Salisbury FES Newsletter

Summer 2002

Editorial

The FES (Functional Electrical Stimulation) Newsletter is a biannual publication with the purpose of promoting the clinical use of FES. It is distributed chiefly to clinicians who have attended the Salisbury introductory FES course but also those who have an interest in the field or those we hope may be interested. FES is a means of producing functional movement in paralysed muscles by the application of electrical impulses to the nerves of those muscles. FES is increasingly used in neurological rehabilitation to improve mobility and upper limb function. The most common use is for the correction of dropped foot in hemiplegic gait, an intervention now recommended by the Royal College of Physicians in their publication "National clinical guidelines on stroke".

In this addition we have a report from the "Upper and Lower Limb Electrical Stimulation in Paediatrics Meeting" held at Queen Mary's Hospital in Roehampton last June and also a report from the IFESS conference held in Ljubljana. We have an article on simple assessment techniques that can be used for reporting case studies. We have a prize-winning paper from Lisa Malone, who received the second price in the student paper competition in Ljubljana for her study on users and carers views on the ODFS. There is advice on the use of foot switches and a case study examining the use of bilateral gluteal stimulation for correction of a Trendelenburg gait. Finally we have the results of the survey carried out by Christine Singleton on the clinical uptake of FES.

Our annual user day has been set for 18th November and will this year be in Salisbury. There will be reports on the latest developments in clinical FES, case studies and a problem solving workshop. These meetings are a good opportunity to swap experience and meet up with others working in the field. We welcome presentations on any aspect of clinical FES. Please return the form at the end of this newsletter.

Thanks to all who have contributed to this newsletter. As always we welcome your feedback and we are pleased to hand on any "good ideas", reports, meeting reviews or adverts that you have through this newsletter. Next addition will be put together in January so please send copy by then.

Paul Taylor

Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ

Tel 01722 429065 e-mail enquiries@salisburyfes.com Web page www.salisburyfes.com

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Sale of stimulators

In our last newsletter we said we were unable to sell stimulators directly to patients and all orders had to go through the hospital or physiotherapist. This coursed some considerable difficulty to a number of FES users and we have now persuaded the managers at Salisbury District Hospital to reverse the decision. To do this we will now include a "condition of sale" with every device supplied that states:

The supplied device will only be fitted by; a person who has been trained to the standards set by the Department of Medical Physics and Biomedical Engineering (MPBE) in the use of a given FES device, or a person approved as being competent in the use of FES techniques by MPBE. The said person must be registered in the list of accredited users held by MPBE.

The registered person and their employer are considered responsible for the continuing support of the use of the device by the end user.

This means that patients may make a payment to Salisbury to for equipment as long as they are supervised by a registered clinician. Stimulators will only be delivered to the registered clinician. Please make orders using the form at the back of this newsletter.

Paul Taylor

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Upper and Lower Limb Electrical Stimulation in Paediatrics

Held at Queen Mary's Hospital, Roehampton, London

Thursday, 13th June 2002

The aim of the workshop was to promote discussion and the exchange of ideas in an informal setting. There were eight presentations covering many aspects of upper and lower limb stimulation. These were followed by an open discussion.

The workshop confirmed that there is considerable interest in stimulation for the paediatric patient group, but that uptake is limited by the lack of assessment/prescription guidelines and clinically relevant outcome measures.

David Ewins

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Lower limb FES for CP Children: A Review of Published Papers

Stevens CHH1, Durham S2, Eve L3, Ewins DJ1,2

1Centre for Biomedical Engineering, University of Surrey, Guildford, UK

2Gait Laboratory, Queen Mary's Hospital, London, UK

3One Small Step Gait Laboratory, Guy's Hospital London, UK

FES has been used for many years in the rehabilitation of muscle activity following neurological damage in adults, e.g. spinal cord injury and stroke. As a result of these studies, it has been suggested that the dynamic nature of FES may promote more normal gait and that FES also has the potential to strengthen and re-educate the affected muscles.

In comparison, less work has been reported in assisting gait in children with cerebral palsy using electrical stimulation. Furthermore there are two apparently opposing approaches with some studies reporting positive results from stimulating the anterior tibial muscles. Other studies report positive results due to stimulating the calf muscle.

The rationale for electrical stimulation of the anterior tibial muscle is to produce active dorsiflexion at the ankle during the swing phase of gait, which at the same time reciprocally inhibits the antagonist, triceps surae. In contrast, stimulating the triceps surae is thought to favourably modify altered muscle activation patterns with a reduction in spasticity.

Christopher Stevens. Tel. 01483 684 589 Fax 01483 879 395 email c.stevens@surrey.ac.uk www.bmesurrey.org

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Electrical Stimulation for the Upper Limb of Children with Cerebral Palsy

Philip Wright

Department of Medical Physics & Biomedical Engineering,

Salisbury District Hospital, Salisbury, Wiltshire SP2 8BJ

www.salisburyfes.com

Upper Limb impairment is a major handicap to many children with Cerebral Palsy (CP). It may make activities of daily living, sitting, balance, and maintaining personal hygiene difficult or impossible without assistance. The existing management techniques of surgery, physiotherapy, orthoses and medication are not always the answer and so the application of Functional Electrical Stimulation (FES) for the upper limb of children with CP has recently been considered.

Atwater et al. (1991) published the first report on the application of FES to the upper limb of children with CP. Two children, aged eleven and twelve years, were given three wrist extensor stimulation sessions of 20 minutes duration each week for eight weeks. Active wrist extension range of motion (ROM) and the time taken to carry out some functional grasp and release tasks were recorded pre-treatment and immediately post-treatment. No significant changes in ROM were recorded. The time taken for the children to complete the hand function tests decreased although the time taken for a group of children not receiving upper limb stimulation to complete the same tasks decreased by a similar amount.

In subsequent case studies by Carmick (1993b, 1997) investigating FES as a treatment for the upper limb of children with CP several qualitative observations were made following treatment. These included improved weight bearing with the impaired upper limb, increased awareness and spontaneous use of the impaired limb and improved hand grasp and release abilities. This work by Carmick suggested that FES could improve hand function and ROM. These were qualitative observations, however, and there was little quantitative evidence to support them. Schecker et al. (1999) reported on 19 children and young people (aged 4 to 19 years) who used a combination of electrical stimulation and dynamic bracing to reduce upper extremity spasticity. Two thirty minute sessions of extensor stimulation combined with dynamic orthotic traction for between 3 and 43 months was given. A static brace was used at night. Spasticity improved by between 1 and 3 levels on the Zancolli classification system for all patients.

Wright and Granat (2000) investigated the effect of cyclic FES on the wrist extensor muscles of a group of eight children with hemiplegic CP (mean age 10 years, 5M 3F). The study design was baseline(three week) – treatment(six week) – follow up(six week). FES was applied for 30 minutes daily during the treatment period of the study. Improvements in hand function (p<=0.039), and active wrist extension (p=0.031) were observed at the end of the treatment period. These improvements were largely maintained until the end of the follow-up period. No significant change was observed in the measurements of wrist extension moment during the treatment period (p=0.274).

