Restoration of gait and motor recovery by functional electrical stimulation therapy in persons with stroke

The efficacy of virtual reality-based rehabilitation in improving motor function in patients with stroke: a systematic review and meta-analysis

Background

Stroke is a major cause of adult disability, prompting the exploration of innovative rehabilitation methods. Virtual rehabilitation (VR), leveraging technological advances, has gained popularity as a treatment for stroke recovery.

Methodology

The authors conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) published in English within the last decade, adhering to the PRISMA guidelines. The authors searched databases such as Medline/PubMed, and the Cochrane Library using specific search keywords and Medical Subject Headings (MeSH). The methodological quality was assessed using the PEDro scale, focusing on RCTs involving adult stroke patients undergoing VR rehabilitation, with outcomes related to motor function and quality of life.

Results

The authors included 15 studies in our meta-analysis. VR rehabilitation offers several advantages over traditional therapy, such as enhanced feedback and increased patient motivation. Engaging VR environments helps improve focus during treatment, potentially boosting recovery from post-stroke impairments. VR therapies significantly benefit motor function, which can improve activities of daily living and overall quality of life.

Conclusion

VR has demonstrated efficacy in improving motor function and quality of life for stroke survivors. Future research should explore patient variability and refine intervention methods. Incorporating VR into rehabilitation programs could optimize stroke recovery outcomes.

Stroke rehabilitation: from diagnosis to therapy

Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.

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.

Functional electrical stimulation to enhance reactive balance among people with hemiparetic stroke

BACKGROUND

Individuals with stroke demonstrate a twofold higher fall incidence compared to healthy counterparts, potentially associated with deficits in reactive balance control, which is crucial for regaining balance from unpredictable perturbations to the body. Moreover, people with higher stroke-related motor impairment exhibit greater falls and cannot recover balance during higher perturbation intensities. Thus, they might need supplemental agents for fall prevention or even to be included in a perturbation-based protocol. Functional electrical stimulation is a widely used clinical modality for improving gait performance; however, it remains unknown whether it can enhance or interfere with reactive balance control.

METHODS

We recruited twelve ambulatory participants with hemiparetic stroke (61.48 ± 6.77 years) and moderate-to-high motor impairment (Chedoke-McMaster Stroke Leg Assessment ≤ 4/7). Each participant experienced 4 unpredicted paretic gait-slips, with and without functional electrical stimulation (provided 50-500 ms after perturbation) in random order. The paretic quadriceps muscle group was chosen to receive electrical stimulation, considering the role of support limb knee extensors for preventing limb-collapse. Outcomes including primary (laboratory falls), secondary (reactive stability, vertical limb support) and tertiary (compensatory step length, step initiation, execution time) measures were compared between the two conditions.

RESULTS

Participants demonstrated fewer falls, higher reactive stability, and higher vertical limb support (p < 0.05) following gait-slips with functional electrical stimulation compared to those without. This was accompanied by reduced step initiation time and a longer compensatory step (p < 0.05).

CONCLUSION

The application of functional electrical stimulation to paretic quadriceps following gait-slips reduced laboratory fall incidence with enhanced reactive balance outcomes among people with higher stroke-related motor impairment. Our results lay the preliminary groundwork for understanding the instantaneous neuromodulatory effect of functional electrical stimulation in preventing gait-slip falls, future studies could test its therapeutic effect on reactive balance. Clinical registry number: NCT04957355.

Machine-learning-based coordination of powered ankle-foot orthosis and functional electrical stimulation for gait control

This study proposes a novel gait rehabilitation method that uses a hybrid system comprising a powered ankle-foot orthosis (PAFO) and FES, and presents its coordination control. The developed system provides assistance to the ankle joint in accordance with the degree of volitional participation of patients with post-stroke hemiplegia. The PAFO adopts the desired joint angle and impedance profile obtained from biomechanical simulation. The FES patterns of the tibialis anterior and soleus muscles are derived from predetermined electromyogram patterns of healthy individuals during gait and personalized stimulation parameters. The CNN-based estimation model predicts the volitional joint torque from the electromyogram of the patient, which is used to coordinate the contributions of the PAFO and FES. The effectiveness of the developed hybrid system was tested on healthy individuals during treadmill walking with and without considering the volitional muscle activity of the individual. The results showed that consideration of the volitional muscle activity significantly lowers the energy consumption by the PAFO and FES while providing adaptively assisted ankle motion depending on the volitional muscle activities of the individual. The proposed system has potential use as an assist-as-needed rehabilitation system, where it can improve the outcome of gait rehabilitation by inducing active patient participation depending on the stage of rehabilitation.

Comparing the Effect of Implanted Peroneal Nerve Stimulation and Ankle-Foot Orthosis on Gait Kinematics in Chronic Hemiparesis: A Randomized Controlled Trial

OBJECTIVE

Impaired ankle dorsiflexion in hemiparesis may be treated with ankle-foot orthosis or functional electrical stimulation. Semi-implanted selective functional electrical stimulation uses independent stimulations of deep and superficial peroneal nerves. The aim of this study was to compare gait kinematics using ankle-foot orthosis or semi-implanted selective functional electrical stimulation over 6 months in hemiparesis.

METHODS

Subjects with chronic hemiparesis, randomized into ankle-foot orthosis or semi-implanted selective functional electrical stimulation groups, underwent comfortable gait analysis without and with device OFF and ON, before, and 3 and 6 months after treatment onset. The effects of condition, visit and group on gait kinematics (analysis of variance; ANOVA) were analysed.

RESULTS

A total of 27 subjects were included (ankle-foot orthosis, n = 13; semi-implanted selective functional electrical stimulation, n = 14). The only between-group difference in changes from OFF to ON conditions was a deteriorated ankle dorsiflexion speed with ankle-foot orthosis at month 6 (condition*group, p = 0.04; ankle-foot orthosis, -60%, p = 0.02; semi-implanted selective functional electrical stimulation, non significant). Both groups pooled, from OFF to ON gait speed (+ 0.07 m/s; + 10%), cadence (+ 4%), step length (+ 6%) and peak ankle dorsiflexion (+ 6°) increased, and peak ankle inversion (-5°) and peak knee flexion (-2°) decreased (p < 0.001); finally, peak knee flexion in the OFF condition increased (+ 2°, p = 0.03).

CONCLUSION

Semi-implanted selective functional electrical stimulation and ankle-foot orthosis similarly impacted gait kinematics in chronic hemiparesis after 6 months of use. Ankle dorsiflexion speed in swing deteriorated markedly with ankle-foot orthosis.

Optimization of electrical stimulation for the treatment of lower limb dysfunction after stroke: A systematic review and Bayesian network meta-analysis of randomized controlled trials

OBJECTIVE

To compare the treatment effect of five electrical stimulation methods commonly used in the treatment of stroke patients with lower limb dysfunction.

METHODS

We implemented a systematic search of 3915 studies published up to January 2023 from eight databases and two clinical trial registries. First, two independent reviewers critically evaluated trial eligibility according to the inclusion and exclusion criteria. Next, they selected and extracted data. Then, they assessed the risk of bias. Pairwise meta-analysis and Bayesian network meta-analysis were conducted to estimate the effectiveness and ranking of the five electrical stimulation methods.

RESULTS

A total of 33 trials with a final total of 2246 subjects were included in the analysis. By combining the comprehensive Rehabilitation Treatment (RT), the treatment effects of using five electrical stimulation methods were surperior to those of using RT only. In the meantime, RT+transcranial Direct Current Stimulation(tDCS) and RT+Functional Electrical Stimulation(FES) could be the optimal electric stimulation schemes for restoring lower limb motor function(SMD 8.35, 95%CI [3.05, 13.34]/ SMD 5.64, 95%CI [3.68, 7.56]), improving balance (SMD 9.80, 95%CI [0.67, 20.93]/ SMD 6.54, 95%CI [3.85, 10.95]) and activities of daily living(SMD 18.95, 95%CI [0.401, 36.9]/ SMD 15.47, 95%CI [7.89, 22.75]), and the treatment effects would be even better using RT+FES+tDCS combination.

