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.

A Brain Computer Interface Neuromodulatory Device for Stroke Rehabilitation: Iterative User-Centered Design Approach

BACKGROUND

Rehabilitation technologies for people with stroke are rapidly evolving. These technologies have the potential to support higher volumes of rehabilitation to improve outcomes for people with stroke. Despite growing evidence of their efficacy, there is a lack of uptake and sustained use in stroke rehabilitation and a call for user-centered design approaches during technology design and development. This study focuses on a novel rehabilitation technology called exciteBCI, a complex neuromodulatory wearable technology in the prototype stage that augments locomotor rehabilitation for people with stroke. The exciteBCI consists of a brain computer interface, a muscle electrical stimulator, and a mobile app.

OBJECTIVE

This study presents the evaluation phase of an iterative user-centered design approach supported by a qualitative descriptive methodology that sought to (1) explore users' perspectives and experiences of exciteBCI and how well it fits with rehabilitation, and (2) facilitate modifications to exciteBCI design features.

METHODS

The iterative usability evaluation of exciteBCI was conducted in 2 phases. Phase 1 consisted of 3 sprint cycles consisting of single usability sessions with people with stroke (n=4) and physiotherapists (n=4). During their interactions with exciteBCI, participants used a "think-aloud" approach, followed by a semistructured interview. At the end of each sprint cycle, device requirements were gathered and the device was modified in preparation for the next cycle. Phase 2 focused on a "near-live" approach in which 2 people with stroke and 1 physiotherapist participated in a 3-week program of rehabilitation augmented by exciteBCI (n=3). Participants completed a semistructured interview at the end of the program. Data were analyzed from both phases using conventional content analysis.

RESULTS

Overall, participants perceived and experienced exciteBCI positively, while providing guidance for iterative changes. Five interrelated themes were identified from the data: (1) "This is rehab" illustrated that participants viewed exciteBCI as having a good fit with rehabilitation practice; (2) "Getting the most out of rehab" highlighted that exciteBCI was perceived as a means to enhance rehabilitation through increased engagement and challenge; (3) "It is a tool not a therapist," revealed views that the technology could either enhance or disrupt the therapeutic relationship; and (4) "Weighing up the benefits versus the burden" and (5) "Don't make me look different" emphasized important design considerations related to device set-up, use, and social acceptability.

CONCLUSIONS

This study offers several important findings that can inform the design and implementation of rehabilitation technologies. These include (1) the design of rehabilitation technology should support the therapeutic relationship between the patient and therapist, (2) social acceptability is a design priority in rehabilitation technology but its importance varies depending on the use context, and (3) there is value in using design research methods that support understanding usability in the context of sustained use.

Peripheral electrical stimulation on neuroplasticity and motor function in stroke patients: a systematic review and meta-analysis

INTRODUCTION

The use of electrotherapy has been presented as a great resource for the professional physiotherapist in the most diverse pathologies. Stroke is a neurological condition responsible for sequelae such as hemiplegia that directly impair the quality of life of patients.

OBJECTIVE

This study aimed to review the literature on the effects of electrotherapeutic resources on motor function and neuroplasticity in individuals with post-stroke sequelae.

MATERIALS AND METHODS

2427 articles were found in databases according to search criteria for each base according to the included descriptors (EndNote Web). After exclusion of duplicate articles, automatically and manually, Phase 1 was performed - reading of titles and abstracts of 1626 articles according to eligibility criteria by two blinded reviewers using the programme Rayyan QCRI (Qatar Computing Research Institute), conflicts were resolved in consensus between the two reviewers. Thus, 13 articles were selected for Phase 2-13 articles were selected for reading in full, leaving 8 articles in this review. To assess the quality of bias of the selected studies, the PEDro Scale was used.

RESULTS

In the assessment of neuroplasticity, statistically significant results were found in two studies (p < 0.05). However, the effects of electrostimulation stood out significantly in the motor function of these individuals (p < 0.05). It can be considered with neuroplasticity, since improved functionality can be related to electrostimulation-induced neuroplasticity. Conclusions Electrostimulation is able to promote neuroplasticity and increase motor function, generating positive effects in the treatment of individuals with post-stroke sequelae.

Development and Validation of a Closed-Loop Functional Electrical Stimulation-Based Controller for Gait Rehabilitation Using a Finite State Machine Model

