Muscle stimulation in stroke patients

A stroke is the result of a disturbance in the flow of blood to the brain. This can either be due to ischemia (lack of blood flow) or haemorrhage. The result of the lack of blood flow is the affected area of the brain stops functioning normally. This lack of function can cause an inability to move fully on one side of the body, difficulty with language and vision impairment. Rehabilitation post stroke can benefit from the use of muscle stimulation devices to aid recovery and help gain function for the affected individual. Gait and upper limb strength and control can be improved in post stroke patients with the use of NMES. Stroke related dysphagia can also be improved with the use of muscle stimulation and VitalStim devices.

Cyclical electrical stimulation increases strength and improves activity after stroke:a systematic reviewNascimento LR, Michaelsen SMAda LPolese JCTeixeira-Salmela LF. Journal of Physiotherapy. 2014 Mar;60(1):22-30.

The purpose of this systematic review with meta-analysis was to examine the efficacy of post-stroke electrical stimulation. It included randomised or controlled trials comparing the use of NMES for strength recovery post stoke,with placebo/other/no interventions were included. The results showed:

  • Overall,electrical stimulation increased strength by a standardised mean difference (SMD) of 47%and this effect was maintained beyond the intervention period.
  • Electrical stimulation also improved activity by SMD of 30%and this effect was also maintained beyond the intervention period

The authors conclude that electrical stimulation increases strength and improves activity after stroke. The increased strength is utilised in daily life and is therefore maintained by ongoing increased activity.

Time to rethink long-term rehabilitation management of stroke patients.  Teasell R, Mehta S, Pereira S, McIntyre A, Janzen S, Allen L, Lobo L, Viana R. Top Stroke Rehabil. 2012 Nov-Dec;19(6):457-62.

The purpose of this study was to identify randomised controlled trials (RCTs) across the continuum of stroke rehabilitation for interventions initiated 6 months or more following the onset of stroke and to determine whether treatments provided post 6 months are effective in improving outcomes among stroke survivors. 339 RCTs were included in the review. The results showed:

  • There is a robust evidence-base for stroke rehabilitation interventions in chronic stroke.
  • NMES and FES (functional ES) were found to be effective treatment modalities for improving gait and mobility, upper extremity disorders, hemiplegic shoulder in chronic stoke patients.

The authors conclude that chronic stroke patients can still improve their motor function with a significant number of rehabilitation interventions, one of them being (functional) electrical stimulation.

Effect of surface sensory and motor electrical stimulation on chronic post stroke oropharyngeal dysfunction.  Rofes L, Arreola V, López I, Martin A, Sebastián M, Ciurana A, Clavé P.   Neurogastroenterol Motil.2013 Nov;25(11):888-e701.

The purpose o this study was to assess and compare the efficacy and safety of treatment with surface electrical stimulation (e-stim) at sensory and motor intensities in patients with chronic post stroke oropharyngeal dysfunction.  20 chronic post stroke patients with OD were randomised to motor e-stim or sensory e-stim and were treated with Intelect VitalStim for 1 h/day for 10 days. The results showed:

  • video fluoroscopy performed at the beginning and end of the study showed that both levels of stimulation improved specific parameters related to the efficacy and safety of swallow.

The authors conclude that this pilot study provides proof of concept that VitalStim is a safe and effective treatment for chronic post stroke dysphagic patients. Following this positive proof of concept, the researchers will further conduct a larger scale study involving a control group, greater number of patients,prolonged follow-up, and effect on clinical outcomes.

Neuromuscular electrical stimulation efficacy in acute stroke feeding tube-dependent dysphagia during in patient rehabilitation. Kushner DS.  Am J PhysMed Rehabil. 2013 Jun;92(6):486-95.

This study compared the efficacy of NMES in addition to traditional dysphagia therapy (TDT) including progressive resistance training (PRT) with that of TDT/PRT alone during inpatient rehabilitation for treatment of feeding tube-dependent dysphagia inpatients who have had an acute stroke.  65 patients received NMES with TDT / PRT and 27 patients received only TDT / PRT (case control group).  All patients received daily treatment session of 1 hour during a mean of 18 days.  The results showed:

  • Patients in NMES group had significantly higher FOIS score and significantly higher gains than TDT group.
  • 46% of NMES patients versus 27%of TDT patients had minimal to no swallowing restrictions after the treatment.

