A novel neuromuscular electrical stimulation treatment for recovery of ankle dorsiflexion in chronic hemiplegia: a case series pilot study

Effectiveness of contralaterally controlled functional electrical stimulation vs. neuromuscular electrical stimulation for recovery of lower extremity function in patients with subacute stroke: A randomized controlled trial

Objective

This study aimed to compare the efficacy of contralaterally controlled functional electrical stimulation (CCFES) vs. neuromuscular electrical stimulation (NMES) for motor recovery of the lower extremity in patients with subacute stroke.

Materials and methods

Seventy patients within 6 months post-stroke were randomly assigned to the CCFES group (n = 35) and the NMES group (n = 35). Both groups underwent routine rehabilitation plus 20-min electrical stimulation (CCFES or NMES) on ankle dorsiflexion muscles per day, 5 days a week, for 3 weeks. Ankle AROM (dorsiflexion), Fugl-Meyer assessment-lower extremity (FMA-LE), Barthel Index (BI), Functional Ambulation Category scale (FAC), 10-meter walking test, and surface electromyography (sEMG) were assessed at the baseline and at the end of the intervention.

Result

Ten patients did not complete the study (five in CCFES and five in NMES), so only 60 patients were analyzed in the end. After the 3-week intervention, FMA-LE, BI, Ankle AROM (dorsiflexion), and FAC increased in both groups (p < 0.05). Patients in the CCFES group showed significantly greater improvements only in the measurement of Fugl-Meyer assessment-lower extremity compared with the NMES group after treatment (p < 0.05). The improvement in sEMG response of tibialis anterior by CCFES was greater than NMES (p < 0.05).

Conclusion

Contralateral controlled functional electrical stimulation can effectively improve the motor function of the lower limbs better than conventional neuromuscular electrical stimulation in subacute patients after stroke, but the effect on improving the ability to walk, such as walking speed, was not good.

Clinical trial registration

http://www.chictr.org.cn/, identifier: ChiCTR2100045423.

Effectiveness of a Novel Contralaterally Controlled Neuromuscular Electrical Stimulation for Restoring Lower Limb Motor Performance and Activities of Daily Living in Stroke Survivors: A Randomized Controlled Trial

Background

Contralaterally controlled neuromuscular electrical stimulation (CCNMES) is a novel electrical stimulation treatment for stroke; however, reports on the efficacy of CCNMES on lower extremity function after stroke are scarce.

Objective

To compare the effects of CCNMES versus NMES on lower extremity function and activities of daily living (ADL) in subacute stroke patients.

Methods

Forty-four patients with a history of subacute stroke were randomly assigned to a CCNMES group and a NMES group (n = 22 per group). Twenty-one patients in each group completed the study per protocol, with one subject lost in follow-up in each group. The CCNMES group received CCNMES to the tibialis anterior (TA) and the peroneus longus and brevis muscles to induce ankle dorsiflexion motion, whereas the NMES group received NMES. The stimulus current was a biphasic waveform with a pulse duration of 200 μs and a frequency of 60 Hz. Patients in both groups underwent five 15 min sessions of electrical stimulation per week for three weeks. Indicators of motor function and ADL were measured pre- and posttreatment, including the Fugl–Meyer assessment of the lower extremity (FMA-LE) and modified Barthel index (MBI). Surface electromyography (sEMG) assessments included average electromyography (aEMG), integrated electromyography (iEMG), and root mean square (RMS) of the paretic TA muscle.

Results

Values for the FMA-LE, MBI, aEMG, iEMG, and RMS of the affected TA muscle were significantly increased in both groups after treatment (p < 0.01). Patients in the CCNMES group showed significant improvements in all the measurements compared with the NMES group after treatment. Within-group differences in all post- and pretreatment indicators were significantly greater in the CCNMES group than in the NMES group (p < 0.05).

Conclusion

CCNMES improved motor function and ADL ability to a greater extent than the conventional NMES in subacute stroke patients.

Smart Protocols for Physical Therapy of Foot Drop Based on Functional Electrical Stimulation: A Case Study

Functional electrical stimulation (FES) is used for treating foot drop by delivering electrical pulses to the anterior tibialis muscle during the swing phase of gait. This treatment requires that a patient can walk, which is mostly possible in the later phases of rehabilitation. In the early phase of recovery, the therapy conventionally consists of stretching exercises, and less commonly of FES delivered cyclically. Nevertheless, both approaches minimize patient engagement, which is inconsistent with recent findings that the full rehabilitation potential could be achieved by an active psycho-physical engagement of the patient during physical therapy. Following this notion, we proposed smart protocols whereby the patient sits and ankle movements are FES-induced by self-control. In six smart protocols, movements of the paretic ankle were governed by the non-paretic ankle with different control strategies, while in the seventh voluntary movements of the paretic ankle were used for stimulation triggering. One stroke survivor in the acute phase of recovery participated in the study. During the therapy, the patient’s voluntary ankle range of motion increased and reached the value of normal gait after 15 sessions. Statistical analysis did not reveal the differences between the protocols in FES-induced movements.

