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

John Eraifej, William Clark, Benjamin France, Sebastian Desando, David Moore, John Eraifej, William Clark, Benjamin France, Sebastian Desando, David Moore

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.

Keywords: Functional electrical stimulation; Meta-analysis, neurorehabilitation; Stroke; Systematic review; Upper limb.

Figures

Fig. 1
Fig. 1
Flow diagram for included studies
Fig. 2
Fig. 2
SMD (95% CI) of functional electrical stimulation (FES) vs control on activities of daily living. a Non-patient recall based measures of ADL. b FES initiated within 2 months of stroke. c FES initiated after 1 year of stroke. d Visual representation of all ADL measures. AMAT Arm Motor Ability Test, CAHAI Chedoke Arm and Hand Activity Inventory, FIM Functional Independence Measure, UEFT Upper Extremity Function Test, HFG higher functioning group, LFG lower functioning group
Fig. 3
Fig. 3
SMD (95% CI) of functional electrical stimulation (FES) vs control on secondary outcomes (functional motor recovery). a FMA. b BBT. c Visual representation of all secondary outcome measures. MAS HM Motor Assessment Scale Hand Movements, MAS UAF Motor Assessment Scale Upper Arm Function, FMA Fugl-Meyer Assessment, BBT Box and Block Test, ARAT Action Research Arm Test, FTHUE Functional Test for the Hemiparetic Upper Extremity, RELHT Rehabilitation Engineering Laboratory Hand Test (Block subscore shown here), CMSA Chedoke McMasters Stroke Assessment, 9HPT Nine Hole Peg Test, 10CMT Ten Cup Moving Test, 5s 5-second stimulation pulse duration, 10s 10-second stimulation pulse duration
Fig. 4
Fig. 4
Visual representation of SMD (95% CI) of functional electrical stimulation (FES) vs control on tertiary outcomes. a Modified Ashworth Scale, upper limb component presented. b Force generation, muscle group/movement presented

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