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Rehabilitation with Functional Electrical Stimulation in Stroke Patients

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DOI: 10.4172/2329-9096.1000147

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 International Journal of Hara, Int J Phys Med Rehabil 2013, 1:6
http://dx.doi.org/10.4172/2329-9096.1000147
Physical Medicine & Rehabilitation
Review Article Open Access

Rehabilitation with Functional Electrical Stimulation in Stroke Patients

Yukihiro Hara*
The Department of Rehabilitation Medicine, Nippon Medical School, Japan

Abstract
In recent years, our understanding of motor learning, neuroplasticity and functional recovery after the occurrence
of brain lesion has grown significantly. New findings in basic neuroscience have provided an impetus for research in
motor rehabilitation. Several prospective studies have shown that repeated motor practice and motor activity in a real
world environment have a favorable effect on motor recovery in stroke patients. Electrical stimulation can be applied
in a variety of ways to the hemiparetic upper extremity following a stroke. In particular, electromyography (EMG)-
triggered electrical muscle stimulation improves the motor function of the hemiparetic arm and hand. Triggered electri-
cal stimulation is reported to be more effective than non-triggered electrical stimulation in facilitating upper extremity
motor recovery after stroke. EMG-controlled functional electrical stimulation (FES) induces greater muscle contraction
by electrical stimulation that is in proportion to voluntary integrated EMG signals. EMG-controlled FES and motor point
block for antagonist muscles have been applied as a new hybrid FES therapy in an outpatient rehabilitation clinic for
patients with stroke with good result. Daily EMG-controlled FES home-program therapy with novel equipment has
been shown to effectively improve wrist, finger extension, and shoulder flexion. Combined modulation of voluntary
movement, proprioceptive sensory feedback, and electrical stimulation might play an important role in improving im-
paired sensory-motor integration by EMG-controlled FES therapy. A multi-channel near-infrared spectroscopy (NIRS)
studies in which the hemoglobin levels in the brain were non-invasively and dynamically measured during functional
activity found that the cerebral blood flow in the injured sensory-motor cortex area is greater during a EMG-controlled
FES session than during simple active movement or simple electrical stimulation. Nevertheless, evidence-based strat-
egies for FES rehabilitation are more and more available, particularly for patients suffering from hemiparesis.

