge and Ladoucer, 2001;Roche, Laighin and Coote, 2009] during the early phase of recovery after stroke and these findings warrant the further investigation of the therapeutic effect of FES in the sub-acute phase of recovery.…”

“…Evidence has emerged in recent years about the efficacy of FES in chronic stroke patients (>6 months post stroke) [Taylor et al, 1999a;Taylor et al, 1999b;Burridge, 2001;Penta et al, 2001;Kottink et al, 2004;Robbins, Houghton, Woodbury and Brown, 2006 ;Laufer, Hausdorff and Ring, 2009;NICE, 2009;Roche, Laighin and Coote, 2009;States, Salem, Pappas, 2009]. This evidence base has reported the positive benefits of FES including; reduction in energy expenditure, increased gait velocity, decreased falls and improved quality of life.…”

“…These physical measures should be considered as secondary outcomes. [Forlander and Bohannon, 1999] Inclusion of measures of quality of life in studies evaluating FES have been recommended [Roche, Laighin and Coote, 2009] and the SIS was collected in this study. The SIS can provide detailed information about the impact of the intervention on health related quality of life.…”

“…A number of authors [Granat et al, 1996;Robbins, Houghton, Woodbury and Brown, 2006;Roche, Laighin and Coote, 2009] have hypothesised that the benefits of FES, demonstrated in chronic stroke populations, may be replicated in the early phase of recovery after stroke. Granat et al, 1996, proposed that the application of FES in the more acute setting may prevent abnormal gait problems becoming established in the longer term.…”