Is functional electrical stimulation effective in improving walking in adults with lower limb impairment due to an upper motor neuron lesion? An umbrella review

PURPOSE

To conduct an umbrella review of systematic reviews on functional electrical stimulation (FES) to improve walking in adults with an upper motor neuron lesion.

METHODS

Five electronic databases were searched, focusing on the effect of FES on walking. The methodological quality of reviews was evaluated using AMSTAR2 and certainty of evidence was established through the GRADE approach.

RESULTS

The methodological quality of the 24 eligible reviews (stroke, n = 16; spinal cord injury (SCI), n = 5; multiple sclerosis (MS); n = 2; mixed population, n = 1) ranged from critically low to high. Stroke reviews concluded that FES improved walking speed through an orthotic (immediate) effect and had a therapeutic benefit (i.e., over time) compared to usual care (low certainty evidence). There was low-to-moderate certainty evidence that FES was no better or worse than an Ankle Foot Orthosis regarding walking speed post 6 months. MS reviews concluded that FES had an orthotic but no therapeutic effect on walking. SCI reviews concluded that FES with or without treadmill training improved speed but combined with an orthosis was no better than orthosis alone. FES may improve quality of life and reduce falls in MS and stroke populations.

CONCLUSION

FES has orthotic and therapeutic benefits. Certainty of evidence was low-to-moderate, mostly due to high risk of bias, low sample sizes, and wide variation in outcome measures. Future trials must be of higher quality, use agreed outcome measures, including measures other than walking speed, and examine the effects of FES for adults with cerebral palsy, traumatic and acquired brain injury, and Parkinson's disease.

Therapeutic effects of functional electrical stimulation on physical performance and muscle strength in post-stroke older adults: a review

Stroke-related disabilities cause poor physical performance, especially among older adults, and can lead to sarcopenia. Functional electrical stimulation (FES) has been used to improve physical performance in individuals with neurological disorders and increase muscle mass and strength to counteract muscle atrophy. This review covers the principles, underlying mechanisms, and therapeutic effects of FES on physical performance and skeletal muscle function in post-stroke older adults. We found that FES restored weakened dorsiflexor and hip abductor strength during the swing and stance phases of gait, respectively, to help support weight-bearing and upright posture and facilitate static and dynamic balance in this population. FES may also be effective in improving muscle mass and strength to prevent muscle atrophy. However, previous studies on this topic in post-stroke older adults are scarce, and further studies are needed to confirm this supposition.

A Clinical Practice Guideline for the Use of Ankle-Foot Orthoses and Functional Electrical Stimulation Post-Stroke

BACKGROUND

Level of ambulation following stroke is a long-term predictor of participation and disability. Decreased lower extremity motor control can impact ambulation and overall mobility. The purpose of this clinical practice guideline (CPG) is to provide evidence to guide clinical decision-making for the use of either ankle-foot orthosis (AFO) or functional electrical stimulation (FES) as an intervention to improve body function and structure, activity, and participation as defined by the International Classification of Functioning, Disability and Health (ICF) for individuals with poststroke hemiplegia with decreased lower extremity motor control.

METHODS

A review of literature published through November 2019 was performed across 7 databases for all studies involving stroke and AFO or FES. Data extracted included time post-stroke, participant characteristics, device types, outcomes assessed, and intervention parameters. Outcomes were examined upon initial application and after training. Recommendations were determined on the basis of the strength of the evidence and the potential benefits, harm, risks, or costs of providing AFO or FES.

RESULTS/DISCUSSION

One-hundred twenty-two meta-analyses, systematic reviews, randomized controlled trials, and cohort studies were included. Strong evidence exists that AFO and FES can each increase gait speed, mobility, and dynamic balance. Moderate evidence exists that AFO and FES increase quality of life, walking endurance, and muscle activation, and weak evidence exists for improving gait kinematics. AFO or FES should not be used to decrease plantarflexor spasticity. Studies that directly compare AFO and FES do not indicate overall superiority of one over the other. But evidence suggests that AFO may lead to more compensatory effects while FES may lead to more therapeutic effects. Due to the potential for gains at any phase post-stroke, the most appropriate device for an individual may change, and reassessments should be completed to ensure the device is meeting the individual's needs.

