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Patient and carers’ experiences of Ankle Foot Orthosis (AFO) and Functional Electrical Stimulation (FES) for the correction of dropped foot after stroke. 1 Katie Wilkie; 1 Jane Shiels; 2 Lisa Salisbury; 3 Cathy Bulley; 2 Dr Stephen Smith; 1 Caroline McGuire

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Patient and carers’ experiences of Ankle Foot Orthosis (AFO) and Functional Electrical Stimulation (FES) for the correction of dropped foot after stroke.

1 Katie Wilkie; 1 Jane Shiels; 2 Lisa Salisbury; 3 Cathy Bulley; 2 Dr Stephen Smith; 1 Caroline McGuire

1Physiotherapy Department, Astley Ainslie Hospital, Edinburgh; 2 Edinburgh University, Edinburgh; 3 Physiotherapy Subject Area, Queen Margaret University, Edinburgh.

Background

Approximately 20% of stroke patients present with dropped foot. The present conventional treatment for the correction of dropped foot is an Ankle Foot Orthosis. An alternative strategy to correct or minimize dropped foot is Functional Electrical Stimulation (FES). FES uses electrical stimulation to elicit functional movement in muscles paralysed due to central nervous system lesions e.g. lifting the dropped foot during walking.

Following an initial service audit and review of an FES pilot clinic, a funding proposal was submitted to Lothian Health for the provision of a permanent FES service. The data submitted with this proposal was quantitative in nature. Recognising the value and importance of service users feedback, anecdotal comments had additionally been gathered.

Aim

To further explore service users views in a more scientific manner, a qualitative project was undertaken.

The aim of this project was to gain insight into patient and carer perceptions of the clinic and FES. This project provided a wealth of rich data on patients’ and carers’ experiences, not only of FES and the clinic, but also on the use of AFO in stroke.

Methods and Analysis

A qualitative study was undertaken using semi-structured interviews on 10 carers and 13 patients. Participants were identified from the Lothian FES service using purposive sampling. Interviews were carried out by independent researcher. Participant verification and cross checking of themes was used to ensure rigour.

Interpretative Phenomenological Analysis was used as a framework for thematic analysis of the transcripts.

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  • Results
  • A number of positive and negative themes were identified in relation to each treatment modality by both patients and carers.
  • In general, several disadvantages were expressed in relation to AFO. This included discomfort, restricted movement and poorer quality of experience. Some participants did report greater faith in the reliability of the AFO. (See patient and carer quotes)
  • The convenience and efficacy of FES led to increased function and quality of life for many of the patients and carers namely in relation to participation, stamina, confidence, independence and mood. Some specific drawbacks were highlighted in relation to FES, including equipment failure, set up issues and skin irritation. (See patient and carer quotes)

FES Experiences - Patient and Carer Quotes

AFO Experiences - Patient and Carer Quotes

Quality of Life

“I just used to sit and look through the window, smoke, watch telly. And when I got this [FES] it made a hell of a difference, I could walk.” (Patient)

“But the foot stimulator yes it has given him an awful lot of confidence and independence. That’s the best thing that ever happened.” (Carer)

Reliability

“I think whether mechanically it did any good in terms of improving the strength in my ankle. It gave me a significant increase in my confidence in my ankle which is, well to me even more valuable.” (Patient)

Discomfort and Restriction of Movement

“With a splint on your foot’s always at the same angle….. which gets very uncomfortable.” (Patient)

“ It stopped the movement, any movement in the ankle. It restricted a lot of movement which that [FES] doesn’t do.” (Carer)

Efficacy and Function

“Well it was 100% improvement compared with the splint.” (Carer)

“The difference between using FES and not using it is something like probably 15 or 20% improvements to the walking.” (Patient)

Negatives

“I wear the splint because I’m safer with that …. that’s why I use it on holiday. It’s to try and retain your independence and the FES with the best will in the world doesn’t give you that amount of confidence because it can break down.” (Patient)

“But the one thing that I did find after using the pads I had terrible rashes and the skin started to break out.” (Patient)

Poorer Quality of Experience

“He had two different sized shoes because the splint took up a lot of space in the shoe, so they had to make special shoes so that he could wear the splint.” (Carer)

“So I think I lasted three days with all these splints and I said to the physiotherapist, this is’nae for me….. they were a symbol of being disabled.” (Patient)

Conclusions and Implications

  • Patients and carers identified benefits in the application of both modalities for the correction of dropped foot following stroke. Overall they felt that FES improved function and quality of life beyond that achieved when using an AFO.
  • These robust results enhance the evidence base for the use of FES in stroke and have informed the strategic development of an optimum FES service in Lothian.
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