Achieving a more functional gait in patients with stroke
Posted on 7th February 2014 by Caitlin Penven-Crew
Kids have been my favorite people for as long as I can remember. So, imagine my surprise when, during a clinical affiliation, I fell in love with neuro—with a specialty that focused on a largely geriatric population! One patient, in particular, was responsible for my new fascination with neurological disorders. She’d had a massive stroke, on her birthday, which left her functionally, and emotionally, devastated. I had the privilege of working with her every day for eight weeks.
Over eight weeks we made tremendous progress with gait (gait is the pattern of movement of the limbs); however, she continued to have trouble activating her hamstrings and her dorsiflexors (the muscles that lift your toes up). She wore an ankle brace that bends at the ankle (an articulating AFO) that kept her toes from dragging on the ground when she walked, but I struggled with her hamstrings. I spent a large amount of my free time pouring over every resource I could, looking for interventions that may have escaped me. Functional electrical stimulation (FES) has been growing in popularity as a neuromuscular rehabilitation technique, especially when a patient has weakness on one side (hemiparesis). Functional electrical stimulation uses electrical current to stimulate nerves that have been damaged after stroke, spinal cord injury, traumatic brain injury, and other neurological disorders.
Springer S, Laufer Y, Becher, Vatine. Dual-channel functional electrical stimulation improvements in speed-based gait classifications. Clinical Interventions in Aging. 2013:271. doi: 10.2147/CIA.S41141.
This study investigated whether FES used during gait was effective at improving a patient’s gait speed classification. Gait is classified into 3 categories based on speed. Limited household ambulation refers to those with gait speeds of less than 0.4 m/s and limited community ambulation is characterized by gait speeds of 0.4 to 0.8 m/s. Finally, functional community ambulators exceed gait speeds of 0.8 m/s. Thirty-six patients with chronic hemiparesis, foot drop, and decreased knee and hip control were separated into three groups based on functional gait category. The FES was applied over the hamstrings and over the dorsiflexors through cuffs for progressively increasing durations until the patients were able to tolerate the stimulation all day. Gait was assessed with the two-minute walk with and without stimulation at baseline and after six weeks of treatment.
The minimal clinically important difference (how much change needs to occur to be significant) for gait speed is 0.1 m/s. While all groups showed improvements in gait speed, groups A and B (limited household and limited community groups, respectively) showed significant improvements. Orthotic effect describes a change in gait speed during ambulation with an FES system and groups A and B showed significant change across six weeks. Therapeutic effect describes the carryover impact of this therapy, and this only showed significant improvement across the three groups as a whole. Habituation refers to the conditioning effect of the user to the FES and was significant across groups A and B. The overall FES effect compares the gait speed at baseline without stimulation to the gait speed after six weeks with stimulation; this was significant in all groups, especially among the limited community ambulators.
Should you take it to the bank?
The sample size in this study was relatively small and the duration was short, but it provides some strong evidence for use of FES to improve gait speed in patients with gait speed. There was no minimal gait speed requirement to be included in the study, so it would be appropriate for just about any patient with hemiparesis. The drawbacks to this study could easily be negated with further research. As a future clinician, taking research “to the bank” can certainly be risky. An in depth review of the evidence, as well as clinician experience, is always essential to providing the best treatment. Having read countless articles about interventions for hemiparesis, including several on the use of FES in hemiparesis, I think that FES has the potential to become a piece of the “go-to” PT toolkit: just like the theraband, and ankle pumps.