Trina L Woldt , OTS EBP Capstone Chatham University November 21, 2013

1. Functional E-Stim on Adults with Stroke Trina L Woldt, OTS EBP Capstone Chatham University November 21, 2013

2. PICO question Do occupation-based, task-specific exercises when used concurrently with functional e-stim (FES) have more positive outcomes on adults with hemiplegia due to stroke than e-stim therapy or task-specific exercises when used independently?

3. Significance &OTPF Relevance FES fits into a multitude of areas as it pertains to the OT scope of practice: • Areas of Occupation: focus on ADL’s but dependent on activity performed during e-stim therapy • Client Factors: Body Functions & Structures • Performance Skills: primarily motor & praxis skills but dependent on the need for other forms of communication (i.e. gestures or ASL), cognitive skills are also impacted • Performance Patterns: Habits, Routines, Roles & Rituals • Context & Environment: Personal, Physical & Social • Activity Demands: Required Actions, Body Functions & Structures

4. Importance of topic & Reasoning for choice • FWIb and FWIIb Experience: Adults in acute care & inpatient rehab • Restoration of hand function is a key priority in rehabilitation given direct involvement in most tasks • There is a need for more studies due to inconclusive results on effectiveness • Physical Modality within Occupational Therapy, but can often times include meaningful activities • Baby Boomer Population

5. Importance of topic & Reasoning for choice • Incorporation of Functional Tasks during implementation • Many studies have not examined the effects on ADLs or QoL • Few studies assess for sustained relearning effects • Grasping, holding, and manipulating objects are daily functions that remain deficient in 55% to 75% of patients 3 to 6 months post-stroke. Close to or complete functional recovery has been documented in only 5% to 20% of stroke survivors

6. Search plan and scope  • Key words • E-stim, Electrical Stimulation, Adult, Stroke, Hemiplegia, Tetraplegia, Functional, Occupational Therapy, ADL, Voluntary, Hand, Upper Extremity, Grasp, Neuromuscular, CVA • Databases • Medline, Cinahl, Google Scholar, AOTA/AJOT • Inclusion criteria • Adults 18 y.o. or older, in English, individuals with difficulty or inability to grasp effectively, ability to give informed consent, stroke occurred within 1 year of participating in study • Exclusion criteria • Articles older than 10 years, Quadriplegia with/without SCI • **I tried to limit it to stroke patients, but applicable background information was available supporting UE e-stim effectiveness with SCI hemi/tetraplegia

7. Nature of Evidence Found • Blinded & Non-blinded, Randomized & Quasi-Randomized Controlled Trials • Qualitative • Quantitative • Pilot studies • Systematic & Critical Reviews

8. Images of FES types Examples of object manipulation during the functional electrical stimulation (FES) therapy. (Popovic, M.R., Kapadia, N., Zivanovic, V., Furlan, J.C., Craven, B. C., & McGillivray, C., 2011)

9. Top 3 ranked articles Sullivan, J., Hurley, D., & Hedman, L. (2012). Afferent stimulation provided by glove electrode during task-specific arm exercise following stroke. Clinical Rehabilitation, 26(11), 1010-1020. Study objectives: To determine if home-based, task-specific arm exercise was more effective when administered concurrent with SES. Methods: Subjects were randomly assigned to an SES (n = 20) or sham stimulation (n = 18) group. Subjects engaged in task-based home exercise for 30 minutes, twice daily, for four weeks while wearing a glove electrode on the impaired hand. Experimental subjects received SES while control subjects received sham stimulation during exercise. Primary outcome measures: FMA and Arm Motor Ability Test (AMAT). Outcomes: This study describes a unique SES delivery system via glove electrode that enabled delivery of SES during home-based arm task practice in stroke survivors. Task practice with concurrent SES did not demonstrate significantly better effects than task practice with sham stimulation, however there was a trend for greater improvement in one activity measure.

10. Images of FES types Subject performing a functional task while wearing the glove electrode and a second electrode on the dorsal forearm. (Sullivan, J., Hurley, D., & Hedman, L., 2012)

