+ Enhancing Motor Recovery in a patient with a history of an acute CVA Lauryl Andrus
+ Objectives n To describe the patient management of the demographic of interest n To examine the evidence for functional electrical stimulation as an effective intervention for a patient with acute stroke n To determine the effectiveness of functional electrical stimulation in enhancing motor return in my patient
+ Patient X- African American Male Age 57 Gender Male Past Medical History Stage IV chronic kidney disease, malignant hypertension Medical Diagnosis L ischemic stroke at the L MCA Patient Presentation Expressive aphasia, R facial droop, dysarthria, R hemiparesis
Physical Therapy Examination Sensation: Pt reports numbness in R UE LE gross Evaluation/Coordination (lim. ROM, MMT, tremors, synergy) R LE: Strength grossly dec. throughout, 2+/3-/5 throughout R UE: Strength grossly dec. throughout, 1+/2-/5 throughout Functional Mobility Bed Mobility Level Roll Right: MinA for UE management using rail Roll Left: MinA for R UE management using rail Sit to Supine: MinA for R LE and UE management, HOB elevated to 30 degrees Supine to Sit: MinA for R LE management to R and to L in bed Sitting Balance: SBA for static short sit without support, no LOB
+ Physical Therapy Examination Admission FIM Scores Bed/Chair/Wheelchair Transfer: 2 Walk: Distance: 0 Level of Assistance: 0 Wheelchair: Distance: 1 (34’) Level of Assistance: 1 Stairs: 0 Locomotion (Walk, w/c, or Both): 0 Walk
+ Physical Therapy Examination n Goals: By the time of d/c, pt will… Perform floor transfer with CGA using furniture for UE 1. support Perform squat pivot transfers ModI 2. Ambulate 150’ with LRAD with supervision 3. Perform car transfer with supervision 4. Complete family training and family will be 5. independent with assistance techniques and safety strategies Go up/down 12 6” steps with single rail and step to 6. pattern with CGA
+ Physical Therapy Examination n POC (IP Rehab): n Transfer training/car transfers n Gait training (lots!) n FES cycle ergometer n Bed mobility training n Strength training (muscles that aide with transfers) n Endurance training n Stair training n W/c mobility
+ In a 57 year old male patient, is functional electrical stimulation of the lower extremity an effective intervention to improve motor recovery and early gait after an acute CVA?
+ “Functional Electrical Stimulation Improves Motor Recovery of the Lower Extremity and Walking Ability of Subjects with First Acute Stroke” (Yan, T., Hui-Chan, C.W ., & Li, L.S., 2005 ) n Study Design: n Single-blind, stratified, randomized control design n Purpose : Whether FES given during acute stroke was more effective in promoting motor recovery of the LE/walking ability than standard rehabilitation (SR) alone.
+ Yan et al., 2005 n Studies have shown that… Motor experiences play a big role in physiological reorganization that occurs in adjacent tissues, and repetitive execution of similar movements of the limbs have been identified as crucial for motor learning and recovery n Hypothesis : “FES induced afferent-efferent stimulation that results in limb movements plus cutaneous and proprioceptive inputs during the acute stage could be important in reminding subjects how to perform the movement properly”.
+ Yan et al., 2005 n Subjects: n Excluding…: n 41 subjects completed n Brainstem/cerebellar study lesions n Unilateral CVA within n Medical comorbidity* carotid artery system n Receptive dysphasia n Ages 45-85 n Cognitive impairment n Independent in ADLs before CVA 3 experimental groups (FES and SR, Placebo stimulation and SR, or SR only)
+ Yan et al., 2005 All subjects received same SR 1x/day, 5 days per week for 3 weeks SR + Placebo group : longer duration of treatment, disconnected electrical stimulation unit Control group: SR only FES + SR group : Surface electrodes on quadriceps, hamstrings, tibialis anterior, and medial gastrocnemius n Subject sidelying (affected LE supported by sling) n Activation sequence that mimicked normal gait
+ Tan et al., 2014
+ Yan et al., 2005
+ Yan et al., 2005 Outcome Measures Composite Spasticity Scale (CSS) 1. Ankle plantar flexor tone 1. Maximum isometric voluntary contraction (MIVC) 2. Ankle plantar and dorsiflexors 1. Co-contraction ratio of PF vs. DF (IEMG) 3. TUG & Percentage of patients able to walk 4.
