Posts Tagged Motor function

[Abstract] Computer-aided prediction of extent of motor recovery following constraint-induced movement therapy in chronic stroke


Constraint-induced movement therapy (CI therapy) is a well-researched intervention for treatment of upper limb function. Overall, CI therapy yields clinically meaningful improvements in speed of task completion and greatly increases use of the more affected upper extremity for daily activities. However, individual improvements vary widely. It has been suggested that intrinsic feedback from somatosensation may influence motor recovery from CI therapy. To test this hypothesis, an enhanced probabilistic neural network (EPNN) prognostic computational model was developed to identify which baseline characteristics predict extent of motor recovery, as measured by the Wolf Motor Function Test (WMFT). Individual characteristics examined were: proprioceptive function via the brief kinesthesia test, tactile sensation via the Semmes-Weinstein touch monofilaments, motor performance captured via the 15 timed items of the Wolf Motor Function Test, stroke affected side. A highly accurate predictive classification was achieved (100% accuracy of EPNN based on available data), but facets of motor functioning alone were sufficient to predict outcome. Somatosensation, as quantified here, did not play a large role in determining the effectiveness of CI therapy.

Source: Computer-aided prediction of extent of motor recovery following constraint-induced movement therapy in chronic stroke – ScienceDirect

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[CORDIS Project] Motor Recovery with Paired Associative Stimulation (RecoveriX) – European Commission

Motor Recovery with Paired Associative Stimulation (RecoveriX)


Source: European Commission : CORDIS : Projects and Results : Motor Recovery with Paired Associative Stimulation (RecoveriX)

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[ARTICLE] AExaCTT – Aerobic Exercise and Consecutive Task-specific Training for the upper limb after stroke: Protocol for a randomised controlled pilot study – Full Text


Motor function may be enhanced if aerobic exercise is paired with motor training. One potential mechanism is that aerobic exercise increases levels of brain-derived neurotrophic factor (BDNF), which is important in neuroplasticity and involved in motor learning and motor memory consolidation. This study will examine the feasibility of a parallel-group assessor-blinded randomised controlled trial investigating whether task-specific training preceded by aerobic exercise improves upper limb function more than task-specific training alone, and determine the effect size of changes in primary outcome measures. People with upper limb motor dysfunction after stroke will be allocated to either task-specific training or aerobic exercise and consecutive task-specific training. Both groups will perform 60 hours of task-specific training over 10 weeks, comprised of 3 × 1 hour sessions per week with a therapist and 3 × 1 hours of home-based self-practice per week. The combined intervention group will also perform 30 minutes of aerobic exercise (70–85%HRmax) immediately prior to the 1 hour of task-specific training with the therapist. Recruitment, adherence, retention, participant acceptability, and adverse events will be recorded. Clinical outcome measures will be performed pre-randomisation at baseline, at completion of the training program, and at 1 and 6 months follow-up. Primary clinical outcome measures will be the Action Research Arm Test (ARAT) and the Wolf Motor Function Test (WMFT). If aerobic exercise prior to task-specific training is acceptable, and a future phase 3 randomised controlled trial seems feasible, it should be pursued to determine the efficacy of this combined intervention for people after stroke.

1. Introduction

1.1. Background

Currently 440,000 persons after stroke live in community settings in Australia [1]. Many with stroke experience chronic disability and although two-thirds receive care each day [1], the majority still have unmet needs [2]. Upper limb dysfunction is a persistent and disabling problem present in 69% of persons after stroke in Australia [3]. Upper limb dysfunction is a major contributor to poor well-being and quality-of-life [4]; [5]; [6] ;  [7]. Unsurprisingly, advancing treatments for upper limb recovery is a top ten research priority for persons after stroke and their carers [8].

In Australia, 87% of persons with stroke-attributable upper limb impairments receive task-specific training [3]. Task-specific training is a progressive training strategy that utilises practice of goal-directed, real-world, context-specific tasks that are intrinsically and/or extrinsically meaningful to the person, to enable them to undertake activities of daily living [9] and may improve upper limb motor function after stroke [9]; [10] ;  [11].

Improvements in motor function coincide with structural and functional reorganisation of the brain [12]; [13]; [14] ;  [15]. The brain’s ability to undergo these changes is denoted as neuroplasticity. Capitalisation and enhancement of neuroplasticity in peri-infarct and non-primary motor regions may promote recovery via an increased response to motor training and other neurorehabilitative interventions [16]; [17] ;  [18].

