Neuromuscular electric stimulation effect on lower-extremity motor recovery and gait kinematics of patients with stroke: a randomized controlled trial

Effects of Stroke Rehabilitation Using Gait Robot-Assisted Training and Person-Centered Goal Setting: A Single Blinded Pilot Study

Many stroke survivors have difficulties due to the mobility and activities required in daily living. A walking impairment negatively affects the independent lifestyle of stroke patients, requiring intensive post-stroke rehabilitation. Therefore, the purpose of this study was to examine the effects of stroke rehabilitation using gait robot-assisted training and person-centered goal setting on mobility, the activities of daily living, stroke self-efficacy, and health-related QoL in stroke patients with hemiplegia. An assessor-blinded quasi-experimental study with a pre-posttest nonequivalent control group was used. Participants who were admitted to the hospital with a gait robot-assisted training system were assigned to the experimental group, and those without gait robots were assigned to the control group. Sixty stroke patients with hemiplegia from two hospitals specialized in post-stroke rehabilitation participated. Stroke rehabilitation using gait robot-assisted training and person-centered goal setting for stroke patients with hemiplegia was conducted for a total of six weeks. There were significant differences between the experimental group and control group in the Functional Ambulation Category (t = 2.89, p = 0.005), balance (t = 3.73, p < 0.001), Timed Up and Go (t = -2.27, p = 0.027), Korean Modified Barthel Index (t = 2.58, p = 0.012), 10 m Walking test (t = -2.27, p = 0.040), stroke self-efficacy (t = 2.23, p = 0.030), and health-related quality of life (t = 4.90, p < 0.001). A gait robot-assisted rehabilitation using goal setting for stroke patients with hemiplegia improved gait ability, balance ability, stroke self-efficacy, and health-related quality of life in stroke patients.

Neuromuscular Electrical Stimulation Improves Activities of Daily Living Post Stroke: A Systematic Review and Meta-analysis

Objectives

(1) To elucidate the effectiveness of neuromuscular electrical stimulation (NMES) toward improving activities of daily living (ADL) and functional motor ability post stroke and (2) to investigate the influence of paresis severity and the timing of treatment initiation for the effectiveness of NMES.

Data Sources

PubMed, MEDLINE, Embase, Physiotherapy Evidence Database (PEDro) and Cochrane Library searched for relevant articles from database inception to May 2020.

Study Selection

The inclusion criteria were randomized controlled trials exploring the effect of NMES toward improving ADL or functional motor ability in survivors of stroke. The search identified 6064 potential articles with 20 being included.

Data Extraction

Two independent reviewers conducted the data extraction. Methodological quality was assessed using the PEDro scale and the Cochrane Risk of Bias Tool.

Data Synthesis

Data from 428 and 659 participants (mean age, 62.4 years; 54% male) for outcomes of ADL and functional motor ability, respectively, were pooled in a random-effect meta-analysis. The analysis revealed a significant positive effect of NMES toward ADL (standardized mean difference [SMD], 0.41; 95% CI, 0.14-0.67; P=.003), whereas no effect on functional motor ability was evident. Subgroup analyses showed that application of NMES in the subacute stage (SMD, 0.44; 95% CI, 0.09-0.78; P=.01) and in the upper extremity (SMD, 0.34; 95% CI, 0.04-0.64; P=.02) improved ADL, whereas a beneficial effect was observed for functional motor abilities in patients with severe paresis (SMD, 0.41; 95% CI, 0.12-0.70; P=.005).

Conclusions

The results of the present meta-analysis are indicative of potential beneficial effects of NMES toward improving ADL post stroke, whereas the potential for improving functional motor ability appears less clear. Furthermore, subgroup analyses indicated that NMES application in the subacute stage and targeted at the upper extremity is efficacious for ADL rehabilitation and that functional motor abilities can be positively affected in patients with severe paresis.

