Posts Tagged Electrical Stimulation

[Workshop] Evidence-Based Upper Limb Retraining after Stroke 2017 – Pre-Reading and Workshop Tasks – PDF

CHAPTER 40: Optimizing motor performance and sensation after brain impairment

ABSTRACT

This chapter provides a framework for optimizing motor performance and sensation in adults with brain impairment. Conditions such as stroke and traumatic brain injury are the main focus, however, the chapter content can apply to adults with other neurological conditions. The tasks of eating and drinking are used as examples throughout the chapter. Skills and knowledge required by graduates are identified, including knowledge of motor behaviour, the essential components of reaching to grasp and reaching in sitting, and how to identify compensatory strategies, develop and test movement hypotheses. Factors that enhance skill acquisition are discussed, including task specificity, practice intensity and timely feedback, with implications for therapists’ teaching skills. Finally, a summary is provided of evidence-based interventions to improve motor performance and sensation, including high intensity, task-specific training, mirror therapy, mental practice, electrical stimulation and constraint therapy.

Key Points:

  1. Essential knowledge in neurological rehabilitation includes an understanding of normal motor behaviour, muscle biology and skill acquisition.
  2. Abnormal motor performance can be observed during a task such as reaching for a cup, and compared with expected performance. Hypotheses about the cause(s) of observed movement differences can then be made and tested.

  3. Paralysis, weakness and loss of co-ordination affect upper limb motor performance. To improve performance after brain impairment, therapists should primarily focus on improving strength and co-ordination.

  4. Many people with brain impairment have difficulty understanding instructions, goals and feedback, and consequently may not practice well. To teach people to practice well and learn skills, therapists need to be good coaches.

  5. Motor performance and sensation can be improved using low-cost evidence-based strategies such as high intensity, repetitive, task-specific training, mirror therapy, mental practice, electrical stimulation and constraint-induced movement therapy.

1. Introduction

Upper motor neuron lesions typically cause impairments such as paralysis, muscle weakness and loss of sensation. These impairments can limit participation in everyday tasks such as eating a meal. Motor control is a term commonly used in rehabilitation (Shumway-Cook, 2012; van Vliet et al 2013) and refers to control of movements such as reaching to grasp a cup and standing up. Occupational therapists and physiotherapists retrain motor and sensory impairments that interfere with tasks such as grasping a cup and sitting safely on the toilet.

The aim of this chapter is to provide a framework that helps therapists to systematically observe, analyse and measure motor and sensory impairments. Targeted evidence-based interventions will be described that can drive neuroplasticity. Therapists need to proactively seek muscle activity and sensation. It is not enough to teach a person how to compensate using one-handed techniques, or to wait for recovery to possibly occur.[…]

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[ARTICLE] Functional Electrical Stimulation with Augmented Feedback Training Improves Gait and Functional Performance in Individuals with Chronic Stroke: A Randomized Controlled Trial – Full Text PDF

Abstract

Purpose: The purpose of this study was to compare the effects of the FES-gait with augmented feedback training to the FES alone on the gait and functional performance in individuals with chronic stroke.

Methods: This study used a pretest and posttest randomized control design. The subjects who signed the agreement were randomly divided into 12 experimental groups and 12 control groups. The experimental groups performed two types of augmented feedback training (knowledge of performance and knowledge of results) together with FES, and the control group performed FES on the TA and GM without augmented feedback and then walked for 30 minutes for 40 meters. Both the experimental groups and the control groups received training five times a week for four weeks.

Results: The groups that received the FES with augmented feedback training significantly showed a greater improvement in single limb support (SLS) and gait velocity than the groups that received FES alone. In addition, timed up and go (TUG) test and six minute walk test (6MWT) showed a significant improvement in the groups that received FES with augmented feedback compared to the groups that received FES alone.

Conclusion: Compared with the existing FES gait training, augmented feedback showed improvements in gait parameters, walking ability, and dynamic balance. The augmented feedback will be an important method that can provide motivation for motor learning to stroke patients.

