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.

Tendon transfers for drop foot correction: long-term results including quality of life assessment, and dynamometric and pedobarographic measurements.

BACKGROUND: Drop foot deformity is a common problem with severe restrictions in quality of life and impairment of daily activities. A technique of posterior tibial tendon transfer through the interosseus membrane and fixation to the anterior tibial and the long peroneal tendon "Bridle procedure" (stirrup-plasty) offers a physiological alternative to surgical correction. METHODS: Data of 53 consecutive patients treated by stirrup-plasty were acquired from patient's charts; 31 were interviewed with standardized questionnaires; 20 were examined physically; 19 received pedobarography, and 8 underwent dynamometric muscle function tests. Follow-up time averaged 6.5 years. RESULTS: The mean range of motion (ROM) in the ankle joint was 8° dorsiflexion and 15° plantar flexion. Most patients achieved plantigrade foot position and the majority developed gait without orthotic devices. As expected, maximum dorsiflexion torque averaged a third of the non-operated leg, according to reduced muscle diameter and strength of the transferred muscle. Pressure distribution of the sole during gait was not relevantly altered by the tendon transfer compared to the non-operated leg. Most patients were satisfied with the operative results and reported a significant increase in quality of life. CONCLUSIONS: Fusion of the transposed posterior tibial, anterior tibial and the peroneus longus tendon prevents drop foot deformity sufficiently. The stirrup mechanism, in combination with tenodesis of the toe extensors, provides a balanced foot and avoids equinovarus and cavus deformity without immobilizing the ankle joint. Improvements in quality of life parameters justify the risk of the operative procedure for the patient.

The drop toe sign: an indicator of neurologic impairment in congenital clubfoot.

UNLABELLED: Nine patients presenting during infancy were identified with clubfeet and absent anterior and lateral compartment functions. We considered these to be neurogenic clubfeet. All patients had the drop toe sign: resting posture of the toes in plantarflexion and absent active dorsiflexion movement after plantar stimulation of the foot. Two patients (three feet) underwent exploration of the peroneal nerve, which revealed anatomic abnormalities. Six patients required more casts than typical for initial correction of deformity; all but two had Achilles tenotomy. Four relapsed despite full-time bracing and eventually needed intraarticular surgery to achieve a plantigrade foot. Idiopathic absent peroneal nerve function is not a well-described entity in the clubfoot literature. All babies with clubfoot should be examined for the drop toe sign. When noted, the feet will likely be more difficult to correct initially, may need early Achilles tendon lengthening, will likely need permanent bracing, are likely to relapse and need intraarticular surgery, and may need multiple surgeries to remain plantigrade throughout growth. LEVEL OF EVIDENCE: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Vitamin D2 potentiates axon regeneration.

To date, the use of autograft tissue remains the "gold standard" technique for repairing transected peripheral nerves. However, the recovery is suboptimal, and neuroactive molecules are required. In the current study, we focused our attention on vitamin D, an FDA-approved molecule whose neuroprotective and neurotrophic actions are increasingly recognized. We assessed the therapeutic potential of ergocalciferol--the plant-derived form of vitamin D, named vitamin D2--in a rat model of peripheral nerve injury and repair. The left peroneal nerve was cut out on a length of 10 mm and immediately autografted in an inverted position. After surgery, animals were treated with ergocalciferol (100 IU/kg/day) and compared to untreated animals. Functional recovery of hindlimb was measured weekly, during 10 weeks post-surgery, using a walking track apparatus and a numerical camcorder. At the end of this period, motor and sensitive responses of the regenerated axons were calculated and histological analysis was performed. We observed that vitamin D2 significantly (i) increased axogenesis and axon diameter; (ii) improved the responses of sensory neurons to metabolites such as KCl and lactic acid; and (iii) induced a fast-to-slow fiber type transition of the Tibialis anterior muscle. In addition, functional recovery was not impaired by vitamin D supplementation. Altogether, these data indicate that vitamin D potentiates axon regeneration. Pharmacological studies with various concentrations of the two forms of vitamin D (ergocalciferol vs. cholecalciferol) are now required before recommending this molecule as a potential supplemental therapeutic approach following nerve injury.

Use of the sensory nerve stimulator to accelerate healing of a venous leg ulcer with sensory nerve dysfunction: a case study.

A new therapy using sensory nerve stimulation [International Patent Application Number PCT/AU2004/001079: "nerve function and tissue healing" (Khalil, Z)] has been developed in our vascular physiology laboratory. This treatment has been found to improve the deficient sensory nerve function and associated deficient wound healing of older persons to levels seen in young people. An 82-year-old man with a small but persistent venous leg ulcer for 18 months, despite apparently appropriate wound dressings and compression therapy, was seen in a specialist wound management service. The patient's sensory and microvascular function was assessed in great detail using the vascular physiology laboratory techniques, and he was provided the sensory nerve stimulation therapy in addition to conventional therapy. His wound healed after 4 weeks. We report the case here. Prior to nerve stimulation therapy, cutaneous sensation, microvascular blood flow and oxygen tension were found to be reduced near the ulcer when compared with the opposite, non ulcerated leg. After therapy, oxygen tension and microvascular blood flow had improved. This case provides further evidence that sensory nerve stimulation therapy at the stipulated parameters improves wound healing. The observation that sensory nerve function improved provides support for the notion that improvement in healing is mediated by improved nerve function.

Clinical use of the Odstock dropped foot stimulator: its effect on the speed and effort of walking.

OBJECTIVE: To assess the clinical effectiveness of the Odstock dropped foot stimulator by analysis of its effect on physiological cost index (PCI) and speed of walking. This functional electrical stimulation (FES) device stimulates the common peroneal nerve during the swing phase of gait. DESIGN: A retrospective study of patients who had used the device for 4 1/2 months. SUBJECTS: One hundred fifty-one patients with a dropped foot resulting from an upper motor neuron lesion. SETTING: A medical physics and biomedical engineering department of a district general hospital specializing in the clinical application of FES and a neurophysiotherapy department at a separate hospital. MAIN OUTCOME MEASURES: Changes in walking speed and effort of walking, as measured by PCI over a 10-meter course. RESULTS: There was a 92.7% compliance with treatment. Stroke patients showed a mean increase in walking speed of 27% (p<.01) and reduction in PCI of 31% (p<.01) with stimulation, and changes of 14% (p<.01) and 19% (p<.01), respectively, while not using the stimulator. Multiple sclerosis patients gained similar orthotic benefit but no "carry-over." CONCLUSIONS: The measured differences in walking with and without stimulation were statistically significant in the stroke and multiple sclerosis groups. In this study use of the stimulator improved walking. Those with stroke demonstrated a short-term "carry-over" effect.