CONCLUSION

tDCS and FES superior to other electrical stimulation methods based on RT in the treatment of lower limb dysfunction after stroke.

Effects of kinesio taping therapy on gait and surface electromyography in stroke patients with hemiplegia

Background: The application of Kinesio Taping (KT) on the lower extremity of stroke patients can improve the quality of somatosensory information by activating lower extremity muscles involved in postural control. Gait analysis and surface electromyography (SEMG) are valuable in assessing the motor ability of the lower extremities.

Objective: This study aimed to investigate the effects of KT therapy on gait and SEMG in stroke patients with hemiplegia.

Methods: Twenty-one stroke patients were included in the study. KT was applied to the lower extremities of the hemiplegic side. Quantitative gait parameters were measured by a gait analysis system (IDEEA, by MiniSun, United States) and activation of the lower extremity muscles were evaluated by the SEMG (Trigno™ Wireless Systems, Delsys Inc., United States) before and after taping. Step length, stride length, pulling acceleration, swing power, ground impact, and energy expenditure were used to evaluate when patients walk as usual. SEMG signals were collected from the anterior bilateral tibialis (TA) and the lateral gastrocnemius (LG). The root mean square (RMS) value was used to assess muscle activity. SEMG signals were examined before and after KT treatment in three different locomotor conditions of the patients: walking at a natural speed, walking with a weight of 5 kg, dual-tasking walking (walking + calculation task) while carrying a weight of 5 kg. The calculation task was to ask the patients to calculate the result of subtracting 7 from 100 and continuing to subtract 7 from the resulting numbers. Comparisons between two normally distributed samples (before and after KT treatment) were evaluated using the two-tailed, paired Student’s t-test.

Results: Stride length (0.89 ± 0.19 vs. 0.96 ± 0.23; p = 0.029), pulling acceleration (0.40 ± 0.21 vs. 1.11 ± 0.74; p = 0.005), and swing power (0.42 ± 0.24 vs. 1.14 ± 0.72; p = 0.004) improved in the hemiplegia side after KT treatment. The RMS value of TA SEMG signals in the limbs on the hemiplegia side decreased after KT treatment during dual-tasking walking carrying a weight of 5 kg (3.65 ± 1.31 vs. 2.93 ± 0.95; p = 0.030).

Conclusion: KT treatment is effective in altering gait and SEMG characteristics in stroke patients with hemiplegia.

Effects of Combination of Functional Electric Stimulation and Robotic Leg Movement Using Dynamic Tilt Table on Walking Characteristics in Post-Stroke Patients with Spastic Hemiplegia: A Randomized Crossover-Controlled Trial

BACKGROUND

Spastic hemiplegia causes slow and unstable walking in post-stroke patients. Dynamic tilt table with robotic leg movement (DTTRLM) is safe and effective in improving walking. Functional electric stimulation (FES) improves walking speed in post-stroke patients with spastic hemiplegia. The aim of this study was to determine the effects of combined DTTRLM + FES on walking speed compared with DTTRLM alone.

METHODS

Twenty post-stroke patients were randomly assigned to receive either a single session of stepping + FES treatment or a single session of stepping alone treatment. After a one-week washout period, the same two groups underwent a single session of the other treatment, and the same measurements were taken. We measured walking speed, cadence, and the number of steps in a 10 m walking test (10MWT) and assessed Modified Ashworth Scale (MAS), Fugl-Meyer Assessment (FMA), and range of motion (ROM) before and after the intervention.

RESULTS

Stepping + FES significantly improved walking speed, number of steps, and ankle inversion ROM, compared with stepping alone. Adverse events were not observed in any subject.

CONCLUSIONS

Robotic stepping therapy combined with FES significantly improved 10 m walking speed (10MWS) compared with stepping only in patients with post-stroke and spastic hemiplegia. Further studies are needed to determine the long-term effects of the combination treatment.

The influence of Gait Training Combined with Portable Functional Electrical Stimulation on motor function, balance and gait ability in stroke patients

BACKGROUND

Problems with motor functions, balance and gait ability commonly occur in stroke patients and cause asymmetric posture imbalance and gait patterns.

OBJECTIVE

We examined the effects of gait training (GT) combined with portable functional electrical stimulation (FES) on motor functions, balance and gait ability of stroke patients.

METHODS

A single blind, randomized control trial was conducted with 34 post stroke patients who were randomly allocated to two groups: 1) FES + GT group (n= 17) and the placebo FES + GT (PLBO + GT) group (n= 17). All interventions were given for 30 minutes, 5 days a week for 4 weeks. Fugl-Meyer assessment (FMA) was used to measure motor function of lower extremity. Performance oriented mobility assessment (POMA) was used to balance and gait ability. OptoGait was used to analyze gait ability.

RESULTS

Both groups showed significant improvements in motor function, balance and gait ability. The FES + GT group showed significantly greater improvement in motor function, balance and gait abilities after four weeks compared to the PLBO + GT group.

CONCLUSION

It was found that the gait training applied with FES is effective in improving the motor function, balance and gait abilities of stroke patients.

Experiences of individuals with multiple sclerosis and stroke using transcutaneous foot drop electrical stimulators: a systematic review and meta-synthesis of qualitative studies

PURPOSE

To explore the end users' experiences of foot drop electrical stimulator use for people with neurological conditions.

MATERIALS AND METHODS

Electronic databases MEDLINE, EMBASE, CINAHL, Scopus, and Google Scholar were searched in March 2022. Included articles were quality assessed using the Critical Appraisal Skills Programme (CASP) checklist. A thematic synthesis approach was used to synthesise the review findings and establish analytical themes. A Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach was used to assess the level of confidence of analytical themes.

RESULTS

Seven qualitative studies were included with 67 participants with stroke and multiple sclerosis. The outcomes to foot drop stimulator use were enhanced walking ability, independence, confidence, and social participation. Main barriers to use were device aesthetics, usability challenges, trustworthiness of device in complex environments, and cost of the device. A conceptual model was created illustrating the barriers and outcomes in managing foot drop.

CONCLUSIONS

We recommend that the outcomes to continued use of foot drop electrical stimulators are carefully considered against the barriers. Our conceptual model may be useful to guide clinical conversations around the possible use of FES for managing foot drop in people with multiple sclerosis and stroke.Implications for rehabilitationThe key outcomes to foot drop electrical stimulator use were enhanced walking ability, improved independence and confidence, and enhanced social participation.The main barriers to foot drop electrical stimulator use were device aesthetics, usability challenges, trustworthiness of device in complex environments, and cost of the device.We created a conceptual model that may be useful to guide clinical conversations around the possible use of FES for managing foot drop in people with multiple sclerosis and stroke.

Therapeutic Effect of Multi-Channel Transcranial Direct Current Stimulation (M-tDCS) on Recovery of Cognitive Domains, Motor Functions of Paretic Hand and Gait in Subacute Stroke Survivors-A Randomized Controlled Trial Protocol

Background

There has been rapid drift of rehabilitation professionals toward the clinical use of technology aided electrical interventions. Brain is a cortical hub of functionally related neural connections. Motor learning entails strong interaction with the cognitive domains. So better outcomes may be expected by optimally targeting functionally correlated areas simultaneously through tDCS.

