RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE
KARNATAKA
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 /NAME OF THE CANDIDATE
AND ADDRESS / PRANAV PANDEY
B-99 PALLAV PURAM PHASE-1
MEERUT (U.P)
2 / NAME OF THE INSTITUTE / KRUPANIDHI COLLEGE OF
PHYSIOTHERAPY, BANGALORE
3 / COURSE OF THE STUDY
AND SUBJECT / MASTER OF PHYSIOTHERAPY
(NEUROLOGICAL AND PSYCHOSOMATIC
DISORDER)
4 / DATE OF ADMISSION TO COURSE / 27 APRIL 2007
5 / TITLE OF THE TOPIC:
RECOVERY OF HAND FUNCTION USING FUNCTIONAL
NEUROMUSCULAR ELECTRICAL STIMULATION IN
STROKE PATIENTS.
6 / BRIEF RESUME OF THE INTENTED WORK
INTRODUCTION
Grasping, holding, and manipulating objects are daily functions that remain deficient in 55% to 75% of patients 3 to 6 months poststroke. Close to complete functional recovery has been documented in only 5% to 20% of stroke survivors. 1 Kwakkel et al reported complete recovery of upper extremity function 6months following an ischemic middle cerebral artery stroke in only 11.6% of patients with routine rehabilitation. There was no indication that the treatment phase in the study by Kwakkel et al included electrical stimulation.20
Intervention studies to improve upper extremity recovery following stroke include increasing exercise duration and intensity, focusing on task-specific training, and enhancing training by surface neuromuscular electrical nerve stimulation. The clinical efficacy, as well as a number of inherent difficulties associated with the various therapeutic intervention options following stroke in general and upper extremity paralysis/paresis in particular, were recently reviewed. Indeed, several researchers reported that adding task-specific, repetitive training with or without constraining the nonparetic extremity had Resulted in significantly faster performance of upper extremity function in both chronic and subacute stroke survivors.20
Surface neuromuscular electrical stimulation (NMES) applied to the muscles that move the wrist and fingers improved joint range of motion and volitional muscle contraction in patients with acute/subacute stroke. NMES also promoted further recovery of motor control muscle strength, reduction of spaticity long after the spontaneous recovery period. Combined the stimulation with both unimanual and bimanual task-oriented functional activities. The combination is most appropriately termed functional electrical stimulation (FES).21,22
Using this concept of FES, the patient is instructed to add volitional movements as much as feasible during the perception of stimulation on time. If the patient is unable to move volitionally, the movements are generated externally with the nonparetic extremity or by the therapist/ caregiver while the patient is asked to imagine the movements. A typical example of task-specific movements that involve all joints of the upper extremity and may be combined with FES is the attempt to reach out, grasp an object, move it to a new location, and release. Initial results using FES indicated significantly better recovery of upper extremity function.20
6.1 NEED FOR STUDY
Various studies in the past has shown that utilization of FES as a part of conventional rehabilitation program is uncommon in today’s clinical practice very less research has been done using FES in improvement of hand function.
The purpose of this study is to determine the effect of FNMES on wrist and finger flexion and extension muscle.
6.2 REVIEW FOR LITERATURE
1. Neuromuscular electrical stimulation improves severe hand dysfunction for individuals with chronic stroke: a pilot study.
Santos M, Zahner LH, McKiernan BJ, Mahnken JD, Quaney B Landon . PMID: 17233925 [PubMed - indexed for MEDLINE]Abstract
Restoring hand function is difficult post-stroke. We sought to determine if applying neuromuscular electrical stimulation (NMES) was beneficial for reducing severe hand impairments. Subjects with chronic stroke (N=8; 3 Fe, 5 M; 58.3 +/- 6.9 y/o) received 10 sessions of NMES using two different methods applied in a counterbalanced order. In one intervention, we applied NMES (active) in a novel fashion using multiple stimulators on the forearm flexors and extensors to assist subjects with grasping and releasing a tennis ball. In the other intervention, the NMES ('passive') stimulated repeated wrist extension and flexion. Motor performance was assessed prior to and immediately following the interventions and at retention. Upper extremity (UE) Fugl-Myer scores significantly improved (p < 0.002) immediately following either intervention. Significant improvement was also observed in the Modified Ashworth Spasticity Scale (MASS) (p < 0.03), immediately following intervention, primarily due to the NMES passive treatment (p < 0.034). Subjects performed grasping tasks significantly faster (p < 0.0433) following interventions, with performance speeds on dexterous manipulation increasing approximately 10% for NMES active immediately following intervention, compared to only 0.1% improvement following NMES passive. Generally, improvements in motor speed remained 10 days following NMES active intervention, although slightly diminished.of NMES therapy in this pilot data set for individuals with chronic stroke. NMES-assisted grasping trended towards greater functional benefit than traditional NMES-activation of wrist flexors/extensors
2. Neuromuscular electrical stimulation during task-oriented exercise improves arm function for an individual with proximal arm dysfunction after stroke.
