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Effectiveness of electrical stimulation therapy in improving arm function after stroke: a systematic review and a meta-analysis of randomised controlled trials

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Objective: The aim of this study is to investigate the effectiveness of electrical stimulation in arm function recovery after stroke. Methods: Data were obtained from the PubMed, Cochrane Library, Embase, and Scopus databases from their inception until 12 January 2019. Only randomized controlled trials (RCTs) reporting the effects of electrical stimulation on the recovery of arm function after stroke were selected. Results: Forty-eight RCTs with a total of 1712 patients were included in the analysis. The body function assessment, Upper-Extremity Fugl-Meyer Assessment, indicated more favorable outcomes in the electrical stimulation group than in the placebo group immediately after treatment (23 RCTs (n = 794): standard mean difference (SMD) = 0.67, 95% confidence interval (CI) = 0.51-0.84) and at follow-up (12 RCTs (n = 391): SMD = 0.66, 95% CI = 0.35-0.97). The activity assessment, Action Research Arm Test, revealed superior outcomes in the electrical stimulation group than those in the placebo group immediately after treatment (10 RCTs (n = 411): SMD = 0.70, 95% CI = 0.39-1.02) and at follow-up (8 RCTs (n = 289): SMD = 0.93, 95% CI = 0.34-1.52). Other activity assessments, including Wolf Motor Function Test, Box and Block Test, and Motor Activity Log, also revealed superior outcomes in the electrical stimulation group than those in the placebo group. Comparisons between three types of electrical stimulation (sensory, cyclic, and electromyography-triggered electrical stimulation) groups revealed no significant differences in the body function and activity. Conclusion: Electrical stimulation therapy can effectively improve the arm function in stroke patients.
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... In recent years, electrical stimulation (ES) of an upper extremity is demonstrated to be a promising intervention to improve arm and hand function in neurorehabilitation [5,6]. Data have been published on the effects of both cyclical and electromyography (EMG)-triggered single-channel ES [6][7][8]. ...
... In recent years, electrical stimulation (ES) of an upper extremity is demonstrated to be a promising intervention to improve arm and hand function in neurorehabilitation [5,6]. Data have been published on the effects of both cyclical and electromyography (EMG)-triggered single-channel ES [6][7][8]. The research exhibits the positive effects of Functional Electrical Stimulation (FES) to improve the ability to perform activities [6,8]. ...
... Data have been published on the effects of both cyclical and electromyography (EMG)-triggered single-channel ES [6][7][8]. The research exhibits the positive effects of Functional Electrical Stimulation (FES) to improve the ability to perform activities [6,8]. ...
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This preliminary randomized clinical trial explores the efficacy of task-oriented electromyography (EMG)-triggered multichannel functional electrical stimulation (EMG-MES) compared to single-channel cyclic neuromuscular electrical stimulation (cNMES) on regaining control of voluntary movements (CVM) and the ability to execute arm-hand-activities in subacute stroke patients with moderate arm paresis. Twelve ischemic stroke patients (Fugl-Meyer Assessment Arm Section (FMA-AS) score: 19–47) with comparable demographics were block-randomized to receive 15 sessions of cNMES or EMG-MES over three weeks additionally to a conventional neurorehabilitation program including task-oriented arm training. FMA-AS, Box-and-Block Test (BBT), and Stroke-Impact-Scale (SIS) were recorded at baseline and follow-up. All participants demonstrated significant improvement in FMA-AS and BBT. Participants treated with EMG-MES had a higher mean gain in FMA-AS than those treated with cNMES. In the SIS daily activities domain, both groups improved non-significantly; participants in the EMG-MES group had higher improvement in arm-hand use and stroke recovery. EMG-MES treatment demonstrated a higher gain of CVM and self-reported daily activities, arm-hand use, and stroke recovery compared to cNMES treatment of the wrist only. The protocol of this proof-of-concept study seems robust enough to be used in a larger trial to confirm these preliminary findings.
