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

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Abstract

Background

Stroke 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.

Methods

Systematic 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.

Results

Twenty 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.

Conclusions

FES 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 Registration

PROSPERO: CRD42015025162, Date:11/08/2015

Electronic supplementary material

The online version of this article (doi:10.1186/s13643-017-0435-5) contains supplementary material, which is available to authorized users.

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Most cited references 24

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Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study).

P M Rothwell, A Coull, L Silver … (2005)

Acute coronary, cerebrovascular, and peripheral vascular events have common underlying arterial pathology, risk factors, and preventive treatments, but they are rarely studied concurrently. In the Oxford Vascular Study, we determined the comparative epidemiology of different acute vascular syndromes, their current burdens, and the potential effect of the ageing population on future rates. We prospectively assessed all individuals presenting with an acute vascular event of any type in any arterial territory irrespective of age in a population of 91 106 in Oxfordshire, UK, in 2002-05. 2024 acute vascular events occurred in 1657 individuals: 918 (45%) cerebrovascular (618 stroke, 300 transient ischaemic attacks [TIA]); 856 (42%) coronary vascular (159 ST-elevation myocardial infarction, 316 non-ST-elevation myocardial infarction, 218 unstable angina, 163 sudden cardiac death); 188 (9%) peripheral vascular (43 aortic, 53 embolic visceral or limb ischaemia, 92 critical limb ischaemia); and 62 unclassifiable deaths. Relative incidence of cerebrovascular events compared with coronary events was 1.19 (95% CI 1.06-1.33) overall; 1.40 (1.23-1.59) for non-fatal events; and 1.21 (1.04-1.41) if TIA and unstable angina were further excluded. Event and incidence rates rose steeply with age in all arterial territories, with 735 (80%) cerebrovascular, 623 (73%) coronary, and 147 (78%) peripheral vascular events in 12 886 (14%) individuals aged 65 years or older; and 503 (54%), 402 (47%), and 105 (56%), respectively, in the 5919 (6%) aged 75 years or older. Although case-fatality rates increased with age, 736 (47%) of 1561 non-fatal events occurred at age 75 years or older. The high rates of acute vascular events outside the coronary arterial territory and the steep rise in event rates with age in all territories have implications for prevention strategies, clinical trial design, and the targeting of funds for service provision and research.

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Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study.

Henrik Jørgensen, Hirofumi Nakayama, Hans Raaschou … (1995)

To determine the time course of both neurological and functional recovery from stroke. Prospective, consecutive, and community based. The stroke unit of a hospital in Copenhagen, Denmark. This setting receives all acute stroke patients admitted from a well-defined catchment area of 239,886 inhabitants within the city of Copenhagen. Acute treatment as well as all stages of rehabilitation are cared for within the stroke unit regardless of age, stroke severity, and premorbid condition. 1,197 patients with acute stroke. Weekly examinations of neurological deficits (using the Scandinavian Neurological Stroke Scale) and functional disabilities (Activity of Daily Living (ADL) measured by the Barthel Index) were performed from the time of acute admission to the end of rehabilitation. These evaluations were repeated 6 months poststroke. Time course of recovery was stratified according to initial stroke severity and disability. Functional recovery was completed within 12.5 weeks (95% confidence interval (CI) 11.6 to 13.4) from stroke onset in 95% of the patients. However, 80% of the patients had reached their best ADL function within 6 weeks (CI 5.3 to 6.7) from onset. The time course of functional recovery was strongly related to initial stroke severity. Best ADL function was reached within 8.5 weeks (CI 8 to 9) in patients with initially mild strokes, within 13 weeks (CI 12 to 14) in patients with moderate strokes, within 17 weeks (CI 15 to 19) in patients with severe strokes, and within 20 weeks (CI 16 to 24) in patients with very severe strokes. After these time-points, no significant changes occurred. However, a valid prognosis of functional outcome can be made much earlier. Best ADL function was reached by 80% of the patients with initially mild strokes within 3 weeks (CI 2.6 to 3.4), within 7 weeks (CI 6 to 8) of the patients with moderate strokes, and within 11.5 weeks (CI 10 to 13) of the patients with severe and very severe strokes. The time course of neurological recovery followed a pattern similar to that of functional recovery, but preceeded functional recovery by 2 weeks on average. A reliable prognosis can in all stroke patients be made within 12 weeks from stroke onset. Even in patients with severe and very severe strokes, neurological and functional recovery should not be expected after the first 5 months.

