Abstract

1. Brain Res. 1998 Jan 26;782(1-2):153-66.
On the reorganization of sensory hand areas after mono-hemispheric lesion: a functional (MEG)/anatomical (MRI) integrative study.
Rossini PM, Tecchio F, Pizzella V, Lupoi D, Cassetta E, Pasqualetti P, Romani GL, Orlacchio A.
Divisione Neurologia, Osp. Fatebenefratelli, Roma, Italy.
The topography of primary sensory cortical hand area following a monohemispheric lesion (sudden = stroke; progressive = neoplasm) was investigated in relationship with clinical recovery of sensorimotor deficits. Twenty seven patients with monohemispheric lesions were studied in a clinically stabilized condition. Functional informations from magnetoencephalography (MEG) were integrated with anatomical data from magnetic resonance imaging (MRI). MEG localizations of the neurons firing at early latencies in primary sensory cortex after separate stimulation of median nerve, thumb and little fingers of each hand were carried out. Characteristics of cerebral equivalent current dipoles (ECDs) activated by each contralateral stimulation, the 'hand extension' (i.e., the distance in millimetres between ECDs of first and fifth digits), as well as interhemispheric differences of the tested parameters were investigated. Finally, ECDs' locations were integrated with MRI. Lesions involving cortical (C) or subcortical (s.c.) areas receiving sensory input from the hand were often combined to increase interhemispheric asymmetry of the tested parameters (22% for C and 49% for s.c. lesions). This might be due to an activation of neuronal districts which in the affected hemisphere (AH) differ from those normally activated in the unaffected hemisphere (UH) and in the control population. Moreover, the 'hand extension' was
enlarged on the AH--more frequently after a SC lesion--mainly due to a medial shift of the little finger ECD, combined to a tendency of both finger ECDs to shift frontally. After a C lesion, responses from the AH were often stronger than normal. Spatial reorganizations were also seen in the UH (7% of C and 14% of SC lesions). 'Hand extension' in the UH was selectively enlarged for the P30m only when combined with a similar enlargement in the AH. Significant interhemispheric asymmetries due to neuronal reorganization in the AH were associated with worse clinical outcomes compared to patients without asymmetries.
PMID: 9519259 [PubMed - indexed for MEDLINE]
1. J Neurol Sci. 2004 Oct 15;225(1-2):105-15.
Feasibility of combining multi-channel functional neuromuscular stimulation with weight-supported treadmill training.
Daly JJ, Ruff RL.
Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA. jjdl7@case.edu
More than 3 million stroke survivors live with residual disabilities and mobility deficits even after rehabilitation. Therefore, it is important to develop new, more effective, gait training methods. The purpose of this study was twofold: (1) testing the feasibility of combining multi-channel functional neuromuscular stimulation (FNS) using intramuscular (IM) electrodes and body weight supported treadmill training (BWSTT) for gait training; and (2) documenting the potential
gait practice advantages afforded by combining FNS-IM and BWSTT. Eight subjects with gait deficits in the chronic phase (>12 months) were enrolled. Intramuscular electrodes were placed in the paretic hip abductors, knee flexors and extensors, and ankle dorsiflexors, plantarflexors, and evertors. Subjects were treated with exercise and gait training using the combined technologies 1 1/2 h/week, four times/week, for 12 weeks. Feasibility was tested according to performance of the technologies, clinician skill factors, and subject satisfaction. Impairment, function, and quality of life were measured. Provision of practice for eight gait characteristics was catalogued. We found the following results for the combined technologies: (1) the combined technologies were safe and feasible; (2) clinicians required five training sessions to reach proficiency; (3) subjects were satisfied; (4) there were significant gains in impairment and functional measures; (5) a greater number of gait practice characteristics were provided with the combined technologies than with either alone.
2. Stroke. 2004 Nov;35(11 Suppl 1):2695-8. Epub 2004 Sep 23.
Functional imaging in stroke recovery.
Cramer SC.
Department of Neurology, University of California Irvine Medical Center, 101 The City Dr S, Bldg 53, Room 203, Orange, CA 92868-4280, USA. scramer@uci.edu
Assessing neurobiology of brain systems can provide information not available
from anatomic or behavioral assessment. Such information may be of value in understanding, defining, and prescribing potential therapeutic interventions that target restorative brain events after stroke. A number of methods have been used to study stroke recovery, each with its relative merits and limitations. Several studies suggest that greater injury is associated with reduced laterality of brain activity. This might be in relation to changes in interhemispheric inhibition and is a phenomenon that is likely useful for functional gains in some patients. Many other features of brain activity change in the months after a stroke, including the site and size of activation in relevant brain network nodes. While there is incomplete agreement regarding which features of altered brain activity predict and parallel better behavioral outcome, studies converge on the conclusion that best outcome is achieved by activating the brain in a pattern that most resembles the normal state.
4. Arch Phys Med Rehabil. 2004 Jun;85(6):902-9.
The effect of combined use of botulinum toxin type A and functional electric stimulation in the treatment of spastic drop foot after stroke: a preliminary investigation.
Johnson CA, Burridge JH, Strike PW, Wood DE, Swain ID.
Department of Medical Physics and Biomedical Engineering, Salisbury Health Care NHS Trust, Salisbury District Hospital, Wiltshire, England, UK.
OBJECTIVE: To investigate the effect of combined botulinum toxin type A (BTX) and functional electric stimulation (FES) treatment on spastic drop foot in stroke. DESIGN: Nonblinded randomized controlled trial. SETTING: Hospitals. PARTICIPANTS: Consecutive sample of 21 ambulant adults within 1 year after stroke with a spastic drop foot, of whom 18 completed the study. INTERVENTIONS: The treatment group received BTX injections (Dysport) on 1 occasion into the medial and lateral heads of the gastrocnemius (200U each) and tibialis posterior (400U each) muscles and FES, used on a daily basis for 16 weeks to assist walking. Both groups continued with physiotherapy at the same rate. MAIN OUTCOME MEASURES: Walking speed, Physiological Cost Index, Modified Ashworth Scale, Rivermead Motor Assessment, and Medical Outcomes Study 36-Item Short-Form Health Survey. RESULTS: Walking speed increased over 12 weeks in both control (P=.020) and treatment groups (nonstimulated, P=.004; stimulated, P=.042). The baseline corrected (analysis of covariance) increase in mean walking speed at 12 weeks, relative to controls, was.04m/s (95% confidence interval [CI],.003-.090) without stimulation, and.09m/s (95% CI,.031-.150) with stimulation. CONCLUSIONS: Combined treatment effectively improved walking and function. A larger study is needed to quantify the treatment effect and to investigate its impact on quality of life.
7. J Rehabil Med. 2003 Mar;35(2):49-54; quiz 56.
Shoulder pain in hemiplegia revisited: contribution of functional electrical stimulation and other therapies.
Vuagnat H, Chantraine A.
Lox Hospital, University Hospitals of Geneva, Geneva, Switzerland. hubert.vuagnat@hcuge.ch
OBJECTIVES: Post-stroke shoulder pain is probably the most frequent complication in hemiplegia and has repercussions on motor rehabilitation and the psychological equilibrium of the patient. The strategies for prevention and treatment are presented. AETIOLOGY: Among the various factors contributing to the occurrence of shoulder pain in hemiplegia, some are related to the joint, such as lesion of the rotator cuff tendons, reflex sympathetic dystrophy, inferior-anterior subluxation of the head of the humerus, whereas others are related to the neurologic lesion such as central post-stroke pain, lack of sensibility, unilateral neglect and spasticity. PREVENTION: Efforts should be made from the start to keep the shoulder in an ideal position at all times and movement of the shoulder and upper limb should be carried out with care. TREATMENT: Will be aimed to the cause of pain and passive or active range of motion exercises will be encouraged. Physical, medical and surgical treatments have improved over the last few decades. Functional electrical stimulation in patients with shoulder pain and subluxation, applied early after onset of the stroke, has shown beneficial positive effects on subluxation, pain and mobility. Efforts should therefore be made to better understand the post-stroke shoulder pain in order to provide better outcomes of rehabilitation and thus improve
quality of life for patients.
10. Ann Neurol. 2002 Jan;51(1):122-5.
Increase in hand muscle strength of stroke patients after somatosensory stimulation.
Conforto AB, Kaelin-Lang A, Cohen LG.
Human Cortical Physiology Section, NINDS, National Institutes of Health, Bethesda, MD 20892-1430, USA.
It has been proposed that somatosensory input in the form of peripheral nerve stimulation can influence functional measures of motor performance. We studied the effects of median nerve stimulation on pinch muscle strength (a function mediated predominantly by median nerve innervated muscles) in the affected hand of chronic stroke patients. A 2-hour period of median nerve stimulation elicited an increase in pinch strength that outlasted the stimulation period. The improvement in muscle strength correlated with stimulus intensity and was identified in the absence of motor training. These results suggest that somatosensory stimulation may be a promising adjuvant to rehabilitation of the motor deficits in stroke patients.
11. Clin Rehabil. 2001 Apr;15(2):217-20.
Functional electrical stimulation by means of the 'Ness Handmaster Orthosis' in chronic stroke patients: an exploratory study.
Hendricks HT, IJzerman MJ, de Kroon JR, in 't Groen FA, Zilvold G.
St Maartenskliniek, Nijmegen, Universitair Medisch Centrum St. Radboud, The Netherlands.
OBJECTIVE: To gain experience with 'Ness Handmaster Orthosis' treatment in chronic stroke patients, to identify suitable patients, and to study the effects of treatment. DESIGN: Exploratory, uncontrolled trial with measurement of motor functions and muscle tone of the upper extremity prior to, during, upon completion, and six weeks after a treatment period. SETTING: A rehabilitation centre in the Netherlands. SUBJECTS: Eighteen chronic stroke patients (more than six months post stroke), who exhibited upper extremity dysfunction due to spastic paresis. INTERVENTION: A 10-week therapy programme of functional electrical stimulation by means of the 'Ness Handmaster Orthosis'. RESULTS: The results of 15 patients were available for analysis. The differences in motor score and muscle tone before and at the end of treatment were statistically significant (p = 0.008 and 0.021, respectively). The follow-up measurements showed that the effects on motor functions and muscle tone decreased after therapy completion. Stratification of the patients in two subgroups indicated that patients with initial high motor scores benefited most during the
intervention period. CONCLUSION: The present study suggests that Handmaster treatment possesses therapeutic opportunities in chronic stroke patients with spastic paresis of the upper extremity.