... Taking the large variety of clinical application areas of sEMG, more knowledge is needed to better understand the benefits, possibilities, and potential clinical effects of the different types of sEMG interventions on motor recovery after stroke (Campanini et al., 2020;Mcmanus et al., 2020). Previous reviews and metaanalyses have exclusively been dedicated to one specific type of sEMG intervention (Schleenbaker and Mainous, 1993;Bolton et al., 2004;Woodford and Price, 2007;Meilink et al., 2008;Norouzi-Gheidari et al., 2012;Basteris et al., 2014;Mehrholz et al., 2015;Eraifej et al., 2017;Takeda et al., 2017;Monte-Silva et al., 2019;Yang et al., 2019;Hameed et al., 2020), and summarized knowledge on the effect of different types of sEMGdriven interventions on upper limb function in stroke is limited. Thus, the aim of this systematic review and meta-analysis is to synthesize existing evidence on the effect of different sEMGdriven interventions on upper limb impairment in people with stroke and identify which type of sEMG intervention could be beneficial for this purpose. ...
... Final search: 1 AND 2 AND 3 AND 4 AND 5 CVA, cerebrovascular accident; EMG, Electromyography. -Gheidari et al., 2012;Basteris et al., 2014;Mehrholz et al., 2015;Eraifej et al., 2017;Takeda et al., 2017;Monte-Silva et al., 2019;Yang et al., 2019;Hameed et al., 2020;Doumas et al., 2021). ...
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Background: Upper limb impairment is common after stroke, and many will not regain full upper limb function. Different technologies based on surface electromyography (sEMG) have been used in stroke rehabilitation, but there is no collated evidence on the different sEMG-driven interventions and their effect on upper limb function in people with stroke. Aim: Synthesize existing evidence and perform a meta-analysis on the effect of different types of sEMG-driven interventions on upper limb function in people with stroke. Methods: PubMed, SCOPUS, and PEDro databases were systematically searched for eligible randomized clinical trials that utilize sEMG-driven interventions to improve upper limb function assessed by Fugl-Meyer Assessment (FMA-UE) in stroke. The PEDro scale was used to evaluate the methodological quality and the risk of bias of the included studies. In addition, a meta-analysis utilizing a random effect model was performed for studies comparing sEMG interventions to non-sEMG interventions and for studies comparing different sEMG interventions protocols. Results: Twenty-four studies comprising 808 participants were included in this review. The methodological quality was good to fair. The meta-analysis showed no differences in the total effect, assessed by total FMA-UE score, comparing sEMG interventions to non-sEMG interventions (14 studies, 509 participants, SMD 0.14, P 0.37, 95% CI -0.18 to 0.46, I2 55%). Similarly, no difference in the overall effect was found for the meta-analysis comparing different types of sEMG interventions (7 studies, 213 participants, SMD 0.42, P 0.23, 95% CI -0.34 to 1.18, I2 73%). Twenty out of the twenty-four studies, including participants with varying impairment levels at all stages of stroke recovery, reported statistically significant improvements in upper limb function at post-sEMG intervention compared to baseline. Conclusion: This review and meta-analysis could not discern the effect of sEMG in comparison to a non-sEMG intervention or the most effective type of sEMG intervention for improving upper limb function in stroke populations. Current evidence suggests that sEMG is a promising tool to further improve functional recovery, but randomized clinical trials with larger sample sizes are needed to verify whether the effect on upper extremity function of a specific sEMG intervention is superior compared to other non-sEMG or other type of sEMG interventions.
... Neuromuscular electrical stimulation (NMES) is one of the most common strategies for improving limb function in the clinical setting. Studies have shown that NMES can improve muscle strength, reduce spasticity, increase joint range of motion by promoting active movement, reorganize the damaged cortico-cerebral circuit, and improve movement control [7][8][9][10]. However, during the NMES process, the hemiplegic limb is passively moved, and bilateral limbs exhibit no movement to work together, which greatly reduces the effect of the patient's rehabilitation training. ...
