Authors (including presenting author) :
Lee WY
Affiliation :
the Jockey Club Integrated Neurological Rehabilitation Centre, Physiotherapist Department, Princess Margaret Hospital
Introduction :
According to the World Health Organization(WHO), stroke is defined as a clinical syndrome characterized by rapidly developing focal or global cerebral function disturbance lasting more than 24 hours or even leading to death with vascular origin. There are approximately 17 million people sustain a stroke each year worldwide. The WHO predicted the disability-adjusted life years(DALYs) lost, representing the sum of the years of life lost due to premature mortality and the years lost due to disability in the population due to the disease, would increase to 61 million in year 2020. Within the past 20 years, the mortality rate for stroke patients was decreasing with a survival rate of 88% in 2015- 2016. A problem was given rise as stroke often leads to significant impairment of upper limb function. Nearly 70% stroke survivors experience altered upper limb function and 40% of them develop permanent upper limb paresis, associated with decreased quality of life. Electrical stimulation applied during a voluntary movement in a coordinated manner is defined as functional electrical stimulation (FES). The primary goal of FES is to supplement lost function in daily life. However, more and more patients found that there would be a ’carry over’ effect after using the device, which made FES turn out to be a viable intervention for improving motor function instead of an assistive device only. Numerous studies reported FES leads to increased ipsilateral sensory-motor cortex perfusion and cortical excitability compared to passive modalities of electrical stimulation. It is believed that afferent fiber activation, proprioceptive input, and increased cognitive sensory attention would result in spasticity reduction and facilitating the return of voluntary movement. Additionally, researchers suggested that functional improvement can be further enhanced by afferent input associated with repetitive movement. Having said that, FES which provokes motor activation associated with cutaneous, muscle and joint proprioceptive afferent feedback may benefit post-stroke rehabilitation. A number of studies reported the superiority of electrical stimulation compared to either no treatment or conventional physical treatment. Several review also tried to evaluate the clinical significance of different training protocols regarding the treatment time and frequency. Nevertheless, there is high heterogeneity among the study design and clear protocols leading to better efficacy are still lacking. Recent systematic reviews investigated if motor performance after stroke could be improved by increasing the amount of usual rehabilitation but with the same content and concluded beneficial effect of extra rehabilitation existed.
Objectives :
The objective of this study is to provide a preliminary exploration between two training protocols with a difference in number of training sessions per week. To a certain extent, offering an insight for the establishment of upper limb FES treatment protocol in public hospital settings in the coming future.
Methodology :
This study was conducted in the Jockey Club Integrated Neurological Rehabilitation Centre (Physiotherapy Department) of the Princess Margaret Hospital.Subjects were eligible to be recruited if they met the following inclusion criteria : (i) subacute or chronic stroke patients (post stroke 2 months or above); ii) Impairment in opening and closing of the hand; iii) No marked joint stiffness in the upper extremity; iv) No other prior neurologic condition. Subjects were excluded if they had i) Any active device implanted in the body; ii) Any metal implant in the affected upper limb; iii) Fractures or dislocation of the fingers, wrist or elbow are present; iv) Cancerous lesion is presented or suspected; v) Unable to communicate or mentally incapacitated. Between November 2018 to March 2019, 9 subjects were recruited and agreed to participate in this study. 4 subjects were assigned to regular frequency group(RFG) and 5 subjects were assigned to high frequency group(HFG) by block randomization. 1 subject from HFG dropped out. Both groups of patients received 10 treatment sessions with the same duration of time in total. Participants in RFG received 2 training sessions per week for 5 consecutive weeks while patients in HFG had a training session every weekday for 2 consecutive weeks. Each treatment session composed of 20 minutes FES training followed by 30 minutes conventional physiotherapy treatment under supervision of the physiotherapist in charge. A Follow-up review was done for the HFG 3 weeks after the end of treatment. Assessment was done by an independent blinded assessor at initial assessment(T0) , by the end of week 2 (T1) and week 5 (T2).
Result & Outcome :
No within nor between groups significant difference was detected in UEFM and BBT. However, both groups showed an increasing trend in UEFM with a larger increase observed in HFG. For BBT, both groups showed an increase at T1 and decrease at T2, higher score at T2 comparing to baseline observed in HFG only. Limited evidence was shown in this study for making comment on the effect of training frequency of FES on upper limb motor performance for stroke patients. Further investigation with larger scale and longer study period to look for the long term effect of FES was required for the standardization of the training regime and maximization of the training effect of FES.
