functional electro stimulation (fes) clinical evidence and study overview · 2019. 11. 14. ·...
TRANSCRIPT
Dr. Thorsten Böing
Functional Electro Stimulation (FES) Clinical evidence and
Study overview
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• Patients with foot drop disability after a damage of the CNS (Central Nervous System)
− Stroke
− Multiple Sclerosis (MS)
− TBI (Traumatic Brain Injury)
− SCI (Spinal Cord Injury)
− CP (Cerebral Palsy)
Functional Electro Stimulation (FES)
Indication
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Lesion of CNS
good irritability with
electro stimulation
Lesion of PNS
poor irritability with
electro stimulation
General introduction electro stimulation
Possible applications
CNS
Lesion
Peripheral nerve
Stimulation
Muscle
CNS
Lesion
Peripheral nerve
Stimulation
Muscle
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• Transcutaneous Electronically Nerve-Stimulation (TENS)
– For pain therapy/treatment
• Therapeutically Electro Stimulation (TES)
– For therapeutic use ( f. ex. Stimulation current)
• Functional Electro Stimulation (FES)
– Stimulation of functional movement
– FES as therapeutic use
– For relearn movement patterns– Neuronal plasticitiy
Definition/ Terminology
General introduction electro stimulation
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FES vs. TENS
Differentiation
• Functional movement
• „Motor Re-Learning“ activation neurological pattern
• Physiological contraction of the muscles
• Higher triggering effect with training mode
• Pain reduction
• Muscle relaxing
• Better blood circulation
• No functional movement!
• No physiological muscle movement!
FES TENS
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The Nerves peroneus communes
innervation
− M. tibialis anterior
− M. extensor halluces longus
− M. extensor digitorum longus
Dorsal extension + Supination
− M. peroneus longus
− M. peroneus brevis
Plantarflexion + Pronation
Reference points
How does FES work?
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Thermoplastic AFO vs. FES
Thanks toSH Klinz, Bernburg
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
3D-Motion detection via
Gyroscope and accelerometer
Patient-AppL300 Go with more channel stimulation for
separate motion control of Dorsal
extension und Eversion
Short and intuitive
Set-Up
Integrated assessments: 10m-Walk test,
TOG
Main functions
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
Pediatric fitting L300 Go for small circumferences
Peroneus paresis Combined with knee
instability in anterior/posterior
f. ex. Genu recurvatum L300 Go + L300 Go
Upgrade
Selective Knee-instability or Quadriceps-insufficiency
L300 Go Stand alone
Peroneus paresis
L300 Go vs.
L100 Go
Clinical Differentiation
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Time (Week)
Per
cent
age
of p
atie
nts
with
wal
king
abi
litie
s
0
10
20
30
40
50
60
70
80
90
0 2 4 6 8 10
84.6%
53.3%
46.2%
Yan T et al. Functional Electrical Stimulation improves motor recovery of the lower extremity and walking ability of subjects with first acute stroke. A randomized placebo-controlled trial. Stroke 2005; 36:80-85
FES and Standard-RehabilitationPlacebo and Standard-RehabilitationControlled (Standard-Rehabilitation)
Early as possible Intervention is successful
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
0,00
0,20
0,40
0,60
0,80
1,00
1,20
Baseline One Month Two Months One Year
Sp
ee
d (m
/se
c.)
Improvement of walking speed
Laufer Y et al.: Gait in Individuals with Chronic Hemiparesis: One-Year Follow-up of the Effects of a Neuroprosthesis That Ameliorates Foot Drop. J Neurol Phys Ther, 2009. 33(2): p. 104-110.
0,67 0,70
0,86
1,06
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
Reduction of energy consumption
Burridge J et al.: The effects of common peroneal nerve stimulator on the effort and speed of walking: a randomized controlled clinical trial with chronic hemiplegic patients. Clin Rehabil 1997, 11:201-210.
