Shruti Sonni, MD

“Foot drop”, difficulty in dorsiflexing (DF) the foot, is a common result of corticospinal damage due to stroke (both ischemic and hemorrhagic). The Functional Ambulation: Standard Treatment vs. Electrical Stimulation Therapy (FASTEST) trial is a randomized trial comparing 30 weeks of traditional ankle foot orthosis (AFO) with a foot drop stimulator (FDS) for foot DF weakness among 197 patients who were >3 months post stroke. FDS is a type of functional electrical stimulation of the peroneal nerve to dorsiflex the foot in the swing phase of gait every time the foot is raised to take a step. Both interventions were found to benefit the gait speed in patients without a significant difference between the two groups.
Traditional AFOs have drawbacks including discomfort, limited ankle mobility, difficulty with standing from a chair and unfavorable aesthetics- all leading to poor compliance. Better user satisfaction was seen in the FDS group (though this group had greater number of patients with AEs from skin irritation). Also, the AFO group received transcutaneous electrical nerve stimulation (TENS) treatment as a “sham” procedure which may have had a beneficial or placebo effect similar to that of the FDS. The patients included in this study had a stroke of any etiology- ischemic or hemorrhagic. Is there enough evidence to show that these two conditions recover in the same way and time course?
Given the equivocal findings regarding these two treatments, the important question arises- what is the cost differential between these two devices, and subsequently how will insurance coverage change given findings of this study?  In addition, the authors mention other meaningful measures that can be compared in the future between the two groups including obstacle avoidance, ankle DF strength, cortical pathways used for muscle activation and use of a validated measure of user satisfaction. This study is the largest randomized trial to date that compares these two interventions in stroke patients. We look forward to further advances in this very important area of stroke rehab.