References

Atwater SW, Tatarka ME, Kathrein JE, Shapiro S. (1991) Electromyography-Triggered Electrical Muscle Stimulation for Children with Cerebral Palsy: A Pilot Study. Pediatric Physical Therapy 3: 4. pp190-199

Carmick J. (1993) Clinical Use of Neuromuscular ES for children with CP, Part 2: Upper Extremity. Physical Therapy 73: 8. pp514-527

Carmick J. (1997) Use of Neuromuscular Electrical Stimulation and a Dorsal Wrist Splint to improve the Hand Function of a Child With Spastic Hemiparesis. Physical Therapy 77: 6. pp661-671

Scheker LR, Chesher SP, Ranirez S (1999) Neuromuscular electrical stimulation and dynamic bracing as a treatment for upper-extremity spasticity in children with cerebral palsy. Journal of Hand Surgery (Br.) 24B, 2, pp226-232

Wright PA and Granat MH (2000): The therapeutic effects of Functional Electrical Stimulation of the upper limb of eight children with Cerebral Palsy. Developmental Medicine and Child Neurology 42, pp724-727

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Study of the Effect of Functional Electrical Stimulation (FES) on walking in children undergoing Botulinum Toxin A therapy

Galen SS*, Granat MH*, McWilliam R**, Wiggins L**.

* University of Strathclyde, Glasgow.

** Yorkhill Hospital NHS trust, Glasgow.

Children with neurological disorders such as cerebral palsy exhibit an abnormal gait mainly due to the loss of selective motor control and spasticity. It has been shown that spasticity can be controlled by using botulinum toxin A. The deactivation of the spastic muscle gives an opportunity for the inactive muscle to be activated. But due to the lesion in the motor cortex the child’s ability to initiate movement in the inactive muscle is very poor. We propose that FES can be used to activate specific inactive muscles.

The aim of this study is to determine the feasibility of using FES for correction of abnormal gait pattern in children who are undergoing botulinum toxin A therapy. Long term application of FES will be used to determine if this would improve the movement pattern.

The subjects are being recruited from the pediatric neurology clinic at Yorkhill Hospital, Glasgow. Subjects will be within the age range of 4-8 years and have gait deviations due to dynamic equinus. The study will involve between 12-15 subjects, with the first 2 or 3 subjects participating in a pilot phase. The FES training involves two phases, each lasting for a period of four weeks. The testing procedure to measure the outcome of the FES integrated training includes gait, electromyography (EMG) and video analyses. Each subject would be participating in the study for twenty weeks.

The combined gait and EMG analyses are carried out to reveal the biomechanical and physiological changes that take place in the muscles undergoing FES. The outcome of this study would demonstrate the feasibility of using FES to improve movement patterns.

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The Effect of Functional Electrical Stimulation on the Gait of Children with Cerebral Palsy: a pilot study

Sally Durham1, Linda Eve2, Chris Stevens3, David Ewins1,3

1 Gait Laboratory Queen Mary’s Hospital, Roehampton, London

2 One Small Step Gait Laboratory, Guys Hospital, London

3 Centre for Biomedical Engineering, University of Surrey

Abstract

Equinus foot disorder (toe walking) is a common problem for patients with cerebral palsy who are able to walk. Functional electrical stimulation is a recommended method of improving foot drop in adult stroke patients. The efficacy of functional electrical stimulation to the anterior tibial muscles was evaluated in a pilot study of 10 children with cerebral palsy who walked with a toe gait. The mean age of the children was 9.1 years.

Electrical stimulation was set up as a functional orthosis with a pressure switch under the heel to time the stimulation of the anterior tibial muscles at the appropriate time in the gait cycle.

The outcome was evaluated using three-dimensional instrumented gait analysis. The primary outcome measure was heel-toe interval. Secondary outcomes were walking speed, step length and knee angle at initial contact and physiological cost index of gait. Joint range of motion at the ankle, height and weight were recorded, and user perspective investigated by questionnaire.

These parameters were determined on setting up the stimulator, after three months of use and three months after discontinuing use.

Descriptive statistics for the whole group suggest an immediate (orthotic) benefit in heel-toe interval and reduction in energy expenditure, but little therapeutic benefit. However, the detailed analysis suggests that some of the children had a better response to stimulation. Reasons for this are being investigated.

Results suggest that functional electrical stimulation to the anterior tibial muscles for this population of patients may be a useful intervention. Further work is needed to develop more lightweight and cosmetic equipment, and refine selection criteria.

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Functional and Therapeutic Electrical Stimulation in Children: an evaluation of the clinical work at Salisbury District Hospital (1996-2002)

Catherine Johnson

Department of Medical Physics, Salisbury District Hospital, Wilts SP2 8BJ

Tel. 01722 429065 Email: calj@salisburyfes.com

Introduction and Aims

The Functional Electrical Stimulation (FES) Clinic was established at Salisbury District Hospital in 1996 as a National Health Service clinic. Paediatric referrals have comprised 5% of the total number of patients seen to date. A review of the service to children was planned with the aim of evaluating clinical effectiveness.

Salisbury FES Clinical Service

The children seen to date have used both therapeutic exercise stimulation (TES) and functional electrical stimulation at the clinic. TES has been used to strengthen the stimulated agonist, to improve passive soft tissue length, and to inhibit antagonist spasticity. It has also been used to prepare children for the use of FES, including helping children accommodate to the sensation of stimulation. FES has been used to increase the mobility of children and improve the quality of their gait pattern.

Methods

The review considered the findings taken from the clinical database of the Salisbury FES Clinic, and the medical notes of children seen. Outcome measures used include walking speed and the Physiological Cost Index of gait.

Results and Discussion

Diagnoses

A total of 65 children have been seen to date. Referrals of children with neurological conditions comprise the largest group (97%). The majority of children (68.2%) have cerebral palsy (CP); acquired hemiplegia form the second biggest cohort (18.1%). Importantly, with respect to the range of conditions, a number of orthopaedic referrals (6%) have also responded positively to stimulation, as have children with facial and Erbs palsy.

TES

33 children have participated in a programme of TES to the lower limb. Parameters used include stimulation of the common peroneal nerve, and the calf, quadriceps and gluteal muscles. 18 children have used TES in the upper limb and 2 children used TES to the facial nerve.

FES

29 children have used the single channel Odstock Dropped Foot Stimulator (ODFS). 12 children are full users of the ODFS, where the device is used throughout the day to assist walking. 17 children are partial users, who use the ODFS during the evenings, weekends and during gait re-education sessions. Some cosmetic issues have also been reported.

