Functional Electrical Stimulation - upper extremity

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Fourteen studies (12 RCTs, 1 non-RCT and 1 review article) have examined the efficacy of functional electrical stimulation (FES) as a means to improve hemiparetic upper extremity function post-stroke. Specifically, studies have investigated the effect of ES for improving muscle strength, spasticity, range of motion (ROM), motor function, manual dexterity, activities of daily living (ADL), reaction time and hand function post-stroke.

Please click here to see the Authors’ Results Table.

Acute phase

Functional independenceNot effective1a

Three high quality RCTs (Mangold et al., 2009; Powell et al., 1999Chae et al., 1998) have investigated the effectiveness of FES for improving functional independence in patients with acute stroke.

The first high quality RCT (Mangold et al., 2009) investigated the effectiveness of FES for improving functional independence in 23 patients with acute and sub-acute stroke. The participants were assigned to receive FES and conventional occupational therapy or conventional therapy only. Both groups received 45 minutes of occupational therapy, 3 to 5 times per week for 4 weeks, where the intervention group replaced 3 of their sessions with FES. Outcomes were measured at post-treatment and at six months. At post-treatment there was a significant difference between the groups in favour of the stimulation group on the Extended Barthel Index. Scores were not reported at the six month follow-up.

The second high quality RCT (Powell et al., 1999) investigated the use of FES for improving functional independence in 60 patients with acute stroke. The participants were assigned to receive either FES in addition to conventional (Bobath) therapy or conventional (Bobath) therapy only. Sessions were given for 30 mins/day, 3 times a week for 8 weeks. Outcomes were measured at eight weeks and a 32 week follow-up. At eight weeks and at a 32 week follow-up, there were no significant between group differences on the Barthel Index or the Rankin scale.

The third high quality RCT (Chae et al., 1998) investigated the effectiveness of FES for improving functional independence in 46 patients with acute stroke. The participants were randomized to receive either FES to produce wrist and finger extension exercises or sham stimulation (control group). The sessions were 1 hour a day for 15 sessions (3 weeks). Outcomes were measured at post-treatment (four weeks) and at a 12 week follow-up. At both the four and 12 week assessment, there were no significant between group differences on the Functional Independence Measure (FIM).

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that FES in combination with conventional therapy is not more effective than conventional therapy (alone or in combination with sham stimulation) for improving functional independence in patients with acute stroke.
Note:
However, one high quality RCT found a significant difference between the groups in favour of the stimulation group on the Extended Barthel Index but scores were not reported at the six month follow-up.

Hand function and dexterityEffective1b

One high quality RCT ( Powell et al., 1999 ) and one fair quality RCT (Alon et al., 2008) have investigated the effectiveness of FES for improving hand function and dexterity in patients with acute stroke.

The high quality RCT (Powell et al., 1999) investigated the use of FES for improving hand function and dexterity in 60 patients with acute stroke. The participants were assigned to receive either FES in addition to conventional (Bobath) therapy or conventional (Bobath) therapy only. Sessions were given for 30 mins/day, 3 times a week for 8 weeks. Outcomes were measured at eight weeks and at 32 weeks. At post-treatment (eight weeks) there was a significant difference in favour of the stimulation group on hand function and dexterity measured on the grip and grasp items of the Action Research Arm test. This difference was not maintained at the 32 week follow-up.

The fair quality RCT (Alon et al., 2008) investigated the effectiveness of FES for improving hand function and dexterity in 26 patients with acute stroke. The participants were assigned to receive either FES in combination with task-specific exercise or task-specific exercise only. Sessions were given 2 times/day for 30 minutes, 5 days/week for 12 weeks. The FES group practiced the exercises while receiving FES as well as received additional FES without exercises for up to an additional 90 minutes twice a day. Outcomes were measured at baseline and at 12 weeks. At 12 weeks, there were no significant between group differences on hand function and dexterity, measured by the Box and Blocks test, or the Jebsen-Taylor light object lift test.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that FES in addition to conventional therapy is more effective than conventional therapy only for improving hand function and dexterity in patients with acute stroke. However these improvements were not maintained in the long-term.
Note:
However, one fair quality RCT did not find any significant between group differences on hand function and dexterity.

Motor functionNot effective1a

Three high quality RCTs (Mangold et al., 2009; Powell et al., 1999.; Chae et al., 1998) and one fair quality RCT (Alon et al., 2008) have investigated the effectiveness of FES for improving motor function in patients with acute stroke.

