+ Enhancing Motor Recovery in a patient with a history of an acute - - PowerPoint PPT Presentation

+

Enhancing Motor Recovery in a patient with a history of an acute CVA

Lauryl Andrus

+Objectives

n To describe the patient management of the demographic of

interest

n To examine the evidence for functional electrical stimulation

as an effective intervention for a patient with acute stroke

n To determine the effectiveness of functional electrical

stimulation in enhancing motor return in my patient

+Patient X- African American Male

Age 57 Gender Male Past Medical History Stage IV chronic kidney disease, malignant hypertension Medical Diagnosis L ischemic stroke at the L MCA Patient Presentation Expressive aphasia, R facial droop, dysarthria, R hemiparesis

Physical Therapy Examination

Sensation: Pt reports numbness in R UE LE gross Evaluation/Coordination (lim. ROM, MMT, tremors, synergy) R LE: Strength grossly dec. throughout, 2+/3-/5 throughout R UE: Strength grossly dec. throughout, 1+/2-/5 throughout Functional Mobility Bed Mobility Level Roll Right: MinA for UE management using rail Roll Left: MinA for R UE management using rail Sit to Supine: MinA for R LE and UE management, HOB elevated to 30 degrees Supine to Sit: MinA for R LE management to R and to L in bed Sitting Balance: SBA for static short sit without support, no LOB

+Physical Therapy Examination

Admission FIM Scores Bed/Chair/Wheelchair Transfer: 2 Walk: Distance: Level of Assistance: Wheelchair: Distance: 1 (34’) Level of Assistance: 1 Stairs: Locomotion (Walk, w/c, or Both): 0 Walk

+Physical Therapy Examination

n Goals:

By the time of d/c, pt will…

1.

Perform floor transfer with CGA using furniture for UE support

2.

Perform squat pivot transfers ModI

3.

Ambulate 150’ with LRAD with supervision

4.

Perform car transfer with supervision

5.

Complete family training and family will be independent with assistance techniques and safety strategies

6.

Go up/down 12 6” steps with single rail and step to pattern with CGA

+Physical Therapy Examination

n POC (IP Rehab):

n Transfer training/car transfers n Gait training (lots!) n FES cycle ergometer n Bed mobility training n Strength training (muscles that aide with transfers) n Endurance training n Stair training n W/c mobility

+

In a 57 year old male patient, is functional electrical stimulation

• f the lower extremity an

effective intervention to improve motor recovery and early gait after an acute CVA?

+ “Functional Electrical Stimulation Improves Motor

Recovery of the Lower Extremity and Walking Ability

• f Subjects with First Acute Stroke” (Yan, T., Hui-Chan,

C.W ., & Li, L.S., 2005 )

n Study Design:

n Single-blind, stratified, randomized control design

n Purpose: Whether FES given during acute

stroke was more effective in promoting motor recovery of the LE/walking ability than standard rehabilitation (SR) alone.

+Yan et al., 2005

n Studies have shown that…

Motor experiences play a big role in physiological reorganization that occurs in adjacent tissues, and repetitive execution of similar movements of the limbs have been identified as crucial for motor learning and recovery

n Hypothesis: “FES induced afferent-efferent

stimulation that results in limb movements plus cutaneous and proprioceptive inputs during the acute stage could be important in reminding subjects how to perform the movement properly”.

+Yan et al., 2005

n Subjects:

n 41 subjects completed

study

n Unilateral CVA within

carotid artery system

n Ages 45-85 n Independent in ADLs

before CVA

n Excluding…:

n Brainstem/cerebellar

lesions

n Medical comorbidity* n Receptive dysphasia n Cognitive impairment

3 experimental groups (FES and SR, Placebo stimulation and SR, or SR only)

+Yan et al., 2005

All subjects received same SR 1x/day, 5 days per week for 3 weeks SR + Placebo group: longer duration of treatment, disconnected electrical stimulation unit Control group: SR only FES + SR group: Surface electrodes on quadriceps, hamstrings, tibialis anterior, and medial gastrocnemius

n Subject sidelying (affected LE supported by sling) n Activation sequence that mimicked normal gait

+Tan et al., 2014

+Yan et al., 2005

+Yan et al., 2005

Outcome Measures

1.

Composite Spasticity Scale (CSS)

1.

Ankle plantar flexor tone

2.

Maximum isometric voluntary contraction (MIVC)

1.

Ankle plantar and dorsiflexors

3.

Co-contraction ratio of PF vs. DF (IEMG)

4.

TUG & Percentage of patients able to walk

+Yan et al., 2005

Significant findings for…

n CSS scores at week 3 showed significantly

increased spasticity in the placebo and control groups than in the FES group

n MIVC

n DF—% increases in MIVC torques and IEMG of the

FES group were significantly larger than those of control group from 1 week onward (P<0.01-0.05)

n And from the placebo group at 3 weeks (P=0.032) n PF—significant effect was found only at week 3

between FES and other two groups (P<0.01)

+Yan et al., 2005

n EMG co-contraction ratio during DF was

significantly reduced in the FES group than the other two groups (P=0.001-0.042)

n Ability to walk- by week 8

n

12.2% walking before treatment à FES group (84.6%), placebo group (60%), control group (46.2)

More subjects receiving FES (84.6%) returned to their own home when compared with those receiving placebo (53.5% and SR (46.2%)

+Yan et al., 2005

Effects of FES on Spasticity and Motor Recovery

n FES might be able to normalize muscle tone in the affected ankle

plantar-flexors

n FES could have activated TA motoneuronal pool antidromically +

directly activated the muscle = increased contraction of TA Effects of FES on Early Mobility

n FES group tended to walk 2-3 days earlier than those receiving

either placebo stimulation or SR alone (84.6% in FES group returned home)

