Scientific Articles and Abstracts
Does
neuro-rehabilitation play a role in the recovery of walking in
neurological populations?
This review demonstrates that
neuro-rehabilitation approaches, based on recent neuroscience
findings, can enhance locomotor recovery after a spinal cord injury
or stroke. Findings are presented from more than 20 clinical studies
conducted by numerous research groups on the effect of locomotor
training using either body weight support (BWS), functional
electrical stimulation (FES), pharmacological approaches or a
combination of them. Among the approaches, only BWS-assisted
locomotor training has been demonstrated to have a greater effect
than conventional or locomotor training alone. However, when study
results were combined and weighted for the number of subjects, the
results indicated that there is a gradient of effects from small
changes with the immediate application of FES or BWS to larger
changes when locomotor training is combined with FES or BWS or
pharmacological approaches. The findings of these studies suggest
that these neuro-rehabilitation approaches do play a role in the
recovery of walking in subjects with spinal cord injury or stroke.
Several factors contribute to the potential for recovery including
the site, etiology and chronicity of the injury, as well as the
type, duration, and specificity of the intervention and whether
interventions are combined. Furthermore, how these
neuro-rehabilitation approaches may take advantage of the plasticity
process following neurological lesion is also discussed.
Barbeau H. et.al. Physical and Occupational Therapy,
McGill University, Montreal, Canada. Ann N Y Acad Sci.
Electrical stimulation for swallowing disorders
caused by stroke.
Background: An estimated 15 million
adults in the United States are affected by dysphagia (difficulty
swallowing). Severe dysphagia predisposes to medical complications
such as aspiration pneumonia, bronchospasm, dehydration,
malnutrition, and asphyxia. These can cause death or increased
health care costs from increased severity of illness and prolonged
length of stay. Existing modalities for treating dysphagia are
generally ineffective, and at best it may take weeks to months to
show improvement. One common conventional therapy, application of
cold stimulus to the base of the anterior faucial arch, has been
reported to be somewhat effective. We describe an alternative
treatment consisting of transcutaneous electrical stimulation (ES)
applied through electrodes placed on the neck. Objective: Compare
the effectiveness of ES treatment to thermal-tactile stimulation
(TS) treatment in patients with dysphagia caused by stroke and
assess the safety of the technique. Methods: In this controlled
study, stroke patients with swallowing disorder were alternately
assigned to one of the two treatment groups (TS or ES). Entry
criteria included a primary diagnosis of stroke and confirmation of
swallowing disorder by modified barium swallow (MBS). TS consisted
of touching the base of the anterior faucial arch with a metal probe
chilled by immersion in ice. ES was administered with a modified
hand-held battery-powered electrical stimulator connected to a pair
of electrodes positioned on the neck. Daily treatments of TS or ES
lasted 1 hour. Swallow function before and after the treatment
regimen was scored from 0 (aspirates own saliva) to 6 (normal
swallow) based on substances the patients could swallow during a
modified barium swallow. Demographic data were compared with the
test and Fisher exact test. Swallow scores were compared with the
Mann-Whitney U test and Wilcoxon signed-rank test. Results: The
treatment groups were of similar age and gender (p > 0.27),
co-morbid conditions (p = 0.0044), and initial swallow score (p =
0.74). Both treatment groups showed improvement in swallow score,
but the final swallow scores were higher in the ES group (p >
0.0001). In addition, 98% of ES patients showed some improvement,
whereas 27% of TS patients remained at initial swallow score and 11%
got worse. These results are based on similar numbers of treatments
(average of 5.5 for ES and 6.0 for TS, p = 0.36). Conclusions: ES
appears to be a safe and effective treatment for dysphagia due to
stroke and results in better swallow function than conventional TS
treatment.
Freed M.L. et.al. Respir. Care.
Electrical stimulation of wrist extensors in
poststroke hemiplegia.
Background and purpose: It has
been suggested that cyclic neuromuscular electrical stimulation (ES)
may enhance motor recovery after stroke. We have investigated the
effects of ES of the wrist extensors on impairment of wrist function
and on upper-limb disability in patients being rehabilitated after
acute stroke. Methods: We recruited 60 hemiparetic patients (mean
age, 68 years) 2 to 4 weeks after stroke into a randomized,
controlled, parallel-group study comparing standard rehabilitation
treatment with standard treatment plus ES of wrist extensors (3
times 30 minutes daily for 8 weeks). Isometric strength of wrist
extensors was measured using a device built for that purpose.