Immediate effect of transcranial direct current stimulation combined with functional electrical stimulation on activity of the tibialis anterior muscle and balance of individuals with hemiparesis stemming from a stroke

[Purpose] The aim of the present study was to evaluate the immediate effects of transcranial direct current stimulation (tDCS) and functional electrical stimulation (FES) on activity of the tibialis anterior muscle (TA) and static balance of individuals with hemiparesis stemming from stroke. [Subjects and Methods] A randomized, double-blind, crossover, clinical trial conducted with 30 individuals with chronic post-stroke hemiparesis. Median frequency of electrical activity of the TA were determined using electromyography in five contractions concentrics and Static balance (body sway velocity and frequency), both before and immediately after the intervention. The participants were submitted to four 20-minute intervention protocols with 48-hour interval: anodal tDCS + sham FES; sham tDCS + active FES; anodal tDCS + active FES and sham tDCS + sham FES. Anodal tDCS was administered over C3 or C4, the cathode was positioned in the supraorbital region on the contralateral side and FES was administered to the affected TA. [Results] No significant differences among the protocols were found regarding electrical activity of the TA and static balance. [Conclusion] The results demonstrate that tDCS alone or in combination with FES had no immediate effect on electrical activity of the TA and static balance of the 30 individuals analyzed.

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.

Changes in center of pressure displacement with the use of a foot drop stimulator in individuals with stroke

BACKGROUND

Center of pressure measured during gait can provide information about underlying control mechanisms and the efficacy of a foot drop stimulator. This investigation evaluated changes in center of pressure displacement in individuals with stroke with and without a foot drop stimulator.

METHODS

Individuals with stroke-related foot drop (n=11) using a foot drop stimulator and healthy controls (n=11). Walking speed and bilateral center of pressure variables: 1) net displacement; 2) position and maximum displacement; and 3) mean velocity during walking.

FINDINGS

On the affected limb with the foot drop stimulator as compared to the affected limb without the foot drop stimulator: 1) increased anterior/posterior maximum center of pressure excursion 8% during stance; 2) center of pressure at initial contact was 6% more posterior; 3) medial/lateral mean, maximum and minimum center of pressure position during stance all significantly decreased; 4) anterior/posterior net displacement increased during stance and single support; and 5) anterior/posterior velocity of the center of pressure increased during stance.

INTERPRETATION

Individuals with stroke using a foot drop stimulator contacted the ground more posterior at initial contact and utilized more of the anterior/posterior plantar surface of the foot on the affected limb during stance. With the foot drop stimulator there was a shift in center of pressure toward the medial side possibly indicating an improvement in equinovarus gait where there is a tendency to load the lateral foot throughout stance. For individuals with stroke a foot drop stimulator can improve displacement of the center of pressure which indicates improved forward progression and stability during walking.

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.

Contralaterally controlled neuromuscular electrical stimulation for recovery of ankle dorsiflexion: a pilot randomized controlled trial in patients with chronic post-stroke hemiplegia

OBJECTIVE

The aim of this study was to compare the effects of contralaterally controlled neuromuscular electrical stimulation (CCNMES) vs. cyclic neuromuscular electrical stimulation (NMES) on lower extremity impairment, functional ambulation, and gait characteristics.

DESIGN

Twenty-six survivors of stroke with chronic (≥6 mos) foot drop during ambulation were randomly assigned to 6 wks of CCNMES or cyclic NMES. Both groups had ten sessions per week of self-administered home application of either CCNMES or cyclic NMES plus two sessions per week of gait training with a physical therapist. Primary outcomes included lower extremity Fugl-Meyer score, modified Emory Functional Ambulation Profile, and gait velocity. Assessments were made at pretreatment and posttreatment and at 1 and 3 mos after treatment.

RESULTS

There were no significant differences between the groups in the outcome trajectories for any of the measures. With data from both groups pooled, there were significant but modest and sustained improvements in the Fugl-Meyer score and the modified Emory Functional Ambulation Profile but not in gait velocity.

CONCLUSIONS

The results support the hypothesis that gait training combined with either CCNMES or cyclic NMES reduces lower extremity impairment and functional ambulation but do not support the hypothesis that CCNMES is more effective than cyclic NMES in patients with chronic post-stroke hemiplegia.

Contralaterally controlled functional electrical stimulation for stroke rehabilitation

Contralaterally controlled functional electrical stimulation (CCFES) is an innovative method of delivering neuromuscular electrical stimulation for rehabilitation of paretic limbs after stroke. It is being studied to evaluate its efficacy in improving recovery of arm and hand function and ankle dorsiflexion in chronic and subacute stroke patients. The initial studies provide preliminary evidence supporting the efficacy of CCFES.

Neuromuscular electrical stimulation for skeletal muscle function

Lack of neural innervation due to neurological damage renders muscle unable to produce force. Use of electrical stimulation is a medium in which investigators have tried to find a way to restore movement and the ability to perform activities of daily living. Different methods of applying electrical current to modify neuromuscular activity are electrical stimulation (ES), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and functional electrical stimulation (FES). This review covers the aspects of electrical stimulation used for rehabilitation and functional purposes. Discussed are the various parameters of electrical stimulation, including frequency, pulse width/duration, duty cycle, intensity/amplitude, ramp time, pulse pattern, program duration, program frequency, and muscle group activated, and how they affect fatigue in the stimulated muscle.