Hedman LD, Sullivan JE, Hilliard MJ, Brown DM.Am J Phys Med Rehabil. 2007 Jul; 86(7): 592-6.
Abstract
This case report examined the effectiveness of a home program using neuromuscular electrical stimulation (NMES) during voluntary task- oriented exercise to achieve functional and impairment improvements for an individual with primarily proximal arm paresis after a stroke. The subject initially achieved a Fugl-Meyer Assessment (FMA) score of 58/66, but she reported minimal functional use of her involved, dominant arm. The 6-wk intervention consisted of NMES-assisted task practice involving repetitive reaching for and manipulation of small objects for three daily 15-min sessions. The subject applied NMES to the deltoid and triceps brachii muscles to augment shoulder flexion and abduction and elbow extension during task practice. Outcome measures included the FMA, the Action Research Arm Test (ARAT), and the Motor Activity Log Quality of Movement subscale (MAL-QOM). The FMA remained unchanged, but the ARAT and MAL-QOM showed improvements, from the beginning to the conclusion of the intervention, that was maintained at 6-wk follow- up.
3. Electrical stimulation driving functional improvements and cortical changes in subjects with stroke.
Kimberley TJ, Lewis SM, Auerbach EJ, Dorsey LL, Lojovich JM, Carey JR.Exp Brain Res. 2004 Feb; 154(4): 450-60. Epub 2003 Nov 15.
Abstract
It has been proposed that somatosensory stimulation in the form of electromyographically triggered neuromuscular electrical stimulation (NMES) to the peripheral nerve can influence functional measures of motor performance in subjects with stroke and can additionally Produce changes in cortical excitability. Using a controlled, double-blind design, we studied the effects of intensive (60 h/3 weeks) Treatment at home with NMES compared with a sham treatment, applied to the extensor muscles of the hemiplegic forearm to facilitate hand opening in 16 chronic stroke subjects. We investigated improvement in functional use of the hand and change in cortical activation as measured by functional magnetic resonance imaging (fMRI). Following treatment, subjects improved on measures of grasp and release of objects (Box and Block Test and Jebsen Taylor Hand Function Test [JTHFT]: small objects, stacking, heavy cans), isometric finger extension strength, and self-rated Motor Activity Log (MAL): Amount of Use and How Well score. The sham subjects did not improve on any grasp and release measure or self-rated scale, but did improve on isometric finger extension strength. Importantly, however, following crossover, these subjects improved further in the measure of strength, grasp and release (Box and Block [JTHFT]: page turning), and self-rated MAL: Amount of Use score and How Well score. Using fMRI and a finger-tracking task, an index of cortical intensity in the ipsilateral somatosensory cortex increased significantly from pre-test to post-test following treatment. Cortical activation, as measured by voxel count, did not change. These findings suggest that NMES may have an important role in stimulating cortical sensory areas allowing for improved motor function.
.4. Functional Electrical Stimulation Enhancement of Upper Extremity Functional Recovery During Stroke Rehabilitation: A Pilot Study
Gad Alon, PhD, PT, Alan F. Levitt, MD, and Patricia A. McCarthy, OTR Neurorehabil Neural Repair Online First, published on March 16, 2007
Abstract
Objective. To test if functional electrical stimulation (FES) can enhance the recovery of upper extremity function during early stroke rehabilitation. Methods. Open-label block-randomized trial, begun during inpatient rehabilitation and continued at the patients’ home. Patients were assigned to either FES combined with task-specific upper extremity rehabilitation (n = 7) or a control group that received task-specific therapy alone (n = 8) over 12 weeks. Outcome measures. Hand function (Box & Blocks, B&B; Jebsen-Taylor light object lift, J-T) and motor control (modified Fugl-Meyer, mF-M) were video-recorded for both upper extremities at baseline, 4, 8, and 12 weeks. Results. B&B mean score at 12 weeks favored (P = .049) the FES group (42.3 ± 16.6 blocks) over the control group (26.3 ± 11.0 blocks). The FES group J-T task was 6.7 ± 2.9 seconds and faster (P =.049) than the 11.8 ± 5.4 seconds of the control group. Mean mF-M score of the FES group at 12 weeks was 49.3 ± 5.1 points out of 54, compared to the control group that scored 40.6 ± 8.2 points (P = .042). All patients regained hand function. Conclusion. Upper extremity task-oriented training that begins soon after stroke that incorporates FES may improve upper extremity functional use in patients with mild/moderate paresis more than task-oriented training without FES.
