Cerebrovascular Accidents: A Literature Review Essay

The goal of this brief review is to investigate potential applicability of electrical stimulation modalities to early mobility treatment of cerebrovascular accidents (CVA or “stroke”). Rehabilitation clinicians working in the acute neurological settings see a diversity of diagnoses, a majority of which is stroke. Orders to treat patients post stroke prioritize early mobility focusing on ambulation. Yet many patients in acute recovery from stroke are non-ambulatory (Miller, Murray, Richards, Zorowitz, Bakas, 2010; Wade & Hewer, 2010).

To decrease ambulation dependencies, gait training incorporates ultiple treatment strategies including neurodevelopmental training, strengthening, gait training with assistive devices requiring intensive manual intervention from the therapist, balance activity, and transfer training. (Miller et al. , 2010; Murphy, 2015) This author has seen the use of elastic bandages as temporary dorsiflexion-assist orthoses at the bedside in acute stroke treatment. This is not a stable device and presents a slip and fall risk.

Some recent evidence makes a stronger case for using FES to treat stroke (Howlett, Lannin, Ada, McKinstry, 2015). To investigate the feasibility and efficacy of using FES in ddition to other therapies for patients who are dependent in ambulation in an acute hospital setting, five articles were located and reviewed (see Table 1). Articles were sought for their focus on acute stroke rehabilitation of dependent ambulation. The most relevant study matching the desired timeline and setting is a case series conducted by Dunning et al. in 2009 (Dunning, Black, Harrison, McBride & Israel, 2009).

The purpose of the case report was to describe in detail the use of FES in early stroke gait training of two patients in an acute hospital. Specifically, the researchers sought to examine otential improvements in foot drop during walking by using the Ness L200 neuroprosthesis on the tibialis anterior during gait. Both patients improved in the Timed Up and Go Test (TUG) and a 6-Minute Walk Test. Authors suggest this presents the possibility that FES can be applied early after stroke, concluding that further research in this setting ought to be conducted (Dunning, 2009).

Dunning’s article met the goals of this report by providing subjective data of patient and clinician experience during treatment in an acute setting. The reported results include valuable therapist perception of the use of europrosthetic device as physically easier than typical treatment. However, the study design provided anecdotal evidence only and was missing data in some outcome measures. In 2005, Yan et al. also looked at acute stroke rehabilitation using FES (Yan, Hui-Chan, Li, 2005). Authors were able to acquire 54 subjects also within 14 days of stroke onset.

The main aim was discovery of whether FES added to a conventional rehabilitation protocol was better than the conventional protocol alone (Yan, 2005). Results documented functional walking speed (measured by the TUG test) (Yan, 2005). Despite no significant differences in TUG scores, authors over-conclude that FES did improve functional mobility possibly because: the FES group walked sooner (“2 to 3 days earlier” with an alpha =. 017); and FES patients had a statistically significant discharge dates than the control and placebo groups (P<. 5) (Yan, 2005 p83).

Despite a lack of concluding recommendations and clinical connection, Yan’s study is useful to this auther because of familiarity with the Empi Respond Select device and early intervention within 3 days of discharge from acute care and within 8. 7 days of stroke onset. It assists in providing some evidence of use in acute care and device parameters. A third research article published in 2008 by Maple Ng in Stroke, studied patients within 16 to 19 days post stroke, with a standard deviation of 8 days (Ng, Tong, Li, 2008).

The subject sample included 54 subjects at Hong Kong University’s Tung Wah Hospital for the purpose of comparing walking ability of patients who received these three interventions: 1) gait training on an electromechanical gait trainer combined with FES (GT- FES); 2) gait trainer alone (GT); and 3) a control group receiving nly standard in-patient overground walking training (Ng, 2008). The authors sought to discover whether two, single-channel FES applications combined with a body-weight-supporting mechanical training positively impacted the walking ability of the patients.

Pertinent findings by Ng included no statistically significant differences among groups in strength, Functional Independence Measure (FIM), Berg Balance Test or the Barthel Index. Significant improvements were, however, shown in gait speed and the Elderly Mobility Scale. Gait speed for five meters showed greater improvement in both the GT-FES and the GT roups versus the control. The elderly mobility scale scores of patients who received the GT-FES were significantly better than patients who only received the GT training (P=. 0005).

Authors concluded early ambulatory training on a gait trainer (with or without FES) was more effective than gait training alone (Ng, 2008). Ng recommends this protocol early in a patient’s recovery prior to independent stance and ambulation (Ng, 2008). Authors did report time stroke onset to time of recruitment for the study, but did not report how many weeks since stroke onset before patient received the intervention. Ng’s study, like others, was not able to incorporate blinding due to safety concerns in the hospital environment (the clinician was required to know patient capabilities and medical history in order to safely treat).

This author was unable to locate corroborating information on the electrical stimulation device used in this trial and description of the FES component of the treatment was not replicable, reducing the impact of the study on incorporating the authors recommendations into clinical practice. A fourth study, conducted earlier at Hong Kong Polytechnic University by the ame team mentioned above, sampled 46 subacute patients 20 days post stroke (Tong, Ng & Li, 2006). This non-blinded RCT utilized the same body-weight-support electromechanical gait trainer, the GT Il designed by Hess (“EGT’) (Tong, 2006).

Authors did not specify a hypothesis, but sought to compare therapeutic efficacy of adding FES to the EGT treatment very soon after stroke onset. Two FES single-channel treatments were applied to the peroneal nerve and quadriceps muscles. No significant difference was found in the EGT+FES versus the EGT alone in any outcome measure except overgound gait speed (Tong, 006). A flaw present in the above-mentioned two studies, is the lack of functional treatments such as dynamic balance in multiple planes. This would assist patients in obstacle navigation.

Tong and colleagues note this and recommend expanding the treatments to include more functional tasks and conclude, rightfully, that a body weight support gait trainer can still be a viable component of a multifaceted treatment of dependent ambulation in “early intensive training” (p. 1303). More recently, in 2015, a team in Austria found that patients who used a lower extremity cycling ergometer in conjunction ith FES to gain significant gait function and balance over patients who actively cycled with no electrical stimulation (Bauer, Krewer, Golaszewski, Koenig & Muller, 2015).

Within seven days to 6 months post stroke, 40 participants in the Bauer study received cycling training (with and without FES). The aim of the investigation was to discover if a lower extremity cycling ergometer with electrical stimulation would improve functional walking more than cycling without FES. Bauer found that FES fostered extra gains in functional ambulation category (FAC) and in balance and concluded that FES cycling training can be ncorporated into training “paretic limbs” (p. 193).

This author agrees with Bauer’s recommendation to use FES cycling ergometer for non-ambulatory patients at early stages of stroke to help with cardiovascular benefit. Studies included in this report vary greatly in design, population and especially in the actual treatments investigated. Overall, they demonstrated some mixed support for using FES in treating early stroke as evidenced by improvement in balance (Bauer, 2015), gait speed (Tong, 2008; Ng, 2006), and mobility independence (Bauer, 2015).

While being the weakest evidence of all studies in this aper, Dunning’s case study provided the most appropriate evidence for this author for its acute subjects, its lower cost mobile treatment, in patient hospital setting, and subjective data. In preparing for work in an acute inpatient setting, this author may be using a neuroprosthesis to treat hemiparesis from traumatic brain injury and will now consider further investigation of functional electrical stimulation intervention for gait training in the stroke population, especially in the form of a neuroprosthesis to replace the elastic bandage foot drop treatment.