LIMITATIONS

This CPG cannot address the effects of one type of AFO over another for the majority of outcomes, as studies used a variety of AFO types and rarely differentiated effects. The recommendations also do not address the severity of hemiparesis, and most studies included participants with varied baseline ambulation ability.

SUMMARY

This CPG suggests that AFO and FES both lead to improvements post-stroke. Future studies should examine timing of provision, device types, intervention duration and delivery, longer term follow-up, responders versus nonresponders, and individuals with greater impairments.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for people with poststroke hemiplegia who have decreased lower extremity motor control that impacts ambulation and overall mobility.A Video Abstract is available as supplemental digital content from the authors (available at: http://links.lww.com/JNPT/A335).

Ankle-foot orthoses and continuous functional electrical stimulation improve walking speed after stroke: a systematic review and meta-analyses of randomized controlled trials

BACKGROUND

Foot-drop is a common impairment after stroke, which reduces walking ability.

OBJECTIVE

To examine the efficacy of interventions aimed at reducing foot-drop, i.e., ankle-foot orthoses and functional electrical stimulation, on walking speed and balance after stroke.

DATA SOURCES

MEDLINE, EMBASE, Cochrane, PsycINFO, and PEDro databases.

ELIGIBILITY CRITERIA

The review included only parallel, randomized trials. Participants were ambulatory adults after stroke. The experimental interventions were the use of an ankle-foot orthosis or functional electrical stimulation.

DATA SYNTHESIS

Outcome data related to walking speed and balance were extracted from the eligible trials and combined in random-effects meta-analyses. The quality of trials was assessed by the PEDro scores and the quality of evidence was determined according the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

Eleven trials involving 1135 participants were included. The mean PEDro score of the trials was 5.8 (ranging from 4 to 7). Ankle-foot orthoses (MD 0.24m/s; 95% CI 0.06 to 0.41) and functional electrical stimulation (MD 0.09m/s; 95% CI 0.03 to 0.14) significantly increased walking speed, compared with no intervention/placebo. Results regarding balance were inconclusive. Ankle-foot orthoses were not superior to functional electrical stimulation for improving walking speed (MD 0.00m/s; 95% CI -0.06 to 0.05) or balance (MD 0.27 points on the Berg Balance Scale; 95% CI -0.85 to 1.39) after stroke.

CONCLUSIONS

This systematic review provided moderate-quality evidence that both ankle-foot orthoses and functional electrical stimulation improve walking speed after stroke, but the effects on balance remain unclear.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019130988.

A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions

BACKGROUND

Assistive products are items which allow older people and people with disabilities to be able to live a healthy, productive and dignified life. It has been estimated that approximately 1.5% of the world's population need a prosthesis or orthosis.

OBJECTIVE

The objective of this study was to systematically identify and review the evidence from randomized controlled trials assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions.

METHODS

Literature searches, completed in September 2015, were carried out in fourteen databases between years 1995 and 2015. The search results were independently screened by two reviewers. For the purpose of this manuscript, only randomized controlled trials which examined interventions using orthotic or prosthetic devices were selected for data extraction and synthesis.

RESULTS

A total of 342 randomised controlled trials were identified (319 English language and 23 non-English language). Only 4 of these randomised controlled trials examined prosthetic interventions and the rest examined orthotic interventions. These orthotic interventions were categorised based on the medical conditions/injuries of the participants. From these studies, this review focused on the medical condition/injuries with the highest number of randomised controlled trials (osteoarthritis, fracture, stroke, carpal tunnel syndrome, plantar fasciitis, anterior cruciate ligament, diabetic foot, rheumatoid and juvenile idiopathic arthritis, ankle sprain, cerebral palsy, lateral epicondylitis and low back pain). The included articles were assessed for risk of bias using the Cochrane Risk of Bias tool. Details of the clinical population examined, the type of orthotic/prosthetic intervention, the comparator/s and the outcome measures were extracted. Effect sizes and odds ratios were calculated for all outcome measures, where possible.

CONCLUSIONS

At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high quality research to allow strong conclusions on their effectiveness and cost-effectiveness.

