Archive for category FES

[REVIEW] CONTROL OF FUNCTIONAL ELECTRICAL STIMULATION FOR RESTORATION OF MOTOR FUNCTION – Full Text PDF

Abstract

An injury or disease of the central nervous system (CNS) results in significant limitations in the communication with the environment (e.g., mobility, reaching and grasping). Functional electrical stimulation (FES) externally activates the muscles; thus, can restore several motor functions and reduce other health related problems.

This review discusses the major bottleneck in current FES which prevents the wider use and better outcome of the treatment. We present a control method that we continually enhance during more than 30 years in the research and development of assistive systems. The presented control has a multi-level structure where upper levels use finite state control and the lower level implements model based control. We also discuss possible communication channels between the user and the controller of the FES. The artificial controller can be seen as the replica of the biological control. The principle of replication is used to minimize the problems which come from the interplay of biological and artificial control in FES. The biological control relies on an extensive network of neurons sending the output signals to the muscles. The network is being trained though many the trial and error processes in the early childhood, but staying open to changes throughout the life to satisfy the particular needs. The network considers the nonlinear and time variable properties of the motor system and provides adaptation in time and space.

The presented artificial control method implements the same strategy but relies on machine classification, heuristics, and simulation of model-based control. The motivation for writing this review comes from the fact that many control algorithms have been presented in the literature by the authors who do not have much experience in rehabilitation engineering and had never tested the operations with patients.

Almost all of the FES devices available implement only open-loop, sensory triggered preprogrammed sequences of stimulation. The suggestion is that the improvements in the FES devices need better controllers which consider the overall status of the potential user, various effects that stimulation has on afferent and efferent systems, reflexive responses to the FES and direct responses to the FES by non-stimulated sensory-motor systems, and the greater integration of the biological control.

Full Text: PDF

References

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http://www.bioness.com/ NESS_L300_for_Foot_Drop.php [Accessed, Dec. 2016]

http://www.bioness.com/ NESS_H200_for_Hand_Rehab.php [Accessed, Dec. 2016]

http://www.walkaide.com/en-US/ Pages/default.aspx [Accessed, Dec. 2016]

http://www.odstockmedical.com/ products/microstim-2v2-kit [Accessed, Dec. 2016]

http://www.markfelling.com/id450.htm [Accessed, Dec. 2016]

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http://musclepower.com/parastep.htm [Accessed, Dec. 2016]

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J. D. Millán, R. Rupp, G. R. Müller-Putz, R. Murray-Smith, C. Giugliemma, M. Tangermann, C. Vidaurre, F. Cincotti, A. Kübler, R. Leeb and C. Neuper, “Combining brain–computer interfaces and assistive technologies: state-of-the-art and challenges”, Frontiers in Neuroscience, vol. 4, 161, 2010.

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G. Pfurtscheller G. R. Müller, J. Pfurtscheller, H. J. Gerner and R. Rupp. ”Thought–control of functional electrical stimulation to restore hand grasp in a patient with tetraplegia”, Neuroscience Letters. vol. 351, no. 1, pp. 33-36. 2003.

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A. M. Savić, N. M. Malešević and M. B. Popović, “Feasibility of a Hybrid Brain-Computer Interface for Advanced Functional Electrical Therapy”, Hindawi Publ Corp, Scientific World Journal, Article ID 797128, 2014.

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Source: CONTROL OF FUNCTIONAL ELECTRICAL STIMULATION FOR RESTORATION OF MOTOR FUNCTION | Popović | Facta Universitatis, Series: Electronics and Energetics

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[VIDEO] Functional electrical stimulation (FES) talk with Christine Singleton and Sarah Joiner – YouTube

Δημοσιεύτηκε στις 22 Μαρ 2017

Lead Clinical Physiotherapist Christine Singleton and Sarah Joiner who has MS discuss Functional electrical stimulation (FES), how it works, who can use it, how to wear it, does it make a difference and how can you get referred for it. For more information about FES visit our website https://www.mstrust.org.uk/a-z/functi…

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[WEB SIDE] WalkAide & Foot Drop – WalkAide.com

WalkAide & Foot Drop

​​​​WalkAide: Helping​​ You Get a Leg Up on Foot Drop

WalkAide is a class II, FDA cleared medical device, designed to improve walking ability in people experiencing foot drop caused by upper motor neuron injuries or conditions such as:

  • Multiple Sc​​lerosis (MS)​
  • Stroke (CVA)
  • Cerebral Palsy (CP)
  • Incomplete Spinal Cord Injury
  • Traumatic Brain Injury (TBI)​​

​Foot Drop or Dropped Foot is a condition caused by weakness or paralysis of the muscles involved in lifting the front part of the foot, which causes a person to drag the toe of the shoe on the ground or slap the foot on the floor.

