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A case history of Patient ‘M’
FES - into the next millennium
Forthcoming courses and lectures
A young South African male of 33 years, previously fit, healthy and a committed sportsman.
In July 1993 he received a gunshot wound to his left frontal region whilst
in church in Capetown, South Africa. A left frontal craniotomy was performed
the same night. Subsequent operations included a burr hole for pneumocranium,
an anterior fossa repair and an acrylic cranioplasty.
Rehabilitation
January 1994 (In-Patient) - Rowans Head Injury Unit, Derriford Hospital, Plymouth. October 1994 (In-Patient and Out-Patient follow-up) - Marie Therese House, St Michael's Hospital, Hayle, Cornwall.
Patient "M" presented as a severe head injury with right sided weakness
and raised tone, especially in the right arm. A slight right foot drop was
present along with a marked flexor withdrawal pattern in the right arm. Return
of movement in the upper limb was very limited with only flickers of shoulder
flexion and elbow flexion/extension with nothing noted in the hand. The patient
was also dysphasic.
For the purposes of this article I shall describe the use of FES in this
patient's rehabilitation. However, it should be noted that normal neuro-rehabilitation
physiotherapy techniques have been used at all times in conjunction with FES.
Starting FES Treatment
FES began on Patient "M's" second session of physiotherapy at Marie Therese House on 19 October 1994. The patient was set up with a home exercise regime of FES to his right dorsiflexors and to his right triceps and wrist extensors. During physiotherapy sessions a novel use of a "skateboard" was devised. Patient "M" had his forearm strapped into a "skateboard" on a table and FES was used to provide a "wheeled" elbow extension. A similar idea was to use sling suspension to assist elbow extension in conjunction with FES to the triceps.
On 27 January 1995, three months after beginning FES on his dorsiflexors, Patient "M" was fitted with a drop foot stimulator by the Odstock Team. The importance of close monitoring by the local physiotherapy department should, however, be noted, since on checking his ODFS three days later Patient "M" was found to be still using it as an exerciser.
The use of FES and assisted weight-bearing on an extended elbow and wrist was successful in treatment sessions. FES was also used on deltoid anterior and lateral fibres to "lift" the arm in a functional way.
In approximately February 1995, four months after beginning FES, some active wrist extension was noted.
In June 1995 the very tight biceps was noted to be releasing well; i.e. coming out of its flexor pattern.
In July 1995 FES to wrist and finger extensors was added to the home exercise regime to hopefully start opening up Patient "M's" flexed fingers. The use of reciprocal FES to wrist flexors and extensors was also used to reduce tone in the arm. In September 1995 Patient "M" was releasing his fingers well enough to drink from a cup.
This was discontinued from 30 June 1995 to 12 January 1996. It was recommenced due to faulty gait patterns creeping back in, due to a remaining foot drop. Thus any carry-over was lost over time and the dorsiflexion in gait had not established itself.
The effect of recommencing DFS was to immediately improve gait and also to facilitate stair climbing by cutting out Patient "M's" abductor swing.
From March 1996 to June 1996 Patient "M" returned to South Africa for three months, taking a letter to explain that he was carrying a DFS and NOT a terrorist bomb through the x-ray and metal detector devices at the airport!
Patient "M's" right foot drop was still present although less marked. His right arm still had an associated reaction although mild. Lack of trunk rotation in gait was noted along with poor hip and knee release and a slight hip hitch. At this stage some gross hand function was returning. FES to wrist extensors and lumbricals was set up to continue at home and Patient "M's" DFS was rechecked.
In October 1996 Patient "M" was a "model" for our FES course at Marie Therese House. FES was simultaneously used on four channels to stimulate wrist extensors with extensor pollicis longus and lumbricals with wrist extensors. A dual channel stimulator was also experimented with, gaining DFS in conjunction with right triceps arm swing. The result of this dual channel stimulation was yet another step forward gaining trunk rotation in gait and a reduction of the right arm associated reactions.
In November 1996 after approximately one year nine months (minus six months) of DFS, Patient "M's" drop foot was no longer a problem; i.e. carry-over had taken place and an active dorsiflexion in gait was now established as normal movement.
At this point we continued to use Patient "M's" single channel DFS to activate triceps via his right heel strike.
After another four months' break to South Africa from February to June 1997 Patient "M" returned. Happily he was still walking two to three miles with no right foot drop problems.
Triceps stimulation with gait recommenced along with concentration on right arm function. Patient "M" was admitted to Marie Therese House for a week to concentrate on right arm function and work with the Occupational Therapist. Due to his triceps stimulation his biceps spasm was gently reducing allowing functional release of his finger flexors. Right thumb adduction and flexion remained a problem with grip. FES is now reaching the other extremity. We are now working on the thumb abductors and extensors with good effect.
Patient "M" is now able to write up high on a blackboard using a "ball" pen - great for right trunk elongation, shoulder girdle stabilisation with distal hand movements.
Patient "M" is regularly walking the Cornish coastal paths and is swimming every week.
Patient "M" continues to use his FES for his right triceps, his wrist extensors and his thumb extensors.
