It has got missed evidences...

Hi Mr Jeyaraj,

Indeed, I don't think there is enough evidence yet (if any) to support the effectiveness of NMES in stroke persons with complete hemiplegia. However, the negative effects of complete immobilization (atrophy, negative plasticity, etc.) are well known, and we can question whether the poor prognosis observed in these stroke cases is solely the consequence of the dramatic cerebral lesion, or is it also because of limited possibility to perform intense rehabilitation interventions. In such cases of flaccidity when so little can be done in physiotherapy, and because NMES is a relatively risk-free intervention (when applied by a trained PT), I would say that using NMES to produce muscle contractions and proprioceptive feedback can be a good choice of intervention even without a supporting litterature. At least, it may help limit muscular atrophy and potentially prevent negative plasticity at the cerebral level.

Cheers

Thanks Mr. Beaulieu for the satisfactory answer. I would surely use NMES in such cases of stroke.

I would like to add that it has considerable value to the patient to know that you are using all tools you can in order to facilitate movement. However, after 10 years with stroke rehabilitation, I am very doubtful about the effectiveness on NMES in completely flaccid limbs. I belive the most important thing to do in those cases, is to prevent contractions due to increasing spacticity, once it starts, by regular passive movements.

I am not sure about the effectiveness of NMES in the management of flaccidity, but I can tell you that here at Cleveland FES Center we applied functional electrical stimulation using percutaneous intramuscular electrodes in a patient without any control over his paralyzed leg and gave him the ability to walk. This can also be done with multi-channel surface stimulation. We implanted electrodes in his quadriceps muscles for knee extension, sartorius, tensor fasciate latae and gracilis for hip flexion, gluteus medius for hip abduction and an electrode next to the peroneal nerve for ankle dorsiflexion. We used a microprocessor controlled stimulator to program a pattern of muscle activation to allow him to stand up and walk. Of course, this is an experimental procedure only available in research. We are also developing a multichannel implantable stimulator which will allow restoration of gait in this type of patients. Please see article by EB Marsolais et al. FNS application for restoring function in stroke and head-injury patients. J Clinical Engineering.15(6):389-496, 1990. As you can see ours is a neuroprosthetic rather than a neurotherapeutic approach. However, with continued application of FNS we often see some volitional improvement and short term carryover effect which has been reported by others as well with peroneal nerve stimulation for dorsiflexion.

I totally agree with Dobetic in order to differentiate neuroprosthetic approach for regaining a function which cannot be restored, from therapeutic approach for facilitating true functional recovery.

NMES could be an interesting tool for rehabilitation procedures, but we have to take into account that it was born more than 30 years ago and, until now, no evidences have been provided on the effectiveness.

I would be more prudent in the use of NMES at early stage in hemorrhagic stroke patients as it could be responsible for an increasing in tonic muscular fibers resulting in more severe spasticity when and if flaccidity disappears.

Moreover very often hemorrhagic stroke patients need longer time for recovery, compared to ischemic stroke, and it means that the timing for shifting from flaccidity to spasticity could be delayed.

Hi everyone in this discussion...

What is the conclusion of above discussion.... whether the NMES is to be continue untill we get an alternative solutions or not? The neuroprosthetic approach is widely availble for general practice in different contries also? And neuroprosthetic approach is having any strong/ enough evidence to support in the management of persistant flaccidity?

Thankyou for this question. May I ask for clarification regarding what you are meaning by NMES, in my recent look at some of the literature regarding functional electrical stimulation, I observed that diferent research groups at times consider the term NMES differently from each other.

Hi Owen,

As a clarification to your question, what i have asked was about neuromuscular electrical stimulation which is also referred to as functional electrical stimulation

(M. Claudia et al.,(2000), Artificial Grasping System for the Paralyzed Hand, International Society for Artificial Organs, Vol 24 No.3)

I think NMES can be used as a larger term to describe the application of a trancutaneous electrical current to induce muscle contractions. However, the term functional electrical stimulation is a bit more precise and should be only used when discussing about electrical stimulation to induce/help a functional task (for example stimulating the tibialis anterior muscle to induce an ankle dorsiflexion during the swing phase of locomotion). Personally, I use the term NMES when describing a muscle (or nerve) stimulation intervention where the patient is passive (no volitional effort) or tries to accompany the movement induced by the stimulation. Of course, the use of volition should be encouraged, based on its greater potential for motor learning, plasticity and also based on the great litterature concerning the effectiveness of motor imagery/mental practice (see paper attached). I think that using mental practice in adjuction to NMES/FES in patients with severe disabilities would be much more effective to induce some motor recovery. I think this a great example showing a combinaison of various (and safe) techniques based on interesting evidences found in the literature. Clinical pratice is challenging because the best intervention is the intervention that we adapt to each different patient, and this kind of evidence can't be found in the literature.

Also, I totally agree that the development of spasticity is an important issue to keep in mind. From what I know from the rich literature in NMES, it is normally applied to paretic (and not spastic) muscles. Knowing that spasticity will normally developp in anti-gravitary muscles (ex: ankle plantar flexors), NMES should therefore be applied to the antagonistic muscles (ex: dorsal flexors) in acute stroke patients with complete flaccidity. But, it should also be kept in mind that based on the normal stages of recovery (Brunnstrom), a flaccid muscle is a null stage of recovery. So, when spasticity developps, it is considered a certain level of recovery. Also, spasticity can often be debilidating, but it can also be functionnaly useful. For example, it is easier for a stroke patient to walk on a spastic leg than on a flaccid one. Finally, there is an actual debate concerning the relationship between spasticity and strength (see Smania et al., 2010). Some propose that the spastic muscle is strong and should not be strengthened, but others say that it is a weak muscle and should therefore be trained. To conclude, I can't tell whether using NMES over flaccid (and future spastic) muscles would be a good choice or not, particularly because no study tested the impact of NMES in acute stroke on the development of spasticity. I would thus follow Mr Posteraro's answer: NMES over 'future' spastic muscles should be used with caution with these patients, but it is not contraindicated. Maybe applying NMES over future paretic muscles is the best choice.

See also Doucet et al., 2012 (attached)

I agree with Mr.Beaulieu here in this topic. NMES.... What i meant was the conventional Electrical stimulation but not the FES which is used for inducing functional gain s/a walking. I hope further discussions would be more precise. Thanks

The use of NME's is basically psychological. However, as professionals we need to be able to justify the need for anything we use for the patient. We all know that stroke is an upper motor neurone lesion. The use of NME's with which current to effect what? The major problem that is likely to elicit here is the continuous activation of the gamma-motor neurone which will definitely result in spasticity. The presence of spasticity imposes more challenges to effective rehabilitation of stroke patient. As I always say, we should find a way to minimise the onset of spasticity in stroke patient. If this can be achieved, the adequate functional recovery can be achieved with reduction in functional limitations.

It is an interesting topic. We have concluded a systematic review regarding the effect of cyclical electrical stimulation on strength and activity after stroke.