Foot drop (also known as drop foot) may result from damage to the central nervous system such as stroke, spinal cord injury, traumatic brain injury, cerebral palsy and multiple sclerosis. The WalkAide is designed to assist with the ability to lift the foot for those individuals who have suffered an injury to their central nervous system. The WalkAide is not designed to work with people who have damage to the lower motor neurons/peripheral nerves.​

WalkAide vs. AFO​

Traditionally, foot drop is treated with bracing using an ankle foot orthosis (AFO). The passive treatement offered by AFOs do not promote active use of neuromuscular systems and also limits ankle range of motion. In addition, AFOs can be uncomfortable, bulky, and, if poorly fitted, produce areas of pressure and tissue breakdown. The WalkAide may replace the traditional AFO to re-engage a person’s existing nerve pathways and muscles. Using the WalkAide, in most cases, frees the patient from AFO restrictions. 

The recruitment of existing muscles results in reduction of atrophy and walking fatigue – a common side effect of foot bracing. WalkAide users have the freedom to walk with or without footwear, up and down the stairs, and even sidestep.

Comparison of Benefits of Functional Electrical
Stimulation (FES) and Ankle Foot Orthosis (AFO) for Foot Drop​

AFO = ankle foot orthosis • FES = functional electrical stimulation • ROM = range of motion
​​

Advanced Technology; Easy to Use

​​​Invented by a team of researchers at the University of Alberta, WalkAide uses functional electrical stimulation (FES) to restore typical nerve-to-muscle signals in the leg and foot, effectively lifting the foot at the appropriate time. The resulting movement is a smoother, more natural and safer stepping motion. It may allow faster walking for longer distances with less fatigue. In fact, many people who try WalkAide experience immediate and substantial improvement in their walking ability, which increases their mobility, functionality, and overall independence.

​A sophisticated medical device, WalkAide uses advanced tilt sensor technology to analyze the movement of your leg. This tilt sensor adjust the timing of stimulation for every step. The system sends electrical signals or stimulation to the peroneal nerve, which controls movement in your ankle and foot. These gentle electrical impulses activate the muscles to raise your foot at the appropriate time during the step cycle.

​Although highly-advanced, WalkAide is surprisingly small and easy to use. It consists of a AA battery-operated, single-channel electrical stimulator, two electrodes, and electrode leads. WalkAide is applied directly to the leg — not implanted underneath the skin — which means no surgery is involved. A cuff holds the system comfortably in place, and it can be worn discreetly under most clothing. With the WalkAide’s patented Tilt Sensor technology, most users do not require additional external wiring or remote heel sensors.

​​WalkAide Provides the Advantages not Found in Typical Foot Drop Treamtents :

  • Easy one-handed operation and application
  • Small, self-contained unit
  • Does not require orthopedic or special shoes
  • May be worn barefoot or with slippers
  • Minimal contact means minimal discomfort with reduced perspiration
  • May improve circulation, reduce atrophy, improve voluntary control and increase joint range of motion

Customized For Individual Walking Pattern

​WalkAide is not a one size fits all device. Rather, a specially trained medical professional customizes and fits the WalkAide. Using WalkAnalyst, a multifaceted computer software program, the clinician can tailor WalkAide to an individual’s walking pattern for optimal effectiveness.

Exercise Mode for Home Use

​In addition fo walking assistance, the WalkAide system includes a pre-programmable exercise mode that allows a user to exercise his/her muscles while resting for a set period of time as prescribed.​

Visit Site —> WalkAide & Foot Drop – WalkAide.com

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[WEB SITE] Bioness Inc. – H200 for Hand Paralysis

Regain More Natural Hand Function — With Wireless Freedom.