0
5
10
15
20
25
30
perc
enta
ge im
prov
emen
t fro
m b
asel
ine
Follow-up 1(4-5 weeks later)
Follow-up 2(12-13 weeks later)
Speed PCISpeed PCI
control
FES(difference between follow-up assessment with stimulation and baseline assessment without stimulation)
5%
18%
6%
21%
5%
21%
5%
25%
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
FES Improves Activity After Stroke
Howlett OA et al. Functional Electrical Stimulation Improves Activity After Stroke: A Systematic Review With Meta-Analysis. Arch phys med rehabil, 2015; 96(5):934-943
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
Long time FES-use with the indication MS
• Background: only a few studies looking over the longtime usability, results and
consequences. This study observed the orthopedic consequences in a Five-Year
Follow-up of a Longitudinal Cohort and examine the additional benefit of FES for the
Patient reported outcome; like f.ex. Pain in the joints.
• Method: 154 Patients, age ⌀ 59,8 (R: 28-74) initially measured 10m- walk-test,
visual analog scale (VAS) und Quality of life, after 6 month and than over 5 years,
each year (T0- T7)
• Results: Significant improvement of all measured parameters.
• Conclusion: Even despite progression of the MS long time users profitable
significantly of the FES
Street T et al. Five-Year Follow-up of a Longitudinal Cohort Study of the Effectiveness of Functional Electrical Stimulation for People with Multiple Sclerosis. Int J MS Care. 2018;20:224-230.
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
Orthopedic- therapeutic effect of FES used by MS patients
• Background: Systematic review and Meta analyze
• Method: Searching in the Data bank PubMed, CINAHL und ProQuest. Contents of the studies with therapeutic and/or orthopedic effects of FES evaluated with gait analyze.
• Results: All over significant orthopedic effects, mainly gait speed. Only 3 Studies looking also over the Carry-over (therapeutic effect; this is showing better gait abilities after the use of FES without any treatment), this was not significant! Conclusion: The most of the studies looking over one channel controlled FES systems, that does show; future studies should be prove the 2 channel systems as the solution with even a higher impact in Gait symmetry, speed and energy consumption.
Springer S et al. Effects of functional electrical stimulation on gait in people with multiple sclerosis - A systematic review. Mult Scler Relat Disord. 2017;13:4-12.
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
• Multicentric (n = 23), international (DACH), consecutive Patient
recruiting from FES-responding patients
• Registration of 10 items each to the gait pattern (NeuroReha-Specialist:
PT, CPO, ) and to the ICF-based participation (Patient!)
• Time zone 08/13 - 05/15
• Cohort:
− n = 169 (cleaned up: n = 151), 67 women, 84 men
− ⌀ age 59,8 (R: 9 – 79)
− Effected since ⌀ 7,3 years (R: 1 – 33)
− CNS-relevant Diagnose (Stroke, MS, TBI, SCI)
Böing T. Hilfsmittelversorgungen bei Peronaeusparese im ICF-Fokus von Aktivität und Teilhabe. 3rd European Congress of NeuroRehabilitation, 2. Dezember 2015, Wien
AFO or FES?
ICF-based Examination
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
Disease
(Stroke, MS, TBI, SCI, CP)
Disease
(Stroke, MS, TBI, SCI, CP)
Body function and -structure
Body function and -structure
activitiesactivitiesPARTICIPATION PARTICIPATION
Environmental factorsEnvironmental factors Personal influenced factors
Personal influenced factors
Support of personal influenced factors:
mental social Networkmotivational social protection Coping-strategies economical situation
Support of environmental factors:
Possibilities of Rehabilitation and qualityCapability in profession and daily living Social norms
*International Classificationof Functioning, Disability, and Health. WHO 2001
ICF*
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FES during daily life
3,2
3,6 3,6
3,4
3,6
2,9
3,3
3,4 3,4
2,9
Ohne Hilfsmittel
No influence
gravedisability
Fulldisability
Böing T. Hilfsmittelversorgungen bei Peronaeusparese im ICF-Fokus von Aktivität und Teilhabe. 3rd European Congress of NeuroRehabilitation, 2. Dezember 2015, Wien
Without treatment
moderatedisability
lightdisability
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
FES in daily life
3,2
3,6 3,6
3,4
3,6
2,9
3,3
3,4 3,4
2,9
2,0
2,32,4
2,2
2,6
1,9
2,22,3
2,4
2,1
Ohne Hilfsmittel
Mit Orthese
Böing T. Hilfsmittelversorgungen bei Peronaeusparese im ICF-Fokus von Aktivität und Teilhabe. 3rd European Congress of NeuroRehabilitation, 2. Dezember 2015, Wien
No influence
gravedisability
Fulldisability
moderatedisability
lightdisability
With FES treatment
FES during daily living is significantly better for the patient!