Aim

To determine the therapeutic effect of Multi Channel tDCS in combination with Functional electrical stimulation, SaeboFlex and conventional rehabilitation on recovery of Cognitive Domains, Motor Functions of Paretic Hand, and Gait in individuals with subacute Stroke.

Methods

This is prospective, randomized, double blind controlled clinical trial. Subacute Stroke Survivors with the age Group (40-75 years) will constitute the Population of the study. Participants will be randomly allocated to experimental or control group. Participants of Experimental group will receive Multi channel tDCS, Functional electrical stimulation, Saebo Flex Training and conventional rehabilitation. Participants of the group B will receive FES, training with SaeboFlex, conventional physiotherapy intervention similar to as given to the participants of group A and sham multi channel tDCS.

Outcome Measures

The primary outcome measures of the study will be Fugl Meyer assessment, Electroencephalogram and secondary outcome measures of the study will be Grip strength, Pinch strength, Nine hole peg test( NHPT), Wisconsin gait scale, Montreal cognitive assessment, Electroencephaloraphy to observe the cortical changes and tDCS adverse effect questionnaire and stroke specific quality of Life scale.

Statistical Analysis

The primary analysis of the study will be done at the end of 4 weeks. Statistical analysis of data will be done using SPSS Version 22 with the help of a statistician.

Conclusion

An insight into the therapeutic interventions augmenting, cognitive and motor domains simultaneously may yield better outcomes in the field of stroke rehabilitation thereby improving quality of life of stroke survivors.

Immediate Effect of Lower-Leg Kinesio Taping on Ankle Dorsiflexion and Gait Parameters in Chronic Stroke with Foot Drop

OBJECTIVE

Kinesio taping (KT) and proprioceptive neuromuscular facilitation (PNF) are interventions mainly used in clinical settings to improve gait after stroke. Lower-leg KT using the concept of PNF (PNF-KT) has been shown to enhance the recovery of gait speed in patients with stroke. But, the effect of PNF-KT on the ankle movement and gait parameters in stroke patients is unclear. We aimed to investigate the immediate effects of PNF-KT on ankle dorsiflexion range of motion (DF-ROM) and gait parameters in patients with stroke with foot drop.

MATERIALS AND METHODS

For the A-KT condition, tape was attached to the gastrocnemius and tibialis anterior muscles, and tape for eversion was attached. In the PNF-KT condition, tape was attached to the tibialis anterior, extensor hallucis and digitorum muscles. Ankle movement was measured as the ankle DF-ROM using an iSEN system. Gait ability was assessed using the GAITRite system. The measured gait variables were gait velocity, cadence, and step length (both sides).

RESULTS

A-KT and PNF-KT significantly improved the ankle DF-ROM, gait velocity, cadence, and the affected- and unaffected-side step length compared to that with no taping. Moreover, PNF-KT significantly increased the ankle DF-ROM, gait velocity, cadence, and the affected- and unaffected-side step length compared to that with A-KT.

CONCLUSIONS

PNF-KT applied to the affect side improved ankle DF-ROM and gait parameters in hemiplegic stroke patients than no taping, A-KT. Lower-leg PNF-KT may be a useful intervention in a rehabilitation program to improve ankle DF-ROM and gait parameters in chronic stroke patients with foot drop in clinical settings.

Muscle Electrical Impedance Properties and Activation Alteration After Functional Electrical Stimulation-Assisted Cycling Training for Chronic Stroke Survivors: A Longitudinal Pilot Study

Electrical impedance myography (EIM) is a sensitive assessment for neuromuscular diseases to detect muscle inherent properties, whereas surface electromyography (sEMG) is a common technique for monitoring muscle activation. However, the application of EIM in detecting training effects on stroke survivors is relatively few. This study aimed to evaluate the muscle inherent properties and muscle activation alteration after functional electrical stimulation (FES)-assisted cycling training to chronic stroke survivors. Fifteen people with chronic stroke were recruited for 20 sessions of FES-assisted cycling training (40 min/session, 3–5 sessions/week). The periodically stimulated and assessed muscle groups were quadriceps (QC), tibialis anterior (TA), hamstrings (HS), and medial head of gastrocnemius (MG) on the paretic lower extremity. EIM parameters [resistance (R), reactance (X), phase angle (θ), and anisotropy ratio (AR)], clinical scales (Fugl-Meyer Lower Extremity (FMA-LE), Berg Balance Scale (BBS), and 6-min walking test (6MWT)] and sEMG parameters [including root-mean square (RMS) and co-contraction index (CI) value] were collected and computed before and after the training. Linear correlation analysis was conducted between EIM and clinical scales as well as between sEMG and clinical scales. The results showed that motor function of the lower extremity, balance, and walking performance of subjects improved after the training. After training, θ value of TA (P = 0.014) and MG (P = 0.017) significantly increased, and AR of X (P = 0.004) value and AR of θ value (P = 0.041) significantly increased on TA. The RMS value of TA decreased (P = 0.022) and a significant reduction of CI was revealed on TA/MG muscle pair (P < 0.001). Significant correlation was found between EIM and clinical assessments (AR of X value of TA and FMA-LE: r = 0.54, P = 0.046; X value of TA and BBS score: 0.628, P = 0.016), and between sEMG and clinical scores (RMS of TA and BBS score: r = −0.582, P = 0.029). This study demonstrated that FES-assisted cycling training improved lower limb function by developing coordinated muscle activation and facilitating an orderly myofiber arrangement. The current study also indicated that EIM can jointly evaluate lower extremity function alteration with sEMG after rehabilitation training.

Clinical Trail Registration: The study was registered on the Clinical Trial Registry (trial registration number: NCT 03208439, https://clinicaltrials.gov/ct2/show/NCT03208439).

Foot angular kinematics measured with inertial measurement units: A reliable criterion for real-time gait event detection

Accurate and reliable real-time detection of gait events using inertial measurement units (IMUs) is crucial for (1) developing clinically meaningful gait parameters to differentiate normal and impaired gait or (2) creating patient-tailored gait rehabilitation strategies or control of prosthetic devices using feedback from gait phases. However, most previous studies focused only on algorithms with high temporal accuracy and neglected the importance of (1) high reliability, i.e., detecting only and all true gait events, and (2) real-time implementation. Thus, in this study, we presented a novel approach for initial contact (IC) and terminal contact (TC) detection in real-time based on the measurement of the foot orientation. Unlike foot/shank angular velocity and acceleration, foot orientation provides physiologically meaningful kinematic features corresponding to our observational recognition of IC and TC, regardless of the walking modality. We conducted an experimental study to validate our algorithm, including seven participants performing four walking/running activities. By analyzing 5,555 ICs/TCs recorded during the tests, only our algorithm achieved a sensitivity and precision of 100%. Our obtained temporal accuracy (mean ± standard deviation of errors ranging from 0 ± 3 to 6 ± 5 time samples; sampling frequency: 100 Hz) was better than or comparable to those reported in the literature. Our algorithm's performance does not depend on thresholds and gait speed/modality, and it can be used for feedback-based therapeutic gait training or real-time control of assistive or prosthetic technologies. Nevertheless, its performance for pathological gait must be validated in the future. Finally, we shared the codes and sample data on https://www.ncbl.ualberta.ca/codes.

The Effect of Virtual Reality-Based Therapy on Improving Upper Limb Functions in Individuals With Stroke: A Randomized Control Trial

Background: Stroke is a common cause of motor disability. The recovery of upper limb after stroke is poor, with few stroke survivors regaining some functional use of the affected upper limb. This is further complicated by the fact that the prolonged rehabilitation is accompanied by multiple challenges in using and identifying meaningful and motivated treatment tasks that may be adapted and graded to facilitate the rehabilitation program. Virtual reality-based therapy is one of the most innovative approaches in rehabilitation technology and virtual reality systems can provide enhanced feedback to promote motor learning in individuals with neurological or musculoskeletal diseases.