14. Clin Rehabil. 2001 Feb;15(1):5-19.
Electrical stimulation for preventing and treating post-stroke shoulder pain: a systematic Cochrane review.
Price CI, Pandyan AD.
Geriatric Medicine, Newcastle University and Northumbria Healthcare NHS Trust, Newcastle upon Tyne, UK. c.i.m.price@ncl.ac.uk
BACKGROUND: Shoulder pain after stroke is common and disabling. The optimal management is uncertain, but electrical stimulation (ES) is often used to treat and prevent pain. OBJECTIVES: The objective of this review was to determine the efficacy of any form of surface ES in the prevention and/or treatment of pain around the shoulder at any time after stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Review Group trials register and undertook further searches of Medline, Embase and CINAHL. Contact was established with equipment manufacturers and centres that have published on the topic of ES. SELECTION CRITERIA: We considered all randomized trials that assessed any surface
ES technique (functional electrical stimulation (FES), transcutaneous electrical nerve stimulation (TENS) or other), applied at any time since stroke for the purpose of prevention or treatment of shoulder pain. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS: Four trials (a total of 170 subjects) fitted the inclusion criteria. Study design and ES technique varied considerably, often precluding the combination of studies. Population numbers were small. There was no significant change in pain incidence (odds ratio (OR) 0.64; 95% CI 0.19-2.14) or change in pain intensity (standardized mean difference (SMD) 0.13; 95% CI -1.0-1.25) after ES treatment compared with control. There was a significant treatment effect in favour of ES for improvement in pain-free range of passive humeral lateral rotation (weighted mean difference (WMD) 9.17; 95% CI 1.43-16.91). In these studies ES reduced the severity of glenohumeral subluxation (SMD -1.13; 95% CI -1.66 to -0.60), but there was no significant effect on upper limb motor recovery (SMD 0.24; 95% CI -0.14-0.62) or upper limb spasticity (WMD 0.05; 95% CI -0.28-0.37). There did not appear to be any negative effects of electrical stimulation at the shoulder. REVIEWERS' CONCLUSIONS: The evidence from randomized controlled trials so far does not confirm or refute that ES around the shoulder after stroke influences reports of pain, but there do appear to be benefits for passive humeral lateral rotation. A possible mechanism is through the reduction of glenohumeral subluxation. Further studies are required.
15. Cochrane Database Syst Rev. 2000;(4):CD001698.
Electrical stimulation for preventing and treating post-stroke shoulder pain.
Price CI, Pandyan AD.
Geriatric Medicine, University of Newcastle, c/o Helen Rodgers secretary, Centre for Health Services Research, 21 Claremont Place, Newcastle Upon Tyne, Tyne and Wear, UK, NE2 4AA. c.i.m.price@ncl.ac.uk
BACKGROUND: Shoulder pain after stroke is common and disabling. The optimal management is uncertain, but electrical stimulation (ES) is often used to treat and prevent pain. OBJECTIVES: The objective of this review was to determine the efficacy of any form of surface ES in the prevention and / or treatment of pain around the shoulder at any time after stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Review Group trials register and undertook further searches of MEDLINE, EMBASE and CINAHL. Contact was established with equipment manufacturers and centres that have published on the topic of ES. SELECTION CRITERIA: We considered all randomised trials that assessed any surface ES technique (functional electrical stimulation (FES), transcutaneous electrical nerve stimulation (TENS) or other), applied at any time since stroke for the purpose of prevention or treatment of shoulder pain. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS: Four trials (a total of 170 subjects) fitted the inclusion criteria. Study design and ES technique varied considerably, often precluding the combination of studies. Population numbers were small. There was no significant
change in pain incidence (Odds Ratio (OR) 0.64; 95% CI 0.19 to 2.14) or change in pain intensity (Standardised Mean Difference (SMD) 0.13; 95% CI -1.0 to 1.25) after ES treatment compared to control. There was a significant treatment effect in favour of ES for improvement in pain-free range of passive humeral lateral rotation (Weighted Mean Difference (WMD) 9.17; 95% CI 1.43 to 16.91). In these studies ES reduced the severity of glenohumeral subluxation (SMD -1.13; 95% CI -1.66 to -0.60), but there was no significant effect on upper limb motor recovery (SMD 0.24; 95% CI -0.14 to 0.62) or upper limb spasticity (WMD 0.05; 95% CI -0.28 to 0.37). There did not appear to be any negative effects of electrical stimulation at the shoulder. REVIEWER'S CONCLUSIONS: The evidence from randomised controlled trials so far does not confirm or refute that ES around the shoulder after stroke influences reports of pain, but there do appear to be benefits for passive humeral lateral rotation. A possible mechanism is through the reduction of glenohumeral subluxation. Further studies are required.
2. Arch Phys Med Rehabil. 1999 Mar;80(3):328-31.
Shoulder pain and dysfunction in hemiplegia: effects of functional electrical stimulation.
Chantraine A, Baribeault A, Uebelhart D, Gremion G.
Department of Neurosciences, University Hospital of Geneva, Switzerland.
OBJECTIVE: To determine the influence of functional electrical stimulation (FES) on subluxation and shoulder pain in hemiplegic patients. DESIGN: Controlled study of 24 months' duration beginning in the first month after onset of stroke. SUBJECTS AND SETTING: One hundred twenty hemiplegic patients with both subluxed and painful shoulder were followed for rehabilitation before and after discharge between 1989 and 1993. All subjects received conventional rehabilitation based on the Bobath concept. In addition, patients were alternately assigned to a control group or to receive additional FES for 5 weeks on muscles surrounding their subluxed and painful shoulder. MAIN MEASURES: Clinical examinations, including range of motion, pain assessment, and x-rays, were performed at the start of the study, between the second and fourth weeks after onset of stroke, and subsequently at 6, 12, and 24 months. RESULTS: The FES group showed significantly more improvement than the control group in both pain relief (80.7% vs. 55.1%, p<.01) and reduction of subluxation (78.9% vs. 58.6%, p<.05). Furthermore, recovery of arm motion appeared to be significantly improved in the FES group (77.1% vs. 60.3% in the control group, p<.01). CONCLUSION: The FES program was significantly effective in reducing the severity of subluxation and pain and possibly may have facilitated recovery of the shoulder function in hemiplegic patients.
5. Stroke. 1998 May;29(5):975-9.
Neuromuscular stimulation for upper extremity motor and functional recovery in
acute hemiplegia.
Chae J, Bethoux F, Bohine T, Dobos L, Davis T, Friedl A.
Department of Physical Medicine and Rehabilitation, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio 44109-1998, USA. jchae@metrohealth.org
BACKGROUND AND PURPOSE: The purpose of this study was to assess the efficacy of neuromuscular stimulation in enhancing the upper extremity motor and functional recovery of acute stroke survivors. METHODS: Forty-six stroke survivors admitted to an inpatient rehabilitation unit were randomly assigned to receive either neuromuscular stimulation or placebo. Twenty-eight subjects completed the study. The treatment group received surface neuromuscular stimulation to produce wrist and finger extension exercises. The control group received placebo stimulation over the paretic forearm. All subjects were treated 1 hour per day, for a total of 15 sessions. Outcomes were assessed in a blinded manner with the upper extremity component of the Fugl-Meyer Motor Assessment and the self-care component of the Functional Independence Measure at pretreatment, after treatment, and at 4 and 12 weeks after treatment. RESULTS: The treatment subjects and control subjects had comparable baseline characteristics. Parametric analyses revealed significantly greater gains in Fugl-Meyer scores for the treatment group after treatment (13.1 versus 6.5; P=0.05), at 4 weeks after treatment (17.9 versus 9.7; P=0.05), and at 12 weeks after treatment (20.6 versus 11.2; P=0.06). Functional Independence Measure scores were not different between groups at any of the time periods (P>0.10). CONCLUSIONS: Data suggest that neuromuscular stimulation enhances the upper
extremity motor recovery of acute stroke survivors. However, the sample size in this study was too small to detect any significant effect of neuromuscular stimulation on self-care function.
4. Arch Phys Med Rehabil. 2006 Dec;87(12 Suppl 2):S1.
Neuroplasticity and brain imaging research: implications for rehabilitation.
Levin HS.
Cognitive Neuroscience Laboratory, Baylor College of Medicine, Houston, TX 77030, USA. hlevin@bcm.edu
Advanced brain imaging technologies have been used recently to investigate neuroplasticity in relation to recovery and treatment of neurologic injury and disease. The contributors to this supplement present data and synthesize the extant literature on the use of functional magnetic resonance imaging, magnetic resonance spectroscopy, optical imaging, transcranial magnetic stimulation, and transcranial direct current stimulation to study remodeling of cortical representation of motor and cognitive abilities after stroke and other etiologies of neurologic impairment. In general, the collective findings of these studies support use-dependent neuroplasticity as a mechanism of recovery and response to training. Brain imaging findings support the role of training effects on increased activation of brain regions ipsilateral to unilateral vascular lesions in facilitating recovery from stroke. The articles in this supplement also report
the potential therapeutic application of stimulation techniques to enhance reorganization of function.
7. Stroke. 2006 Dec;37(12):2995-3001. Epub 2006 Oct 19.
Randomized controlled trial to evaluate the effect of surface neuromuscular electrical stimulation to the shoulder after acute stroke.
Church C, Price C, Pandyan AD, Huntley S, Curless R, Rodgers H.
Department of Geriatric Medicine, Northumbria Healthcare NHS Trust, North Tyneside General Hospital, North Shields, UK.
