Spinal orthoses are common in the treatment of various conditions that affect the spine. They encompass both the spine and pelvis and thus have implications for pelvic and lower-limb motion during walking in addition to a direct effect on spinal motion. The role of the spine in walking is largely ill-defined, and the consequences of restricted spinal motion on walking have yet to be explored. This study investigated the effect of spinal restriction on gait in able-bodied persons. Gait analyses were performed on 10 able-bodied subjects as they walked at five different speeds that were distributed across their comfortable range of speeds. Data were collected during walking with and without spinal restriction by a fiberglass body jacket, which is similar to a thoracolumbosacral orthosis (TLSO). With spinal restriction, peak-to-peak (PP) pelvic obliquity and rotation were significantly reduced across all walking speeds (p < 0.001), while PP pelvic tilt was significantly reduced at only the fastest walking speeds (p = 0.017). PP hip abduction-adduction motion was significantly reduced with spinal restriction across all speeds (p < 0.001), while PP hip flexion-extension significantly increased at only the slow and very slow speeds (p < 0.001 and p = 0.023, respectively). A better understanding of the effects of restricted spinal motion on gait may help clinicians predict and avoid development of additional problems from TLSO use or surgical restriction of spinal motion. An awareness of these issues will enable clinicians to monitor patients for problems that may result from decreased spine and pelvic motion.

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Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke.

Background
Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

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What is the evidence for physical therapy poststroke? A systematic review and meta-analysis.

Background
Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking.

Objectives
To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke.

Methods
Search methods: We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews.

Selection criteria: We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this.

Data collection and analysis: Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research.

Main results
Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.

Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.

Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.

Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning.

Authors' conclusions
Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.

Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.

Interventions for improving upper limb function after stroke

Lack of neural innervation due to neurological damage renders muscle unable to produce force. Use of electrical stimulation is a medium in which investigators have tried to find a way to restore movement and the ability to perform activities of daily living. Different methods of applying electrical current to modify neuromuscular activity are electrical stimulation (ES), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and functional electrical stimulation (FES). This review covers the aspects of electrical stimulation used for rehabilitation and functional purposes. Discussed are the various parameters of electrical stimulation, including frequency, pulse width/duration, duty cycle, intensity/amplitude, ramp time, pulse pattern, program duration, program frequency, and muscle group activated, and how they affect fatigue in the stimulated muscle.

Neuromuscular electrical stimulation for skeletal muscle function.

Rehabilitation of arm function after stroke. Literature review.

Objective: Electrical stimulation can be applied in a variety of ways to the hemiparetic upper extremity following stroke. The aim of this review is to explore the relationship between characteristics of stimulation and the effect of electrical stimulation on the recovery of upper limb motor control following stroke. Methods: A systematic literature search was performed to identify clinical trials evaluating the effect of electrical stimulation on motor control. The reported outcomes were examined to identify a possible relationship between the reported effect and the following characteristics: duration of stimulation, method of stimulation, setting of stimulation parameters, target muscles and stage after stroke. Results: Nineteen clinical trials were included, and the results of 22 patient groups were evaluated. A positive effect of electrical stimulation was reported for 13 patient groups. Positive results were more common when electrical stimulation was triggered by voluntary movement rather than when non-triggered electrical stimulation was used. There was no relation between the effect of electrical stimulation and the other characteristics examined. Conclusion: Triggered electrical stimulation may be more effective than non-triggered electrical stimulation in facilitating upper extremity motor recovery following stroke. It appears that the specific stimulus parameters may not be crucial in determining the effect of electrical stimulation.

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Relation between stimulation characteristics and clinical outcome in studies using electrical stimulation to improve motor control of the upper extremity in stroke

Objective: To compare the effect of cyclic and electromyography (EMG)-triggered electrical stimulation on motor impairment and function of the affected upper extremity in chronic stroke. 

Design: Randomized controlled trial.

Setting: Outpatient clinic of a rehabilitation centre.

Subjects and intervention: Twenty-two subjects in the chronic stage after stroke were randomly assigned to receive either cyclic (n = 11) or EMG-triggered electrical stimulation (n = 11) of the wrist and finger extensor muscles for a six-week period. 

Outcome measures: The primary outcome measure was the Action Research Arm test (0—57 points) to assess arm function. Grip strength, Fugl-Meyer Motor Assessment and Motricity Index were secondary outcome measures. Assessments were made at the start of the treatment and after 4, 6 and 12 weeks. 

Results: Both groups improved on the Action Research Arm test. The group receiving cyclic stimulation improved by 2.3 points, and the group receiving EMG-triggered stimulation improved by 4.2 points. The difference in functional gain was not statistically significant. Differences in gain on the secondary outcome measures were not significant either. 

Conclusion: The present study did not detect a significant difference between EMG-triggered and cyclic electrical stimulation with respect to improvement of motor function of the affected arm in chronic stroke.

Joke R. de Kroon

Papers

Relation between stimulation characteristics and clinical outcome in studies using electrical stimulation to improve motor control of the upper extremity in stroke

Electrical stimulation of the upper extremity in stroke: cyclic versus EMG-triggered stimulation