+ Yan et al., 2005 Significant findings for… n CSS scores at week 3 showed significantly increased spasticity in the placebo and control groups than in the FES group n MIVC n DF—% increases in MIVC torques and IEMG of the FES group were significantly larger than those of control group from 1 week onward (P<0.01-0.05) n And from the placebo group at 3 weeks (P=0.032) n PF—significant effect was found only at week 3 between FES and other two groups (P<0.01)
+ Yan et al., 2005 n EMG co-contraction ratio during DF was significantly reduced in the FES group than the other two groups (P=0.001-0.042) n Ability to walk- by week 8 12.2% walking before treatment à FES group n (84.6%), placebo group (60%), control group (46.2) More subjects receiving FES (84.6%) returned to their own home when compared with those receiving placebo (53.5% and SR (46.2%)
+ Yan et al., 2005 Effects of FES on Spasticity and Motor Recovery n FES might be able to normalize muscle tone in the affected ankle plantar-flexors n FES could have activated TA motoneuronal pool antidromically + directly activated the muscle = increased contraction of TA Effects of FES on Early Mobility n FES group tended to walk 2-3 days earlier than those receiving either placebo stimulation or SR alone (84.6% in FES group returned home)
+ Yan et al., 2005 Possible Mechanisms for Effects n Frequently repeated movements of affected LE induced by FES in stroke patients might reinforce network connection patterns n Brain plasticity could underline improvements seen in the FES group Limitations n FES during gait??? n Generalization of subjects n Smaller sample size
+ Cycling induced by electrical stimulation improves motor recovery in postacute hemiparetic patients a randomized controlled trial” (Ambrosini, E., Ferrante, S., Pedrocchi, A., Ferrigno, G., Molteni, F., 2011) n Study Design: n Double-blind, randomized clinical trial n Purpose : Whether cycling induced by functional electrical stimulation (FES) was more effective than passive cycling with placebo stimulation in promoting motor recovery and walking ability in postacute hemiparetic patients
+ Ambrosini et al., 2011 n Studies have shown that… Elements of afferent stimulation, including repetition, functional goal-directed activity, and FES have been beneficial in reducing motor impairment for persons with hemiparesis. n Hypothesis : Because of the similarities between cycling and walking, FES-induced cycling applied in postacute phase could play a crucial role in promoting motor recovery and improving locomotion
+ Ambrosini et al., 2011 n Excluding… n Subjects n 35 subjects n Cardiac pacemakers n First time stroke (n=32) n Allergy to electrodes or traumatic brain injury* (n=3) resulting in n Inability to tolerate hemiparesis stimulation n Acute interval <6 months before study onset n Low spasticity in lower limb (<2 on modified Ashworth) n Able to sit up for 30 minutes 2 experimental groups (cycling training synchronized to FES or passive cycling training with FES placebo)
+ Ambrosini et al., 2011 Both groups trained 5x/week for 4 weeks, 25 minutes a session + own standard rehabilitation program 8-channel stimulator with electrodes on BOTH legs: n quadriceps, n hamstrings, n gluteus maximum, and n tibialis anterior
+ Ambrosini et al., 2011 • 5-minute warm-up, 15-minute training of FES cycling or placebo FES cycling [passive cycling and no stimulation current], and 5- minute cool-down of passive cycling • Pts were required not to contribute voluntarily to pedaling
+ Ambrosini et al., 2011 Primary Outcome Measures 1. BS&F—Motricity Index (leg subscale) Motor power of paretic LE (0-100) 1. 2. Activity—overground walking speed (50m self-selected speed)
+ Ambrosini et al., 2011 Secondary Outcome Measures n Trunk Control Test, Upright Motor Control Test n Patient’s ability to perform an active, coordinated, bilateral movement, assessed through a pedaling test Resistance strain gauges mounted on crank arms to 1. measure torque of each leg 1 minute passive cycling, 2 minutes voluntary pedaling 2. Pedaling unbalance (U) measured by: 3.
+ Ambrosini et al., 2011 Significant findings for… n FES group—at 4 weeks n Primary outcomes: MI (p<0.001), gait speed (p<0.028) n Secondary outcomes: TCT, UMCT and W(PL) n Maintained at follow-up (112 ± 25 and 105 ± 25 days for FES, placebo) n Placebo group—at 4 weeks n NO statistically significant changes in primary or secondary n At follow-up: MI, gait speed
+ Ambrosini et al., 2011 n The results of this study demonstrated that 20 sessions of FES-induced cycling training significantly reduced both impairments and activity limitations in postacute hemiparetic patients n Significant increase in gait speed after training and at follow-up for participants receiving FES, whereas placebo group obtained significant improvements only after follow-up = FES cycling promotes a faster recovery in terms of locomotion [carryover]
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