Purpose: This study investigated the effect of virtual reality-based therapy on improving upper limb functions in individuals with chronic stroke.

Methods: Forty Saudi individuals with chronic stroke (6–24 months following stroke incidence) and degree of spasticity ranged between 1, 1 + and 2 according to Modified Ashworth Scale were included in this study. Participants were randomly assigned into two groups, experimental and control, with the experimental group undertaking a conventional 1-h functional training program, followed by another hour of virtual reality-based therapy using Armeo Spring equipment and the control group received 2 h of a conventional functional training program. The treatment program was conducted three times per week for three successive months. The change in the scores of Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), WMFT-Time (time required to complete the test) and Hand Grip Strength (HGS) were recorded at baseline and after completion of the treatment. Parametric (paired and unpaired t-tests) non-parametric (Wilcoxon and Mann–Whitney tests) statistical tests were used to identify the differences within and between groups (experimental group and control group) and evaluation times (pre- and immediately post-treatment).

Results: Both groups showed significant differences (all, P < 0.05) in all measured variables after 3 months of the treatment. Individuals with stoke in the experimental group had a better improvement in ARAT (P < 0.01), WMFT (P < 0.01) and WMFT-Time (P < 0.01) scores after completion of the treatment compared to the control group. No significant difference in HGS scores was detected between groups after completion of the treatment (P = 0.252).

Conclusion: The use of combined treatment of virtual reality-based therapy and conventional functional training program is more effective for improving upper limb functions in individuals with chronic stroke than the use of the conventional program alone.

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.

DNN-Based FES Control for Gait Rehabilitation of Hemiplegic Patients

In this study, we proposed a novel machine-learning-based functional electrical stimulation (FES) control algorithm to enhance gait rehabilitation in post-stroke hemiplegic patients. The electrical stimulation of the muscles on the paretic side was controlled via deep neural networks, which were trained using muscle activity data from healthy people during gait. The performance of the developed system in comparison with that of a conventional FES control method was tested with healthy human subjects.

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).

Nonsurgical Treatment Options for Muscle Contractures in Individuals With Neurologic Disorders: A Systematic Review With Meta-Analysis

OBJECTIVE

To investigate whether nonsurgical treatment can reduce muscle contractures in individuals with neurologic disorders. The primary outcome measure was muscle contractures measured as joint mobility or passive stiffness.

DATA SOURCES

Embase, MEDLINE, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database in June-July 2019 and again in July 2020.

STUDY SELECTION

The search resulted in 8020 records, which were screened by 2 authors based on our patient, intervention, comparison, outcome criteria. We included controlled trials of nonsurgical interventions administered to treat muscle contractures in individuals with neurologic disorders.

DATA EXTRACTION

Authors, participant characteristics, intervention details, and joint mobility/passive stiffness before and after intervention were extracted. We assessed trials for risk of bias using the Downs and Black checklist. We conducted meta-analyses investigating the short-term effect on joint mobility using a random-effects model with the pooled effect from randomized controlled trials (RCTs) as the primary outcome. The minimal clinically important effect was set at 5°.

DATA SYNTHESIS

A total of 70 trials (57 RCTs) were eligible for inclusion. Stretch had a pooled effect of 3° (95% CI, 1-4°; prediction interval (PI)=-2 to 7°; I 2=66%; P<.001), and robot-assisted rehabilitation had an effect of 1 (95% CI, 0-2; PI=-8 to 9; I 2=73%; P=.03). We found no effect of shockwave therapy (P=.56), physical activity (P=.27), electrical stimulation (P=.11), or botulinum toxin (P=.13). Although trials were generally of moderate to high quality according to the Downs and Black checklist, only 18 of the 70 trials used objective measures of muscle contractures. In 23 trials, nonobjective measures were used without use of assessor-blinding.

CONCLUSIONS

We did not find convincing evidence supporting the use of any nonsurgical treatment option. We recommend that controlled trials using objective measures of muscle contractures and a sufficiently large number of participants be performed.

The Effects of Combining Transcranial Direct Current Stimulation and Gait Training with Functional Electrical Stimulation on Trunk Acceleration During Walking in Patients with Subacute Stroke

OBJECTIVES

This study aimed to investigate whether the combination of transcranial direct current stimulation (tDCS) and gait training with FES affected walking speed and trunk accelerometry-based gait characteristics in patients with subacute stroke, compared with FES or tDCS gait training only.

MATERIALS AND METHODS

Stroke patients (n = 34; female 15; mean age, 72.5 ± 11.2 years; mean days poststroke, 38.7) with resultant paresis in the lower extremity (mean Fugl-Meyer score, 25.5) were enrolled. Patients were randomly assigned to one of three groups: combined anodal tDCS and gait training with FES (tDCS+FES, n = 11), anodal tDCS with gait training (tDCS, n = 11), or combined sham tDCS and gait training with FES (FES, n = 12). Participants received the intervention for 20 minutes and a 40-minute conventional rehabilitative intervention daily for a week. Patients' walking ability was evaluated using walking speed, harmonic ratio (HR), autocorrelation coefficient (AC), and root mean square (RMS) along each axis using a wearable trunk accelerometer.

RESULTS

The tDCS+FES group had a significantly greater change in AC in the anteroposterior axis and mediolateral axis than the FES and tDCS groups and FES group, respectively. There were no significant effects on walking speed or other parameters (HR and RMS) among the groups.

CONCLUSIONS

The combination of anodal tDCS and gait training with FES improved the post-stroke patients' gait regularity than FES gait training intervention only. Thus, combined tDCS and FES gait training, as a novel intervention, could be an important therapeutic tool in improving walking performance.

Effect of Functional Electrical Stimulation of the Gluteus Medius during Gait in Patients following a Stroke

Many stroke patients rely on cane or ankle-foot orthosis during gait rehabilitation. The purpose of this study was to investigate the immediate effect of functional electrical stimulation (FES) to the gluteus medius (GMed) and tibialis anterior (TA) on gait performance in stroke patients, including those who needed assistive devices. Fourteen stroke patients were enrolled in this study (mean poststroke duration: 194.9 ± 189.6 d; mean age: 72.8 ± 10.7 y). Participants walked 14 m at a comfortable velocity with and without FES to the GMed and TA. After an adaptation period, lower-limb motion was measured using magnetic inertial measurement units attached to the pelvis and the lower limb of the affected side. Motion range of angle of the affected thigh and shank segments in the sagittal plane, motion range of the affected hip and knee extension-flexion angle, step time, and stride time were calculated from inertial measurement units during the middle ten walking strides. Gait velocity, cadence, and stride length were also calculated. These gait indicators, both with and without FES, were compared. Gait velocity was significantly faster with FES (p = 0.035). Similarly, stride length and motion range of the shank of the affected side were significantly greater with FES (stride length: p = 0.018; motion range of the shank: p = 0.026). Meanwhile, cadence showed no significant difference (p = 0.238) in gait with or without FES. Similarly, range of motion of the affected hip joint, knee joint, and thigh did not differ significantly depending on FES condition (p = 0.115‐0.529). FES to the GMed and TA during gait produced an improvement in gait velocity, stride length, and motion range of the shank. Our results will allow therapists to use FES on stroke patients with varying conditions.

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.

Motor neuroprosthesis for promoting recovery of function after stroke

BACKGROUND

Motor neuroprosthesis (MN) involves electrical stimulation of neural structures by miniaturized devices to allow the performance of tasks in the natural environment in which people live (home and community context), as an orthosis. In this way, daily use of these devices could act as an environmental facilitator for increasing the activities and participation of people with stroke.