Upper-limb disability was assessed with use of the Action Research
Arm Test (ARAT). Observations were continued for 32 weeks (24 weeks
after the finish of ES or the control intervention phase). Results:
The change in isometric strength of wrist extensors (at an angle of
0 degrees extension) was significantly greater in the ES group than
the control group at both 8 and 32 weeks (P=0.004, P=0.014 by Mann
Whitney U test). At week 8 the grasp and grip subscores of the ARAT
increased significantly in the ES group compared with that in the
control group (P=0.013 and P=0.02, respectively); a similar trend
was seen for the total ARAT score (P=0.11). In the subgroup of 33
patients with some residual wrist extensor strength at study entry
(moment at 0 degrees extension >0), the ARAT total score had
increased at week 8 by a mean of 21.1 (SD, 12.7) in the ES group
compared with 10.3 (SD, 9.0) in the control group (P= 0.024, Mann
Whitney U test); however, at 32 weeks the differences between these2
subgroupswere no longer statistically significant. Conclusions: ES
of the wrist extensors enhances the recovery of isometric wrist
extensor strength in hemiparetic stroke patients. Upper-limb
disability was reduced after 8 weeks of ES therapy, with benefits
most apparent in those with some residual motor function at the
wrist...
Powell J. et.al. Dep. Bioengineering,
University of Strathclyde, Glasgow, Scotland. Journal:
Stroke.
Functional electrostimulation in poststroke
rehabilitation: a meta-analysis of the randomized controlled trials.
Objective: To assess the efficacy of functional
electrical stimulation (FES) in the rehabilitation of hemiparesis in
stroke. Design: A meta-analysis combined the reported randomized
controlled trials of FES in stroke, using the effect size method of
Glass, and the DerSimonian-Laird Random Effects Method for pooling
studies. Setting: The included studies were published between 1978
and 1992. They were conducted In academic rehabilitation medicine
settings. Patients: In all included studies, patients were in
poststroke rehabilitation. The mean time after stroke varied from
1.5 to 29.2 months. Intervention: FES applied to a muscle or
associated nerve in a hemiparetic extremity was compared to No FES.
Main outcome measure: Change in paretic muscle force of contraction
following FES was compared to change without FES. Results: For the
four included studies, the mean effect size was .63 (95% CI: .29,
.98). This result was statistically significant (p < .05).
Conclusion: Pooling from randomized trials supports FES as promoting
recovery of muscle strength after stroke. This effect is
statistically significant. There is a reasonable likelihood of
clinical significance as well.
Glanz M. et.al.
Harvard School of Public Health, Boston, USA. Arch Phys Med
Rehabilitation
The
effects of functional electrical stimulation on shoulder
subluxation, arm function recovery, and shoulder pain in hemiplegic
stroke patients.
The purpose of this study was to
evaluate the effectiveness of a functional electrical stimulation
(FES) treatment program designed to prevent glenohumeral joint
stretching and subsequent subluxation and shoulder pain in stroke
patients. Twenty-six recent hemiplegic stroke patients with shoulder
muscle flaccidity were randomly assigned to either a control group
(n = 13; 5 female, and 8 male) or experimental group (n = 13; 6
female, and 7 male). Both groups received conventional physical
therapy. The experimental group received additional FES therapy
where two flaccid/paralyzed shoulder muscles (supraspinatus and
posterior deltoid) were induced to contract repetitively up to 6
hours a day for 6 weeks. Duration of both the FES session and muscle
contraction/relaxation ratio were progressively increased as
performance improved. The experimental group showed significant
improvements in arm function, electromyographic activity of the
posterior deltoid, range of motion, and reduction in subluxation (as
indicated by x-ray) compared with the control group. We concluded
that the FES program was effective in reducing the severity of
shoulder subluxation and pain, and possibly facilitating recovery of
arm function.
Faghri P.D. Rehabilitation
Institute of Ohio, Dayton. Arch Phys Med Rehabilitation
Electrical stimulation of wrist and fingers for
hemiplegic patients.
