Rehabilitation for foot drop (weakness or muscle shortening (contracture) at the ankle joint)

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

Published Online:

July 8, 2009

Foot drop is the term commonly used to describe weakness or contracture of the muscles at the ankle joint. It may arise from many neuromuscular diseases. Interventions might include a 'wait and see' approach, physiotherapy, orthotics (appliances), surgery or drug therapy. The review update identified four randomised controlled trials that met the criteria for inclusion, including 152 participants in total. In one trial strength training had a significant beneficial effect on walking ability in people with Charcot-Marie-Tooth disease (hereditary motor and sensory neuropathy), but no significant effect on walking ability in people with myotonic dystrophy. In another study strength training had no significant effect on ankle strength in people with facioscapulohumeral muscular dystrophy. Night splinting of the ankle had no significant effect on flexibility or muscle strength around the ankle in people with Charcot-Marie-Tooth disease, and surgery on the Achilles tendon in boys with Duchenne muscular dystrophy had no significant effect on their walking ability. Further randomised controlled trials are needed.

Abstract (click to read)

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.

This record should be cited as:

Sackley C, Disler PB, Turner-Stokes L, Wade DT, Brittle N, Hoppitt T. Rehabilitation interventions for foot drop in neuromuscular disease. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD003908. DOI: 10.1002/14651858.CD003908.pub3

Assessed as up to date:

April 24, 2009

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Primary Review Group:

Neuromuscular Disease Group

Health topics:

Neurology > Multiple sclerosis > Rehabilitation

Neurology > Muscle disease > Rehabilitation

Neurology > Peripheral neuropathy > Peroneal nerve palsy & foot drop

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Rehabilitation for foot drop (weakness or muscle shortening (contracture) at the ankle joint)

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