5. Feasibility of randomised clinical trial of early initiation and prolonged, homebased FES training to enhance upper limb functional recovery following stroke11,12
Alon G , McBride K , Levitt AF,Published (2003)
Abstract
Purpose: Test the feasibility and safety of early initiation and prolonged FES training to enhance upper limb functional recovery following ischemic stroke in a randomised clinical trial. Method: The experimental group received 12weeks of FES program plus standardized PT/OT rehabilitation while a severity matched (FuglMeyer score) group received standardized PT/OT rehabilitation alone over the 12week period. Training began within 714 days of admission to acute rehabilitation and continued after discharge, at the patients' residence. Patients practiced 60 min every day. The experimental group combined PT/OT exercises with up to 4 hrs of daily FES to the forearm-wrist-hand flexors/extensors using the HandmasterÔ FES system. The stimulation was combined with taskspecific training tailored and modified to each patient's ability. Outcome measures of hand function (Box & Blocks [B&B]; Jebsen Taylor [JT] and motor control (FM) were recorded at baseline, 4, 8 and 12 weeks. Results: To date, 9 patients completed the trial. All tolerated and complied with the daily training. At study end, the B&B mean score of the stimulated group was 34.7 % greater than the control group. Similarly the JT task time was 34.8% faster and the FM score 32.1% higher in the stimulated group. Six/nine patients improved hand Function and 8/9 motor controls. Conclusion: RCT with early and prolonged FES is feasible and may provide considerably better functional recovery of the upper limb.
6. Electrical stimulation driving functional improvements and cortical changes in subjects with stroke: TeresaJ.Kimberley, ScottM.Lewis, EdwardJ.Auerbach, LisaL.
Minnesota Published November 15, 2003, in "Experimental Brain Research".
Abstract
It has been proposed that somatosensory stimulation in the form of electromyographically triggered neuromuscular electrical stimulation (NMES) to the peripheral nerve can influence functional measures of motor performance in subjects with stroke and can additionally produce changes in cortical excitability. Using a controlled, double-blind design, we studied the effects of intensive (60h/3weeks) treatment at home with NMES compared with a sham treatment, applied to the extensor muscles of the hemiplegic forearm to facilitate hand opening in 16 chronic stroke subjects. We investigated improvement in functional use of the hand and change in cortical activation as measured by functional magnetic resonance imaging (fMRI). Following treatment, subjects improved on measures of grasp and release of objects (Box and Block Test and Jebsen Taylor Hand Function Test [JTHFT]: small objects, stacking, heavy cans), isometric finger extension strength, and self-rated Motor Activity Log (MAL): Amount of Use and How Well score. The sham subjects did not improve on any grasp and release measure or self-rated scale, but did improve on isometric finger extension strength. Importantly, however, following crossover, these subjects improved further in the measure of strength, grasp and release (Box and Block [JTHFT]: page turning), and self-rated MAL: Amount of Use score and How Well score.Using fMRI and a finger-tracking task, an index of cortical intensity in the ipsilateral somatosensory cortex increased significantly from pre-test to post-test following treatment. Cortical activation, as measured by voxel count, did not change. These Findings suggest that NMES may have an important role in stimulating cortical sensory areas allowing for improved motor function.
7. A randomised controlled pilot study to investigate the effect of Neuromuscular Electrical Stimulation on upper limb function and hand sensation following stroke06,07,14
J.H.Burridge, G.E.Mann, L Malone and PN Taylor Published 1995
AbstractThe objectives of this study were to compare the effect on upper limb function of cyclic neuromuscular electrical stimulation of the elbow, wrist and finger extensors with passive stretching exercises through a similar range of movement. Data collected and experience gained will be used to design a prospective, larger scale randomised controlled trial (RCT). Twenty-two individuals with hemiplegia as a result of a stroke during the previous twelve months were randomly allocated into stimulation (treatment) and passive stretching (control) groups. In the treatment group, stimulation was applied to triceps and wrist and finger extensors. Subjects in the control group were taught stretching exercises. Primary outcome measure was the Action Research Arm Test (ARAT). Sensation was tested using two-point discrimination. Mean increase in ARAT score between 0 and 12weeks: treatment group (n=11) 17.5 points, control group (n=11) 4.6 points. Non-parametric tests (Mann Whitney U) showed a statistically significant difference between the two groups p=0.002 at 12 weeks. A significant difference in sensation scores was also identified between the two groups (P=0.034) at 12 weeks. No significant differences were identified in any of the outcome measures at 24 weeks