Functional electrical stimulation (FES) can be used to initiate lower limb muscle contractions and has been widely applied in gait rehabilitation. Establishing the correct timing of FES activation during each phase of the gait (walking) cycle remains challenging as most FES systems rely on open-loop control, whereby the controller receives no feedback about joint kinematics and instead relies on predetermined/timed muscle stimulation. The objective of this study was to develop and validate a closed-loop FES-based control solution for gait rehabilitation using a finite state machine (FSM) model. A two-phased study approach was taken: (1) Experimentally-Informed Study: A neuromuscular-derived FSM model was developed to drive closed-loop FES-based control for gait rehabilitation. The finite states were determined using electromyography and joint kinematics data of 12 non-disabled adults, collected during treadmill walking. The gait cycles were divided into four states, namely: swing-to-stance, push off, pre-swing, and toe up. (2) Simulation Study: A closed-loop FES-based control solution that employed the resulting FSM model, was validated through comparisons of neuro-musculo-skeletal computer simulations of impaired versus healthy gait. This closed-loop controller yielded steadier simulated impaired gait, in comparison to an open-loop alternative. The simulation results confirmed that accurate timing of FES activation during the gait cycle, as informed by kinematics data, is important to natural gait retraining. The closed-loop FES-based solution, introduced in this study, contributes to the repository of gait rehabilitation control options and offers the advantage of being simplistic to implement. Furthermore, this control solution is expected to integrate well with powered exoskeleton technologies.

Spatiotemporal, kinematic and kinetic assessment of the effects of a foot drop stimulator for home-based rehabilitation of patients with chronic stroke: a randomized clinical trial

Background

Gait disability affects the daily lives of patients with stroke in both home and community settings. An abnormal foot–ankle position can cause instability on the supporting surface and negatively affect gait. Our research team explored the ability of a portable peroneal nerve-targeting electrical stimulator to improve gait ability by adjusting the foot–ankle position during walking in patients with chronic stroke undergoing home-based rehabilitation.

Methods

This was a double-blinded, parallel-group randomized controlled trial. Thirty-one patients with chronic stroke and ankle–foot motor impairment were randomized to receive 3 weeks of gait training, which involved using the transcutaneous peroneal nerve stimulator while walking (tPNS group; n = 16, mean age: 52.25 years), or conventional home and/or community gait training therapy (CT group; n = 15, mean age: 54.8 years). Functional assessments were performed before and after the 3-week intervention. The outcome measures included spatiotemporal gait parameters, three-dimensional kinematic and kinetic data on the ankle–foot joint, and a clinical motor and balance function assessment based on the Fugl–Meyer Assessment of Lower Extremity (FMA-LE) and Berg Balance scales (BBS). Additionally, 16 age-matched healthy adults served as a baseline control of three-dimensional gait data for both trial groups.

Results

The FMA-LE and BBS scores improved in both the tPNS groups (p = 0.004 and 0.001, respectively) and CT groups (p = 0.034 and 0.028, respectively) from before to after training. Participants in the tPNS group exhibited significant differences in spatiotemporal gait parameters, including double feet support, stride length, and walking speed of affected side, and the unaffected foot off within a gait cycle after training (p = 0.043, 0.017, 0.001 and 0.010, respectively). Additionally, the tPNS group exhibited significant differences in kinematic parameters, such as the ankle angle at the transverse plane (p = 0.021) and foot progression angle at the frontal plane (p = 0.009) upon initial contact, and the peak ankle joint angle at the transverse plane (p = 0.023) and foot progression angle (FPA) at the frontal and transverse planes (p = 0.032 and 0.046, respectively) during gait cycles after 3 weeks of training.

Conclusions

Use of a portable tPNS device during walking tasks appeared to improve spatiotemporal gait parameters and ankle and foot angles more effectively than conventional home rehabilitation in patients with chronic stroke. Although guidelines for home-based rehabilitation training services and an increasing variety of market devices are available, no evidence for improvement of motor function and balance was superior to conventional rehabilitation.

Trial registration Chictr, ChiCTR2000040137. Registered 22 November 2020, https://www.chictr.org.cn/showproj.aspx?proj=64424

Effect of functional electrical stimulation combined with stationary cycling and sit to stand training on mobility and balance performance in a patient with traumatic brain injury: A case report

INTRODUCTION AND IMPORTANCE

This case study investigates the effects of functional electrical stimulation, stationary cycling, and sit-to-stand training in a patient with severe chronic traumatic brain injury.

CASE PRESENTATION

The participant was a 24-year-old man with a traumatic brain injury two years prior to the intervention described in this case report. The accident caused right hemiplegia, right foot drop, aphasia, and poor coordination of movement in both upper and lower limbs. He was using a wheeled walker for functional mobility and was receiving routine rehabilitation before the initiation of treatment. A four week intervention in this study included functional electrical stimulation of the quadriceps and tibialis anterior muscles combined with stationary cycling and sit-to-stand training.

CLINICAL DISCUSSION

Active and passive range of motion of right ankle dorsiflexion, strength of ankle dorsiflexor, balance performance, and mobility were measured before and after the intervention. Active range of motion of right ankle dorsiflexion increased by 8°. In addition, manual muscle test and Brief-BESTest scores increased from 3+ to 5 and from 7 to 9, respectively. Walking speed over the 10-m distance and timed up and go test score improved.

CONCLUSION

Functional electrical stimulation combined with stationary cycling and sit-to-stand training resulted in increased muscle strength and range of motion, improved balance performance, and improved mobility in an individual with a traumatic brain injury.

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.