10 children have used the Odstock 2 channel stimulator (O2CHS): six children stimulating the common peroneal nerve bilaterally; three the common peroneal and calf; one the common peroneal and quadriceps; one the calf bilaterally.

Walking tests used to monitor an individual’s response to stimulation have not been as consistently carried out as in the adult population. Qualitative improvements in walking pattern do not always correlate with increases in walking speed. Individual patient response curves are variable, and there was missing data. Mean scores of the most complete results have been analysed. Walking speed tests have shown an increase of 8% in non stimulated walking at 6 weeks, of 10% at 6 months, and 22% at 12 months. The total orthotic effect at 12 months was 27%.

Conclusions

The benefits that have been demonstrated, and the reported practical and cosmetic problems warrant further study. A debate on the best clinical measures to use with children would also be of value.

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Electrical Stimulation Of The Gluteus Maximus In Children With Cerebral Palsy: Effects On Muscle Strength And Gait Characteristics

van der Linden ML PhD, Hazlewood ME MCSP, Hillman SJ MSc, Kerr AM BSc MCSP, Robb JE FRCS

Anderson Gait Analysis Laboratory, Edinburgh, Scotland.

Introduction

Electrical stimulation (ES) has been suggested as a treatment to increase muscle strength, range of motion and motor function in cerebral palsy (1,2). The aim of this study was to investigate whether ES to the gluteus maximus would improve muscle strength, gait characteristics and motor function of children with cerebral palsy.

Patients and Methods

Twenty-two children (aged 5-14) with cerebral palsy and no previous surgery to the hips were recruited. Each child was matched with another child on age, estimated hip extensor strength and internal hip rotation in gait. The children of each pair were then randomly allocated to either the ES or the control group. All children in the study continued with their normal physiotherapy sessions and home exercises. Surface stimulation was applied using the NeuroTrac 2 stimulator to the most affected leg. The parents were asked to apply the stimulation 6 days a week for one hour a day. The first two weeks were used to familiarise the child with the sensation and to condition the muscle using a low intensity and low frequency (10Hz) stimulation. In the remaining 6 weeks the stimulation frequency was 30Hz, the pulse width 100m s, with a 5-10s on-off cycle and 0.8 ramp at both sides of the stimulation period.

The following pre and post test measurements were taken for all children: 3D gait analysis, strength of the gluteus maximus measured using the MIE Myometer, passive range of movement of the hips and Section E of the GMFM. The parents of the children in the stimulation group were given a questionnaire on the use of the electrical stimulator. The differences between the measurements taken in the first and second assessment were compared between the stimulation and control group using paired t-tests (p<0.05).

Results

In most of the children a good visible contraction of the gluteus maximus was achieved. The majority of the parents thought the stimulator was easy to use and only two children disliked using the stimulator. Subjectively, seven parents thought that the treatment made a difference to their child. However, no significant objective differences were found between the ES and control group for GMFM score, walking speed, muscle strength, peak internal rotation and peak hip extension in gait or passive limits of hip rotation, passive hip extension and femoral anteversion.

Discussion

No significant effects of ES to the gluteus maximus on the any of the measurements taken were found. One possible explanation is that the gluteus maximus has more muscle mass than for example, the tibialis anterior where ES has proven successful (1). It was therefore more difficult to stimulate the whole muscle without discomfort. Further, the external rotation of the hip in prone lying or sitting as triggered by ES in this study is considerably different from the function of the gluteus maximus during gait. It has been suggested (3) that electrical stimulation is more successful when the movement achieved by stimulation is more functional.

Conclusion

This study did not support the use of electrical stimulation to the gluteus maximus, using this protocol, as a treatment option for children with cerebral palsy in order to improve muscle strength, gait characteristics or motor function.

REFERENCES

[1] Hazlewood ME et al. (1994) Dev Med Child Neurol 36(8):661-673.

[2] Pape KE et al. (1993) J Pediatr Orthop 13(5):628-633.

[3] Comeaux P et al. (1997) Pediatr Phys Ther 9:103-109.

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Night Time Use Of Threshold Electrical Stimulation - A Case Study

Mary Mehl

Purpose: To help reflect on changes in the gait pattern of a child with mild spastic diplegia following night-time use of threshold electrical stimulation over motor points. The muscles stimulated were initially hamstrings and the calf muscle group. Later this was changed to the Quadriceps and Tibialis Anterior Muscle Group.

Method: The stimulators used were initially the NT2000 and later the NTTES. There had been a gait analysis prior to electrical stimulation and this was repeated one year later following night-time electrical stimulation.

Results: These indicated an improvement in the gait pattern showing that ground contact ,swing phase and range of movement had improved.

Follow-up: There is no carry over effect noted with discontinuation of electrical stimulation over a 2 month period. Gait improvements were restored with the restoration of the night-time electrical stimulation program. Over time the motor points are changed to stimulate quadriceps and tibialis anterior.

Conclusion: It is difficult to be conclusive as further gait analyses are pending in the future to monitor gait.

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Functional Electrical Stimulation (FES) to improve Gait in Cerebral Palsy

A Case Study

G.E. Mann

Department of Medical Physics and Biomedical Engineering

Salisbury District Hospital, Salisbury, Wilts. SP2 8BJ

Tel 01722 429065 E-mail g.mann@mpbe-sdh.demon.co.uk

Background

G. is a 12 year old boy with cerebral palsy, referred to the Salisbury Medical Physics department in February 2000 for FES assessment to improve gait. He has an asymmetrical diplegic gait with a greater degree of flexion and internal rotation of the right leg. Plaster casting and night splinting have been used to treat shortening of the lower limb tendons. These produced little improvement. Ankle-foot orthoses (AFOs) were subsequently prescribed. Future surgery has been proposed.

Initial Assessment

Muscle weakness in the lower limb was greater on the right than the left. G. walked quickly with bilateral toe strike and knee flexion on initial contact. The right hip was weak and flexed, adducted and internally rotated. Hip ‘hitching’ during swing phase allowed the foot to clear the ground. G. achieved heel strike only when wearing the AFOs. Both feet were inverted. He was able to walk ½ a mile without a walking aid. Initially, G. was sensitive to the sensation of the stimulation and unable to tolerate the intensity necessary to produce muscle contraction.

Treatment

G. used an exercise stimulator for 8 weeks to stimulate the right common peroneal nerve, in order to reduce his sensitivity to the sensation of stimulation. At the end of this period the Odstock Dropped Foot Stimulator (ODFS) was set up successfully. G. had also stopped using his AFOs because of blistering on both feet. His usual toe walking pattern was improved by stimulation achieving a neutral flat foot position with occasional heel strike. G. was able to improve his gait pattern still further with conscious effort. He wore the ODFS daily and carried out exercise stimulation once a day. After 6 weeks his walking speed increased by 2% and effort reduced by 39.3%. After 9 months using both the ODFS and exercise stimulation G. continues to toe walk without stimulation and does not gain consistent heel strike unless he concentrates on doing so. His walking pattern is improved by stimulation and is less effort. However, poor alignment at the trunk and hip compound his walking problems.