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The electromyography bridge (EMGB) plays an important role in promoting the recovery of wrist joint function in stroke patients. We investigated the effects of the EMGB on promoting the recovery of upper limb function in hemiplegia. Twenty-four stroke patients with wrist dorsal extension dysfunction were recruited. Participants were randomized to undergo EMGB treatment or neuromuscular electrical stimulation (NMES). Treatments to wrist extensors were conducted for 25 min, twice a day, 5 days per week, for 1 month. Outcome measures: active range of motion (AROM) of wrist dorsal extension; Fugl-Meyer assessment for upper extremity (FMA-UE); Barthel index (BI); and muscle strength of wrist extensors. After interventions, patients in the NMES group had significantly greater improvement in the AROM of wrist dorsal extension at the 4th week and 1st month follow-up (p < 0.05). However, patients in the EMGB group had a statistically significant increase in AROM only at the follow-up assessment. No significant differences were observed in the AROM between the EMGB group and the NMES group (p>0.05). For secondary outcomes in the EMGB group, compared to baseline measurements, FMA-UE, BI, extensor carpi radialis and extensor carpi ulnaris muscle strength were significantly different as early as the 4th week (p < 0.05). The muscle strength of the extensor digitorum communis muscle showed significant differences at the follow-up (p < 0.05). There were no statistically significant differences between patients in the two groups in any of the parameters evaluated (p > 0.05). The combination of EMGB or NMES with conventional treatment had similar effects on the improvement of the hemiplegic upper limb as assessed by wrist dorsal extension, FMA-UE, and activities of daily living. The improvement in both groups was maintained until 1 month after the intervention.
... At present, western medicine has no specific and systematic treatment method for ULPSS. It mainly conducts rehabilitation training, such as physical therapy, drug therapy, botulinum toxin A (BoNT-A), and external mechanical adjuvant therapy (12)(13)(14). However, each traditional treatment method has its limitations. ...
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Background Upper limb spasticity (ULS) is a common complication after stroke, which seriously affects the quality of life and rehabilitation of patients. There are different treatment methods for post-stroke spasticity (PSS). Our group found that functional acupuncture (FA) can effectively improve forearm spasticity and hand dysfunction after stroke, but the efficacy of ULS needs to be further verified. Therefore, this subject has mainly used clinical randomized controlled trials to evaluate the clinical efficacy of FA in the treatment of ULS after ischemic stroke. Method This is a parallel design and randomized controlled trial. We selected 108 patients who met the predefined criteria and randomized them into two groups, the experimental group and the control group. The experimental group receives FA and routine rehabilitation treatment. The control group received traditional acupuncture (TA) and routine rehabilitation treatment. All patients received 20 courses of treatment for 4 weeks, and the modified Ashworth score (MAS), clinical neurological deficit score (CSS), Fugl-Meyer upper extremity function assessment (FMA-UE), and the Modified Barthel Index (MBI) scores were evaluated before and after treatment. Discussion This trial is mainly to study the clinical efficacy of FA in the treatment of ULS after ischemic stroke. It will not only provide a new idea for the clinical treatment of upper limb post-stroke spasticity (ULPSS) but also will provide effective experimental support and a theoretical basis for the clinic. Trial registration China Clinical Trials Registry No. ChiCTR2100050440. Registered on 27 August 27 2021.
... Therapeutic radiation CIED should be evaluated prior to radiation and a patient-specific treatment plan (including radiation dose estimation or measurement) should be outlined by CIED specialists and radiation oncologists prior to initiation of treatment CIED interrogation and ECG monitoring should be performed according to risk stratification during radiation therapy and after completion of the last fraction of treatment CIED-trained personnel readily available or on call is encouraged during radiation fractions for all CIED patients Relocation of a CIED for radiotherapy is not indicated, unless the device interferes with adequate tumour treatment Transcutaneous electrical nerve stimulation, electrical muscle stimulation, spinal cord stimulation Incidence and risk factors Electrical stimulation therapy (EST) such as transcutaneous electrical nerve stimulation (TENS), electrical muscle stimulation (EMS), or spinal cord stimulation (SCS) have been used for decades for the treatment of various pain conditions and other neuromuscular disorders including stroke, spinal cord injury, and refractory angina pectoris. [89][90][91][92][93][94] In TENS and EMS, different modalities of electrical current are applied using temporarily attached stimulation patches, whereas SCS requires surgical implantation of stimulation electrodes. In general, asymmetric biphasic impulses are delivered continuously with a frequency of 2-80 Hz. ...
