1. FES EDUCATION DAY WELCOME Jon Graham BA BSc MSc MCSP Clinical Director Neurological Physiotherapy Services PhysioFunction

3. Independent FES Service Started in 2004 with ODFSIII Outreach service for National FES Centre from 2007 Walkaide from 2008 Bioness L300 from 2009

4. Beyond Beyond Boundaries

5. MY ASPIRATION I do not want to see an individual in the street, supermarket, pub/restaurant, with a Foot Drop and be wondering: DO THEY KNOW ABOUT FES?

6. Email Dear Jon I am the person you spoke to in Costa Coffee this morning. First of all, may I just say how much I appreciated you talking to me this morning. It can't have been easy approaching a complete stranger and talking about something so obviously personal. So thanks for being prepared to take your life in your hands!

7. Learning Objectives 1.Understand how FES can help patients avoid trips and falls, and maximise their independence. 2.Gain knowledge of the different FES systems currently available in UK. 3.Learn who is suitable for which particular FES technology.

8. Overview Foot Drop – central and peripheral causes Neurophysiology of Functional electrical stimulation (FES) Evidence of effectiveness of FES FES systems with surface electrodes: –ODFS Pace and O2CHSII Channel (OML) –Walkaide (Innovative Neurotronics) –L300 (Bioness)

9. Overview FES systems with implanted electrodes: –STIMuSTEP (OML) –ActiGait (Otto Bock) Cost-effectiveness Sources of funding

10. Inability to lift the foot at the ankle

12. Problems associated with Foot Drop Reduced mobility and independence – reduced speed of walking – increased risk of trips and falls – increased fatigue – reduced confidence – secondary MSK complications – retard upper limb recovery

13. Causes of Foot Drop Central Neurological –Stroke –Multiple Sclerosis –Parkinson’s Disease –HSP –Spinal Injury (above T12)

14. Spinal Cord versus Cauda Equina

16. Causes of Foot Drop Peripheral Neurological –nerve injury (including Cauda Equina) –Neuropathy Muscular –trauma –structural muscle changes

17. FES v AFO Gait pattern Stairs Compliance Additional cost for patients Carry-over Participation

18. What is FES? Method of applying low level electrical currents directly to the motor nerves of the body to restore function.

19. Neurophysiology…

20. FES The first commercially available FES system was developed by the medical physics department at Salisbury District General Hospital – the Odstock Drop Foot Stimulator (ODFS)

22. Stimulation Main Stimulation Time Extension Ramp Up Ramp Down Time Heel Rise Heel Strike

23. “Go Compare.fes”

25. Who can benefit? Foot drop caused by –Multiple Sclerosis –Stroke –Incomplete Spinal Cord Injuries –Cerebral Palsy –Familial/Hereditary Spastic Paralysis –Head Injuries –Orthopaedic injuries requiring muscle strengthening or movement retraining

26. Who is suitable for FES? Able to stand up from sitting independently Able to walk about 10m +/- appropriate aid Absence of contractures in the calf muscle

27. Who is NOT suitable? Complete lower motor neuron/ peripheral nerve lesions Polio Motor Neuron Disease Fixed contractures

28. Benefits of FES More normal walking pattern Improves balance during walking Increases speed of walking Reduction in effort Increased walking distance Reduced falls Reduction of freezing in Parkinson’s Disease

29. What the Users say... “Walking without FES is liking dragging a bag of potatoes along with my weak leg. FES makes my leg feel normal” Lynn M, MS

30. What the Users do...

31. Precautions Pacemakers Cognitive impairment Intolerance to level of stimulation

32. Contraindications Uncontrolled Epilepsy Pregnancy Broken skin Exposed orthopaedic metal work Malignancy

33. EVIDENCE

34. NICE January 2009 “This procedure can be offered routinely as a treatment option for people with drop foot caused by damage to the brain or spinal cord…”

35. NICE January 2009 1.1 Current evidence on the safety and efficacy (in terms of improving gait) of functional electrical stimulation (FES) for drop foot of central neurological origin appears adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit.