The first high quality RCT (Mangold et al., 2009) investigated the effectiveness of FES for improving motor function in 23 patients with acute and sub-acute stroke. The participants were assigned to receive FES and conventional occupational therapy or conventional therapy only. Both groups received 45 minutes of occupational therapy, 3 to 5 times per week for 4 weeks, where the intervention group replaced 3 of their sessions with FES. Outcomes were measured at post-treatment (four weeks). At post-treatment there was no significant difference between the groups on the Chedoke McMaster Stroke Assessment. Scores at the six month follow-up were not reported.

The second high quality RCT ( Powell et al., 1999) investigated the effectiveness of FES for improving motor function in 60 patients with acute stroke. The participants were assigned to receive either FES in addition to conventional (Bobath) therapy or conventional (Bobath) therapy only. Sessions were given for 30 mins/day, three times a week for eight weeks. Outcomes were measured at eight weeks and at a 32 week follow-up. At post treatment (8 weeks) and at the 32 week follow-up, there were no significant between group differences on the Nine-hole peg test.

The third high quality RCT ( Chae et al., 1998) investigated the effectiveness of FES for improving motor function in 46 patients with acute stroke. The participants were randomized to receive either FES to produce wrist and finger extension exercises or sham stimulation (control group). The sessions were 1 hour a day for 15 sessions (3 weeks). Outcomes were measured at four weeks and at 12 weeks. At post-treatment, there was a significant between group difference in favour of the experimental group on the Fugl-Meyer Assessment, however, this difference was not maintained at the 12 week follow-up.

The fair quality RCT (Alon et al., 2008) investigated the effectiveness of FES for improving motor function in 26 patients with acute stroke. The participants were assigned to receive either FES in combination with task-specific exercise or task-specific exercise only. Sessions were given 2 times/day for 30 minutes, 5 days/week for 12 weeks. The FES group practiced the exercises while receiving FES as well as received additional FES without exercises for up to an additional 90 minutes twice a day. Outcomes were measured at post-treatment (12 weeks). At post-treatment, there was a significant between group difference on the upper extremity section of the modified Fugl-Meyer Assessment in favour of the experimental group.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that FES in addition to conventional therapy or no therapy is not more effective than conventional therapy or no therapy alone for improving motor function in patients with acute stroke.
Note:
However, one high quality RCT and one fair quality RCT found a significant difference between the groups in favour of the stimulation group (this difference was not maintained at the 12 week follow-up for the high quality RCT).

Range of motionNot effective1b

One high quality RCT (Powell et al., 1999) has investigated the effectiveness of FES for improving range of motion in patients with acute stroke.

The high quality RCT (Powell et al., 1999) investigated the effectiveness of FES for improving range of motion in 60 patients with acute stroke. The participants were assigned to receive either FES in addition to conventional (Bobath) therapy or conventional (Bobath) therapy only. Sessions were given for 30 mins/day, 3 times a week for 8 weeks. Outcomes were measured at eight weeks, and at a 32 weeks follow-up. At post-treatment and at the 32 week follow-up, there were no significant between group differences on passive and active range of motion.

Conclusion: There is moderate evidence (Level 1b) from one high RCT that FES in addition to conventional therapy is not more effective than conventional therapy alone for improving range of motion in patients with acute stroke.

Reaction timeEffective1b

One high quality RCT (Powell et al., 1999) has investigated the effectiveness of FES for improving reaction time in patients with acute stroke.

The high quality RCT (Powell et al., 1999) investigated the effectiveness of FES for improving reaction time in 60 patients with acute stroke. The participants were assigned to receive either FES in addition to conventional (Bobath) therapy or conventional (Bobath) therapy only. Sessions were given for 30 mins/day, 3 times a week for 8 weeks. Outcomes were measured at post-treatment (eight weeks) and at a 32 weeks. At post-treatment and at the 32 week follow-up, there was a significant difference between the groups in favour of the experimental group on reaction time.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that FES in addition to conventional therapy is more effective than conventional therapy only for improving reaction time in patients with acute stroke.

SpasticityNot effective1a

Two high quality RCTs (Mangold et al., 2009, Powell et al., 1999) have investigated the effectiveness of FES for improving spasticity in patients with acute stroke.

The first high quality RCT (Mangold et al., 2009) investigated the effectiveness of FES for improving spasticity in 23 patients with acute and sub-acute stroke. The participants were assigned to receive FES and conventional occupational therapy or conventional therapy only. Both groups received 45 minutes of occupational therapy, 3 to 5 times per week for 4 weeks, where the intervention group replaced 3 of their sessions with FES. Outcomes were measured at four weeks. At post-treatment, there was no significant between group difference on the Modified Ashworth Scale. Scores at the six month follow-up were not reported.

