User experiences, preferences and choices relating to functional electrical stimulation and ankle foot orthoses for foot-drop after stroke
Introduction
This article uses qualitative data to explore experiences, preferences and choices relating to the use of ankle foot orthoses (AFOs) and functional electrical stimulation (FES) among people with foot-drop after stroke and their carers. People who survive a stroke often require orthotic support to reduce the impact of lower limb disability. In 2000, an estimated 1.1 million people in Europe had a stroke [1]. Post stroke, many people experience impaired motor function in the lower limb; this was reported by approximately 72% of 1259 survivors of a first stroke in the UK [2]. Impaired mobility often results from altered neural transmission and reduced active control of the foot during walking, leading to ‘foot-drop’ [3]. Walking becomes less safe and efficient, requiring greater effort [4], [5], and the impact on function and participation should be minimised.
Foot-drop is frequently managed using an AFO. This is advocated for those who demonstrate benefit in clinical guidelines for stroke from the Royal College of Physicians (RCP) [6]. A systematic review addressed the impact of AFOs on the gait of hemiplegic adults [7]. Thirteen studies compared walking barefoot or in shoes with AFO use, eight of which included stroke survivors (nine crossover designs and four single case studies). Six of these studies used posterior plastic AFOs, two studies each used metal, dynamic, and hinged AFOs, and one study each used an air-stirrup brace, and a plastic anterior AFO. Three studies used two types of AFO. Significant improvements were found in seven of nine studies that evaluated walking speed, and five of seven studies that measured stride length. Gait pattern and energy expenditure required when walking also improved. Most studies demonstrating improvements used posterior plastic AFOs, although improvements were also demonstrated with the one-bar rigid and hinged AFOs, and the air-stirrup brace. High variability in results may also be due to varied trial characteristics, a lack of randomised controlled trials (RCTs) and small samples. More recent evidence was reviewed by the RCP's revised clinical guidelines [6], [8], which judged four studies to be of good quality. All were randomised controlled crossover trials [9], [10], [11], [12] including 10 to 28 participants in acute and chronic phases post stroke. Various AFOs were used: carbon composite anterior AFO [9], plastic rigid AFO [10], metallic and plastic custom-made AFOs [11], and a custom-made semi-rigid AFO [12]. Statistically significant improvements were demonstrated in step length, walking speed, timed up-and-go, time walking up stairs, energy cost, postural sway and standing symmetry. Seventy percent found increased self-confidence. No changes were demonstrated in cadence, step time, double support time, oxygen consumption and heart rate. However, studies of participants’ satisfaction raised concerns about the cosmetic appearance, ease of application, reduced ankle movement and weight of the AFO; these included studies using posterior and anterior rigid AFOs [7]. The lack of rigorous qualitative evidence regarding individuals’ experiences of AFOs indicates a need for further work.
Another approach to management of foot-drop is FES; the electrical stimulation of nerves that generate contraction of the muscles required to lift the foot, first developed in 1961 by Liberson, cited by Wong et al. [13]. Two systematic reviews have investigated orthotic effects [14], [15]. The first included seven non-randomised trials and one RCT, with varied rigour, and found positive effects on walking speed (both implanted and transcutaneous electrodes) and physiological cost index (transcutaneous electrodes) [14]. More recently, four RCTs and four non-randomised trials were included in a meta-analysis that looked at both orthotic and therapeutic effects of single-channel or multichannel transcutaneous FES (five studies) or single-channel Transcutaneous Electrical Nerve Stimulation (three studies). It identified significantly higher gait speeds in three of the trials using FES [15]. The recently updated RCP guidelines [6] state that FES should only be considered non-routinely for people with foot-drop that is not well controlled using AFOs, and who demonstrate evidence of benefit.
