FES following peroneal injury

[PT2MD]

I have a patient with a traumatic injury to her peroneal nerve at the fibular head. She has all the predictible weaknesses within this distribution (0-1/5). I have attempted NMES in just about every conceivable electrode position, pulse width, frequency, imaginable.

The referring physician specifically asked me to administer FES, but I see evidence that is conflicting at best with some even suggesting FES would deter the natural recovery of muscle function. Again, I am sorry if this is not the place for this, but I am curious how some of you feel about FES for denervated muscles. Thanks in advance.

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[Xardas]

I have a patient with a traumatic injury to her peroneal nerve at the fibular head. She has all the predictible weaknesses within this distribution (0-1/5). I have attempted NMES in just about every conceivable electrode position, pulse width, frequency, imaginable.

The referring physician specifically asked me to administer FES, but I see evidence that is conflicting at best with some even suggesting FES would deter the natural recovery of muscle function. Again, I am sorry if this is not the place for this, but I am curious how some of you feel about FES for denervated muscles. Thanks in advance.

I don't think the evidence is there to support this treatment quite honestly.

How far out is the patient from the date of injury? Do you have NCS evidence of the degree of axonal injury?

 

[PMR 4 MSK]

I just had a case today - pt I saw last week with "left leg weakness". 4/5 dorsiflexors. Complaints of numbness, but exam normal to touch. EMG today showed NCV 48 m/s b/w fibular head and ankle, and 36 b/w above knee and fibular head. Amplitude was slightly low at 2.1 mV, but the right side was slightly low also (pt is about 68 years old, both EDB's barely visible), but normal NCV's above and below the fibular head. Tibial motors were normal, H-reflexes slightly delayed bilaterally. Peroneal F Waves were absent on the left, delayed on the right. Tibial F-waves normal. Sural sensories were normal, peroneal, tibial and saphenous sensories all absent (normal for age to me).

Needle exam showed normal VM, gastroc, Tib Ant and FDIP, 1+ fibs and PSWs in the left EDB.

I wrote for PT with strengthening and EStim, might get him a home unit.

To me, unless the EMG shows complete denervation (no response from EDB and TibAnt with NCS and 3+ fibs/PSW's in both + PerLong), I think Estim is very appropriate. When I was a resident, we were taught that in complete denervation, Estim might be detrimental

 

[Xardas]

I just had a case today - pt I saw last week with "left leg weakness". 4/5 dorsiflexors. Complaints of numbness, but exam normal to touch. EMG today showed NCV 48 m/s b/w fibular head and ankle, and 36 b/w above knee and fibular head. Amplitude was slightly low at 2.1 mV, but the right side was slightly low also (pt is about 68 years old, both EDB's barely visible), but normal NCV's above and below the fibular head. Tibial motors were normal, H-reflexes slightly delayed bilaterally. Peroneal F Waves were absent on the left, delayed on the right. Tibial F-waves normal. Sural sensories were normal, peroneal, tibial and saphenous sensories all absent (normal for age to me).

Needle exam showed normal VM, gastroc, Tib Ant and FDIP, 1+ fibs and PSWs in the left EDB.

I wrote for PT with strengthening and EStim, might get him a home unit.

To me, unless the EMG shows complete denervation (no response from EDB and TibAnt with NCS and 3+ fibs/PSW's in both + PerLong), I think Estim is very appropriate. When I was a resident, we were taught that in complete denervation, Estim might be detrimental

I would agree with you on that one; most of the foot drop cases I get are people who have completely blown out the peroneal nerve in which case there is little to do conservatively.

 

[PT2MD]

I don't think the evidence is there to support this treatment quite honestly.

How far out is the patient from the date of injury? Do you have NCS evidence of the degree of axonal injury?

It's a little complicated. On 9/5, she sustained a direct blunt trauma to her peroneal nerve about a week after she developed an L5 radiculopathy which also produced motor deficits. The radiculopathy was managed surgically via laminectomy and is recovering well. The peroneal injury has not been recovering as well.

Her latest EMG indicates "severe denervation" of the peroneal nerve that is "unchanged from last study" in September of this year. There is no NCS to go along with the EMG. Is that common? I usually see both studies in these reports.

The orthopedic surgeon is adamant about performing the NMES, but I'm not sure he's too tuned in to the literature which doesn't seem to support it's use in these circumstances. There are plenty of secondary complications we can manage clinically such as loss of passive motion and proximal deconditioning.

Our third NMES trial this evening produced predictable results - noxious with no evidence of motor response. I anticipate a conversation with the doctor regarding this issue. Hopefully he'll hear me out without getting his knickers in a twist.

Thanks very much for your input on this case. She is otherwise pleased with her progress to this point as we have her AFO fitting comfortably and she is ambulating without limitation in her community.

 

[Xardas]

It's a little complicated. On 9/5, she sustained a direct blunt trauma to her peroneal nerve about a week after she developed an L5 radiculopathy which also produced motor deficits. The radiculopathy was managed surgically via laminectomy and is recovering well. The peroneal injury has not been recovering as well.

Her latest EMG indicates "severe denervation" of the peroneal nerve that is "unchanged from last study" in September of this year. There is no NCS to go along with the EMG. Is that common? I usually see both studies in these reports.

The orthopedic surgeon is adamant about performing the NMES, but I'm not sure he's too tuned in to the literature which doesn't seem to support it's use in these circumstances. There are plenty of secondary complications we can manage clinically such as loss of passive motion and proximal deconditioning.

Our third NMES trial this evening produced predictable results - noxious with no evidence of motor response. I anticipate a conversation with the doctor regarding this issue. Hopefully he'll hear me out without getting his knickers in a twist.

Thanks very much for your input on this case. She is otherwise pleased with her progress to this point as we have her AFO fitting comfortably and she is ambulating without limitation in her community.

It is *not* common to do EMG without NCS. In fact the two go hand in hand generally as you do your EMG in peripheral nerve cases based on what you see on history, physical and NCS.

Going by "severe denervation" on EMG alone is not adequate; the # of fibrillations and sharp waves (which I assume is what they are using to call severe denervation) is not a quantitative measure for the degree of axonal involvement.

Also what was the first study? In fact there should be an NCS on the first study and the second study so you can see the degree of axonal (amplitude) changes if any, assuming this injury was severe enough to cause significant axonal damage.

In fact, I would actually kindly call the surgeon and express concerns about what you think is missing from the studies.