A randomized crossover study of functional electrical stimulation during walking in spastic cerebral palsy: the FES on participation (FESPa) trial

Background Spastic cerebral palsy is the most common cause of motor disability in children. It often leads to foot drop or equinus, interfering with walking. Ankle-foot orthoses (AFOs) are commonly used in these cases. However, AFOs can be too restrictive for mildly impaired patients. Functional electrical stimulation (FES) of the ankle-dorsiflexors is an alternative treatment as it could function as a dynamic functional orthosis. Despite previous research, high level evidence on the effects of FES on activities and participation in daily life is missing. The primary aim of this study is to evaluate whether FES improves the activity and participation level in daily life according to patients, and the secondary aim is to provide evidence of the effect of FES at the level of body functions and activities. Furthermore, we aim to collect relevant information for decisions on its clinical implementation. Methods A randomized crossover trial will be performed on 25 children with unilateral spastic cerebral palsy. Patients aged between 4 and 18 years, with Gross Motor Functioning Classification System level I or II and unilateral foot drop of central origin, currently treated with AFO or adapted shoes, will be included. All participants will undergo twelve weeks of conventional treatment (AFO/adapted shoes) and 12 weeks of FES treatment, separated by a six-week washout-phase. FES treatment consists of wearing the WalkAide® device, with surface electrodes stimulating the peroneal nerve during swing phase of gait. For the primary objective, the Goal Attainment Scale is used to test whether FES improves activities and participation in daily life. The secondary objective is to prove whether FES is effective at the level of body functions and structures, and activities, including ankle kinematics and kinetics measured during 3D-gait analysis and questionnaire-based frequency of falling. The tertiary objective is to collect relevant information for clinical implementation, including acceptability using the device log file and side effect registration, cost-effectiveness based on quality adjusted life years (QALYs) and clinical characteristics for patient selection. Discussion We anticipate that the results of this study will allow evidence-based use of FES during walking in children with unilateral spastic cerebral palsy. Trial registration ClinicalTrials.gov: NCT03440632.

Low Cost, User-Controlled Peroneal Stimulator for Foot Drop in Patients With Stroke

Foot drop is a common disabling condition following stroke. It has been conventionally managed using an ankle foot orthosis (AFO). An alternate rehabilitation option is the functional electrical stimulation (FES) systems that has undergone numerous improvisations over past few decades to make it more efficient and user friendly. This chapter aims to evaluate a prototype low-cost FES device in an Indian rehabilitation set-up to match the patients' cultural and socio-economic needs. It illustrates a pilot study designed to test the orthotic and clinical efficacy of the device in terms of dynamic ankle angle change during ambulation and comparing the walking speed and endurance with the AFO. A significant change with nearly two-thirds of normal ankle angle change during swing phase of the gait cycle was observed with nearly equivalent orthotic effects in terms of walking endurance and speed. In terms of receptivity, the device received a mixed response from the patients regarding its effectiveness as an orthosis.

Limited Discectomy for single level lumbar disc herniation: a retrospective study in a tertiary level hospital

Objective: To perform retrospective analysis of 1000 patients who underwent open limited discectomy (OLD) for single level lumbar disc herniation (LDH) and to assess the long- term clinical outcomes. Methods: 745 men and 255 women, with mean age of 38.03 ± 9.14 years (range 19- 55 years) who had primary LDH at L4-5 (n=640), L5-S1 (n=352), and L3-4 (n=8); underwent OLD were reviewed. Records were obtained regarding their demographic data, the side and level of disc herniation, operating time period, intraoperative blood loss, hospital stay, and perioperative complications. VAS score was measured before and after operation, for the assessment of low back pain (LBP) and radicular pain. Comprehensive outcome outcomes were measured postoperatively with the modified Macnab criteria and the Oswestry Disability Index (ODI) score. Results: The mean follows up was 24.5 (range 24-70) months. Significant improvement of mean VAS score for back and leg pain was achieved. At the two years follow-up, results were excellent in 525 (52.50%), good in 325 (32.50%), fair in 140 (14.00%) and poor in 10 (1.00%). Complications found were reherniation (n=52), discitis (n=19), superficial wound infection (n=7), dural tear (n=7) and foot drop (n=2). Conclusion: Open limited discectomy following fenestration or laminotomy is a safe and effective procedure and achieved favorable long-term outcome (e.g., low rate of recurrent LBP) and excellent patients’ satisfaction. Bangladesh Journal of Medical Science Vol. 21(1) 2022 Page : 37-44

Sudden bilateral foot drop due to dorsally unilateral migration of the herniated lumbar disc: A case report

BACKGROUND: Due to the anatomical characteristics of the anterior epidural space, dorsal migration of material from herniated lumbar disc is quite rare. Also, bilateral foot drop due to unilateral dorsal migration of disc herniation is extremely rare. This report presents a case of sudden bilateral foot drop caused by the unilateral dorsal migration of material from a herniated lumbar disc. CASE DESCRIPTION: A 51-year-old male presented with sudden onset severe leg pain with bilateral foot drop. The patient was referred to our emergency department by a local clinic. Neurological examination showed bilateral ankle and big toe dorsiflexion weakness grade 1. There was no perianal anesthesia, anal sphincter weaknesses, or voiding difficulty. Apart from essential hypertension, this patient’s medical history was unremarkable. Magnetic resonance imaging showed that intervertebral disc material in the dorsal extradural space at the L3-4 level had compressed the dural sac from the left side to the center. We performed an emergency operation. The pathologic result revealed fibrous cartilaginous materials. After the operation, the leg pain was markedly resolved. At postoperative three months, the patient showed improvement of foot drop. CONCLUSION: We recommended emergent mass removal, which produced a favorable outcome.