Keywords: Stroke; Functional electrical stimulation; Rehabilitation often released to home with a paralyzed arm. Chronic stroke motor
problems that begin in the first year after stroke may lead to learned
Introduction nonuse as individuals stop trying to voluntarily move the affected
Upper extremity hemiplegia is the primary impairment underlying upper extremity. Especially, constrained induced movement therapy
stroke-induced disability. Reducing chronic hemiplegic upper (CIMT) has recently been developed specifically for rehabilitation of
extremity impairment is generally difficult, and is the impairment most upper-extremity function [5]. A 2-week program of CIMT for chronic
frequently treated by therapists [1]. Even 3 months after stroke only stroke patients who maintain some hand and wrist movement can
20% of the stroke survivors, however, have normal upper extremity improve upper extremity function for more than a year. However, only
function [2]. Whereas motor practice improves motor skill learning a small percentage of individuals with hemiparesis display sufficient
[3], commonly used rehabilitation protocols have been found to voluntary hand-opening to qualify for CIMT.
be ineffective [4]. A number of promising therapeutic advances are Another approach is based on functional electrical stimulation
emerging in the field of stroke rehabilitation at acute and/or chronic (FES) of muscles to augment hand function [6]. FES of upper limb
phase. None of these is yet universally accepted for enhancing outcome muscles has been receiving increasing attention as a therapeutic
after stroke. Most of the approaches are currently being studied at the modality in post-stroke rehabilitation. A meta-analysis of controlled
preclinical or early-phase human clinical trial stage. studies supported the conclusion that FES promotes the recovery of
In the upper extremities of patients who have had a stroke, a muscle strength after stroke, with a reasonable likelihood of clinically
common course of hemiparetic recovery reveals the development of significant results [7]. FES has been used for many years in clinical
uncontrolled flexion synergy. This pathological synergy is induced in settings to help facilitate function of upper extremities among stroke
the hemiparetic limb during efforts to use it for a specific task. Often patients, but research regarding its benefit had not been convincing.
the individual is able to close the fingers into a fist, which is part of Recently, electrical stimulation of the upper limb has been receiving
the flexion synergy, but is unable to open the fingers. Patients who increasing attention as a therapeutic modality in post-stroke
continue to recover may regain the ability to produce movements rehabilitation. A meta-analysis of controlled studies supported the
outside of synergy patterns and, finally, to make isolated movements. conclusion that FES promotes the recovery of muscle strength after
Abnormal synergies constitute significant impairment that needs to be cerebrovascular accident, with a reasonable likelihood of clinically
addressed by rehabilitation.
Stroke patients are often unable to perform important activities
with their affected arms due to diminished active distal movement. *Corresponding author: Yukihiro Hara, Nippon Medical School, Chiba
Hokusoh Hospital, Department of Rehabilitation Medicine, 1715 Kamakari,
Few motor therapies are available for patients exhibiting minimal Inzai-city, Chiba Prefecture, Japan, Tel: +81-476-99-1111, +81-3-3980-8221;
movement in the affected arms, and no home-based therapies have Fax: +81-476-99-1917; E-mail: hara-y@nms.ac.jp
shown efficacy for such patients. Stroke patients with unilateral upper Received July 06, 2013; Accepted August 24, 2013; Published August 28, 2013
extremity paralysis rarely improve arm and hand functions to the
point of effective use in activities of daily living (ADL). Established Citation: Hara Y (2013) Rehabilitation with Functional Electrical Stimulation in
Stroke Patients. Int J Phys Med Rehabil 1: 147. doi:10.4172/2329-9096.1000147
occupational therapy and physiotherapy, which are commonly
applied to rehabilitate these patients, seldom facilitate significant Copyright: © 2013 Hara Y. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
improvements in reaching, grasping and releasing functions. As a use, distribution, and reproduction in any medium, provided the original author and
result, these patients frequently exhibit a “no-use pattern” and are source are credited.

Int J Phys Med Rehabil Special Issue on Stroke Rehabilitation Volume 1 • Issue 6 • 1000147
ISSN: 2329-9096 JPMR, an open access journal
Citation: Hara Y (2013) Rehabilitation with Functional Electrical Stimulation in Stroke Patients. Int J Phys Med Rehabil 1: 147. doi:10.4172/2329-
9096.1000147

Page 2 of 6

significant results [7]. Some recent FES modalities are overviewed with
the discussion of their effectiveness and mechanism for improvement
in this paper. We conducted a representative review of the literature,
which included classic publications as well as more recent key
publications. Due to the nature of the intervention, evaluations of FES
therapy are not easily amenable to classic double-blinded, randomized
clinical trials (RCT) designs.

FES prosthesis
Devices that provide FES are also referred to as neuroprosthesis.
NESS Handmaster [8]” or “Bioness H-200 [9,10]” is a neuroprosthesis
which combines a wrist-hand orthosis to provide stabilization with
muscle activation of the paralyzed forearm and hand via integrated
surface electrodes. The control unit is attached via a cable to the splint
and allows the user to select between 3 exercise and 3 functional
modes. The exercise modes provide stimulation to the targeted finger
and thumb extensor and flex or muscles. The functional modes Figure 1: Contralaterally controlled functional electrical stimulation system
provide sequential key grip or palmer grasp and release patterns. The (CCFES) [15].
design of the Handmaster provides reproducible, accurate electro Volitional opening of the unaffected hand produces a proportional intensity of
depositioning by the patient. The spiral design allows for wrist stimulation to the paretic handextensors. The system enables patients with
hemiplegia to practice tasks.
stabilization and maintains the wrist in a functional position of 10
to 20 degrees of extension. Subjects were issued a progressive home
exercise program and were required to follow a conditioning paradigm
1 EMG triggered FES
using the system’s exercise modes. Once fitted into the orthosis, the Electrical stim.
Muscle1
electrodes remain in position for all subsequent applications and allow
consistent replication of the grasp, hold, and release hand function. A Elect. Stim.