Many studies show that aerobic exercise (prolonged, rhythmical activity using large muscle groups to increase heart rate) enhances neuroplasticity [19], grey matter volume, white matter integrity [20]; [21] ;  [22] and brain activation [23]; [24] ;  [25]. Furthermore increasing evidence indicates that lower limb aerobic exercise increases upper limb motor function. A single bout of aerobic cycling exercise can improve long-term retention of a motor skill in healthy individuals [26], regardless of whether performed immediately before or after motor training [27].

Aerobic exercise increases BDNF [28]. Improvements in motor skill learning and memory induced by aerobic exercise have been associated with increased peripheral blood concentrations of BDNF [26]. BDNF is involved with neurogenesis [29] and neuroprotection [30] in the human brain [31], thereby playing an important role in stroke recovery, including facilitating functional upper limb motor rehabilitation [32].

In chronic stroke, an 8-week programme of lower extremity endurance cycling enhanced upper extremity fine motor control [33]. Also, a single bout of aerobic treadmill exercise improved grasp function of the hemiparetic hand [34]. As aerobic exercise alone can enhance motor function after stroke, motor learning in stroke rehabilitation may be facilitated if aerobic exercise is paired with motor training [35] ;  [36].

1.2. Aims and objectives

The aims of this study are to 1) assess the feasibility of conducting a randomised controlled trial to compare the effects of task-specific training preceded by aerobic exercise to task-specific training alone on upper limb motor function after stroke; and 2) calculate the effect size of changes in primary clinical outcome measures to evaluate proof-of-concept and inform calculation of sample size for a future phase III trial. This includes investigating potential neural correlates of exercise-induced motor function changes using peripheral blood serum BDNF measurement and multi-modal MRI.

2. Methods

2.1. Study design

This is a parallel-group assessor-blinded randomised controlled pilot study (Fig. 1). One group will undertake task-specific training alone and the other group will undertake 30 minutes of aerobic cycling exercise prior to their task-specific training. The interventions will be delivered by a therapist 3 days per week for 10 weeks. Both groups will be provided with an individually-prescribed task-specific training programme to practice at home for 60 minutes, 3 times per week. Assessments will be conducted at baseline, within 1 week from the end of intervention, and 1 and 6 months following the end of the intervention period. Ethics approval has been obtained from the Hunter New England Human Research Ethics Committee (14/12/10/4.07) and registered with the University of Newcastle Human Research Ethics Committee (H-2015-0105). The study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12616000848404).

Continue —>  AExaCTT – Aerobic Exercise and Consecutive Task-specific Training for the upper limb after stroke: Protocol for a randomised controlled pilot study

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[Abstract] A Longitudinal EMG Study of Complex Upper-limb Movements in Post-stroke Therapy. 1: Heterogeneous EMG Changes despite Consistent Improvements in Clinical Assessments

Post-stroke weakness on the more-affected side may arise from reduced corticospinal drive, disuse muscle atrophy, spasticity, and abnormal co-ordination. This study investigated changes in muscle activation patterns to understand therapy-induced improvements in motor-function in chronic stroke compared to clinical assessments, and to identify the effect of motor-function level on muscle activation changes.

Electromyography (EMG) was recorded from 5 upper-limb muscles on the more-affected side of 24 patients during early- and late-therapy sessions of an intensive 14-day program of Wii-based Movement Therapy, and for a subset of 13 patients at 6-month follow-up. Patients were classified according to residual voluntary motor capacity with low, moderate or high motor-function. The area under the curve was calculated from EMG amplitude and movement duration. Clinical assessments of upper-limb motor-function pre- and post-therapy included the Wolf Motor Function Test, Fugl-Meyer Assessment and Motor Activity Log Quality of Movement scale.

Clinical assessments improved over time (p<0.01) with an effect of motor-function level (p<0.001). The pattern of EMG change by late-therapy was complex and variable, with differences between patients with low compared to moderate or high motor-function. The area under the curve (p=0.028) and peak amplitude (p=0.043) during Wii-tennis backhand increased for patients with low motor-function whereas EMG decreased for patients with moderate and high motor-function. The reductions included: movement duration during Wii-golf (p=0.048, moderate; p=0.026, high), and Wii-tennis backhand (p=0.046, moderate; p=0.023, high) and forehand (p=0.009, high); and the area under the curve during Wii-golf (p=0.018, moderate) and Wii-baseball (p=0.036, moderate). For the pooled data over time there was an effect of motor-function (p=0.016) and an interaction between time and motor-function (p=0.009) for Wii-golf movement duration. Wii-baseball movement duration decreased as a function of time (p=0.022). There was an effect on Wii-tennis forehand duration for time (p=0.002) and interaction of time and motor-function (p=0.005); and an effect of motor-function level on the area under the curve (p=0.034) for Wii-golf.

