(includes CMT) Rehabilitation interventions for foot drop in neuromuscular disea

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Cochrane Database Syst Rev. 2009 Jul 8;(3):CD003908. Links

Rehabilitation interventions for foot drop in neuromuscular disease.

Sackley C, Disler PB, -Stokes L, Wade DT, Brittle N, Hoppitt T.

Primary Care and General Practice, University of Birmingham, Primary Care

Clinical Sciences Building, Edgbaston, Birmingham, UK, B15 2TT.

BACKGROUND: " Foot drop " or " Floppy foot drop " is the term commonly used to

describe weakness or contracture of the muscles around the ankle joint. It may

arise from many neuromuscular diseases.

OBJECTIVES: To conduct a systematic review of randomised trials for the

treatment of foot drop resulting from neuromuscular disease.

SEARCH STRATEGY: In this update, we searched the Cochrane Neuromuscular Disease

Group Trials Register (April 2009), MEDLINE (January 1966 to April 24 2009),

EMBASE January 1980 to April 24 2009), CINAHL (January 1982 to May 6 2009), AMED

(January 1985 to April 24 2009), the British Nursing Index (January 1985 to

January 2008) and Royal College of Nursing Journal of Databases (January 1985 to

January 2008).

SELECTION CRITERIA: Randomised and quasi-randomised trials of physical, orthotic

and surgical treatments for foot drop resulting from lower motor neuron or

muscle disease and related contractures were included. People with primary joint

disease were excluded. Interventions included a 'wait and see' approach,

physiotherapy, orthoses, surgery and pharmacological therapy. The primary

outcome measure was quantified ability to walk whilst secondary outcome measures

included range of movement, dorsiflexor torque and strength, measures of

activity and participation, quality of life and adverse effects.

DATA COLLECTION AND ANALYSIS: Methodological quality was evaluated by two

authors using the van Tulder criteria. Four studies with a total of n = 152

participants were included in the update to the original review. Heterogeneity

of the studies precluded pooling the data.

MAIN RESULTS: Early surgery did not significantly affect walking speed in a

trial including 20 children with Duchenne muscular dystrophy. Both groups

deteriorated during the 12 months follow-up. After one year, the mean difference

(MD) of the 28 feet walking time was 0.00 seconds (95% confidence interval (CI)

-0.83 to 0.83) and the MD of the 150 feet walking time was -2.88 seconds,

favouring the control group (95% CI -8.18 to 2.42). Night splinting of the ankle

did not significantly affect muscle force or range of movement about the ankle

in a trial of 26 participants with Charcot-Marie-Tooth disease. Improvements

were observed in both the splinting and control groups.

In a trial of 26 participants with Charcot-Marie-Tooth disease and 28

participants with myotonic dystrophy, 24 weeks of strength training

significantly improved six-metre timed walk in the Charcot-Marie-Tooth group

compared to the control group (MD 0.70 seconds, favouring strength training, 95%

CI 0.23 to 1.17), but not in the myotonic dystrophy group (MD -0.20 seconds,

favouring the control group, 95% CI -0.79 to 0.39). No significant differences

were observed for the 50 metre timed walk in the Charcot-Marie-Tooth disease

group (MD 1.90 seconds, favouring the training group, 95% CI -0.29 to 4.09) or

the myotonic dystrophy group (MD -0.80 seconds, favouring the control group, 95%

CI -5.29 to 3.69).

In a trial of 65 participants with facioscapulohumeral muscular dystrophy, 26

weeks of strength training did not significantly affect ankle strength. After

one year, the mean difference in maximum voluntary isometric contraction was

-0.43 kg, favouring the control group (95%CI -2.49 to 1.63) and the mean

difference in dynamic strength was 0.44 kg, favouring the training group (95%CI

-0.89 to 1.77).

AUTHORS' CONCLUSIONS: Only one study, involving people with Charcot-Marie-Tooth

disease, demonstrated a statistically significant positive effect of strength

training. No effect of strength training was found in people with either

myotonic dystrophy or facioscapulohumeral muscular dystrophy. Surgery had no

significant effect in children with Duchenne muscular dystrophy and night

splinting of the ankle had no significant effect in people with

Charcot-Marie-Tooth disease. More evidence generated by methodologically sound

trials is required.