The efficiency of mirror therapy on drop foot in Multiple Sclerosis Patients

INTRODUCTION

Although the effectiveness of mirror therapy (MT) has been proved in stroke persons, there is no scientific evidence about the results in people with multiple sclerosis. The aim was to investigate whether adding MT to exercise training and neuromuscular electrical stimulation (NMES) has any effect on clinical measurements, mobility, and functionality in people with multiple sclerosis (MS).

METHODS

Ambulatory people with MS, with unilateral drop foot, were included. MT group (n = 13) applied bilateral ankle exercise program with mirror following NMES for 3 days a week at hospital and exercise program for 2 days a week at home. Control group (n = 13) performed same treatment without mirror box (6 weeks). The later 6 weeks both groups performed only exercise program. Clinical measurements included proprioception, muscle tone of plantar flexor muscles (MAS), muscle strength of dorsiflexor, ankle angular velocity, and range of motion (ROM) of ankle. Functionality (Functional Independence Measurement-FIM), mobility (Rivermead Mobility Index-RMI), ambulation (Functional Ambulation Scale-FAS), duration of stair climb test, and 25-foot walking velocity were assessed at the beginning, in 6th and 12th weeks.

RESULTS

More positive improvements were obtained in MT group than control group in terms of range of motion (0.012), muscle strength (0.008), proprioception (0.001), 25 feet walking duration (0.015), step test duration (0.001), FAS (0.005), RMI (0.001), and FIM (0.001) after 6 weeks treatment. It was seen that this improvement maintained to 12th week on all clinical and functional measurements (p < .05).

CONCLUSION

The trial revealed that adding MT to exercise training and NMES has more beneficial effects on clinical measurements, mobility, and functionality in people with multiple sclerosis with unilateral drop foot.

Effects of neuromuscular electrical stimulation on gait performance in chronic stroke with inadequate ankle control - A randomized controlled trial

Neuromuscular electrical stimulation (NMES) has been used to improve muscle strength and decrease spasticity of the ankle joint in stroke patients. However, it is unclear how NMES could influence dynamic spasticity of ankle plantarflexors and gait asymmetry during walking. The study aimed to evaluate the effects of applying NMES over ankle dorsiflexors or plantarflexors on ankle control during walking and gait performance in chronic stroke patients. Twenty-five stroke participants with inadequate ankle control were recruited and randomly assigned to an experimental or a control group. The experimental group received 20 minutes of NMES on either the tibialis anterior muscle (NMES-TA) or the medial gastrocnemius muscle (NMES-MG). The control group received 20 minutes of range of motion and stretching exercises. After the 20 minutes of NMES or exercises, all participants received ambulation training for 15 minutes. Training sessions occurred 3 times per week for 7 weeks. The pre- and post-training assessments included spatio-temporal parameters, ankle range of motion, and dynamic spasticity of ankle plantarflexors during walking. Muscle strength of ankle dorsiflexors and plantarflexors as well as static spasticity of ankle plantarflexors were also examined. The results showed that the static and dynamic spasticity of ankle plantarflexors of the NMES-TA group were significantly decreased after training. Reduction in dynamic spasticity of ankle plantarflexors of the NMES-TA group was significantly greater than that of the NMES-MG group. When compared to the control group, the NMES-TA group had greater improvements in spatial asymmetry, ankle plantarflexion during push off, and muscle strength of ankle dorsiflexors, and the NMES-MG group showed a significant decrease in temporal asymmetry. In summary, NMES on ankle dorsiflexors could be an effective management to enhance gait performance and ankle control during walking in chronic stroke patients. NMES on ankle plantarflexors may improve gait symmetry.

Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review

OBJECTIVE

To investigate the effects of various rehabilitative interventions aimed at enhancing poststroke motor recovery by assessing their effectiveness when compared with no treatment or placebo and their superiority when compared with conventional training program (CTP).

DATA SOURCE

A literature search was based on 19 Cochrane reviews and 26 other reviews. We also updated the searches in PubMed up to September 30, 2017.

STUDY SELECTION

Randomized controlled trials associated with 18 experimented training programs (ETP) were included if they evaluated the effects of the programs on either upper extremity (UE) or lower extremity (LE) motor recovery among adults within 6 months poststroke; included ≥10 participants in each arm; and had an intervention duration of ≥10 consecutive weekdays.

