An Examination of the Effects of Electrical Stimulation

on Upper Extremity Strength in Patients Post-Stroke

Submitted by:
Kristen Cobus, SPT
Mason Freehling, SPT
Ben Slocum, SPT
Elizabeth Osantowski, SPT

Central Michigan University

 [On average, a stroke occurs every forty seconds and results in a fatality every four

minutes, making it the fifth leading cause of death in the United States.1 When blood flow to an

area of the brain is occluded, depriving the brain of oxygen, it can cause brain tissue damage or

death, resulting in a stroke. This can affect memory or motor control areas, however the severity

can vary depending on what area of the brain is affected. Symptoms of a stroke include unilateral

numbness or weakness in the face, arm, or leg, confusion, trouble speaking, slurred speech,

difficulty walking, or a sudden severe headache. With every minute that a stroke goes untreated,

1.9 million neurons die in the brain and the chance of recovery diminishes drastically, thus

making recognition of the signs and symptoms critical.1 Following a stroke, a patient may

experience symptoms such as dysphagia, fatigue, foot drop, hemiparesis, incontinence, pain,

paralysis, spasticity, or vision problems. Recovery often includes the use of rehabilitation to

improve independence and facilitate return to normal functioning, but the outcomes can vary

based on location and severity of stroke, how quickly medical intervention took place, and how

early the patient begins the rehabilitation process.1 This paragraph is unnecessary.]

Aside from being one of the leading causes of death, stroke is also one of the most
Formatted: Superscript
common causes of long-term adult disability in the United States.1 For this reason, the focus of

this review was directed over towards the effects of electrical stimulation (e-stim), a rehabilitative

modality potentially beneficial to this population. E-stim has multiple known motor and sensory

effects including decreasing pain, eliciting a muscle contraction, and muscle re-education. E-stim

can be utilized to stimulate muscles of the affected upper extremity (UE), leading to

improvements in strength. The purpose of this literature review was to examine several scholarly

articles to determine the effectiveness of electrical stimulation as a treatment, using different

parameters, to improve UE muscle strength in patients who are post-stroke, leading to improved

motor function outcomes.

Cui et al.2 assessed the effects of neuromuscular electrical stimulation (NMES) in 45

subjects with hemiplegia resulting from a stroke. The study used three trial groups to compare

the effects of NMES: a 12-hour NMES group, a NMES group, and a control group. NMES was

delivered using a rectangular-wave pulsed current with a pulse width of 300 µs, a frequency of

40 Hz, and 1-second on/off ramp to the affected upper extremities of the subjects. The amplitude

and intensity were adjusted to obtain the maximum range of wrist and finger extension as well as

to produce a small muscle contraction without discomfort or limb movement in the 12-hour

NMES group. Both groups that received NMES were allotted different treatment times: the 12-

hour NMES group received treatment for 12 hours in the evening during rest whereas the NMES

group received 30 minutes during each day. Treatment was administered to each group 6 days a

week for 4 weeks.2

After the 4 weeks of NMES treatment, significant improvements in UE distal

components of the arm were discovered in the 12-hour NMES group compared to the NMES

group. Furthermore, there was a significant difference between the 12-hour NMES group and

control group in the subjects’ UE proximal components of the arm, whereas the NMES group did

not have a significant difference compared to the control group. Both NMES groups also showed

significant improvements on the Action Research Arm Test (ARAT), however, the 12-hour

NMES program better facilitated motor function recovery (higher ARAT score) of the affected

UE post-stroke, especially in the distal components. Despite being limited by a small sample size

and having to utilize different stroke types, the study found that the 12-hour NMES group had

better improvement of motor function in the affected UE, especially in the wrist-hand function.
With this improvement, it can be inferred that a certain degree of strength (Or, better control of

neurological spasticity.) was gained in order to achieve higher ARAT scores. Thus, Cui et al.2

supports the use of e-stim for treatment of UE strength deficits following stroke, which

subsequently leads to improved UE motor function.2

Shimodozono et al.3 examined the effectiveness of repetitive facilitative exercise (RFE)

in combination with low amplitude, continuous neuromuscular electrical stimulation (NMES) on

patients with hemiplegia after a stroke. Low amplitude, continuous NMES is used to generate

small continuous muscle contractions in the paralyzed muscle without inducing passive

movement of the affected limb. This study consisted of 27 patients randomly assigned to three

groups: RFE under NMES, RFE alone, or conventional rehabilitation. All three groups

participated in 40-minute sessions, 5 days per week, for 4 weeks. In addition, 30 minutes of

dexterity training (i.e. grasping different sized blocks) was performed each day after each

treatment session. The RFE group performed two or three sets with 50 repetitions, allowing 1 to

2-minute rest periods, for a total of 300-450 repetitions during each treatment session. The RFE

under NMES group performed the same exercises as the RFE group, but in combination with the

applied low amplitude, continuous NMES. A symmetrical biphasic waveform with a pulse width

of 250 µs and a frequency of 20 Hz was used. Intensity was adjusted to produce a small

contraction of the desired muscles without inducing passive movement of the joints in the limb.