case report describes a task-specific training protocol incorporating Muscle2

EMG
threshhold

FES neuroprosthesis (Ness H-200) for a person who had chronic ENG
stroke and who initially exhibited no active wrist or finger movement
[11]. Page et al. [9] reported that subjects administered 120 minutes
2 EMG-controlled FES
per day of repetitive task-specific practice augmented with FES
Electrial stim. Elect. Stim.
neuroprosthesis (Ness H-200) exhibit large, consistent upper extremity
motor changes, even years after their strokes. However, chronic stroke Muscle1.
EMG
subjects exhibited no changes in the various functional tests, indicating EMG

that changes in paretic upper extremity movement realized through

repetitive task-specific practice using FES neuroprosthesis appear to Figure 2: Schema of EMG-triggered FES and EMG-controlled FES
be retained 3 months after the intervention [10]. Furthermore, the In EMG-triggered FES (①), EMG signal is picked up from muscle 2 and
electrical stimulation is applied for muscle1. Surface electrodes pick up
Ness H200 does not extend to the upper arm for elbow extension, the EMG signal at the target muscles and simultaneously stimulate same
limiting its use for ADL to those subjects who have functioning elbow muscles in proportion to the picked-up integrated EMG signal by the same
extension. A study by Chae and Hart [12] showed that muscle activity surface electrodes in EMG-cntrolled FES (②) with enabling more delicate
stimulation of muscles compared to EMG-triggered neuromuscular electrical
from attempted movements in the paretic limb could be recorded
stimulation. Because EMG-cntrolled FES device steadily records voluntary
by percutaneous intramuscular electrodes, which, in turn, triggered EMG only from the stimulated muscles, contraction of the wrong muscle can
selective stimulation to similar electrodes implanted at selected motor be avoided.
point sites for functional movements in hemiparetic patients. They
reported that there were no failures in the implanted radiofrequency hand opening were the extensor digitorum communis and extensor
microstimulator electronics and no infections in the adjacent tissues, pollicis longs. No more than 3 independent monopolar channels
and targeted and stimulated nerves appeared to be unharmed. This (using a common anode) of stimulation were used. The stimulator was
stimulator system was programmed to produce effective personalized programmed to modulate the pulse duration from each stimulation
functional muscle activity with little to no discomfort [13]. channel from minimum to maximum in proportion to the amount
Contralaterally Controlled Functional Electrical of opening of an instrumented glove worn on the non-paretic hand.
The glove consisted of an assembly of 3 bend sensors in cloth sheaths
Stimulation (CCFES) attached to the dorsal side of the index, middle, and ring fingers.
CCFES is a new treatment aimed at improving recovery of Proportional impedance changes in the sensors modulated an analog
volitional hand function in patients with hemiplegic stroke [14]. voltage input to the stimulator. CCFES produced larger improvements
CCFES stimulates the paretic finger and thumb extensors with intensity than cyclic neuromuscular electrical stimulation on upper extremity
in proportional to the degree of volitional opening of the contralateral impairment and activity limitation in patients ≤ 6 months post stroke
unimpaired hand. The unimpaired hand wears an instrumented glove in every clinical measure [15].
that detects the degree of hand opening [14]. The device enables
patients with hemiplegia to open their paretic hand and practice using EMG triggered FES
it in functional tasks (Figure 1). Surface electrodes were positioned on NM 900 [16] (Stroke Recovery Systems Inc., Littleton, CO, USA) is
the forearm and hand. The muscles targeted for activation of functional an electromyography monitored neuromuscular electrical stimulation

Int J Phys Med Rehabil Special Issue on Stroke Rehabilitation Volume 1 • Issue 6 • 1000147
ISSN: 2329-9096 JPMR, an open access journal
Citation: Hara Y (2013) Rehabilitation with Functional Electrical Stimulation in Stroke Patients. Int J Phys Med Rehabil 1: 147. doi:10.4172/2329-
9096.1000147