Comment in Stroke. 2007 Aug;38(8):e71; author reply e72-3.
BACKGROUND AND PURPOSE: Surface neuromuscular electrical stimulation (sNMES) after stroke aims to improve upper limb function and reduce shoulder pain, but current evidence of effectiveness is inconclusive. We have undertaken a randomized controlled trial to evaluate sNMES to the shoulder after acute stroke. METHODS: One hundred seventy-six patients, within 10 days of stroke onset, were randomized to receive sNMES or placebo in addition to stroke unit care. The primary outcome measure was upper limb function measured by the Action Research Arm Test (ARAT) 3 months after stroke. Secondary outcome measures included other measures of upper limb function, upper limb impairment, pain, disability, and
global health status. Outcome assessments were blinded. RESULTS: There was no difference in arm function between groups in terms of the primary outcome measure. The median ARAT at 3 months was 50 in the intervention group and 55.5 in the control group (P=0.068). Significant differences were seen at 3 months in favor of the control group for other measures of arm function and impairment: grasp and gross movement subsections of the ARAT, Frenchay Arm Test, and the arm subsection of the Motricity Index. Secondary analysis suggested that these differences were most marked in subjects with severe initial upper limb weakness. CONCLUSIONS: A 4-week program of sNMES to the shoulder after acute stroke does not improve functional outcome and may worsen arm function in severely impaired stroke patients. "Routine" use of sNMES to the proximal affected upper limb after acute stroke cannot be recommended.
11. Cogn Behav Neurol. 2006 Mar;19(1):34-40.
Paretic hand in stroke: from motor cortical plasticity research to rehabilitation.
Hlustk P, Mayer M.
Clinic of Neurology, Faculty of Medicine, Palacky University in Olomouc, Czech Republic. phlustik@upol.cz
Research in neural plasticity of adult cortical representations brought hope of
significant potential for further improvement in therapy after cerebrovascular stroke, but the same processes involved in plasticity also allow for maladaptive changes whether spontaneous or caused by inappropriate therapeutic manipulations. Within the extensive network of multiple and bilateral motor cortical and subcortical areas, this paper focuses on the primary motor cortex. We review selected data from humans and primates regarding its functional anatomy and the mechanisms of adaptive neuroplasticity in the presence of brain insults, and the impact of motor skill learning in normals and rehabilitation therapy in patients. The discussion centers on the potential impact of the mechanisms of motor cortex neuroplasticity, especially of the phenomenon of competition among primary motor cortical representations, on the rehabilitation of paretic hand and shoulder after stroke. Application of results from neurophysiology and functional brain imaging research into the clinical practice is in the initial stages and remains a challenge for the future. Nevertheless, even the available research provides an important message for clinical rehabilitation of stroke patients: the need to widen multimodal and interdisciplinary approaches to rehabilitation of the paretic hand.
12. Cogn Behav Neurol. 2006 Mar;19(1):21-33.
Hand motor recovery after stroke: tuning the orchestra to improve hand motor function.
Fregni F, Pascual-Leone A.
Harvard Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA. ffregni@bidmc.harvard.edu
The motor deficits after stroke are not only the manifestation of the injured brain region, but rather the expression of the ability of the rest of the brain to maintain function. After a lesion in the primary motor cortex, parallel motor circuits might be activated to generate some alternative input to the spinal motoneurons. These parallel circuits may originate from areas such as the contralateral, undamaged primary motor area, bilateral premotor areas, bilateral supplementary motor areas, bilateral somatosensory areas, cerebellum, and basal ganglia. Most importantly, the efferent, cortico-spinal output pathways must be preserved for a desired behavioral result. Most of the recovery of function after a stroke may represent actual relearning of the skills with the injured brain. The main neural mechanisms underlying this relearning process after stroke involve shifts of distributed contributions across a specific neural network (fundamentally the network engaged in skill learning in the healthy). If these notions are indeed correct, then neuromodulatory approaches, such as transcranial magnetic stimulation, targeting these parallel circuits might be useful to limit injury and promote recovery after a stroke. This paper reviews the stroke characteristics that can predict a good recovery and compensations across brain areas that can be implemented after a stroke to accelerate motor function recovery.
14. J Rehabil Med. 2006 Jan;38(1):13-9.
Can electroacupuncture or transcutaneous nerve stimulation influence cognitive and emotional outcome after stroke?
Rorsman Ia, Johansson B.
Department of Neurology, Lund University Hospital, Lund. Ia.Rorsman@skane.se
OBJECTIVE: The authors know of no controlled randomized studies on the cognitive effects of acupuncture following stroke. The aim of this study is to assess the effects of acupuncture combined with electroacupuncture and transcutaneous electrical nerve stimulation on emotional and cognitive functioning. METHODS: Five to 10 days after stroke, 54 patients with moderate or severe functional impairment were randomized to 1 of 3 interventions: (i) acupuncture, including electroacupuncture; (ii) sensory stimulation with high-intensity, low-frequency transcutaneous electrical nerve stimulation that induced muscle contractions; and (iii) low-intensity (subliminal) high-frequency transcutaneous electrical nerve stimulation (control group). Twenty treatment sessions were performed over 10 weeks. Outcome measures included cognitive performance and emotional functioning. Measures were obtained prior to any stimulation treatment and at 3 and 12 months. RESULTS: At baseline, groups were comparable with regard to demographic, medical, emotional and functional status. The control group demonstrated lower cognitive performances, but this difference did not remain at 3 or 12 months. There were no treatment effects on emotional status. When pooling treatment groups, there were significant cognitive and emotional improvements. CONCLUSION: Although patients from all 3 groups demonstrated cognitive and emotional improvements, the present study does not suggest any treatment effects
on emotional status or cognitive functioning.
16. Arch Phys Med Rehabil. 2006 Jan;87(1):27-31.
Back from the brink: electromyography-triggered stimulation combined with modified constraint-induced movement therapy in chronic stroke.
Page SJ, Levine P.
Department of Physical Medicine and Rehabilitation, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA.
Erratum in Arch Phys Med Rehabil. 2006 Mar;87(3):447.
OBJECTIVE: To determine the efficacy of a regimen that combines electromyography-triggered neuromuscular stimulation (ETMS) with modified constraint-induced movement therapy (mCIMT) in patients with chronic stroke. DESIGN: Pre-post, case series. SETTING: Outpatient rehabilitation hospital. PARTICIPANTS: Six subjects who had had a stroke more [corrected] than 1 year before the study and who had upper-limb hemiparesis. All subjects were only able to activate the affected wrist extensors. INTERVENTION: Subjects underwent ETMS twice every weekday in 35-minute increments during an 8-week period. One week after they completed the ETMS regimen, and
after the outcome measures were readministered, subjects participated in mCIMT, which consisted of structured therapy sessions that emphasized use of the more affected arm in valued activities. The sessions were held 3 times a week for 10 weeks. The less affected arms were also restrained 5 days a week for 5 hours. MAIN OUTCOME MEASURES: The Fugl-Meyer Assessment (FMA) of motor recovery, Action Research Arm Test (ARAT), and goniometry. RESULTS: Subjects had nominal changes on the ARAT (mean change, 0.3), and no functional changes after ETMS. However, they had a mean increase of 21.5 degrees in affected wrist extension and an improved ability to perform the wrist items of the FMA (reflected by a mean increase of 4.1 points on the FMA), which qualified them for mCIMT. After mCIMT, subjects had a 15.5-point change on the FMA, an 11.4-point change on the ARAT, and a new ability to perform valued activities. CONCLUSIONS: ETMS alone does not result in functional changes. However, it may elicit sufficient active affected wrist and finger extension increases to permit possible participation in mCIMT, which can result in marked functional gains. This study is among the first to show improved function in stroke patients who initially had little hand motor control, and it is among the first to effectively combine 2 singularly efficacious regimens.
17. Neurosci Lett. 2006 Apr 10-17;397(1-2):135-9. Epub 2005 Dec 27.
Neurochemical effects of exercise and neuromuscular electrical stimulation on brain after stroke: a microdialysis study using rat model.
Leung LY, Tong KY, Zhang SM, Zeng XH, Zhang KP, Zheng XX.
Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong.
Treadmill exercise and neuromuscular electrical stimulation are common clinical approaches for stroke rehabilitation. Both animal and clinical studies have shown the functional improvements after these interventions. However, the neurochemical effects on the ischemic brain had not been well studied. This study aimed at evaluating the effects of treadmill exercise and neuromuscular electrical stimulation (NMES), and studying their effects during a 2-week training, on the levels of common neurotransmitters (aspartate, glutamate, taurine and gamma-aminobutyric acid (GABA)) in the hippocampus following transient focal cerebral ischemia. Either treadmill exercise or neuromuscular electrical stimulation was prescribed to the rats 24 h after cerebral ischemia whereas Control group remained in cages for 2 weeks. Microdialysis technique was used to collect dialysates from ipsilesional hippocampus in vivo. It was found that the glutamate level was increased significantly during treadmill exercise and then returned to baseline level. Both interventions did not trigger significant effects on aspartate and glutamate basal levels during the 2 weeks. The relatively high taurine level in Control groups may suggest that the interventions might suppress the taurine release in hippocampus. GABA and aspartate levels did not showed significant changes over the 2 weeks in all groups. These results provide insights to explain the neurochemical effects on the ischemic injured brain during the course of rehabilitation.
2. Di Yi Jun Yi Da Xue Xue Bao. 2005 Aug;25(8):1054-5.
[Effects of functional electric stimulation on shoulder subluxation and upper limb motor function recovery of patients with hemiplegia resulting from stroke].
[Article in Chinese]
Liu J, You WX, Sun D.