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[Abstract] Targeting interhemispheric inhibition with neuromodulation to enhance stroke rehabilitation

Highlights

  • This review focuses on interhemispheric inhibition and its role in the healthy and stroke lesioned brain.
  • Measurement method and movement phase should be considered when comparing studies associating interhemispheric inhibition with functional recovery.
  • Neuromodulation of interhemispheric inhibition to augment stroke recovery requires the targeting of specific neural circuitry. We discuss the effectiveness of current and novel neurostimulation techniques at targeting interhemispheric inhibition and enhancing stroke rehabilitation.

Abstract

Background/Objectives

Interhemispheric inhibition in the brain plays a dynamic role in the production of voluntary unimanual actions. In stroke, the interhemispheric imbalance model predicts the presence of asymmetry in interhemispheric inhibition, with excessive inhibition from the contralesional hemisphere limiting maximal recovery. Stimulation methods to reduce this asymmetry in the brain may be promising as a stroke therapy, however determining how to best measure and modulate interhemispheric inhibition and who is likely to benefit, remain important questions.

Methods

This review addresses current understanding of interhemispheric inhibition in the healthy and stroke lesioned brain. We present a review of studies that have measured interhemispheric inhibition using different paradigms in the clinic, as well as results from recent animal studies investigating stimulation methods to target abnormal inhibition after stroke.

Main findings/Discussion

The degree to which asymmetric interhemispheric inhibition impacts on stroke recovery is controversial, and we consider sources of variation between studies which may contribute to this debate. We suggest that interhemispheric inhibition is not static following stroke in terms of the movement phase in which it is aberrantly engaged. Instead it may be dynamically increased onto perilesional areas during early movement, thus impairing motor initiation. Hence, its effect on stroke recovery may differ between studies depending on the technique and movement phase of eliciting the measurement. Finally, we propose how modulating excitability in the brain through more specific targeting of neural elements underlying interhemispheric inhibition via stimulation type, location and intensity may raise the ceiling of recovery following stroke and enhance functional return.

Source: Targeting interhemispheric inhibition with neuromodulation to enhance stroke rehabilitation – Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation

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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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[WEB SITE] Foot Drop: Causes, Prevention and How You can Treat It

What is foot drop & what causes it?

Foot drop is a simple name but its cause and treatment may be less than simple.

If you are unable to lift your foot up at the ankle and it makes walking difficult, you may have something called foot drop. This could be due to weakness in one of the muscles responsible for lifting, or dorsiflexing, your foot. It could also be caused by tightness or spasticity in the calf muscles of your leg that cause your toes to point downward.

The cause of foot drop can be from several different sources – neurological, muscular, a side effect from medication, or from a lack of movement.

People with stroke, multiple sclerosis, acquired brain injury, spinal cord injury, or cerebral palsy have a central neurological reason causing weakness, tightness or spasticity. People with peripheral neurologic disease may also have foot drop. These diagnoses could include neuropathy, injury to the lower spinal cord, nerve damage, or illnesses like Guillain-Barre syndrome.

Those who have a traumatic accident or muscular damage could also suffer from foot drop because of damage from swelling and compression.

Certain medications are known to potentially cause foot drop. Talk to your doctor about your medications.

Foot drop can also occur in people who are in bed for a prolonged amount of time. When lying on your back, gravity pulls down your foot, and can cause weakness and overstretch the muscles and nerves on the front of your lower leg.

Can foot drop be prevented?

If you or your loved one is required to be on bedrest or immobile, you can help to prevent foot drop by using a padded splint, by doing stretching, and by doing active exercises like ankle pumps.

If you have an underlying condition, it may be impossible to fully prevent foot drop from occurring. But often you can improve the flexibility and strength in your leg, or use an orthosis or splint to help maintain your foot in a position that will allow you to walk and move safely.

How can foot drop be treated?

The treatment of foot drop depends on the cause and the symptoms you have. Below are some suggestions on what you can do, but make sure to talk to your doctor, therapist or orthotist about the best treatment options for you.

