Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018 Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded Obtained data were synthesized thematically and descriptively analyzed Results: One thousand nine hundred and ninety six studies were identified while 347 (6522% high quality) RCTs were found to be eligible for the review The most commonly assessed variables (and outcome measure utility) were activities of daily living [7579% of the studies, with Barthel Index (3702%)], motor function [6657%; with Fugl Meyer scale (7188%)], and gait [3112%; with 6 min walk test (3867%)] Majority of the innovatively high technology interventions such as robot therapy (9524%), virtual reality (9444%), transcranial direct current stimulation (7895%), transcranial magnetic stimulation (880%) and functional electrical stimulation (8500%) were conducted in high income countries Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life

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Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review.

Objectives This scoping review was undertaken to synthetize and appraise the literature on the potential mechanisms of action of functional electrical stimulation therapy in combination with task-specific training (FEST + TST) in the rehabilitation following stroke, spinal cord injury, traumatic brain injury, or multiple sclerosis. Materials and methods The literature search was performed using multiple databases (including APA, PsycInfo, Medline, PubMed, EMBASE, CCRCT, and Cochrane Database of Systematic Reviews) from 1946 to June 2020. The literature search used the following terms: (spinal cord injury, paraplegia, tetraplegia, quadriplegia, stroke, multiple sclerosis, traumatic brain injury, or acquired brain injury) AND (functional electrical stimulation or FES). The search included clinical and preclinical studies without limits to language. Results Of the 8209 titles retrieved from the primary search, 57 publications fulfilled the inclusion and exclusion criteria for this scoping review. While most publications were clinical studies (n = 50), there were only seven preclinical studies using animal models. The results of this review suggest that FEST + TST can result in multiple effects on different elements from the muscle to the cerebral cortex. However, most studies were focused on the muscle changes after FEST + TST. Conclusions The results of this scoping review suggest that FEST + TST can result in multiple effects on different elements of the neuromuscular system, while most research studies were focused on the muscle changes after FEST + TST. Despite the efficacy of the FEST + TST in the neurorehabilitation after CNS injury or disease, the results of this review underline an important knowledge gap with regards to the actual mechanism of action of FEST + TST.

Insights on the Potential Mechanisms of Action of Functional Electrical Stimulation Therapy in Combination With Task-Specific Training: A Scoping Review.

Objectives: Neuromuscular electrical stimulation (NMES) is a popular rehabilitative modality to improve motor function of the extremities and trunk. In this study, we investigated changes of hand function and the contralateral corticospinal tract (CST) with treatment by NMES on the finger extensor muscles for 2 weeks, using serial diffusion tensor tractography (DTT). Methods: Thirteen right handed normal subjects were recruited. Treatment was applied to the left hand (the NMES side), and the right hand was the control side. NMES was applied for 30 min/day, 7 days per week, for 2 weeks. Hand motor function was evaluated twice at pre-NMES and post-NMES training using grip strength (GS), Purdue pegboard test (PPT) and tip pinch. The fractional anisotropy (FA), mean diffusivity (MD) and tract volume (TV) of the CST in both hemispheres were measured using DTT. Results: On the control side, the clinical scores did not differ significantly between pre- and post-NMES training (p > 0.05). However, on the NMES side, PPT and tip pinch improved significantly (p 0.05). By contrast, FA, MD and TV on the left CST did not change significantly (p > 0.05). Conclusion: We demonstrated facilitation of the contralateral CST with improvement of fine motor activity by 2 weeks of NMES training of peripheral muscles in normal subjects. We think our results can be applied to the normal subjects and patients with brain injury to improve the fine motor function of the hand and facilitate the normal CST or healing of the injured CST.

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Effect of Neuromuscular Electrical Stimulation Training on the Finger Extensor Muscles for the Contralateral Corticospinal Tract in Normal Subjects: A Diffusion Tensor Tractography Study.

Based on functional imaging methods of resting state DTI (Diffusion tensor imaging), this study reveals the structural changes and functional abnormalities of white matter fibers in patients with stroke from two levels of structure and function, and analyzes the effects of exercise on brain function remodeling in patients with stroke. The effects of the process, explore the central effect mechanism of scalp acupuncture to promote the recovery of motor function, and provide ideas for optimizing the rehabilitation treatment after stroke. There was no statistically significant difference in the general situation of the motion observation group and the conventional rehabilitation treatment group based on DTI technology at the time of enrollment, the NIHS S score, the fugl-meyerassessmenta score, the modified ashworth scale score, and the Brunnstrom staging assessment (P>0.05). After the week, 8 weeks, and 12 weeks of follow-up, the national institutes of health stroke scale, fugl-meyerassessmenta score, modified ashworth scale score, and Brunnstrom motor function staging score of the two groups of patients were significantly improved over time before treatment. The difference was statistically significant (P>0.05); the comparison between groups, the scores of patients in the action observation group and the difference before and after treatment were significantly higher than those in the conventional rehabilitation treatment group, and the difference was statistically significant (P>0.05). Conclusion: Action observation therapy can improve the degree of neurological deficits and promote the recovery of neurological function in patients with stroke. It can improve the score of motor function, reduce the muscle tension of key muscles in patients with stroke, and promote the recovery of motor function in patients.