DATA EXTRACTION

Four reviewers evaluated the eligibility and quality of literature. Methodological quality was assessed using the PEDro scale.

DATA SYNTHESIS

Among the 178 included studies, 129 including 7450 participants were analyzed in this meta-analysis. Six ETPs were significantly effective in enhancing UE motor recovery, with the standard mean differences (SMDs) and 95% confidence intervals outlined as follow: constraint-induced movement therapy (0.82, 0.45-1.19), electrostimulation (ES)-motor (0.42, 0.22-0.63), mirror therapy (0.71, 0.22-1.20), mixed approach (0.21, 0.01-0.41), robot-assisted training (0.51, 0.22-0.80), and task-oriented training (0.57, 0.16-0.99). Six ETPs were significantly effective in enhancing LE motor recovery: body-weight-supported treadmill training (0.27, 0.01-0.52), caregiver-mediated training (0.64, 0.20-1.08), ES-motor (0.55, 0.27-0.83), mixed approach (0.35, 0.15-0.54), mirror therapy (0.56, 0.13-1.00), and virtual reality (0.60, 0.15-1.05). However, compared with CTPs, almost none of the ETPs exhibited significant SMDs for superiority.

CONCLUSIONS

Certain experimented interventions were effective in enhancing poststroke motor recovery, but little evidence supported the superiority of experimented interventions over conventional rehabilitation.

Efficacy of neuromuscular electrical stimulation for preventing quadriceps muscle wasting in patients with moderate or severe acute stroke: A pilot study

BACKGROUND

Stroke-related muscle wasting is one of the factors leading to long-term disability and functional dependency. No study has reported an effective therapeutic intervention for such muscle wasting.

OBJECTIVE

The purpose of this study was to investigate the effects of neuromuscular electrical stimulation (NMES) on quadriceps muscle mass preservation in patients with acute moderate or severe stroke by using ultrasonography (US).

METHODS

Twenty patients with acute, moderate, or severe stroke (age: 68±11 years) were divided into usual care group (control group) and intervention groups (NMES group), respectively. Patients in the NMES group underwent NMES treatment for bilateral quadriceps muscles for 2 weeks in addition to the usual care. Quadriceps muscle thickness was measured on admission and 2 weeks after the first measurement.

RESULTS

The quadriceps muscle thickness on the paretic and non-paretic sides in the NMES group (-12.4% ±12.7%, -5.5% ±15.3%, respectively) significantly decreased to a lesser degree than that in the control group (-29.5% ±12.1%, P = 0.004; and -22.0% ±16.8%, P = 0.04, respectively).

CONCLUSIONS

NEMS seemed to have preserved the quadriceps muscle mass in patients with moderate or severe acute stroke.

Effectiveness of Faradic and Russian currents on plantar flexor muscle spasticity, ankle motor recovery, and functional gait in stroke patients

BACKGROUND AND PURPOSE

Spasticity is a major disabling symptom in patients post stroke. Though studies have demonstrated that electrical stimulation (ES) can reduce spasticity and improve passive ankle range of motion (ROM), not many studies have evaluated the effectiveness of ES on active ankle ROM. The purpose of this study was to determine the effectiveness of Faradic and Russian currents in the reduction of ankle plantar-flexor spasticity and improving motor recovery in patients post stroke.

METHODS

Eighty-three patients (29 females and 54 males; mean age of 57.12 years) were randomly assigned to Group 1 (task-oriented exercises), Group 2 (Faradic current for 10 min and task-oriented exercises), and Group 3 (Russian current for 10 min and task-oriented exercises) for a period of 5 sessions per week for 6 weeks. All patients were assessed for soleus and gastrocnemius muscles spasticity measured by modified modified Ashworth scale; active and passive range ROM measured by goniometer; and functional ambulation measured by modified Emory Functional Ambulation Profile at the time of recruitment to study and after 6 weeks.

