Trouble shooting workshop questions. FES User Day April 2017

Transcription

1 Trouble shooting workshop questions FES User Day April 2017

2 1. What is the best strategy for using FES on exercise mode for the LL & UL?

3 Suggestions for 1 Use physiotherapy principles, particularly: A pleasant/engaging task (to encourage compliance) A relevant movement and appropriate posture (so the stretch is safe & effective) Getting many repetitions (dose for effectiveness) Build up exercises gradually (to avoid over-use injury) Depends on goal eg: re-ed/pre-gait training/reducing spasticity/strengthening/pain reduction/acute or chronic treatments etc Ensure clear objective markers, baseline outcome measures in order to monitor progress/effective/non effective. Eg: videos, photos, RoM, Muscle power etc Increase to 1 hour per day for 6 weeks and review results (using varied electrode positions can help to facilitate muscle fibres particularly in the UL) Progress to PACE for (LL) walking if RoM improved/spasticity reduced

4 Suggestions for 1 continued Progress to alternate days and review after 6 weeks (for strength/rom/spasticity maintenance) Keep reducing treatment over time to reach optimum level for maintenance No change after 6 months consider reviewing technique or stopping treatment depends on goal! For UL, consider the use of an arm support so the user doesn t have to work against gravity. Review how long the contraction holds and what rest period is appropriate for patient

5 2. What are the current recommendations for using Microstim for UL inc shoulder subluxation?

6 Suggestions for 2 Depends on your therapy goals: Maintaining muscle condition and/or ROM. Managing tone/spasticity Facilitating exercise/task practice For shoulder subluxation, use two channels in overlapping mode: middle deltoid vs anterior/posterior deltoid. Start with 20Hz if flaccid/weak muscles and treat up to 1 hour per day Progress to 40Hz if able as demonstration of improvement in muscle exercise endurance etc Encourage active movement with the stimulator avoiding excessive spasticity with effort. Encourage active shoulder shrugging/other movements during the day particularly when UL starts to ache or has been dependent for too long (can be done whilst walking to reduce weight of arm/gravity effect) Same treatment strategy as above to encourage rehab Review 3 and 6 monthly for effectiveness and compliance See OML information sheet and website demo

7 4 What is the best way to use the stimulator in conjunction with AFO?

8 Suggestions for 4 In the case of ankle instability, use the AFO to provide stability in stance, and use the FES to provide active dorsiflexion. If possible, use a hinged AFO. As dropped foot stimulator to reduce weight of splint and facilitate hip flexion (in standard or pop fossa electrode position) Attach footswitch to base of splint to reduce shoe infilling. May increase trauma to footswitch so patient to check regularly. Alternatively attach footswitch to shortened insole (heel section only) to reduced shoe infilling. Alternatively use footswitch in contralateral foot on heel strike action (PACE XL to reduce wires) Clip stimulator to top of splint/on strap using shortened leads/footswitch Ensure the patient is vigilant for any skin complications and that the electrodes remain securely on the skin Can alternate between AFO and FES depending on activity eg: going swimming/gym etc Can use AFO & FES initially until effect of FES improves strength/rom etc then can wean off AFO if appropriate

9 5 Tips for using Pop Fossa set-up

10 Biceps Femoris Tendon Blue Pals electrodes contour to the skin well Head of Fibula Popliteal Fossa electrode positions Bottom edge of the electrode along knee crease

11 Popliteal fossa Increased knee and hip flexion due to increased flexion withdrawal reflex - stronger muscle contraction Electrode on biceps femoris tendon and lateral border of of the popliteal fossa Avoid the popliteal nerve Motor point tibialis anterior Strongest effect Moderate effect More dorsiflexion less eversion

12 Suggestions for 5 Must be comfortable for patient and providing necessary action of facilitation knee flexion as well as dorsflexion/hip flexion. Worth trying reducing the frequency of the PACE stimulator first for desired action. Cover electrodes with tubigrip separately eg: one above and one below the knee Alternatively use cropped leggies which cover both Cover back of electrode with durapore in 3 strips to strengthen shape of electrode and prevent folding/curling. Done for other positions too. (can demonstrate) Wrap pop fossa electrode around the lateral hamstring, immediately proximal to the crease of knee. Test with the patients sitting or standing (holding on to something) a test stimulation should make their knee flex in sitting or standing. If you go too far into the pop fossa you may pick up the posterior tibial nerve.

13 7 Are there ways to minimise spasticity in the posterior compartment?

14 Suggestions for 7 Exercise programme first particularly in the morning when patient is likely to be tight into dorsiflexion range from sleeping position (feet pointing down) Increase output from sensory level to movement level to increase range without adverse discomfort or inappropriate movement Both above are good pre walking preparation Support the foot in a dorsiflexed position rather than plantarflexed position to facilitate correct movement into dorsiflexion thus overcoming gravity effect or weak dorsiflexors. Think of the pulley system of the tendons and make it as easy as possible for them to function Consider using longer rising ramp. In walking if you see the foot momentarily bounce down (planterflexion) then a rising ramp needs to be in place but appropriate for walking speed

15 Suggestions for 7 continued Massage posterior compartment Pressure point releasing posterior compartment including evertors as they could be tight Double cork heel until stretch has been achieved of posterior component Stretching exercises pre FES treatment BTX treatment if progress not being made though need to be careful not to knock out activity too much (no push off possible) If toe clawing consider more distal position of electrode for toe extensor facilitation Deep massage to plantar aspect of foot to reduce spasticity and lengthen structures

16 8 What is the best way to manage patients who spasm with the FES?