The second high quality RCT (Powell et al., 1999) investigated the effectiveness of FES for improving spasticity in 60 patients with acute stroke. The participants were assigned to receive either FES in addition to conventional (Bobath) therapy or conventional (Bobath) therapy only. Sessions were given for 30 mins/day, 3 times a week for 8 weeks. Outcomes were measured at eight weeks and at a 32 week follow-up. At post-treatment and at the 32 week follow-up, there was no significant difference in spasticity between the groups measured by the Modified Ashworth Scale.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that FES in addition to conventional therapy is not more effective than conventional therapy alone for improving spasticity in patients with acute stroke.

StrengthNot effective1b

One RCT (Powell et al., 1999) has investigated the effectiveness of FES for improving strength in patients with acute stroke.

The high quality RCT (Powell et al., 1999) investigated the effectiveness of FES for improving strength in 60 patients with acute stroke. The participants were assigned to receive either FES in addition to conventional (Bobath) therapy or conventional (Bobath) therapy only. Sessions were given for 30 mins/day, 3 times a week for 8 weeks. Outcomes were measured at eight weeks, and at a 32 weeks follow-up. At post-treatment and at a 32 week follow-up, there was no significant difference in grip strength between the groups.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that FES in addition to conventional therapy is not more effective than conventional therapy alone for improving strength in patients with acute stroke.

Subacute phase

Functional independenceEffective1b

One high  quality RCT (Francisco et al., 1998) has investigated the effectiveness of FES for improving functional independence in patients with sub-acute stroke.

The high quality RCT (Francisco et al., 1998) investigated the effectiveness of FES for improving functional independence in 9 patients with sub-acute stroke. The participants were assigned to receive either EMG-triggered FES in combination with conventional therapy or conventional therapy only. The sessions were 30 minutes a day, 5 days a week for the duration of the participants stay in the hospital. Outcomes were measured at the end of each participants hospital stay. At post-treatment there was a significant difference in favour of the experimental group on the self-care items of the Functional Independence Measure (FIM).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT  that EMG-triggered FES in combination with conventional therapy is more effective than conventional therapy alone for improving functional independence in patients with sub-acute stroke.

Hand function and dexterityNot effective2a

One fair quality RCT (Hemmen & Seelen, 2007) has investigated the effectiveness of FES for improving hand function and dexterity in patients with sub-acute stroke.

The fair quality RCT (Hemmen & Seelen, 2007) investigated the effectiveness of FES for improving hand function and dexterity in 27 patients with sub-acute stroke. The participants were assigned to receive either movement imagery-assisted electromyography (EMG)-triggered feedback, or electrostimulation. Both groups received their treatments for 30 minutes a day, 5 days a week for 12 weeks in addition to conventional therapy. Outcomes were measured at post-treatment (three months) and at a 12 month follow-up. A significant increase in arm-hand function within each group was found at post-treatment and at the 12 month follow-up within each group, however, there was no significant difference found between the groups on the Action Research Arm Test.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that imagery-assisted electromyography (EMG)-triggered feedback in combination with conventional therapy is not more effective than electrostimulation in combination with conventional therapy for improving hand function and dexterity in patients with sub-acute stroke.

Motor functionEffective1b

One high quality RCT (Francisco et al., 1998) and one fair quality RCT (Hemmen & Seelen, 2007) have investigated the effectiveness of FES for improving motor function in patients with sub-acute stroke.

The high quality RCT (Francisco et al., 1998) investigated the effectiveness of FES for improving motor function in 9 patients with sub-acute stroke. The participants were assigned to receive either EMG-triggered FES in combination with conventional therapy or conventional therapy only. The sessions were 30 minutes a day, 5 days a week for the duration of the participants stay in the hospital. Outcomes were measured at the end of each participants hospital stay. At post-treatment there was a significant difference in favour of the experimental group on the upper limb section of the Fugl-Meyer Assessment.