+Yan et al., 2005

Possible Mechanisms for Effects

n Frequently repeated movements of affected LE induced by

FES in stroke patients might reinforce network connection patterns

n Brain plasticity could underline improvements seen in the

FES group Limitations

n FES during gait??? n Generalization of subjects n Smaller sample size

+

Cycling induced by electrical stimulation improves

motor recovery in postacute hemiparetic patients a randomized controlled trial” (Ambrosini, E., Ferrante, S., Pedrocchi, A., Ferrigno, G., Molteni, F., 2011)

n Study Design:

n Double-blind, randomized clinical trial

n Purpose: Whether cycling induced by

functional electrical stimulation (FES) was more effective than passive cycling with placebo stimulation in promoting motor recovery and walking ability in postacute hemiparetic patients

+Ambrosini et al., 2011

n Studies have shown that…

Elements of afferent stimulation, including repetition, functional goal-directed activity, and FES have been beneficial in reducing motor impairment for persons with hemiparesis.

n Hypothesis: Because of the similarities

between cycling and walking, FES-induced cycling applied in postacute phase could play a crucial role in promoting motor recovery and improving locomotion

+Ambrosini et al., 2011

n Subjects

n 35 subjects n First time stroke (n=32)

• r traumatic brain injury*

(n=3) resulting in hemiparesis

n Acute interval <6 months

before study onset

n Low spasticity in lower

limb (<2 on modified Ashworth)

n Able to sit up for 30

minutes

n Excluding… n Cardiac pacemakers n Allergy to electrodes n Inability to tolerate

stimulation

2 experimental groups (cycling training synchronized to FES or passive cycling training with FES placebo)

+Ambrosini et al., 2011

Both groups trained 5x/week for 4 weeks, 25 minutes a session + own standard rehabilitation program 8-channel stimulator with electrodes on BOTH legs:

n quadriceps, n hamstrings, n gluteus maximum, and n tibialis anterior

+Ambrosini et al., 2011

• 5-minute warm-up, 15-minute training of FES cycling or placebo

FES cycling [passive cycling and no stimulation current], and 5- minute cool-down of passive cycling

• Pts were required not to contribute voluntarily to pedaling

+Ambrosini et al., 2011

Primary Outcome Measures

• 1. BS&F—Motricity Index (leg subscale)

1.

Motor power of paretic LE (0-100)

• 2. Activity—overground walking speed (50m self-selected

speed)

+Ambrosini et al., 2011

Secondary Outcome Measures

n Trunk Control Test, Upright Motor Control Test n Patient’s ability to perform an active, coordinated,

bilateral movement, assessed through a pedaling test

1.

Resistance strain gauges mounted on crank arms to measure torque of each leg

2.

1 minute passive cycling, 2 minutes voluntary pedaling

3.

Pedaling unbalance (U) measured by:

+Ambrosini et al., 2011

Significant findings for…

n FES group—at 4 weeks

n Primary outcomes: MI (p<0.001), gait speed (p<0.028) n Secondary outcomes: TCT, UMCT and W(PL) n Maintained at follow-up (112 ± 25 and 105 ± 25 days for

FES, placebo)

n Placebo group—at 4 weeks

n NO statistically significant changes in primary or

secondary

n At follow-up: MI, gait speed

+Ambrosini et al., 2011

n The results of this study demonstrated that 20 sessions of

FES-induced cycling training significantly reduced both impairments and activity limitations in postacute hemiparetic patients

n Significant increase in gait speed after training and at

follow-up for participants receiving FES, whereas placebo group obtained significant improvements only after follow-up = FES cycling promotes a faster recovery in terms of locomotion [carryover]

+Ambrosini et al., 2011

n Conclusion

n Motor recovery in hemiparetic patients could be explained by

the increase sensorial input provided to the brain by FES

n Supported by… n Functional MRI studies that demonstrate that FES-induced

movements activated a significantly greater area in the sensorimotor regions than passive movements

n Limitations

n Heterogeneous population of participants n Number of participants

+

In a 57 year old male patient, is functional electrical stimulation

• f the lower extremity an

effective intervention to improve motor recovery and early gait after an acute CVA?

+Significance to Patient X

Yes, what can FES do for my patient?

n Earlier mobility (Yan et al., 2005) n Motor Recovery (Yan et al., 2005) n Motor power, gait speed, trunk control (Ambrosini et al.,

2011)

+Limitations and Improvements

n Yan et al., 2005 excluded medical comorbidities

(Patient X- HTN, CKD)

n Low spasticity? n FES during gait?

n Yan studyà non weight bearing FES?? n More applicable if during gait and weight bearing

n Longer follow-up?

+Patient Progress

Upon d/c, pt was:

• 1. At supervision level for transfers including floor

recovery techniques.

• 2. Required contact guard assistance for ambulation

including 4 steps and negiotiating curbs.

• 3. Independent with bed mobility
• 4. At supervision level for w/c mobility

+References

1.

Yan, T., C.W . Hui-Chan, and L.S. Li, Functional electrical stimulation improves motor recovery of the lower extremity and walking ability of subjects with first acute stroke: a randomized placebo-controlled trial. Stroke, 2005. 36(1): p. 80-5.

2.

Ambrosini, E., et al., Cycling induced by electrical stimulation improves motor recovery in postacute hemiparetic patients: a randomized controlled trial. Stroke, 2011. 42(4): p. 1068-73.

3.

Tan, Z., Liu, H., Yan, T., Jin, D., He, X., Zheng, X., ... & Tan, C. (2014). The effectiveness of functional electrical stimulation based on a normal gait pattern on subjects with early stroke: a randomized controlled trial. BioMed research international, 2014.