NMES was continuously applied, so it did not have an on/off mode. The control group did a

conventional arm rehabilitation program for the same allotted time. All groups ended their

treatment session with the same dexterity training protocol.3

The Fugl-Meyer Assessment (FMA) Scale results showed there was a statistically

significant difference with RFE under NMES compared to the control group, but there was no
significant difference between the RFE group and the control group. Muscle strength results

showed significant improvements in the RFE under NMES group when compared to the

control group. These results could not have been solely from RFE (Or, there was an additional

variable that wasn’t controlled for influence.) due to the RFE group’s lack of significant

differences in comparison to the control group. Therefore, the combination of RFE with low

amplitude, continuous NMES may be associated with increased strength and motor recovery in

patients with UE impairments post-stroke.3 In conclusion, the results support the use of NMES

in combination with RFE to improve strength in the affected arm of stroke survivors.

In Doucet and Griffin’s 4 experimental study, high versus low frequency electrical

stimulation was compared in the UE of patients with post-stroke hemiplegia. The purpose of this

study was to compare the effects of each group in improving fine motor control within the

affected hands of the chronic stroke population; more specifically, the strength, dexterity and

endurance of pinching, functional grip and release skills, and prehensile digit patterns. The

research team looked to compare a 1-month, in-home regimen e-stim treatment of either high-

frequency (40Hz) or low-frequency (20 Hz) implemented 4 times per week. 16 subjects were

recruited for this study and then placed into high functioning and low functioning groups based

on the Fugl-Meyer Motor Assessment (FMA). Random assignment was then used to discern

which subjects were to receive high or low-frequency treatment.4

Regardless of high or low frequency treatment, this study revealed no significant changes

within the low-functioning group. However, there was a significant difference seen in the high-

functioning group, with the high-frequency treatment eliciting significantly greater gains in

strength compared to those given the low-frequency treatment. For prehensile strength, a

significant difference was noted in the lateral pinch in the high-functioning group.4
 A curious dilemma, however, falls within the realization that only those in the high-

functioning group saw significant results from the high-frequency treatment. This leads one to

question what major differences between the groups could have caused the inconsistency in

results. The researchers attempt to relate this difference to the idea that sensorimotor recovery is

normally rapid in cases of acute stroke, but is less predictive and optimistic for those suffering

from chronic, lower-functioning conditions. They also note that deficient sensation may limit the

effectiveness of e-stim treatment all together for patients with chronic stroke conditions. Despite

these limitations, patients receiving high-frequency e-stim saw a noticeable increase in strength

post-intervention in comparison to those receiving low-frequency stimulation.4

Boyaci et al.5 compared the effects of electromyography (EMG) triggered active and

passive NMES in UE motor function and functional recovery of post-stroke patients. 31 patients

were randomly assigned to three groups: active NMES, passive NMES, or a control group. Each

group completed their treatment session for 45 minutes, 5 times per week, for a total of 3 weeks.

The active and passive NMES groups received a 10 second symmetrical biphasic stimulation at a

frequency of 50 Hz, 20-47 mA, a pulse width of 200 µs, with a 2 second ramp up/ramp down.

Current amplitude was adjusted to the comfort of the patient. The subjects were assessed based

on their grip strength, the Fugl-Meyer Assessment (FMA) Scale, Functional Independence

Measure (FIM), Motor Activity Log (MAL), and Modified Ashworth Scale.5

The results showed significant improvements in FMA, MAL, FIM, and grip strength

scores for both the active NMES and passive NMES (You should have defined ‘passive NMES’,

since it is not included in your abstract.) treatment groups when compared to the control group.

However, there were no statistically significant differences between the active NMES and

passive NMES groups. This study concluded NMES, while combined with exercise, improved
motor function of the paralyzed UE in patients with subacute and chronic strokes.5 Given the

final results of this study, it can be inferred that the use of e-stim can improve UE strength, more

specifically, grip strength in patients post-stroke.

Guo, Fan, and Mao6 refuted the therapeutic benefits of electrical stimulation in patients

who were post-stroke. This study was conducted on the effectiveness of using NMES in patients

during wrist rehabilitation after an acute ischemic stroke (AIS). 82 Eighty two (If number at

start of sentence, spell it out!) subjects were selected based upon diagnosis of single AIS without

any other neurological deficits and were placed into either an intervention group or a control

group. Each group received 4 weeks of physical training 3 days per week. In addition to the

physical training, the intervention group received NMES for 30 minutes each day. NMES was

placed at the dorsal surface of the forearm with parameters set at a pulse width of 300 µs, a

frequency of 40 Hz, and 15 seconds on/off time. These specific settings produced the maximum

possible range of wrist and finger extension that was tolerable to patients. Arm function,

activities of daily living (ADLs) and pain were measured pre and post intervention. Arm

recovery was measured by the Action Research Arm Test (ARAT), ADLs were measured by the