Keep your foot and ankle flexible:

  • Use a foot splint at night

  • Complete daily stretches. The ProStretch gives a great stretch

Improve the tone in your leg:

  • Use an orthosis that puts your ankle in a slight stretch

Strengthen your leg:

  • Use neuromuscular electrical stimulation

  • Complete exercises against gravity or with resistance like a Theraband

  • Stand on a variety of surfaces like an Airex balance pad or a Bosu ball to challenge your muscles in your legs. Hold onto something sturdy or have someone nearby to help

Improve the safety of your walking and prevent falls:

  • Use an ankle foot orthosis to keep your toes up when walking. Depending on your strength level, you may need a flexible one or a rigid one

  • Walk with an assistive device, like a walker or cane

  • Modify your home to prevent you from tripping or falling – consider removing rugs and floor clutter, sitting on a shower chair instead of standing, and observe your home for other potential hazards

Prevent skin problems with the use of splints and orthotics:

  • Make sure to check your skin after you’ve been wearing it, and more often if you have impaired sensation in your legs, diabetes, or a history of wounds. Use a hand held inspection mirror to help

Keep the rest of yourself of healthy:

  • Consider activities like stationary biking or swimming to complete overall strengthening and conditioning

  • Strengthen your core muscles to improve your overall balance and stability

What are the dangers of not treating foot drop?

The biggest risk of not treating foot drop is tripping and falling. Falls lead to injury and other unnecessary treatments or hospitalizations. In order to clear your toes to avoid falling, you will have to change the way you walk. Over time, this could lead to pain or discomfort in your back or legs. Also, if your ankle loses flexibility and you cannot move it at you may need surgery.

Most importantly, without treatment you will have more difficulty doing the things in life that you enjoy doing. Unfortunately, there may be no cure, but there are things you can do to help improve the quality of your life.

Who should I ask for more information?

If you have already been diagnosed or are concerned about your risk for foot drop, you should speak with your healthcare provider about what you can do to prevent and treat it.

Source: Foot Drop: Causes, Prevention and How You can Treat It

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[ARTICLE] Electrical somatosensory stimulation followed by motor training of the paretic upper limb in acute stroke: study protocol for a randomized controlled trial | Trials – Full Text

Abstract

Background

Upper limb paresis is one of the most frequent and persistent impairments following stroke. Only 12–34% of stroke patients achieve full recovery of upper limb functioning, which seems to be required to habitually use the affected arm in daily tasks. Although the recovery of upper limb functioning is most pronounced during the first 4 weeks post stroke, there are few studies investigating the effect of rehabilitation during this critical time window. The purpose of this trial is to determine the effect of electrical somatosensory stimulation (ESS) initiated in the acute stroke phase on the recovery of upper limb functioning in a nonselected sample of stroke patients.

Methods/design

A sample of 102 patients with upper limb paresis of varying degrees of severity is assigned to either the intervention or the control group using stratified random sampling. The intervention group receives ESS plus usual rehabilitation and the control group receives sham ESS plus usual rehabilitation. The intervention is applied as 1 h of ESS/sham ESS daily, followed by motor training of the affected upper limb. The ESS/sham ESS treatment is initiated within 7 days from stroke onset and it is delivered during hospitalization, but no longer than 4 weeks post stroke. The primary outcome is hand dexterity assessed by the Box and Block Test; secondary outcomes are the Fugl-Meyer Assessment, hand grip strength, pinch strength, perceptual threshold of touch, degree of pain, and modified Rankin Scale score. Outcome measurements are conducted at baseline, post intervention and at 6-month follow-up.

Discussion

Because of the wide inclusion criteria, we believe that the results can be generalized to the larger population of patients with a first-ever stroke who present with an upper limb paresis of varying severity. On the other hand, the sample size (n = 102) may preclude subgroup analyses in such a heterogeneous sample. The sham ESS treatment totals a mere 2% of the active ESS treatment delivered to the intervention group per ESS session, and we consider that this dose is too small to induce a treatment effect.

Background

Stroke is ranked as the third largest cause of disease burden globally [1], causing substantial physical, psychological and financial demands on patients, families, and societies at large [2, 3, 4]. Upper limb paresis is one of the most frequent impairments following stroke and affects 48–77% of patients in the acute stroke phase [5, 6, 7]. Moreover, upper limb paresis has been identified as a major obstacle to regaining independence in activities of daily living (ADLs) [8]. In fact, only 12–34% of the patients achieve full functional recovery of the affected upper limb at 6 months post stroke [9, 10]. This represents a considerable challenge since near complete functional recovery is required to routinely involve the affected upper limb in performing ADLs [11].