The authors conclude that NMES added to traditional therapy is significantly more effective than traditional therapy alone during inpatient rehabilitation in reducing feeding tube-dependent dysphagia in patients who have had an acute stroke.

Combined Neuromuscular Electrical Stimulation (NMES) with Fiber optic Endoscopic Evaluation of Swallowing(FEES) and Traditional Swallowing Rehabilitation in the Treatment of Stroke-Related Dysphagia.  Sun SF, Hsu CW, Lin HS, Sun HP, Chang PH, Hsieh WL, Wang JL.  Dysphagia. 2013 Dec;28(4):557-66. 

The objective of this study was to evaluate whether combined NMES, FEES (fiber optic endoscopic evaluation of swallowing) and traditional swallowing rehabilitation can improve swallowing functions in stroke patients with moderate to severe dysphagia. Patients received 12 sessions of NMES for 1 h/ day,5 days/ week with in a period of 2-3 weeks.  FEES was done before and after NMES for evaluation and to guide dysphagic therapy.  All patients subsequently received 12 sessions of traditional swallowing rehabilitation (50 min/day ,3 days/week) for 4 weeks.  Patients were assessed at base line, after NMES, at 6-month follow-up, and at 2-year follow-up.  The results showed:

  • All outcomes improved significantly after NMES, at the 6-month follow-up, and at the 2-year follow-up (p< 0.001,each compared with baseline).
  • Most patients reported considerable satisfaction with no serious adverse events.
  • 23 of the 29(79.3%) patients maintained oral diet with no pulmonary complications at 2-year follow-up.

The authors conclude that the improved swallowing functions and patient satisfaction with combined NMES and traditional therapy provide support for introducing this promising combination into clinical practice.

Comparison of the effectiveness of active and passive neuromuscular electrical stimulation of hemiplegic upper extremities: a randomized, controlled trial.  Boyaci A,  Topuz OAlkan HOzgen MSarsan AYildiz NArdic F.  Int J Rehabil Res.2013Apr 11.[Epub aheadofprint]

The onjective of this study was to compare the efficacy of electro myography (EMG)-triggered (active) neuromuscular electrical stimulation (NMES) and passive NMES in enhancing the upper extremity (UE) motor and functional recovery of sub acute and chronic stage stroke patients.  31 hemiplegic patients were randomly assigned to actives EMG triggered NMES (n=11), passive NMES (n=10), and control (sham stimulation)(n=10) groups. Wrist & finger extensors were stimulated. The results showed:

  • Outcomes (except for spasticity) were significantly improved in both ‘passive’ NMES and ‘active’s EMG+ Stim groups compared with controls.
  • Significant improvement versus controls was seen in more out come measures for the ‘active’ versus ‘passive’ stim.
  • There were no significant differences between ‘active’ and ’passive’ stim groups at the end of treatment.

The authors concluded that both active (sEMG+ stim) and passive (stim only) NMES as adjunct therapy in the neurophysiologic exercise program effectively enhanced the UE motor and functional recovery of stroke survivors.

Immediate effects of electrical stimulation combined with passive locomotion-like movement on gait velocity and spasticity in persons with hemiparetic stroke: a randomized controlled study.” Yamaguchi  T, Tanabe SMuraoka YMasakado YKimura ATsuji TLiu M.

The onjective of this study was to examine the immediate effects of electrical stimulation combined with passive locomotion-like movement on gait velocity and spasticity. 27 sub acute stroke patients were randomised to receive either: combined ES + passive motion (PM), ES only, or PM only. The results showed:

  • There was significantly more improvement in gait velocity with the combined ES+PM treatment compared to the individual treatment modalities.
  • Although modified Ashworth scale (spasticity) improved in more patients in the ES+PM group than in the other groups (67% of ES+PM patients versus 33% of ES patients and 22% of PM patients), this difference was not statistically significant.

The authors conclude that this study can support the use of the new Active K combined with the EMPI 300PV e-stim device which can be connected to the Active K.