Application of neuromuscular electrical stimulation on the support limb during reactive balance control in persons with stroke: a pilot study

The aim of the present study was to investigate the effect of the application of neuromuscular electrical stimulation to the quadriceps muscle of the paretic limb during externally induced stance perturbations on reactive balance control and on fall outcomes in people with chronic stroke. Ten participants experienced 12 stance treadmill perturbation trails, 6 forward balance perturbation trials and 6 backward balance perturbation trials. For each perturbation condition, three perturbation trials were delivered synchronized with neuromuscular electrical stimulation applied to the quadriceps of the paretic limb and three perturbation trials were delivered without stimulation. Behavioral outcome measures, such as incidence of laboratory falls and number of compensatory steps, kinematic outcome measures, such as margin of stability and minimum hip high values after the perturbation, step initiation time, step execution time and step length of the stepping leg were analyzed. The application of neuromuscular electrical stimulation on the paretic quadriceps between the range of 50 and 500 ms after stance forward and backward perturbations reduced the laboratory falls incidence (p < 0.05), improved stability values (p < 0.05) and reduced the hip height descent (p < 0.05) compared to the experimental condition in which participants were exposed to stance perturbations without neuromuscular electrical stimulation. Additionally, step initiation time of the recovery step was lower in neuromuscular electrical stimulation condition during the forward balance perturbation protocol. Our results showed that the application of neuromuscular electrical stimulation on the knee extensor muscles of the paretic limb reduces the incidence of laboratory falls, enhances reactive stability control and reduces vertical limb collapse after stance forward and backward perturbations in people with chronic stroke.

Trends and Technologies in Rehabilitation of Foot Drop: A Systematic Review

INTRODUCTION

Foot Drop (FD) is a condition, which is very commonly found in post-stoke patients; however it can also be seen in patients with multiple sclerosis, and cerebral palsy. It is a sign of neuromuscular damage caused by the weakness of the muscles. There are various approaches of FD's rehabilitation, such as physiotherapy, surgery, and the use of technological devices. Recently, researchers have worked on developing various technologies to enhance assisting and rehabilitation of FD.

AREAS COVERED

This review analyzes different types of technologies available for FD. This include devices that are available commercially or still under research. 101 studies published between 2015 and 2020 were identified for the review, many were excluded due to various reasons, e.g., were not robot-based devices, did not include FD as one of the targeted diseases, or was insufficient information. 24 studies that met our inclusion criteria were assessed. These studies were further classified into two different categories: robot-based ankle-foot orthosis (RAFO) and Functional Electrical Stimulation (FES) devices.

EXPERT OPINION

Studies included showed that both RAFO and FES showed considerable improvement in the gait cycle of the patients. Future trends are inclining towards integrating FES with other neuro-concepts such as muscle-synergies for further developments.

Does cycling induced by functional electrical stimulation enhance motor recovery in the subacute phase after stroke? A systematic review and meta-analysis

OBJECTIVE

To investigate the effects of cycling with functional electrical stimulation on walking, muscle power and tone, balance and activities of daily living in subacute stroke survivors.

DATA SOURCES

Ten electronic databases were searched from inception to February 2020.

REVIEW METHODS

Inclusion criteria were: subacute stroke survivors (<6 months since stroke), an experimental group performing any type of cycling training with electrical stimulation, alone or in addition to usual care, and a control group performing usual care alone. Two reviewers assessed eligibility, extracted data and analyzed the risks of bias. Standardized Mean Difference (SMD) or Mean Difference (MD) with 95% Confidence Intervals (CI) were estimated using fixed- or random-effects models to evaluate the training effect.

RESULTS

Seven randomized controlled trials recruiting a total of 273 stroke survivors were included in the meta-analyses. There was a statistically significant, but not clinically relevant, effect of cycling with electrical stimulation compared to usual care on walking (six studies, SMD [95% CI] = 0.40 [0.13, 0.67]; P = 0.004), capability to maintain a sitting position (three studies, MD [95% CI] = 7.92 [1.01, 14.82]; P = 0.02) and work produced by the paretic leg during pedaling (2 studies, MD [95% CI] = 8.13 [1.03, 15.25]; P = 0.02). No significant between-group differences were found for muscular power, tone, standing balance, and activities of daily living.

CONCLUSIONS

Cycling training with functional electrical stimulation cannot be recommended in terms of being better than usual care in subacute stroke survivors. Further investigations are required to confirm these results, to determine the optimal training parameters and to evaluate long-term effects.

Functional electrical stimulation of the peroneal nerve improves post-stroke gait speed when combined with physiotherapy. A systematic review and meta-analysis

BACKGROUND

Functional electrical stimulation (FES) applied to the paretic peroneal nerve has positive clinical effects on foot drop secondary to stroke.

OBJECTIVE

To evaluate the effectiveness of FES applied to the paretic peroneal nerve on gait speed, active ankle dorsiflexion mobility, balance, and functional mobility.

METHODS

Electronic databases were searched for articles published from inception to January 2020. We included randomized controlled trials or crossover trials focused on determining the effects of FES combined or not with other therapies in individuals with foot drop after stroke. Characteristics of studies, participants, comparison groups, interventions, and outcomes were extracted. Statistical heterogeneity was assessed with the I² statistic.