Page 3 of 6

device approved by the federal Food and Drug Administration of biphasic rectangular electric impulses via surface electrodes with a
(FDA) for use by stroke survivors. The NM 900 uses three reusable, pulse width of 50 μs. Details of the specifications and a performance
self-adhering, round surface electrodes (one ground over a bony test are given elsewhere [19]. The EMG-controlled FES device uses
protrusion; two active electrodes over the motor point of the targeted 3 reusable, self-adhering, round surface electrodes (1 reference
muscle). One active electrode is placed on the motor points of wrist electrode; 2 active electrodes over the motor point of the targeted
or finger extensor muscle, while the other is placed approximately one muscles). Channel 1 has 1 reference and 1 active surface electrodes
inch below the first active electrode. The ground electrode is placed and channel 2 has 1 active surface electrode. Surface electrodes pick
anywhere on the forearm as long as it is at least three inch away from up the EMG signal at the target muscles and simultaneously stimulate
either active electrode. The best position of the electrodes is to detect these same muscles in proportion to the picked-up integrated EMG
electromyography in the affected muscles, and to provide stimulation signal by the same surface electrodes. In particular, as this novel FES
to them. A computer inside the device evaluates the amount of activity device steadily records from the stimulated muscles, contraction of the
present in the muscle, and determines whether the patient’s muscle wrong muscle can be avoided. A computer inside the device evaluates
activity meets or exceeds a preset threshold (Figure 2). If the subject the amount of activity present in the muscle, and determines whether
attains the threshold, the NM 900 activates the muscle with its own stimulation intensity is proportional to muscle activity. The stimulator
biphasic waveform with pulse width ranging between 100 and 400 ms. will not work when target muscles display no muscle contraction at
A home-based electromyography triggered neuromuscular stimulation all. This novel EMG-controlled FES device has the specific function for
program is twice every weekday in 35-min increments during an eight- setting parameter memory compared to the former version one. Two
week period. The NM 900’s safety and efficacy have been repeatedly experimental trials by the EMG-controlled FES were applied for stroke
demonstrated with no side-effects. Cauraough [17] and Chae [18] have patients to improve arm and hand function [20,21].
reported that EMG-triggered neuromuscular electrical stimulation
treatment is useful for rehabilitating wrist and finger extension Hybrid EMG-controlled FES
movements in hemiparetic individuals. Antagonist muscle spasticity often disturbs agonist muscle activity;
therefore, it is important to reduce finger and wrist flexor spasticity
EMG-controlled FES to improve hemiparetic hand function. FES is believed to inhibit
A novel EMG-controlled FES system (Integrated Volitional antagonist muscle activity [22], but the effect sometimes is insufficient
Control Electrical Stimulator (IVES): OG GIKEN, Okayama, Japan) to control antagonist spasticity. Nerve or motor point block with
is a portable, 2-channel neuromuscular stimulator which works to phenol, in combination with FES, is useful for improving hemiparetic
promote wrist, finger extension or shoulder flexion movement during hand function. It is used clinically to improve the balance of activity at
coordinate movement, but will not work when target muscles have no a joint, to improve motor control, or to increase tolerance to splinting
muscle contraction. This device induces greater muscle contraction by and passive stretching. The rationale for using both modalities is to
electrical stimulation in proportion to the voluntary integrated EMG reduce the neurogenic component of finger flexor spasticity by means
signal picked up. The system comprises 2 instruments: a setting and of a motor point block with the FES as adjunct therapy to improve
input system and a stimulator (Figure 3). The portable stimulator is hand function. EMG-controlled FES and motor point block for
powered by very small batteries. Individual FES settings are saved in the antagonist muscles have been applied as a hybrid FES therapy in an
portable FES stimulator device for home use via the setting and input outpatient rehabilitation clinic for patients with stroke [20]. Chronic
system. The device can be set to pick up EMG signal sensitivities between stroke patients who had spastic upper-extremity impairments more
1000- and 10,000-times by a sensitivity controller and can be set for than 1 year after stroke were recruited in this trial. Patients underwent
an electrical stimulation range with voltage (0∼160V) by a stimulation hybrid FES therapy on their extensor carpi radialislongus and brevis
range controller. Controlled by the clinician, the device delivers a train (ECRL & B), extensor digitorum communis (EDC), and extensor
indicisproprius (EIP) muscles once or twice a week for 4 months after
motor point blocks at the spastic finger flexor muscles. The movement,
EMG-controlled FES: integrated volitional control spasticity, and coordination function showed marked improvement in
electrical stimulator (IVESTM: OG giken co. Japan) all outpatients with the hybrid treatment consisted of the FES and the
motor point block as compared to the controls. This hybrid therapy
Program unit consisting of a motor point block decreasing negative factor (antagonist
muscle spasticity) and the EMG-controlled FES increasing positive
Parameter setting
factor (agonist muscle strength) has the potential to effectively improve
Electrical stimulation in proportion to ・EMG sensitivity hemiparetic hand function. Now we are using botulinumtoxin. A
the integrated EMG signal picked-up ・Range of electrical injection instead of motor point block as this hybrid therapy after its
stimulation intensity
injection therapy had been supported by health insurance.
portable stimulator
A home-based rehabilitation program
Picked-up integrated EMG signal
Targets on the hemiparetic side were the wrist and finger extensors
for one group, comprising the ECRL & B, EDC and EIP muscles. For
Figure 3: EMG-controlled FES instrumentation another patients group, the targets were the anterior potion of deltoid
A surface electrode picks up the EMG signal and stimulates the target muscle muscle and triceps brachiimuscle. Subjects and family members or
in proportion to the integrated signal. The EMG signal sensitivity is obtained attendants learned how to operate the FES device (including electrode
and the electrical stimulation range is set. This device induces greater muscle
contraction because electrical stimulation is proportional to the EMG signal. positions) from a physician at the hospital following completion of
The EMG-controlled FES unit is an auto-driven system without an on-off initial assessment. Electrode positioning and intensity of stimulation
switch; therefore, no more operation was required after it had been initially were individualized for each patient to provide active movement
set.
throughout the available ROM. Patients were given a protocol for