... The efficacy of PES in the recovery of paralyzed muscles has long been reported and has been suggested by recent meta-analyses. [12][13][14][15][16] The putative mechanisms have been reported to include GABAergic interneurons at the level of the cerebral cortex, alteration of spinal excitability, antidromic activation of motor and Renshaw neurons, promotion of synapse formation, and release of neurotransmitters that facilitate synapse formation. [17][18][19] We examined whether the combination of tDCS and PES, which have different mechanisms of action, could restore motor function in an additive manner. ...
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We report the immediate improvement of weakened muscles after combined treatment with transcranial direct current stimulation (tDCS) and peripheral electrical stimulation (PES) in a patient with acute central cord syndrome (CCS) who presented with severe upper limb motor dysfunction. A 70-year-old man sustained CCS with severe motor deficits in the left upper limb, which did not improve with conventional training until 6 days after injury. On the seventh day after the injury, the left upper limb was targeted with combined tDCS (1 mA for 20 minutes/day, anode on the right, cathode on the left) and PES (deltoid and wrist extensors, 20 minutes/day at the motor threshold), and his performance score immediately improved from 0 to 6 on the Box and Block test. After four sessions, the left upper limb function improved to 32 on the Box and Block test, and manual muscle test scores of the stimulated deltoid and wrist extensors improved from 1 to 2. This improvement of the left upper limb led to improved self-care activities such as eating and changing clothes. Exercise combined with tDCS and PES may be a novel treatment for upper limb movement deficits after acute CCS.
... Functional electrical stimulation can improve the function of paralyzed muscles, such as those of patients with spinal cord injury or stroke. 6,7 Recent studies, have demonstrated the potential benefits of functional electrical stimulation in patients with heart failure, including improved functional status, 8 exercise capacity, 9 endothelial function, 10 quality of life, 11 and emotional stress. 12 Three meta-analyses published in 2010, 2013, and 2016 included only two, five, and seven randomized controlled trials, respectively, that compared functional electrical stimulation and control treatments. ...
Article
Objective To investigate the effectiveness of functional electrical stimulation of the legs in patients with heart failure. Methods Data were obtained from PubMed, Cochrane Library, and Embase databases until August 12, 2021. We included randomized controlled trials that evaluated the effects of functional electrical stimulation applied to the legs of patients with heart failure, namely changes in cardiopulmonary function, muscle strength, and quality of life. Results In total, 14 randomized controlled trials (consisting of 518 patients) were included in our article. Pooled estimates demonstrated that functional electrical stimulation significantly improved peak oxygen consumption (peak VO 2 ; standardized mean difference = 0.33, 95% confidence interval = 0.07–0.59, eight randomized controlled trials, n = 321), 6-min walking distance (mean difference = 48.03 m, 95% confidence interval = 28.50–67.57 m, 10 randomized controlled trials, n = 380), and Minnesota Living with Heart Failure Questionnaire quality of life score (mean difference = − 8.23, 95% confidence interval = − 12.64 to − 3.83, nine randomized controlled trials, n = 383). Muscle strength of lower extremities was not significantly improved in the functional electrical stimulation group compared with that in the control group (standardized mean difference = 0.26, 95% confidence interval = − 0.18 to 0.71, five randomized controlled trials, n = 218). Furthermore, the subgroup analysis revealed that functional electrical stimulation significantly improved peak VO 2 , 6-min walking distance, and Minnesota Living with Heart Failure Questionnaire quality of life score in the heart failure with reduced ejection fraction and heart failure with preserved ejection fraction subgroups. Conclusion Functional electrical stimulation can effectively improve the cardiopulmonary function and quality of life in patients with heart failure. However, functional electrical stimulation did not significantly improve muscle strength in the legs.
Chapter
This chapter provides a summary and selection of interesting and relevant scientific evidence on functional electrical stimulation (FES). Studies, reviews, and current guidelines on FES are reviewed and presented in a comprehensible manner. However, this book chapter does not claim to be exhaustive, but offers a glimpse of scientific research priorities in this topic area. These include studies addressing the sequelae of stroke, multiple sclerosis, infantile cerebral palsy (ICP), and tetraplegia following paraplegia. Furthermore, FES therapy is used and applicable for damage to the peripheral nervous system (more specifically the second motor neuron), also known as lower motor neuron syndrome (LMNS).
