Effect of a 2-week trial of functional electrical stimulation on gait function and quality of life in people with multiple sclerosis

Feasibility of Telerehabilitation-Monitored Functional Electrical Stimulation on Walking and Quality of Life in People With Multiple Sclerosis: A Case Series

BACKGROUND

Foot drop in people with multiple sclerosis (MS) commonly leads to decreased mobility and quality of life (QOL). Functional electrical stimulation (FES) of the peroneal nerve can improve the gait of people with foot drop, yet various barriers restrict widespread use. The purpose of this case series was to examine the feasibility of a telerehabilitation-monitored FES device and report changes in functional mobility and QOL in people with moderate MS-related disability.

METHODS

FES use was progressed over 8 weeks via 3 telerehabilitation sessions. Feasibility of telerehabilitation was assessed by percentage of telerehabilitation visits completed and participant-reported satisfaction. At baseline and study completion, functional mobility with and without FES were assessed by the Timed 25-Foot Walk (T25FW), Timed Up and Go (TUG), and 2-Minute Walk Test (2MWT), Multiple Sclerosis Impact Scale (MSIS-29), and the 12-item Multiple Sclerosis Walking Scale (MSWS-12). Fatigue was assessed via the Modified Fatigue Impact Scale (MFIS) before and after the intervention.

RESULTS

Eleven participants (mean age = 50.4 years [SD 10.8]; 2 males) completed the study. All (33/33) telerehabilitation visits were completed and participants attained high levels of satisfaction with no adverse events. At 8 weeks, compared to baseline, there were clinically meaningful improvements on the T25FW, 2MWT, and TUG for 45%, 55%, and 82% of participants, respectively. Clinically meaningful improvements on the MSIS-29 and MSWS-12 were also recorded for 64% and 36% of participants, respectively.

CONCLUSIONS

Telerehabilitation was safe and feasible for FES intervention, and improvements in functional mobility and QOL were observed. Telerehabilitation to monitor FES may improve access and reduce patient burden; therefore, studying its efficacy is warranted.

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.

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.

Experiences of individuals with multiple sclerosis and stroke using transcutaneous foot drop electrical stimulators: a systematic review and meta-synthesis of qualitative studies

PURPOSE

To explore the end users' experiences of foot drop electrical stimulator use for people with neurological conditions.

MATERIALS AND METHODS

Electronic databases MEDLINE, EMBASE, CINAHL, Scopus, and Google Scholar were searched in March 2022. Included articles were quality assessed using the Critical Appraisal Skills Programme (CASP) checklist. A thematic synthesis approach was used to synthesise the review findings and establish analytical themes. A Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach was used to assess the level of confidence of analytical themes.

RESULTS

Seven qualitative studies were included with 67 participants with stroke and multiple sclerosis. The outcomes to foot drop stimulator use were enhanced walking ability, independence, confidence, and social participation. Main barriers to use were device aesthetics, usability challenges, trustworthiness of device in complex environments, and cost of the device. A conceptual model was created illustrating the barriers and outcomes in managing foot drop.

CONCLUSIONS

We recommend that the outcomes to continued use of foot drop electrical stimulators are carefully considered against the barriers. Our conceptual model may be useful to guide clinical conversations around the possible use of FES for managing foot drop in people with multiple sclerosis and stroke.Implications for rehabilitationThe key outcomes to foot drop electrical stimulator use were enhanced walking ability, improved independence and confidence, and enhanced social participation.The main barriers to foot drop electrical stimulator use were device aesthetics, usability challenges, trustworthiness of device in complex environments, and cost of the device.We created a conceptual model that may be useful to guide clinical conversations around the possible use of FES for managing foot drop in people with multiple sclerosis and stroke.

Retention of Physical Gains in the Community Following Physical Training for Multiple Sclerosis: A Systematic Review and Implications

Multiple sclerosis (MS) is a progressive neurological illness whose typically young adult onset results in a nearly entire lifetime of worsening disability. But despite being an unrelenting neurodegenerative disease, numerous clinical trials over the past 40 years for MS have vigorously attempted to improve or at least stabilize declining physical function. Although the vast majority of the studies assessed training effects only within controlled laboratory or clinic settings, in recent years a growing interest has emerged to test whether newer therapies can instead benefit real-life activities in the community. Nonetheless, comparatively little attention has been paid to whether the training gains can be retained for meaningful periods. This review discusses the comparative success of various physical training methods to benefit within-community activities in MS, and whether the gains can be retained long afterward. This review will suggest future research directions toward establishing efficacious treatments that can allow persons with MS to reclaim their physical abilities and maximize functionality for meaningful periods.

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.

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.