Recovery of upper limb functioning is typically pronounced during the first month and subsequently levels off by 6 months post stroke [12, 13, 14]. Regaining hand dexterity (i.e., motor skills such as reaching, grasping, gripping, moving and releasing objects) is often achieved already within the first 4 weeks, implying that there may be a critical time window for recovery of upper limb functioning [9, 10] during which rehabilitation efforts may maximize functional recovery. However, there are few studies investigating the effect of motor rehabilitation methods in the initial weeks after stroke.

Electrical stimulation (ES) is one of the methods that have been used to facilitate recovery of upper limb functioning following stroke. ES can induce a muscle contraction, or it can be a somatosensory stimulation below the motor threshold [15]. The majority of studies using ES have been conducted in chronic stroke and, therefore, it remains unknown to what extent ES applied in the acute phase after stroke could affect the recovery of upper limb functioning. Also, these investigations have largely focused on ES that induces muscle contraction. In healthy persons, the application of low-intensity ES with no or small motor responses to peripheral hand nerves [16, 17, 18, 19, 20], forearm muscles [21] or the whole hand [22, 23] elicits an increase in the cortical excitability of the representations that control the stimulated body parts, which seems to outlast the stimulation period itself [18, 21, 23]. It has been hypothesized that increasing the amount of somatosensory input may enhance the motor recovery of patients following stroke [24]. Recent data on acute, subacute and mostly chronic stroke patients suggest that a single 2-h session of ESS to the peripheral hand nerves leads to transient improvement of pinch force, movement kinematics and upper limb motor skills required for ADL performance [25, 26, 27, 28, 29, 30, 31]. However, ESS was only used in conjunction with motor training in one of these studies [29]. Interestingly, there is some evidence that multiple sessions of ESS to the peripheral hand nerves, in conjunction with motor training, might improve motor skills of the paretic upper limb in subacute [32, 33] and chronic stroke patients [34], and, moreover, that these positive results seems to be long lasting [34]. However, the effect of ESS in conjunction with motor training has never been investigated in acute stroke patients. It is noteworthy that ESS is benign in nature, causes patients minimal discomfort and adverse effects (itch and blushing), is relatively inexpensive and can easily be incorporated into clinical practice [35]. Therefore, it would be valuable to establish the effect of multiple sessions of ESS in conjunction with motor training in the restoration of upper limb functioning in the acute stroke phase.

The purpose of the present trial is to investigate the effect of multiple sessions of ESS treatment accompanied by motor training on the recovery of the affected upper limb following stroke. The ESS treatment is initiated in the acute stroke phase and each ESS session is immediately followed by motor training of the paretic upper limb. Specifically, we wish to address the following:

  1. (1)

    Does ESS treatment: (a) reduce motor and sensory impairments, (b) improve hand dexterity and (c) reduce disability at the end of the intervention period (short-term effect)?

  2. (2)

    Are the changes that can be observed at the end of the intervention period still present or improved at 6 months post stroke (long-term effect)?

Our hypothesis is that ESS treatment initiated in the acute stroke phase will improve paretic upper limb functioning as measured by the Box and Block Test (BBT) (primary outcome measure) at 6 months post stroke.

Continue —> Electrical somatosensory stimulation followed by motor training of the paretic upper limb in acute stroke: study protocol for a randomized controlled trial | Trials | Full Text

Fig. 2 Placement of the electrodes

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[Literature Overview] EBRSR – 9 Mobility and the Lower Extremity – Full Text PDF

Abstract

Rehabilitation techniques of sensorimotor complications post stroke fall loosely into one of two categories; the compensatory approach or the restorative approach. While some overlap exists, the underlying philosophies of care are what set them apart. The goal of the compensatory approach towards treatment is not necessarily on improving motor recovery or reducing impairments but rather on teaching patients a new skill, even if it only involves pragmatically using the non-involved side (Gresham et al. 1995). The restorative approach focuses on traditional physical therapy exercises and neuromuscular facilitation, which involves sensorimotor stimulation, exercises and resistance training, designed to enhance motor recovery and maximize brain recovery of the neurological impairment (Gresham et al. 1995).In this review, rehabilitation of mobility and lower extremity complications is assessed. An overview of literature pertaining to the compensatory approach and the restorative approach is provided. Treatment targets discussed include balance retraining, gait retraining, strength training, cardiovascular conditioning and treatment of contractures in the lower extremities. Technologies used to aid rehabilitation include assistive devices, electrical stimulation, and splints.