RESULTS

We included 14 studies providing data for 1115 participants. FES did not enhance gait speed as compared with conventional treatments (i.e., supervised/unsupervised exercises and regular activities at home). FES combined with supervised exercises (i.e., physiotherapy) was better than supervised exercises alone for improving gait speed. We found no effect of FES combined with unsupervised exercises and inconclusive effects when FES was combined with regular activities at home. When FES was compared with conventional treatments, it improved ankle dorsiflexion, balance and functional mobility, albeit with high heterogeneity for these last 2 outcomes.

CONCLUSIONS

This meta-analysis revealed low quality of evidence for positive effects of FES on gait speed when combined with physiotherapy. FES can improve ankle dorsiflexion, balance, and functional mobility. However, considering the low quality of evidence and the high heterogeneity, these results must be interpreted carefully.

Advances in neuroprosthetic management of foot drop: a review

This paper reviews the technological advances and clinical results obtained in the neuroprosthetic management of foot drop. Functional electrical stimulation has been widely applied owing to its corrective abilities in patients suffering from a stroke, multiple sclerosis, or spinal cord injury among other pathologies. This review aims at identifying the progress made in this area over the last two decades, addressing two main questions: What is the status of neuroprosthetic technology in terms of architecture, sensorization, and control algorithms?. What is the current evidence on its functional and clinical efficacy? The results reveal the importance of systems capable of self-adjustment and the need for closed-loop control systems to adequately modulate assistance in individual conditions. Other advanced strategies, such as combining variable and constant frequency pulses, could also play an important role in reducing fatigue and obtaining better therapeutic results. The field not only would benefit from a deeper understanding of the kinematic, kinetic and neuromuscular implications and effects of more promising assistance strategies, but also there is a clear lack of long-term clinical studies addressing the therapeutic potential of these systems. This review paper provides an overview of current system design and control architectures choices with regard to their clinical effectiveness. Shortcomings and recommendations for future directions are identified.

Neurorestoration: Advances in human brain–computer interface using microelectrode arrays

Neural damage has been a great challenge to the medical field for a very long time. The emergence of brain–computer interfaces (BCIs) offered a new possibility to enhance the activity of daily living and provide a new formation of entertainment for those with disabilities. Intracortical BCIs, which require the implantation of microelectrodes, can receive neuronal signals with a high spatial and temporal resolution from the individual’s cortex. When BCI decoded cortical signals and mapped them to external devices, it displayed the ability not only to replace part of the human motor function but also to help individuals restore certain neurological functions. In this review, we focus on human intracortical BCI research using microelectrode arrays and summarize the main directions and the latest results in this field. In general, we found that intracortical BCI research based on motor neuroprosthetics and functional electrical stimulation have already achieved some simple functional replacement and treatment of motor function. Pioneering work in the posterior parietal cortex has given us a glimpse of the potential that intracortical BCIs have to control external devices and receive various sensory information.

The effects of ankle-foot orthoses on walking speed in patients with stroke: a systematic review and meta-analysis of randomized controlled trials

Objective:

The aim of this study was to evaluate the effects of ankle-foot orthoses on speed walking in patients with stroke.

Data sources:

PubMed, Embase, Web of Science, Scopus, CENTRAL, PEDro, RehabData, RECAL, and ProQuest were searched from inception until 30 September 2019.

Review methods:

This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline statement. Risk of bias assessment was performed using the Cochrane Risk of Bias Tool. Begg’s test and Egger’s regression method were used to assess the publication bias. Trim and fill analysis was also used to adjust any potential publication bias. Sensitivity analysis was performed to evaluate the effect of individual studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Results:

Overall, 14 studies were included with a total of 1186 participants. A small-to-moderate and non-significant improvement in favor of the ankle-foot orthosis versus without ankle-foot orthosis (standardized mean difference (SMD) = 0.41, 95% confidence interval = −0.15 to 0.96), similar effects of ankle-foot orthosis and functional electrical stimulation (SMD = 0.00, 95% confidence interval = −0.16 to 0.16), and a small and non-significant improvement in favor of ankle-foot orthosis versus another type of ankle-foot orthosis (SMD = 0.22, 95% confidence interval = −0.05 to 0.49) in walking speed were found. However, the quality of evidence for all comparisons was low or very low.

Conclusion:

Despite reported positive effects in some studies, there is no firm evidence of any benefit of ankle-foot orthoses on walking speed.

Rationale and design of the theRapeutic effects of peroneal nerve functionAl electrical stimuLation for Lower extremitY in patients with convalescent poststroke hemiplegia (RALLY) study: study protocol for a randomised controlled study

INTRODUCTION

Increasing evidence supports the utilisation of functional electrical stimulation (FES) to improve gait following stroke; however, few studies have focused exclusively on its use in the convalescent phase. In addition, its efficacy in patients with a non-Western life style has not been evaluated.

