Electrical Stimulation in the Treatment of Strokes

Submitted by: Ali Eggenberger, Macayla Greiner, Mike Neal & Perla Perez

Central Michigan University

November 6, 2017
Use of Electrical Stimulation in Stroke Patients 2

A cerebrovascular accident (CVA), which is more commonly known as a stroke, is a

medical condition characterized by the occlusion of oxygen-rich blood flow to the brain due to a

blood vessel bursting or being blocked by a clot. The lack of oxygen and nutrient supply from

the bloodstream to the brain results in damage to brain tissue.1 The effects of a stroke depend on

which part of the brain is injured, how severely it is affected, and how much time passes before

the cerebral accident is treated.2

Stroke survivors are often faced with a variety of long-term complications and

impairments, such as reduced lower extremity motor functioning, dysphagia, abnormal gait

patterns, trunk control, and upper extremity motor functioning. The goal of the recovery process

is often focused upon returning the patient back to their normal life and living as independent as

possible.3 One rehabilitation method commonly used with patients following a stroke is electrical

stimulation (ES). ES is a therapeutic treatment used to elicit a muscle contraction or reduce pain

using electrical impulses. The electrical current is sent from a unit to the electrodes, which is

then delivered to the muscles.4 Upon revision of the research presented, we will be analyzing the

use of ES in stroke patients and concluding its efficacy.

An impairment resulting from a stroke is loss of control in lower limb motor function.

This decrease in motor function often results in an inability to perform activities of daily living

(ADLs). Therefore, reestablishing a normal gait pattern in post-stroke patients is an imperative

therapeutic goal for patients. Past research has shown that ES can aid in the recovery process of

many chronic stroke patients, by providing the potential to “increase muscle strength, improve

gait velocity and rhythmicity, enhance trunk control and balance, and improve quality of life.”5

Research has also proven the necessity of early-rehabilitation in patients attempting to recover

from a stroke in returning to normal function. You, Guoqing et al performed a study in 2014 in
Use of Electrical Stimulation in Stroke Patients 3

attempts to investigate whether early application of functional electrical stimulation (FES) in

rehabilitation promotes the return to ADLs in post-stroke patients.5

Their study included 37 subjects split up randomly into two groups, a control group (18)

and an FES group (19). Both groups received a standardized rehabilitation program, which

included 60 minutes, 5 days a week focusing on ADLs. In addition to the standardized

rehabilitation, the FES group also received ES using a dual-channel stimulator.5 The pads for the

ES were placed over the motor points of the tibialis anterior and the peroneus longus and brevis

muscles to induce ankle dorsiflexion, and ankle eversion respectively. The patients were

positioned sitting in a chair or lying supine on the bed with tibialis anterior slightly extended.

The parameters of the stimulation included 200 μs pulses at 30 HZ. The treatment continued for

a total of 30 minutes, one time a day, 5 days out of the week for 3 weeks.5

Measurements were taken prior to treatment and during treatment in the second and third

weeks using a variety of standardized scales. These scales indicated the level plantarflexor

spasticity, balance, lower limb mobility, and the ability to perform ADLs.5 The results showed

that in time, patients amongst both groups suffered from lower limb spasticity. However, it was

found that the spasticity progressed much slower in the FES group compared to the control

group. In regards to balance, the FES group performed better after 3 weeks of treatment

compared to the control group.5 The lower limb mobility scores showed that after 3 weeks, both

groups had increased, but the FES group had increased more in comparison to the control group.

The scores on the subjects’ ADLs also showed an increase in functionality of both groups,

however a greater increase in those subjects in the FES group. These results indicate the potential

benefits patients can receive from the addition of FES into their therapeutic intervention by
Use of Electrical Stimulation in Stroke Patients 4

improving their ADLs, increasing balance, increasing lower limb mobility and by slowing the

progression of spasticity.5

A stroke can also have adverse effects that results in difficulty swallowing. Patients may

struggle with dysphagia for a few weeks after its onset or for the rest of their life. Dysphagia

interferes with their ability to orally consume food or liquid, putting patients at higher risks of

malnutrition or pneumonia.6 ES has resulted to be an effective intervention to assist patients in

recovering or improving their ability to swallow. With the use of neuromuscular stimulation with

an electrical current in a noninvasive manner, Shu-Fen et al6 found compelling evidence to

support such claims.

Their study consisted of 29 outpatient participants who ranged from moderate to severe

dysphagia. Twenty-one of those patients were reported to be tube-feeding-dependent. For 2 to 3

weeks these patients received ES above the hyoid and on their thyrohyoid muscles for a total of

12 treatments. Each session lasted about an hour a day with a dual channel electrotherapy system

at 80 hertz and with a pulse rate of 700 μs. The current level was administered to the highest

tolerance of the patient that brought about maximum muscle contraction.6

To measure the outcomes, researchers used fiberoptic endoscopic evaluation of

swallowing (FEES) to monitor and guide the treatment of dysphagia. After each ES session,

traditional swallowing exercises were administered to patients through a speech therapist with

the help of FEES. To evaluate the effects that ES had on the participants, researchers monitored

dietary intake, degree of dysphagia, appraisal of own ability of swallowing and satisfaction of the

treatment.6

With follow ups at 6 months and 2 years, results showed that 15 of the 21 patients who

were tube-feeding-dependent, recovered their ability to swallow and intake foods without the
Use of Electrical Stimulation in Stroke Patients 5

assistance of a feeding tube. Participants also showed a decrease in their level of dysphagia by

increasing their dietary intake and swallowing ability.6 These results support ES as a treatment of

dysphagia in stroke patients and encouraged the combination of subsequent exercise to most

effectively improve or regain functional swallowing abilities.