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Evaluation of Motor Function Rehabilitation for Stroke Patients Based on Magnetic Resonance DTI Technology

OBJECTIVE To investigate the effects of combination functional electrical stimulation (FES) and standing frame training on standing balance in stroke patients. METHODS Patients who had hemiparesis and postural instability after stroke were randomly assigned to one of the two groups; study group underwent FES on the quadriceps and tibialis anterior muscle simultaneously with standing balance training. The control group received standing frame training and FES separately. Both the groups received their respective therapies for 3 weeks. Stability index in Biodex Balance master system, Berg Balance Scale (BBS), manual muscle test, the Korean version of Modified Barthel Index, and Korean version of Mini-Mental State Examination were used to evaluate the effects of the treatment. RESULTS In total, 30 patients were recruited to the study group and 30 to the control group. Three weeks after treatment, both the groups showed improvement in postural stability scores and physical and cognitive functions. When changes in postural stability were compared between the groups, the study group showed more significant improvement than the control group with regards to the scores of BBS and the stability indices. CONCLUSION In this study, we found the therapeutic effectiveness of combined therapy of FES and standing frame in subacute stroke patients. The presented protocol is proposed as time-saving and can be applied easily in the clinical setting. Thus, the proposed combined therapy could be a useful method for improving standing balance in subacute stroke patients.

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Combined Therapy With Functional Electrical Stimulation and Standing Frame in Stroke Patients.

Objective
To explore the possible mechanisms for improving lower extremity motor function in patients with early stroke through combining magnetic resonance diffusion tensor imaging (DTI) technology and functional electrical stimulation (FES) based on human walking patterns.


Methods
From August 2012 to September 2013, a total of 48 eligible patients were stratified according to age, gender, disease course, Brunnstrom staging and types of stroke. And the Minimize software was used to divided them randomly into four-channel FES group (n=18), dual-channel FES group (n=15) and comfort stimulation group (n=15). For all three groups, general medication and standard rehabilitation were provided. Based on normal walking pattern design of FES treatment, four-channel FES groups received the stimulations of quadriceps, hamstring, anterior tibialis and medial gastrocnemius. For the dual-channel FES group, the stimulations of tibialis anterior, peroneus longus and peroneus brevis muscles were applied. In comfort electrical stimulation group, the electrode positions were identical to the stimulation group, but there was no current output during stimulation. Before and after 3-week treatment, three groups received weekly rehabilitation evaluations of Fugl-Meyer assessment (FMA), posture assessment of stroke scale (PASS), Brunel balance assessment (BBA), Berg balance scale (BBS) and modified Barthel index (MBI). Before and after treatment, DTI examination was performed for some patients.


Results
Among three groups, general patient profiles and pre-treatment evaluations showed no significant difference. For intra-group comparisons versus pre-treatment, at week 1, 2 and 3, the scores of PASS, BBA, BBS, FMA and MBI had statistically significant differences (P<0.05); At week 3 post-treatment, when four-channel and double-channel FES groups were compared versus pre-treatment, the scores of ipsilateral FA had statistically significant differences (P<0.05). At week 1 post-treatment, MBI had statistically significant difference among 3 groups (P=0.037). As compared with placebo, four-channel group had statistically significant difference [(52±12) vs (38±18), P<0.05]; At week 2 post-treatment, the scores of PASS and MBI were (29±3, 73±13) in four-channel FES group versus (24±8, 60±17) in dual-channel FES group. And the scores of PASS, BBA, BBS, FMA and MBI were (9±3, 8.3±2.4, 37±7, 22±5, 73±13) in four-channel FES group versus (21±7, 6.2±3.1, 24±16, 15±8, 47±20) in comfort electrical stimulation group. When dual-channel FES and comfort stimulation groups were compared, MBI had significant statistical difference [(60±17) vs (47±20), P<0.05]. At week 3 post-treatment, four-channel and dual-channel FES groups were compared, there was also statistical significance in FMA [(25±5) vs (20±7), P=0.055]. The scores of PASS, BBS, FMA and MBI were (31±3, 43±8, 25±5, 81±13) in four-channel FES group versus (25±8, 29±17, 17±9, 54±25) in comfort stimulation group respectively. When dual-channel FES and comfort stimulation groups were compared, the scores of MBI were (71±15) and (54±25) respectively. And the difference was statistically significant (P<0.05). At week 3 post-treatment, the scores of FA significantly increased [four-channel FES group (0.321±0.172) vs comfort stimulation group (0.217±0.135) (P=0.020)]. When dual-channel FES group (0.333±0.164) and comfort stimulation group (0.217±0.135) (P=0.049) were compared, the differences were statistically significant. DTI showed that four-channel FES group increased significantly, but contralateral fiber bundle was not obvious. And the improvements of dual-channel FES and comfort stimulation groups were insignificant.


Conclusion
Compared with traditional dual-channel FES, functional electrical stimulation based on human walking patterns is more efficacious. And it helps to restore brain structure and function and promote motor function recovery in patients with early stroke.


Key words: 
Stroke; Functional electrical stimulation; Lower extremity; Diffusion tensor imaging

[Functional electrical stimulation based on a working pattern influences function of lower extremity in subjects with early stroke and effects on diffusion tensor imaging: a randomized controlled trial].

Fangming Li

Papers

[Functional electrical stimulation based on a working pattern influences function of lower extremity in subjects with early stroke and effects on diffusion tensor imaging: a randomized controlled trial].