Department of Neurology, First People's Hospital of Shunde, Shunde 528300, China. library_1sthsp@yahoo.com.cn
OBJECTIVE: To observe the effects of functional electric stimulation (FES) on shoulder subluxation and motor function recovery of the upper extremities of patients with hemiplegia resulting from stroke. METHODS: Forty-eight hemiplegic patients were randomly divided into two groups for treatment with FES and shoulder pads, respectively. The recovery of the patient's shoulder subluxation and movement function of upper extremities were evaluated 6 weeks after treatment and the effects of two therapies were compared. RESULTS: The shoulder subluxation and movement function of the upper extremities were improved after treatment with both therapies (P<0.01, and FES showed better effect (P<0.01). CONCLUSIONS: FES can improve shoulder subluxation and motor function of the upper extremities affected by hemiplegia resulting from stroke.
4. J Rehabil Res Dev. 2004 Nov-Dec;41(6A):807-20.
Response of sagittal plane gait kinematics to weight-supported treadmill training and functional neuromuscular stimulation following stroke.
Daly JJ, Roenigk KL, Butler KM, Gansen JL, Fredrickson E, Marsolais EB, Rogers J, Ruff RL.
Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA. jjd17@case.edu
After stroke, persistent gait deficits cause debilitating falls and poor functional mobility. Gait restoration can preclude these outcomes. Sixteen subjects (>12 months poststroke) were randomized to two gait training groups. Group 1 received 12 weeks of treatment, 4 times a week, 90 min per session, including 30 min strengthening and coordination, 30 min over-ground gait training, and 30 min weight-supported treadmill training. Group 2 received the same treatment, but also used functional neuromuscular stimulation (FNS) with intramuscular (IM) electrodes (FNS-IM) for each aspect of treatment. Outcome measures were kinematics of gait swing phase. Both groups showed no significant pre-/posttreatment gains in peak swing hip flexion. Group 1 (no FNS) had no significant gains in other gait components at posttreatment or at follow-up. Group 2 (FNS-IM) had significant gains in peak swing knee flexion and mid-swing ankle dorsiflexion (p < 0.05) that were maintained for 6 months.
5. Brain. 2005 Mar;128(Pt 3):490-9. Epub 2005 Jan 5.
Effects of non-invasive cortical stimulation on skilled motor function in chronic stroke.
Hummel F, Celnik P, Giraux P, Floel A, Wu WH, Gerloff C, Cohen LG.
Human Cortical Physiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20817, USA.
Stroke is a leading cause of adult motor disability. Despite recent progress, recovery of motor function after stroke is usually incomplete. This double blind, Sham-controlled, crossover study was designed to test the hypothesis that non-invasive stimulation of the motor cortex could improve motor function in the paretic hand of patients with chronic stroke. Hand function was measured using the Jebsen-Taylor Hand Function Test (JTT), a widely used, well validated test for functional motor assessment that reflects activities of daily living. JTT measured in the paretic hand improved significantly with non-invasive transcranial direct current stimulation (tDCS), but not with Sham, an effect that outlasted the stimulation period, was present in every single patient tested and that correlated with an increment in motor cortical excitability within the affected hemisphere, expressed as increased recruitment curves (RC) and reduced short-interval intracortical inhibition. These results document a beneficial effect of non-invasive cortical stimulation on a set of hand functions that mimic activities of daily living in the paretic hand of patients with chronic stroke,
and suggest that this interventional strategy in combination with customary rehabilitative treatments may play an adjuvant role in neurorehabilitation.
3. ScientificWorldJournal. 2007 Dec 20;7:2031-45.
Construction of efficacious gait and upper limb functional interventions based on brain plasticity evidence and model-based measures for stroke patients.
Daly JJ, Ruff RL.
DVA FES Center of Excellence, Louis Stokes Cleveland VA Medical Center, Cleveland, USA. jjd17@case.edu
For neurorehabilitation to advance from art to science, it must become evidence-based. Historically, there has been a dearth of evidence from which to construct rehabilitation interventions that are properly framed, accurately targeted, and credibly measured. In many instances, evidence of treatment response has not been sufficiently robust to demonstrate a change in function that is clinically, statistically, and economically important. Research evidence of activity-dependent central nervous system (CNS) plasticity and the requisite motor learning principles can be used to construct an efficacious motor recovery intervention. Brain plasticity after stroke refers to the regeneration of brain neuronal structures and/or reorganization of the function of neurons. Not only can CNS structure and function change in response to injury, but also, the changes may be modified by "activity". For gait training or upper limb functional
training for stroke survivors, the "activity" is motor behavior, including coordination and strengthening exercise and functional training that comprise motor learning. Critical principles of motor learning required for CNS activity-dependent plasticity include: close-to-normal movements, muscle activation driving practice of movement; focused attention, repetition of desired movements, and training specificity. The ultimate goal of rehabilitation is to restore function so that a satisfying quality of life can be experienced. Accurate measurement of dysfunction and its underlying impairments are critical to the development of accurately targeted interventions that are sufficiently robust to produce gains, not only in function, but also in quality of life. The Classification of Functioning, Disability, and Health Model (ICF) model of disablement, put forth by the World Health Organization, can provide not only some guidance in measurement level selection, but also can serve as a guide to incorporate function and quality of life enhancement as the ultimate goals of rehabilitation interventions. Based on the evidence and principles of activity-dependent plasticity and motor learning, we developed gait training and upper limb functional training protocols. Guided by the ICF model, we selected and developed measures with characteristics rendering them most likely to capture change in the targeted aspects of intervention, as well as measures having membership not only in the impairment, but also in the functional or life role participation levels contained in the ICF model. We measured response to innovative gait training using a knee flexion coordination measure, coefficient of coordination consistency (ACC) of relative hip/knee (H/K) movement across multiple steps (H/K ACC), and milestones of participation in life role activities. We measured response to upper limb functional training according to measures designed to quantify functional gains in response to treatment targeted at wrist/hand or shoulder elbow training (Arm Motor Ability Test for wrist/hand
(AMAT W/H) or shoulder/elbow (AMAT S/E)). We found that there was a statistically significant advantage for adding FES-IM gait training to an otherwise comparable and comprehensive gait training, according to the following measures: H/K ACC, the measure of consistently executed hip/knee coordination during walking; a specific measure of isolated joint knee flexion coordination; and a measure of multiple coordinated gait components. Further, enhanced gains in gait component coordination were robust enough to result in achievement of milestones in participation in life role activities. In the upper limb functional training study, we found that robotics + motor learning (ROB ML; shoulder/elbow robotics practice plus motor learning) produced a statistically significant gain in AMAT S/E; whereas functional electrical stimulation + motor learning (FES ML) did not. We found that FES ML (wrist/hand FES plus motor learning) produced a statistically significant gain in AMAT W/H; whereas ROB ML did not. These results together, support the phenomenon of training specificity in that the most practiced joint movements improved in comparison to joint movements that were practiced at a lesser intensity and frequency. Both ROB ML and FES ML protocols addressed an array of impairments thought to underlie dysfunction. If we are willing to adhere to the ICF model, we accept the challenge that the goal of rehabilitation is life role participation, with functional improvement as in important intermediary step. The ICF model suggests that we intervene at multiple lower levels (e.g., pathology and impairment) in order to improve the higher levels of function and life role participation. The ICF model also suggests that we measure at each level. Not only can we then understand response to treatment at each level, but also, we can begin to understand relationships between levels (e.g., impairment and function). With the ICF model proffering the challenge of restoring life role participation, it then becomes important to design and test interventions that result in impairment gains sufficiently robust to be reflected
in functional activities and further, in life role participation. Fortunately, CNS plasticity and associated motor learning principles can serve well as the basis for generating such interventions. These principles were useful in generating both efficacious gait training and efficacious upper limb functional training interventions. These principles led to the use of therapeutic agents (FES and robotics) so that close-to-normal movements could be practiced. These principles supported the use of specific therapeutic agents (BWSTT, FES, and robotics) so that sufficient movement repetition could be provided. These principles also supported incorporation of functional task practice and the demand of attention to task practice within the intervention. The ICF model provided the challenge to restore function and life role participation. The means to that end was provided by principles of CNS plasticity and motor learning.
5. Arch Phys Med Rehabil. 2007 Nov;88(11):1369-76.
Somatosensory stimulation enhances the effects of training functional hand tasks in patients with chronic stroke.
Celnik P, Hummel F, Harris-Love M, Wolk R, Cohen LG.
Human Cortical Physiology Section and Stroke Neurorehabilitation Clinic, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
OBJECTIVE: To test the hypothesis that somatosensory stimulation would enhance
the effects of training functional hand tasks immediately after practice and 1 day later in chronic subcortical stroke patients. DESIGN: Single-blinded and randomized, crossover study. SETTING: Human research laboratory. PARTICIPANTS: Nine chronic subcortical stroke patients. INTERVENTIONS: Three separate sessions of motor training preceded by (1) synchronous peripheral nerve stimulation (PNS), (2) no stimulation, or (3) asynchronous PNS. MAIN OUTCOME MEASURES: Time to complete the Jebsen-Taylor Hand Function Test (JTHFT time) and corticomotor excitability tested with transcranial magnetic stimulation. RESULTS: After familiarization practice, during which all patients reached a performance plateau, training under the effects of PNS reduced JTHFT time by 10% beyond the post-familiarization plateau. This behavioral gain was accompanied by a specific reduction in GABAergically mediated intracortical inhibition in the motor cortex. These findings were not observed after similar practice under the influence of no stimulation or asynchronous PNS sessions. CONCLUSIONS: Somatosensory stimulation may enhance the training of functional hand tasks in patients with chronic stroke, possibly through modulation of intracortical GABAergic pathways.
8. Int J Rehabil Res. 2007 Sep;30(3):227-30.
Functional vibratory stimulation on the hand facilitates voluntary movements of a hemiplegic upper limb in a patient with stroke.
Shirahashi I, Matsumoto S, Shimodozono M, Etoh S, Kawahira K.