The relative efficacy of FES and AFOs requires further rigorous comparative investigation. One study has compared customised AFOs (varied in design), transcutaneous FES and no orthotic in a small sample of 14 people with chronic stroke [16]. Use of FES and AFOs demonstrated significantly improved function, with a trend towards superiority of AFOs. However, participants used their own individualised AFOs and only received a single day of FES training. The study also found a preference for FES use in 12 of 14 participants, which requires further exploration.
A survey into perceptions of a transcutaneous FES model [17] included 55% of all past and present FES users from the clinic; 73% (n = 78) and 85% (n = 45) of whom were stroke survivors, respectively. The primary reasons for FES use were described by most as reduced effort in walking and increased confidence. However, a survey design is usually optimal when based on initial open exploration of individuals’ experiences, and there is a distinct lack of published qualitative research in this area.
When deciding on management strategies, it is important to consider users’ views as well as cost and efficacy; the former has been emphasised at government level [18]. There is increasing evidence in different fields of health care that users’ preferences and satisfaction are important to decision-making and outcomes of management. Studies have shown that respect for treatment preferences has increased satisfaction with health care in people with mental health conditions and heart failure [19], [20], and improved management outcomes in mental health and addiction care [19], [21]. However, the strength of the preference in relation to mental health management was important, associated with choices to initiate treatment and 12-week adherence rate [22].
The evidence suggests that considering individuals’ preferences is important in relation to different conditions, affecting choices to initiate treatment, adherence, satisfaction and outcomes. However, the relationships are not necessarily clear, and no studies were located that addressed the management of foot-drop after stroke. Therefore, an exploratory study was designed to provide greater insight into experiences that influence preferences and choices. This was well suited to a qualitative approach that focuses on interpreting the words of individuals to gain insights into their experiences. Therefore, this qualitative study explored experiences of FES and AFO use among people in the chronic stage of stroke and among their carers. The purpose was to inform clinical decision-making that aims to achieve optimal engagement with management strategies and, ultimately, outcomes.
Section snippets
Study design
The aim was to explore lived experiences, described and interpreted through a phenomenological perspective, to encompass a collaborative and interpretative approach [22]. Face-to-face, semi-structured interviews enabled focus on the individual aspects of FES use [23]. The Lothian Research Ethics Committee and NHS Lothian approved the study.
Sampling and recruitment
A purposive sample of people who had suffered a stroke and carers was sought through the FES Clinic at the Astley Ainslie Hospital (Edinburgh). Inclusion of
Results
Nine people who had suffered a stroke and four carers agreed to participate. All carers were married to the FES-user. Participant characteristics are listed in Table 1. Characteristics are generalised to a degree to ensure anonymity; due to the small size of the pool of potential participants, combining data increases the risk of identifiability.
After data analysis, it was evident that participants were processing information from various experiences of AFO and FES use. Some experiences were
Discussion
The results of this qualitative analysis demonstrated a preference among most participants for using FES as the primary tool for managing foot-drop after stroke, although different experiences of both tools led to frequent choices to supplement FES with use of different types of AFO in specific situations.
Comparison of the study findings with those of previous qualitative research is limited by availability. Experiences of FES were explored by Taylor et al. in a previous survey [17], and
Conclusions
This study explored interview data from nine people who had suffered a stroke and four carers who described choosing between AFOs and FES for managing foot-drop post stroke. All but one person expressed a preference for FES use, due to improved ability to move the ankle; walk more normally, safely and independently; and greater comfort. However, some people described using AFOs in specific circumstances, such as when experiencing or anticipating FES equipment failure, when travelling and when
Acknowledgments
The authors wish to thank all the participants in this study for their time and insights. The authors would also like to acknowledge the contribution of Caroline McGuire to the design and delivery of the FES service, and the original concept behind this study.
Ethical approval: The Lothian NHS Research Ethics Committee (Ref. No. 06/S1101/37).
Funding: The Centre for Integrated Healthcare Research [Grant No. CIHR\2005\PP\10]; the Lothian Stroke MCN provides financial support for the FES service.
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