RESULTS

Both the types of stimulation and exercises were not associated with improvements in modified Emory Functional Ambulation Profile (p > 0.05). The results showed that all the groups are effective in improving passive ankle ROM (p < 0.05) and reducing soleus and gastrocnemius muscles spasticity (p < 0.05). Though all the groups were effective in improving active ankle ROM, no group was found to be superior to another after treatment CONCLUSION: Adding ES to exercises are associated with low to medium effect sizes (<0.5) in reducing spasticity and improving ankle ROM.

Neuromuscular Electrical Stimulation for Treatment of Muscle Impairment: Critical Review and Recommendations for Clinical Practice

Purpose: In response to requests from physiotherapists for guidance on optimal stimulation of muscle using neuromuscular electrical stimulation (NMES), a review, synthesis, and extraction of key data from the literature was undertaken by six Canadian physical therapy (PT) educators, clinicians, and researchers in the field of electrophysical agents. The objective was to identify commonly treated conditions for which there was a substantial body of literature from which to draw conclusions regarding the effectiveness of NMES. Included studies had to apply NMES with visible and tetanic muscle contractions. Method: Four electronic databases (CINAHL, Embase, PUBMED, and SCOPUS) were searched for relevant literature published between database inceptions until May 2015. Additional articles were identified from bibliographies of the systematic reviews and from personal collections. Results: The extracted data were synthesized using a consensus process among the authors to provide recommendations for optimal stimulation parameters and application techniques to address muscle impairments associated with the following conditions: stroke (upper or lower extremity; both acute and chronic), anterior cruciate ligament reconstruction, patellofemoral pain syndrome, knee osteoarthritis, and total knee arthroplasty as well as critical illness and advanced disease states. Summaries of key details from each study incorporated into the review were also developed. The final sections of the article outline the recommended terminology for describing practice using electrical currents and provide tips for safe and effective clinical practice using NMES. Conclusion: This article provides physiotherapists with a resource to enable evidence-informed, effective use of NMES for PT practice.

Changes in Quadriceps Muscle Thickness, Disease Severity, Nutritional Status, and C-Reactive Protein after Acute Stroke

BACKGROUND

Lower leg muscle wasting is common in stroke patients; however, patient characteristics in the acute phase are rarely studied. This study aimed to examine the relationship between changes in quadriceps muscle thickness and disease severity, nutritional status, and C-reactive protein (CRP) levels after acute stroke.

METHODS

Thirty-one consecutive patients with acute intracerebral hemorrhage or ischemic stroke had quadriceps muscle thickness measured in the paretic and nonparetic limbs within 1 week after admission (first week) and 2 weeks after the first examination (last week) using ultrasonography. We also determined the relationship between the percentage change in muscle thickness and disease severity, nutritional status, and CRP levels on admission.

RESULTS

There was a significant correlation between changes in muscle thickness for both paretic and nonparetic sides and National Institutes of Health Stroke Scale (NIHSS) scores (paretic limb: r = -.46, P = .01; nonparetic limb: r = -.54, P = .002, respectively); however, there was no significant correlation with nutritional status on admission. Quadriceps muscle thickness was reduced more in the CRP-positive (≥.3 mg/dL) patients than in the CRP-negative (<.3 mg/dL) patients in the nonparetic limb (positive: -21.4 ± 12.1, negative: -11.4 ± 16.4%; P = .039), but not in the paretic limb (positive: -23.4 ± 9.0, negative: -19.1 ± 15.7; P = .27).

CONCLUSIONS

A high NIHSS score and a positive CRP on admission were both significantly correlated with decreased quadriceps muscle thickness after acute stroke. Nutritional status on admission was not correlated with changes in quadriceps muscle thickness for these patients.

Interrater and intrarater reliability and minimal detectable change of the Wisconsin Gait Scale when used to examine videotaped gait in individuals post-stroke

Background

Often, interventions targeting the kinematic and temporal and spatial changes in gait commonly seen after a stroke are based on observations of walking. Having the capacity to objectively identify such changes and track improvements over time using reliable and valid measures is important. The Wisconsin Gait Scale (WGS), which is comprised of 14 items, was developed specifically to examine and document gait changes occurring after a stroke. The purpose of the study was to explore the interrater and intrarater reliability and minimal detectable change (MDC) of the WGS when used by physical therapists to examine gait in adults post-stroke.

