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.

Web-based physiotherapy for people affected by multiple sclerosis: a single blind, randomized controlled feasibility study

Objective:

To examine the feasibility of a trial to evaluate web-based physiotherapy compared to a standard home exercise programme in people with multiple sclerosis.

Design:

Multi-centre, randomized controlled, feasibility study.

Setting:

Three multiple sclerosis out-patient centres.

Participants:

A total of 90 people with multiple sclerosis (Expanded Disability Status Scale 4–6.5).

Interventions:

Participants were randomized to a six-month individualized, home exercise programme delivered via web-based physiotherapy ( n = 45; intervention) or a sheet of exercises ( n = 45; active comparator).

Outcome measures:

Outcome measures (0, three, six and nine months) included adherence, two-minute walk test, 25 foot walk, Berg Balance Scale, physical activity and healthcare resource use. Interviews were undertaken with 24 participants and 3 physiotherapists.

Results:

Almost 25% of people approached agreed to take part. No intervention-related adverse events were recorded. Adherence was 40%–63% and 53%–71% in the intervention and comparator groups. There was no difference in the two-minute walk test between groups at baseline (Intervention-80.4(33.91)m, Comparator-70.6(31.20)m) and no change over time (at six-month Intervention-81.6(32.75)m, Comparator-74.8(36.16)m. There were no significant changes over time in other outcome measures except the EuroQol-5 Dimension at six months which decreased in the active comparator group. For a difference of 8(17.4)m in two-minute walk test between groups, 76 participants/group would be required (80% power, P > 0.05) for a future randomized controlled trial.

Conclusion:

No changes were found in the majority of outcome measures over time. This study was acceptable and feasible by participants and physiotherapists. An adequately powered study needs 160 participants.

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.

Access to and Use of Clinical Services and Disease-Modifying Therapies by People with Progressive Multiple Sclerosis in the United Kingdom

Background

According to current UK guidelines, everyone with progressive multiple sclerosis (MS) should have access to an MS specialist, but levels of access and use of clinical services is unknown. We sought to investigate access to MS specialists and use of clinical services and disease-modifying therapies (DMTs) by people with progressive MS in the United Kingdom.

Methods

A UK-wide online survey was conducted via the UK MS Register. The inclusion criteria were age 18 years or older, primary or secondary progressive MS, and a member of the UK MS Register. Participants were asked about access to MS specialists, recent clinical service use, receipt of regular review, and current and previous DMT use. Participant demographic data, quality of life, and disease impact measures were from the UK MS Register.

Results

In total, 1298 individuals responded: 7% were currently taking a DMT, 23% had previously taken a DMT, and 95% reported access to an MS specialist. The most used practitioners were MS doctors/nurses (50%), general practitioners (45%), and physiotherapists (40%). Seventy-four percent of participants received a regular review, although 37% received theirs less often than annually. Current DMT use was associated with better quality of life, but past DMT use was associated with poorer quality of life and higher impact of disease.

Conclusions

Access to and use of MS specialists was high. However, a gap in service provision was highlighted in both receipt and frequency of regular reviews.

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.

The impact of walking speed on the effects of functional electrical stimulation for foot drop in people with multiple sclerosis

PURPOSE

Functional electrical stimulation (FES) is effective in assisting people with multiple sclerosis (pwMS) with gait. Previous studies have investigated the effects of FES in pwMS with slow self-selected walking speeds (SSWS). This study reports on the effect of the Odstock Dropped Foot Stimulator (ODFS) on the speed and oxygen (O2) cost of gait in pwMS walking at a range of SSWS.

METHODS

Twenty pwMS (mean age 50.4 ± 7.3 years) currently using FES walked at their SSWS for 5 min with and without FES. O2 cost of gait was measured using a gas analysis system, and gait speed was calculated. Data were analysed for all participants, and comparisons were made between those with a SSWS < and >0.8 m/s (walking speed required for community ambulation).

RESULTS

Significant improvements in the speed and O2 cost of gait were seen using FES in the group with SSWS <0.8 m/s (n = 11, p = 0.005). When participants' SSWS >0.8 m/s, no difference in gait speed was noted, and a significant increase in O2 cost of gait using FES (n = 9, p = 0.004) was noted.

