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A combination therapy that pairs special exercises with electrical stimulation of the muscles can help patients who have one arm weakened by stroke, a small study suggests. Researchers at the University of Florida, Gainesville, found that patients who went through 2 weeks of the therapy regained more arm function compared with those not on the dual treatment. Dr. James H. Cauraugh and Sangbum Kim report their findings in the June, 2002 issue of Stroke: Journal of the American Heart Association. One part of the combination therapy involves placing electrodes on patients' forearms to stimulate their working muscles as they perform various tasks--such as reaching for, grasping and moving small blocks. This small shot of electricity is known as electromyogram-triggered neuromuscular stimulation, or EMG-triggered stimulation. The other aspect of the therapy requires patients to perform movements with both the stroke-affected and healthy arm. Such bilateral movement, in contrast to moving only the affected side, is thought to potentially recruit new nerve pathways to assist the weakened limb. Cauraugh told Reuters Health that the electrical-stimulation therapy--which he said has grown increasingly popular over the past 5 years--gives a "boost" to the muscles at the back of the forearm, helping patients extend their wrists and fingers. Few studies have looked at bilateral movement in stroke recovery, but researchers have long known that executing the same motion with both arms facilitates the movement of the individual arm, according to Cauraugh. "When the same movement signal is sent to both arms, then movements are readily executed," he explained. And he said, combining EMG stimulation and bilateral movement "takes advantage of the strengths of each." To test this idea, the Florida researchers had 10 patients train with the combination therapy, while 10 others received electrical stimulation while moving only their weakened arms. A third, "control" group of five patients exercised the impaired limb only, with no electrical stimulation. All had suffered strokes at least one year before the study, and had continuing weakness on one side of the upper body. After 2 weeks of therapy, those in the bilateral/stimulation group were outperforming the other two groups in tests of movement and muscle contraction, the report indicates. The researchers also found marked improvements among patients who received EMG-triggered stimulation while moving only their stroke-affected arm. They were able, for example, to move more blocks than control-group patients were, and showed faster reaction times when cued to move their wrists and fingers. However they note, the even greater improvements in the bilateral/stimulation group suggest that the two approaches together are "better than one." Cauraugh said he will continue to study how the injured brain can "reorganize" with the help of behavioral therapies and try to identify those that provide the greatest movement recovery.
Amy Norton Reuters Health

A group of forty-nine hemiparetic patients with limited emotional, communication and sensibility involvement and with recent lesion of cerebrovascular aetiology was randomly divided into two groups of twenty-four and twenty-five subjects. Both groups received traditional physiotherapy treatment for one hour/day, one group received twenty min/day of peroneal nerve stimulation. The maximum voluntary dorsal flexion moments of the ankle joint of the affected and non affected extremities were measured with an isometric brace twice a week for one month and for both groups. The recovery of moment in the stimulated group turned out to be about three times greater than in the control group and considerably less dependent upon age, time from lesion, initial value, side of lesion. Three patients using a peroneal brace at home as an assisting device were again evaluated two months later and a further improvement was observed. This work gives statistical support to previous observations based on very few cases and provides a statistically reliable answer concerning the entity of FES induced recovery of muscle force in hemiparetic subjects. 
Merletti R. et al Scand J Rehabilitation Med. 

Positional feedback (PF) and electrical stimulation were combined in a new treatment modality for facilitating wrist extension in stroke patients. Thirty adult hemiparetic patients lacking normal voluntary wrist extension were randomly placed in control and study groups. The control group received conventional therapy while the study group received positional feedback stimulation training (PFST) in addition to conventional treatment. At the end of the 4-week program, study patients showed a 280% increase in isometric extension torque when the wrist was positioned in 30 degrees of extension and 70% increase when positioned in 30 degrees of flexion. Control patients showed no significant changes in torque. Study patients made an average 200% gain in selective range of motion over their starting levels while controls made only a 50% increase. Treatment using automated PFST equipment allows controlled repetitive isotonic exercise and facilitation of wrist extension without continuous one-on-one therapist/patient supervision. 
Bowman B. et al Arch Phys Med Rehabilitation 