Interventions to Improve Movement and Functional Outcomes in Adult Stroke Rehabilitation: Review and Evidence Summary

Background

Patients who have had a stroke may not be familiar with the terminology nor have the resources to efficiently search for evidence-based rehabilitation therapies to restore movement and functional outcomes. Recognizing that a thorough systematic review on this topic is beyond the scope of this article, we conducted a rapid review evidence summary to determine the level of evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Objective

The objective of this study was to find evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Methods

Medline Complete, PubMed, CINAHL Complete, Cochrane Database, Rehabilitation and Sports Medicine Source, Dissertation Abstracts International, and National Guideline Clearinghouse, from 1996 to April of 2016, were searched. From 348 articles, 173 met the following inclusion criteria: (1) published systematic reviews or meta-analyses, (2) outcomes target functional movement or motor skills of the upper and lower limbs, (3) non-pharmacological interventions that are commonly delivered to post-stroke population (acute and chronic), (4) human studies, and (5) English. Evidence tables were created to analyze the findings of systematic reviews and meta-analyses by category of interventions and outcomes.

Results

This rapid review found that the following interventions possess credible evidence to improve functional movement of persons with stroke: cardiorespiratory training, therapeutic exercise (ie, strengthening), task-oriented training (task-specific training), constraint-induced movement therapy (CIMT), mental practice, and mirror therapy. Neuromuscular electrical stimulation (NMES) (ie, functional electrical stimulation) shows promise as an intervention for stroke survivors.

Conclusions

Most commonly delivered therapeutic interventions to improve motor recovery after a stroke possess moderate quality evidence and are effective. Future research recommendations, such as optimal timing and dosage, would help rehabilitation professionals tailor interventions to achieve the best outcomes for stroke survivors.

Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis

BACKGROUND

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

METHODS

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

RESULTS

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [-0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD -0.10; CI [-0.59, 0.38], n = 35). Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

CONCLUSIONS

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

TRIAL REGISTRATION

PROSPERO: CRD42015025162 , Date:11/08/2015.

Functional Electrical Stimulation for Foot Drop in Multiple Sclerosis: A Systematic Review and Meta-Analysis of the Effect on Gait Speed

OBJECTIVE

To review the efficacy of functional electrical stimulation (FES) used for foot drop in people with multiple sclerosis (pwMS) on gait speed in short and long walking performance tests.

DATA SOURCES

Five databases (Cochrane Library, CINAHL, Embase, MEDLINE, and PubMed) and reference lists were searched.

STUDY SELECTION

Studies of both observational and experimental design where gait speed data in pwMS could be extracted were included.

DATA EXTRACTION

Data were independently extracted and recorded. Methodologic quality was assessed using the Effective Public Health Practice Project tool.

DATA SYNTHESIS

Nineteen studies (described in 20 articles) recruiting 490 pwMS were identified and rated as moderate or weak, with none gaining a strong rating. All studies rated weak for blinding. Initial and ongoing orthotic and therapeutic effects were assessed regarding the effect of FES on gait speed in short and long walking tests. Meta-analyses of the short walk tests revealed a significant initial orthotic effect (t=2.14, P=.016), with a mean increase in gait speed of .05m/s, and ongoing orthotic effect (t=2.81, P=.003), with a mean increase of .08m/s. There were no initial or ongoing effects on gait speed in long walk tests and no therapeutic effect on gait speed in either short or long walk tests.

CONCLUSIONS

FES used for foot drop has a positive initial and ongoing effect on gait speed in short walking tests. Further fully powered randomized controlled trials comparing FES with alternative treatments are required.

A review of the design and clinical evaluation of the ShefStim array-based functional electrical stimulation system

Functional electrical stimulation has been shown to be a safe and effective means of correcting foot drop of central neurological origin. Current surface-based devices typically consist of a single channel stimulator, a sensor for determining gait phase and a cuff, within which is housed the anode and cathode. The cuff-mounted electrode design reduces the likelihood of large errors in electrode placement, but the user is still fully responsible for selecting the correct stimulation level each time the system is donned. Researchers have investigated different approaches to automating aspects of setup and/or use, including recent promising work based on iterative learning techniques. This paper reports on the design and clinical evaluation of an electrode array-based FES system for the correction of drop foot, ShefStim. The paper reviews the design process from proof of concept lab-based study, through modelling of the array geometry and interface layer to array search algorithm development. Finally, the paper summarises two clinical studies involving patients with drop foot. The results suggest that the ShefStim system with automated setup produces results which are comparable with clinician setup of conventional systems. Further, the final study demonstrated that patients can use the system without clinical supervision. When used unsupervised, setup time was 14min (9min for automated search plus 5min for donning the equipment), although this figure could be reduced significantly with relatively minor changes to the design.