Article
Background: Electrical stimulation has been employed as a safe and effective therapy for improving arm function after stroke. Contralaterally controlled functional electrical stimulation (CCFES) is a unique method that has progressed from application in small feasibility studies to implementation in several randomized controlled trials. However, no meta-analysis has been conducted to summarize its efficacy. Objective: To summarize the effect size of CCFES through measures of upper extremity motor recovery compared with that of neuromuscular electrical stimulation (NMES). Methods: The PubMed, Cochrane Library, EMBASE, Scopus, and Google Scholar databases were searched. Randomized controlled trials (RCTs) were selected and subjected to meta-analysis and risk of bias assessment. Results: 6 RCTs were selected and 267 participants were included. The Upper Extremity Fugl-Meyer assessment (UEFMA) was included in all studies, the Box and Blocks test (BBT) and active range of motion (AROM) were included in 3 and 4 studies, respectively. The modified Barthel Index (mBI) and Arm Motor Abilities Test (AMAT) were included in 2 and 3 studies, respectively. The CCFES group demonstrated greater improvement than the NMES did in UEFMA (SMD = .42, 95% CI = .07-.76), BBT (SMD = .48, 95% CI = .10-.86), AROM (SMD = .54, 95% CI = .23-.86), and mBI (SMD = .54, 95% CI = .12-.97). However, the results for AMAT did not differ significantly (SMD = .34, 95% CI = -.03-.72). Conclusion: Contralaterally controlled functional electrical stimulation produced greater improvements in upper extremity hemiplegia in people with stroke than NMES did. PROSPERO registration number: CRD42021245831.
Chapter
Enthalten in diesem Kapitel: Trainierbarkeit und Rehabilitation; Test- und Trainingssysteme für Ausbildung und Praxis; Propädeutikum zur aktiven Tastsinnesleistung (PakT) - Die Fähigkeit, haptische, propriozeptive und taktile Reize zu verarbeiten, kann aufgrund der neuronalen Plastizität des menschlichen Zentralnervensystems trainiert werden. Plastizität im neurowissenschaftlichen Sinne beschreibt die Fähigkeit des zentralen Nervensystems, sich an veränderte Umgebungsbedingungen und Anforderungen anzupassen. Ausgehend von einem individuell unterschiedlichen Leistungsniveau kann durch geeignete Trainingsmaßnahmen die Leistungsfähigkeit des Tastsinnessystems verbessert werden, ähnlich wie bei motorischen Trainingsprozessen. Hierfür ist der haptische Schwellenwert eine relevante Messgröße.
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The peripheral sensory system is critical to regulating motor plasticity and motor recovery. Peripheral electrical stimulation (ES) can generate constant and adequate sensory input to influence the excitability of the motor cortex. The aim of this proof of concept study was to assess whether ES prior to each hand function training session for eight weeks can better improve neuromuscular control and hand function in chronic stroke individuals and change electroencephalography-electromyography (EEG-EMG) coherence, as compared to the control (sham ES). We recruited twelve subjects and randomly assigned them into ES and control groups. Both groups received 20-minute hand function training twice a week, and the ES group received 40-minute ES on the median nerve of the affected side before each training session. The control group received sham ES. EEG, EMG and Fugl-Meyer Assessment (FMA) were collected at four different time points. The corticomuscular coherence (CMC) in the ES group at fourth weeks was significantly higher (p = 0.004) as compared to the control group. The notable increment of FMA at eight weeks and follow-up was found only in the ES group. The eight-week rehabilitation program that implemented peripheral ES sessions prior to function training has a potential to improve neuromuscular control and hand function in chronic stroke individuals.