Int J Phys Med Rehabil Special Issue on Stroke Rehabilitation Volume 1 • Issue 6 • 1000147
ISSN: 2329-9096 JPMR, an open access journal
Citation: Hara Y (2013) Rehabilitation with Functional Electrical Stimulation in Stroke Patients. Int J Phys Med Rehabil 1: 147. doi:10.4172/2329-
9096.1000147

Page 4 of 6

daily home electrical stimulation. Specific affected limb exercises in FES program would need such a long time as five or six months to
the home exercise program included: supination/pronation exercises; improve upper extremity function. For long-term daily use as a home-
flexion and extension of individual fingers; wrist extension and based FES system, the device should be easy and safe to operate. As
flexion exercises; elbow flexion and extension exercises; and shoulder The EMG-controlled FES system device is portable, easy and safe to
adduction and abduction exercises. The instrumental tasks consisted operate, rehabilitation training is easily performed at home every day
of reaching, grasping, moving (e.g., pulling, rotating) and releasing an compared with other FES devices.
object on a desk using the hemiparetic upper extremity. Objects were
Some studies analyzing FES describing relief of spasticity and
chosen on the basis of the ability to grasp the object with FES assistance
opening of the hemiplegic hand have attributed this finding to the
at the beginning of the training period. ADL training such as washing,
mechanism of reciprocal inhibition of the finger flexor muscles, at
drying dishes and folding cloths was also performed using an EMG-
the moment when the extensor muscles in hemiplegic patients are
controlled FES device according to individual ability. Electrodes and
stimulated [27-30]. Not only reciprocal inhibition of antagonist muscle
lead wires were covered under the clothes and the portable stimulator
electrical stimulation, but simultaneous voluntary muscle contraction
was held in a small waist bag. As the EMG-controlled FES is portable
could also decrease antagonist muscle tone. This represents another
and light, patients could perform ADL exercises with the hemiparetic
merit of EMG-controlled FES.
hand and arm FES inside or outside the house. A 30-min FES program
session was started at home about 5 days/week at first. During the first Triggered electrical stimulation may be more effective than non-
10 days, stimulation time was gradually increased to a maximum of 1 triggered electrical stimulation in facilitating upper extremity motor
h/session. Some patients could continue to perform ADL training with recovery following stroke [31]. Repetitive movement therapy where
home FES as long as possible. In one way, this home FES program may the subject is cognitively involved in generating the movement is more
offer the same effects as CIMT from that point of view. Since the FES likely to be important and meaningful than therapy where the subject
unit is a closed-loop system without on-off switch, no operation of the is not cognitively involved [30]. EMG-controlled FES device stimulates
FES device was required after initially setting the FES system. Patients hemiparetic muscles in proportion to the integrated EMG signal
were seen in follow-up visits to ensure proper use of the equipment and picked up from the target muscles, enabling more delicate stimulation
to supervise progression in the protocol. Most patients were able to use of muscles compared to EMG-triggered neuromuscular electrical
the device after the first session, and all were independent in operating stimulation, and thus has potential for use in such rehabilitation
it by the second or third visit. The physician checked the settings of the training methods as muscle relaxation and task-oriented exercise [21].
FES device and modified parameter settings for individuals as needed It appears that the specific stimulus parameters may not be crucial in
during follow-up visits. Safety and efficacy of the EMG-controlled FES determining the effect of electrical stimulation [31].
device have been repeatedly demonstrated with no adverse effects. The