OBJECTIVES

To assess the effects of MN for improving independence in activities of daily living (ADL), activities involving limbs, participation scales of health-related quality of life (HRQoL), exercise capacity, balance, and adverse events in people after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (searched 19 August 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (August 2019), MEDLINE (1946 to 16 August 2019), Embase (1980 to 19 August 2019), and five additional databases. We also searched trial registries, databases, and websites to identify additional relevant published, unpublished, and ongoing trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and randomized controlled cross-over trials comparing MN for improving activities and participation versus other assistive technology device or MN without electrical stimulus (stimulator is turned off), or no treatment, for people after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed risk of bias of the included studies. Any disagreements were resolved through discussion with a third review author. We contacted trialists for additional information when necessary and performed all analyses using Review Manager 5. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included four RCTs involving a total of 831 participants who were more than three months poststroke. All RCTs were of MN that applied electrical stimuli to the peroneal nerve. All studies included conditioning protocols to adapt participants to MN use, after which participants used MN from up to eight hours per day to all-day use for ambulation in daily activities performed in the home or community context. All studies compared the use of MN versus another assistive device (ankle-foot orthosis [AFO]). There was a high risk of bias for at least one assessed domain in three of the four included studies. No studies reported outcomes related to independence in ADL. There was low-certainty evidence that AFO was more beneficial than MN on activities involving limbs such as walking speed until six months of device use (mean difference (MD) -0.05 m/s, 95% confidence interval (CI) -0.10 to -0.00; P = 0.03; 605 participants; 2 studies; I² = 0%; low-certainty evidence); however, this difference was no longer present in our sensitivity analysis (MD -0.07 m/s, 95% CI -0.16 to 0.02; P = 0.13; 110 participants; 1 study; I² = 0%). There was low to moderate certainty that MN was no more beneficial than AFO on activities involving limbs such as walking speed between 6 and 12 months of device use (MD 0.00 m/s, 95% CI -0.05 to 0.05; P = 0.93; 713 participants; 3 studies; I² = 17%; low-certainty evidence), Timed Up and Go (MD 0.51 s, 95% CI -4.41 to 5.43; P = 0.84; 692 participants; 2 studies; I² = 0%; moderate-certainty evidence), and modified Emory Functional Ambulation Profile (MD 14.77 s, 95% CI -12.52 to 42.06; P = 0.29; 605 participants; 2 studies; I² = 0%; low-certainty evidence). There was no significant difference in walking speed when MN was delivered with surface or implantable electrodes (test for subgroup differences P = 0.09; I² = 65.1%). For our secondary outcomes, there was very low to moderate certainty that MN was no more beneficial than another assistive device for participation scales of HRQoL (standardized mean difference 0.26, 95% CI -0.22 to 0.74; P = 0.28; 632 participants; 3 studies; I² = 77%; very low-certainty evidence), exercise capacity (MD -9.03 m, 95% CI -26.87 to 8.81; P = 0.32; 692 participants; 2 studies; I² = 0%; low-certainty evidence), and balance (MD -0.34, 95% CI -1.96 to 1.28; P = 0.68; 692 participants; 2 studies; I² = 0%; moderate-certainty evidence). Although there was low- to moderate-certainty evidence that the use of MN did not increase the number of serious adverse events related to intervention (risk ratio (RR) 0.35, 95% CI 0.04 to 3.33; P = 0.36; 692 participants; 2 studies; I² = 0%; low-certainty evidence) or number of falls (RR 1.20, 95% CI 0.92 to 1.55; P = 0.08; 802 participants; 3 studies; I² = 33%; moderate-certainty evidence), there was low-certainty evidence that the use of MN in people after stroke may increase the risk of participants dropping out during the intervention (RR 1.48, 95% CI 1.11 to 1.97; P = 0.007; 829 participants; 4 studies; I² = 0%).

AUTHORS' CONCLUSIONS

Current evidence indicates that MN is no more beneficial than another assistive technology device for improving activities involving limbs measured by Timed Up and Go, balance (moderate-certainty evidence), activities involving limbs measured by walking speed and modified Emory Functional Ambulation Profile, exercise capacity (low-certainty evidence), and participation scale of HRQoL (very low-certainty evidence). Evidence was insufficient to estimate the effect of MN on independence in ADL. In comparison to other assistive devices, MN does not appear to increase the number of falls (moderate-certainty evidence) or serious adverse events (low-certainty evidence), but may result in a higher number of dropouts during intervention period (low-certainty evidence).

Use of a Novel Functional Electrical Stimulation Gait Training System in 2 Adolescents With Cerebral Palsy: A Case Series Exploring Neurotherapeutic Changes

BACKGROUND AND PURPOSE

Cerebral palsy (CP) is characterized by decreased passive joint range-of-motion and impaired walking, resulting in progressive loss of function. Typical gait training interventions for children with CP appear insufficient to mitigate these effects. The purpose of this case report is to describe the use of a new treadmill-based gait training intervention using active correction with functional electrical stimulation (FES) in 2 adolescents with CP.

CASE DESCRIPTION

Two participants with CP (13-year-old girls, Gross Motor Function Classification System [GMFCS] level II and III) trained by walking on a treadmill, with FES assistance, for 30 minutes, 3 times per week, for 12 weeks. The intervention used a feedback control system to detect all 7 phases of gait in real time and triggered FES to the appropriate muscle groups (up to 5 bilaterally) based on the detected gait phase. Joint kinematics, step width, stride length, walking endurance, peak oxygen uptake ($\dot{v}^{o}_{2}$), and oxygen (O2) cost of walking were evaluated preintervention and postintervention.

OUTCOMES

Both participants showed improved knee and ankle angles and step width relative to children who are typically developing, and both exhibited increased stride length. One participant (GMFCS III) improved peak $\dot{v}^{o}_{2}$and walking endurance but not O2 cost of walking at her original self-selected walking speed. The other participant (GMFCS II) improved O2 cost of walking but not peak $\dot{v}^{o}_{2}$ or walking endurance. These differences are partly explained by differences in gait type, functional abilities, and initial fitness levels. Most improvements persisted at follow-up, indicating short-term neurotherapeutic effects.

DISCUSSION

Most improvements persisted at follow-up, suggesting short-term neurotherapeutic effects. This case series demonstrates the promising utility of FES-assisted gait-training interventions, tailored to target individual gait deviations, in improving walking performance.

Effect of Kinesio Taping on the Walking Ability of Patients with Foot Drop after Stroke

Objective

The purpose of this study was to investigate the effect of kinesio taping on the walking ability in patients with foot drop after stroke.

Methods

Sixty patients were randomly divided into the experimental group (with kinesio taping) and the control group (without kinesio taping). The 10-Meter Walking Test (10MWT), Timed Up and Go Test (TUGT), stride length, stance phase, swing phase, and foot rotation of the involved side were measured with the German ZEBRIS gait running platform analysis system and were used to evaluate and compare the immediate effects of kinesio taping. All the measurements were made in duplicate for each patient.

Results

The demographic variables of patients in both groups were comparable before the treatment (p>0.05). After kinesio taping treatment, significant improvement was found in the 10MWT and the TUGT for patients in the experimental group (p<0.05). There were significant differences in the 10MWT and TUGT between the experimental and control groups after treatment (p<0.05). In terms of gait, we found significant improvement in stride length (p<0.001), stance phase (p<0.001), swing phase (p<0.001), and foot rotation (p<0.001) of the involved side in experimental group after treatment compared with those before treatment. Further, the functional outcomes and gait ability were significantly improved in the experimental group after treatment (p<0.05), compared to the control group.

Conclusion

Kinesio taping can immediately improve the walking function of patients with foot drop after stroke.