Why?
1. Higher Compliance
2. Higher acceptance to use a fitting
3. Significantly more participation!
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
Documentation
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
• High grade of compatibility to neurophysiological
therapeutic technics, Vojta; PNF; Bobath
• Regulation of tone
• Daily living quality increased
• Full contact; also barefoot!
CP patient treatment FES
Pool D et al. Daily functional electrical stimulation during everyday walking activities improves performance and satisfaction in children with unilateral spastic cerebral palsy: a randomized controlled trial. Arch Physiother. 2015;5:5. Published online 2015 Jul 18. doi: 10.1186/s40945-015-0005-x
Bethoux F et al. Long-term follow-up to a randomized controlled trial comparing peroneal nerve functional electrical stimulation to an ankle foot orthosis for patients with chronic stroke. Neurorehabil Neural Repair. 2015;29(10):911-22
Postans NJ et al. Effect of functional electrical stimulation applied during walking, on gait in spastic cerebral palsy a small study of only eight children. Developmental Medicine & Child Neurology 2005,47:46–52
Kerr C et al. Electrical stimulation in cerebral palsy: a review of effects on strength and motor function. Dev Med Child Neurol. 2004;46(3):205-13.00472.x/full
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
Guidelines for differentiated use of FES
1
American Stroke Association – Clinical Practice Guideline (2010)2
3
Ottawa Panel – Clinical Practice Guidelines for Gait Training (2006)
40%
Increased Gait speed
15%
Increased balance(decreased risk of falling)
20%
Increased distance of walking
25%
Increased therapeutic effect
Gait symmetry and higher quality of life
Patient satisfaction and compliance
Increased
National Clinical Guidelines for Stroke, GB (2012)
4
Rehabilitation of mobility after stroke , S2e-Leitlinie der DGNR (2015)
1.O’Dell MW et al. Response and Prediction of Improvement in Gait Speed From Functional Electrical Stimulation in Persons With Poststroke Drop Foot. PM&R, 2014; 6(7):587-6012.Bethoux F et al. The Effects of Peroneal Nerve Functional Electrical Stimulation Versus Ankle-Foot Orthosis in Patients With Chronic Stroke: A Randomized Controlled Trial. Neurorehabil Neural
Repair, 2014; 28(7):688-6973.Kluding P et al. Foot drop stimulation versus ankle foot orthosis after stroke: 30-week outcomes. Stroke; 2013; 44(6):1660-16694.Everaert DG et al. Effect of a foot-drop stimulator and ankle-foot orthosis on walking performance after stroke: a multicenter randomized controlled trial. Neurorehabil Neural Repair, 2013;
27(7):579-591 5.Dunning K et al. The Functional Ambulation: Standard Treatment versus Electrical Stimulation Therapy (FASTEST) trial for stroke: study design and protocol. Open Access Journal of Clinical
Trials, 2013; 5:39‐49. 6.Auchstaetter N. et al. Physical Therapists' Use of Functional Electrical Stimulation for Clients With Stroke: Frequency, Barriers, and Facilitators. Phys Ther, 2016; 96(7):995-10057.Howlett OA et al. Functional Electrical Stimulation Improves Activity After Stroke: A Systematic Review With Meta-Analysis. Arch phys med rehabil, 2015; 96(5):934-943 8.Teasell R et al. Evidence-Based Review of Stroke Rehabilitation - Mobility and the Lower Extremity; 2014, http://www.ebrsr.com/sites/default/files/Chapter%204A_Lower%20Extremity%20Post%
20Stroke.pdf
FES-Evidence: summary
excellent
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
FES-treatment: Target and claim
• Optimal (not maximal!) treatment
• Constructive partnership of
Physician CPO
Therapist Patient
Payer
• Participation is the target for rehabilitation!
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
T.Böing: Funktionelle Elektrostimulation - Klinische Evidenz und Überblick zur Studienlage | © Otto Bock HealthCare Deutschland
Steering Electrode
Quick Fit Electrode
Erweiterte Steuerung/Stimulation
Medial
Lateral