Department of Rehabilitation and Physical Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kirishima-shi, Kagoshima, Japan. izmine@m.kufm.kagoshima-u.ac.jp
The use of a new device consisting of a small vibrator to deliver functional vibratory stimulation (FVS) to the arm resulted in improvements of flexion of the hemiparetic shoulder in a man with thalamic bleeding. FVS delivered to the palm enabled the patient to repeat flexing his hemiparetic shoulder to manipulate objects with his hand. The functions of the patient's hemiparetic shoulder and fingers improved after treatments using FVS for 1 month. We examined whether FVS of the hemiplegic upper limb could facilitate voluntary movements of the limb by increasing the excitability of the motor cortex or the spinal motor neurons using somatosensory-evoked potentials, transcranial magnetic stimulation, F-wave, and single photon emission computed tomography. Our results did not detect an increase of excitability in the motor cortex or in spinal motor neurons by FVS.
11. Med Arh. 2007;61(2):82-5.
[Gait training and functional electric stimulation with hemiplegic patients].
[Article in Bosnian]
Tanovi E.
Institut za fizijatriju i rehabilitaciju, Centar za paraplegije, Klinicki centar Univerziteta u Sarajevu. tanovicharis@hotmail.com
Cerebrovascular accident (stroke) is focal neurological deficiency occurring suddenly and lasting for more than 24 hours. Among its consequences are hemiplegia, speech impairment, swallowing impairment, changes of the facial nerve, sensibility, sphincter control or physiological changes. The goals of the study are to show the place functional electrical stimulation (FES) in the rehabilitation hemiplegic patients after cerebrovascular accident. In our study we analyzed two comparative groups with 40 hemiplegic patients, the first one, control group treated only with kinezitheraphy, and the second one, tested group treated with kinezitheraphy and functional electrical stimulation. Both groups of patients were analyzed according to gender, the etiology of the cerebrovascular accident and the duration of rehabilitation. We also had special analyzed of walking by BI index. Results has shown that we had two comparative groups according to gender and the etiology of the cerebrovascular accident. The duration of rehabilitation was longer in control group (77.5% for four months, 10% for five months) which is treated with kinezitherapy than in the tested group treated with kinezitheraphy and functional electrical stimulation (80% for three months, 20% for four months). After 4 weeks of rehabilitation of hemiplegic patients there are no significant differences between groups tested by BI index. After 8 and 12 weeks of rehabilitation tested gruop of patients treated with kinezitheraphy and functional electrical stimulation showed statistically significant better results than control group by BI index. In the conclusion we can say that functional electrical stimulation and kinezitherapy is methods which
is faster, more successful and with better results in gait training.
12. Phys Ther. 2007 Sep;87(9):1144-54. Epub 2007 Jul 3.
Gait training combining partial body-weight support, a treadmill, and functional electrical stimulation: effects on poststroke gait.
Lindquist AR, Prado CL, Barros RM, Mattioli R, da Costa PH, Salvini TF.
Department of Physical Therapy, Federal University of Rio Grande do Norte, Brazil.
BACKGROUND AND PURPOSE: Treadmill training with harness support is a promising, task-oriented approach to restoring locomotor function in people with poststroke hemiparesis. Although the combined use of functional electrical stimulation (FES) and treadmill training with body-weight support (BWS) has been studied before, this combined intervention was compared with the Bobath approach as opposed to BWS alone. The purpose of this study was to evaluate the effects of the combined use of FES and treadmill training with BWS on walking functions and voluntary limb control in people with chronic hemiparesis. SUBJECTS: Eight people who were ambulatory after chronic stroke were evaluated. METHODS: An A(1)-B-A(2) single-case study design was applied. Phases A(1) and A(2) included 3 weeks of gait training on a treadmill with BWS, and phase B included 3 weeks of treadmill training plus FES applied to the peroneal nerve. The Stroke Rehabilitation Assessment of Movement was used to assess motor
recovery, and a videography analysis was used to assess gait parameters. RESULTS: An improvement (from 54.9% to 71.0%) in motor function was found during phase B. The spatial and temporal variables cycle duration, stance duration, and cadence as well as cycle length symmetry showed improvements when phase B was compared with phases A(1) and A(2). DISCUSSION AND CONCLUSION: The combined use of FES and treadmill training with BWS led to an improvement in motor recovery and seemed to improve the gait pattern of subjects with hemiparesis, indicating the utility of this combination method during gait rehabilitation. In addition, this single-case series showed that this alternative method of gait training--treadmill training with BWS and FES--may decrease the number of people required to carry out the training.
14. Neurorehabil Neural Repair. 2007 Nov-Dec;21(6):561-7. Epub 2007 Mar 16.
Intramuscular electrical stimulation for shoulder pain in hemiplegia: does time from stroke onset predict treatment success?
Chae J, Ng A, Yu DT, Kirsteins A, Elovic EP, Flanagan SR, Harvey RL, Zorowitz RD, Fang ZP.
Cleveland Functional Electrical Stimulation Center, Cleveland, Ohio, USA. jchae@metrohealth.org
BACKGROUND: A randomized clinical has shown the effectiveness of intramuscular electrical stimulation for the treatment of poststroke shoulder pain.
OBJECTIVE: Identify predictors of treatment success and assess the impact of the strongest predictor on outcomes. METHOD: This is a secondary analysis of a multisite randomized clinical trial of intramuscular electrical stimulation for poststroke shoulder pain. The study included 61 chronic stroke survivors with shoulder pain randomized to a 6-week course of intramuscular electrical stimulation (n = 32) versus a hemisling (n = 29). The primary outcome measure was Brief Pain Inventory Question 12. Treatment success was defined as > or = 2-point reduction in this measure at end of treatment and at 3, 6, and 12 months posttreatment. Forward stepwise regression was used to identify factors predictive of treatment success among participants assigned to the electrical stimulation group. The factor most predictive of treatment success was used as an explanatory variable, and the clinical trials data were reanalyzed. RESULTS: Time from stroke onset was most predictive of treatment success. Subjects were divided according to the median value of stroke onset: early (<77 weeks) versus late (> 77 weeks). Electrical stimulation was effective in reducing poststroke shoulder pain for the early group (94% vs 7%, P < .001) but not for the late group (31% vs 33%). Repeated-measure analysis of variance revealed significant treatment (P < .001), time from stroke onset (P = .032), and treatment by time from stroke onset interaction (P < .001) effects. CONCLUSIONS: Stroke survivors who are treated early after stroke onset may experience greater benefit from intramuscular electrical stimulation for poststroke shoulder pain. However, the relative importance of time from stroke onset versus duration of pain is not known.
2. Bosn J Basic Med Sci. 2009 Feb;9(1):49-53.
Effects of functional electrical stimulation in rehabilitation with hemiparesis patients.
Tanovic E.
Institute for Physiotherapy and Rehabilitation, University of Sarajevo Clinics Centre, Bolnicka 25, 71000 Sarajevo, Bosnia and Herzegovina.
Cerebrovascular accident is a focal neurological deficiency occurring suddenly and lasting for more than 24 hours. The purpose of our work is to determine the role of the functional electrical simulation (FES) in the rehabilitation of patients with hemiparesis, which occurred as a consequence of a cerebrovascular accident. This study includes the analysis of two groups of 40 patients with hemiparesis (20 patients with deep hemiparesis and 20 patients with light hemiparesis), a control group which was only treated with kinesiotherapy and a tested group which was treated with kinesiotherapy and functional electrical stimulation. Both groups of patients were analyzed in respect to their sex and age. Additional analysis of the walking function was completed in accordance with the BI and RAP index. The analysis of the basic demographical data demonstrated that there is no significant difference between the control and tested group. The patients of both groups are equal in respect of age and sex. After 4 weeks of rehabilitation of patients with deep and light hemiparesis there were no statistically significant differences between the groups after evaluation by the BI index. However, a statistically significant difference was noted between the groups by the RAP index among patients with deep hemiparesis. After 8 weeks of
rehabilitation the group of patients who were treated with kinesiotherapy and functional electrical stimulation showed better statistically significant results of rehabilitation in respect to the control group with both the BI index and the RAP index (p<0,001). In conclusion, we can state that the patients in rehabilitation after a cerebrovascular accident require rehabilitation longer than 4 weeks. Walking rehabilitation after stroke is faster and more successful if we used functional electrical stimulation, in combination with kinesiotherapy, in patients with disabled extremities.
3. J Neurol Phys Ther. 2008 Dec;32(4):192-202.
Gait training after stroke: a pilot study combining a gravity-balanced orthosis, functional electrical stimulation, and visual feedback.
Krishnamoorthy V, Hsu WL, Kesar TM, Benoit DL, Banala SK, Perumal R, Sangwan V, Binder-Macleod SA, Agrawal SK, Scholz JP.
Physical Therapy Department, University of Delaware, Newark, Delaware, USA.
RATIONALE: This case report describes the application of a novel gait retraining approach to an individual with poststroke hemiparesis. The rehabilitation protocol combined a specially designed leg orthosis (the gravity-balanced orthosis), treadmill walking, and functional electrical stimulation to the ankle muscles with the application of motor learning principles. CASE: The participant was a 58-year-old man who had a stroke more than three
years before the intervention. He underwent gait retraining over a period of five weeks for a total of 15 sessions during which the gravity compensation provided by the gravity-balanced orthosis and visual feedback about walking performance was gradually reduced. OUTCOMES: At the end of five weeks, he decreased the time required to complete the Timed Up and Go test; his gait speed increased during overground walking; gait was more symmetrical; stride length, hip and knee joint excursions on the affected side increased. Except for gait symmetry, all other improvements were maintained one month post-intervention. CONCLUSIONS: This case report describes possible advantages of judiciously combining different treatment techniques in improving the gait of chronic stroke survivors. Further studies are planned to evaluate the effectiveness of different components of this training in both the subacute and chronic stages of stroke recovery.
4. J Rehabil Med. 2009 Mar;41(4):242-6.
Effects of a functional electrical stimulation-assisted leg-cycling wheelchair on reducing spasticity of patients after stroke.
Lo HC, Tsai KH, Su FC, Chang GL, Yeh CY.
Institute of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.