Objective: To compare the gains for chronic stroke patients in volitional gait pattern attained from treatment with functional neuromuscular stimulation (FNS) and intramuscular electrodes (IM) with gains attained using conventional therapy, including treatment with FNS using surface electrodes (surface-stimulation). Design: This single-subject research design consisted of a series of two subjects. Three months of conventional therapy and surface-stimulationb were followed by treatment using the FNS-IM system. Two stroke patients had cerebrovascular accident 1 or 4 yr before the study and ambulated with a cane. Interventions consisted of 3 months of conventional exercise and gait training including surface-stimulation, followed by 7-14 months of treatment with the FNS-IM system. Treatments occurred up to 3 times/wk for 1-hr sessions and a home program. Outcome measures consisted of six kinematic gait components, as measured by a six-camera video-based data-acquisition system. Coordination of isolated joint movement was measured according to the Fugl-Meyer scale. Results: Both subjects improved during conventional therapy to some degree. During FNS-IM treatment, gains were made beyond those attained during conventional therapy. Statistically significant differences were found between conventional and FNS-IM therapy. Conclusions: For these two subjects, gains in volitional control of gait were made during conventional treatment (including surface-stimulation); for these two subjects during FNS-IM treatment, additional gains were made in volitional gait pattern, beyond those attained during conventional therapy. Functional electrical stimulation-assisted walking for persons with incomplete spinal injuries: changes in the kinematics and physiological cost of overground walking. 
Daly J. et al, Walsh University, N. Canton, Ohio, USA. Am J Phys Med Rehabil. 

Use of electrical stimulation early in stroke rehabilitation may benefit recovery of function. This case report describes the clinical outcomes following electrical stimulation for the supraspinatus of a 25-year-old patient four weeks after a right sided stroke. In this patient, use of electrical stimulation for a total of four hours in 4.5 weeks, appeared to have a number of benefits: subluxation was reduced and patient attention to the arm was increased. There was also a notable improvement in functional use of the arm when task-specific upper limb training was incorporated. Whilst not conclusive, the results of this case study reinforce the value of electrical stimulation in the early management of the upper limb in a stroke patient who clearly demonstrated inattention to his upper limb. The results also highlight the need for well controlled studies to investigate the benefits of electrical stimulation and to establish the optimal timing and parameters for this intervention. Therapists can then more effectively optimise effective upper limb rehabilitation following stroke. 
Mackenzie-Knapp M. School of Physiotherapy, La Trobe University, Bundoora, Australia. Aust J Physiotherapy

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. et al Resp. Care Dep. Univ. Cleveland, USA Respiratory Care 

This case report describes the first survivor with chronic stroke who was treated with percutaneous, intramuscular neuromuscular electrical stimulation (NMES) for shoulder subluxation and pain. The patient developed shoulder subluxation and pain within 2 mo of his stroke. After discharge from acute inpatient rehabilitation, he developed shoulder and hand pain, which was treated with subacromial bursa steroid injection and ibuprofen with eventual resolution. The patient remained clinically stable until approximately 15 mo after his stroke-when he developed severe shoulder pain associated with shoulder abduction, external rotation, and downward traction. The patient could not tolerate transcutaneous NMES because of the pain of stimulation. At approximately 17 mo post-stroke, the patient's posterior deltoid, middle deltoid, and supraspinatus muscles were percutaneously implanted with intramuscular electrodes. After 6 wk of percutaneous, intramuscular NMES treatment, marked improvements in shoulder subluxation and pain, and modest improvements in activities of daily living and motor function were noted. One year after the onset of treatment, the patient remained pain free, but subluxation had recurred. However, the patient was able to volitionally reduce the subluxation by abducting his shoulder. The patient remained pain free for up to 40 mo after the initiation of percutaneous, intramuscular NMES treatment. This case report demonstrates the feasibility of using percutaneous, intramuscular NMES for treating shoulder subluxation and pain in hemiplegia. 
Chae J. et al Am J. Phys Dep. Physical Medicine and Rehabilitation, Cleveland, USA Med Rehabilitation 

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. 