The fair quality RTC (Hemmen & Seelen, 2007) investigated the effectiveness of FES for improving hand function and dexterity in 27 patients with sub-acute stroke. The participants were assigned to receive either movement imagery-assisted electromyography (EMG)-triggered feedback, or electrostimulation. Both groups received their treatments for 30 minutes a day, 5 days a week for 12 weeks in addition to conventional therapy. Outcomes were measured at post-treatment (three months) and at a 12 week follow-up. At post-treatment and at a 12 month follow-up, there was no significant difference found between the groups on the Brunnstrom Fugl-Meyer.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that EMG-triggered FES in addition to conventional therapy is more effective than conventional therapy alone for improving motor function in patients with sub-acute stroke.
Note:
However, one fair quality RCT did not find any significant between group differences on motor function.

Range of motionEffective2a

One fair quality RCT (Bowman et al., 1979) has investigated the effectiveness of FES for improving range of motion in patients with sub-acute stroke.

The fair quality RCT (Bowman et al., 1979) investigated the effectiveness of FES for improving range of motion in 30 patients with sub-acute stroke. The participants were assigned to receive either positional feedback stimulation in addition to conventional therapy, or conventional therapy only. Sessions were 30 minutes a day, 5 days a week, for 4 weeks. Outcomes were measured at post-treatment (four weeks). At post-treatment, there was a significant difference in favour of the group receiving positional feedback stimulation in addition to conventional therapy on selective range of motion.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that positional feedback stimulation in addition to conventional therapy is  more effective than conventional therapy alone for improving range of motion in patients with sub-acute stroke.

Chronic phase

Electromyographic measuresEffective2a

One fair quality RCT ( Hara et al., 2008 ) has investigated the effectiveness of FES for improving electromyographic measures in patients with chronic stroke.

The fair quality RCT (Hara et al., 2008 ) investigated the effectiveness of daily power-assisted FES for improving electromyographic measures in 20 patients with chronic stroke. The experimental group received, at home, power-assisted FES and standard therapy, and the control group received standard therapy alone. The FES treatment was conducted for 1 hour a day for 5 months. Standard therapy was received once a week for 40 minutes over the 5 months. Outcomes were assessed at post-treatment (5 months). At post-treatment there was a statistically significant between-group difference in favor of the group receiving FES on electromyographic measures.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that power-assisted FES in combination with conventional therapy is more effective than conventional therapy alone for improving electromyographic measures in patients with chronic stroke.

Functional independenceNot effective1b

One high quality RCT  (Chan et al., 2009) has investigated the effectiveness of FES for improving functional independence in patients with chronic stroke.

The high quality RCT (Chan et al., 2009) has investigated the effectiveness of FES for improving functional independence in 20 patients with chronic stroke. The participants were assigned to receive either FES in combination with bilateral upper limb motor training and conventional therapy, or bilateral upper limb training and conventional therapy only. 15 sessions were given, each one 20 minutes in length. Each session was preceded by 10 minutes of stretching and followed by 60 minutes of conventional occupational therapy. Outcomes were measured at the end of the 15 sessions. At post-treatment there was no difference between the groups on the Functional Independence Measure (FIM).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that FES in combination with bilateral motor training and conventional therapy is not more effective than bilateral motor training and conventional therapy only for improving functional independence in patients with chronic stroke.

Hand function and dexterityEffective1a

One meta-analysis (Bolton et al., 2004), two high quality RCTs ( Cauraugh & Kim, 2003a , Cauraugh & Kim, 2003b ) and three fair quality RCTs ( Cauraugh et al., 2000 , Cauraugh & Kim, 2002 , Hara et al., 2008 ) have investigated the effectiveness of FES for improving hand function and dexterity in patients with chronic stroke.

The meta-analysis (Bolton et al., 2004) examined five studies to assess the effect of EMG-triggered neuromuscular stimulation on arm and hand function post-stroke. 84% of the patient population were in the chronic stage of recovery, and the remainder were acute and sub-acute. The total number of individuals studied was 47 in the treatment groups and 39 in the control groups. Subjects in the control group received usual stroke therapy (i.e. ROM stretching, neuromuscular facilitation, and functional training of the affected upper extremity). Overall, there was a significant difference between the patients treated with FES compared to those that received conventional therapy on the Box and Blocks Test.

The first high quality RCT (Cauraugh & Kim, 2003a) investigated the effectiveness of FES for improving hand function and dexterity in 26 patients with chronic stroke. The participants were assigned to receive 1) 0 seconds of active neuromuscular stimulation (control group), 2) 5 seconds of active neuromuscular stimulation or 3) 10 seconds of neuromuscular stimulation applied to the back of the impaired forearm. In addition, all participants received bilateral movement training. All participants completed 4 days (90 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 3 sets of 30 active neuromuscular stimulation trials (either 0, 5 or 10 sec depending on group assignment) along with 3 sets of 30 bilateral extension movements of the hand. At post-treatment, there was a significant difference between the 10 second group and the 5 second group on the number of blocks moved on the Box and Blocks Test.

