NICE guidance for functional electrical stimulation for dropped foot
Geraldine Mann, Consultant Physiotherapist
National Clinical FES Centre, Salisbury District Hospital, Salisbury
Way Ahead 2009;13(3):5
Introduction
Functional electrical stimulation (FES) is a treatment modality in which electrical impulses are applied to intact peripheral nerves supplying paralysed muscles in order to produce functional movement. Its most common application is in the correction of dropped foot during gait following a central nervous system lesion. FES has been successfully used in people with stroke, multiple sclerosis (MS), incomplete spinal cord injury, traumatic brain injury and cerebral palsy.
FES research
The first randomised controlled trial to investigate the effect of FES for correction of dropped foot in stroke was conducted at Salisbury District Hospital in the mid 1990s1. Two groups were compared. One received physiotherapy and FES, using the Odstock Dropped Foot Stimulator, and one received only physiotherapy. The results demonstrated significant improvements in speed and effort of walking with stimulation compared to walking without stimulation over 10 metres in the FES group. Improvements in speed and effort of walking were also significantly greater in the FES and physiotherapy group than in the group that received physiotherapy alone.
Subsequent studies using different stimulation devices supported these findings. Following publication of the Salisbury study the South West Development and Evaluation Committee (DEC) approved the use of FES for dropped foot in central nervous system conditions in the NHS. This led to the start of the clinical FES service in Salisbury in 1996, at which time approximately 75% of those referred for treatment were recovering from stroke, 20% had MS and 5% presented with neurological conditions. Since then that service has grown and others have been set up around the UK and abroad. In Salisbury the proportion of people referred for treatment who have MS has reached almost 50% of total referrals.
NICE guidance
In 2008 the National Institute for Health and Clinical Excellence (NICE) examined the published evidence for treatment of dropped foot with FES and in the process consulted a number of experienced FES clinicians to assist in formulating guidance for its use. The guidance, published earlier this year, supports the use of FES within the NHS and applies to all patient groups who have dropped foot due to an upper motor neuron lesion. The advice applies to both external and implanted systems.
An excerpt from the guidance states that:
'Current evidence on the safety and efficacy (in terms of improving gait) of functional electrical stimulation (FES) for dropped foot of central neurological origin appears adequate to support the use of this procedure, provided that normal arrangements are in place for clinical governance, consent and audit2'.
In the accompanying publication 'Understanding NICE guidance: Information for people who use NHS services: Treating dropped foot using electrical stimulation' there is the following summary:
'This procedure can be offered routinely as a treatment option for people with dropped foot caused by damage to the brain or spinal cord, provided doctors are sure that the patient understands what is involved and agrees to treatment and the results of the procedure are monitored3'.
Conclusion
The recognition of FES as an effective evidence based treatment is enormously encouraging both for those who provide clinical FES services and for those who could benefit from treatment.
It is particularly good news for people with MS that the guidance specifically refers to its application in those with lesions of 'central nervous system origin' as some funders have restricted funding to those with stroke and have argued lack of evidence for its use in people with MS. While the guidance does not oblige NHS funders to pay for the treatment, it does mean that they will no longer be able to claim lack of evidence for the technique.
- Read the full published guidance on the NICE website
- Read, order or download the MS Trust's factsheet on functional electrical stimulation
References
- Burridge JH, Taylor PN, Hagan SA, et al.
The effects of common peroneal stimulation on the effort and speed of walking: A randomized controlled trial with chronic hemiplegic patients.
Clin Rehabil 1997; 11(3): 201-210. - National Institute for Health and Clinical Excellence.
IPG278 Functional electrical stimulation for drop foot of central neurological origin: guidance.
London: NICE; 2009. - National Institute for Health and Clinical Excellence.
IPG278 Functional electrical stimulation for drop foot of central neurological origin: public information.
London: NICE; 2009.
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