G. is now growing rapidly. Recently, his mother reported that his hamstrings were becoming tighter and that G. was weight bearing on a very flexed right knee. A second channel of stimulation for the right quadriceps was tried in the clinic with good response. This has not yet been set up for G. to use at home as it remains to be seen whether the optimum second channel is the quadriceps or the gluteal muscles. The latter may allow the hip to be aligned so that greater stability and more effective use of the knee extensors during stance are possible. This will be discussed video evidence presented of the effect of stimulation on G’s walking pattern.

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A note on foot-switches

We have had a few enquires about the use of foot-switches. Generally the new design is working for longer and more reliably. However, some people still have some problems.

Use of an Insole

At our clinics we use an insole, sticking the foot-switch on the underside of the insole. The underside is made of cork, which in our experience is durable enough to give a reasonable life. Because the footswitch is held in a repeatable position this provides reliable triggering of the stimulator. It also allows easy transfer of the footswitch to different shoes, creating less stress on the switch compared with sticking it to the sole of the shoe. Taping direct to the heel sometimes deforms the foot-switch, damaging the seal, allowing sweat to damage the sensor. The insole may take some of the shear forces away from the foot-switch, prolonging its life.

Which way round to have the foot-switch?

The ‘active’ part of the foot-switch is the black circle, so the user's weight must be placed on this area. While earlier models of the switch were completely symmetrical, the present design has a backing plate on one side and the sensor the other. Some people have found that the switch can work more reliably with some people if it is placed "up-side-down", i.e., with the serial number facing the innersole (see diagram). For this reason the foot-switch now comes with double-sided tape on both sides so they can be placed either way up.

Footswitches can also be stuck directly to the skin using medical tape. The adhesive rings used to attach TcPO2 sensors (blood gas saturation sensors used in ICU) are also good for this but quite expensive. This positioning is liked by some users who wish to wear stockings or tights, enabling all the wires to be under the clothing. Switches may receive more stressing used in this way so may not last as long.

Stacey Finn

 

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Thoughts from IFESS-2002

Last month four of Salisbury FES team attended the annual conference of the International Functional Electrical Stimulation Society (IFESS) in Ljubljana, the capital of Slovenia. As well as sampling some of the beautiful scenery and hospitality, we also listened to some of the current research and studies in the field of FES.

For those of you not familiar with IFESS, it states as part of its mission "to promote the research, application and understanding of electrical stimulation as it is utilised in the field of medicine…". So is this being achieved?

Basically ‘yes’. The research tended to be of a high standard and the list of authors demonstrated the sheer quantity of collaborative work between centres and between countries. It is always difficult to summarise a conference, but perhaps four papers stood out as being of direct relevance to our clinical work today.

The first two papers were results from surveys. The Slovene group described a survey of 50 spinal cord injured (SCI) FES users, with the results indicating an improvement in function and quality of life. This study was particularly interesting because it questioned users on issues that are often neglected, such as digestion, urinary tract infections and pain. However, disappointingly, and reinforced at visits to their rehabilitation centre, the use of measurable outcomes is very poor, both for SCI and other patient groups, such as stroke. On the other side of the euro (so to speak), a Dutch group asked physiotherapists to prioritise walking impairments in incomplete SCI persons. Two findings came out that could either be construed as obvious or as potentially significant in FES treatment: /1/ impairments at the hip and pelvis were scored highest, and /2/ though FES is viewed favourably it is not widely used.

I think both these surveys emphasise the importance of closer co-operation between ‘research’ and ‘clinical’ groups. In the current ‘political’ environment, if FES is to be more widely used then we need to support our claims through the use of effective and relevant outcome measures. Only then will we be able to persuade funding bodies and other clinicians, including those who are in a position to prescribe but do not, to become more actively involved. Secondly, any research and application of FES needs to be clinically relevant, addressing real issues and concerns, but at the same time not necessarily precluding the more ‘blue skies research’.

The second two papers were from small studies. Postans and Granat (Strathclyde) presented a paper on preliminary results indicating positive effects from using FES to assist walking in CP children. While this is not necessarily new, it highlighted the need for a serious trial in CP and also in defining outcome measures from ‘gait analysis’ for each child and in setting clinically significant targets for these outcomes. Gregoric (Ljubljana) described some results (though take with caution, as numbers were very small!) suggesting that improvements in voluntary wrist movement following botulinum toxin injections to treat flexor spasticity decreased towards the baseline as the effect diminished over time. However, using FES with the toxin maintained the improvements. Since FES and botulinum toxin are being increasingly used as combined treatments, these results suggest a trial in this area.

I am also pleased to say that one of our therapists, Lisa Malone, received second prize in the student paper competition. Researched as part of her Masters, this nice piece of qualitative work into ‘Users and patients perspectives of using the ODFS’ addressed an area often overlooked in research and clinics, so recognition was very deserved and welcome. To give it justice, I’ll let you read Lisa’s article within this newsletter, but just to say the results brought a loud ‘phew’ from us!

As to the future … the make-up of the conference delegates reflected the primary academic and clinical research institutions across each of the continents. Unfortunately, but as is generally the case, the clinicians that should be prescribing these systems and assisting in our research were scarce. Therefore, perhaps the "application" part of the IFESS mission statement is lagging behind. We hope this will change and for our sins Salisbury has agreed to host the same meeting in 2004. Titled as "Getting FES into clinical practice", it is planned for this meeting to be held jointly with medical and paramedical rehabilitation societies and to include workshops on clinical FES techniques and related issues, e.g. spasticity. We therefore hope there will be a very strong clinical representation – so you will be hassled at every opportunity from each and every one of us, both to present and attend! You have been warned.

FES Educational Resource

It is interesting to note that the International Functional Electrical Stimulation Society (IFESS) has provided an invaluable educational resource. It is written primarily for patients and their families and health care professionals – introducing what FES is and its potential applications. For those of us delivering FES treatment packages, this resource may be useful in developing patient information sheets and in describing these approaches to potential purchasers. You may therefore like to visit their web site at http://www.ifess.org.

Duncan Wood

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Using the Odstock Dropped Foot Stimulator: User’s and Partner’s Perspectives.

L. Malone, *C. Ellis-Hill, I. Swain

Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital, UK.

*University of Southampton, UK. Email: C.H.Ellis-Hill@soton.ac.uk

Abstract

The Odstock Dropped Foot Stimulator (ODFS) is a single channel neuromuscular stimulator providing peroneal stimulation to correct dropped foot. Previous studies are quantitative in nature. There is no research exploring people’s use of the device from their own perspective. By using a qualitative design, this study explored the experiences of people using the device and their partner’s views. The participants reported that the ODFS had changed their lives. The ODFS users were more socially confident with the device, as it reduced the risk of tripping and/ or falling. Partners felt more confident leaving the ODFS user alone at home. The main problems reported included electrode positioning and finding suitable clothes to wear with the device. Overall, the participants wished that more people were aware of the device and that access to it was made easier.