Changes in gait pattern is another effect that patients face after a CVA. These changes in

gait pattern are often due to an increase in muscle stiffness along with a decrease in muscle

activation.7 It has been proven that functional ES can be used to activate upper motor neurons,

thus generating a muscle contraction. The application of the functional ES has been used in

previous studies to prevent drop foot in patients and to improve walking in chronic stroke

patients.7 However, none of these studies attempted to correlate the walking speed of patients

with the amplitude of the EMG signal to the tibialis anterior muscle. Sukanta et al created a study

with this exact purpose.

This study included 15 patients between the ages of 45-60 years old with drop foot from a

recent stroke (at least 3 months prior). The subjects were all treated for one hour each day, 5 days

a week, for 12 weeks.7 The treatment included a conventional stroke rehab program in addition

to receiving 30 minutes of ES to the tibialis anterior muscle on the affected leg. The stimulation

was produced to initiate the normal swing phase and was given at a bi-phasic rectangular pulse

of 300 μs with intensity of 0-80 μA with a frequency pf 40 HZ.7 The amplitude of the EMG was

recorded using a software program. In addition, the following parameters were also recorded at

the baseline and at the end of treatments: walking speed, effort of walking speed, metabolic

responses such as oxygen consumption (VO2), carbon dioxide production (VCO2), expiratory

minute ventilation (VE), energy cost (EC), and heart rate (HR).7
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The results of the EMG measurements after the twelve weeks showed an overall

significant increase, indicating that there was an improvement in the maximum voluntary control

of the muscle after functional ES treatment to the tibialis anterior.7 From baseline to post-

treatment measurements, all of the subjects reported a significant improvement in walking speed

as well as an increase in effort of walking speed. The walking speed increased an average of

38.7% with a reduction in the effort of walking speed of 34.6% on average. The correlation

between the amplitude of EMG and walking speed showed to be moderate with a correlation of

0.783.7 As for the cardiopulmonary health parameters, the ES showed improvement for the

subjects, resulting in a decrease in heart rate, VO2, VCO2, and an increase in EC. Overall, this

study suggests that the functional electricity stimulation combined with a conventional

rehabilitation program therapy can provide benefits in therapy to correct drop foot in post stroke

patients.7

A subsequent side effect associated with CVA is difficulty controlling the trunk. Weak

or stiff trunk muscles lead to an increased risk of falls in post-stroke patients. ES on the trunk

musculature has been shown to have mixed reviews in the rehabilitation process of stroke

patients. The effect of weight-shifting exercise (WSE) combined with transcutaneous electrical

nerve stimulation (TENS) was conducted on 60 stroke patients by Jung et-al to identify its

effectiveness on balance control.8

The 6-week study was completed on 3 groups, all including 20 patients; WSE+TENS,

WSE+placebo TENS, and a control group.8 All of the groups received a normal rehabilitative

exercise plan during the study 5 days per week for 1 hour per day. An additional 30 minutes of

exercise was given to each group 5 times a week depending on the assigned group.8 The

WSE+TENS and WSE+placebo TENS groups received weight shifting exercise. In addition to
Use of Electrical Stimulation in Stroke Patients 7

the WSE mentioned, the WSE+TENS patients also received ES during the exercises at 100 Hz,

with a pulse duration of 200 μs to the erector spinae and external oblique muscle groups. The

control group received stretching exercises and rode an exercise bike during the 30 minutes.8

The outcomes evaluated for the effectiveness of ES included external oblique activity,

erector spinae activity, maximum reaching distance, coordination, static sitting balance and

dynamic sitting balance. To assess muscle contraction, electromyogram was attached to the

surface of the muscles during the weight shifting exercises.8 Maximum reaching distance was

recorded according to the movement of the acromion during weight shift to the side with

hemiparesis. When looking at the results of coordination, static sitting balance, and dynamic

sitting balance a trunk impairment scale was used (TIS).8

After 30 sessions of training, results showed the effectiveness of TENS with weight

shifting exercise combination therapy improved external oblique activity, maximum weight

shifting, coordination, and overall trunk performance. However, both experimental groups had

an equal enhancement in erector spinae activity and dynamic sitting compared to the control

group.8 This indicates that adding ES to weight shifting exercise does not result in additional

benefits. Among all patients, regardless of groups, static sitting balance improved, but did not

differ significantly between all of the patients.