METHODS AND ANALYSIS

This is a randomised, controlled, open-label multicentre study, comparing rehabilitation with and without FES. The purpose of our study is to test the hypothesis that the FES system improves walking ability in Japanese patients with hemiplegia during the convalescent phase. Two hundred patients aged 20-85 years who had an initial stroke ≤6 months prior to the enrolment, are in a convalescent phase (after the end of acute phase treatment, within 6 months after the onset of stroke) with functional ambulation classification 3 or 4 and have a hemiplegic gait disorder (drop foot) due to stroke have been recruited from 21 institutions in Japan. The patients are randomised in 1:1 fashion to usual gait rehabilitation or rehabilitation using FES (Walkaide). The trial duration is 8 weeks, and the primary outcome measured will be the change in maximum distance from baseline to the end of the trial, as measured with the 6 min walk test (6-MWT). The 6-MWT is performed barefoot, and the two treatment groups are compared using the analysis of covariance.

ETHICS AND DISSEMINATION

This study is conducted in accordance with the principles of the Declaration of Helsinki and the Ethical Guidelines for Medical and Health Research Involving Human Subjects and is approved by the ethics committee of all participating institutions. The published results will be disseminated to all the participants by the study physicians.

TRIAL REGISTRATION NUMBER

The University Hospital Medical Information Network-Clinical Studies Registry (UMIN000020604).

The effects of cycling with and without functional electrical stimulation on lower limb dysfunction in patients post-stroke: A systematic review with meta-analysis

BACKGROUND

One of the leading causes of disability in the world with enormous economic burden is stroke.

OBJECTIVE

To quantify the effectiveness of different protocols of cycling with/without functional electrical stimulation on functional mobility after stroke.

METHODS

Multiple databases were searched till 2018. Data extraction was performed using a pre-determined data collection form. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

A total of 14 trials satisfied eligibility criteria and were included. Cycling had a positive effect on the 6-meter walking test performance (SMD, 0.41; 95% CI, 0.11 -0.71; I2 = 0% ) compared with no or placebo intervention (control). Compared with control, cycling had a positive effect on 10-meter walking speed (SMD, 0.30; 95% CI, 0.05 -0.55; I2 = 0% ), and on balance based on the Berg score (SMD, 0.32; 95% CI, 0.06 -0.57; I2 = 49% ). Cycling with functional electrical stimulation had a positive effect on balance (SMD, 1.48; 95% CI, 0.99 -1.97; I2 = 91% ) compared with cycling alone.

CONCLUSIONS

It appears that cycling has a positive effect on walking speed, walking ability and balance. Functional electrical stimulation combined with cycling has positive effects on balance beyond cycling alone.

Short-term effects of neuromuscular electrical stimulation and ultrasound therapies on muscle architecture and functional capacity in knee osteoarthritis: a randomized study

Objective:

To determine the effects of ultrasound therapy and neuromuscular electrical stimulation (NMES) application on the muscle architecture and functional capacity in patients with knee osteoarthritis.

Design:

A randomized study.

Subjects:

A total of 60 patients with knee osteoarthritis.

Interventions:

Participants were randomized into one of the following two intervention groups, five days a week, for three weeks: the combination of NMES application, hot pack, and exercise therapy was applied to the NMES group. The combination of therapeutic ultrasound, hot pack and exercise therapy was applied to the ultrasound therapy group.

Main measures:

Subjects were evaluated for pain and functional capacity with the use of the visual analog pain scale (VAS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), and 15 meter walking test. The muscle architecture (muscle thickness, pennation angle and fascicle length) was assessed from vastus lateralis and quadriceps femoris muscles bilaterally by ultrasonography.

Results:

Two groups presented significant improvements in all outcome measures before and after treatment ( P < 0.01). There were significant improvements in VAS rest pain ( P < 0.05), VAS activity pain ( P < 0.05), WOMAC pain ( P < 0.05), WOMAC stiffness score ( P < 0.05), and WOMAC physical function ( P < 0.05) for the ultrasound therapy group in comparison to the NMES group. NMES group exhibited more increases in the muscle thickness and fascicle length values when compared to ultrasound therapy group ( P < 0.05).

Conclusion:

Ultrasound therapy appears to be an effective treatment in reducing pain and improving functional capacity. NMES application has more effects on the muscle architecture.