A model of hemiplegic spasticity based on electromyographical and biomechanical parameters measured during passive muscle stretching is presented. Two components of spasticity can be distinguished -phasic and tonic. This classification depends on the pattern of stretch reflex activity which can be either phasic or tonic as well as on the muscle stretch/tension characteristic. Stretch reflex, as a control loop, is in phasic spasticity characterized by increased sensitivity to velocity of stretching. In tonic spasticity, sensitivity to length of stretching is increased. After the injury, phasic spasticity appears first and invokes monosynaptic reflex pathways. The intensity of tonic spasticity increases with the duration of disability and hence causes changes in muscle fiber biomechanical properties. The model mentioned above has been used to evaluate the effects of FES on spasticity. Hemiplegic patients with implanted peroneal nerve stimulator for gait correction were followed up for one year starting a week before implantation. Long-term use of FES resulted in decrease of tonic spasticity in both ankle joint antagonistic muscle groups. In stimulated tibialis anterior muscle, the phasic type of spasticity increased. To obtain the correlation between changes in spasticity and functional abilities of patients, the maximal voluntary isometric contraction of both muscle groups was also measured. An improvement in voluntary strength was also observed. This can be taken as additional evidence that tonic spasticity is of greater physiological and clinical significance than phasic spasticity. It may be concluded that use of FES can decrease tonic spasticity and, if applied early after the injury, can prevent the appearance of tonic spasticity. 
Stefanovska A. et al IEEE Trans Biomed Eng. 

The goal of this research was to determine if cutaneous electrotherapy would temporarily reduce muscle spasticity. Five traumatically brain injured (TBI) and five spinal cord injured (SCI) subjects, all with clinically evident spasticity, received surface electrical stimulation over the tibialis anterior muscle. Using the Spasticity Measurement System, stiffness around the ankle was measured before, immediately after, and 24 hours after treatment. With stimulation, ipsilateral ankle viscoelastic stiffness immediately decreased in 9 of 10 subjects and remained significantly depressed for up to 24 hours. Contralateral ankle spasticity did not significantly change. Using the same subjects under sham conditions, no significant decrements in spasticity occurred. In a subjective survey, only SCI participants reported functionally evident spasticity reductions. Also within this subgroup, efficacy of treatment was directly proportional to the severity of pre-stimulation clonus. We conclude that (1) cutaneous electrotherapy transiently decreases both TBI and SCI related spasticity and (2) pre-stimulation clonus may function as a clinical indicator of SCI patients most likely to benefit from this process. 

Seib T. et al Univ. of Washington School of Medicine, Seattle. Arch Phys Med Rehabilitation 

Twelve spinal cord injured subjects participated in a study of the short-term effects on leg spasticity of electrical stimulation of the quadriceps. Spasticity was quantified through the use of a normalized relaxation index (R2n) obtained from the pendulum drop test both before and after measurement of isometric quadriceps torque in response to 20 minutes of cyclic electrical stimulation. Two or three baseline evaluations were made on each subject, tests being at least one day apart. By comparing the first prestimulus baseline assessment of spasticity with that obtained poststimulus, we obtained a measure of changes in spasticity brought about by fatiguing exercise. We found that spasticity significantly (p less than or equal to 0.005) decreased after stimulation. To investigate whether this change was due to electrical stimulation or was a function of the performance of the drop test itself (ie, passive range of motion of the knees), drop-to-drop variability during the pendulum drop test both before and after stimulation was assessed. A comparison was made of the R2n value of the last drop before stimulation to that of the first drop afterward, to assess the direct effect of stimulation on spasticity. Spasticity decreased significantly (p less than or equal to 0.05) during the leg ranging inherent in the drop test itself, particularly for subjects with shorter times postinjury. Spasticity also decreased significantly as a direct result of electrical stimulation. This latter change could be accounted for by an interaction of peak quadriceps torque and the initial measure of spasticity before stimulation. 
Robinson C. et al Rehabilitation R & D Center, Veterans Adm. Hospital, Hines, USA Arch Phys Med Rehabilitation


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