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.

Systematic review and meta-analysis: Associations of vitamin D with pulmonary function in children and young people with cystic fibrosis.

BACKGROUND: Increasing evidence suggests that vitamin D is associated with pulmonary health, which may benefit children and young people diagnosed with Cystic Fibrosis (cypCF). Therefore, the aim of this systematic review was to evaluate primary research to establish associations between 25OHD and pulmonary health in cypCF. METHODS: Electronic databases were searched with keywords related to CF, vitamin D, children/young people and pulmonary function. Included studies were cypCF (aged ≤21 years) treated in a paediatric setting. The primary outcome was lung function [forced expiratory volume in 1 s (FEV1% predicted)] and secondary outcomes were rate of pulmonary exacerbations, 25OHD status and growth. Evidence was appraised for risk of bias using the CASP tool, and quality using the EPHPP tool. A Meta-analysis was performed. RESULTS: Twenty-one studies were included with mixed quality ratings and heterogeneity of reported outcomes. The Meta-analysis including 5 studies showed a significantly higher FEV1% predicted in the 25OHD sufficiency compared to the deficiency group [FEV1% predicted mean difference (95% CI) was 7.71 (1.69-13.74) %; p = 0.01]. The mean ± SD FEV1% predicted for the sufficient (≥75 nmol/L) vs. deficient (<50 nmol/L) group was 94.7 ± 31.9% vs. 86.9 ± 13.2%; I2 = 0%; χ2 = 0.5; df = 4). Five studies (5/21) found significantly higher rate of pulmonary exacerbations in those who were 25OHD deficient when compared to the sufficient group and negative associations between 25OHD and FEV% predicted. The effects of vitamin D supplementation dosages on 25OHD status (10/21) varied across studies and no study (12/21) showed associations between 25OHD concentration and growth. CONCLUSION: This systematic review suggests that 25OHD concentration is positively associated with lung function and a concentration of >75 nmol/L is associated with reduced frequency of pulmonary exacerbations, which may slow lung function decline in cypCF. Future randomised clinical trials and mechanistic studies are warranted.

Walking measures to evaluate assistive technology for foot drop in multiple sclerosis: A systematic review of psychometric properties.

BACKGROUND: Foot drop in people with multiple sclerosis (pwMS) often managed with assistive technologies, such as functional electrical stimulation and ankle foot orthoses. No evidence synthesis exists for the psychometric properties of outcomes used to evaluate the efficacy of these interventions. OBJECTIVE: This systematic review aimed to identify the outcome measures reported to assess the benefits of assistive technology for pwMS and then synthesize the psychometric evidence in pwMS for a subset of these measures. METHODS: Two searches in eight databases were conducted up to May 2017. Methodological quality was rated using the COSMIN guidelines. Overall level of evidence was scored according to the Cochrane criteria. RESULTS: The first search identified 27 measures, with the 10 m walk test, gait kinematics and Physiological Cost Index (PCI) most frequently used. The second search resulted in 41 studies evaluating 10 measures related to walking performance. Strong levels of evidence were found for the internal consistency and test-retest reliability of the Multiple Sclerosis Walking Scale-12 and for the construct validity for Timed 25 Foot Walk. No psychometric studies were identified for gait kinematics and PCI in pwMS. There was a lack of evidence for measurement error and responsiveness. CONCLUSION: Although a strong level of evidence exists for some measures included in this review, there was an absence of psychometric studies on commonly used measures such as gait kinematics. Future psychometric studies should evaluate a wider range of walking related measures used to assess the efficacy of interventions to treat foot drop in pwMS.

Habitual functional electrical stimulation therapy improves gait kinematics and walking performance, but not patient-reported functional outcomes, of people with multiple sclerosis who present with foot-drop.

BACKGROUND: People with Multiple Sclerosis (pwMS) often experience a disturbed gait function such as foot-drop. The objective of this pilot study was to investigate the medium term effects of using Functional Electrical Stimulation (FES) to treat foot-drop over a period 12 weeks on gait and patient reported outcomes of pwMS. METHODS AND FINDINGS: Nine pwMS aged 35 to 64 (2 males, 7 females) were assessed on four occasions; four weeks before baseline, at baseline and after six weeks and twelve weeks of FES use. Joint kinematics and performance on the 10 meter and 2 minute walk tests (10WT, 2 minWT) were assessed with and without FES. Participants also completed the MS walking Scale (MSWS), MS impact scale (MSIS29), Fatigue Severity Score (FSS) and wore an activity monitor for seven days after each assessment. Compared to unassisted walking, FES resulted in statistically significant improvements in peak dorsiflexion in swing (p = 0.006), 10MWT (p = 0.006) and 2 minWT (p = 0.002). Effect sizes for the training effect, defined as the change from unassisted walking at baseline to that at 12 weeks, indicated improved ankle angle at initial contact (2.6°, 95% CI -1° to 4°, d = 0.78), and a decrease in perceived exertion over the 2 min walking tests (-1.2 points, 95% CI -5.7 to 3.4, d = -0.86). Five participants exceeded the Minimally Detectable Change (MDC) for a training effect on the 10mWT, but only two did so for the 2 minWT. No effects of the use of FES for 12 weeks were found for MSWS, MSIS29, FSS or step count. CONCLUSION: Although FES to treat foot-drop appears to offer the potential for a medium term training effect on ankle kinematics and walking speed, this was not reflected in the patient reported outcomes. This observed lack of relationship between objective walking performance and patient reported outcomes warrants further investigation. TRIAL REGISTRATION: ClinicalTrials.gov NCT01977287.