Advances in neuroprosthetic management of foot drop: a review

This paper reviews the technological advances and clinical results obtained in the neuroprosthetic management of foot drop. Functional electrical stimulation has been widely applied owing to its corrective abilities in patients suffering from a stroke, multiple sclerosis, or spinal cord injury among other pathologies. This review aims at identifying the progress made in this area over the last two decades, addressing two main questions: What is the status of neuroprosthetic technology in terms of architecture, sensorization, and control algorithms?. What is the current evidence on its functional and clinical efficacy? The results reveal the importance of systems capable of self-adjustment and the need for closed-loop control systems to adequately modulate assistance in individual conditions. Other advanced strategies, such as combining variable and constant frequency pulses, could also play an important role in reducing fatigue and obtaining better therapeutic results. The field not only would benefit from a deeper understanding of the kinematic, kinetic and neuromuscular implications and effects of more promising assistance strategies, but also there is a clear lack of long-term clinical studies addressing the therapeutic potential of these systems. This review paper provides an overview of current system design and control architectures choices with regard to their clinical effectiveness. Shortcomings and recommendations for future directions are identified.

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.

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.

Neuromodulation in multiple sclerosis

Neuromodulation, or the utilization of advanced technology for targeted electrical or chemical neuronal stimulation or inhibition, has been expanding in several neurological subspecialties. In the past decades, immune-modulating therapy has been the main focus of multiple sclerosis (MS) research with little attention to neuromodulation. However, with the recent advances in disease-modifying therapies, it is time to shift the focus of MS research to neuromodulation and restoration of function as with other neurological subspecialties. Preliminary research supports the value of intrathecal baclofen pump and functional electrical stimulation in improving spasticity and motor function in MS patients. Deep brain stimulation can improve MS-related tremor and trigeminal neuralgia. Spinal cord stimulation has been shown to be effective against MS-related pain and bladder dysfunction. Bladder overactivity also responds to sacral neuromodulation and posterior tibial nerve stimulation. Despite limited data in MS, transcranial magnetic stimulation and brain-computer interface are promising neuromodulatory techniques for symptom mitigation and neurorehabilitation of MS patients. In this review, we provide an overview of the available neuromodulatory techniques and the evidence for their use in MS.

Effects of functional electrical stimulation on gait in people with multiple sclerosis - A systematic review

BACKGROUND

Functional electrical stimulation (FES) is commonly used to ameliorate gait deficits in patients with multiple sclerosis (PwMS). This review critically evaluates the literature describing the orthotic and therapeutic effects of FES on gait in PwMS.

METHODS

The PubMed, CINAHL, and ProQuest databases were searched. Included were studies that evaluated therapeutic and/or orthotic effects of FES in PwMS with at least one outcome measure related to gait. Methodology was assessed using the Downs and Black checklist.

RESULTS

Twelve relevant studies were reviewed. Their methodological quality ranged from 14 to 21 of 28. Eleven studies reported the effects of peroneal stimulation. Most found a significant orthotic effect (measured during stimulation), mainly on walking speed. Only three assessed the therapeutic effect (carry-over), which was not significant.

CONCLUSIONS

The evidence presented in this review suggests that FES has a positive orthotic effect on walking in PwMS. Yet, more robust trials are needed to substantiate this finding. Therapeutic efficacy of FES was not demonstrated, and almost all studies tested a single channel peroneal stimulator. Future studies involving FES technological innovations with advanced clinical approaches might contribute to a carry-over effect from FES and increase the percentage of PwMS who benefit from this technology.

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

OBJECTIVE

To review the efficacy of functional electrical stimulation (FES) used for foot drop in people with multiple sclerosis (pwMS) on gait speed in short and long walking performance tests.

DATA SOURCES

Five databases (Cochrane Library, CINAHL, Embase, MEDLINE, and PubMed) and reference lists were searched.

STUDY SELECTION

Studies of both observational and experimental design where gait speed data in pwMS could be extracted were included.

DATA EXTRACTION

Data were independently extracted and recorded. Methodologic quality was assessed using the Effective Public Health Practice Project tool.

DATA SYNTHESIS

Nineteen studies (described in 20 articles) recruiting 490 pwMS were identified and rated as moderate or weak, with none gaining a strong rating. All studies rated weak for blinding. Initial and ongoing orthotic and therapeutic effects were assessed regarding the effect of FES on gait speed in short and long walking tests. Meta-analyses of the short walk tests revealed a significant initial orthotic effect (t=2.14, P=.016), with a mean increase in gait speed of .05m/s, and ongoing orthotic effect (t=2.81, P=.003), with a mean increase of .08m/s. There were no initial or ongoing effects on gait speed in long walk tests and no therapeutic effect on gait speed in either short or long walk tests.

CONCLUSIONS

FES used for foot drop has a positive initial and ongoing effect on gait speed in short walking tests. Further fully powered randomized controlled trials comparing FES with alternative treatments are required.