To improve gait of freezing in patients with Parkinson′s disease by electrical stimulation to common peroneal nerve delivered by wearable stimulator
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Abstract:
Objective
To explore whether the proprioceptive sensory cueing delivered by electrical stimulator to common peroneal nerve can improve the freezing of gait of parkinsonian patients.
Methods
Thirty patients with Parkinson′s disease experiencing freezing of gait (FOG) admitted to the First Affiliated Hospital of Anhui Medical University from January to December 2018 were included in the trial. Proprioceptive sensory cueing was provided by alternating electrical stimuli to bilateral common peroneal nerves delivered through the wearable electrical stimulator automatically triggered by walking. The modified 12 meters Timed Walking Test, six items of the modified Parkinson Activity Scale (PSA-6), and FOG score were used to test the gait function respectively when the stimulator was turned on and off.
Results
Compared to the off status, time duration for two 360° turns (T360), initiating (T1) and the turning (T2) was reduced with statistical significance when the stimulator was turned on in the three trial situations which were walking with no extra task (17.49 (13.55, 23.48) s vs 14.73 (10.31, 21.71) s, 2.16 (1.78, 2.68) s vs 1.70 (1.38, 2.29) s, 6.37 (4.10, 7.45) s vs 4.77 (3.40, 6.85) s; Z=-3.219, -4.206, -2.910, P<0.05), walking with cognitive task (21.35 (16.30, 30.72) s vs 18.36 (13.83, 27.98) s, 2.80 (2.05, 3.75) s vs 2.04 (1.64, 3.00) s, 6.58 (5.23, 8.96) s vs 5.75 (4.59, 7.76) s; Z=-3.486, -4.206, -3.363, P<0.05) and walking with motor task (25.34 (17.79, 30.30) s vs 22.24 (14.11, 29.33) s, 2.46 (2.19, 3.18) s vs 2.35 (1.66, 2.59) s, 7.77 (4.75, 9.93) s vs 6.45 (3.81, 7.66) s; Z=-3.468, -3.983, -3.570, P<0.05). In all the three exercise modes, the maintaining time (T3) was not significantly different. With the stimulator turned on, the total walking time (Tt) was not significantly different when the patients walked without extra task and with cognitive task but obviously improved with motor task (29.26 (20.11, 33.21) s vs 27.66 (17.70, 32.73) s, Z=-2.644, P=0.008). Compared to the off status, patients showed higher PAS-6 scores (18.99±2.55 vs 16.82±2.92, t=-6.617, P=0.000) and lower FOG scores (14.10±5.02 vs 10.61±5.05, t=6.151, P=0.000) with statistical significance when the stimulator was turned on.
Conclusion
The wearable electrical stimulator can alleviate FOG in patients with Parkinson′s disease by improving rotation, gait initiation and turning and may be used as a new rehabilitative therapy for patients with FOG.
Key words:
Parkinson disease; Freezing of gait; Peroneal nerve; Electrical stimulation; ProprioceptionKeywords:
Proprioception
Common peroneal nerve
Functional electrical stimulation
To assess whether the application of Functional Electrical Stimulation improves gait kinematics and walking ability in people with multiple sclerosis who experience foot drop.Acute open labelled comparative observation trial.Twelve people (3 females, 9 males, EDSS 2-4) with relapsing remitting multiple sclerosis (47.8 years (standard deviation 6.6)) who were new users of functional electrical stimulation.Gait kinematics were recorded using 3D gait analysis. Walking ability was assessed through the 10-m walk test and the 6-min walk test. All assessments were performed with and without the assistance of functional electrical stimulation. The effect of functional electrical stimulation was analysed using paired t-tests.Ankle dorsiflexion at initial contact (p = 0.026), knee flexion at initial contact (p = 0.044) and peak knee flexion during swing (p = 0.011) were significantly greater whilst walking with Functional Electrical Stimulation. The increased peak dorsiflexion in swing of nearly 4 degrees during functional electrical stimulation assisted walking approached significance (p = 0.069). The 10-m walk time was significantly improved by functional electrical stimulation (p = 0.004) but the 6 min walk test was not.The acute application of functional electrical stimulation resulted in an orthotic effect through a change in ankle and knee kinematics and increased walking speed over a short distance in people with multiple sclerosis who experience foot drop.