This study demonstrated different patterns of EMG changes according to residual voluntary motor-function levels despite heterogeneity within each level that was not evident following clinical assessments alone. Thus, rehabilitation efficacy might be underestimated by analyses of pooled data.

Source: Frontiers | A Longitudinal EMG Study of Complex Upper-limb Movements in Post-stroke Therapy. 1: Heterogeneous EMG Changes despite Consistent Improvements in Clinical Assessments | Neurology

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[Abstract] Music-based interventions in neurological rehabilitation


During the past ten years, an increasing number of controlled studies have assessed the potential rehabilitative effects of music-based interventions, such as music listening, singing, or playing an instrument, in several neurological diseases. Although the number of studies and extent of available evidence is greatest in stroke and dementia, there is also evidence for the effects of music-based interventions on supporting cognition, motor function, or emotional wellbeing in people with Parkinson’s disease, epilepsy, or multiple sclerosis. Music-based interventions can affect divergent functions such as motor performance, speech, or cognition in these patient groups. However, the psychological effects and neurobiological mechanisms underlying the effects of music interventions are likely to share common neural systems for reward, arousal, affect regulation, learning, and activity-driven plasticity. Although further controlled studies are needed to establish the efficacy of music in neurological recovery, music-based interventions are emerging as promising rehabilitation strategies.

Source: Music-based interventions in neurological rehabilitation

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[ARTICLE] Using Brain Oscillations and Corticospinal Excitability to Understand and Predict Post-Stroke Motor Function – Full Text

What determines motor recovery in stroke is still unknown and finding markers that could predict and improve stroke recovery is a challenge. In this study, we aimed at understanding the neural mechanisms of motor function recovery after stroke using neurophysiological markers by means of cortical excitability (Transcranial Magnetic Stimulation – TMS) and brain oscillations (electroencephalography – EEG). In this cross-sectional study, fifty-five subjects with chronic stroke (62±14 yo, 17 women, 32±42 months post-stroke) were recruited in two sites. We analyzed TMS measures (i.e. motor threshold – MT – of the affected and unaffected sides) and EEG variables (i.e. power spectrum in different frequency bands and different brain regions of the affected and unaffected hemispheres) and their correlation with motor impairment as measured by Fugl-Meyer. Multiple univariate and multivariate linear regression analyses were performed to identify the predictors of good motor function. A significant interaction effect of MT in the affected hemisphere and power in beta bandwidth over the central region for both affected and unaffected hemispheres was found. We identified that motor function positively correlates with beta rhythm over the central region of the unaffected hemisphere, while it negatively correlates with beta rhythm in the affected hemisphere. Our results suggest that cortical activity in the affected and unaffected hemisphere measured by EEG provides new insights on the association between high frequency rhythms and motor impairment, highlighting the role of excess of beta in the affected central cortical region in poor motor function in stroke recovery.


Stroke is a leading cause of morbidity, mortality, and disability worldwide (12). Among the sequels of stroke, motor impairment is one of the most relevant, since it conditions the quality of life of patients, it reduces their capability to perform their daily activities and it impairs their autonomy (3). Despite the advancements of the acute stroke therapy, patients require an intensive rehabilitation program that will partially determine the extent of their recovery (4). These rehabilitation programs aim at stimulating cortical plasticity to improve motor performance and functional recovery (5). However, what determines motor improvement is still unknown. Indeed, finding markers that could predict and enhance stroke recovery is still a challenge (6). Different types of biomarkers exist: diagnostic, prognostic, surrogate outcome, and predictive biomarkers (7). The identification of these biomarkers is critical in the management of stroke patients. In the field of stroke research, great attention has been put to biomarkers found in the serum, especially in acute care. However, research on biomarkers of stroke recovery is still limited, especially using neurophysiological tools.

A critical research area in stroke is to understand the neural mechanisms underlying motor recovery. In this context, neurophysiological techniques such as transcranial magnetic stimulation (TMS) and electroencephalography (EEG) are useful tools that could be used to identify potential biomarkers of stroke recovery. However, there is still limited data to draw further conclusions on neural reorganization in human trials using these techniques. A few studies have shown that, in acute and sub-acute stage, stroke patients present increased power in low frequency bands (i.e., delta and theta bandwidths) in both affected and unaffected sides, as well as increased delta/alpha ratio in the affected brain area; these patterns being also correlated to functional outcome (811). Recently, we have identified that, besides TMS-indexed motor threshold (MT), an increased excitability in the unaffected hemisphere, coupled with a decreased excitability in the affected hemisphere, was associated with poor motor function (12), as measured by Fugl-Meyer (FM) [assessing symptoms severity and motor recovery in post-stroke patients with hemiplegia—Fugl-Meyer et al. (13); Gladstone et al. (14)]. However, MT measurement is associated with a poor resolution as it indexes global corticospinal excitability. Therefore, combining this information with direct cortical measures such as cortical oscillations, as measured by EEG, can help us to understand further neural mechanisms of stroke recovery.