Gait Rehabilitation Using Functional Electrical Stimulation Induces Changes in Ankle Muscle Coordination in Stroke Survivors: A Preliminary Study

Background: Previous studies have demonstrated that post-stroke gait rehabilitation combining functional electrical stimulation (FES) applied to the ankle muscles during fast treadmill walking (FastFES) improves gait biomechanics and clinical walking function. However, there is considerable inter-individual variability in response to FastFES. Although FastFES aims to sculpt ankle muscle coordination, whether changes in ankle muscle activity underlie observed gait improvements is unknown. The aim of this study was to investigate three cases illustrating how FastFES modulates ankle muscle recruitment during walking.

Methods: We conducted a preliminary case series study on three individuals (53–70 y; 2 M; 35–60 months post-stroke; 19–22 lower extremity Fugl-Meyer) who participated in 18 sessions of FastFES (3 sessions/week; ClinicalTrials.gov: NCT01668602). Clinical walking function (speed, 6-min walk test, and Timed-Up-and-Go test), gait biomechanics (paretic propulsion and ankle angle at initial-contact), and plantarflexor (soleus)/dorsiflexor (tibialis anterior) muscle recruitment were assessed pre- and post-FastFES while walking without stimulation.

Results:Two participants (R1, R2) were categorized as responders based on improvements in clinical walking function. Consistent with heterogeneity of clinical and biomechanical changes commonly observed following gait rehabilitation, how muscle activity was altered with FastFES differed between responders. R1 exhibited improved plantarflexor recruitment during stance accompanied by increased paretic propulsion. R2 exhibited improved dorsiflexor recruitment during swing accompanied by improved paretic ankle angle at initial-contact. In contrast, the third participant (NR1), classified as a non-responder, demonstrated increased ankle muscle activity during inappropriate phases of the gait cycle. Across all participants, there was a positive relationship between increased walking speeds after FastFES and reduced SOL/TA muscle coactivation.

Conclusion:Our preliminary case series study is the first to demonstrate that improvements in ankle plantarflexor and dorsiflexor muscle recruitment (muscles targeted by FastFES) accompanied improvements in gait biomechanics and walking function following FastFES in individuals post-stroke. Our results also suggest that inducing more appropriate (i.e., reduced) ankle plantar/dorsi-flexor muscle coactivation may be an important neuromuscular mechanism underlying improvements in gait function after FastFES training, suggesting that pre-treatment ankle muscle status could be used for inclusion into FastFES. The findings of this case-series study, albeit preliminary, provide the rationale and foundations for larger-sample studies using similar methodology.

A systematic review of physical rehabilitation interventions for stroke in low and lower-middle income countries

Purpose: Approximately 70% of strokes occur in low and middle income countries, yet the effectiveness of physical rehabilitation in these contexts remains undetermined. This systematic review identifies and summarises the current evidence supporting physical rehabilitation interventions post-stroke in low and lower-middle income countries.Methods: Five databases were comprehensively searched (April 2017) for randomised controlled trials, clinical controlled trials, and cohort studies testing rehabilitation interventions post-stroke in these countries. The Effective Public Health Practice Project Tool assessed quality of included studies.Results: Sixty-two studies (2115 participants) were included. Interventions addressed upper limb (n = 26), lower limb (n = 22), and other (n = 14) outcomes. Seven studies were rated as strong in quality, 16 moderate and 39 rated as weak. Overall, in addition to usual care, physical rehabilitation interventions improved outcomes for stroke survivors. Best evidence synthesis provides level I (b) evidence supporting constraint induced movement therapy and mirror therapy to improve upper limb functional outcomes. Level I (b) evidence supports multimodal interventions that include lower limb motor imagery to improve gait parameters. Level II (b) evidence supports sit-to-stand training to improve balance outcomes.Conclusions: Exercise-based and brain training interventions improved functional outcomes post-stroke in low and lower-middle income countries. Further high-quality studies including participation outcomes are required.Implications for RehabilitationLow-cost physical rehabilitation interventions requiring minimal resources can improve functional outcomes after stroke in low and lower-middle income countries.Exercise-based interventions can improve upper limb, lower limb, gait, and balance outcomes after stroke.Brain training paradigms such as mirror therapy and motor imagery, when included in therapy packages, can improve upper limb and gait outcomes.The proven efficacy for rehabilitation interventions in improving stroke outcomes in low and lower-middle income countries supports the need to strengthen the rehabilitation workforce in this context.

Effects of biofeedback versus switch-triggered functional electrical stimulation on sciatica-related foot drop

BACKGROUND

Sciatica-related Foot Drop is a peripheral nervous condition that produces a loss of power in the ankle dorsiflexion muscles. Functional electrical stimulation is a modality of electrical stimulation that produces muscle contraction in a functional movement of the limb. This technique was utilized with positive effects in central nervous afflictions but it is not known whether or not it has any influence in motor recovery following peripheral nervous system problems. This study aims to clarify the effects of functional electrical stimulation on foot drop caused by peripheral nerve compression resulting from lumbar disc herniation.

METHODS

Fifty patients were enrolled in our study; of whom 25 were treated with EMG triggered electrical stimulation (EMG-FES) and 25 with heel-floor sensor triggered electrical stimulation (SWITCH-FES) during normal gait cycle. Patients received functional electrical stimulation (with a pulse of 60 Hz and phase duration of 200 ms) once a day, for 30 minutes during 5 consecutive days, over a period of 4 weeks. Electrical diagnostic tests (nerve conduction velocity/NCV and the amplitude of compound muscle action potential/CMAP), dynamometry and Osvestry Disability Index scores were measured at baseline and after treatment.

RESULTS

We found that axonal loss was lower in the EMG-FES group than in the SWITCH-FES group (p< 0.004). The motor functional recovery was higher in terms of muscle force and overall functional status for the EMG-FES group compared to the SWITCH-FES group. This was underlined by Dynamometry test with a p value of < 0.0001 and ODI score with a statistical significant p value of < 0.0001.

CONCLUSIONS

The overall results showed that there was a significant increase in all the parameters studied for both types of FES applications. However we found that the EMG triggered electrical stimulation technique had a higher influence on the quality of the muscle action control. For patients who cannot yet produce minimal muscle active contraction we recommend switch triggered stimulation first and then, immediately after the recovery of the motor control, to change to EMG triggered functional electrical stimulation.

Novel multi-pad functional electrical stimulation in stroke patients: A single-blind randomized study

BACKGROUND

Foot drop is common gait impairment after stroke. Functional electrical stimulation (FES) of the ankle dorsiflexor muscles during the swing phase of gait can help correcting foot drop.

OBJECTIVE

To evaluate efficacy of additional novel FES system to conventional therapy in facilitating motor recovery in the lower extremities and improving walking ability after stroke.

METHODS

Sixteen stroke patients were randomly allocated to the FES group (FES therapy plus conventional rehabilitation program) (n = 8), and control group (conventional rehabilitation program) n = 8. FES was delivered for 30 min during gait to induce ankle plantar and dorsiflexion.

MAIN OUTCOME MEASURES

gait speed using 10 Meter Walk Test (10 MWT), Fugl-Meyer Assessment (FMA), Berg Balance Scale (BBS) and modified Barthel Index (MBI).

RESULTS

Results showed a significant increase in gait speed in FES group (p < 0.001), higher than the minimal detected change. The FES group showed improvement in functional independence in the activities of daily living, motor recovery and gait performance.

CONCLUSIONS

The findings suggest that novel FES therapy combined with conventional rehabilitation is more effective on walking speed, mobility of the lower extremity, balance disability and activities of daily living compared to a conventional rehabilitation program only.