Functional electrical stimulation
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STRIDE
Gait cycle
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Background: Neurodegenerative diseases like diabetes can significantly impair patients' postural balance and gait. These negative alterations in balance and gait coupled with peripheral neuropathy (PN) can dramatically reduce patients' ability to perform activities of daily living and also put them on high fall-risk. The purpose of this study is to treat balance deficit due to diabetes and PN using a home wearable technology based on plantar electrical stimulation. Methods: An innovative and low-cost therapeutic electrical stimulation (ES) device initially designed for pain management (SENSUS, NEUROMetrix Inc, MA, USA) was customized to deliver electrical stimulation to plantar regions of interest, Figure 1. Since neuropathy patients lack plantar sensations, the intensity of stimulation was set based on perception on senate skin. The therapy session was performed at home for 2 hours a day per week on each foot (at night before sleep and morning). The effect of ES was quantified by measuring changes in sway of ankle, hip and center of mass (CoM) and gait changes using body-worn sensors (LegSySTM, Biosensics LLC, MA, USA). Results: Five patients were recruited so far (Age 53.8±5.7, BMI=30±5 Kg/m2) with average vibration perception threshold score of 26.2±5.3V. Preliminary data analysis included baseline measurements on 5 patients and follow up on 3 after a period of one week. On average we observed a reduction of 23% (1.39±0.67deg to 1.07±0.78deg), 25% (1.08±0.85deg to 0.82±0.4deg) and 22% (0.25±0.16cm2 to 0.19±0.08 cm2) in ankle, hip and body sway during eyes open assessment. For gait we observed reduction in gait velocity (11%), increase in CoM sway (9.4%) and increase in double support (17.5%) during steady state gait. Interestingly, there was 34% decrease in gait unsteadiness during steady state gait. There was no changes in knee range of motion and stride length. Conclusion: The preliminary results from this study have demonstrated that plantar electrical stimulation may be beneficial for patients with diabetic peripheral neuropathy in improving postural stability. Immediate improvements in balance are more prominent than gait. The reductions in gait unsteadiness are promising; it seems that patients are walking more cautious post therapy. Follow up measurements after continued use of device for months will reveal significant changes in gait and balance.
Functional electrical stimulation
Foot (prosody)
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The purpose of this study was to investigate the effect of finger movement on ankle control for gait initiation in patients with Parkinson's disease (PD patients). The subjects were 13 PD patients and 6 age-matched healthy adults. The subjects moved fingers before or after gait initiation, or initiated gait without finger movement. Ankle joint movement in the stance leg was recorded to estimate the duration of ankle dorsiflexion (DIF duration), which reflects the degree of disturbance in ankle control for gait initiation in PD patients. In the PD patients with prolonged D/F duration, finger movement that preceded gait initiation shortened the D/F duration, but in the PD patients without prolonged D/F duration and in healthy subjects, the effect was not found. Accordingly, finger movement that precedes gait initiation improves ankle control for gait initiation in PD patients who suffer disturbance in ankle control for gait initiation.
Ankle dorsiflexion
Gait Disturbance
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The study objective was to assess the effect of functional electrical stimulation (FES) applied to the peroneal nerve and thigh muscles on gait performance in subjects with hemiparesis. Participants were 45 subjects (age 57.8 ± 14.8 years) with hemiparesis (5.37 ± 5.43 years since diagnosis) demonstrating a foot-drop and impaired knee control. Thigh stimulation was applied either to the quadriceps or hamstrings muscles, depending on the dysfunction most affecting gait. Gait was assessed during a two-minute walk test with/without stimulation and with peroneal stimulation alone. A second assessment was conducted after six weeks of daily use. The addition of thigh muscles stimulation to peroneal stimulation significantly enhanced gait velocity measures at the initial and second evaluation. Gait symmetry was enhanced by the dual-channel stimulation only at the initial evaluation, and single-limb stance percentage only at the second assessment. For example, after six weeks, the two-minute gait speed with peroneal stimulation and with the dual channel was 0.66 ± 0.30 m/sec and 0.70 ± 0.31 m/sec, respectively (). In conclusion, dual-channel FES may enhance gait performance in subjects with hemiparesis more than peroneal FES alone.