A Functional and Radiological Outcome Analysis of Hip Forage Procedure, done for Early Stages(Ficat and Arlet Grade 1 and 2A) of Avascular Necrosis of Head of Femur

Background: Avascular necrosis of the femoral head is a severe disease and causes osteoarthritis of the hip joint in young adults. Early diagnosis leads to better prognosis and therapeutic success. Aim: To study pain, radiological outcome & functional outcome post hip forage procedure in patients of avascular necrosis of head of femur (Ficat and Arlet grade 1 and grade 2A). Study Design: This was a prospective observational study. Place and Duration of Study: Conducted in the Department of Orthopaedics, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Nerul, Navi Mumbai over a period of 2 years from 2015 to 2017 Methodology: We included 50 patients (39 males, 11 females) with Avascular necrosis of unilateral or bilateral head of femur (Grade 1 and Grade 2A), clinical, radiological and functional(with the help of Harris hip score) examination was done at 6 months and 12 months follow up post operatively. Results: Out of the 50 patients, pre-peratively, 60% reported moderate pain, 20% mild pain and 20% severe pain. At follow-up, 36% patients reported slight pain, 26% mild pain, 26% moderate pain, 8% marked pain, and no pain was reported by 4% patients. Pre-operatively, no limp was seen in 34% patients, while 66% patient had a limp. At follow-up, 70% patient had a limp and no limp in 30% patients. Before surgery, support (cane use) was required by 6% patients, while at follow-up, support was noted by 12% patients. Preoperative mean Harris Hip Score was 63.6, while that at follow-up it was 74.74. Radiological worsening of the disease occurred only in 38% of the patients which suggests that disease progression was delayed in most patients(62%). 2% patients had a complication of foot drop. Conclusion: Avascular necrosis of femoral head is more common in young males. Core decompression by multiple drilling and/or core decompression with fibular strut grafting are equally effective in pre collapse stages (stage 1 and stage 2A) with better functional and radiological outcomes and hence these procedures can play a vital role in delaying the disease progression.

Limb Muscle Reinnervation with the Nerve-Muscle-Endplate Grafting Technique: An Anatomical Feasibility Study

Background. Peroneal nerve injuries results in tibialis anterior (TA) muscle paralysis. TA paralysis could cause “foot drop,” a disabling condition that can make walking difficult. As current treatment methods result in poor functional recovery, novel treatment approaches need to be studied. The aim of this study was to explore anatomical feasibility of limb reinnervation with our recently developed nerve-muscle-endplate grafting (NMEG) in the native motor zone (NMZ). Methods. As the NMEG-NMZ technique involves in nerves and motor endplates (MEPs), the nerve supply patterns and locations of the MEP bands within the gastrocnemius (GM) and TA muscles of rats were investigated using Sihler’s stain and whole-mount acetylcholinesterase (AChE) staining, respectively. Five adult rats underwent TA nerve transaction. The denervated TA was reinnervated by transferring an NMEG pedicle from the ipsilateral lateral GM. At the end of a 3-month recovery period, maximal muscle force was measured to document functional recovery. Results. The results showed that the TA was innervated by the deep peroneal nerve. A single MEP band was located obliquely in the middle of the TA. The GM was composed of two neuromuscular compartments, lateral (GM-l) and medial (GM-m), each of which was innervated by a separate nerve branch derived from the tibial nerve and had a vertically positioned MEP band. The locations of MEP bands in the GM and TA muscles and nerve supply patterns demonstrated that an NMEG pedicle can be harvested from the GM-l and implanted into the NMZ within the TA muscle. The NMEG-NMZ pilot study showed that this technique resulted in optimal muscle force recovery. Conclusion. NMEG-NMZ surgery is feasible for limb reinnervation. Specifically, the denervated TA caused by peroneal nerve injuries can be reinnervated with a NMEG from the GM-l.

A Case Series of Intraneural Ganglion Cyst Involving the Common Peroneal Nerve: Potential Cause for Foot Drop

Background: Intraneural ganglion cysts (IGC) are non-neoplastic mucinous cysts that form when thick mucinous fluid accumulates in the epineurium of peripheral nerves, with the majority of cases occurring in the para-articular or articular areas. Case Presentation: The two cases of a 69-year-old man and a 59-year-old man who acquired peroneal nerve neuropathy as a result of an intraneural ganglion cyst are presented here. The L.L.R.M. Medical College Department of Orthopedics provided care for them. There was complete nerve recovery in all patients after substantial cyst wall dissection and secretion removal. Conclusion: An intraneural ganglion cyst and trauma may exacerbate nerve damage, despite the fact that it is difficult to detect the cyst before surgery. An early diagnosis and prophylactic actions are typically associated with better outcomes. KEY WORDS: Intraneural ganglion, Common peroneal nerve, Foot drop.