Introduction

The Odstock Dropped Foot Stimulator was designed at the Department of Medical Physics at Salisbury District Hospital in 1988 to correct dropped foot. This is a common problem experienced by people with an upper motor neurone lesion, where somebody is unable to lift their toes clear of the ground when walking. The ODFS is a single channel portable device providing electrical stimulation to the common peroneal nerve, to elicit ankle dorsiflexion and eversion. A clinical service was established at the Department of Medical Physics and Biomedical Engineering in 1996, following submission of research findings to the United Kingdom South West Region Development and Evaluation Committee. Previous studies published on the use of devices to correct dropped foot have focused on the effects on walking ability using standardised measures, such as walking speed and effort involved1. Questionnaires2,3 designed examining the use of devices at home report potential benefits as well as problems associated with its use. There are no studies, which explore people’s use of the device from their own perspective. Subsequently the aims of the study were: a) To explore the personal experiences of people using the ODFS and the meaning that the device holds in their lives, b) To explore partner’s views of the device and the meaning that the device holds in their lives.

Methodology

Ethical approval for the study was obtained from Salisbury Local Research Ethics Committee. Professor Swain, as the guardian of the database held at the Department of Medical Physics and Biomedical Engineering, identified the names of people using the ODFS between 6-24 months, living within 50 miles of Salisbury, who were unknown to the researcher. Professor Swain obtained written consent from the doctors who referred the patients to the department, to invite those patients to take part in the study. Twelve people out of seventeen contacted the researcher agreeing to participate. Separate narrative interviews were conducted with ten of the ODFS users (length of use, median = 8 months, range 6-19 months) and five partners in their own homes. In addition, two couples chose to be interviewed together. People were asked to tell their story of their life before and after ODFS use. Data on demographics, ODFS use, social and work activity (using the Frenchay Activities Index)4 were collected to describe the participant group and aid comparison with previous quantitative studies. The interviews were tape-recorded and transcribed verbatim. Each transcript was read and re-read to identify issues important to each participant. Similarities and differences were compared across all the interviews. A small number of transcripts were read by a second researcher and the interpretations compared.

Results

The age of the participants ranged from 41-73 years with a mean of 54.7 years. Interviewed were eight men and four women using the ODFS. Six participants had multiple sclerosis, four had a stroke, one had spinal cord damage and one person had cerebral palsy. Out of 45 on the Frenchay Activities Index, the participants using the ODFS scored from 13-40, with a median of 31. This indicated that overall the participants appeared to be managing at a fairly high level of social independence5.

All the participants reported that the ODFS had changed their lives. Although this is just a small piece of equipment, the benefits reported were wide ranging. People described it as being an integral part of their lives, so much so that one participant using the stimulator stated "I often think to myself when I’m walking home, what if I was mugged. In all that time to get it, two years. What if I were mugged. You know, that would be awful." (04/1284). The benefits described appeared to be linked back to people’s mobility.

Prior to using the ODFS all the participants reported tripping and falling. As one lady said "I was falling over at least once a day and I mean really, really bad, sort of smashing up face kind, of breaking glasses and bruises like you’ve never seen. I described it as if someone was picking me up and throwing me". (06/555). The participants reported spending time in and out of hospital. They described losing confidence with their walking. They had to concentrate all the time, looking at their feet, and overall they became more and more tired, which impacted on other areas of their lives.

With the ODFS, the participants described feeling more socially confident as the device reduced the risk of tripping and falling. They were able to walk faster and over a longer distance. Participants described feeling that their walking was more normal and required less effort, as they did not have to concentrate so much on their walking. Five participants using the ODFS spoke of not needing to use their walking stick any longer. As one gentleman described after a period of using the ODFS, "I dropped the walking stick, which forced me to walk more upright, almost like a neolithic man coming up and the sun’s come out ever since." (05/476). There appeared to be a knock on effect in performing activities of daily living. Opportunities for work, social and leisure activities increased. Partners reported feeling more confident to leave the ODFS user on their own at home.

The main problems experienced with its use included, initial difficulty finding the correct electrode positions. As one person stated "It was a nightmare to begin with. I nearly binned it." (07/235). However, this was resolved by all but two of the participants. In addition, all the women and their partners and several of the men, described difficulties finding suitable clothes, as they all wanted the device to be kept hidden from the sight of others. All the women felt that it was difficult to wear a skirt or dress with the device although most found ways of keeping it discrete. The participants felt that the stimulator box could be made more compact, and some felt that an implanted device would be advantageous. Problems with unreliable equipment, namely the foot switch, was experienced by two of the participants using the ODFS. Overall however, the participants reported that the benefits far outweighed any difficulties reported. As one lady stated "After my glasses it is the first thing I put on in the morning and the last thing I take off at night." (06/786). Even though the researcher was not actively involved in the treatment of the patients, the researcher was a member of the Department of Medical Physics and Biomedical Engineering. Ideally the study should have been conducted through an independent organisation.

Conclusions

This limited study has shown that the ODFS had far reaching effects on the participant’s lives. Throughout the NHS, although it is recognised by the Royal College of Physicians of England as a suitable treatment for people following stroke, some areas of the United Kingdom are able to refer people with a wide range of neurological conditions. Some just people with stroke, whereas others are unable to refer in significant numbers. The participants who took part in this study were generally pleased with the ODFS as well as the service received, and all expressed a wish that it was more widely available. As one gentleman summarised "It has been absolutely outstanding. It has really changed my life completely. The world looks complete again because you can touch it, you can taste it all. Because you can walk better, you can do more things. You find things are available to you, you thought the door had been closed on. You obviously can’t see these things, nobody can, but it doesn’t just stop with being able to put one foot in front of the other. The benefits to society are far reaching and so it should be marketed that way. It could change people’s lives. They could be more useful members of society rather than sitting indoors alone, not wanting to go out, because they are afraid to walk." (09/2304).

Acknowledgments

This study was conducted as the final part of a Masters Degree in Rehabilitation and Research at the University of Southampton. The work was funded partly by a grant from the Department of Health; the Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital; and the University of Southampton. The researcher would like to thank her supervisor Dr Caroline Ellis-Hill, at the University of Southampton; the team at the Department of Medical Physics, at Salisbury District Hospital; and especially the participants themselves.

References

[1] Taylor P. et al. "Clinical use of the Odstock Dropped Foot Stimulator - its effect on speed and effort of walking." Archives of Physical Medicine and Rehabilitation, 80, 1577-1583, 1999.

[2] Taylor P. et al. "Patient’s perceptions of the Odstock Drop Foot Stimulator." Clinical Rehabilitation, 13, 439-446, 1999.