stroke patients with the EMG-controlled FES displayed significantly Mechanism of FES Effects
greater improvements in active ROM, spasticity, EMGroot mean square It has been reported that stroke survivors with lower sensorimotor
and motor performance tests and were able to smoothly perform ADL function have a decreased potential for recovery than those who are
using the hemiparetic upper extremities. Some patients also revealed less severely affected [32]. The sensory components of large afferent
decreased lower extremity spasticity with improvements to severe fiber activation, proprioceptive input and increased cognitive sensory
spasticity of the upper extremity. Daily EMG-controlled FES home attention are all weighted in the direction of spasticity reduction, and
program therapy can effectively improve wrist, finger extension and are thus helpful in the return of voluntary movement and increased
shoulder flexion. Home-based EMG-controlled FES made hemiparetic function [33]. Nudo et al. [34] suggest that afferent input associated with
patients to increase the chance of regaining use of the hemiparetic arm repetitive movements facilitates improvement of motor function. For
in ADLs [21]. this reason, motor movement stimulation might be more effective in
improving motor control than simple sensory stimulation. This is likely
Dailysession, exercise dose and regulation of FES
since electrical stimulation that provokes motor activation is associated
Gritsenko et al. [23] reported that the use of FES-assisted exercise with cutaneous, muscle and joint proprioceptive afferent feedback. In
therapy in conjunction with an instrumented workstation was another way, the mechanism underlying the EMG-controlled FES
associated with improvements in hand function in a group of hemiplegic therapy is that alternative motor pathways are recruited and activated to
people whose level of motor function would have excluded them from assist impaired efferent pathways [33]. This explanation is based on the
CIMT. The eventual goal of this research is to provide workstations for sensory-motor integration theory that sensory input from movement
home use that will allow people with hemiplegia to engage in regular of an affected limb directly influences subsequent motor output [35].
tele-therapy sessions to improve upper-extremity function. But this
Iftime-Nielsen et al. [36] reported that neuromuscular stimulation
equipment was too large to be set up at home. Daily electrical afferent
combined with voluntary activation produces more activation of the
stimulation applied via a mesh-glove reportedly modifies altered motor
cerebellum and less activation of secondary somatosensory cortex
control and improves voluntary wrist extension movement in stroke
than dose neuromuscular stimulation alone in normal subjects.
patients with chronic neurological deficits [24].
Neuroimaging studies of FES-evoked (FES delivered in the absence
Smith et al. [25] demonstrated a dose-response relationship of voluntary activation) and FES-assisted (FES delivered to augment
between FES to the lower extremity and brain-activation in sensory voluntary activation) movements have suggested bilateral secondary
and motor regions contralateral to the stimulation. Other studies have somatosensory cortex (S2) activation is related to the application
also examined whether daily home use of an upper limb FES device of therapeutic FES [36]. Another study suggested FES-related S2
can change the physical status and functional abilities in patients with activation is mainly a sensory phenomenon and does not reflect
chronic hemiparesis who are already receiving long-term physical integration of sensory signals with motor commands [37]. Those
therapy [26,27]. Lourencao et al. [28] reported that at least 6 months neuroimaging studies about combined FES and voluntary activation
is necessary for FES use to generate a significant improvement in grip were investigated among normal subjects. We investigated increased
speed in hemiplegic patients. They hypothesized that an effective home cerebral blood flow in the sensory-motor cortex area on the injured

