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

Effects of end-effector robotic arm reach training with functional electrical stimulation for chronic stroke survivors

BACKGROUND

Upper-extremity dysfunction significantly affects dependence in the daily lives of stroke survivors, limiting their participation in the social environment and reducing their quality of life.

OBJECTIVES

This study aimed to investigate the effect of end-effector robotic arm reach training (RAT) with functional electrical stimulation (FES) on upper-limb motor recovery in chronic stroke survivors.

METHODS

In this single-blinded randomized controlled trial, 28 chronic stroke survivors were randomized to receive RAT-with-FES and RAT-without-FES for 40 min/day, three times per week over a 4-week period, and the data of 26 participants were used in the final analysis. Upper-limb motor recovery was measured using the Fugl-Meyer assessment (FMA), and kinematics (movement time, speed, and distance) during reaching movements toward targets placed in three directions (ipsilateral, median, and contralateral sides) were measured using a robotic arm.

RESULTS

The upper-limb motor recovery (FMA and kinematics) improvement for the within-group comparisons tended to be greater in the RAT-with-FES group than in the RAT-without-FES group. However, in the between-group comparison, no significant differences were found in FMA, and significant differences were observed only for 2 distance parameters of kinematic factors: total (23.0% vs. 1.7%) and straight total (25.5% vs. 2.6%) distance on the ipsilateral side (p < 0.05).

CONCLUSIONS

This study was unable to clearly reveal the positive effects of electrical stimulation combined with robotic arm training. However, we believe that it provides basic data that furthers our understanding of the role of hybrid neuroprostheses in stroke rehabilitation and the factors determining successful treatment.

A new modular neuroprosthesis suitable for hybrid FES-robot applications and tailored assistance

BACKGROUND

To overcome the application limitations of functional electrical stimulation (FES), such as fatigue or nonlinear muscle response, the combination of neuroprosthetic systems with robotic devices has been evaluated, resulting in hybrid systems that have promising potential. However, current technology shows a lack of flexibility to adapt to the needs of any application, context or individual. The main objective of this study is the development of a new modular neuroprosthetic system suitable for hybrid FES-robot applications to meet these needs.

METHODS

In this study, we conducted an analysis of the requirements for developing hybrid FES-robot systems and reviewed existing literature on similar systems. Building upon these insights, we developed a novel modular neuroprosthetic system tailored for hybrid applications. The system was specifically adapted for gait assistance, and a technological personalization process based on clinical criteria was devised. This process was used to generate different system configurations adjusted to four individuals with spinal cord injury or stroke. The effect of each system configuration on gait kinematic metrics was analyzed by using repeated measures ANOVA or Friedman's test.

RESULTS

A modular NP system has been developed that is distinguished by its flexibility, scalability and personalization capabilities. With excellent connection characteristics, it can be effectively integrated with robotic devices. Its 3D design facilitates fitting both as a stand-alone system and in combination with other robotic devices. In addition, it meets rigorous requirements for safe use by incorporating appropriate safety protocols, and features appropriate battery autonomy, weight and dimensions. Different technological configurations adapted to the needs of each patient were obtained, which demonstrated an impact on the kinematic gait pattern comparable to that of other devices reported in the literature.

CONCLUSIONS

The system met the identified technical requirements, showcasing advancements compared to systems reported in the literature. In addition, it demonstrated its versatility and capacity to be combined with robotic devices forming hybrids, adapting well to the gait application. Moreover, the personalization procedure proved to be useful in obtaining various system configurations tailored to the diverse needs of individuals.

Mapping the development process of transcutaneous neuromuscular electrical stimulation devices for neurorehabilitation, the associated barriers and facilitators, and its applicability to acquired dysarthria: a qualitative study of manufacturers' perspectives

PURPOSE

The fragmented nature of the medical device market limits our understanding of how particular sub-markets navigate the device development process. Despite the widespread use of transcutaneous neuromuscular electrical stimulation (NMES), its use for acquired dysarthria treatment has not been sufficiently explored. This study aims to provide a preliminary understanding of the stages involved in the development of NMES devices designed for neurorehabilitation. It also aims to investigate manufacturers' perceptions concerning factors that facilitate or impede its development and determine its applicability for acquired dysarthria.

MATERIALS AND METHODS

In-depth semi-structured online interviews were conducted with eight NMES device manufacturers located across Europe, North America and Oceania. The interviews were video-recorded, automatically transcribed, manually reviewed, and analysed using a qualitative content analysis.

