Presentation on theme: "WELCOME FES EDUCATION DAY Jon Graham BA BSc MSc MCSP Clinical Director"— Presentation transcript:
1WELCOME FES EDUCATION DAY Jon Graham BA BSc MSc MCSP Clinical Director Neurological Physiotherapy Services PhysioFunction
2Independent FES Service Started in 2004 with ODFSIIIOutreach service for National FES Centre from 2007Walkaide from 2008Bioness L300 from 2009Actigait Trained March 2011Bioness L300 Plus Trained August 2011
4Overview Foot drop – central and peripheral causes Neurophysiology of Functional electrical stimulation (FES)Evidence of effectiveness of FESFES systems with surface electrodes:ODFS Pace and O2CHSII Channel (OML)Walkaide (Innovative Neurotronics)L300 and L300 Plus(Bioness)
5Overview FES systems with implanted electrodes: STIMuSTEP (OML) ActiGait (Otto Bock)Cost-effectivenessSources of funding
17Who can benefit? Foot drop caused by Multiple Sclerosis Stroke Incomplete Spinal Cord InjuriesCerebral PalsyFamilial/Hereditary Spastic ParalysisHead InjuriesOrthopaedic injuriesIncomplete peripheral nerve injuries
18Who is suitable for FES? Able to stand up from sitting independently Able to walk about 10m +/- appropriate aidAbsence of contractures in the calf muscle
19Who is NOT suitable?Complete lower motor neuron/ peripheral nerve lesionsPolioMotor Neuron DiseaseFixed contractures
20Benefits of FES More normal walking pattern Improves balance during walkingIncreases speed of walkingReduction in effortReduced fallsReduction of freezing in Parkinson’s DiseaseGreater confidence when walking, greater independence and participation and an overall improvement in quality of life.
21FES v AFO Gait pattern Stairs Compliance and participation In a recent trial of dropped foot intervention 30% had rejected their AFOs1Preference of FES over AFO for primary management2Additional cost for patientsCarry-over1JE Esnouf, PN Taylor, GE Mann, CL Barrett. Impact on falls and activities of daily living of use of a Functional Electrical Stimulation (FES)device for correction dropped foot in people with multiple sclerosis. Multiple Sclerosis accepted for publication 10th Feb 20102 Bulley C, Shiels J, Wilkie K, Salisbury L User experiences, preferences and choices relating to functional electrical stimulation and anklefoot orthoses for foot-drop after stroke. Physiotherapy, 97 (2011) pp
22What the Users say...“Walking without FES is liking dragging a bag of potatoes along with my weak leg. FES makes me my leg feel normal” Lynn M, MS
27NICE 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…”
28NICE JanuaryCurrent 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.
29NICE JanuaryPatient selection for implantable FES for drop foot of central neurological origin should involve a multidisciplinary team specialising in rehabilitation.
30NICE JanuaryFurther 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.
31Evidence for Increased Walking Speed and Reduced Effort Burridge et al (1997)32 subjects > 6 months stroke3 month studyIncrease in Walking speed of 20.5 %Reduction in effort of 25%
32Literature: Effect of FES on walking speed FES LITERATURESpeed(% Change with FES) AuthorStimulatorComparisonConditionN#FES UseOrthot.Therap.Comb.Stein, 2010WalkAideOn/OffStable1411 mo2943Progress.195712Kottink, 2004Meta-analysisStroke11638Burridge, 1997ODFSPT/FES+PT323 mo6-220.120.5Burridge, 2000181623Taylor, 19991114.5 mo27MS21-710SCI8Wieler, 1999Unistim313 mo-1yr19-21*28*54QuadstimCerebral92-10*8*Kim, 2004Nothing AFO/FES FES+AFO1 sessionSheffler, 2006Nothing AFO/FESBurridge, 2007ActiGait (I)1311.6 mo**12^22^Kottink, 2007STIMuSTEP (I)FES/AFO6.5 moKottink, 20080*Paul, 2008> 6 mo15Hausdorff, 2008L300242 mo1715^34Literature: Effect of FES on walking speed
33Comparison of FES and AFO effect on walking speed (% Change) AuthorStimulatorSubjectsNFES UseConditionsOrthotTherapStein, 2010WalkAideSCI, StrokeMS, FSP141911 moFES5297Kim, 2004SCI1 sessionAFOFES+AFO81018Sheffler, 2006ODFSStrokeKottink, 2007STIMuSTEP (Implanted)6.5 mo323
34Evidence for Reduction in Falls Mann et al. (2005)Group 1 (n=21) FES groupGroup 2 (n=24) Exercise group18 week study
35FES group experience fewer falls at all stages than the exercise group
36Selection Considerations Sensitivity to stimulation parametersTriggeringPaediatric or AdultRequirement for secondary muscle groups to be stimulatedSkin irritationBudget
40O2CHSII Channel System Two ODFS’ in one box Able to work simultaneously, independently or interact with each otherBilateral drop footStimulation of other muscle groups in conjunction/independently of the foot
46Triggering ODFS Pace Walkaide L300 Foot switch Heel-rise Heel- strike Inclinometer & AccelerometerFoot sensorHeel-rise only
47Programming/ Setup ODFS Pace Walkaide L300 Internal menu system Laptop via Blue-tooth and WalklinkPDA via proprietary wireless communicationRequires training data
48Electrodes – Placement & Specifications ODFS PaceWalkaideL300Manually positionedContained within the cuffLarge variety of electrodes and positionsSmall and medium size electrodesMedium sizeCottonLarge ClothSymmetrical & Asymmetrical BiphasicAsymmetrical Biphasic
49Home Training and Clinical Therapy ODFS PaceWalkaideL300Time-baseddirect wired triggeringWalklink (wired)Remote clinician/ user trigger
53FES Implanted Systems STIMuSTEP ActiGait Stimulator Electrodes Two-channel 2-poledstimulating deep and superficial branches of Common PeronealFour channel single cuff electrode on common peroneal nerve
54FES Implanted Systems STIMuSTEP ActiGait Programming External unit Personal ComputerTriggeringHeel switchWireless
55Cost-effectivenessCost per quality adjusted life years data of supplying FESCost from risk of NOT supplying FESSecondary complications e.g. back painFracture risk from avoidable fallsLitigation
56Funding NHS FES services National FES Centre plus Outreach ClinicsNHS Hospital FES Services eg Selly OakNHS via Specialist Commissioning and Extraordinary Equipment requestsAccess to WorkPrivate / self-fundedInterim or settlement payments
57“ABSOLUTELY FABULOUS, thankyou so much for yoday,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 aide,I walked up the stytep into the butchers, bought some lovely sirloin steak for supper this evening...
58...it hass cwertainly pressed a button somewhere, walking up the ramp and step into the house was more like a jump,so easyI havn't been this happy for nearly6 years.”
5918 Months Latermorning jon ,I am walkklking everywhere up loads of steps easily ,thank you for helping me I never thought I would ever be this happy again ever my son wants to know "what are you on mum"it's called happiness ,I can dress myself , walk where ever with or with or without the walk aid.
60Thia lasrt weekend we visited friends for a christening in a very old house full of horrid steps but I managed on my own! ... life is fantastic thank you for making this possible with the walk aide.