Barthel Index (BI), and pain was measured by the numerical rating scale (NRS).6

After 4 weeks of treatment, the intervention group did not show statistically significant

differences compared to the control group. Though this study did not directly measure arm

strength, both the ARAT score and ADLs require muscle strength to better perform the actions of

these tests. Therefore, it can be inferred that an increase in muscle strength from treatment should

improve these scores. The authors stated that in regards to previous studies conducted, “the

results showed that NMES can either improve muscle strength or reduce pain...” The results of
this study were found to be inconsistent with previous studies and indicated that NMES may not

be beneficial for patients post-AIS with wrist dysfunction.6

The use of electrical stimulation to facilitate increased strength for patients post-stroke

with UE deficits has a copious amount of literature supporting its therapeutic benefits. With

stroke being one of the most leading causes of disability and death, it is important as physical

therapists to determine the best course of treatment for this population. The literature

supporting the use of e-stim used similar settings, however, no two studies were identical.

These studies all concluded that intervention groups receiving e-stim (NMES or FES) showed

statistically significant differences from the control groups in UE strength. Yet, some

literature has shown little advantage from the use of e-stim.

Though Guo, Fan, and Mao6 disproved provided evidence of the lack of the benefits of e-

stim, the time allotted that the patients received treatment was drastically less than the studies in

favor of this treatment. All of the articles also stated that further research should be conducted in

order to better prove or disprove the use of this intervention for patients who are post-stroke.

Though the literature shows substantial support, conducting studies to determine which cases

would most likely benefit from this type of treatment should be the next step. Deciphering what

parameters are the most effective (pulse width, frequency, pulse duration, time period), which

factors are most improved (strength, spasticity, motor function, etc.), which type/severity of

stroke is most receptive to treatment (chronic, subacute, acute), and determining the efficiency

between lower extremity and upper extremity deficits would help to increase strong supporting

evidence for the use of electrical stimulation post-stroke.

The purpose of this literature review was to determine the effectiveness of electrical

stimulation as a treatment to improve UE muscle strength in patients who were post-stroke.

Despite the indication that e-stim could be a great beneficial addition to physical therapy and aid

in the efficacy of treatment post-stroke, implications will arise and may not be the best option for

all patients. This specific therapy may not be appropriate for patients with dementia, poor skin

quality/poor sensation, or on children. Any patients with contraindications may also not be

applicable. In addition to patient barriers, physical therapist barriers also play a role in the use of

e-stim in practice. In a study conducted by Auchstaetter et al.,7 a survey of 298 physical therapists

reported that they never or rarely used this therapy on patients who are post-stroke. Common

barriers that decrease use of this in practice include cost of equipment, time, and

training/education. Improvement in supportive evidence and training of physical therapists in

electrical stimulation could drastically increase its use in practice resulting in improved outcomes

of patients recovering from strokes.7 Even though some studies dispute the therapeutic benefits of

e-stim in patients who are post-stroke, there is extensive indications that it is a viable and

advantageous treatment option for patients with UE complications following a stroke.

References

1. National Stroke Association. Hope After Stroke. http://www.stroke.org/. Published 2018.

Accessed November 8, 2018.

2. Cui B-J, Wang D-Q, Qiu J-Q, et al. Effects of a 12-hour neuromuscular electrical stimulation
treatment program on the recovery of upper extremity function in sub-acute stroke patients: a
randomized controlled pilot trial. Journal of Physical Therapy Science. 2015;27(7):2327-2331.
doi:10.1589/jpts.27.2327

3. Shimodozono M, Noma T, Matsumoto S, Miyata R, Etoh S, Kawahira K. Repetitive

facilitative exercise under continuous electrical stimulation for severe arm impairment after
subacute stroke: A randomized controlled pilot study. Brain Injury. 2013;28(2):203-210.
doi:10.3109/02699052.2013.860472

4. Doucet BM, Griffin L. High-Versus Low-Frequency Stimulation Effects on Fine Motor

Control in Chronic Hemiplegia: A Pilot Study. Topics in Stroke Rehabilitation.
2013;20(4):299307. doi:10.1310/tsr2004-299
5. Boyaci A, Topuz O, Alkan H, Ozgen M, Sarsan A, Yildiz N, Ardic F. Comparison of the
effectiveness of active and passive neuromuscular electrical stimulation of hemiplegic upper
extremities: a randomized, controlled trial. International Journal of Rehabilitation
Research. 2013; 36 (4):315-22. doi: 10.1097/MRR.0b013e328360e541

6. Guo X-X, Fan B-Y, Mao Y-Y. Effectiveness of neuromuscular electrical stimulation for wrist
rehabilitation after acute ischemic stroke. Medicine. 2018;97(38).
doi:10.1097/md.0000000000012299

7. Auchstaetter N, Luc J, Lukye S, et al. Physical Therapists Use of Functional Electrical

Stimulation for Clients With Stroke: Frequency, Barriers, and Facilitators. Physical
Therapy. 2016;96(7):995-1005. doi:10.2522/ptj.20150464