17 Suggestions for 8 Start with 20Hz exercise if effective and progress to 40Hz if needed Use long ramps as exercise program pre walking Watch for latent spasm not connected to the timing of the stimulator as this is indicative of a contraindication seen with PwMS more than other conditions Use at sensory level first and build up to movement as accommodation occurs Sometimes the sensory response is always greater than the motor response and elicits an adverse reaction. Usually happens in the upper limb. If this happens then FES may be contraindicated until a future review if patient s condition changes Sometimes testing in sitting causes spasms so check if walking is more comfortable Striated (hitch-hiker s) toe needs monitoring as do not want FES to make worse. Consider other interventions eg: BTX or medications (signpost if necessary)

18 10 Please provide some good management techniques for reactions to electrodes.

19 Suggestions for 10 Check what may be the cause of the reaction. Illness? Electrode property change? Hot climates? Medication changes? Poor care of electrodes or skin cleanliness? Insect bite? Virus infection? Allergy to soap/skin care products recently changed? etc Stop treatment with FES immediately until skin condition resolved If irritation under one electrode try changing to symmetrical waveform if tolerated Convert to hypoallergenic electrodes if not already using Change to symmetrical waveform if using asymmetrical (check comfort/tolerability) If able move the electrodes to clean unaffected skin to get the same desired function If not able to move the electrodes for desired effect then do not restart until the skin has completely healed. This can take up to 4-6 weeks. Ensure patient has alternative for safe walking eg: AFO/footup/Boxia splints etc

20 Suggestions for 10 continued Use alternative electrode positions on different days (gives skin a rest) Alternate two sets of electrodes on different days (reduce microbes?) Use lower current and/or frequency Recommend changing the electrodes forthnightly Use Savlon to prevent infection or Hc45 cream for a short time period (5 days max) to heal skin. Longer use of hydrocortisone creams leads to thinning of the skin and greater risk of breakdown Use baby wipes after removing FES to wipe where electrodes have been Teach patients how to look after the electrodes Teach patients how to look after skin particularly if dry non perfumed moisturiser eg: E45 Avoid long soaks in bath or use of bubblebath Patients should be able to contact clinic at anytime to report skin irritation or stimulator fault Don t be worried about erythema following use as this should disappear within an hour and is not indicative of a reaction Follow the guidance which is on the website and in the user manual

21 11 Are there any ways of using patient s PACE for optimising rehab sessions with current set-up without risking altering set up?

22 Suggestions for 11 Record settings pre rehab session by using the parameter check mode ( two button trick ) in case changes are made during the session for different reasons. Re-programme post session. Some setting changes may be an improvement in which case keep them Have a spare PACE for rehab sessions which can be used for anyone so you can move among functions like quads/gluts/hamstrings/ul positions etc Some of the parameters maybe in a different part of the menu for example changing for the switch from heelrise to heelstrike Allocate time, eg: an in service, to have a good play and get confident adjusting parameters

23 12 Inconsistent responses to same setup/stimulation settings any advice on how to resolve?

24 Suggestions for 12 Check the settings are appropriate particularly if only used the default settings Some patients fluctuate due to their condition eg: PwMS so try the following Larger electrodes to reduce error of electrode position Check skin care is the skin too dry? Use gel consistently If not triggering properly then consider contralateral footswitch position or sandwich footswitch for improved contact. Check quality of footswitch by squeezing between thumb and finger. If have to squeeze hard to activite then replace. If only works on certain sections of the footswitch then replace. If split then replace Check shoes are not too tightly done up

25 Suggestions for 12 continued Check all wires as old hard wires will produce an inconsistency as a result of the quality of the wire (unseen cracks) and the jack/shroud connectors into the stimulator which may be worn. This can be tested by spinning the connector around while stimulator on. If faulty the stimulation will go on and off Stimulation may be at a marginal level of recruitment. Perhaps a higher current would be helpful (if tolerated). For MS, this could be just part of the patient s day-to-day variability Some patient groups eg: MS fatigue very quickly resulting in a reduced output over time so need to increase pulsewidth (their power control) Don t spend too much time testing in sitting position as when patient walks inconsistencies can resolve Check stimulator is not faulty

26 13 What are the contraindications for FES referral?

27 Pregnancy (unknown) Uncontrolled epilepsy Suggestions for 13 Severe active skin condition in region of stimulation eg: psoriasis Active Ca, proximity of malignant tumour, patient choice if current FES user Fixed contractures Complete peripheral nerve lesion?? Depends on what the need is as you can treat around the lesion such as brachial plexus injuries eg: shoulder girdle stimulation may be appropriate Receptive dysphasia Poor cognition/problem solving Pacemaker users (Pacemaker/defibs are contraindicated in the upper limb but FES can be used in the lower limb if testing demonstrates no interference) Implanted metalwork in the area of stimulation Caution: Diabetes: poor skin vasculature can lead to bruising under electrodes Caution: SCI above T6 may cause autonomic dysreflexia. Co-morbidity - unlikely to be effective in any disease/injury affecting the motor neurons

28 16 Epilepsy as a precaution for using FES how stable does their epilepsy need to be?

29 Suggestions for 16 6 months of regular pattern of seizures with or without medication is the standard for the Birmingham FES Clinic Salisbury recommends no fits in the last year If in doubt request approval for FES use from treating Consultant/GP

30 What are your preferred default settings? Current default settings had a slow walking stroke patient in mind...things have changed with our current caseloads and the default settings need reviewing... Your suggestions...