Influence of Elbow Flexion and Stimulation Site on Neuromuscular Electrical Stimulation of the Biceps Brachii

Functional electrical stimulation (FES) can help individuals with physical disabilities by assisting limb movement; however, the change in muscle geometry associated with limb movement may affect the response to stimulation. The aim of this paper was to quantify the effects of elbow flexion and stimulation site on muscle torque production. Contraction torque about the elbow was measured in 12 healthy individuals using a custom elbow flexion testbed and a transcutaneous electrode array. Stimulation was delivered to six distinct sites along the biceps brachii over 11 elbow flexion angles. Flexion angle was found to significantly influence the optimal (i.e., torque-maximizing) stimulation site ( ), with post hoc analysis indicating a proximal shift in optimal stimulation site with increased flexion. Similarly, the biceps stimulation site was found to significantly influence the flexion angle at which peak torque occurred ( ), with post hoc analysis indicating an increase in peak-torque flexion angle as stimulation site is moved proximally up the biceps. Since maximizing muscle force per unit stimulation is a common goal in rehabilitative FES, future efforts could examine methods which compensate for the shift in optimal stimulation site during FES-induced limb movement.

A systematic review of mechanisms of gait speed change post-stroke. Part 1: spatiotemporal parameters and asymmetry ratios

BACKGROUND

In walking rehabilitation trials, self-selected walking speed (SSWS) has emerged as the dominant outcome measure to assess walking ability. However, this measure cannot differentiate between recovery of impaired movement and compensation strategies. Spatiotemporal variables and asymmetry ratios are frequently used to quantify gait deviations and are hypothesized markers of recovery.

OBJECTIVES

The purpose of this review is to investigate spatiotemporal variables and asymmetry ratios as mechanistic recovery measures in physical therapy intervention studies post-stroke.

METHODS

A systematic literature search was performed to identify physical therapy intervention studies with a statistically significant change in SSWS post intervention and concurrently collected spatiotemporal variables. Methodological quality was assessed using the Cochrane Collaboration's tool. Walking speed, spatiotemporal, and intervention data were extracted.

RESULTS

46 studies met the inclusion criteria, 41 of which reported raw spatiotemporal measures and 19 reported asymmetry ratio calculations. Study interventions included: aerobic training (n = 2), functional electrical stimulation (n = 5), hippotherapy (n = 2), motor dual task training (n = 2), multidimensional rehabilitation (n = 4), robotics (n = 4), sensory stimulation training (n = 8), strength/resistance training (n = 4), task specific locomotor rehabilitation (n = 9), and visually guided training (n = 6).

CONCLUSIONS

Spatiotemporal variables help describe gait deviations, but scale to speed, so consequently, may not be an independent factor in describing functional recovery and gains. Therefore, these variables are limited in explaining mechanistic changes involved in improving gait speed. Use of asymmetry measures provides additional information regarding the coordinative requirements for gait and can potentially indicate recovery. Additional laboratory-based mechanistic measures may be required to truly understand how walking speed improves.

Effect of electrical stimulation as an adjunct to botulinum toxin type A in the treatment of adult spasticity: a systematic review

OBJECTIVE

To investigate whether electrical stimulation (ES) as an adjunct to BTX-A boosts botulinum activity and whether the combined therapeutic procedure is more effective than BTX-A alone in reducing spasticity in adult subjects.

DATA SOURCES

A search was conducted in PubMed, EMBASE, Cochrane Central Register, and CINAHL from January 1966 to January 2016.

STUDY SELECTION

Only randomized controlled studies (RCT) involving the combination of BTX-A and ES were considered. RCTs were excluded if BTX plus ES was investigated in animals or healthy subjects; certain techniques were used as an adjunct to BTX-A, but ES was not used; BTX-A or ES were compared but were not used in combination. ES was divided into neuromuscular stimulation (NMS), functional electrical stimulation (FES), and transcutaneous electrical nerve stimulation (TENS). Two authors independently screened all search results and reviewed study characteristics using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Fifteen RCTs were pinpointed and nine studies were included. Trials varied in methodological quality, size, and outcome measures used. ES was used in the form of NMS and FES in seven and two studies, respectively. No study investigating BTX-A plus TENS was found. BTX-A plus ES produced significant reduction in spasticity on the Ashworth Scale (AS) and on the modified AS in seven studies, but only four showed high quality on the PEDro scale. Significant reduction in compound muscular action potential (CMAP) amplitude was detected after BTX-A plus ES in two studies.

CONCLUSIONS

ES as an adjunctive therapy to BTX-A may boost BTX-A action in reducing adult spasticity, but ES variability makes it difficult to recommend the combined therapy in clinical practice. Implications for rehabilitation Electrical stimulation (ES) as adjunct to botulinum toxin type A (BTX-A) injections may boost neurotoxin action in treating adult spasticity. Given the variability of ES characteristics and the paucity of high-quality trials, it is difficult to support definitively the use of BTX-A plus ES to potentiate BTX-A effect in clinical practice. A vast array of rehabilitation interventions combined with BTX-A have been provided in reducing spasticity, but the present evidence is not sufficient to recommend any combined therapeutic strategy.

A Personalized Multi-Channel FES Controller Based on Muscle Synergies to Support Gait Rehabilitation after Stroke

It has been largely suggested in neuroscience literature that to generate a vast variety of movements, the Central Nervous System (CNS) recruits a reduced set of coordinated patterns of muscle activities, defined as muscle synergies. Recent neurophysiological studies have recommended the analysis of muscle synergies to finely assess the patient's impairment, to design personalized interventions based on the specific nature of the impairment, and to evaluate the treatment outcomes. In this scope, the aim of this study was to design a personalized multi-channel functional electrical stimulation (FES) controller for gait training, integrating three novel aspects: (1) the FES strategy was based on healthy muscle synergies in order to mimic the neural solutions adopted by the CNS to generate locomotion; (2) the FES strategy was personalized according to an initial locomotion assessment of the patient and was designed to specifically activate the impaired biomechanical functions; (3) the FES strategy was mapped accurately on the altered gait kinematics providing a maximal synchronization between patient's volitional gait and stimulation patterns. The novel intervention was tested on two chronic stroke patients. They underwent a 4-week intervention consisting of 30-min sessions of FES-supported treadmill walking three times per week. The two patients were characterized by a mild gait disability (walking speed > 0.8 m/s) at baseline. However, before treatment both patients presented only three independent muscle synergies during locomotion, resembling two different gait abnormalities. After treatment, the number of extracted synergies became four and they increased their resemblance with the physiological muscle synergies, which indicated a general improvement in muscle coordination. The originally merged synergies seemed to regain their distinct role in locomotion control. The treatment benefits were more evident for one patient, who achieved a clinically important change in dynamic balance (Mini-Best Test increased from 17 to 22) coupled with a very positive perceived treatment effect (GRC = 4). The treatment had started the neuro-motor relearning process also on the second subject, but twelve sessions were not enough to achieve clinically relevant improvements. This attempt to apply the novel theories of neuroscience research in stroke rehabilitation has provided promising results, and deserves to be further investigated in a larger clinical study.