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Early prediction of outcome of activities of daily living after stroke: a systematic review.

J M Veerbeek, Martijn W. Heymans, Erik Limbergen … (2011)

Knowledge about robust and unbiased factors that predict outcome of activities of daily living (ADL) is paramount in stroke management. This review investigates the methodological quality of prognostic studies in the early poststroke phase for final ADL to identify variables that are predictive or not predictive for outcome of ADL after stroke. PubMed, Ebsco/Cinahl and Embase were systematically searched for prognostic studies in which stroke patients were included ≤2 weeks after onset and final outcome of ADL was determined ≥3 months poststroke. Risk of bias scores were used to distinguish high- and low-quality studies and a qualitative synthesis was performed. Forty-eight of 8425 identified citations were included. The median risk of bias score was 17 out of 27 (range, 6-22) points. Most studies failed to report medical treatment applied, management of missing data, rationale for candidate determinants and outcome cut-offs, results of univariable analysis, and validation and performance of the model, making the predictive value of most determinants indistinct. Six high-quality studies showed strong evidence for baseline neurological status, upper limb paresis, and age as predictors for outcome of ADL. Gender and risk factors such as atrial fibrillation were unrelated to this outcome. Because of insufficient methodological quality of most prognostic studies, the predictive value of many clinical determinants for outcome of ADL remains unclear. Future cohort studies should focus on early prediction using simple models with good clinical performance to enhance application in stroke management and research.

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Author and article information

Contributors

John Eraifej: +44 (0)121 414 7449 , jxe117@student.bham.ac.uk

William Clark: wec136@student.bham.ac.uk

Benjamin France: bnf105@student.bham.ac.uk

Sebastian Desando: sxd194@student.bham.ac.uk

David Moore: D.J.Moore@bham.ac.uk

Journal

Journal ID (nlm-ta): Syst Rev

Journal ID (iso-abbrev): Syst Rev

Title: Systematic Reviews

Publisher: BioMed Central (London )

ISSN (Electronic): 2046-4053

Publication date (Electronic): 28 February 2017

Publication date PMC-release: 28 February 2017

Publication date Collection: 2017

Volume: 6

Electronic Location Identifier: 40

Affiliations

[1 ]ISNI 0000 0004 1936 7486, GRID grid.6572.6, School of Medicine, College of Medical and Dental Sciences, , University of Birmingham, ; Edgbaston, Birmingham, B15 2TT UK

[2 ]ISNI 0000 0004 1936 7486, GRID grid.6572.6, Institute of Applied Health Research, College of Medical and Dental Sciences, , University of Birmingham, ; Edgbaston, Birmingham, B15 2TT UK

Article

Publisher ID: 435

DOI: 10.1186/s13643-017-0435-5

PMC ID: 5331643

PubMed ID: 28245858

SO-VID: d696a5ba-09da-4642-af86-e887660ca4e6

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 19 September 2016

Date accepted : 15 February 2017

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ScienceOpen disciplines: Public health

Keywords: functional electrical stimulation,upper limb,stroke,systematic review,meta-analysis, neurorehabilitation

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ScienceOpen disciplines: Public health

Keywords: functional electrical stimulation, upper limb, stroke, systematic review, meta-analysis, neurorehabilitation

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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

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Abstract

Background

Methods

Results

Conclusions

Trial Registration

Electronic supplementary material

Related collections

Karger: Neurology and Neuroscience

Most cited references 24

Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study).

Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study.

Early prediction of outcome of activities of daily living after stroke: a systematic review.

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Cited by 65

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