[3] Karzsnia A. et al. "Why patient’s use or reject a peroneal muscle stimulator." Advances in External Control of Human Extremities, 251-260, 1990.

[4] Holbrook M. & Skilbeck C. "An activities index for use with stroke patients." Age and Aging, 12, 166-170, 1983.

[5] Wade D.T, Leigh-Smith J. & Langton Hewer R. "Stroke: measurement and natural history using the Frenchay Activities Index." International Rehabilitation Medicine, 7, 176- 181, 1985.

******

NEWS FROM BIRMINGHAM

A BIG THANK YOU to everyone who took part in the survey which formed part of my Masters Degree. As promised the following is a brief summary of my dissertation. It was completed and delivered in May and I await results.

Christine Singleton

A survey amongst Allied Healthcare Professionals (AHPs) trained in the use of Functional Electrical Stimulation (FES) to identify barriers encountered by them in implementing FES services for acute and chronic neurological conditions in the United Kingdom (UK).

Purpose:

The remit of the NHS Plan 2000 is to ensure patients receive appropriate evidence based health care, where available, by medical and allied healthcare professionals. FES and in particular the Odstock Dropped Foot Stimulator (ODFS) has been shown to be effective for the treatment of dropped foot, which is a functional problem experienced by many neurological patients.

This research project reports a survey of AHPs trained in providing FES as a treatment modality for the rehabilitation of patients with acute and chronic neurological conditions. In particular, the survey aimed to identify FES service provision nationally and the barriers encountered by trained professionals in providing FES services to patients. The survey also provided reflection on current FES training programmes.

Literature Review:

A review of FES and conventional treatment modalities for neurological patients was undertaken.

Barriers to implementation of research in the healthcare environment were identified and fall within four distinct headings: individual, educational, organisational and cultural. Frequent policy and organisational changes and insufficient funds for service delivery are also cited as barriers to research implementation.

 

 

Design:

A postal questionnaire survey, with reminders, was sent to all UK AHPs (n=316) registered as having attended the two day Introductory FES course provided by training FES clinicians based at Salisbury District Hospital, Salisbury and City Hospital, Birmingham from September 1995 to August 2001.

Results of the Study:

Response rate was 74% with 200 questionnaires accepted for analysis.

The questionnaire consisted of three sections.

  1. About You:- 174 female, 26 male. 186 were physiotherapists with majority having >6 years experience and working full time. Most were located in the south of England and worked in out-patient neurological settings followed closely by head injury units, care of the elderly, community, spinal and stroke units. 64% rated themselves as ‘good- excellent’ leaders.
  2. About the Courses:- A high level of satisfaction was recorded for standard of FES courses, usefulness, meeting expectation and value of equipment loan provision. Most course members were self-motivated to attend. There was a fall in respondent’s confidence/competence in their ability to provide FES now as compared to immediately following the course.
  3. About current FES service delivery:- 53.5% (n=107) of respondents do not provide FES for the following main reasons:- no funding for equipment, no funding for staff, insufficient resources within current therapy service provision to introduce a change in practice and no managerial support for FES treatments in the hospital/institution.

43.5% (n =87) of respondents provide a varied FES service. Only 7 described their FES service as ‘comprehensive and complete’. 42 described FES services as limited or ‘ad hoc’. 78% (n = 68) stated their FES service did not meet demand. 84% did not have departmental or institutional funding and 79% stated the equipment was funded by the patients.

Patient evaluation of FES services had a high rating with high patient compliance and quality of life improvements.

Conclusion:

Barriers to FES service implementation were identified and include the lack of funding for equipment and staff as well as insufficient support from management and organisations to implement a change in practice. Implemented FES services have been identified as varied and inadequate in meeting patient needs. Strategies to overcome identified barriers can now be considered by the training FES clinicians for future FES service delivery and FES course planning. However, the current changing NHS climate provides respondents with the best ever opportunity to influence change and implement effective and efficient services. Phil Gray, Chief Executive of the Chartered Society of Physiotherapy, has called to arms all therapist in the turf war of service delivery by stating:-

"Physios should be preparing their plans now and making sure that they get in early to demonstrate that they have a big contribution to make in delivering change in the NHS and improving services for patients and that therefore physio services deserve to receive substantial new investment."

(Physiotherapy Frontline, 1st May 2002, pg9)

It is hoped that results of this study will be published in order to disseminate information to the wider audience.

CHANGE OF ADDRESS

Please note that from September 2002 my contact details are:-

Christine Singleton, Clinical Specialist (FES), West Midlands Rehabilitation Centre, 91 Oak Tree Lane, Selly Oak, Birmingham B29 6JA

Tel: 0121 6278122. E-mail: christine.singleton@btinternet.com

I look forward to hearing from you with comments on the survey.

******

  Case Study

Correction of Trendelenburg gait using bilateral gluteal stimulation

Katherine Johnson

Salisbury District Hospital

History

A 55 year old man was referred for FES, presenting with radiation radiculopathy. He had testicular cancer in 1977 and was treated with radiotherapy. In 1979 he experienced a gradual onset of lower limb weakness, which he describes as progressing in a gentle downward slope of deterioration, with some more sudden step-downs. The prognosis for his condition is not known.

Mobility

On presentation, he was mobile independently and occasionally used a walking pole. He reported difficulties negotiating stairs and slopes, finding walking up hill harder than down hill. He was able to walk just 10-15 metres up hill before stopping to rest, and attributed this limitation to the weakness of his calf muscles. His balance was affected; he occasionally fell, and had great difficulty walking on uneven surfaces. He was not driving.

Objective assessment

On examination he had a Trendelenberg gait. He had full passive range of movement in both lower limbs. He scored grade 1 on the Modified Ashworth Scale for hamstrings bilaterally, and had no other increase in muscle tone, nor any ankle clonus. The distribution of lower limb weakness was recorded using the Oxford scale of manual muscle testing, and has been included here to give illustrate the clinical presentation. Repeated measures have not been recorded to date.

Oxford scale muscle power

 

Right

Left

Hip

 

 

Flexion

5

4

Extension

3

3

Abduction

3-

3-

Adduction

3

3

Knee

 

 

Flexion

4

4

Extension

5

5

Ankle

 

 

Dorsiflexion

5

5

Plantarflexion

3

3

Response to FES

The patient attended the initial assessment clinic to determine his suitability for the use of FES. He did not respond to stimulation of his tibial nerve – no contraction of his calf muscle could be elicited, probably due to denervation. His response to stimulation of the sciatic nerve elicited a hamstrings contraction equal to his voluntary effort. A good response was achieved with gluteal nerve stimulation, which gave a strong contraction of his glutei and increased hip extension.