Veterinary Neurologic Rehabilitation: The Rationale for a Comprehensive Approach

The increase in client willingness to pursue surgical procedures, the heightened perceived value of veterinary patients, and the desire to provide comprehensive medical care have driven the recent demand of using an integrative treatment approach in veterinary rehabilitation. Physical therapy following neurologic injury has been the standard of care in human medicine for decades, whereas similar rehabilitation techniques have only recently been adapted and utilized in veterinary medicine. Spinal cord injury is the most common neurologic disease currently addressed by veterinary rehabilitation specialists and will be the primary focus of this review; however, research in other neurologic conditions will also be discussed. Of particular interest, to clients and veterinarians are techniques and modalities used to promote functional recovery after neurologic injury, which can mean the difference between life and death for many veterinary patients. The trend in human neurologic rehabilitation, often regardless of etiology, is a multimodal approach to therapy. Evidence supports faster and improved recoveries in people after neurologic injury using a combination of rehabilitation techniques. Although the primary neurological disorders researched tend to be spinal cord injury, peripheral neuropathies, allodynia, multiple sclerosis, and strokes-many correlations can be made to common veterinary neurological disorders. Such comprehensive protocols entail gait training activities in combination with neuromuscular electrical stimulation and directed exercises. Additionally, pain-relieving and functional benefits are bolstered when acupuncture is used in addition to rehabilitation. Studies, both laboratory and clinical, support the use of acupuncture in the management of neurologic conditions in small animals, specifically in cases of intervertebral disc disease, other myelopathies, and neuropathic pain conditions. Acupuncture's ability to promote analgesia, stimulate trophic factors, and decrease inflammation, including neuroinflammation, make it an alluring adjunct therapy after neurologic injury. Although there is limited research in veterinary medicine on physical techniques that expedite recovery after neurologic injury, there are sparse publications on clinical veterinary research suggesting the benefits of acupuncture, rehabilitation, and LASER in dogs with intervertebral disk disease. Accordingly, due to the relative lack of evidence-based studies in veterinary neurologic rehabilitation, much of the data available is human or laboratory-animal based, however, evidence supports the utilization of an early, comprehensive treatment protocol for optimal neurologic recovery. The rationale for why an integrative approach is critical will be detailed in this review; in addition, literature on specific physical rehabilitation techniques that have evidence of improved recoveries after neurologic injury, will be addressed.

Biological effects of dosing aerobic exercise and neuromuscular electrical stimulation in rats

Aerobic exercise (AE) and non-aerobic neuromuscular electric stimulation (NMES) are common interventions used in physical therapy. We explored the dose-dependency (low, medium, high) of these interventions on biochemical factors, such as brain derived neurotrophic growth factor (BDNF), vascular endothelial growth factor-A (VEGF-A), insulin-like growth factor-1 (IGF-1) and Klotho, in the blood and brain of normal rats, as well as a treadmill-based maximum capacity test (MCT). A medium dose of AE produced the most improvement in MCT with dose-dependent changes in Klotho in the blood. A dose-dependent increase of BDNF was evident following completion of an NMES protocol, but there was no improvement in MCT performance. Gene expression in the hippocampus was increased after both AE and NMES, with IGF-1 being a signaling molecule that correlated with MCT performance in the AE conditions, but also highly correlated with VEGF-A and Klotho. Blood Klotho levels can serve as a biomarker of therapeutic dosing of AE, whereas IGF-1 is a key molecule coupled to gene expression of other molecules in the hippocampus. This approach provides a translatable paradigm to investigate the mode and mechanism of action of interventions employed in physical therapy that can improve our understanding of how these factors change under pathological conditions.

Single Session of Functional Electrical Stimulation-Assisted Walking Produces Corticomotor Symmetry Changes Related to Changes in Poststroke Walking Mechanics

BACKGROUND

Recent research demonstrated that the symmetry of corticomotor drive with the paretic and nonparetic plantarflexor muscles was related to the biomechanical ankle moment strategy that people with chronic stroke used to achieve their greatest walking speeds. Rehabilitation strategies that promote corticomotor balance might improve poststroke walking mechanics and enhance functional ambulation.

OBJECTIVE

The study objectives were to test the effectiveness of a single session of gait training using functional electrical stimulation (FES) to improve plantarflexor corticomotor symmetry and plantarflexion ankle moment symmetry and to determine whether changes in corticomotor symmetry were related to changes in ankle moment symmetry within the session.

DESIGN

This was a repeated-measures crossover study.

METHODS

On separate days, 20 people with chronic stroke completed a session of treadmill walking either with or without the use of FES of their ankle dorsi- and plantarflexor muscles. We calculated plantarflexor corticomotor symmetry using transcranial magnetic stimulation and plantarflexion ankle moment symmetry during walking between the paretic and the nonparetic limbs before and after each session. We compared changes and tested relationships between corticomotor symmetry and ankle moment symmetry following each session.

RESULTS

Following the session with FES, there was an increase in plantarflexor corticomotor symmetry that was related to the observed increase in ankle moment symmetry. In contrast, following the session without FES, there were no changes in corticomotor symmetry or ankle moment symmetry.

LIMITATIONS

No stratification was made on the basis of lesion size, location, or clinical severity.

CONCLUSIONS

These findings demonstrate, for the first time (to our knowledge), the ability of a single session of gait training with FES to induce positive corticomotor plasticity in people in the chronic stage of stroke recovery. They also provide insight into the neurophysiologic mechanisms underlying improvements in biomechanical walking function.

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.

Effects of functional electrical stimulation on gait in people with multiple sclerosis - A systematic review

BACKGROUND

Functional electrical stimulation (FES) is commonly used to ameliorate gait deficits in patients with multiple sclerosis (PwMS). This review critically evaluates the literature describing the orthotic and therapeutic effects of FES on gait in PwMS.