OBJECTIVE: To determine whether short-term propulsion of a functional electrical stimulation-assisted leg-cycling wheelchair (FES-LW) in patients with stroke can reduce spasticity of the affected leg and whether FES has additional effects on reducing spasticity. DESIGN: Within-subject comparison. SUBJECTS: A total of 17 patients after stroke were recruited from the university hospital. METHODS: Subjects propelled 2 leg-cycling wheelchairs (the FES-LW and the LW) and a manual wheelchair along an oval pathway. The Modified Ashworth Scale (MAS), H reflex/maximal M response (H/M ratio) and relaxation index were used to evaluate the immediate effects on leg spasticity. The changes in MAS, H/M and relaxation index were used to evaluate the effect of FES in comparing 2 leg-cycling wheelchairs. RESULTS: The MAS and H/M ratio were significantly decreased and the relaxation index significantly increased by FES-LW and LW usage. For subjects with higher muscle tone, significant lowering of the changes in MAS, H/M ratio and higher relaxation index were found for FES-LW usage compared with LW usage. CONCLUSION: Leg spasticity is reduced after short-term propulsion of the FES-LW and LW. The application of FES has an additional effect on reducing spasticity in subjects with higher muscle tone.
9. Neurorehabil Neural Repair. 2009 Feb;23(2):125-32. Epub 2008 Dec 5.
Motor improvement and corticospinal modulation induced by hybrid assistive
neuromuscular dynamic stimulation (HANDS) therapy in patients with chronic stroke.
Fujiwara T, Kasashima Y, Honaga K, Muraoka Y, Tsuji T, Osu R, Hase K, Masakado Y, Liu M.
Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo. tofuji@xc5.so-net.ne.jp
BACKGROUND AND OBJECTIVE: We devised a therapeutic approach to facilitate the use of the hemiparetic upper extremity (UE) in daily life by combining integrated volitional control electrical stimulation with a wrist splint, called hybrid assistive neuromuscular dynamic stimulation (HANDS). METHODS: Twenty patients with chronic hemiparetic stroke (median 17.5 months) had moderate to severe UE weakness. Before and immediately after completing 3 weeks of training in 40-minute sessions, 5 days per week over 3 weeks and wearing the system for 8 hours each day, clinical measures of motor impairment, spasticity, and UE functional scores, as well as neurophysiological measures including electromyography activity, reciprocal inhibition, and intracortical inhibition were assessed. A follow-up clinical assessment was performed 3 months later. RESULTS: UE motor function, spasticity, and functional scores improved after the intervention. Neurophysiologically, the intervention induced restoration of presynaptic and long loop inhibitory connections as well as disynaptic reciprocal inhibition. Paired pulse transcranial magnetic stimulation study indicated disinhibition of the short intracortical inhibition in the affected hemisphere. The follow-up assessment showed that improved UE functions were maintained at 3 months.
CONCLUSION: The combination of hand splint and volitional and electrically induced muscle contraction can induce corticospinal plasticity and may offer a promising option for the management of the paretic UE in patients with stroke. A larger sample size with randomized controls is needed to demonstrate effectiveness.
12. Annu Rev Med. 2009;60:55-68.
Stroke rehabilitation: strategies to enhance motor recovery.
O'Dell MW, Lin CC, Harrison V.
Department of Rehabilitation Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York 10021, USA. mio2005@med.cornell.edu
Recent evidence indicates that the brain can remodel after stroke, primarily through synaptogenesis. Task-specific and repetitive exercise appear to be key factors in promoting synaptogenesis and are central elements in rehabilitation of motor weakness following stroke. Expert medical management ensures a patient is well enough to participate in rehabilitation with minimal distractions due to pain or depression. Contraint-induced motor therapy and body-weight-supported ambulation are forms of exercise that "force use" of an impaired upper extremity. Technologies now in common use include robotics, functional electrical stimulation, and, to a lesser degree, transcranial magnetic stimulation and virtual reality. The data on pharmacological interventions are mixed but
encouraging; it is hoped such treatments will directly stimulate brain tissue to recovery. Mitigation of factors preventing movement, such as spasticity, might also play a role. Research evaluating these motor recovery strategies finds them generally good at the movement level but somewhat less robust when looking at functional performance. It remains unclear whether inconsistent evidence for functional improvement is a matter of poor treatment efficacy or insensitive outcome measures.
14. Neurorehabil Neural Repair. 2008 Nov-Dec;22(6):728-36. Epub 2008 Sep 10.
Electrodermal recording and fMRI to inform sensorimotor recovery in stroke patients.
MacIntosh BJ, McIlroy WE, Mraz R, Staines WR, Black SE, Graham SJ.
Heart and Stroke Foundation Centre for Stroke Recovery, Toronto, Canada. bmac@fmrib.ox.ac.uk
BACKGROUND: Functional magnetic resonance imaging (fMRI) appears to be useful for investigating motor recovery after stroke. Some of the potential confounders of brain activation studies, however, could be mitigated through complementary physiological monitoring. OBJECTIVE: To investigate a sensorimotor fMRI battery that included simultaneous measurement of electrodermal activity in subjects with hemiparetic stroke to provide a measure related to the sense of effort during motor performance.
METHODS: Bilateral hand and ankle tasks were performed by 6 patients with stroke (2 subacute, 4 chronic) during imaging with blood oxygen level-dependent (BOLD) fMRI using an event-related design. BOLD percent changes, peak activation, and laterality index values were calculated in the sensorimotor cortex. Electrodermal recordings were made concurrently and used as a regressor. RESULTS: Sensorimotor BOLD time series and percent change values provided evidence of an intact motor network in each of these well-recovered patients. During tasks involving the hemiparetic limb, electrodermal activity changes were variable in amplitude, and electrodermal activity time-series data showed significant correlations with fMRI in 3 of 6 patients. No such correlations were observed for control tasks involving the unaffected lower limb. CONCLUSIONS: Electrodermal activity activation maps implicated the contralesional over the ipsilesional hemisphere, supporting the notion that stroke patients may require higher order motor processing to perform simple tasks. Electrodermal activity recordings may be useful as a physiological marker of differences in effort required during movements of a subject's hemiparetic compared with the unaffected limb during fMRI studies.
19. Neuropsychol Rehabil. 2009 Jun;19(3):364-82. Epub 2008 Jul 1.
Left-hand somatosensory stimulation combined with visual scanning training in rehabilitation for post-stroke hemineglect: a randomised, double-blind study.
Polanowska K, Seniw J, Paprot E, Leniak M, Czonkowska A.
2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland. kpolanow@ipin.edu.pl
The aim of this randomised, double-blind study was to investigate the therapeutic effectiveness of left-hand electrical stimulation for patients with post-stroke left visuo-spatial neglect. This approach was hypothesised to enhance activation of the right hemisphere attention system and to improve visual exploration of extrapersonal space. Participants (n = 40) in the study were in a relatively early stage of recovery from their first right hemisphere stroke, and were randomly assigned to the experimental (E) or control (C) group. Group E received conventional visual scanning training combined with electrostimulation of the left hand, while Group C received scanning training with sham stimulation. Their visuo-spatial neglect was assessed twice, prior to the rehabilitation programme and on its completion, using cancellation tests and a letter-reading task. The effect of electrostimulation on hemineglect was assessed following a single administration and after a month-long rehabilitation programme. Although the immediate effect of stimulation was poor, after a month-long rehabilitation period we found significantly greater improvement in Group E patients than in Group C patients. Interestingly, the presence of hemisensory loss did not weaken the observed effect. Therefore, we claim that contralesional hand stimulation combined with visual scanning was a more effective treatment for hemineglect rehabilitation than scanning training alone.
20. Exp Brain Res. 2008 Oct;191(1):57-66. Epub 2008 Jul 29.
Cortical excitability changes following grasping exercise augmented with electrical stimulation.
Barsi GI, Popovic DB, Tarkka IM, Sinkjaer T, Grey MJ.
Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7 D-3, 9220, Aalborg, Denmark. barsi@hst.aau.dk
Rehabilitation with augmented electrical stimulation can enhance functional recovery after stroke, and cortical plasticity may play a role in this process. The purpose of this study was to compare the effects of three training paradigms on cortical excitability in healthy subjects. Cortical excitability was evaluated by analysing the input-output relationship between transcranial magnetic stimulation intensity and motor evoked potentials (MEPs) from the flexor muscles of the fingers. The study was performed with 25 healthy volunteers who underwent 20-min simulated therapy sessions of: (1) functional electrical stimulation (FES) of the finger flexors and extensors, (2) voluntary movement (VOL) with sensory stimulation, and (3) therapeutic FES (TFES) where the electrical stimulation augmented voluntary activation. TFES training produced a significant increase in MEP magnitude throughout the stimulation range, suggesting an increase in cortical excitability. In contrast, neither the FES nor voluntary movement alone had such an effect. These results suggest that the combination of voluntary effort and FES has greater potential to induce plasticity in the motor cortex and that TFES might be a more effective approach in rehabilitation after stroke than FES or repetitive voluntary training alone.
3. Physiother Can. 2010 Spring;62(2):114-9. Epub 2010 Apr 23.
The effect of functional electrical stimulation on balance function and balance confidence in community-dwelling individuals with stroke.
Robertson JA, Eng JJ, Hung C.
Acquired Brain Injury Program and Rehab Research Lab, GF Strong Rehab Centre, Vancouver, British Columbia, Canada.
Comment in Physiother Can. 2010 Spring;62(2):120-1.
PURPOSE: The purpose of this study was to evaluate the change in balance function and balance confidence in adults with chronic stroke who are starting a gait re-education program with functional electrical stimulation (FES). METHODS: The study used a before-after study design. Fifteen community-dwelling adults with chronic stroke completed four weekly sessions (2 hours each) of balance and ambulation training with FES applied to the ankle dorsiflexors during the swing phase. Following this familiarization period, participants were assessed for balance and mobility with and without the use of FES. Balance confidence was assessed before and after the familiarization period using the Activities-specific Balance Confidence (ABC) scale. RESULTS: There was a small but statistically significant improvement in toe
clearance and balance function with the FES device, but no detectable change in gait speed. More than half of participants reported reduced balance confidence with the FES device; one-third showed a large (>11 ABC points) reduction in balance confidence. CONCLUSION: Physical improvements can occur during FES treatment of individuals post-stroke; however, this may be associated with a clinically important impairment in balance confidence as patients with stroke familiarize themselves with FES treatment.