To date, there are very few studies looking into EEG and motor recovery. For that reason, we aimed, in the present study, to investigate the relationship between motor impairment, EEG, and TMS variables. To do so, we conducted a prospective multicenter study of patients who had suffered from a stroke, in which we measured functional outcome using FM and performed TMS and EEG recordings. Based on our preliminary work, we expected to identify changes in interhemispheric imbalances on EEG power, especially in frequency bands associated with learning, such as alpha and beta bandwidths. […]

Continue —> Frontiers | Using Brain Oscillations and Corticospinal Excitability to Understand and Predict Post-Stroke Motor Function | Neurology

Figure 1. Topoplots showing the topographic distribution of high-beta bandwidth (25 Hz) for every individual. Red areas represent higher high-beta activity, while blue areas represent lower high-beta activity. Central region (C3 or C4) in red stands for the affected side. For patients with poor motor function, a higher beta activity of the affected central region as compared to the affected side is observed in 16 out of 28 individuals. For patients with good motor function, a similar activity over central regions bilaterally, or higher activity over the unaffected central area can be identified in 21 out of 27 individuals. FM = Fugl-Meyer.

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[Abstract] Low-frequency rTMS of the unaffected hemisphere in stroke patients: A systematic review


The aim of this review was to summarize the evidence for the effectiveness of low-frequency (LF) repetitive transcranial magnetic stimulation (rTMS) over the unaffected hemisphere in promoting functional recovery after stroke. We performed a systematic search of the studies using LF-rTMS over the contralesional hemisphere in stroke patients and reviewed the 67 identified articles. The studies have been gathered together according to the time interval that had elapsed between the stroke onset and the beginning of the rTMS treatment. Inhibitory rTMS of the contralesional hemisphere can induce beneficial effects on stroke patients with motor impairment, spasticity, aphasia, hemispatial neglect and dysphagia, but the therapeutic clinical significance is unclear. We observed considerable heterogeneity across studies in the stimulation protocols. The use of different patient populations, regardless of lesion site and stroke aetiology, different stimulation parameters and outcome measures means that the studies are not readily comparable, and estimating real effectiveness or reproducibility is very difficult. It seems that careful experimental design is needed and it should consider patient selection aspects, rTMS parameters and clinical assessment tools. Consecutive sessions of rTMS, as well as the combination with conventional rehabilitation therapy, may increase the magnitude and duration of the beneficial effects. In an increasing number of studies, the patients have been enrolled early after stroke. The prolonged follow-up in these patients suggests that the effects of contralesional LF-rTMS can be long-lasting. However, physiological evidence indicating increased synaptic plasticity, and thus, a more favourable outcome, in the early enrolled patients, is still lacking. Carefully designed clinical trials designed are required to address this question. LF rTMS over unaffected hemisphere may have therapeutic utility, but the evidence is still preliminary and the findings need to be confirmed in further randomized controlled trials.

Source: Low-frequency rTMS of the unaffected hemisphere in stroke patients: A systematic review – Sebastianelli – 2017 – Acta Neurologica Scandinavica – Wiley Online Library

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[ARTICLE] Impact of virtual reality games on psychological well-being and upper limb performance in adults with physical disabilities: A pilot study – Full Text PDF


Introduction: There is limited information regarding the effects of interactive virtual reality (VR) games on psychological and physical well-being among adults with physical disabilities. We aimed to examine the impact of VR games on psychological well-being, upper limb motor function and reaction time in adults with physical disabilities.

Methods: Fifteen participants completed the intervention using Wii VR games in this pilot study. Depressive, Anxiety and Stress Scales (DASS) and Capabilities of Upper Extremity (CUE) questionnaires were used to measure psychological well-being and upper limb motor function respectively. Upper limb reaction time was measured using reaction time test.

Results: Results showed that there was a significant difference (p<0.05) in DASS questionnaire and average reaction time score after intervention.

Conclusion: There is a potential for using interactive VR games as an exercise tool to improve psychological wellbeing and upper limb reaction time among adults with disabilities.