The second high quality RCT (Cauraugh & Kim, 2003b) investigated the effectiveness of FES for improving hand function and dexterity in 34 patients with chronic stroke. The participants were assigned to receive 1) blocked practice (repetitive movements) in combination with active neuromuscular stimulation; (2) random practice (different movements) in combination with active stimulation; or (3) no active neuromuscular stimulation intervention (control). Extension of the wrist/fingers joint, elbow joint, and shoulder joint were performed by all subjects for 2, 90-minute sessions a week for a period of 2 weeks. At post-treatment there was a significant difference between the blocked practice group and the control group, in favour of the blocked practice group, and between the random practice group and the control group (in favour of the random practice group) on the number of blocks moved on the Box and Blocks Test.

The first fair quality RCT (Cauraugh et al., 2000) investigated the effectiveness of FES for improving hand function and dexterity in 11 patients with chronic stroke. The participants were assigned to receive 1) electrical stimulation during voluntary extension of the wrist/fingers, 2) voluntary extension of the wrist/fingers alone. Both groups received passive range of motion (ROM) and stretching exercises prior to the treatment. All participants completed 3 days (60 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 2 sets of 30 active neuromuscular stimulation trials. The control group also performed voluntary extension of the wrist/fingers for 60 minutes per day (2 sets of 30 movements). At post-treatment, there was a significant difference in favour of the stimulation group on the number of blocks moved on the Box and Blocks Test.

The second fair quality RCT (Cauraugh & Kim, 2002) investigated the effectiveness of FES for improving hand function and dexterity in 25 patients with chronic stroke. The participants were assigned to receive 1) EMG-triggered stimulation and bilateral movement, 2) EMG-triggered stimulation and unilateral movement or 3) a control group that performed wrist and finger exercises only. All participants completed 4 days (90 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 3 sets of 30 active neuromuscular stimulation trials along with either bilateral or unilateral training (extensions of the wrist/fingers); the control group executed 90 voluntary wrist/finger extensions of the impaired hand per session without active stimulation. At post-treatment, there was a significant difference in favour of the stimulation and bilateral training group compared to the stimulation and unilateral training group and the control group on the number of blocks moved on the Box and Blocks Test. There was also a significant difference between the stimulation and unilateral training group compared to the control group on the number of blocks moved on the Box and Blocks Test.

The third fair quality RCT (Hara et al., 2008) investigated the effectiveness of FES for improving hand function and dexterity in 20 patients with chronic stroke. The experimental group received, at home, power-assisted FES and standard therapy, and the control group received standard therapy alone. The FES treatment was conducted for 1 hour a day for 5 months. Standard therapy was received once a week for 40 minutes over the 5 months. At post-treatment, there was a significant difference in favour of the FES group compared to the control group on both the 10 Cup Moving Test & Nine-Hole-Peg Test.

Conclusion: There is strong evidence (level 1a) from one meta-analysis, two high quality RCTs and three fair quality RCTs that FES in combination with conventional therapy or training is more effective than conventional therapy or training only for improving hand function and dexterity in patients with chronic stroke.

Motor functionEffective1a

One meta-analysis (Bolton et al., 2004), one high quality RCT ( Chan et al., 2009 ), one fair quality RCT (Cauraugh et al., 2000 ) and one pre-post study (Gritsenko & Prochazka, 2004) have investigated the effectiveness of FES for improving motor function in patients with chronic stroke.

The meta-analysis (Bolton et al., 2004) examined five studies to assess the effect of EMG-triggered neuromuscular stimulation on arm and hand function post-stroke. 84% of the patient population were in the chronic stage of recovery, and the remainder were acute and sub-acute. The total number of individuals studied was 47 in the treatment groups and 39 in the control groups. Subjects in the control group received usual stroke therapy (i.e. ROM stretching, neuromuscular facilitation, and functional training of the affected upper extremity). Overall, there was a significant difference between the patients treated with FES compared to those that received conventional therapy on the Fugl-Meyer Assessment, Box and Blocks Test and the Rivermead Motor Assessment.

