Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis

Abstract

BackgroundStroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.MethodsSystematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.ResultsTwenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.ConclusionsFES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.Trial RegistrationPROSPERO: CRD42015025162, Date:11/08/2015 Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-017-0435-5) contains supplementary material, which is available to authorized users.

Using functional electrical stimulation with stroke survivors: A survey of Victorian occupational therapists and physiotherapists

“…As clinicians gain clinical experience, if they have not observed the intervention of FES to produce tangible outcomes, they may be less inclined to use FES for stroke rehabilitation. Reasons for not experiencing positive outcomes may include the intervention not demonstrating implementation fidelity (Carroll et al ., ) or the treatment effects being estimated from the systematic reviews may be inflated due to small trial bias (Howlett et al ., ) or the methodological biases of included trials (Eraifej et al ., ). To better understand why there is variability in use of FES between different therapists, future implementation studies should explore the effect of clinician clinical experience and undergraduate training on FES use.…”

“…As clinicians gain clinical experience, if they have not observed the intervention of FES to produce tangible outcomes, they may be less inclined to use FES for stroke rehabilitation. Reasons for not experiencing 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Inpatient public hospital rehabilitation 15 (30) 14 (28) 9 (18) 1 (2) 3 (6) Inpatient private hospital rehabilitation 1 (2) 1 (2) 1 (2) 0 (0) 0 (0) Home-based rehabilitation (public funded) 3 (6) 3 (6) 3 (6) 0 (0) 0 (0) Home-based rehabilitation (private funded) 1 (2) 1 (2) 1 (2) 0 (0) 0 (0) Centre or clinic based outpatient rehabilitation (public funded) 16 (32) 14 () 7 (14) 8 (16) 2 (4) Centre or clinic based outpatient rehabilitation (private funded) 2 (4) 2 (4) 1 (2) 1 (2) 0 (0) Other 1 (2) 1 (2) 1 (2) 0 (0) 0 (0) Years working with stroke survivors <2 years of experience 4 (8) ≥2 to 5 years of experience 19 (38) ≥5 to 10 years of experience 19 (38) ≥10 years of experience 8 (16) positive outcomes may include the intervention not demonstrating implementation fidelity (Carroll et al, 2007) or the treatment effects being estimated from the systematic reviews may be inflated due to small trial bias (Howlett et al, 2015) or the methodological biases of included trials (Eraifej et al, 2017). To better understand why there is variability in use of FES between different therapists, future implementation studies should explore the effect of clinician clinical experience and undergraduate training on FES use.…”

“…Much of the focus of stroke rehabilitation, and in particular that of physiotherapists and occupational therapists, is on recovery of impaired movement and functional ability to move the arm and leg. Functional electrical stimulation (FES), defined as electrically stimulating weak muscles to enable functional based movements during activities for therapeutic purposes (Peckham & Knutson, 2005), is able to improve the movement of the arm and leg after stroke (Howlett, Lannin, Ada & McKinstry, 2015) and improve performance of activities of daily living for participants in the first two months after stroke (Eraifej, Clark, France, Desando & Moore, 2017).…”

The Effects of Upper Limb Motor Recovery on Submovement Characteristics among the Patients with Stroke: A Meta‐Analysis

“…The upper limb has been demonstrated to be affected in more than 75% of patients with stroke . Rehabilitative techniques such as occupational therapy (OT), robotics, virtual reality, and functional electrical stimulation are used for upper limb recovery after stroke. The OT programs for upper extremity are usually selected based on the therapist's training and personal experience, leading to less optimal treatments .…”

The use of the electrical stimulation device for the muscles in the limit determines the elbow joint during the lifting of the disabled weightlifting players

“…In this treatment the doctors can determines the limitation of the muscle strength and improve the condition of the patient according to the sustainable capacity of the patient. In this treatment the severity of the injury is also playing vital role in determining the period of treatment and intervals to apply the treatment per day (Eraifej et al, 2017). The latest devices available in the market has become viable for the patients also.…”