Gait kinematics of people with multiple sclerosis and the acute application of functional electrical stimulation.

This study aimed to (i) compare the gait characteristics of people with Multiple Sclerosis (pwMS) to those of healthy controls walking at the same average speed, and (ii) assess the effects of the acute application of Functional Electrical Stimulation (FES) to the dorsiflexors. Twenty-two people with pwMS (mean age 49 years), prescribed FES, and 11 age matched healthy controls participated. Three dimensional gait kinematics were assessed whilst (i) pwMS and healthy controls walked at self-selected speeds (SSWS), (ii) healthy controls also walked at the average walking speed of the pwMS group, and (iii) people with MS walked using FES. Compared to healthy controls walking at their SSWS, pwMS walked slower and showed differences in nearly all gait characteristics (p<0.001). Compared to healthy controls walking at the same average speed, pwMS still exhibited significantly shorter stride length (p=0.007), reduced dorsiflexion at initial contact (p=0.002), reduced plantar flexion at terminal stance (p=0.008) and reduced knee flexion in swing (p=0.002). However, no significant differences were seen between groups in double support duration (p=0.617), or hip range of motion (p=0.291). Acute application of FES resulted in a shift towards more normal gait characteristics, except for plantar flexion at terminal stance which decreased. In conclusion, compared to healthy controls, pwMS exhibit impairment of several characteristics that appear to be independent of the slower walking speed of pwMS. The acute application of FES improved most impaired gait kinematics. A speed matched control group is warranted in future studies of gait kinematics of pwMS.

Quantification of gait kinematics and walking ability of people with multiple sclerosis who are new users of functional electrical stimulation.

OBJECTIVE: To assess whether the application of Functional Electrical Stimulation improves gait kinematics and walking ability in people with multiple sclerosis who experience foot drop. DESIGN: Acute open labelled comparative observation trial. PARTICIPANTS: Twelve people (3 females, 9 males, EDSS 2-4) with relapsing remitting multiple sclerosis (47.8 years (standard deviation 6.6)) who were new users of functional electrical stimulation. METHODS: Gait kinematics were recorded using 3D gait analysis. Walking ability was assessed through the 10-m walk test and the 6-min walk test. All assessments were performed with and without the assistance of functional electrical stimulation. The effect of functional electrical stimulation was analysed using paired t-tests. RESULTS: Ankle dorsiflexion at initial contact (p = 0.026), knee flexion at initial contact (p = 0.044) and peak knee flexion during swing (p = 0.011) were significantly greater whilst walking with Functional Electrical Stimulation. The increased peak dorsiflexion in swing of nearly 4 degrees during functional electrical stimulation assisted walking approached significance (p = 0.069). The 10-m walk time was significantly improved by functional electrical stimulation (p = 0.004) but the 6 min walk test was not. CONCLUSION: The acute application of functional electrical stimulation resulted in an orthotic effect through a change in ankle and knee kinematics and increased walking speed over a short distance in people with multiple sclerosis who experience foot drop.

Functional electrical stimulation to the dorsiflexors and quadriceps in children with cerebral palsy.

PURPOSE: To assess the effects of functional electrical stimulation (FES) of the ankle dorsiflexors and quadriceps in children with cerebral palsy. METHODS: Fourteen children (mean age 8 years) were randomly allocated to a treatment or control group. The treatment group received 2 weeks of neuromuscular electrical stimulation followed by 8 weeks of FES used at home and school. The control group continued with its usual physiotherapy program. Assessment took place at baseline and before and after the treatment period. Both control and treatment groups were fitted with FES for gait analysis at the second and final assessments. RESULTS: In both groups, FES of the ankle dorsiflexors resulted in a significant (p < 0.01) effect on gait kinematics. However, no long-term treatment effect of using FES for 8 weeks was found. CONCLUSIONS: FES for selected children with cerebral palsy, receiving adequate support, can be a practical treatment option to improve gait kinematics.