11. Top 3 ranked articles Brauer, S.G., Hayward, K.S., Carson, R.G., Cresswell, A.G., & Barker, R.N. (2013). The efficacy of SMART Arm training early after stroke for stroke survivors with severe upper limb disability: a protocol for a randomised controlled trial. BMC Neurology 13, 71-79. Study objectives: To evaluate whether the use of the SMART Arm (Sensori-Motor Active Rehabilitation Training of the Arm), a non-robotic device that enables intensive and repetitive practice of reaching by stroke survivors with severe UE disability, will improve UE function with or without outcome-triggered electrical stimulation (OT-stim) as compared to usual therapy alone. Methods: Assessor-blinded parallel, three-group randomized controlled trial, assessed 75 participants with first-ever unilateral stroke less than 4 mo previously, with severe arm disability. Four assessments will be performed. Groups receive 20 hours of therapy, one group with SMART Arm training with OT-stim & usual therapy, one group with SMART Arm training without OT-stim and usual therapy, and one group with usual therapy alone. Outcomes: The first two groups will have the opportunity to have functional movement occurring while gauging the effectiveness of OT-stim. This will be the first large study to determine the effect of OT-stim, and will provide instights into the effects of practice on regaining motor skill in those with severe UE disability following stroke.

12. Images of FES types SMART Arm utilized for individuals post stroke with severe UE disability Brauer, S.G., Hayward, K.S., Carson, R.G., Cresswell, A.G., & Barker, R.N. (2013).

13. Top 3 ranked articles Lourencao, M., Battistella, L., Moran de Brito, C., Rodrigues Tsukimoto, G., & Harumi Miyazaki, M. (2008). Effect of biofeedback accompanying occupational therapy and functional electrical stimulation in hemiplegic patients. International Journal of Rehabilitation Research 31(1), 33-41. Study objectives: To determine the effect that electromyographic biofeedback (EMG-BFB), used in conjunction with occupational therapy (OT) and functional electrical stimulation (FES), has on spasticity, range of motion, and upper extremity function in hemiplegic patients. Methods: A total of 59 patients treated at a university-based rehabilitation centre were studied over 1 year. 31 received 2x/wk sessions of OT + FES, together with weekly sessions of EMG-BFB, and 28 received only the 2x/wk sessions of OT + FES. Evaluated at baseline, at 6 mo& at 12 mo, using the hand function test, the Minnesota manual dexterity test, the joint range of motion scale, and the modified Ashworth scale. Outcomes: At 6 months, the patients receiving EMG-BFB presented significantly greater improvement in upper extremity function than those receiving only OT + FES. Incorporating EMG-BFB into the txregimen had a positive effect on the ROM and on the recovery of upper extremity function in hemiplegic patients.

14. Clinical Relevance of the Body of Evidence • Supports foundation of OT practice that occupation-based interventions are more beneficial that rote activity • E-stim can be used as a supplemental element to intervention to improve physical outcomes and overall QoL • Task-specific e-stim can be utilized in a variety of settings, to include in-home or the least restrictive environment for the client

15. Limitations of the Body of Evidence • Recent investigations focused on regaining UE function rather than simply minimizing impairments, in particular the recovery of the ability to grasp, hold, and release. • Small sample sizes • Large/Adequate sample sizes but with no control group • Late/Inconsistent commencement • Short duration of the treatment program • Comparisons made (e-stim or functional task making the impact): • Task-specific e-stim vs. non task-specific e-stim • Task-specific e-stim vs. task-specific activity (no e-stim) • Task-specific e-stim vs. nothing • E-stim with biofeedback vs. e-stim alone • Level of monitoring of participants (in homes or clinic, can see it being used but not knowing for what activity, etc.) • Not all Occupational Therapy based

16. Additional areas of Interest/Importance • Biofeedback & Levels of Effectiveness: • Results are more and more consistently showing that the use of FES improves motor performance after stroke, with or without the use of biofeedback. • In a systematic review, Barreca et al. (2003) stated that motor impairment after stroke can be reduced using any of a number of strategies: sensorimotor training; motor learning that includes the use of imagery; electrical stimulation – alone or combined with biofeedback; and engaging the patient in repetitive, novel tasks. • Biofeedback training might represent an important therapeutic tool for the rehabilitation of stroke patients. • The rehabilitation process involves remapping of the cortical system and biofeedback appears to actively and directly involve that process. Similar to CBT concepts. • Generally speaking, more research is necessary as results are inconclusive. • E-stim is proving to beneficial enough that studies have increased over the last few years in other emerging areas of practice.