Methods

Fourteen physical therapists from 3 different acute inpatient rehabilitation centers rated videotapes of the gait of 6 adults post-stroke using the WGS. To minimize subject variability from fatigue, videotapes created by using 4 cameras provided right and left lateral, anterior, and posterior views of walking on a level surface. One complete ambulation trial from each subject post-stroke, which included 4 views of the same ambulation trial, was examined by the licensed physical therapists using the WGS. An opportunity was provided to review the tool and a practice trial was performed using an additional videotape not included in the analysis. Gait was examined on 2 different occasions separated by a period of approximately 21 days to minimize the effects of recall bias. Intraclass Correlation Coefficients (ICC) were used to examine the interrater and intrarater reliability of the WGS.

Results

Interrater (ICC = 0.83) and intrarater (ICC = 0.91) reliability were both good. The standard error of the measurement (SEM) was 1.47 and the MDC₉₅ was 4.24. There was no statistically significant difference between the scores on the WGS when comparing the 2 different sessions.

Conclusions

The WGS shows promise as an instrument that can make observational gait analysis more reliable. High intrarater reliability and low SEM suggests that the WGS is stable when administered across multiple sessions by the same rater. The ICC for interrater reliability was also good, which suggests that multiple examiners can effectively use the instrument. With minimal training, the physical therapists in the study were able to produce highly reliable results using the WGS to objectively document gait dysfunction.

Full-movement neuromuscular electrical stimulation improves plantar flexor spasticity and ankle active dorsiflexion in stroke patients: a randomized controlled study

Objective:

To investigate whether full-movement neuromuscular electrical stimulation, which can generate full range of movement, reduces spasticity and/or improves motor function more effectively than control, sensory threshold—neuromuscular electrical stimulation, and motor threshold—neuromuscular electrical stimulation in sub-acute stroke patients.

Design:

A randomized, single-blind, controlled study.

Setting:

Physical therapy room and functional assessment room.

Participants:

A total of 72 adult patients with sub-acute post-stroke hemiplegia and plantar flexor spasticity.

Method:

Patients received 30-minute sessions of neuromuscular electrical stimulation on the motor points of the extensor hallucis and digitorum longus twice a day, five days per week for four weeks.

Measures:

Composite Spasticity Scale, Ankle Active Dorsiflexion Score, and walking time in the Timed Up and Go Test were assessed at pretreatment, posttreatment, and at two-week follow-up.

Results:

After four weeks of treatment, when comparing interclass pretreatment and posttreatment, only the full-movement neuromuscular electrical stimulation group had a significant reduction in the Composite Spasticity Scale (mean % reduction = 19.91(4.96)%, F = 3.878, p < 0.05) and improvement in the Ankle Active Dorsiflexion Score (mean scores = 3.29(0.91), F = 3.140, p < 0.05). Furthermore, these improvements were maintained two weeks after the treatment ended. However, there were no significant differences in the walking time after four weeks of treatment among the four groups (F = 1.861, p > 0.05).

Conclusions:

Full-movement neuromuscular electrical stimulation with a stimulus intensity capable of generating full movement can significantly reduce plantar flexor spasticity and improve ankle active dorsiflexion, but cannot decrease walking time in the Timed Up and Go Test in sub-acute stroke patients.

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

BACKGROUND

Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

METHODS AND FINDINGS

Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

CONCLUSIONS

There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.

Effectiveness of thermal stimulation for the moderately to severely paretic leg after stroke: serial changes at one-year follow-up

Liang C-C, Hsieh T-C, Lin C-H, Wei Y-C, Hsiao J, Chen J-C. Effectiveness of thermal stimulation for the moderately to severely paretic leg after stroke: serial changes at one-year follow-up.

OBJECTIVE

To evaluate the serial changes of long-term effects of thermal stimulation (TS) on acute stroke patients.