Functional electrical stimulation
Hemiparesis
Leg muscle
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Functional electrical stimulation
Foot drop
Common peroneal nerve
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Foot drop
Foot (prosody)
Stroke
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OBJECTIVES To examine the effect of sensorimotor and gait training on proprioception, nerve function, and muscle activation in diabetic peripheral neuropathy (DPN) patients. METHODS Thirty-eight (25 male and 13 female) participants with DPN were selected and randomly allocated to intervention and control group. Participants in the intervention group were provided sensorimotor and gait training for eight weeks (3 days/week) along with diabetes and foot care education; participants in the control group received diabetes and foot care education only. Outcome measures involved proprioception, nerve conduction studies of peroneal and tibial nerve, and activation of lower limb muscles and multifidus while standing with eyes open and eyes closed, and treadmill walking. RESULTS Mixed ANOVA revealed significant time effect and time×group interaction of proprioception in all four directions (p<0.05). The conduction velocity of peroneal nerve revealed significant time effect (p=0.007) and time×group interaction (p=0.022). Interaction effect was found to be significant for medial gastrocnemius and multifidus while standing with eyes open as well as with eyes closed (p≤0.004). Only multifidus showed significant group (p=0.002) and interaction effect (p=0.003) during walking. CONCLUSIONS Sensorimotor and gait training is an effective tool for improvement of proprioception and nerve function. It benefits muscle activation around ankle and multifidus during postural control and walking in DPN patients. Clinical Trials Registry - India, National Institute of Medical Statistics (Indian Council of Medical Research): Registration Number - CTRI/2017/08/009328.
Proprioception
Diabetic Neuropathy
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Drop foot is a frequent abnormality in gait after central nervous system lesions. Different treatment strategies are available to functionally restore dorsal extension during swing phase in gait. Orthoses as well as surface and implantable devices for electrical stimulation of the peroneal nerve may be used in patients who do not regain good dorsal extension. While several studies investigated the effects of implanted systems on walking speed and gait endurance, only a few studies have focussed on the system's impact on kinematics and long-term outcomes. Therefore, our aim was to further investigate the effects of the implanted system ActiGait on gait kinematics and spatiotemporal parameters for the first time with a 1-year follow-up period. 10 patients were implanted with an ActiGait stimulator, with 8 patients completing baseline and follow-up assessments. Assessments included a 10-m walking test, video-based gait analysis and a Visual Analogue Scale (VAS) for health status. At baseline, gait analysis was performed without any assistive device as well as with surface electrical stimulation. At follow-up patients walked with the ActiGait system switched off and on. The maximum dorsal extension of the ankle at initial contact increased significantly between baseline without stimulation and follow-up with ActiGait (p = 0.018). While the spatio-temporal parameters did not seem to change much with the use of ActiGait in convenient walking speed, patients did walk faster when using surface stimulation or ActiGait compared to no stimulation at the 10-m walking test at their fastest possible walking speed. Patients rated their health better at the 1-year follow-up. In summary, a global improvement in gait kinematics compared to no stimulation was observed and the long-term safety of the device could be confirmed.
Functional electrical stimulation
Foot drop
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Direct electrical stimulation of the peroneal nerve, using the implantable ActiGait® system, enables a therapy of the centrally caused drop foot, to improve the gait of the patients. In this paper, we present long-term results at 36-month follow-up post implantation.A total of 33 patients, 27 stroke and six multiple sclerosis (MS) patients, suffering from spastic drop foot were implanted in our center and assessed in terms of gait endurance, speed, risk of fall, and life quality at baseline and 36 months following implantation.The six min gait endurance test increased significantly from 202 ± 41 m without walking aids to 380 ± 30 m (p=0.038), while using the implant. Moreover, the time in the gait speed measured over 20 m decreased from 31.8 ± 10.2 s without to 18.5 ± 4.6 s by using the ActiGait® system (p=0.039). Similarly, gait steadiness, measured by the Timed Up and Go (TUG) test improved by 36.6%, with patients demonstrating a reduced time from 18.6 ± 5.5 to 11.2 ± 3.8 s (p=0.041) upon implant activation. Most importantly, 31 of 33 patients reported remarkable improvements of their quality of life following direct electrical nerve stimulation.Our findings confirm previously published efficacy data at 12 months after implantation and underline the long-lasting effect of the ActiGait® system.
Foot drop
Functional electrical stimulation
Foot (prosody)
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