PMCID: PMC2871018 PMID: 21359041 [PubMed]
7. Arch Phys Med Rehabil. 2010 Nov;91(11):1731-6.
Effect of a bout of leg cycling with electrical stimulation on reduction of hypertonia in patients with stroke.
Yeh CY, Tsai KH, Su FC, Lo HC.
Chung Shan Medical University, Chung Shan Medical University Hospital, Taichung City, Taiwan.
OBJECTIVES: To evaluate whether a bout of leg cycling in patients with stroke reduces muscle tone and to determine whether neuromuscular functional electrical stimulation (FES) to the affected leg during cycling is more effective than cycling without FES. DESIGN: Within-subject comparison.
SETTING: University hospital. PARTICIPANTS: Patients with stroke (N=16; age range, 42-72y; <8wk poststroke) with hypertonia in the affected leg. INTERVENTIONS: Subjects' affected leg (1) performed cycling exercise with the assistance of FES (assisted-cycling session) and (2) performed cycling exercise without the assistance of FES (nonassisted-cycling session). Subjects sat in a specially designed wheelchair positioned on a resistance-free roller for each 20-minute session. MAIN OUTCOME MEASURES: Changes in muscle tone pre- and posttest session were compared by using the Modified Ashworth Scale and the pendulum test (relaxation index and peak velocity). RESULTS: Modified Ashworth Scale scores were significantly lower (P<.05) and relaxation index and peak velocity values were significantly higher (P<.05) after both sessions. Changes in Modified Ashworth Scale scores, relaxation index, and peak velocity values showed a significant (P<.05) difference between the 2 sessions, and assisted cycling reduced hypertonia more than nonassisted cycling. CONCLUSIONS: The hypertonia of patients with stroke showed a significant decrease immediately after a bout of leg-cycling exercise. FES-assisted leg cycling was better than nonassisted cycling for reducing hypertonia.
Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
8. Med Hypotheses. 2011 Feb;76(2):197-8. Epub 2010 Oct 23.
On-line 'automatic pilot' training for hand and arm motor rehabilitation after stroke.
Zeng J, Sun Y, Jiang L.
Department of Computer Science and Technology, Tongji University, China. 0mrzeng@tongji.edu.cn
As stroke being one of the most leading causes of death worldwide, even stroke survivors have to suffer from dysfunctions of limb controls and inabilities of speech or vision. Cognitive neuroscientists have found various forms of automatic behaviours in healthy people, which generally cover motor components of upper limbs and are essential for coordination and mobility relevant activities. Meanwhile, the robot-assisted therapy and functional electrical stimulation have become prominent rehabilitation techniques for patients' rehabilitation after stroke. With the integration of robot-aided therapeutic systems and the functional electrical stimulation, the on-line 'automatic pilot' training of the visual inspired stimulation for upper limbs can offer a feasible treatment for patients after stroke to recover motor performance.
Copyright 2010 Elsevier Ltd. All rights reserved.
13. Disabil Rehabil. 2010;32(7):560-6.
The effectiveness of functional electrical stimulation for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients: A randomized controlled trial.
Koyuncu E, Nakipolu-Yzer GF, Doan A, Ozgirgin N.
5th Physical Medicine and Rehabilitation Clinic, Ankara Physical Medicine and Rehabilitation Education and Research Hospital, Ankara, Turkey.
PURPOSE: To investigate the effect of functional electrical stimulation (FES) for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients. METHOD: A total of 50 hemiplegic patients with shoulder subluxation and shoulder pain were included in the study. The patients were randomly divided into the study and control groups. All patients were put on a rehabilitation program using conventional methods while the study group patients were additionally applied FES to supraspinatus and posterior deltoid muscles. The shoulder pain of all patients during resting, passive range of motion (PROM) and active range of motion (AROM) was measured with the visual analog scale (VAS) while the shoulder subluxation levels were evaluated with the classification developed by Van Langenberghe and by using the millimetric measurements on anteroposterior shoulder X-ray before and after the physical treatment and rehabilitation program and compared. RESULTS: Comparison of the resting AROM vs. PROM VAS value changes showed no significant difference between the groups. There was a significant difference between the two groups for the amount of change in shoulder subluxation in favor of the study group. CONCLUSIONS: The results of our study have shown that applying FES treatment to the supraspinatus and posterior deltoid muscles in addition to conventional
treatment when treating the subluxation in hemiplegic patients is more beneficial than conventional treatment by itself.
3. Conf Proc IEEE Eng Med Biol Soc. 2011;2011:4136-9.
The impact of shoulder abduction loading on EMG-based intention detection of hand opening and closing after stroke.
Lan Y, Yao J, Dewald JP.
Interdepartmental Neuroscience Program and Department of Physical Therapy and Human Movement Sciences, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA. yiyunlan2009@u.northwestern.edu
Many stroke patients are subject to limited hand functions in the paretic arm due to a significant loss of Corticospinal Tract (CST) fibers. A possible solution for this problem is to classify surface Electromyography (EMG) signals generated by hand movements and uses that to implement Functional Electrical Stimulation (FES). However, EMG usually presents an abnormal muscle coactivation pattern shown as increased coupling between muscles within and/or across joints after stroke. The resulting Abnormal Muscle Synergies (AMS) could make the classification more difficult in individuals with stroke, especially when attempting to use the hand together with other joints in the paretic arm. Therefore, this study is aimed at identifying the impact of AMS following stroke on EMG pattern recognition between two hand movements. In an effort to achieve
this goal, 7 chronic hemiparetic chronic stroke subjects were recruited and asked to perform hand opening and closing movements at their paretic arm while being either fully supported by a virtual table or loaded with 25% of subject's maximum shoulder abduction force. During the execution of motor tasks EMG signals from the wrist flexors and extensors were simultaneously acquired. Our results showed that increased synergy-induced activity at elbow flexors, induced by increasing shoulder abduction loading, deteriorated the performance of EMG pattern recognition for hand opening for those with a weak grasp strength and EMG activity. However, no such impact on hand closing has yet been observed possibly because finger/wrist flexion is facilitated by the shoulder abduction-induced flexion synergy.
PMID: 22255250 [PubMed - in process]
5. Clin EEG Neurosci. 2011 Oct;42(4):245-52.
Brain-computer interface in stroke: a review of progress.
Silvoni S, Ramos-Murguialday A, Cavinato M, Volpato C, Cisotto G, Turolla A, Piccione F, Birbaumer N.
Department of Neurophysiology S.Camillo Hospital Foundation I.R.R.C.S., Venice, Italy. stefano.silvoni@ospedalesancamillo.net
Brain-computer interface (BCI) technology has been used for rehabilitation after stroke and there are a number of reports involving stroke patients in BCI-feedback training. Most publications have demonstrated the efficacy of BCI
technology in post-stroke rehabilitation using output devices such as Functional Electrical Stimulation, robot, and orthosis. The aim of this review is to focus on the progress of BCI-based rehabilitation strategies and to underline future challenges. A brief history of clinical BCI-approaches is presented focusing on stroke motor rehabilitation. A context for three approaches of a BCI-based motor rehabilitation program is outlined: the substitutive strategy, classical conditioning and operant conditioning. Furthermore, we include an overview of a pilot study concerning a new neuro-forcefeedback strategy. This pilot study involved healthy participants. Finally we address some challenges for future BCI-based rehabilitation.
7. Brain Imaging Behav. 2011 Dec 28. [Epub ahead of print]
Mean diffusivity as a potential diffusion tensor biomarker of motor rehabilitation after electrical stimulation incorporating task specific exercise in stroke: a pilot study.
Boespflug EL, Storrs JM, Allendorfer JB, Lamy M, Eliassen JC, Page S.
Psychiatry and Behavioral Neurosciences & Center for Imaging Research & Neuroscience Graduate Program, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Suite E685, Cincinnati, OH, 45267-0583, USA, boespfel@mail.uc.edu.
Changes in diffusion tensor imaging (DTI) values co-occur with neurological and
functional changes after stroke. However, quantitative DTI metrics have not been examined in response to participation in targeted rehabilitative interventions in chronic stroke. The primary purpose of this pilot study was to examine whether changes in DTI metrics co-occur with paretic arm movement changes among chronic stroke patients participating in a regimen of electrical stimulation targeting the paretic arm. Three subjects exhibiting stable arm hemiparesis were administered 30-minute (n=1) or 120-minute (n=2) therapy sessions emphasizing paretic arm use during valued, functional tasks and incorporating an electrical stimulation device. These sessions occurred every weekday for 8 weeks. A fourth subject served as a treatment control, participating in a 30-minute home exercise regimen without electrical stimulation every weekday for 8 weeks. DTI and behavioral outcome measures were acquired at baseline and after intervention. DTI data were analyzed using a region of interest (ROI) approach, with ROIs chosen based on tract involvement in sensorimotor function or as control regions. Behavioral outcome measures were the Fugl-Meyer Scale (FM) and the Action Research Arm Test (ARAT). The treatment control subject exhibited gains in pinch and grasp, as shown by a 5-point increase on the ARAT. The subject who participated in 30-minute therapy sessions exhibited no behavioral gains. Subjects participating in 120-minute therapy sessions displayed consistent impairment reductions and distal movement changes. DTI changes were largest in subjects two and three, with mean diffusivity (MD) decreases in the middle cerebellar peduncle and posterior limb of the internal capsule following treatment. No changes in fractional anisotropy (FA) were observed for sensorimotor tracts. Our preliminary results suggest that active rehabilitative therapies augmented by electrical stimulation may induce positive behavioral changes which are underscored by DTI changes indicative of increased white matter tract integrity in regions specific to sensory-motor function.