The high quality RCT (Chan et al., 2009) has investigated the effectiveness of FES for improving motor function in 20 patients with chronic stroke. The participants were assigned to receive either FES in combination with bilateral upper limb motor training and conventional therapy, or bilateral upper limb training and conventional therapy only. 15 sessions were given, each one 20 minutes in length. Each session was preceded by 10 minutes of stretching and followed by 60 minutes of conventional occupational therapy. Outcomes were measured after the 15 sessions. At post-treatment there was a significant difference between the groups in favour of the stimulation group on the Functional Test for the Hemiplegic Upper Limb (FTHUE) and on the Fugl-Meyer Assessment.

The fair quality RCT (Cauraugh et al., 2000) investigated the effectiveness of FES for improving motor function in 11 patients with chronic stroke. The participants were assigned to receive 1) electrical stimulation during voluntary extension of the wrist/fingers, 2) voluntary extension of the wrist/fingers alone. Both groups received passive range of motion (ROM) and stretching exercises prior to the treatment. All participants completed 3 days (60 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 2 sets of 30 active neuromuscular stimulation trials. The control group also performed voluntary extension of the wrist/fingers for 60 minutes per day (2 sets of 30 movements). Outcomes were measured at post-treatment (two weeks). At post-treatment there was no significant difference between the groups on the Fugl-Meyer Assessment and the Motor Assessment Scale.

The pre-post study (Gritsenko & Prochazka, 2004) investigated the effectiveness of FES for improving motor function in 6 patients with chronic stroke. The participants received FES-assisted exercise therapy (reaching, grasping and moving) for 12 sessions of one hour each. Outcomes were measured at post-treatment (after 12 sessions) and at a two month follow-up. At post-treatment and at the two month follow-up, there were no significant improvements on the Fugl-Meyer Assessment and Motor Activity Log, however, these patients did show significant improvements between pre-and post-assessment on the Wolf Motor Function Test following therapy.

Conclusion: There is strong evidence (level 1a) from one meta-analysis and one high quality RCT that FES in combination with voluntary movement, bilateral motor training or conventional therapy is more effective than bilateral motor training or conventional therapy only for improving motor function in patients with chronic stroke.
Note:
However, one fair quality RCT did not find any significant between group differences on the Fugl-Meyer Assessment and the Motor Assessment Scale.

Range of motionEffective1b

One high quality RCT (Chan et al., 2009) and one fair quality RCT (Hara et al., 2008) has investigated the effectiveness of FES for improving range of motion in patients with chronic stroke.

The high quality RCT (Chan et al., 2009) has investigated the effectiveness of FES for improving range of motion in 20 patients with chronic stroke. The participants were assigned to receive either FES in combination with bilateral upper limb motor training and conventional therapy, or bilateral upper limb training and conventional therapy only. 15 sessions were given, each one 20 minutes in length. Each session was preceded by 10 minutes of stretching and followed by 60 minutes of conventional occupational therapy. Outcomes were measured after 15 sessions. At post-treatment there was a significant difference in favour of the stimulation group on active range of motion of the wrist, however no difference was found between the groups on forward reaching distance.

The fair quality RCT (Hara et al., 2008) investigated the effectiveness of FES for improving range of motion in 20 patients with chronic stroke. The experimental group received, at home, power-assisted FES and standard therapy, and the control group received standard therapy alone. The FES treatment was conducted for one hour a day for five months. Standard therapy was received once a week for 40 minutes over the five months. Outcomes were measured at post-treatment (five months). At post-treatment, there was a significant difference in favour of the stimulation group on measures of range of motion (measured by goniometry).

Conclusion: There is moderate evidence (level 1b) from one high quality and one fair quality RCT that FES in addition to bilateral motor training or conventional therapy is more effective than bilateral motor training or conventional therapy only for improving active range of motion in patients with chronic stroke.

Reaction timeConflicting4

Two high quality RCTs (Cauraugh & Kim, 2003a, Cauraugh & Kim, 2003b) and two fair quality RCTs (Cauraugh et al., 2000; Cauraugh & Kim, 2002) have investigated the effectiveness of FES for improving reaction time in patients with chronic stroke.

The first high quality RCT (Cauraugh & Kim, 2003a) investigated the effectiveness of FES for improving reaction time in 26 patients with chronic stroke. The participants were assigned to receive 1) 10 seconds of neuromuscular stimulation applied to the back of the impaired forearm, 2) 5 seconds of active neuromuscular stimulation or 3) 0 seconds of active neuromuscular stimulation (control group). In addition, all participants received bilateral movement training. All participants completed 4 days (90 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 3 sets of 30 active neuromuscular stimulation trials (either 0, 5 or 10 sec depending on group assignment) along with 3 sets of 30 bilateral extension movements of the hand. Outcomes were measured at post-treatment (two weeks). At post-treatment, there were no significant differences between the groups on reaction time.