The H200 Wireless Hand Rehabilitation System

Now you can get back to your daily living activities with the H200 Wireless Hand Rehabilitation System that offers the freedom and convenience of wireless operation. The H200 Wireless Hand Rehabilitation System is an ergonomically designed, easy-to-operate system that helps you achieve your personal recovery goals. Reaching, grasping, opening and closing the hand are all possible with the H200 Wireless Hand Rehabilitation System.

100% Wireless

With wireless operation, it’s easy to integrate into your daily life.

The system’s advanced technology delivers low-level electrical stimulation to activate the nerves that control the muscles in the hand and forearm, helping you regain your freedom and independence.1

The H200 Wireless Hand Rehabilitation System is a medical device cleared by the U.S. Food and Drug Administration (FDA) and CE-marked for the European Union.

If you are currently a H200 Hand Rehabilitation System user, Bioness will continue to support your current system through April 2014. However, to help you upgrade to the new H200 Wireless System, we are offering a substantial trade-in allowance for your current system for a limited time.

1. Hausdorff JM, Ring H. 2006. The effect of the NESS L300 neuroprosthesis on gait stability and symmetry (abstract included in CSM 2007 Platform Presentations). J Neurol Phys Ther. 30(4):198.

H200 for Hand Paralysis

 

Visit Site —> Bioness Inc. – H200 for Hand Paralysis

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[ARTICLE] Compensating the effects of FES-induced muscle fatigue by rehabilitation robotics during arm weight support – Full Text

Abstract

Motor functions can be hindered in consequence to a stroke or a spinal cord injury. This often results in partial paralyses of the upper limb. The effectiveness of rehabilitation therapy can be improved by the use of rehabilitation robotics and Functional Electrical Stimulation (FES). We consider a hybrid arm weight support combining both.

In order to compensate the effect of FES-induced muscle fatigue, we introduce a method to substitute the decreasing level of FES support by cable-driven robotics. We evaluated the approach in a trial with one healthy subject performing repetitive arm lifting. The controller automatically adapted the support and thus no increase in user generated volitional effort was observed when FES induced muscle fatigue occured.

Continue —> Compensating the effects of FES-induced muscle fatigue by rehabilitation robotics during arm weight support : Current Directions in Biomedical Engineering

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[Abstract] Effects of sit-to-stand training combined with transcutaneous electrical stimulation on spasticity, muscle strength and balance ability in patients with stroke: a randomized controlled study

Highlights

  • The effect of sit-to-stand training combined with TENS was evaluated in stroke patients with spastic plantar flexor.
  • TENS followed by sit-to-stand training may improve spasticity, muscle strength and balance.
  • Clinician should consider TENS application prior to sit to stand training for stroke patients with spastic plantar flexor.

Abstract

Sit-to-stand is a fundamental movement of human being for performing mobility and independent activity. However, Stroke people symptoms experience difficulty in conducting the sit-to-stand due to paralysis and especially ankle spasticity. Recently, transcutaneous electrical- stimulation (TENS) is used to reduce pain but also to manage spasticity.

The purpose of this study was to determine

  1. whether TENS would lead to ankle spasticity reduction and (
  2. whether sit-to-stand training combined with TENS would improve spasticity, muscle strength and balance ability in stroke patients.

Forty-stroke patients were recruited and were randomly divided into two groups: TENS group (n = 20) and sham group (n = 20). All participants underwent 30-sessions of sit-to-stand training (for 15-minutes, five-times per week for 6-weeks). Prior to each training session, 30-minutes of TENS over the peroneal nerve was given in TENS group, whereas sham group received non-electrically stimulated TENS for the same amount of time. Composite-Spasticity-Score was used to assess spasticity level of ankle plantar-flexors. Isometric strength in the extensor of hip, knee and ankle were measured by handhelddynamometer. Postural-sway distance was measured using a force platform.

The spasticity score in the TENS group (2.6 ± 0.8) improved significantly greater than the sham group (0.7 ± 0.8, p < 0.05). The muscle strength of hip extensor in the TENS group (2.7 ± 1.1 kg) was significantly higher than the sham group (1.0 ± 0.8 kg, p < 0.05). Significant improvement in postural-sway was observed in the TENS group compared to the sham group (p < 0.05).

Thus, sit-to-stand training combined with TENS may be used to improve the spasticity, balance function and muscle strength in stroke patients.