CONCLUSION

FES has a different effect on the speed and O2 cost of gait dependent on the SSWS of pwMS. This requires further investigation. Implications for Rehabilitation Functional electrical stimulation (FES) used for foot drop is effective in improving the speed and oxygen cost of walking in pwMS walking at SSWS <0.8 m/s. FES does not seem to have a beneficial effect on the speed and oxygen cost of walking in pwMS walking at SSWS >0.8 m/s. Further research is needed to understand the possible mechanisms involved so that FES for foot drop can be efficiently prescribed.

Short-term effect of aerobic exercise on symptoms in multiple sclerosis and chronic fatigue syndrome: a pilot study

BACKGROUND

This pilot study was conducted to determine whether a 15-minute bout of moderate-intensity aerobic cycling exercise would affect symptoms (pain and fatigue) and function (Timed 25-Foot Walk test [T25FW] and Timed Up and Go test [TUG]) in people with multiple sclerosis (MS) or chronic fatigue syndrome (CFS), and to compare these results with those of a healthy control group.

METHODS

Eight people with MS (Expanded Disability Status Scale score 5-6; Karnofsky score 50-80), eight people with CFS (Karnofsky score 50-80), and eight healthy volunteers participated in the study. Pain and fatigue levels and results of the T25FW and TUG were established at baseline as well as at 30 minutes, 2 hours, and 24 hours following a 15-minute stationary cycling aerobic exercise test. Repeated-measures analysis of variance (ANOVA) and covariance (ANCOVA) were used to analyze the findings over time.

RESULTS

At baseline there were statistically significant differences between groups in fatigue (P = .039), T25FW (P = .034), and TUG (P = .010). A significant group/time interaction emerged for fatigue levels (P= .005). We found no significant group/time interaction for pain levels or function.

CONCLUSIONS

Undertaking 15 minutes of moderate-intensity aerobic cycling exercise had no significant adverse effects on pain or function in people with MS and CFS (with a Karnofsky score of 50-80) within a 24-hour time period. These initial results suggest that people with MS or CFS may undertake 15 minutes of cycling as moderate aerobic exercise with no expected negative impact on pain or function.

Evaluation of the effects of reflexology on quality of life and symptomatic relief in multiple sclerosis patients with moderate to severe disability; a pilot study

Objective:

To examine the feasibility of delivering reflexology to people moderately to severely affected by multiple sclerosis and to investigate the effect on a range of symptoms.

Methods:

A pilot single-blind randomized placebo controlled trial.

Setting:

An outpatient multiple sclerosis rehabilitation centre.

Subjects:

Twenty people moderately to severely affected by multiple sclerosis were randomized into one of two groups receiving either reflexology or sham reflexology.

Intervention:

Each participant received 8 weeks, 1 hour per week of either reflexology or sham reflexology.

Main measures:

Primary outcome measure was the Multiple Sclerosis Impact Scale (MSIS29). Secondary measures assessed a range of symptoms at baseline, 8 weeks and 16 weeks.

Results:

There were no statistically significant differences between the two groups at either 8 ( P = 0.538) or 16 ( P = 0.112) weeks for the primary outcome measure; however, both groups demonstrated small improvements from 92.3 (SD 20.9) to 75.6 (SD 3.3) with reflexology, and 91.3 (SD 29.9) to 81.5 (±18.5) with sham reflexology group after 8 weeks of treatment. Small improvements were noted in most of the secondary outcome measures at 8 weeks. There was no difference between the groups at 8 weeks except for bladder function ( P = 0.003) and most scores returned to baseline at follow-up.

Conclusions:

The results do not support the use of reflexology for symptom relief in a more disabled multiple sclerosis population and are strongly suggestive of a placebo response. This study demonstrates, however, that reflexology can be delivered and is well tolerated by people who are moderately to severely affected by multiple sclerosis.

A qualitative exploration of the impact of a 12-week group exercise class for those moderately affected with multiple sclerosis

PURPOSE

The evidence base to support therapeutic exercise for people with multiple sclerosis (MS) is improving; however few studies have considered the patients' perspective. This study aimed to explore the experiences and views of people moderately affected with MS following participation in a 12-week exercise programme.

METHOD

Twenty people with MS participated in a group exercise class. Subsequently, four men and ten women took part in one of two focus groups. Semi-structured questions were used to elicit participants' views on the exercise class, outcomes from exercise and the exercise class and any perceived facilitators or barriers to exercise. Data were analysed using a general inductive method.

RESULTS

Benefits to participating in exercise for those with MS included social support and symptom improvement. Psychosocial factors, symptoms and lack of service emerged as exercise barriers. Three inter-related themes emerged; (1) The exercise class developed as a bridge to allow participants to realise, (2) the benefits of the class, helping them to overcome and (3) barriers to exercise.