DESIGN

A prospective study with follow-up at 3, 6, and 12 months after TS to assess motor and balance function of the paretic leg of acute stroke patients.

SETTING

A general hospital rehabilitation department.

PARTICIPANTS

Poststroke patients (N=30) with moderate to severe impairment of leg function.

INTERVENTIONS

In addition to receiving standard rehabilitation, eligible patients were randomly assigned to a TS group (5 thermal stimulations per week for 6wk) or a control group (3 consultations per week for 6wk).

MAIN OUTCOME MEASURES

Fugl-Meyer lower extremity score, Medical Research Council Scale for the Lower Extremity, Berg Balance Scale, Modified Motor Assessment Scale, Functional Ambulation Classification, and Barthel Index were administered at baseline, after 4 and 6 weeks of treatment, and at the 3-, 6-, and 12-month follow-up.

RESULTS

No significant differences were found between the 2 groups at baseline. After TS, the Fugl-Meyer lower extremity score, Medical Research Council Scale for the Lower Extremity, Modified Motor Assessment Scale, and Functional Ambulation Classification were significantly better in the TS group, and the effects persisted for 3 months (P<.05). Significant differences were found between the 2 groups for the Berg Balance Scale and Barthel Index only at the 3-month follow-up (P<.05). However, all the effects except for the Fugl-Meyer lower extremity score had disappeared at the 6-month follow-up (P>.05).

CONCLUSIONS

The long-term benefits of TS for patients with acute stroke may be sustained for 3 months but disappear by the 6-month and 1-year follow-up.

Facilitation of motor and balance recovery by thermal intervention for the paretic lower limb of acute stroke: a single-blind randomized clinical trial

OBJECTIVE

To evaluate the effectiveness of thermal stimulation accompanied by either active or passive movement added to standard rehabilitation in facilitating motor and balance function of the paretic leg of acute stroke.

DESIGN

Pilot, observer-blinded, randomized clinical trial.

SETTING

Department of rehabilitation medicine in a general hospital.

SUBJECTS

Thirty-six patients were enrolled within four weeks of the onset of a stroke causing moderate to severe leg paresis (Brunnstrom stage ≤III).

INTERVENTIONS

Patients were randomly assigned to thermal (standard rehabilitation plus approximately 30-40 minutes of thermal stimulation therapy daily for six weeks) and control (standard rehabilitation only) groups.

MAIN MEASURES

Fugl-Meyer lower extremity score, Medical Research Council scale for lower extremity, Modified Motor Assessment Scale, Postural Assessment Scale for Stroke Patients Trunk Control, Berg Balance Scale, Functional Ambulation Classification and Modified Ashworth Scale.

RESULTS

Patients in the thermal group experienced significantly better median scores for Fugl-Meyer lower extremity (14.0; interquartile range, 10.5-15.5), Medical Research Council scale for lower extremity (6.0; 4.0-7.0), Modified Motor Assessment Scale (16.0; 12.5-18.5), Berg Balance Scale (28.0; 20.5-33.5), and Functional Ambulation Classification (2.0; 2.0-2.0) (all P < 0.05). The thermal group also had more independent walkers (15/17; 88.2%) than the control group (9/16; 56.3%) after six weeks (P = 0.06). No adverse effect occurred.

CONCLUSIONS

Thermal stimulation accompanied by either manual facilitation or encouragement for active participation of the paretic lower limb may be an effective promising supplementary treatment for the early-phase rehabilitation of moderate to severe stroke that warrants additional study.

Effects of combining electric stimulation with active ankle dorsiflexion while standing on a rocker board: a pilot study for subjects with spastic foot after stroke

OBJECTIVE

To investigate the therapeutic effects of combining electric stimulation (ES) with active ankle dorsiflexion while standing on a rocker board in subjects with plantarflexor spasticity after stroke.

DESIGN

Randomized controlled trial.

SETTING

A rehabilitation medical center.

PARTICIPANTS

Subjects (N=15) with spastic foot after stroke.