RESULTS

NMES device development for neurorehabilitation involves six complex phases with sequential and overlapping activities. Some emerging concepts were comparable to established medical device models, while others were specific to NMES. Its adaptability to different neurological disorders, the positive academia-industry collaborations, the industry's growth prospects and the promising global efforts for standardised regulations are all key facilitators for its development. However, financial, political, regulatory, and natural constraints emerged as barriers. Indications and challenges for the applicability of NMES for acquired dysarthria treatment were also discussed.

CONCLUSION

The findings provide a foundation for further investigations on the NMES market sub-sector, particularly in the context of neurorehabilitation. The study also provides insights into the potential adoption of NMES for acquired dysarthria, which can serve as a reference for future research.

Electrotherapy in stroke rehabilitation can improve lower limb muscle characteristics: a systematic review and meta-analysis

PURPOSE

This review assesses the effect of electrotherapy (e.g. functional electrical stimulation (FES), motor and sensor therapeutic electrical stimulation (TES)) on muscle strength and skeletal muscle characteristics in individuals post-stroke compared to conventional or sham therapy.

METHODS

A systematic literature search was conducted in MEDLINE, SCOPUS, and Web of Science, focusing on randomized controlled trials investigating the effect of electrotherapy. Data of interest was extracted from eligible studies, and risk of bias was assessed.

RESULTS

In total, 23 studies (933 people post-stroke) were included, of which 17, which mainly focus on patients in a chronic stage of stroke recovery and the implementation of FES, were incorporated in the meta-analysis. A significant increase in muscle strength was found favoring electrotherapy over conventional therapy (SMD 0.63, 95% CI 0.34-0.91, I2 = 37%, p = 0.07) and over sham therapy (SMD 0.44, 95% CI 0.20-0.68, I2 = 38%, p = 0.08). Three studies investigated the effect on muscle thickness and found a significant increase in favor of electrostimulation when compared to conventional therapy (MD 0.11 cm, 95% CI 0.06-0.16, I2 = 0%, p = 0.50).

CONCLUSION

Current evidence suggests electrotherapy in combination with physiotherapy has positive effects on lower limb muscle strength and skeletal muscle characteristics in patients recovering from stroke.

Rehabilitative effects of electrical stimulation on gait performance in stroke patients: A systematic review with meta-analysis

BACKGROUND

Electrical stimulation techniques are widely utilized for rehabilitation management in individuals with stroke patients.

OBJECTIVES

This review aims to summarize the rehabilitative effects of electrical stimulation therapy on gait performance in stroke patients.

METHODS

This review included randomized controlled trials (RCT) investigating the therapeutic effects of electrical stimulation in stroke patients throughout five databases. This review qualitatively synthesized 20 studies and quantitatively analyzed 11 RCTs.

RESULTS

Functional electrical stimulation (FES) was the most commonly used electrical stimulation type to improve postural stability and gait performance in stroke patients. The clinical measurement tools commonly used in the three studies to assess the therapeutic effects of FES were Berg balance scale (BBS), 10-meter walk test (10MWT), 6-minute walk test (6mWT), and gait velocity. The BBS score and gait velocity had positive effects in the FES group compared with the control group, but the 10MWT and 6mWT showed the same effects between the two groups. The heterogeneity of BBS scores was also high.

CONCLUSION

The results of this review suggest that electrical stimulation shows little evidence of postural stability and gait performance in stroke patients, although some electrical stimulations showed positive effects on postural stability and gait performance.

High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) impacts activities of daily living of patients with post-stroke cognitive impairment: a systematic review and meta-analysis

OBJECTIVE

To systematically evaluate the impact of high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) on activities of daily living (ADLs) of patients with post-stroke cognitive impairment (PSCI).

DATA SOURCES

Relevant studies published as of November 2022 (English and Chinese) were searched in Web of Science, PubMed, Embase, Cochrane Library, OVID, China Science and Technology Journal Database (VIP), Wanfang, Chinese National Knowledge Infrastructure (CNKI), and SinoMed databases.

REVIEW METHODS

Randomized controlled trials (RCTs) that used HF-rTMS for the treatment of ADLs in patients with PSCI were included in this meta-analysis. Two reviewers independently screened literature, extracted the data, evaluated the risk of bias using the Cochrane Risk of Bias Tool, and cross-checked.