Patient "M" is due for a week's admission before Christmas 1997 to work on his right arm function and to perfect his cooking skills.
This patient's progress has been steady and, despite being four years since his head injury, his progress is continuing.
His commitment to the long-term use of his DFS has paid off in terms of eradicating his foot drop, which was the cause of so many other gait related problems.
His commitment to a home exercise programme for his right arm has, I am sure, helped maximise his recovery and enabled some function to return.
The interesting question to ponder on is "How much recovery would have taken place without the use of FES"?
This colloquium was assembled to aid communication between centres involved in the development of FES. Better communication will reduce the overlapping of projects and encourage centres to work together, and hence make good use of the limited resources available.
The first presentation by Martin Fraser from the Southern General Hospital, Glasgow on neuro prosthetic advances in the treatment of spinal cord injury , gave an insight into this branch of FES. The discussion that followed emphasised three points which were to be repeated throughout the day. Firstly, the need for further technological development to increase the muscle specificity of stimulation and to reduce muscle nerve fatigue. Secondly, the need for further clinical evaluations to increase the general acceptance of stimulators. And finally, the fact that the FES field has developed as a use for advancing technology and perhaps the patients should be asked about what they would find useful.
The next time tabled speaker was unable to attend, so her place was filled by Philip Wright from the University of Strathclyde, who spoke about the application of FES to the upper limbs of children with cerebral palsy. So far the results of this study have been fairly positive in the area of increased function and inconclusive on the subject of increased brain plasticity.
Jane Burridge from Salisbury District Hospital then spoke on improvement of hemiplegic gait with single channel surface stimulation. This study is looking at the EMG signals from the calf and anterior tibial muscles during gait. The hope is that information about abnormal muscle activation patterns will help to predict an individual’s response to stimulation, enable finer control of stimulator periods and help to identify when a 2 channel stimulator may be appropriate.
The discussion that followed focused on the problems of finding reliable subjective tests that do not involve the patients in hours of tedious examinations. Are long ‘good’ tests actually preferable to short ‘bad’ tests?
New implanted devices for the neural interface were presented by Nick Donaldson of University College London. These implants will allow selective activation of the small muscle fibres. Although human trials have yet to be carried out, the potential applications of such a device are numerous.
Ian Swain spoke about the development of a clinical FES service drawing from his experience of the standing system and drop foot stimulator clinics at Salisbury District Hospital. His presentation included promising results from the drop foot clinic database and patient reactions surveyed by questionnaire. The discussion which followed brought up the problems incurred in finding funding for FES patients and trials. Also mentioned was the encouraging use of an acupuncture motor point locator to correctly position surface electrodes.
An overview of the methodological considerations of evaluations of FES was given by Malcolm Granat of the University of Strathclyde. The use of rigorous single case studies repeated on a number of patients at different centres was encouraged, as opposed to randomised controlled trials. This was mainly due to the difficulties involved in setting up satisfactory dummy treatments and the large range of inter-subject variability.
The final presentation was by Jonathan Adler of Finetech Medical Ltd giving a commercial perspective of FES systems. This involved an summary of how the Active Implant Medical Devices Directive and the Medical Devices Directive affect the field of FES. His conclusions echoed those reached in the first discussion of the day and included the need to increase the awareness of prospective purchasers to FES. This could involve publications in relevant journals and possibly professional marketing.
The final discussion of the day drew on many of the points raised in earlier
presentations. It was decided to organise an FES symposium at the conference
of either the British Society of Rehabilitation Medicine or the Society
of Research in Rehabilitation. There was an unified call for a multi centre
trial. This trial might be of the Odstock Drop Foot Stimulator as it has
reached a useful level of technological function, and it may use Finetech
Medical Ltd as a industrial partner, which should help in attracting funding.
An e-mail listing of all centres and persons involved in the development
of FES, together with their facilities and skills, will be set up for aiding
communication in the future.
Leicester Hospital Physiotherapy Dept Half day study day March 7th. 10.00am - 3.00pm (contact Nicky Clague Tel 0116 2490 490 ext 4076)
Salisbury District Hospital Two Channel course March 13th.
RUH Bath Two day FES course March 21st - 22nd. (contact Geraldine Mann Tel 01225 824293 bleep 7560)
Victoria Hospital Frome ACPIN meeting May 11th. 7.30pm (contact Ros Edwards 01373 456628)
Worthing Two Day FES course June 11th and 12th (contact Penny Bell Tel 01903
205111 ext 5810)
This meeting will be held in the Post Graduate Medical Centre at Salisbury District Hospital. Presentations are invited from all users. They can be Case Histories, reports on studies, or prospective studies, or anything else that you might feel moved to talk about! There will be a forum for discussion and the opportunity to meet other users. We also hope to have an invited speaker.
There is no charge for the meeting per se but a nominal charge will be made
for tea/coffee/lunch. If you are interested in coming please complete the
Reply Form [deleted] and press the submit button, or contact Jane Burridge
Dept of Medical Physics Salisbury District Hospital, Salisbury SP2 8BJ
and we will send you details in the New Year.
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