INTERVENTIONS

Subjects were randomly assigned to an experimental or a control group. The experimental group received ES of ankle dorsiflexors in concert with a motor training paradigm that required the subject to dorsiflex the ankles in response to a cue while standing on a rocker board. After 30 minutes of this exercise, subjects received ambulation training focusing on ankle control for 15 minutes. The control group received general range of motion and strength exercises for 30 minutes, followed by 15 minutes of ambulation training focusing on ankle control. Sessions occurred 3 times a week for 4 weeks.

MAIN OUTCOME MEASURES

Dynamic spasticity of plantarflexors, dorsiflexor muscle strength, balance performance, gait kinematics, and functional gait performance as assessed by the Emory Functional Ambulation Profile (EFAP) were used as outcome measurements.

RESULTS

The experimental group demonstrated a greater decrease in dynamic ankle spasticity at a comfortable gait speed (P=.049), a greater improvement in spatial gait symmetry (P=.015), and a greater improvement in functional gait ability as indicated by the EFAP (P=.015) than the control group.

CONCLUSIONS

Our results suggest that repeated ES with volitional ankle movements can decrease dynamic ankle spasticity in subjects with stroke. Furthermore, such improvement parallels better gait symmetry and functional gait performance.

A three-dimensional biomechanical evaluation of quadriceps and hamstrings function using electrical stimulation

Neurological disorders such as stroke impair locomotor control and result in abnormal 3-D gait kinematics. Establishment of effective rehabilitation strategies requires an understanding of how individual muscles contribute to pathological movement. Forward dynamic simulations account for complexities of interjoint coupling and can be used to predict dynamic muscle function. However to date, limited experimental validations of dynamic models have been performed. Our objective was to measure 3-D movement induced by the biceps femoris (BF), rectus femoris (RF), and vastus lateralis (VL) in limb configurations corresponding to the swing phase of gait, and to assess the biomechanical factors that affect dynamic function. Subjects were positioned in a robotic gait orthosis that included a compliant interface. Electrical stimulation was introduced into individual muscles while induced hip and knee joint movements were recorded. Measured hip to knee sagittal plane acceleration ratios were consistent with dynamic musculoskeletal model simulations. However RF and VL induced substantially larger frontal plane hip movements than model-based predictions. Sensitivity analyses on musculoskeletal model parameters revealed that muscle function depends primarily on moment arm assumptions. Though generic musculoskeletal models are suitable for predicting sagittal plane muscle function, improvements in moment arm accuracy are essential for investigation of 3-D pathological gait.

The effects of balance training on gait late after stroke: a randomized controlled trial

OBJECTIVE

To investigate the effects of balance training, using force platform biofeedback, on quantitative gait characteristics of hemiparetic patients late after stroke.

DESIGN

Randomized, controlled, assessor-blinded trial.

SETTING

Rehabilitation ward and gait laboratory of a university hospital.

SUBJECTS

Forty-one patients (mean (standard deviation; SD) age of 60.9 (11.7) years) with hemiparesis late after stroke (median time since stroke six months) were randomly assigned to an experimental or a control group.

INTERVENTIONS

The control group (n = 19) participated in a conventional stroke inpatient rehabilitation programme, whereas the experimental group (n = 22) received 15 sessions of balance training (using force platform biofeedback) in addition to the conventional programme.

MAIN OUTCOME MEASURES

Selected paretic side time-distance, kinematic and kinetic gait parameters in sagittal, frontal and transverse planes were measured using a three-dimensional computerized gait analysis system, one week before and after the experimental treatment programme.

RESULTS

The control group did not show any statistically significant difference regarding gait characteristics. Pelvic excursion in frontal plane improved significantly (P = 0.021) in the experimental group. The difference between before-after change scores of the groups was significant for pelvic excursion in frontal plane (P = 0.039) and vertical ground reaction force (P = 0.030) in favour of experimental group.

CONCLUSION

Balance training using force platform biofeedback in addition to a conventional inpatient stroke rehabilitation programme is beneficial in improving postural control and weight-bearing on the paretic side while walking late after stroke.