The second high quality RCT (Cauraugh & Kim, 2003b) investigated the effectiveness of FES for improving reaction time in 34 patients with chronic stroke. The participants were assigned to receive 1) blocked practice (repetitive movements) in combination with active neuromuscular stimulation; (2) random practice (different movements) in combination with active stimulation; or (3) no active neuromuscular stimulation intervention (control). Extension of the wrist/fingers joint, elbow joint, and shoulder joint were performed by all subjects for 2, 90-minute sessions a week for a period of two weeks. At post-treatment (two weeks) there was a significant difference between in favour of the two stimulation groups compared to the control group on reaction time. No significant difference was found between the blocked and random practice stimulation groups.

The first fair quality RCT (Cauraugh et al., 2000 investigated the effectiveness of FES for improving reaction time in 11 patients with chronic stroke. The participants were assigned to receive 1) electrical stimulation during voluntary extension of the wrist/fingers, 2) voluntary extension of the wrist/fingers alone. Both groups received passive range of motion (ROM) and stretching exercises prior to the treatment. All participants completed 3 days (60 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 2 sets of 30 active neuromuscular stimulation trials. The control group also performed voluntary extension of the wrist/fingers for 60 minutes per day (2 sets of 30 movements). Outcomes were measured at post-treatment (2 weeks). At post-treatment there were no significant differences between the groups on reaction time.

The second fair quality RCT (Cauraugh & Kim, 2002) investigated the effectiveness of FES for improving reaction time in 25 patients with chronic stroke. The participants were assigned to receive 1) EMG-triggered stimulation and bilateral movement, 2) EMG-triggered stimulation and unilateral movement or 3) a control group that performed wrist and finger exercises only. All participants completed 4 days (90 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 3 sets of 30 active neuromuscular stimulation trials along with either bilateral or unilateral training (extensions of the wrist/fingers); the control group executed 90 voluntary wrist/finger extensions of the impaired hand per session without active stimulation. Outcomes were measured at post-treatment (two weeks). At post-treatment there was a significant difference in favour of the two stimulation groups compared to the control group on reaction time.

Conclusion: There is conflicting evidence (Level 4) from two high quality RCTs and two fair quality RCTs of whether FES in combination with conventional therapy or training is more effective than conventional therapy or training alone for improving reaction time in patients with chronic stroke.
Note: These studies have small sample sizes which may, in part, be contributing to the divergent findings.

SpasticityNot effective1b

One high quality RCT ( Chan et al., 2009 ) and one fair quality RCT (Hara et al., 2008) have investigated the effectiveness of FES for improving spasticity in patients with chronic stroke.

The high quality RCT (Chan et al., 2009) has investigated the effectiveness of FES for improving spasticity in 20 patients with chronic stroke. The participants were assigned to receive either FES in combination with bilateral upper limb motor training and conventional therapy, or bilateral upper limb training and conventional therapy only. 15 sessions were given, each one 20 minutes in length. Each session was preceded by 10 minutes of stretching and followed by 60 minutes of conventional occupational therapy. Outcomes were measured after the 15 sessions. At post-treatment there was no significant difference between the groups on the Modified Ashworth Scale.

The fair quality RCT (Hara et al., 2008) investigated the effectiveness of FES for improving spasticity in 20 patients with chronic stroke. The experimental group received, at home, power-assisted FES and standard therapy, and the control group received standard therapy alone. The FES treatment was conducted for 1 hour a day for five months. Standard therapy was received once a week for 40 minutes over the five months. Outcomes were measured at post-treatment (five months). At post-treatment, there was a significant difference between the groups in favour of the stimulation group on the Modified Ashworth Scale.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that FES in addition to bilateral motor training or conventional therapy is not more effective than bilateral motor training or conventional therapy only for improving spasticity in patients with chronic stroke.
Note:
However, one fair quality RCT found a significant difference between the groups in favour of the stimulation group on the Modified Ashworth Scale.

StrengthEffective1a

One meta-analysis (Glanz et al., 1996), three high quality RCTs ( Chan et al., 2009 ; Cauraugh & Kim, 2003a; Cauraugh & Kim, 2003b) and two fair quality RCTs (Cauraugh et al., 2000; Cauraugh & Kim, 2002) have investigated the effectiveness of FES for improving strength in patients with chronic stroke.