CONCLUSION

Taking part in an exercise class was a positive experience for people with MS. Healthcare professionals should work with exercise professionals to provide feasible exercise opportunities to help those with MS benefit from therapeutic exercise.

The effects of a 12-week leisure centre-based, group exercise intervention for people moderately affected with multiple sclerosis: a randomized controlled pilot study

OBJECTIVE

To establish the effects of a 12-week, community-based group exercise intervention for people moderately affected with multiple sclerosis.

DESIGN

Randomized controlled pilot trial.

SETTING

Two community leisure centres.

PARTICIPANTS

Thirty-two participants with multiple sclerosis randomized into intervention or control groups.

INTERVENTION

The intervention group received 12 weeks of twice weekly, 60-minute group exercise sessions, including mobility, balance and resistance exercises. The control group received usual care.

MAIN OUTCOME MEASURES

An assessor blinded to group allocation assessed participants at baseline, after eight weeks and after 12 weeks. The primary outcome measure was 25-foot (7.6 m) walk time, secondary outcomes assessed walking endurance, balance, physical function, leg strength, body mass index, activity levels, fatigue, anxiety and depression, quality of life and goal attainment.

RESULTS

The intervention made no statistically significant difference to the results of participants' 25-foot walk time. However the intervention led to many improvements. In the intervention group levels of physical activity improved statistically between baseline and week 8 (P < 0.001) and baseline and week 12 (P = 0.005). Balance confidence results showed a significant difference between baseline and week 12 (P = 0.013). Good effect sizes were found for dynamic balance (d = 0.80), leg strength (d = 1.33), activity levels (d = 1.05) and perceived balance (d = 0.94).

CONCLUSION

The results of the study suggest that community-based group exercise classes are a feasible option for people moderately affected with multiple sclerosis, and offer benefits such as improved physical activity levels, balance and leg strength.

Evaluation of a home-based physiotherapy programme for those with moderate to severe multiple sclerosis: a randomized controlled pilot study

OBJECTIVE

To investigate the effect of an eight-week home-based physiotherapy programme in reducing physical impairment, disability and psychological distress for people with moderate to severe multiple sclerosis (MS).

DESIGN

Pilot randomized controlled trial.

SETTING

Community; subjects' homes.

SUBJECTS

Thirty people moderately to severely affected by MS (Extended Disability Status Score, EDSS, 6.5-8) were randomized to an intervention or control group.

INTERVENTION

The intervention group received twice weekly, home-based physiotherapy for eight weeks and the control group received usual care.

MAIN MEASURES

The following outcome measures were recorded at baseline, post-intervention (Week 8) and at follow-up (Week 16). Primary outcome measure; Multiple Sclerosis Impact Scale (MSIS29) and secondary outcome measures assessed physical impairment, MS symptoms, quality of life, mood, and disability.

RESULTS

Although the Group * Time interaction failed to reach statistical significance with MSIS29 (p = 0.925), MS - related symptom checklist (MS-RS) (p = 0.627) and for lower limb strength, right knee extension (p = 0.375) and right knee flexion (p = 0.794), there is more evidence of altered levels in the treatment group than in the control group.

CONCLUSION

A minimum of 58 subjects per group are required to achieve a power of 80% at the 5% level of significance based on the MSIS29. A larger scale study is required.

The effect of functional electrical stimulation on the physiological cost of gait in people with multiple sclerosis

OBJECTIVE

Functional electrical stimulation (FES) is used clinically in the management of drop foot in people suffering from neurological conditions. The aim of the study was to investigate the effects of FES, in terms of speed and physiological cost of gait, in people with multiple sclerosis (pwMS).

METHODS

Twelve pwMS and 12 healthy matched controls walked at their own preferred walking speed (PWS) for 5 min around a 10 m elliptical course. Subjects with MS completed the protocol with and without using their FES. In addition, control subjects completed the protocol twice more walking at the same PWS of the pwMS to which they were matched.

RESULTS

Wearing FES lead to a significant improvement in walking speed (0.49 ms(-1) and 0.43 ms(-1) with and without their FES respectively; P<0.001) and a significant reduction in the physiological cost of gait (0.41 mL min(-1) kg(-1) m(-1) and 0.46 mL min(-1) kg(-1) m(-1) with and without FES respectively; P=0.017) in pwMS. The speed of walking, oxygen uptake, and physiological cost were significantly different between pwMS and controls both at preferred and matched speeds. Although pwMS exhibit a higher physiological cost of walking, FES offers an orthotic benefit to pwMS and should be considered as a possible treatment option.