Adults with disabilities around the world have been estimated to be around one billion, which consist of 15% of the world’s population.1 In Malaysia, there are approximately 300,000 adults with disabilities.2 Impairments in cardiovascular fitness, balance, motor control, sensation, proprioception and coordination are common in adults with physical disabilities.3 These impairments can lead to functional dependence, poor quality of life, limited mobility and decreased participation in leisure activities.

Opportunities to participate in regular exercise are especially important for groups that are less physically active than the
general population. This is because adults with disabilities are more prone to secondary complications such as pain, fatigue and de-conditioning.4 Virtual reality (VR) games are games played in a stimulated 3-dimensional (3D) environment. VR games have been developed for leisure activities but we found VR to be beneficial for rehabilitation in our local studies.5-7

Involvement in physical activity among people with disabilities is limited. Utilisation of technology may promote adherence, motivation and participation in physical activity and exercise programmes. However, as opposed to conventional rehabilitation and physiotherapy for adults with disabilities, evidence of VR games in improving function is limited. Therefore, the aim of this study was to examine the impact of VR games on psychological well-being, upper limb motor function and reaction time in adults with physical disabilities. …

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[ARTICLE] The effect of bilateral trainings on upper extremities muscle activation on level of motor function in stroke patients – Full Text PDF


[Purpose] This study was conducted in order to compare muscle activation level on the affected and unaffected limb according to the recovery level of upper limb between bilateral activity with hands clasped and bilateral activity with pilates ring.

[Subjects and Methods] Twenty inpatient who have had a stroke were recruited. Subjects were divided into two groups by the Fugl-Meyer Assessment of Motor Function score of moderately recovered group and well recovered group. The muscles activation of upper extremity and Co-Contraction Ratio (CCR) were analyzed.

[Results] In the muscles activation of the well group, trapezius, anterior deltoid, and triceps muscles of affected side and biceps muscles of both sides were significantly higher when activity with pilates ring than activity with hands clasped. CCR of both side in the well group was significantly decreased during activity with pilates ring and in the moderate group, CCR of affected side was significantly decreased during activity with pilates ring.

[Conclusion] Bilateral activity with a pilates ring is more effective than activity with hands clasped for the facilitation of muscle activation and coordination in stroke patients.


Functional limitation imposed due to a paretic upper limb affects more than 80% of stroke survivors1) . Upper limb impairment is the leading cause of limitation of motor function. Therefore, restoration of upper limb function is an essential aspect of stroke rehabilitation for regaining functional independency2) . An abnormal pattern of upper limb movement may occur caused by the compensation for muscle paralysis and imbalance. By training to perform a functional task, movement re-education is used to treat the abnormal pattern of muscle weakness3) . Although rehabilitation specialists are trying various approaches to facilitate the restoration of upper limb function, rehabilitation of upper limb function remains a challenge. Consequently, a number of researchers and therapists are seeking more effective therapeutic techniques of upper limb rehabilitation to restore voluntary motor control. Bilateral training (BT) is a therapeutic technique of upper limb rehabilitation. A recent meta-analysis revealed that BT has a positive effect on poststroke upper limb rehabilitation4) . BT induces motor synergy between limbs to activate the motor capacity of the affected limb. In other words, voluntary movements of the unaffected limb facilitate voluntary movements of the affected limb5) . Activation of the primary and supplementary motor cortex for the unaffected limb increases voluntary muscle contraction of the affected limb during symmetrical movements6) . Even though BT is performed by using both the unaffected and the affected limbs simultaneously, most studies have reported the effect of BT on the affected limb. Morris & Wijck reported one randomized controlled trial that investigated the effect of BT on the unaffected limb. In that report, subjects were classified into two groups, the bilateral group and unilateral group divided who scored ≤6 on the motor assessment7) . However, no study has addressed the effect of upper limb muscle activation on the unaffected limb during bilateral activity and the comparison of change in activity between the affected and unaffected limbs. The effect of BT on the recovery level of the upper limb remains unclear. BT includes various activities such as targeted reaching activity using a peg, grasping and bringing a glass to the mouth, picking up and placing a towel, and manipulating and playing cards. While various activities are used, it is important to ensure that the movements involve both the upper limbs4) . For assessing bilateral activity, movements involving hand clasped or grasping and lifting up an instrument such as a rod are used. However, no study has investigated the difference in amounts of upper limb muscle activation between bilateral activity with hands clasped and bilateral activity while lifting an instrument. Therefore, the purpose of the present study was to compare the muscle activation level on the affected and unaffected limbs according to the recovery level of the upper limb between bilateral activity with hands clasped and bilateral activity with a pilates ring.

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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



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.


Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and 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.


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.


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.


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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