Passive cyclical electrical
stimulation was applied during a four-week treatment program to the
wrist and finger extensors of 16 hemiplegic patients with flexor
spasticity. The study noted the effects of this treatment on the
patients' sensation; spasticity; passive range of motion of the
wrist, metacarpophalangeal, and proximal interphalangeal joints; and
strength in the wrist extensor muscles. Patients were divided into
chronic and subacute groups. Both groups received electrical
stimulation for three half-hour periods a day, seven days a week, as
a substitute for all other range-of-motion techniques. Flexion
contractures were prevented in the subacute group of patients at the
wrist, metacarpophalangeal, and proximal interphalangeal joints. A
statistically and clinically significant increase in wrist extension
range occurred in the chronic group that had wrist flexion
contractures before the electrical stimulation. Increased extension
was noted at the metacarpophalangeal and proximal interphalangeal
joints of patients in the chronic group. Those patients with some
voluntary wrist extension before the treatment began were able to
increase their extension strength during stimulation. No changes in
skin sensation were noted and only a general trend in decreasing
spasticity was apparent.
Baker L. Physical
Therapy
A pilot
study to investigate the combined use of botulinum neurotoxin type a
and functional electrical stimulation, with physiotherapy, in the
treatment of spastic dropped foot in subacute stroke.
The objective was to inform sample size calculations for a
full randomized controlled trial (RCT). The design included an RCT
pilot trial with a 16 week study period, including a 4 week baseline
phase. The subjects were adults within 1 year of first stroke,
ambulant with a spastic dropped foot. Twenty-one participants were
recruited from the stroke services of 4 centers. For intervention
all participants received physiotherapy; the treatment group also
received botulinum neurotoxin Type A (BoNTA) intramuscular
injections to triceps surae (800 U Dysport) and functional
electrical stimulation (FES) of the common peroneal nerve to assist
walking. The main outcome measure was walking speed. The result was
a significant upward trend in median walking speed for both the
control (p = 0.02) and treatment groups (nonstimulated p = 0.004,
stimulated p = 0.042). Trend lines were different in location (p =
0.04 and p = 0.009, respectively). In conclusion, there is evidence
of an additional, beneficial effect of BoNTA and FES. Sufficient
information has been gained on the variability of the primary
outcome measure to inform sample size calculations for a full RCT to
quantify the treatment effect with precision.
Johnson C. Dep. Medical Physics, Salisbury District
Hospital, UK
The
effects of ipsilateral forearm movement and contralateral hand grasp
on the spastic hand opened by electrical stimulation.
The purpose of this study was to investigate the effects
of ipsilateral arm movement and contralateral hand grasp on the
spastic hand opened by open-loop electrical stimulation. The major
problem of applying proper electrical stimulation is variable
spasticity, the intensity of which changes with posture and
movements of other parts of the body. Electrical stimulation was
applied to extensor digitorum communis and ulnar nerve to open the
affected hand. Different procedures were then used to assess the
effects of moving the ipsilateral forearm and contracting the
contralateral normal hand. Electrical stimulation opened the spastic
hand in more than 95% of trials in all subjects, whether stimulation
was applied before or after the movement of the forearm. Moving the
ipsilateral forearm did have an effect on opening the hand, and
making adjustment of stimulation intensities was necessary in all
subjects. The stimulation opened the spastic hand during the
contraction of the contralateral normal hand. Electrical stimulation
could open the spastic hands most of the time, in the resence of
ipsilateral forearm movement and contralateral normal hand
contraction. If electrical stimulation was applied before the
ipsilateral forearm was moved toward the target, stimulation
intensities needed to be adjusted.
Lin C. Dep.
Neurology, National Cheng-Kung University Hospital, Taiwan
Neurorehabilitation Neural Repair
The
effects of neuromuscular stimulation-induced muscle contraction
versus elevation on hand edema in CVA patients.
The
purpose of this study was to evaluate the efficacy of the use of
neuromuscular stimulation (NMS)-induced contraction of the paralyzed
muscles to produce an active muscle pump for removing excess fluid
and compare its effect with elevation of the upper extremity. The
effects of 30 minutes of NMS of the finger and wrist flexors and
extensors were compared with the effects of 30 minutes of limb
elevation alone. Each of eight cerebrovascular accident (CVA)
patients with visible hand edema received both treatments, one on
each of 2 consecutive days. Measures of hand and arm volume and
upper and lower arm girth were taken before and after each
treatment. Analyses comparing mean percentage change scores for both
treatments showed large and significant treatment effects for all
dependent measures. The finding suggests that NMS was more effective
for reduction of hand edema than limb elevation alone for this
sample of eight CVA patients.
Faghri PD. Uni.
of Connecticut, USA. Journal Hand Therapy
|