Research articles up to this point have indicated improvements in regaining swallowing

abilities, regaining lower limb mobility, gait and trunk performance. However the latter of the

previous article shows that ES may not always be appropriate or show additional benefits. This

is also seen in the following study that explored prevention of wrist contractures, spasticity, and

stiffness.
Use of Electrical Stimulation in Stroke Patients 8

Malhotra et al. examined the effect of surface neuromuscular ES in the prevention of

upper limb pain, wrist flexor spasticity and contractures in a population of acute stroke

patients.9All participants had no useful hand function resulting from a stroke within 6 weeks

prior to the start of the trial. The participants were divided into two groups, a treatment group

and a control group. For 6 weeks, each patient in the treatment group received 30 minutes of

surface neuromuscular ES to the wrist and finger extensors for 2 to 3 times per day and 5 days

per week.9

The parameters were set at 300 μs for pulse duration, 40 Hz for frequency, and 15

seconds for the on and off times with ramp up and ramp down times of 6 seconds. The intensity

of the ES was adjusted so the patients were able to achieve maximum wrist and finger extension

without pain or fatigue. The participants in the control group received no ES. During the 6

weeks, both groups also participated in routine physical therapy and clinical treatment on the

stroke unit.9

The primary clinical outcome measures were tested every 6 weeks. Pain was measured

using a five-point numerical scale, and spasticity was analyzed by measuring muscle activity

during passive wrist extension. Wrist contractures were evaluated by measuring passive range of

motion and stiffness at slow stretch of the wrist. The results of the study showed that the

treatment of surface neuromuscular ES had a significant effect in the prevention of pain. There

was some evidence that expressed a reduction in the formation of contractures, but only in

patients that had not regained any functional movement in the paretic limb. The ES treatment had

no effect on the prevention of spasticity or stiffness.9 These findings show that ES may be an

effective treatment method for pain in the paretic limb of stroke patients, but an ineffective

treatment method for the prevention of wrist contractures, spasticity, and stiffness.
Use of Electrical Stimulation in Stroke Patients 9

ES has been found to be used in rehabilitation of patients who experience a CVA.

Research has found this modality to have various outcomes in combination with exercise and

rehabilitation programs. Improvements to stroke patients’ ADLs were reported, as well as

slowing the progression of spasticity, increasing balance and lower limb mobility.5 Benefits also

were seen in preventing pain in the upper limbs, correcting drop foot and recuperation of

functional swallowing abilities.6,9,7 No sufficient differences have been noted when used to

improve muscle activity and trunk control in stroke patient’s rehabilitation.8 ES paired with

exercise or a rehabilitation program has not shown any benefits in the prevention of wrist

contractures, spasticity or stiffness.9 As research has shown ES in stroke patients’ rehabilitation

process has some benefits for certain deficits post stroke. In this literature review we recommend

ES to be a modality that should be considered as a possibility to enhance the rehabilitation

process in stroke survivors.

Use of Electrical Stimulation in Stroke Patients 10

References

1. Cerebrovascular accident. World Health Organization.

http://www.who.int/topics/cerebrovascular_accident/en/. Accessed on November 3rd,

2017.

2. Stroke (Cerebrovascular Accident). PubMed Health.

https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024234. Accessed on November

3rd, 2017.

3. Stroke Recovery. National Stroke Association. http://www.stroke.org/we-can-

help/survivors/stroke-recovery. Accessed on November 4th, 2017.

4. Electrical Stimulation. Advance Physical and Aquatic Therapy.

http://advanceaquaticpt.com/electric-stimulation/. Accessed on November 4th, 2017.

5. Guoqing Y., Huiying L., Tiebin Y. (2014). Functional electrical stimulation early after

stroke improves lower limb motor function and ability in activities of daily living.

NeuroRehabilitation 35: 381-389. doi:10.3233/NRE-141129

6. Shy-Fen S., Chien-Wei H., Huey-Shyan L., et al. (2013). Combined Neuromuscular

Electrical stimulation (NMES) with fiberoptic endoscopic evaluation of swallowing

(FEES) and traditional swallowing rehabilitation in the treatment of stroke-related

dysphagia. Springer US. 28:557-566. Doi: 10.1007?s00455-013-9466-9.

7. Sukanta K. S., Prasanna K. L., Ratnesh K., & Manjunatha M. (2010). Effect of functional

electrical stimulation on the effort and walking speed, surface electromyography activity,

and metabolic responses in stroke subjects. Journal of Electromyography and

Kinesiology. 20(6), 1170-1177. doi:https://doi.org/10.1016/j.jelekin.2010.07.003

Use of Electrical Stimulation in Stroke Patients 11

8. Jung K, Jung J, In T, Cho H. Effects of Weight-shifting Exercise Combined with

Transcutaneous Electrical Nerve Stimulation on Muscle Activity and Trunk Control in

Patients with Stroke. Occupational Therapy Internatinal [serial online]. December 2016;

(4):436-443.

9. Malhotra S., Rosewilliam S., Hermens H., et al. A randomized control trial of surface

neuromuscular electrical stimulation applied early after acute stroke: Effects on wrist

pain, spasticity, and contractures. Clinical Rehabilitation. September 20, 2012; 27(7),

579-590.