The effects of transcutaneous electrical nerve stimulation (TENS) on spasticity in multiple sclerosis

Spasticity is a common and often disabling symptom associated with multiple sclerosis (MS). Transcutaneous electrical nerve stimulation (TENS) has been found effective in reducing spasticity in conditions such as stroke, but there is little evidence to support its use in MS. The aim of this study was to evaluate the effectiveness of TENS on spasticity in MS and, furthermore, to compare two different application times. Thirty-two subjects were randomized into two groups, and a single, blind, crossover design was used to compare two weeks of 60 minutes and 8 hours daily of TENS applications (100 Hz and 0.125 ms pulse width). Outcomes were examined using the Global Spasticity Score (GSS), the Penn Spasm Score (PSS), and a visual analogue scale (VAS) for pain. The results of the study demonstrated that there were no statistically significant differences in the GSS following either 60 minutes or 8 hours daily of TENS (P=0.433 and 0.217, respectively). The 8-hour application time led to a significant reduction in muscle spasm (P=0.038) and pain (P = 0.008). Thus, this study suggests that, whilst TENS does not appear to be effective in reducing spasticity, longer applications may be useful in treating MS patients with pain and muscle spasm. Multiple Sclerosis 2007; 13: 527-533. http://msj.sagepub.com

An Audit of a New System of Self–Referral in the Management of Multiple Sclerosis

A random sample of the referral notes of 35 multiple sclerosis patients experiencing relapse and referred via the current general practitioner (GP) system was reviewed. The time between receipt of the referral and assessment/admission (lead time) was examined. The mean value was obtained and a self referral system was initiated and monitored for a period of five months. The mean referral times were compared. The patients' disability status before and after treatment was measured using the Expanded Disability Status Scale (EDSS) and Functional Independence Measure (FIM), and we invited the patients' opinions about the self-referral system.

The goals of the newly implemented self-referral system were to reduce lead time to less than 6.5 days, improve patient disability, and avoid inappropriate referral; the new system was also to be “user friendly.”

The new system reduced referral times by a statistically significant amount (P = 0.0016). There was a significant objective improvement in patients' disability as measured by the EDSS and FIM scores (P = 0.031 and P = 0.04, respectively). There was a subjective improvement, and patients expressed a preference for the new system. There were no inappropriate referrals. These findings suggest that the self-referral system is efficient and effective and should be further evaluated. (Int J MS Care. 2002; 4: 10–12)

Dermatitis on construction sites

Safety has been the main focus of the current drive to improve standards within the construction industry, however, following a survey on dermatitis among construction workers, Peter Mattison found that occupational health issues have been equally neglected.

The comparative effects of paracetamol and indomethacin on renal function in healthy female volunteers

1. Renal function was assessed in 10 healthy female volunteers during administration of placebo, paracetamol (acetaminophen) (4.0 g daily) and indomethacin (150 mg daily) for 3 days under conditions of controlled sodium and fluid intake. 2. Paracetamol and indomethacin had no significant effect on the glomerular filtration rate and effective renal plasma flow as measured by the renal clearances of inulin, creatinine and p-aminohippurate (PAH). 3. Compared with placebo, paracetamol reduced the mean urinary excretion of prostaglandin E2 by 43% on the second day and 58% on the third treatment day (P less than 0.01). With indomethacin the corresponding reductions were 73 and 80%. Paracetamol and indomethacin had much less effect on the excretion of prostaglandin 6-keto F1 alpha, and a significant decrease was observed only on the third day. 4. The decreased urinary excretion of prostaglandin E2, produced by paracetamol was associated with a reduction in sodium excretion of more than 50% (P less than 0.01) and delay in the onset of diuresis following an acute water load. 5. The renal effects of paracetamol and indomethacin appear to differ. Although indomethacin reduced prostaglandin excretion more than paracetamol it had a similar effect on sodium excretion and less initial antidiuretic action. Unlike paracetamol, indomethacin also reduced basal plasma renin activity. 6. Paracetamol reduced the total body clearance of PAH and increased its plasma half-life. This effect could be attributed to inhibition of the acetylation of PAH by paracetamol. 7. In normal use paracetamol does not appear to have the adverse renal effects associated with the non-steroidal anti-inflammatory analgesics and further studies are required to establish the clinical significance of these findings.