Int J Phys Med Rehabil Special Issue on Stroke Rehabilitation Volume 1 • Issue 6 • 1000147
ISSN: 2329-9096 JPMR, an open access journal
Citation: Hara Y (2013) Rehabilitation with Functional Electrical Stimulation in Stroke Patients. Int J Phys Med Rehabil 1: 147. doi:10.4172/2329-
9096.1000147

Page 5 of 6

side during EMG-controlled FES session compared to simple active

movement or simple electrical stimulation in a multi-channels Near SMA
lesion
Infrared Spectroscopy (NIRS) study to non-invasively and dynamically PM
measure hemoglobin levels in the brain during functional activity M1
(Figure 4) [38]. Figure 5 shows NIRS mapping and waveforms from
a 70-year-old male stroke patient with left hemiparesis. He showed
dominant perfusion in the contralesional sensory motor cortex (SMC)
during the voluntary movement condition and in the ipsilesional
SMC during the EMG-controlled FES condition. A shift in dominant
perfusion from the contralesional to the ipsilesional SMC was therefore Figure 6: Physiological recovery mechanism of hemiparesis
induced by EMG-controlled FES. This experiment suggests combined Non-affected side motor related area facilitation induce the hemiparesis
improvement at acute recovery phase [41]. Non-affected side motor related
voluntary intension and electrical components as a possible mechanism area cortex activity decreased at half and one year after stroke onset [42].
for motor improvement due to brain functional reorganization. Finally affected side motor related area cortex activity increase is important
for recovery. (SMA; supplementary motor area, PM; premotor area, M1;
Increase in somatosensory stimulation applied to a hemiparetic primary motor area)
limb can benefit performance in functional tests for patients with
chronic stroke [39]. This result supports the proposal that electrical that occurs during the EMG-controlled FES increased perfusion of
sensory stimulation in combination with training protocols may the ipsilesional SMC and resulted in functional improvement in the
enhance the benefits of standard neuro-rehabilitative treatments, and hemiparetic upper extremity in chronic stroke patients. A5-month
may also facilitate motor learning [40]. The sensory motor integration treatment intervention of EMG-controlled FES and motorlearning
produced cortical reorganization correlated with functional gains as
shift of the brain perfusion from the contralesional to the ipsilesional
hemisphere [38]. Figure 6 shows physiological recovery mechanism
Lt. wrist extension schema of hemiparetic stroke. Non-affected side motor related area
VOL facilitation induces the hemiparesis improvement at acute recovery
phase [41]. Non-affected side motor related area cortex activity
decreased at half and one year after stroke onset [42]. Finally affected
Lt. ECRL ES side motor related area cortex activity increase is important for
ES
recovery. The patterns of cortical activity in chronic stroke patients
support the view that recovery from hemiparetic stroke depends on
the recruitment of alternative systems even in the affected hemisphere
Oxy Hb.
[43]. From a point of view about this recovery mechanism, the FES
Deoxy Hb.
Lt. ECRL EMG-FES
Total Hb.
increasing the activity of affected side SMC possibly induces brain
FES reorganization to recover hemiparetic impairment in chronic stage.
Figure 4: NIRS wave-form at left SMC area (cerebral infarction 57 years old References
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Int J Phys Med Rehabil Special Issue on Stroke Rehabilitation Volume 1 • Issue 6 • 1000147
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Citation: Hara Y (2013) Rehabilitation with Functional Electrical Stimulation in Stroke Patients. Int J Phys Med Rehabil 1: 147. doi:10.4172/2329-
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28. Lourenção MI, Battistella LR, Martins LC, Litvoc J (2005) Analysis of the results Submit your next manuscript and get advantages of OMICS
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