36. NICE January 2009 1.2 Patient selection for implantable FES for drop foot of central neurological origin should involve a multidisciplinary team specialising in rehabilitation.

37. NICE January 2009 1.3 Further publication on the efficacy of FES would be useful, specifically including patient-reported outcomes, such as quality of life and activities of daily living, and these outcomes should be examined in different ethnic and socioeconomic groups.

38. Evidence for Increased Walking Speed and Reduced Effort (Stroke) Burridge et al (1997) –32 subjects > 6 months stroke –3 month study –Increase in Walking speed of 20.5 % –Reduction in effort of 25%

39. Evidence for Reduction in Falls (MS) Mann et al. (2005) –Group 1 (n=21) FES group –Group 2 (n=24) Exercise group –18 week study

40. FES group experience fewer falls at all stages than the exercise group

41. Evidence for use in Parkinson’s Disease Mann et al. (2008) –Pilot study –7 Subjects –History of trips/falls and freezing during gait –Single-channel FES on more severely affected side –Daily use

42. The pilot study demonstrated FES can improve –Average stride length –Speed of gait –Walking distance –Reduction in falls Carry-over effect also demonstrated on all of the above except falls Small reduction in reports of freezing (ns)

43. Triggering

44. Footswitch OML FSR Bioness Intelligait Sensor Otto Bock Heel Switch

45. Tilt Sensor

46. FES Systems using Surface Electrodes ODFS Pace and O2CHSII Channel Walkaide Bioness L300

47. ODFS Pace

48. Odstock Pace Programmable single-channel digital FES FES and exercise modes Data logging

49. O2CHSII

50. O2CHSII Channel System Two ODFS’ in one box Able to work simultaneously, independently or interact with each other Bilateral drop foot Stimulation of other muscle groups in conjunction/independently of the foot

51. Walkaide

52. VIDEO

53. Bioness L300

55. Triggering ODFS PaceWalkaideL300 Foot switch Heel-rise Heel-strike Inclinometer & Accelerometer Footsensor Heel-rise only

56. Programming/ Setup ODFS PaceWalkaideL300 Internal menu system Laptop via Blue- tooth and Walklink PDA via proprietary wireless communication Requires training data

57. Electrode Placement ODFS PaceWalkaideL300 User/carer manually positions Contained within the cuff

58. Training ODFS PaceWalkaideL300 Time-based Remote clinician/user trigger

59. FES Implanted Systems STIMuSTEP (OML) ActiGait (Otto Bock)

60. STIMuSTEP (OML)

61. ActiGait (Otto Bock)

62. External control unit External antenna and implanted receiver Implanted electrode Heel switch

63. FES Implanted Systems STIMuSTEPActiGait Stimulator Electrodes Two-channel stimulating deep and superficial branches of Common Peroneal 4 channel cuff electrode stimulator on Common Peroneal

64. STIMuSTEPActiGait ProgrammingExternal unitPersonal Computer TriggeringHeel switch FES Implanted Systems

65. Cost-effectiveness Cost per quality adjusted life years data of supplying FES Cost risk on not supplying FES –Secondary complications eg back pain –Fracture risk from avoidable falls –Litigation

66. Funding NHS via Specialist Commissioning and Extraordinary Equipment requests Access to Work Private/self-funded Interim or settlement payments

67. “ABSOLUTELY FABULOUS, thank you so much for today, I want to tell the world I CAN WALK AGAIN! I realize I have grieved for my legs, they died and have come to life again, what a stupendous gift you have given me using this wonderful aid. I walked up the step into the butchers, bought some lovely sirloin steak for supper this evening...

68. ...it has certainly pressed a button somewhere, walking up the ramp and step into the house was more like a jump, so easy. I haven't been this happy for nearly 6 years.”