He was set up with an Odstock 2-Channel Stimulator (O2CHS) to assist his mobility. His gluteal nerves were stimulated bilaterally using seven centimetre round silver platinum PALS electrodes. The active pole was placed distal and lateral to the posterior superior iliac spines and the indifferent over the motor points of gluteus medius (see diagram below). The timing of the stimulator was set to produce gluteal contraction during the stance phase of walking or in standing. Two footswitches were used, one under each heel and the stimulator set to ‘no time out’. Both channels operated on heel strike. Stimulation to each gluteal group was therefore given for as long as weight was maintained on the foot switch under the heel on the same side. Please refer to the diagrams below for the settings shown on the O2CHS and the new updated model, the O2CHSII.

Outcome Measures

The main outcome measures used were walking speed and the physiological cost index of gait. These were recorded over a 10 metre level walkway, with 2 metres at each end for acceleration and deceleration. The mean of 3 measurements were recorded consecutively for walking with stimulation and without. The order was a random sequence to avoid a bias from fatigue: 2 non-stimulated, 3 stimulated, 1 non-stimulated. A video recording was made of his walking pattern for observational gait analysis. A falls diary was also kept by the patient for 10 weeks prior using FES and for a period of 23 weeks once he was using FES.

Results

Subjectively the patient reported various benefits to his outdoor mobility from using FES. His confidence greatly increased when out shopping - he was no longer worried when in a crowd of being knocked off balance. He described a reduction in the effort of his walking; at first he noticed that he could walk as far with less effort; later he found he could walk further and more quickly. Before using FES his walk from home into town took 25 minutes and he was unable to walk back. After using FES for 9 months, the same journey took 15 minutes and he was able to complete the return journey without difficulty. He had more confidence walking on uneven ground, and could join his wife to their allotment, and visiting gardens, which he had previously been unable to do. He felt that FES had made a, ‘Big difference’ to his social life as a result of the increase in his mobility.

Falls diary

Prior to using FES, the average number of falls per day was 3.8. This number decreased significantly when using FES to 0.37 falls per day.

Gait pattern and walking tests

Observational gait analysis showed a reduction in lateral trunk lean when using stimulation. In the table below, the results of the walking speed and physiological cost index (PCI) are given.

Walking speed

Initial Assessment

3 months

9 months

Non-stimulated walking speed

0.97

0.97

1.18

Stimulated walking speed

1.06

1.14

1.27

% difference

9% increase

18% increase

8% increase

Carry over effect

N/a

0%

22% increase

Total orthotic benefit

9%

18%

31%

PCI

Initial Assessment

3 months

9 months

Non-stimulated PCI

0.56

0.48

0.44

Stimulated PCI

0.47

0.42

0.39

% difference

16% reduction

12% reduction

11% reduction

Carry over effect

N/a

14%

21% increase

Total orthotic benefit

16% reduction

25% reduction

30% reduction

 

******

  Recording outcomes

Paul Taylor, Carol McFadden

In these days of evidence based health care it is increasing important to be able to justify the treatment that you chose for your patient. The established gold standard for scientific evidence is the large scale randomised controlled trial (RCT) where the progress of two identical groups of patients are compared, one group using a new treatment, the other group using a sham treatment. Both the patients and the clinicians would be "blinded", i.e. neither know which patients received the real treatment. This type of trial is expensive and often not practical in a rehab setting, particularly when an intervention may be self evident to both the patient and the clinician. Often patients changing regardless of intervention and it is difficult achieve a sufficiently large and homogeneous group with which to apply statistics. Because of these difficulties it is increasingly being recognised that case study data, while obviously not as definitive as RCT, can still have an important role in informing the rehab community of the possible validity of new techniques and the data collected can be useful when designing larger trials. Additionally it useful to report back to referring doctors or funding bodies the progress of individual patients.

We have put together a series of forms for the collection of case series data. It is intended that the forms could be adapted to different treatments and circumstances and perhaps their chief roll is as a reminder to record information in a consistent way so comparisons can be made easily. We would be pleased to hear your opinions of the forms and any suggestions for additions or improvements. Please feel free to photocopy the forms and blow them up to A4 size. A good source for assessments used in neurological rehabilitation is the book by Derek Wade "Measurement in Neurological Rehabilitation" published by Oxford University Press, 1992, ISBN 0 19 262180 7.

Case Study Report Forms

These forms have been produce to help produce a standard reporting format for case studies. They are to be used as an addition to standard clinical notes and as a reminder to do repeated assessments. They can be applied to different interventions and the users can chose which parts to miss out or include as is appropriate to the intervention they are using.

Top form

Diagnosis and history: give brief overview of the relevant medical history.

Present condition: Describe how the patient is now, in particular features that are relevant to the planned intervention

Patient Goals: describe the goals which the patient wishes to achieve from the treatment.

Therapist: describe the goals the therapist wishes to achieve.

Treatment plan: describe the planned intervention including time scale

Assessments: tick the assessments you wish to include. Not all assessments need to be done. Chose the ones that are relevant to the patient and therapist goals.

 

10 m walking speed and PCI form

The form can be used for walking speed alone or walking speed and PCI.

Heart rate is measured using a Polar Heart Rate monitor.

To record the resting heart the monitor is first warn and then the patient is asked to sit quietly for 3 minutes. The heart rate is recorded once the rate has stopped falling.

Starting from 1m in front of the line, the patient's time to walk 10m is recorded. Allow at least 1m the other side of the line for deceleration. Record the heart rate as soon as the patient crosses the line. If the heart rate is still rising at this point, weight until it stops rising and record the highest heart rate reached. Record three runs with FES and three without. Vary the order in which they are recorded, for example, 1st with out, 2nd and 3rd with, 4th and 5th without, 6th with. Record any walking aids used and make sure the same ones are used for re-assessments if appropriate.

Average the walking times and changes in heart rate, then work out the means. Calculate the mean walking speed and PCI using the formulas on the form.

Work out the percentage differences with and without FES. If this is a reassessment, work out the percentage changes of carryover effect (the change in speed or PCI when walking without FES) and orthotic effect (the change in speed or PCI comparing walking without FES at the beginnings to walking with FES now)

6 minute endurance walk

The patient is asked to walk continually for 6 minutes with or without FES. This can be done in a corridor, counting the number of times the length of the corridor completed and multiplying it by the length, or in gym around a circular of figure of 8 course. It is important that it is done the same way each time. If 6 minutes is to long, the test can also be done for 3 minutes but record this. PCI is recorded in the same way as the 10 metre walk. As fatigue may well occur, do not record runs with and without FES at the same session if significantly affected. If a patient fatigued before the end of the 6 minutes and wishes to stop, record the distance they have walked to that point and use that as the result.

Pain Visual Analogue Scales

The patient is asked to mark on a line the point which represents the severity of any pain they experience where 0 is no pain and 10 is the worst possible pain. This can be done for pain experienced at rest and during a specific activity. Record the activity and make sure the same activity is used when reassessing.

Rivermead Motor assessment measure

A standardised questionnaire giving a description of functional mobility. (see Wades book)

Ashworth, Passive and Active ROM, Muscle Power

These should be self explanatory

Video

This is a reminder to video if appropriate. Remember to get written consent for video and showing at meetings or teaching if you plan to do this.