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Background Repetitive sensory stimulation (RSS) adapts the timing of stimulation protocols used in cellular studies to induce synaptic plasticity. In healthy subjects, RSS leads to widespread sensorimotor cortical reorganization paralleled by improved sensorimotor behavior. Here, we investigated whether RSS reduces sensorimotor upper limb impairment in patients with subacute stroke more effectively than conventional therapy. MethodsA single-blinded sham-controlled clinical trial assessed the effectiveness of RSS in treating sensorimotor deficits of the upper limbs. Patients with subacute unilateral ischemic stroke were randomly assigned to receive standard therapy in combination with RSS or with sham RSS. Patients were masked to treatment allocation. RSS consisted of intermittent 20 Hz electrical stimulation applied on the affected hand for 45 min/day, 5 days per week, for 2 weeks, and was transmitted using custom-made stimulation-gloves with built-in electrodes contacting each fingertip separately. Before and after the intervention, we assessed light-touch and tactile discrimination, proprioception, dexterity, grip force, and subtasks of the Jebsen Taylor hand-function test for the non-affected and the affected hand. Data from these quantitative tests were combined into a total performance index serving as primary outcome measure. In addition, tolerability and side effects of RSS intervention were recorded. ResultsSeventy one eligible patients were enrolled and randomly assigned to receive RSS treatment (n = 35) or sham RSS (n = 36). Data of 25 patients were not completed because they were transferred to another hospital, resulting in n = 23 for each group. Before treatment, sensorimotor performance between groups was balanced (p = 0.237). After 2 weeks of the intervention, patients in the group receiving standard therapy with RSS showed significantly better restored sensorimotor function than the control group (standardized mean difference 0.57; 95% CI -0.013–1.16; p = 0.027) RSS treatment was superior in all domains tested. Repetitive sensory stimulation was well tolerated and accepted, and no adverse events were observed. Conclusions Rehabilitation including RSS enhanced sensorimotor recovery more effectively than standard therapy alone. Rehabilitation outcome between the effects of RSS and standard therapy was largest for sensory and motor improvement; however, the results for proprioception and everyday tasks were encouraging warranting further studies in more severe patients. Trial registrationThe trial was retrospectively registered January 31, 2012 under DRKS00003515 (https://www.drks.de/drks_web/navigate.do;jsessionid=AEE2585CCB82A22A2B285470B37C47C8?navigationId=results).
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Purpose Motor recovery of persons after stroke may be enhanced by a novel approach where residual muscle activity is facilitated by patient-controlled electrical muscle activation. Myoelectric activity from hemiparetic muscles is then used for continuous control of functional electrical stimulation (MeCFES) of same or synergic muscles to promote restoration of movements during task-oriented therapy (TOT). Use of MeCFES during TOT may help to obtain a larger functional and neurological recovery than otherwise possible. Study design Multicenter randomized controlled trial. Methods Eighty two acute and chronic stroke victims were recruited through the collaborating facilities and after signing an informed consent were randomized to receive either the experimental (MeCFES assisted TOT (M-TOT) or conventional rehabilitation care including TOT (C-TOT). Both groups received 45 minutes of rehabilitation over 25 sessions. Outcomes were Action Research Arm Test (ARAT), Upper Extremity Fugl-Meyer Assessment (FMA-UE) scores and Disability of the Arm Shoulder and Hand questionnaire. Results Sixty eight subjects completed the protocol (Mean age 66.2, range 36.5–88.7, onset months 12.7, range 0.8–19.1) of which 45 were seen at follow up 5 weeks later. There were significant improvements in both groups on ARAT (median improvement: MeCFES TOT group 3.0; C-TOT group 2.0) and FMA-UE (median improvement: M-TOT 4.5; C-TOT 3.5). Considering subacute subjects (time since stroke < 6 months), there was a trend for a larger proportion of improved patients in the M-TOT group following rehabilitation (57.9%) than in the C-TOT group (33.2%) (difference in proportion improved 24.7%; 95% CI -4.0; 48.6), though the study did not meet the planned sample size. Conclusion This is the first large multicentre RCT to compare MeCFES assisted TOT with conventional care TOT for the upper extremity. No adverse events or negative outcomes were encountered, thus we conclude that MeCFES can be a safe adjunct to rehabilitation that could promote recovery of upper limb function in persons after stroke, particularly when applied in the subacute phase.
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[Purpose] To investigate the effect of mental practice combined with electromyogram-triggered electrical stimulation (MP-EMG ES) on the upper extremity of stroke patients. [Subjects and Methods] Participants were randomly assigned to experimental group or control group. The experimental group received MP-EMG ES plus conventional rehabilitation therapy for 5 days per week for 4 weeks. The control group received only conventional rehabilitation therapy. Outcome measure included the Fugl-Meyer Assessment (FMA) and Motor Activity Log (MAL). [Results] Experimental group showed more improved in the FMA, MAL-AOU, MAL-QOM compared with the control group. [Conclusion] These results suggest that MP-EMG ES improves the upper extremity of subacute stroke patients better than conventional rehabilitation therapy alone.