Wireless, accelerometry-triggered functional electrical stimulation of the peroneal nerve in spastic paresis: A randomized, controlled pilot study

In hemiparesis, Wireless, Accelerometry-Triggered Functional Electrical Stimulation (WAFES) of the common peroneal nerve may hold intrinsic rehabilitative properties. The present pilot study analyzes WAFES against conventional therapy. Twenty adults with chronic hemiparesis (time since lesion 7(6) years; median (interquartile range)) were randomized into 2 10-week rehabilitation programs: a 45-minute (min) daily walk using WAFES (n = 10) and conventional physical therapy (CPT), 3 × 45 min per week (n = 10). The outcomes were 3D sagittal speed measurements, step length, cadence, maximal amplitude and velocity of hip, knee, and ankle during gait at free and fast speed without WAFES and clinical assessments of plantar flexor angles of shortening, spasticity, and weakness, before (D1) and after the program (W10). Kinematic and spasticity improvements occurred in the WAFES group only: (i) ankle dorsiflexion velocity (D1 versus W10, free speed, WAFES, +4(5)°/sec, p = 0.002; CPT, -3(8)°/sec, p = 0.007; fast, WAFES, +8(6)°/sec, p = 0.03; CPT, -1(4)°/sec, NS); (ii) maximal passive ankle dorsiflexion (WAFES,+26(85)%; CPT,+0(27)%; group-visit, p = 0.007) and knee flexion (WAFES, +13(17)%; CPT, -1(11)%; group-visit, p = 0.006) at fast speed only; (iii) 15% plantar flexor spasticity grade reduction with WAFES. Over 10 weeks, gait training using WAFES improved ankle and knee kinematics and reduced plantar flexor spasticity compared with CPT. Studies with longer WAFES use should explore functional effects.

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.).

Neuromuscular Electrical Stimulation for Motor Restoration in Hemiplegia

This article reviews the most common therapeutic and neuroprosthetic applications of neuromuscular electrical stimulation (NMES) for upper and lower extremity stroke rehabilitation. Fundamental NMES principles and purposes in stroke rehabilitation are explained. NMES modalities used for upper and lower limb rehabilitation are described, and efficacy studies are summarized. The evidence for peripheral and central mechanisms of action is also summarized.

Surface peroneal nerve stimulation in lower limb hemiparesis: effect on quantitative gait parameters

OBJECTIVE

The objective of this study was to evaluate possible mechanisms for functional improvement and compare ambulation training with surface peroneal nerve stimulation vs. usual care via quantitative gait analysis.

DESIGN

This study is a randomized controlled clinical trial.

SETTING

The setting of this study is a teaching hospital of an academic medical center.

PARTICIPANTS

One hundred ten chronic stroke survivors (>12 wks poststroke) with unilateral hemiparesis participated in this study.

INTERVENTIONS

The subjects were randomized to a surface peroneal nerve stimulation device or usual care intervention. The subjects were treated for 12 wks and followed up for 6-mo posttreatment.

MAIN OUTCOME MEASURES

Spatiotemporal, kinematic, and kinetic parameters of gait were the main outcome measures.

RESULTS

Cadence (F3,153 = 5.81, P = 0.012), stride length (F3,179 = 20.01, P < 0.001), walking speed (F3,167 = 18.2, P < 0.001), anterior-posterior ground reaction force (F3,164 = 6.61, P = 0.004), peak hip power in preswing (F3,156 = 8.76, P < 0.001), and peak ankle power at push-off (F3,149 = 6.38, P = 0.005) all improved with respect to time. However, peak ankle ankle dorsiflexion in swing (F3,184 = 4.99, P = 0.031) worsened. In general, the greatest change for all parameters occurred during the treatment period. There were no significant treatment group × time interaction effects for any of the spatiotemporal, kinematic, or kinetic parameters.

CONCLUSIONS

Gait training with peroneal nerve stimulation and usual care was associated with improvements in peak hip power in preswing and peak ankle power at push-off, which may have resulted in improved cadence, stride length, and walking speed; however, there were no differences between treatment groups. Both treatment groups also experienced a decrease in peak ankle ankle dorsiflexion in swing, although the clinical implications of this finding are unclear.

EMG of the tibialis anterior demonstrates a training effect after utilization of a foot drop stimulator

BACKGROUND

Functional Electrical Stimulation (FES) applied through a foot drop stimulator (FDS) is a rehabilitation intervention that can stimulate the common peroneal nerve to provide dorsiflexion at the correct timing during gait.

OBJECTIVE

To determine if FES applied to the peroneal nerve during walking through a FDS would effectively retrain the electromyographic temporal activation of the tibialis anterior in individuals with stroke.

METHODS

Surface electromyography (EMG) were collected bilaterally from the tibialis anterior (TA) while participants (n = 4) walked with and without the FDS at baseline and 4 weeks. Comparisons were made between stimulation timing and EMG activation timing to produce a burst duration similarity index (BDSI).

RESULTS

At baseline, participants displayed variable temporal activation of the TA. At 4 weeks, TA activation during walking without the FDS more closely resembled the pre-programmed FDS timing demonstrated by an increase in BDSI scores in all participants (P = 0.05).

CONCLUSIONS

Continuous use of FDS during a task specific movement can re-train the neuromuscular system. After 4 weeks of utilization the FDS trained the TA to replicate the programmed temporal activation patterns. These findings begin to establish the FDS as a rehabilitation intervention that may facilitate recovery rather than just compensate for stroke related gait impairments due to foot drop.

Effects of functional electrical stimulation on gait function and quality of life for people with multiple sclerosis taking dalfampridine

BACKGROUND

Multiple sclerosis (MS) can adversely affect gait, causing gait slowing, loss of balance, decreased functional mobility, and gait deficits, such as footdrop. Current treatments for gait dysfunction due to MS are pharmacologic, using dalfampridine, or orthotic, using an ankle-foot orthosis. Functional electrical stimulation (FES) to the fibular nerve stimulates active dorsiflexion and provides an alternative treatment for gait dysfunction caused by footdrop. The objective of this study was to determine the effect of FES on gait function and the impact of MS on walking and quality of life for people with MS taking a stable dalfampridine dose.

METHODS

Participants demonstrating gait slowing and footdrop completed the Timed 25-Foot Walk (T25FW) test, 6-Minute Walk (6MW) test, GaitRite Functional Ambulation Profile, 12-item Multiple Sclerosis Walking Scale (MSWS-12), and 36-item Short Form Health Status Survey (SF-36) at screening without FES; the measures were repeated with FES at baseline, 1 month, and 3 months.

RESULTS

Twenty participants (8 men and 12 women) completed this unblinded case series study. The mean age, duration of MS, and time taking dalfampridine were 51.7, 15.8, and 1.4 years, respectively. Changes from screening to baseline and screening to 3 months were analyzed. Significant improvement was noted from screening to baseline for the MSWS-12 (P = .024) and SF-36 Physical Function domain (P = .028) and from screening to 3 months for the T25FW (P = .015), MSWS-12 (P = .003), and SF-36 Physical Function (P = .032) and Role Limitation-Physical Health (P = .012) domains.

CONCLUSIONS

Improvements above those induced pharmacologically suggest that FES can augment pharmacologic intervention and significantly improve gait function, decrease the impact of MS on walking, and improve quality of life for people with MS.

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.

Therapeutic effects of functional electrical stimulation on gait in individuals post-stroke

Functional electrical stimulation (FES) to lower extremity (LE) muscles is used by individuals post-stroke as an alternative to mechanical orthotic devices during gait or as a training modality during rehabilitation. Technological developments which improve the feasibility, accessibility and effectiveness of FES systems as orthotic and training devices, highlight the potential of FES for rehabilitating LE function in individuals post-stroke. This study presents a systematic review of the carryover effects of LE FES to motor performance when stimulation is not applied (therapeutic effects) in subjects post-stroke. A description of advances in FES technologies, with an emphasis on systems designed to promote LE function is included, and mechanisms that may be associated with the observed therapeutic effects are discussed. Eligible studies were reviewed for methodological quality, population, intervention and outcome characteristics. Therapeutic effects of FES were consistently demonstrated at the body function and activity levels when it was used as a training modality. Compared to matched treatments that did not incorporate FES, no definite conclusions can be drawn regarding the superiority of FES. When FES was used as an alternative to an orthotic device, it had no superior therapeutic effects at the activity level, yet patients still seemed to prefer it.

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.