Source: Effects of sit-to-stand training combined with transcutaneous electrical stimulation on spasticity, muscle strength and balance ability in patients with stroke: a randomized controlled study – Gait & Posture

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[ARTICLE] Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis – Full Text

Abstract

Background

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

Methods

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

Results

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).

Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

Conclusions

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

Background

Stroke is defined as a clinical syndrome characterised by rapidly developing focal or global disturbance in cerebral function lasting more than 24 h or leading to death due to a presumed vascular cause [1]. Globally, approximately 16 million people have a stroke each year [2] and in the UK, first-ever stroke affects about 230 people per 100,000 population each year [3]. Stroke represents a cost to the UK economy of approximately £9 billion annually, of which £1.33 billion results from productivity losses [4].

Stroke often leads to significant impairment of upper limb function and is associated with decreased quality of life in all domains except for mobility [5]. Few patients attain complete functional recovery [6]; this deficit impairs performance of activities of daily living (ADL), including self-care and social activities [7, 8]. ADL reflect the level of functional impairment in daily life and are therefore the most clinically relevant outcome measures in assessing recovery after stroke [9].

Functional electrical stimulation (FES) was well established as an intervention for motor rehabilitation. FES is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract and create/augment a moment about a joint [2]. Transcutaneous electrodes offer the most immediate and clinically viable treatment option as they are non-invasive and may permit home-based treatment.

There are various terms used in the literature to describe different forms of electrical stimulation, often inconsistently. Some authors define FES as electrical stimulation applied to a subject which causes muscle contraction. This passive modality is also referred to as neuromuscular electrical stimulation [10]. Others define FES as electrical stimulation applied during a voluntary movement [4]. This definition acknowledges the volitional component of physical rehabilitation and was used in this systematic review. The distinction is important because neuroimaging studies have identified different cortical mechanisms according to stimulation type [11, 12, 13]. Indeed, perfusion to the ipsilesional sensory-motor cortex and cortical excitability were increased with FES when compared to passive modalities of electrical stimulation [12, 13, 14]. These findings could indicate greater potential for volitional FES to induce neuroplasticity. This is believed to play an important role in neurorehabilitation [15] and is a key objective of post-stroke functional recovery [16].

FES has been widely researched for post-stroke lower limb rehabilitation; several systematic reviews [17, 18, 19] and national guidelines [20, 21] exist. Improvement in upper limb function is central to post-stroke rehabilitation as it positively affects ADL and quality of life [22]. Yet, there is still a lack of clarity on the effectiveness of FES in post-stroke upper limb rehabilitation [23] despite systematic reviews having been undertaken [24, 25, 26, 27, 28]. In part, this is due to methodological limitations [27, 28] or the outdated nature of some existing reviews [24, 25, 26]. The latter was highlighted by a recent Cochrane overview of reviews calling for an up-to-date review and meta-analysis of randomised controlled trials (RCTs) related to electrical stimulation [29]. A more recent systematic review found a significant improvement in motor outcomes with upper limb FES [27]. However, this was based on a single meta-analysis that combined ADLs with upper limb-specific measures of functional motor ability, including studies where results were at risk of performance bias (intervention groups receiving greater duration of treatment than control groups) [27]. Another found no improvement in motor function when FES was applied within 6 months of stroke [28]. However, this predominantly included studies that applied electrical stimulation in the absence of volitional muscle contraction, confounding interpretation of the results. This inconsistency is reflected in the 2016 guidelines set by the Royal College of Physicians which recommends FES only in the context of clinical trials as an adjunct to conventional therapy [21].

This systematic review aims to elucidate the effectiveness of upper limb FES compared to standard therapy in improving ADL, in addition to motor outcomes, post-stroke. It represents an important addition to the literature that focuses on the use of volitional FES and, for the first time, distinguishes its effect on clinically relevant patient outcomes from surrogate markers of patient rehabilitation. This includes analyses based on patient sub-groups defined by the time after stroke at which FES was initiated.

Fig. 1 Flow diagram for included studies

Continue —> Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis | Systematic Reviews | Full Text

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[WEB SITE] Restorative Therapies to Showcase Xcite FES System at APTA Combined Sections Meeting in San Antonio, TX February.