PMID: 22203524 [PubMed - as supplied by publisher]
8. Gait Posture. 2012 Mar;35(3):506-10. Epub 2011 Dec 6.
Cycling exercise with functional electrical stimulation improves postural control in stroke patients.
Lo HC, Hsu YC, Hsueh YH, Yeh CY.
Department of Product Design, Ming Chuan University, Taiwan.
The aim of this study is to determine whether short term functional electrical stimulation (FES)-assisted cycling training can affect the postural control of stroke patients, and whether the application of FES can enhance the effect of cycling training. 20 stroke patients were randomly assigned to the FES-cycling group (FES-CG) or the cycling group (CG). Measurements were completed before and immediately after each 20min training sessions. The measurements included a balance test (to quantify the postural control ability), a Hoffmann's reflex/motor response ratio (H/M ratio) test and a pendulum test (to quantify the muscle tone). In the balance test, some parameters in all directions exhibited significant intervention effects between the FES-CG group and the CG group. The H/M ratios (p=.014; .005, FES-CG and CG respectively) and relaxation index (p=.005; .047, FES-CG and CG respectively) revealed significant difference between FES-CG and CG group. The change ratios of directional control in the forward direction and H/M ratio revealed significant difference (p=.022; .015)
between FES-CG and CG among subjects with higher muscle tone. The stroke subjects' postural control was improved while their muscle tone was reduced after the 20min cycling training program both with and without FES. We conclude that cycling training, with or without FES may reduce spasticity in stroke patients. The application of FES in cycling exercise was shown to be more effective in stroke patients with higher muscle tone.
Copyright 2011 Elsevier B.V. All rights reserved.
10. Rev Bras Fisioter. 2011 Nov-Dec;15(6):436-44. Epub 2011 Oct 27.
Effects of the addition of functional electrical stimulation to ground level gait training with body weight support after chronic stroke.
Prado-Medeiros CL, Sousa CO, Souza AS, Soares MR, Barela AM, Salvini TF.
Physical Therapy Department, Universidade Federal de So Carlos, So Carlos, SP, Brazil. medeirosclp@gmail.com
BACKGROUND: The addition of functional electrical stimulation (FES) to treadmill gait training with partial body weight support (BWS) has been proposed as a strategy to facilitate gait training in people with hemiparesis. However, there is a lack of studies that evaluate the effectiveness of FES addition on ground level gait training with BWS, which is the most common locomotion surface. OBJECTIVE: To investigate the additional effects of commum peroneal nerve FES
combined with gait training and BWS on ground level, on spatial-temporal gait parameters, segmental angles, and motor function. METHODS: Twelve people with chronic hemiparesis participated in the study. An A1-B-A2 design was applied. A1 and A2 corresponded to ground level gait training using BWS, and B corresponded to the same training with the addition of FES. The assessments were performed using the Modified Ashworth Scale (MAS), Functional Ambulation Category (FAC), Rivermead Motor Assessment (RMA), and filming. The kinematics analyzed variables were mean walking speed of locomotion; step length; stride length, speed and duration; initial and final double support duration; single-limb support duration; swing period; range of motion (ROM), maximum and minimum angles of foot, leg, thigh, and trunk segments. RESULTS: There were not changes between phases for the functional assessment of RMA, for the spatial-temporal gait variables and segmental angles, no changes were observed after the addition of FES. CONCLUSION: The use of FES on ground level gait training with BWS did not provide additional benefits for all assessed parameters.
11. Disabil Rehabil. 2012;34(2):151-6. Epub 2011 Oct 15.
The efficacy of electrical stimulation in reducing the post-stroke spasticity: a randomized controlled study.
Sahin N, Ugurlu H, Albayrak I.
Physical Medicine and Rehabilitation Department, Selcuk University, Meram Faculty of Medicine, Meram, Konya, Turkey. nilaysahin@gmail.com
PURPOSE: The purpose of this study is to evaluate the efficacy of surface electrical stimulation on the spasticity occurring in the wrist flexor muscles after a cerebrovascular event. METHOD: Hemiplegic patients with stage 2-3 spasticity in the wrist muscles based on the Ashworth scale were divided into two groups. Both groups were applied stretching. One group was additionally administered neuromuscular electrical stimulation (NMES) to the wrist extensors, in the form of pulsed current, 100 Hz, with a pulse duration of 0.1 msec, and a resting duration of 9 seconds, for 15 minutes to provide the maximum muscular contraction. The efficacy of the treatment was evaluated using the following: modified Ashworth scale (MAS), Fmax/Mmax ratio, Hmax/Mmax ratio, wrist extension range of motion (ROM). The daily activities were assessed by Functional Independence Measurement (FIM) and the motor recovery was evaluated by Brunnstrom motor staging. RESULTS: Both groups revealed a significant recovery after the treatment based on the MAS, the electrophysiological evaluation results, wrist ROM, FIM and Brunnstrom motor staging. The group receiving the combined treatment showed a better recovery in terms of MAS, wrist ROM, FIM and Brunnstrom motor staging compared to the group doing the stretching alone. CONCLUSIONS: The results of this study showed that NMES given together with stretching of the wrist extensor muscles was more effective than stretching of the wrist extensor muscles alone in reducing spasticity.
13. NeuroRehabilitation. 2011;29(1):67-77.
Assisted leg displacements and progressive loading by a tilt table combined with FES promote gait recovery in acute stroke.
Solopova IA, Tihonova DY, Grishin AA, Ivanenko YP.
Institute for Information Transmission Problems of RAS, Moscow, Russia. solopova@iitp.ru
OBJECTIVE: Here we developed and tested a novel system for early motor rehabilitation in acute stroke when patients are unable to stand and walk without assistance. Stepping performance may be largely facilitated by providing treatment in the supine position on a tilt table using step-synchronized functional electrical stimulation (FES) with assisted leg movements and progressive limb loading. METHODS: Sixty-one individuals with acute stroke were randomly assigned to two groups, experimental and control. The first group received both a conventional therapy and FES-therapy combined with progressive limb loading, whereas the control group received a conventional therapy only. Changes after treatment were assessed using clinical scores and neurophysiological measurements of movement performance. RESULTS: After treatment, there was an improvement of the clinical scores, muscle forces and everyday life activity performance in both groups, however, significantly higher in the experimental group. Active rhythmic movements of the non paretic leg often provoked muscle activity in the paretic leg as well as there was a reduction of the contralateral leg muscle contraction during paretic
leg movements. CONCLUSION: The developed FES and leg displacement-assisted therapy facilitates a smooth transition to walking in the vertical position and increases the patient's functional abilities and the effectiveness of rehabilitation.
19. Prog Brain Res. 2011;192:147-59.
Technology improves upper extremity rehabilitation.
Kowalczewski J, Prochazka A.
Centre for Neuroscience, School of Molecular and Systems Medicine, University of Alberta, Edmonton, Alberta, Canada.
Stroke survivors with hemiparesis and spinal cord injury (SCI) survivors with tetraplegia find it difficult or impossible to perform many activities of daily life. There is growing evidence that intensive exercise therapy, especially when supplemented with functional electrical stimulation (FES), can improve upper extremity function, but delivering the treatment can be costly, particularly after recipients leave rehabilitation facilities. Recently, there has been a growing level of interest among researchers and healthcare policymakers to deliver upper extremity treatments to people in their homes using in-home teletherapy (IHT). The few studies that have been carried out so far have encountered a variety of logistical and technical problems, not least the difficulty of conducting properly controlled and blinded protocols that satisfy
the requirements of high-level evidence-based research. In most cases, the equipment and communications technology were not designed for individuals with upper extremity disability. It is clear that exercise therapy combined with interventions such as FES, supervised over the Internet, will soon be adopted worldwide in one form or another. Therefore it is timely that researchers, clinicians, and healthcare planners interested in assessing IHT be aware of the pros and cons of the new technology and the factors involved in designing appropriate studies of it. It is crucial to understand the technical barriers, the role of telesupervisors, the motor improvements that participants can reasonably expect and the process of optimizing IHT-exercise therapy protocols to maximize the benefits of the emerging technology.
Copyright 2011 Elsevier B.V. All rights reserved.
22. Arch Phys Med Rehabil. 2011 May;92(5):837-40.
Single-lead percutaneous peripheral nerve stimulation for the treatment of hemiplegic shoulder pain: a case report.
Wilson RD, Bennett ME, Lechman TE, Stager KW, Chae J.
Cleveland Functional Electrical Stimulation Center, Case Western Reserve University, Cleveland, OH, USA.
Previous studies demonstrated the efficacy of 6 weeks of a 4-lead percutaneous, peripheral nerve stimulation system in reducing hemiplegic shoulder pain. This case report describes the first stroke survivor treated for 3 weeks with a less complex, single-lead approach. The participant was a 59-year-old male who developed hemiplegic shoulder pain shortly after his stroke 7.5 years prior to study enrollment and was treated with multiple modalities without sustained pain relief. After study enrollment, a single intramuscular lead was placed percutaneously into the deltoid muscle. He was treated 6 hours per day for 3 weeks and the lead was removed. The primary outcome measure was the Brief Pain Inventory (Short-Form) Question 3 (BPI-3), which queries the worst pain in the last week on a 0 to 10 numeric rating scale. At baseline, BPI 3 was an 8. At the end of treatment and at 1 and 4 weeks after treatment was completed, BPI 3 scores were 3, 2, and 2, respectively. Substantial improvements in quality of life measures were also observed. The participant remained infection-free and the lead was removed fully intact. After completing the study protocol, the participant was followed clinically for 13 months posttreatment with complete resolution of hemiplegic shoulder pain. This case report demonstrates the feasibility of a single-lead peripheral nerve stimulation for the treatment of chronic hemiplegic shoulder pain. Additional studies are needed to further demonstrate safety and efficacy, determine optimal dose, define optimal prescriptive parameters, expand clinical indications, and demonstrate long-term effect.
Copyright 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
PMCID: PMC3086727 [Available on 2012/5/1] PMID: 21530732 [PubMed - indexed for MEDLINE]

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