RESULTS

Forty-one RCTs involving 2855 patients with PSCI were included. In 30 RCTs, the experimental group received HF-rTMS in addition to the interventions used in the control group. In 11 RCTs, the experimental group received HF-rTMS while the control group received sham-rTMS. Barthel Index (BI), Modified Barthel Index (MBI), and Functional Independence Measure (FIM) were higher in the HF-rTMS group than in the control group, whereas scores of Blessed Behavior Scale was lower in the HF-rTMS group than in the control group. All P < 0.05. In 36 studies, the stimulation sites were on the dorsolateral prefrontal cortex (DLPFC).

CONCLUSION

HF-rTMS can ameliorate ADLs of patients with PSCI and has a better rehabilitation effect on PSCI.

A national survey of evidence-based stroke rehabilitation intervention use in clinical practice among Canadian occupational therapists

BACKGROUND: More than 1,000 randomized controlled trials have been published examining the effectiveness of stroke rehabilitation interventions. OBJECTIVE: The objective of this study was to explore the use and non-use of evidence-based stroke rehabilitation interventions in clinical practice among Occupational Therapists across various stroke rehabilitation settings in Canada. METHODS: Participants were recruited from medical centres providing rehabilitation to stroke patients in each of the ten provinces across Canada (January-July 2021). Adult (18 + years) Occupational Therapists who provide direct rehabilitative care to individuals after a stroke completed a survey in either English or French. Therapists rated their awareness, use, and reasons for non-use of stroke rehabilitation interventions. RESULTS: 127 therapists (female = 89.8%), largely from Ontario or Quebec (62.2%) were included; most worked full-time (80.3%) in moderate-large (86.1%) cities. The greatest use of interventions were those applied to the body peripherally, without a technological component. Few individuals were aware of interventions applied to the brain (priming or stimulating) with a technological component, and they were rarely, if ever, used. CONCLUSION: Significant efforts should be made to increase the awareness of interventions which are supported by strong evidence through knowledge translation and implementation initiatives, particularly for those with a technological component.

Constant Load Pedaling Exercise Combined with Electrical Muscle Stimulation Leads to an Early Increase in Sweat Lactate Levels

A novel exercise modality combined with electrical muscle stimulation (EMS) has been reported to increase cardiovascular and metabolic responses, such as blood lactate concentration. We aimed to examine the effect of constant load pedaling exercise, combined with EMS, by non-invasively and continuously measuring sweat lactate levels. A total of 22 healthy young men (20.7 ± 0.8 years) performed a constant load pedaling exercise for 20 min at 125% of the pre-measured ventilatory work threshold with (EMS condition) and without (control condition) EMS stimulation. Blood lactate concentration was measured by blood samples obtained from the earlobe every minute. Sweat lactate was monitored in real time using a sensor placed on the forearm. The sweat lactate threshold (sLT) was defined as the point of increase in sweat lactate. sLT occurred significantly earlier in the EMS condition than in the control condition. In the single regression analysis, the difference in sLT between the two conditions, as the independent variable, was a significant predictor of the difference in blood lactate concentrations at the end of the exercise (p < 0.05, r = −0.52). Sweat lactate measurement may be a noninvasive and simple alternative to blood lactate measurement to determine the effectiveness of exercise combined with EMS.

Usability of Functional Electrical Stimulation in Upper Limb Rehabilitation in Post-Stroke Patients: A Narrative Review

Stroke leads to significant impairment in upper limb (UL) function. The goal of rehabilitation is the reestablishment of pre-stroke motor stroke skills by stimulating neuroplasticity. Among several rehabilitation approaches, functional electrical stimulation (FES) is highlighted in stroke rehabilitation guidelines as a supplementary therapy alongside the standard care modalities. The aim of this study is to present a comprehensive review regarding the usability of FES in post-stroke UL rehabilitation. Specifically, the factors related to UL rehabilitation that should be considered in FES usability, as well a critical review of the outcomes used to assess FES usability, are presented. This review reinforces the FES as a promising tool to induce neuroplastic modifications in post-stroke rehabilitation by enabling the possibility of delivering intensive periods of treatment with comparatively less demand on human resources. However, the lack of studies evaluating FES usability through motor control outcomes, specifically movement quality indicators, combined with user satisfaction limits the definition of FES optimal therapeutical window for different UL functional tasks. FES systems capable of integrating postural control muscles involving other anatomic regions, such as the trunk, during reaching tasks are required to improve UL function in post-stroke patients.