Restorative Therapies, Inc, the leader in FES powered systems, announced today that it will be exhibiting the new Xcite FES system at APTA’s Combined Sections Meeting taking place at the Henry B. González Convention Center in San Antonio, TX over February 15 to 18, 2017.

Restorative Therapies will be featuring live demonstrations of their new Xcite FES system, and experts will be on hand at booth number 442 to discuss the clinical applications.

Xcite FES Clinical Station is a portable, multi-channel FES therapy system. Easy to use pre-programmed activity libraries for upper extremity, lower extremity and general activities deliver sequenced stimulation enabling a patient’s weak or paralyzed muscles to move through dynamic movement patterns. Xcite assists patients to perform task specific, strengthening and gross motor activities using up to 12 channels of stimulation.

The on screen photo guide for electrode placement facilitates easy set up. An avatar demonstrates each activity and there are chimes to indicate transitions providing visual and auditory cues that assist your patient with timing and awareness of movements.

“Repetitive practice of task specific, strengthening and gross motor activities have long been a cornerstone of PT and OT programs for patients with neurological impairments or muscle weakness,” says Wendy Warfield, MSHA, OTR/L, Clinical Education Manager of Restorative Therapies. “Xcite is designed to be easily integrated into these traditional programs. Xcite enhances the impact of the traditional therapeutic activities that support neuromuscular reeducation.”

“There is nothing else on the market that compares to Xcite…It is great to finally have a device that allows you to work on precise motor control and dexterity while providing FES…Xcite’s ability to control each movement channel individually allows you to facilitate more accurate and functional movement patterns for greater recovery,” said Jenny Suggit, MS OTR/L, CLT, Occupational Therapist, Centre Manager, Neurokinex-Gatwick, UK.

Also on display will be RT300 supine. RT300 supine allows people to leg or arm cycle while in bed. Cycling from bed can be an important component in an Early Mobility program. Early Mobility programs are being adopted by a growing number of Intensive Care Units with the goal of enhancing patient outcomes and reducing lengths of stay.

About Restorative Therapies
Restorative Therapies mission is to help people with a neurological impairment or in critical care achieve their full recovery potential. Restorative Therapies is one of the first companies to target activity-based physical therapy and Functional Electrical Stimulation as a rehabilitation therapy for immobility associated with paralysis such as stroke, multiple sclerosis and spinal cord injury or for patients in critical care.

Restorative Therapies is a privately held company headquartered in Baltimore. To learn more about Restorative Therapies please visit us at http://www.restorative-therapies.com

There is nothing else on the market that compares to Xcite…It is great to finally have a device that allows you to work on precise motor control and dexterity while providing FES

 

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[Abstract] Single Session of Functional Electrical Stimulation−Assisted Walking Produces Corticomotor Symmetry Changes Related to Changes in Poststroke Walking Mechanics

Abstract

Background: Recent research demonstrated that symmetry of corticomotor drive to paretic and nonparetic plantarflexor muscles are related to the biomechanical ankle moment strategy that individuals with chronic stroke used to achieve their greatest walking speeds. Rehabilitation strategies that promote corticomotor balance could potentially improve post-stroke walking mechanics and enhance functional ambulation.

Objective: To 1) test the effectiveness of a single session of gait training using functional electrical stimulation (FES) to improve plantarflexor corticomotor symmetry and plantarflexion ankle moment symmetry and 2) determine if changes in corticomotor symmetry relate to changes in ankle moment symmetry within the session.

Design: A repeated measures cross-over study.

Methods: On separate days, twenty individuals with chronic stroke completed a session of treadmill walking either with or without the use of FES to their ankle dorsi- and plantarflexors muscles. We calculated plantarflexor corticomotor symmetry using transcranial magnetic stimulation and plantarflexion ankle moment symmetry during walking between the paretic and nonparetic limbs before and after each session. We compared changes and tested relationships between corticomotor and ankle moment symmetry following each session.

Results: Following the session with FES there was an increase in plantarflexor corticomotor symmetry that was related to the observed increase in ankle moment symmetry. In contrast, following the session without FES there were no changes in corticomotor symmetry or ankle moment symmetry.

Limitations: No stratification was made based on lesion size, location, or clinical severity.