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Objectives: This study investigated the efficacy of Task-Related Training (TRT) Combined with Transcutaneous Electrical Nerve Stimulation (TENS) on the improvement of upper limb muscle activation in chronic stroke survivors with mild or moderate paresis. Methods: A single-blind, randomized clinical trial was conducted with 46stroke survivors with chronic paresis. They were randomly allocated two groups: the TRT+TENS group (n = 23) and the TRT+ placebo TENS (TRT+PLBO) group (n = 23). The TRT+TENS group received 30 minutes of high-frequency TENS on wrist and elbow extensors, while the TRT+PLBO group received placebo TENS that was not real ES. Both groups did 30 minutes of TRT after TENS application. Intervention was given five days a week for four weeks. The primary outcomes of upper limb muscle activation were measured by integrated EMG (IEMG), a digital manual muscle tester for muscle strength, active range of motion (AROM) and Fugl-Meyer Assessment of the upper extremity (FMA-UE). The measurements were performed before and after the 4 weeks intervention period. Results: Both groups demonstrated significant improvements of outcomes in IEMG, AROM, muscle strength and FMA-UE during intervention period. When compared with the TRT+PLBO group, the TRT+TENS group showed significantly greater improvement in muscle activation (wrist extensors, P = 0.045; elbow extensors, P = 0.004), muscle strength (wrist extensors, P = 0.044; elbow extensors, P = 0.012), AROM (wrist extension, P = 0.042; elbow extensors, P = 0.040) and FMA-UE (total, P < 0.001; shoulder/elbow/forearm, P = 0.001; wrist, P = 0.002; coordination, P = 0.008) at the end of intervention. Conclusions: Our findings indicate that TRT Combined with TENS can improve paretic muscle activity in upper limb paresis, highlighting the benefits of somatosensory stimulation from TENS.
Article
Objective: Determine whether somatosensory stimulation affects outcomes of motor training for moderate-to-severe upper extremity hemiparesis less than 12 months post-stroke. Design: 55 adults participated in 18 intervention sessions pairing 2 hours of active (n=33) or sham (n=22) somatosensory stimulation with 4 hours of intensive task-oriented motor training. Wolf Motor Function Test, Action Research Arm Test, Fugl-Meyer Assessment, and Stroke Impact Scale were administered at baseline, post-intervention, and 1- and 4-month follow-up. Results: Statistically significant between-groups differences favored the active condition on Wolf Motor Function Test at post (p=0.04) and Action Research Arm Test at post (p=0.02), 1-month (p=0.01), and 4-month (p=0.01) but favored the sham condition on Stroke Impact Scale at 1-month (p=0.03). There were no significant between-groups differences on Fugl-Meyer Assessment. Conclusion: Somatosensory stimulation can improve objective outcomes of motor training for moderate-to-severe hemiparesis less than 12 months after stroke, although the magnitude of between-groups differences in this study needs to be determined if they are clinically relevant. Future studies should investigate the intervention's impact on disability and functional recovery for this population as well as neurophysiological mechanisms underlying intervention effects.