METHODS

The PubMed, CINAHL, and ProQuest databases were searched. Included were studies that evaluated therapeutic and/or orthotic effects of FES in PwMS with at least one outcome measure related to gait. Methodology was assessed using the Downs and Black checklist.

RESULTS

Twelve relevant studies were reviewed. Their methodological quality ranged from 14 to 21 of 28. Eleven studies reported the effects of peroneal stimulation. Most found a significant orthotic effect (measured during stimulation), mainly on walking speed. Only three assessed the therapeutic effect (carry-over), which was not significant.

CONCLUSIONS

The evidence presented in this review suggests that FES has a positive orthotic effect on walking in PwMS. Yet, more robust trials are needed to substantiate this finding. Therapeutic efficacy of FES was not demonstrated, and almost all studies tested a single channel peroneal stimulator. Future studies involving FES technological innovations with advanced clinical approaches might contribute to a carry-over effect from FES and increase the percentage of PwMS who benefit from this technology.

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.

Effects of Functional Electrical Stimulation on Reducing Falls and Improving Gait Parameters in Multiple Sclerosis and Stroke

BACKGROUND

Loss of neuromuscular control of the ankle joint is a common impairment in neurologic conditions, leading to abnormal gait and a greater risk of falling. Limited information, however, is available on the effectiveness of functional electrical stimulation (FES) on reducing falls, and no studies have investigated its usefulness in improving lower limbs kinematics related to foot clearance and energy recovery.

SETTING

Clinical setting.

STUDY DESIGN

Prospective longitudinal study.

PARTICIPANTS

Twenty-four subjects, 14 people with multiple sclerosis (mean age ± standard deviation 50.93 ± 8.72 years) and 10 people with stroke (55.38 ± 14.55 years).

METHODS

The number of falls was assessed at baseline and after 8 weeks, and a clinical assessment was performed at the baseline, 4-week, and 8-week time points. A subsample of the 24 subjects comprising 5 people with multiple sclerosis and 5 people with stroke performed a gait analysis assessment at baseline and after 4 weeks. After receiving the equipment and the training schedule, subjects performed daily home walking training using FES for 8 weeks.

MAIN OUTCOME MEASUREMENTS

The main outcomes were (1) the number of falls, (2) foot clearance, and (3) energy recovery.

RESULTS

A reduction in the number of falls was observed from baseline (n = 10) to the 8-week assessment (n = 2), P = .02. Foot clearance increased (+5.26 mm, P = .04) between the baseline without FES and at 4 weeks with FES (total effect). No statistically significant differences were found in energy recovery between baseline and 4 weeks.

CONCLUSIONS

The use of FES had an impact on gait, specifically reducing the number of falls and improving walking. A specific effect at the ankle joint was observed, increasing foot clearance during the swing phase of gait. This effect was not accompanied with a reduction in the energetic expenditure during walking in subjects with multiple sclerosis and stroke.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Reducing The Cost of Transport and Increasing Walking Distance After Stroke: A Randomized Controlled Trial on Fast Locomotor Training Combined With Functional Electrical Stimulation

Background Neurorehabilitation efforts have been limited in their ability to restore walking function after stroke. Recent work has demonstrated proof-of-concept for a functional electrical stimulation (FES)-based combination therapy designed to improve poststroke walking by targeting deficits in paretic propulsion. Objectives To determine the effects on the energy cost of walking (EC) and long-distance walking ability of locomotor training that combines fast walking with FES to the paretic ankle musculature (FastFES). Methods Fifty participants >6 months poststroke were randomized to 12 weeks of gait training at self-selected speeds (SS), fast speeds (Fast), or FastFES. Participants' 6-minute walk test (6MWT) distance and EC at comfortable (EC-CWS) and fast (EC-Fast) walking speeds were measured pretraining, posttraining, and at a 3-month follow-up. A reduction in EC-CWS, independent of changes in speed, was the primary outcome. Group differences in the number of 6MWT responders and moderation by baseline speed were also evaluated. Results When compared with SS and Fast, FastFES produced larger reductions in EC (Ps ≤.03). FastFES produced reductions of 24% and 19% in EC-CWS and EC-Fast (Ps <.001), respectively, whereas neither Fast nor SS influenced EC. Between-group 6MWT differences were not observed; however, 73% of FastFES and 68% of Fast participants were responders, in contrast to 35% of SS participants. Conclusions Combining fast locomotor training with FES is an effective approach to reducing the high EC of persons poststroke. Surprisingly, differences in 6MWT gains were not observed between groups. Closer inspection of the 6MWT and EC relationship and elucidation of how reduced EC may influence walking-related disability is warranted.