Conclusions: For the first time, these findings demonstrate the ability of a single session of gait training with FES to induce positive corticomotor plasticity in individuals in the chronic stage of stroke recovery and provide insight into the neurophysiologic mechanisms underlying improvements in biomechanical walking function.

Source: Single Session of Functional Electrical Stimulation−Assisted Walking Produces Corticomotor Symmetry Changes Related to Changes in Poststroke Walking Mechanics | Physical Therapy | Oxford Academic

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[Systematic Review] Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis – Full Text

Abstract

Background

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

Methods

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

Results

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).

Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

Conclusions

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

Background

Stroke is defined as a clinical syndrome characterised by rapidly developing focal or global disturbance in cerebral function lasting more than 24 h or leading to death due to a presumed vascular cause [1]. Globally, approximately 16 million people have a stroke each year [2] and in the UK, first-ever stroke affects about 230 people per 100,000 population each year [3]. Stroke represents a cost to the UK economy of approximately £9 billion annually, of which £1.33 billion results from productivity losses [4].

Stroke often leads to significant impairment of upper limb function and is associated with decreased quality of life in all domains except for mobility [5]. Few patients attain complete functional recovery [6]; this deficit impairs performance of activities of daily living (ADL), including self-care and social activities [7, 8]. ADL reflect the level of functional impairment in daily life and are therefore the most clinically relevant outcome measures in assessing recovery after stroke [9].

Functional electrical stimulation (FES) was well established as an intervention for motor rehabilitation. FES is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract and create/augment a moment about a joint [2]. Transcutaneous electrodes offer the most immediate and clinically viable treatment option as they are non-invasive and may permit home-based treatment.

There are various terms used in the literature to describe different forms of electrical stimulation, often inconsistently. Some authors define FES as electrical stimulation applied to a subject which causes muscle contraction. This passive modality is also referred to as neuromuscular electrical stimulation [10]. Others define FES as electrical stimulation applied during a voluntary movement [4]. This definition acknowledges the volitional component of physical rehabilitation and was used in this systematic review. The distinction is important because neuroimaging studies have identified different cortical mechanisms according to stimulation type [11, 12, 13]. Indeed, perfusion to the ipsilesional sensory-motor cortex and cortical excitability were increased with FES when compared to passive modalities of electrical stimulation [12, 13, 14]. These findings could indicate greater potential for volitional FES to induce neuroplasticity. This is believed to play an important role in neurorehabilitation [15] and is a key objective of post-stroke functional recovery [16].

FES has been widely researched for post-stroke lower limb rehabilitation; several systematic reviews [17, 18, 19] and national guidelines [20, 21] exist. Improvement in upper limb function is central to post-stroke rehabilitation as it positively affects ADL and quality of life [22]. Yet, there is still a lack of clarity on the effectiveness of FES in post-stroke upper limb rehabilitation [23] despite systematic reviews having been undertaken [24, 25, 26, 27, 28]. In part, this is due to methodological limitations [27, 28] or the outdated nature of some existing reviews [24, 25, 26]. The latter was highlighted by a recent Cochrane overview of reviews calling for an up-to-date review and meta-analysis of randomised controlled trials (RCTs) related to electrical stimulation [29]. A more recent systematic review found a significant improvement in motor outcomes with upper limb FES [27]. However, this was based on a single meta-analysis that combined ADLs with upper limb-specific measures of functional motor ability, including studies where results were at risk of performance bias (intervention groups receiving greater duration of treatment than control groups) [27]. Another found no improvement in motor function when FES was applied within 6 months of stroke [28]. However, this predominantly included studies that applied electrical stimulation in the absence of volitional muscle contraction, confounding interpretation of the results. This inconsistency is reflected in the 2016 guidelines set by the Royal College of Physicians which recommends FES only in the context of clinical trials as an adjunct to conventional therapy [21].

This systematic review aims to elucidate the effectiveness of upper limb FES compared to standard therapy in improving ADL, in addition to motor outcomes, post-stroke. It represents an important addition to the literature that focuses on the use of volitional FES and, for the first time, distinguishes its effect on clinically relevant patient outcomes from surrogate markers of patient rehabilitation. This includes analyses based on patient sub-groups defined by the time after stroke at which FES was initiated.

Continue —> Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis | Systematic Reviews | Full Text

Fig. 1 Flow diagram for included studies

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