The meta-analysis (Glanz et al., 1996) examined four randomized controlled trials to assess the effectiveness of functional electrical stimulation (FES) therapy for improving muscular strength in patients with chronic stroke. The range of mean time since onset of symptoms for the individuals in the four studies included was 1.5 months to 29.2 months. The treatment group received FES for a muscle in their hemiparetic extremity (ankle, knee or wrist), along with standard physical therapy. The control group received physical therapy alone for all studies except one, where these patients received a sham treatment. All four studies generated a positive effect size (0.63), where patients who received FES had significant improvements in muscle strength of the hemiparetic extremity (ankle, knee or wrist) at post-treatment, in comparison to those who received standard physical therapy or even a sham treatment.

The first high quality RCT (Chan et al., 2009) has investigated the effectiveness of FES for improving strength in 20 patients with chronic stroke. The participants were assigned to receive either FES in combination with bilateral upper limb motor training and conventional therapy, or bilateral upper limb training and conventional therapy only. 15 sessions were given, each one 20 minutes in length. Each session was preceded by 10 minutes of stretching and followed by 60 minutes of conventional occupational therapy. Outcomes were measured after the 15 sessions. At post-treatment there was no difference between the groups on grip power.

The second high quality RCT (Cauraugh & Kim, 2003a) investigated the effectiveness of FES for improving strength in 26 patients with chronic stroke. The participants were assigned to receive 1) 0 seconds of active neuromuscular stimulation (control group), 2) 5 seconds of active neuromuscular stimulation or 3) 10 seconds of neuromuscular stimulation applied to the back of the impaired forearm. In addition, all participants received bilateral movement training. All participants completed 4 days (90 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 3 sets of 30 active neuromuscular stimulation trials (either 0, 5 or 10 sec depending on group assignment) along with 3 sets of 30 bilateral extension movements of the hand. Outcomes were measured at two weeks. At post-treatment there were no significant differences between the groups on sustained contraction of wrist extension.

The third high quality RCT (Cauraugh & Kim, 2003b) investigated the effectiveness of FES for improving strength in 34 patients with chronic stroke. The participants were assigned to receive 1) blocked practice (repetitive movements) in combination with active neuromuscular stimulation; (2) random practice (different movements) in combination with active stimulation; or (3) no active neuromuscular stimulation intervention (control). Extension of the wrist/fingers joint, elbow joint, and shoulder joint were performed by all subjects for 2, 90-minute sessions a week for a period of 2 weeks. Outcomes were measured at two weeks. At post-treatment there was a significant difference in favour of both stimulation groups compared to the control group on sustained contraction of wrist extension.

The first fair quality RCT (Cauraugh et al., 2000) investigated the effectiveness of FES for improving strength in 11 patients with chronic stroke. The participants were assigned to receive 1) electrical stimulation during voluntary extension of the wrist/fingers, 2) voluntary extension of the wrist/fingers alone. Both groups received passive range of motion (ROM) and stretching exercises prior to the treatment. All participants completed 3 days (60 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 2 sets of 30 active neuromuscular stimulation trials. The control group also performed voluntary extension of the wrist/fingers for 60 minutes per day (2 sets of 30 movements). Outcomes were measured at post-treamtent (two weeks). At post-treatment there was a significant difference between the groups in favour of the stimulation group on sustained contraction of wrist extension.

The second fair quality RCT (Cauraugh & Kim, 2002) investigated the effectiveness of FES for improving strength in 25 patients with chronic stroke. The participants were assigned to receive 1) EMG-triggered stimulation and bilateral movement, 2) EMG-triggered stimulation and unilateral movement or 3) a control group that performed wrist and finger exercises only. All participants completed 4 days (90 minutes per day) of rehabilitation training over a 2-week period. Each session consisted of 3 sets of 30 active neuromuscular stimulation trials along with either bilateral or unilateral training (extensions of the wrist/fingers); the control group executed 90 voluntary wrist/finger extensions of the impaired hand per session without active stimulation. Outcomes were measured at post-treatment (two weeks). At post-treatment, there were no significant differences between the groups on sustained contraction of wrist extension.

Conclusion: There is strong evidence (level 1a) from one meta-analysis, one high quality RCT and one fair quality RCT that FES in addition to bilateral motor training or conventional therapy is more effective than bilateral training or conventional therapy alone for improving strength in patients with chronic stroke.
Note:
However, two high quality RCTs  and one fair quality RCT  did not find any significant between group differences on the grip power or the sustained contraction of wrist extension.


Reference list:

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