17. Alon, G., Levitt, A., & McCarthy, P. (2007). Functional Electrical Stimulation Enhancement of Upper Extremity Functional Recovery During Stroke Rehabilitation: A Pilot Study. Neurorehabilitation and Neural Repair, 21(3), 207-215. Barreca, S., Wolf, S.L., Fasoli, S., & Bohannon, R. (2003). Treatment interventions for the paretic upper limb of stroke survivors: a critical review.Neurorehabilitation and Neural Repair, 17(4), 220-226. Brauer, S.G., Hayward, K.S., Carson, R.G., Cresswell, A.G., & Barker, R.N. (2013). The efficacy of SMART Arm training early after stroke for stroke survivors with severe upper limb disability: a protocol for a randomised controlled trial. BMC Neurology 13, 71-79. Chae, J., Harley, M.Y., Hisel, T.Z., Corrigan, C.M., Demchak, J.A., Wong, Y., & Fang, Z. (2009). Intramuscular Electrical Stimulation for Upper Limb Recovery in Chronic Hemiparesis: An Exploratory Randomized Clinical Trial. Neurorehabilitation and Neural Repair, 23, 569. Hara, Y., Ogawa, S., Tsujiuchi, K., & Muraoka, Y. (2008). A home-based rehabilitation program for the hemiplegic upper extremity by power-assisted functional electrical stimulation. Disability and Rehabilitation, 30(4), 296-304. Hardy, K., Suever, K., Sprague, A., Hermann, V., Levine, P., & Page, S.J. (2010). Combined bracing, electrical stimulation, and functional practice for chronic, upper-extremity spasticity. American Journal of Occupational Therapy, 64, 720– 726. References

18. Knutson, J.S., Harley, M.Y., Hisel, T.Z., Hogan, S.D., Maloney, M.M., & Chae, J. (2012). Contralaterally Controlled Functional Electrical Stimulation for Upper Extremity Hemiplegia: An Early-Phase Randomized Clinical Trial in Subacute Stroke Patients. Neurorehabilitation and Neural Repair, 26: 239. Lourencao, M., Battistella, L., Moran de Brito, C., Rodrigues Tsukimoto, G., & Harumi Miyazaki, M. (2008). Effect of biofeedback accompanying occupational therapy and functional electrical stimulation in hemiplegic patients. International Journal of Rehabilitation Research, 31(1), 33-41. Makowski, N., Knutson, J., PhD., Chae, J. MD., & Crago, P., PhD. (2013). Interaction of poststroke voluntary effort and functional neuromuscular electrical stimulation. Journal of Rehabilitation Research and Development, 50, 85-98. Mann, G., Taylor, P., & Lane, R. (2011). Accelerometer-Triggered Electrical Stimulation for Reach and Grasp in Chronic Stroke Patients: A Pilot Study. Neurorehabilitation and Neural Repair, 25(8), 774–780. Popovic, M.R., Kapadia, N., Zivanovic, V., Furlan, J.C., Craven, B.C., & McGillivray, C. (2011). Functional Electrical Stimulation Therapy of Voluntary Grasping Versus Only Conventional Rehabilitation for Patients With Subacute Incomplete Tetraplegia : A Randomized Clinical Trial. Neurorehabilitation and Neural Repair, 25(5), 433-442. Sullivan, J., Hurley, D., & Hedman, L. (2012). Afferent stimulation provided by glove electrode during task-specific arm exercise following stroke. Clinical Rehabilitation, 26(11), 1010-1020. Woodford H.J., & Price, C. (2007). EMG biofeedback for the recovery of motor function after stroke (Review). Cochrane Database of Systematic Reviews. Issue 2. Art. No.: CD004585. References

19. Dogan-Aslan, M., Nakipoglu-Yuzer, G.F., Dogan, A., Karabay, I., & Ozgirgin, N. (2012). The effect of electromyographic biofeedback treatment in improving upper extremity functioning of patients with hemiplegic stroke. Journal of Stroke & Cerebrovascular Disease, 21(3), 187-192. Hong, I.K., Choie, J.B., & Lee, J.H. (2012). Cortical Changes After Mental Imagery Training Combined With Electromyography-Triggered Electrical Stimulation in Patients With Chronic Stroke. Stroke, 43, 2506-2509. Khedr, E.M., Etraby, A.E., Hemeda, M., Nasef, A.M., & Razek, A.A. (2010). Long-term effect of repetitive transcranial magnetic stimulation on motor function recovery after acute ischemic stroke. ActaNeurologicaScandinavica, 121(1), 30-37. Koyuncu, E., Nakipoglu-Yuzer, G.F., Dogan, A., & Ozgirgin, N. (2010). The effectiveness of functional electrical stimulation for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients: A randomized controlled trial. Disability and Rehabilitation, 32(7), 560–566. Page, S.J., Levin, L., Hermann, V., Dunning, K., & Levine P. (2012). Longer versus shorter daily durations of electrical stimulation during task-specific practice in moderately impaired stroke. Archives of Physical Medicine & Rehabilitation, 93(2), 200-206. Smith, G.S., PhD. (2013). Aging and Neuroplasticity. Dialogues in Clinical Neuroscience, 15(1), 3–5. Additional References (Background Information)