Falls Diary

Subjects are given a diary to record the number of times they fall. It is best if the patient is contacted weekly, by telephone if not in person, and the number of falls recorded otherwise it is easy for the patient to use the form. A fall is defined as losing your balance so that the person comes to rest on a lower surface. The lower surface can be the floor or an item of furniture such as a bed or chair. If the person saves them self from falling by grabbing a near by object or another person, this also counts as a fall. If they trip but save them selves without assistance or without grabbing a near by object, this does not count as a fall.

Other assessment

Other assessments can be added as appropriate. Write down on the top form which assessment is to be used.

 

 

 

 

 

Week

Unaided / STIM / AFO

Mon

Tue

Wed

Thur

Fri

Sat

Sun

1

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

2

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

3

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

4

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

5

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

6

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

7

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

8

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

9

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

10

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

11

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

12

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

13

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

Week

Unaided / AFO / STIM

Mon

Tue

Wed

Thur

Fri

Sat

Sun

14

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

15

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

16

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

17

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

18

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

19

Unaided

 

 

 

 

 

 

 

 

STIM

 

 

 

 

 

 

 

 

AFO

 

 

 

 

 

 

 

Falls Diary

As part of the assessment of your treatment we are asking you to record the number of times you fall while walking.

Please record the number of times you fall each day on the table. Do this by marking a line ( / ) for each fall. If you were not using any aid to correct your dropped foot, please place the ( / ) in the top box for each day. If you were using the stimulator (switched on!) when you fell, please mark the ( / ) in the middle box labelled STIM. If you were using an AFO or splint, please mark the ( / ) in the bottom box labelled AFO.

A fall is defined as losing your balance so that you come to rest on a lower surface. The lower surface can be the floor or an item of furniture such as a bed or chair.

If you save your self from falling by grabbing a near by object or another person, this also counts as a fall.

If you trip but save your self without assistance or without grabbing a near by object, this does not count as a fall.

Please bring this form with you to your next appointment.

Thank you for your assistance.

 

Patient Consent to Video

 

You have been asked that a video recording be made of you to record present condition. It may be possible to recognise you from this recording. The video recording may be used for training other staff from this hospital and others. You do not have to agree to this being done. If you do not wish to take part, this will not effect in any way your treatment from this hospital.

 

I give my permission for video recordings to be taken during this project for use in analysing my walking patterns.

Please tick Y / N

I give my permission for the video recording to be used for educational and training purposes.

Please tick Y / N

Name of Patient____________________________________________________

Signature__________________________________________________________

Date_________________________

 

Name of Clinician_____________________________________________________

Signature_____________________________________________________________

Date______________________

 

One copy should be given to the patient and one copy retained in the notes.

******

FES Equipment Order Form

Please use this form to order FES equipment from the department of Medical Physics & Biomedical Engineering - Salisbury District Hospital. All orders must have the name of the FES trained clinician. Please read the conditions of sale overleaf.

Name of supervising clinician or therapist

that has attended the Salisbury FES course:________________________________________

Name & address to send the equipment to (stimulators

will only be sent to the trained therapist or clinician): ________________________________

___________________________________________________________________________

___________________________________________________________________________

Name & address to send the invoice to: ___________________________________________

___________________________________________________________________________

___________________________________________________________________________

Contact phone number for queries with this order: __________________________________

Code Items Number required

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

________ ____________________________________________________ _________

 

Stimulators can be supplied with electrodes, electrode and foot switch lead lengths and shoe inner sole size of your choice. Please specify your requirements.

Cheques should be made payable to Salisbury Health Care NHS Trust.

Please send order to:

Mr Stacey Finn, Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ. UK

Fax: 0044 (0)1722 425 263, Tel: 0044 (0)1722 429 118, E-mail: s.finn@salisburyfes.com

Condition of sale

The Odstockâ range of neuromuscular stimulators are supplied under the following conditions of sale:

The supplied device will only be fitted by; a person who has been trained to the standards set by the Department of Medical Physics and Biomedical Engineering (MPBE) in the use of a given FES device, or a person approved as being competent in the use of FES techniques by MPBE. The said person must be registered in the list of accredited users held by MPBE.

The registered person and their employer are considered responsible for the continuing support of the use of the device by the end user.

 

Warranty

The Odstockâ range of stimulators and accessories are warranted for a period of twelve months from date of initial fitting by a FES trained and registered clinician. This is with the exception of the footswitch, which is warranted for a period of one month only. Also excluded are electrodes, and batteries which are considered to be consumable items. Should the unlikely event of any failure of the device occur during the warranty period, the device should be returned to the address shown below for inspection. Should the failure be due to a manufacturing or material defect the device will be repaired or a replacement supplied free of charge. This warranty is valid providing that:

  1. the failure cannot be attributed to misuse or improper fitting
  2. the warranty registration form has been completed and returned to the address shown below within 14 days of initial fitting
  3. it can be certified by demonstrable evidence that the fitting of the Odstockâ device has been carried out by a registered and approved clinician

This warranty is in addition to any statutory rights available to the purchaser

Repairs outside the warranty period

Repairs occurring outside the warranty period will be charged at a flat rate of £35* +VAT. Alternatively an extended 5 year (from first use of the device) warranty can be purchased at a cost of £100* + VAT. The extended warranty must be purchased at the same time as the device. The device accessories (leads, sounders etc.) are excluded from the extended warranty and are subject to a one year warranty only.

 

The Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury, Wiltshire, SP2 8BJ, UK.

*Price correct at time of printing July 2002

 ******

 

FES User Day

Post Graduate Education Centre

Salisbury District Hospital

Monday 18th November

10am - 5pm

We invite 15 minute presentations on any aspect of the clinical application of electrical stimulation. Presentations may be of original research, clinical experience or of case studies. The aim of the meeting is to promote discussion and the exchange of ideas in an informal setting.

It is hoped to have sessions on the following areas:

Use of FES to improve mobility in stroke, MS and spinal cord injury

FES in Cerebral palsy

FES in stroke upper limb

Electrical stimulation in conjunction with Botulinum toxin.

Facial palsy

Stimulator technology update

Please provide a 300-500 approx. abstract, which we will be made available on the day and will also be included in the winter addition of the FES Newsletter.

Power point, slides, OHP and video will be available for your use. If using power point, please bring your talk on disk, CDROM or Zip disk so a single computer can be used. This saves time between presentations.

The cost of the meeting is £30. Please make cheques payable to the Medical Physics Trust Fund.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Name _____________________________________________________

Address _____________________________________________________

_____________________________________________________

_____________________________________________________

Phone number _______________________________________________

I will attend the FES User Day Meeting Y / N

I wish to present a presentation Y / N

Tittle __________________________________________________________

________________________________________________________________

 

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