Hardware System for Real-Time EMG Signal Acquisition and Separation Processing during Electrical Stimulation

The study aimed to develop a real-time electromyography (EMG) signal acquiring and processing device that can acquire signal during electrical stimulation. Since electrical stimulation output can affect EMG signal acquisition, to integrate the two elements into one system, EMG signal transmitting and processing method has to be modified. The whole system was designed in a user-friendly and flexible manner. For EMG signal processing, the system applied Altera Field Programmable Gate Array (FPGA) as the core to instantly process real-time hybrid EMG signal and output the isolated signal in a highly efficient way. The system used the power spectral density to evaluate the accuracy of signal processing, and the cross correlation showed that the delay of real-time processing was only 250 μs.

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.

Effects of Robot-assisted Gait Training Combined with Functional Electrical Stimulation on Recovery of Locomotor Mobility in Chronic Stroke Patients: A Randomized Controlled Trial

[Purpose] The purpose of the present study was to investigate the effects of robot-assisted gait training combined with functional electrical stimulation on locomotor recovery in patients with chronic stroke. [Subjects] The 20 subjects were randomly assigned into either an experimental group (n = 10) that received a combination of robot-assisted gait training and functional electrical stimulation on the ankle dorsiflexor of the affected side or a control group (n = 10) that received robot-assisted gait training only. [Methods] Both groups received the respective therapies for 30 min/day, 3 days/week for 5 weeks. The outcome was measured using the Modified Motor Assessment Scale (MMAS), Timed Up-and-Go Test (TUG), Berg Balance Scale (BBS), and gait parameters through gait analysis (Vicon 370 motion analysis system, Oxford Metrics Ltd., Oxford, UK). All the variables were measured before and after training. [Results] Step length and maximal knee extension were significantly greater than those before training in the experimental group only. Maximal Knee flexion showed a significant difference between the experimental and control groups. The MMAS, BBS, and TUG scores improved significantly after training compared with before training in both groups. [Conclusion] We suggest that the combination of robot-assisted gait training and functional electrical stimulation encourages patients to actively participate in training because it facilitates locomotor recovery without the risk of adverse effects.

Effects of functional electrical stimulation on gait recovery post-neurological injury during inpatient rehabilitation

This stage 2 trial investigated the therapeutic effect of single channel, peroneal functional electrical stimulation (FES) for improving gait and muscle activity in people with neurological injuries who were enrolled in an inpatient rehabilitation program. Twenty-six patients (16 male; M age = 51.3 yr., SD = 16.2; 2-33 days post-injury) completed the study. Participants were randomly assigned to an experimental group (n = 13) or control group (n = 13). The experimental group received FES and the control group received sensory stimulation during 45-min. gait training sessions three times a week for the duration of their stay in a rehabilitation facility (average of four sessions for both groups). Changes in gait speed, tibialis anterior muscle electromyography (EMG), and FIM™ locomotion scores were compared between groups. No significant differences were found, as both groups demonstrated similar improvements. The current results with this small sample suggest a low dose of gait training with single channel FES did not augment gait nor EMG activity beyond gait training with sensory stimulation; therefore, clinicians will likely be better served using a larger dose of FES or multichannel FES in this clinical population.

Therapeutic effect of functional electrical stimulation-triggered gait training corresponding gait cycle for stroke

The purpose of this study was to determine the therapeutic effects of functional electrical stimulation (FES) applied to the gluteus medius and tibialis anterior muscles during the gait cycle in individuals with hemiparetic stroke. Eighteen patients who had suffered a stroke were enrolled in this study. The participants were divided into either the gluteus medius and tibialis anterior (GM + TA) training group (n = 9) or the control group (n = 9). The GM + TA group received FES-triggered gait training to the gluteus medius (GM) in the stance phase and the tibialis anterior (TA) in the swing phase for 30 min, 5 session a week over a 6-week period, and control group who received only gait training without FES-triggered for the same duration of time. A foot-switch sensor was used to trigger the device in the stance (GM) and swing (TA) phases of the gait cycle reciprocally. This study measured three types of outcome measures, including spatiotemporal gait parameters, muscles activities, and balance function. After 6 weeks training, there was a significant improvement in gait velocity, cadence, stride length, and gait symmetry in the GM + TA training group compared to the control group. Dynamic balance function was significantly improved in the GM + TA training group compared to the control group. The mean changeable values of the GM was significantly greater strength in the GM + TA training group than the control group. These findings suggest that FES-triggered gait training of the GM in the stance phase and TA in the swing phase may improve the spatiotemporal parameters of gait in persons with hemiparetic stroke.

Rethinking the continuum of stroke rehabilitation

Suffering a stroke can be a devastating and life-changing event. Although there is a large evidence base for stroke rehabilitation in the acute and subacute stages, it has been long accepted that patients with stroke reach a plateau in their rehabilitation recovery relatively early. We have recently published the results of a systematic review designed to identify all randomized controlled trials (RCTs) where a rehabilitation intervention was initiated more than 6 months after the onset of the stroke. Of the trials identified, 339 RCTs met inclusion criteria, demonstrating an evidence base for stroke rehabilitation in the chronic phase as well. This seems at odds with the assumption that further recovery is unlikely and the subsequent lack of resources devoted to chronic stroke rehabilitation and management.