Technical developments of functional electrical stimulation to correct drop foot: sensing, actuation and control strategies

This work presents a review on the technological advancements over the last decades of functional electrical stimulation based neuroprostheses to correct drop foot. Functional electrical stimulation is a technique that has been put into practice for several years now, and has been shown to functionally restore and rehabilitate individuals with movement disorders, such as stroke, multiple sclerosis and traumatic brain injury, among others. The purpose of this technical review is to bring together information from a variety of sources and shed light on the field's most important challenges, to help in identifying new research directions. The review covers the main causes of drop foot and its associated gait implications, along with several functional electrical stimulation-based neuroprostheses used to correct it, developed within academia and currently available in the market. These systems are thoroughly analyzed and discussed with particular emphasis on actuation, sensing and control of open- and closed-loop architectures. In the last part of this work, recommendations on future research directions are suggested.

Functional electrical stimulation improves activity after stroke: a systematic review with meta-analysis

OBJECTIVE

To investigate the effect of functional electrical stimulation (FES) in improving activity and to investigate whether FES is more effective than training alone.

DATA SOURCES

Cochrane Central Register of Controlled Trials, Ovid Medline, EBSCO Cumulative Index to Nursing and Allied Health Literature, Ovid EMBASE, Physiotherapy Evidence Database (PEDro), and Occupational Therapy Systematic Evaluation of Effectiveness.

STUDY SELECTION

Randomized and controlled trials up to June 22, 2014, were included following predetermined search and selection criteria.

DATA EXTRACTION

Data extraction occurred by 2 people independently using a predetermined data collection form. Methodologic quality was assessed by 2 reviewers using the PEDro methodologic rating scale. Meta-analysis was conducted separately for the 2 research objectives.

DATA SYNTHESIS

Eighteen trials (19 comparisons) were eligible for inclusion in the review. FES had a moderate effect on activity (standardized mean difference [SMD], .40; 95% confidence interval [CI], .09-.72) compared with no or placebo intervention. FES had a moderate effect on activity (SMD, .56; 95% CI, .29-.92) compared with training alone. When subgroup analyses were performed, FES had a large effect on upper-limb activity (SMD, 0.69; 95% CI, 0.33-1.05) and a small effect on walking speed (mean difference, .08m/s; 95% CI, .02-.15) compared with control groups.

CONCLUSIONS

FES appears to moderately improve activity compared with both no intervention and training alone. These findings suggest that FES should be used in stroke rehabilitation to improve the ability to perform activities.

Feasibility study of a take-home array-based functional electrical stimulation system with automated setup for current functional electrical stimulation users with foot-drop

OBJECTIVE

To investigate the feasibility of unsupervised community use of an array-based automated setup functional electrical stimulator for current foot-drop functional electrical stimulation (FES) users.

DESIGN

Feasibility study.

SETTING

Gait laboratory and community use.

PARTICIPANTS

Participants (N=7) with diagnosis of unilateral foot-drop of central neurologic origin (>6mo) who were regular users of a foot-drop FES system (>3mo).

INTERVENTION

Array-based automated setup FES system for foot-drop (ShefStim).

MAIN OUTCOME MEASURES

Logged usage, logged automated setup times for the array-based automated setup FES system and diary recording of problems experienced, all collected in the community environment. Walking speed, ankle angles at initial contact, foot clearance during swing, and the Quebec User Evaluation of Satisfaction with Assistive Technology version 2.0 (QUEST version 2.0) questionnaire, all collected in the gait laboratory.

RESULTS

All participants were able to use the array-based automated setup FES system. Total setup time took longer than participants' own FES systems, and automated setup time was longer than in a previous study of a similar system. Some problems were experienced, but overall, participants were as satisfied with this system as their own FES system. The increase in walking speed (N=7) relative to no stimulation was comparable between both systems, and appropriate ankle angles at initial contact (N=7) and foot clearance during swing (n=5) were greater with the array-based automated setup FES system.

CONCLUSIONS

This study demonstrates that an array-based automated setup FES system for foot-drop can be successfully used unsupervised. Despite setup's taking longer and some problems, users are satisfied with the system and it would appear as effective, if not better, at addressing the foot-drop impairment. Further product development of this unique system, followed by a larger-scale and longer-term study, is required before firm conclusions about its efficacy can be reached.