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[Abstract] Targeting interhemispheric inhibition with neuromodulation to enhance stroke rehabilitation. – Brain Stimulation

Highlights

  • This review focuses on interhemispheric inhibition and its role in the healthy and stroke lesioned brain.
  • Measurement method and movement phase should be considered when comparing studies associating interhemispheric inhibition with functional recovery.
  • Neuromodulation of interhemispheric inhibition to augment stroke recovery requires the targeting of specific neural circuitry. We discuss the effectiveness of current and novel neurostimulation techniques at targeting interhemispheric inhibition and enhancing stroke rehabilitation.

Abstract

Background/Objectives

Interhemispheric inhibition in the brain plays a dynamic role in the production of voluntary unimanual actions. In stroke, the interhemispheric imbalance model predicts the presence of asymmetry in interhemispheric inhibition, with excessive inhibition from the contralesional hemisphere limiting maximal recovery. Stimulation methods to reduce this asymmetry in the brain may be promising as a stroke therapy, however determining how to best measure and modulate interhemispheric inhibition and who is likely to benefit, remain important questions.

Methods

This review addresses current understanding of interhemispheric inhibition in the healthy and stroke lesioned brain. We present a review of studies that have measured interhemispheric inhibition using different paradigms in the clinic, as well as results from recent animal studies investigating stimulation methods to target abnormal inhibition after stroke.

Main findings/Discussion

The degree to which asymmetric interhemispheric inhibition impacts on stroke recovery is controversial, and we consider sources of variation between studies which may contribute to this debate. We suggest that interhemispheric inhibition is not static following stroke in terms of the movement phase in which it is aberrantly engaged. Instead it may be dynamically increased onto perilesional areas during early movement, thus impairing motor initiation. Hence, its effect on stroke recovery may differ between studies depending on the technique and movement phase of eliciting the measurement. Finally, we propose how modulating excitability in the brain through more specific targeting of neural elements underlying interhemispheric inhibition via stimulation type, location and intensity may raise the ceiling of recovery following stroke and enhance functional return.

Source: Targeting interhemispheric inhibition with neuromodulation to enhance stroke rehabilitation – Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation

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[Abstract] Contralaterally Controlled Functional Electrical Stimulation Improves Hand Dexterity in Chronic Hemiparesis

Abstract

Background and Purpose—It is unknown whether one method of neuromuscular electrical stimulation for poststroke upper limb rehabilitation is more effective than another. Our aim was to compare the effects of contralaterally controlled functional electrical stimulation (CCFES) with cyclic neuromuscular electrical stimulation (cNMES).

Methods—Stroke patients with chronic (>6 months) moderate to severe upper extremity hemiparesis (n=80) were randomized to receive 10 sessions/wk of CCFES- or cNMES-assisted hand opening exercise at home plus 20 sessions of functional task practice in the laboratory for 12 weeks. The task practice for the CCFES group was stimulation assisted. The primary outcome was change in Box and Block Test (BBT) score at 6 months post treatment. Upper extremity Fugl–Meyer and Arm Motor Abilities Test were also measured.

Results—At 6 months post treatment, the CCFES group had greater improvement on the BBT, 4.6 (95% confidence interval [CI], 2.2–7.0), than the cNMES group, 1.8 (95% CI, 0.6–3.0), between-group difference of 2.8 (95% CI, 0.1–5.5), P=0.045. No significant between-group difference was found for the upper extremity Fugl–Meyer (P=0.888) or Arm Motor Abilities Test (P=0.096). Participants who had the largest improvements on BBT were <2 years post stroke with moderate (ie, not severe) hand impairment at baseline. Among these, the 6-month post-treatment BBT gains of the CCFES group, 9.6 (95% CI, 5.6–13.6), were greater than those of the cNMES group, 4.1 (95% CI, 1.7–6.5), between-group difference of 5.5 (95% CI, 0.8–10.2), P=0.023.

Conclusions—CCFES improved hand dexterity more than cNMES in chronic stroke survivors.

Source: Contralaterally Controlled Functional Electrical Stimulation Improves Hand Dexterity in Chronic Hemiparesis | Stroke

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