Article
Objective: To compare the efficacy of neuromuscular electrical stimulation (NMES) and transcutaneous nerve stimulation (TENS) on hemiplegic shoulder pain (HSP). Design: This is a prospective randomized controlled trial (RCT). Setting: A total of 184 HSP patients, aged 18-80 years, were recruited in the Rehabilitation Hospital from February 2014 to July 2016. The Ethics approval was obtained from the Institutional Review Board of the Hospital. This study was conducted in accordance with the Declaration of Helsinki. Participants: 90 Participants were randomized into NMES (n=36), TENS (n=36), or control groups (n=18). Interventions: NMES (15Hz, pulse width 200μs) was applied to supraspinatus and deltoids (medial and posterior parts), while TENS (100Hz, pulse width 100μs) was used on the same areas. The surface electrodes were placed near the motor points of the supraspinatus and medial/posterior bundle of deltoids. The 4-week treatment consisted of 20 sessions, and each session comprised of1h stimulation/day. Routine rehabilitation program without any stimulation was administered to the control and the NMES/TENS groups. Numerical rating scale (NRS), active/passive range of motion (AROM/PROM) of shoulder, upper-extremity Fugl-Meyer assessment (FMA), modified Ashworth scale (MAS), Barthel index (BI), and stroke-specific quality of life scale (SSQOLS) were assessed in a blinded manner at baseline, 2, 4, and 8 weeks after treatment, respectively. Main outcome measures: The primary endpoint was the improvement from baseline in NRS for HSP at 4 weeks. Results: NRS scores in NMES, TENS, and control groups had decreased by 2.03, 1.44, and 0.61 points, respectively after 4 weeks treatment, with statistically significant differences among the three groups (P<0.001). The efficacy of the NMES group was significantly better than that of the TENS group (P=0.043). Moreover, the efficacy of NMES and TENS groups was superior to that of the control group (P<0.001, P=0.044, respectively). The differences in the therapeutic efficacy on shoulder AROM/PROM, FMA, MAS, BI, and SSQOLS scores were not significant among the three groups. Conclusions: TENS and NMES can effectively improve HSP; the efficacy of NMES being distinctly superior to that of TENS in maintaining long-term analgesia. However, NMES was not more efficacious than the TENS or control group in improving the shoulder joint mobility, upper limb function, spasticity, the ability of daily life activity,and stroke-specific quality of life in HSP patients.
Article
Background: Stroke survivors with severe upper limb disability need opportunities to engage in task-oriented practice to achieve meaningful recovery. Objective: To compare the effect of SMART Arm training, with or without outcome-triggered electrical stimulation to usual therapy, on arm function for stroke survivors with severe upper limb disability undergoing inpatient rehabilitation. Methods: A prospective, multicenter, randomized controlled trial was conducted with 3 parallel groups, concealed allocation, assessor blinding and intention-to-treat analysis. Fifty inpatients within 4 months of stroke with severe upper limb disability were randomly allocated to 60 min/d, 5 days a week for 4 weeks of (1) SMART Arm with outcome-triggered electrical stimulation and usual therapy, (2) SMART Arm alone and usual therapy, or (3) usual therapy. Assessment occurred at baseline (0 weeks), posttraining (4 weeks), and follow-up (26 and 52 weeks). The primary outcome measure was Motor Assessment Scale item 6 (MAS6) at posttraining. Results: All groups demonstrated a statistically ( P < .001) and clinically significant improvement in arm function at posttraining (MAS6 change ≥1 point) and at 52 weeks (MAS6 change ≥2 points). There were no differences in improvement in arm function between groups (P = .367). There were greater odds of a higher MAS6 score in SMART Arm groups as compared with usual therapy alone posttraining (SMART Arm stimulation generalized odds ratio [GenOR] = 1.47, 95%CI = 1.23-1.71) and at 26 weeks (SMART Arm alone GenOR = 1.31, 95% CI = 1.05-1.57). Conclusion: SMART Arm training supported a clinically significant improvement in arm function, which was similar to usual therapy. All groups maintained gains at 12 months.
Article
Background: Stroke is the leading cause of long-term disability. Stroke survivors seldom improve their upper-limb function when their deficit is severe, despite recently developed therapies. Purpose: This study aims to assess the efficacy of functional electrical stimulation therapy in improving voluntary reaching and grasping after severe hemiplegia. Method: A post hoc analysis of a previously completed randomized control trial ( clinicaltrials.gov , No. NCT00221078) was carried out involving 21 participants with severe upper-limb hemiplegia (i.e., Fugl-Meyer Assessment-Upper Extremity [FMA-UE] ≤ 15) resulting from stroke. Findings: Functional Independence Measure Self-Care subscores increased 22.8 (±6.7) points in the intervention group and 9 (±6.5) in the control group, following 40 hr of equal-intensity therapy. FMA-UE score changes were 27.2 (±13.5) and 5.3 (±11.0) for the intervention and control groups, respectively. Implications: The results may represent the largest upper-limb function improvements in any stroke population to date, especially in those with severe upper-limb deficit.