Functional electrical stimulation improves activity after stroke

Article Reviews
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Read Full Text: Functional electrical stimulation improves activity after stroke: A systematic review with meta-analysis (Not available for free, but we felt it was important to discuss)
Journal: Archives of Physical Medicine and Rehabilitation
Year Published: 2015
Ranked 15th on our 2015-2020 list of the 100 most influential OT-related articles

One of the topics we’ve covered the most in the Club is stroke (CVA). I think it is one of the most researched conditions, and we can already find tons of guidance out there for how to tailor our OT treatments for the stroke population.

And yet…there is still so much we don’t know.

In this week’s article, we examine a systematic review of functional electrical stimulation (FES) and stroke recovery. Spoiler alert: the authors make the conclusion that, based on the evidence that is currently available, “FES is beneficial in improving aspects of everyday activity performance after stroke.”

But, it’s important to note that this conclusion comes with lots of qualifiers and limitations.

Ultimately, this article serves as a reminder that, in light of rapidly evolving technologies, your individual clinical reasoning is still the foundation of how you should approach treating patients following stroke or CVA.

A quick refresher on FES

Functional electrical stimulation (FES) uses electrical currents to cause muscles to contract during the performance of a functional activity.

To get an exciting taste of where this technology is headed, I encourage you to spend 12 minutes hearing from an inventor in the field (who is also an FES user!):

(The video focuses on using FES for spinal cord injuries, but I think you will see the possibilities for stroke, as well.)

Variations of FES

As you can guess from the video above, the variations of FES are likely to continue their rapid expansion as the technology continues to advance.

But, looping back to our article, here are some basic variations in FES in stroke care:

  • FES is used for both chronic and acute stroke
  • FES can be used on upper and lower limbs
  • The FES currents can be manually triggered by the therapist/patient, or they can be mechanically triggered
  • The frequency and pulse of the electrical stimulation can vary
  • There are tons of FES units on the market, ranging from around $40 to thousands of dollars
  • And, finally, the frequency and duration of the actual sessions vary widely in the absence of widely accepted protocols

(I want to point out that it’s crucial to recognize how many variations of FES are available. This awareness will be key to our ability to unpack the limitations of this study.)

What studies did the researchers find related to FES and stroke?

18 studies were identified that met the researchers’ criteria, notably that each study:

  • Was a randomized or controlled trial
  • Involved FES as the primary intervention
  • Compared the use of FES to either no intervention, a placebo, or an activity training program

There was quite a bit of variety in these studies (as you can imagine, considering all of the variables we looked at above). But, some of highlights were:

  • 10 studies looked at FES versus training; the rest looked at placebo/no treatment
  • 7 were with patients who were in the acute stage of stroke
  • 8 involved the lower limb
  • 16 had data available for meta-analysis

What were commonly used outcome measures?

Speaking of meta-analysis (which is when the researchers attempt to pool data) this was completed, albeit imperfectly. That’s because there were a wide variety of outcome measures utilized, particularly for the upper extremity (UE).

Here are some of the UE activity assessments that were included:

Overall, what were the authors’ conclusions?

Ultimately, the authors concluded that FES has a “small to moderate” effect on activity, compared to doing nothing.

And, the study provides evidence that FES use is superior to activity training alone (moderate effect).

However, as OTs, our aim is to make a long-lasting impact on our patients’ function—and there simply was a lack of available data on whether gains in activity actually translate to real-life function.

Unfortunately, even though there were a variety of outcome measures used, they all focused on the activity level instead of what’s more important to us and our patients: actual participation in daily activities.

Takeaways for OT practitioners

(These are my personal takeaways, and were not mentioned in the article.)

1. You can feel confident that FES has early evidence to support its use.

Ok, even though this article was full of nuance, and there’s still much that we have to learn about FES, the authors believed this early evidence is enough to justify its use— and to justify the necessary resources and training to carry it out.

So, if you do decide to use FES as part of a comprehensive stroke care plan, you can feel confident that there is enough of an evidence base to justify that decision.

2. But, don’t be afraid to trust your clinical judgement.

The caveat is: even though there is currently evidence supporting the use of FES, we need to remember that there is still a lot we do not know. And, we cannot automatically assume that FES will be the right fit for every individual who has had a stroke.

Here are some recommendations from the UK Stroke Guidelines we found really helpful to help aid your clinical reasoning:

  • Do not routinely offer people with stroke electrical stimulation for their hand and arm
  • Consider a trial of electrical stimulation in people who have evidence of muscle contraction after stroke but cannot move their arm against resistance
  • If a trial of treatment is considered appropriate, ensure that electrical stimulation therapy is guided by a qualified rehabilitation professional
  • The aim of electrical stimulation should be to improve strength while practicing functional tasks in the context of a comprehensive stroke rehabilitation program
  • Continue electrical stimulation if progress towards clear functional goals has been demonstrated (for example, maintaining range of movement, or improving grasp and release)

3. Finally, don’t get too comfy in your current FES practice. We can expect recommendations about this treatment to evolve over the next few decades.

For any intervention that involves technology, all I can say is get ready for a wild ride over the next decades. We are going to see some remarkable changes in what technology like FES has to offer. And, the good news for our patients is that there is a good chance that many more affordable options will emerge.

Even in the short time between when this systematic review was published and the release date of the TED talk I linked above, we saw a remarkable leap. So, we should be standing alongside our patients looking forward to these advances…

Listen to my takeaways in podcast form:

Find platforms for listening to the [OT Potential Podcast here.](https://otpotential.com/ot-potential-podcast) ## (Possibly) Earn CEUs/PDUs for reading this article

Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.

And, here’s the full APA citation you many need:

Howlett, O. A., Lannin, N. A., Ada, L., & McKinstry, C. (2015). Functional electrical stimulation improves activity after stroke: A systematic review with meta-analysis. Archives of Physical Medicine and Rehabilitation, 96(5), 934-943. doi:Redirecting

What questions/thoughts does this article raise for you?

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I am on Level 2s and I work with children who have hemiplegia secondary to pediatric stroke and I often wonder if this could be translate to them. I know that are contraindications for FES for younger children, but when is it appropriate. Also, it would be interesting for another study to address a different stage of stroke rather than the acute stage like this article. Though there is little known for adults using FES there does not seem to be a negative or decline in progress, so for now until more information is researched or discovered I think this is a great intervention.

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Great to watch the Ted talk and options that will be available in the future.
At our inpatient rehab center and acute care, we have utilized NMES (neuromuscular electrical stimulation) and FES (Bioness 200) for UE rehab after a stroke. PTs also use the LE Bioness for rehab and gait training. We also have the body weight supported treadmill trainer.
I have used NMES in shoulder subluxation for muscle reeducation in conjunction with active exercises or in flaccid muscles to increase tone and decrease subluxation. In a very spastic muscle, NMES can be used to overstimulate and fatigue the spastic muscle in an attempt to decrease the flexion contracture. As with any modality, practitioners have to remember that it is most effective when used as an adjunct to the OT intervention plan.
The Bioness 200 showed promising results as it is cordless and can be used for doing functional tasks. The cost of the Bioness is a deterrent though. We have 2 units and we use it only during OT sessions and patients cannot take it home. Hopefully, the costs will decrease in the near future and more centers and patients will be able to afford it.

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Hi @sanchala! I was hoping people would share which devices they are actually using in the clinic. I’m seeing that the Bioness 200 is over $6,000 (yikes!)

I’m also glad you brought up the broader category of NMES. I’m also super curious what specific devices therapists are using.

And, I agree, I really hope we see costs decrease. I have to imagine that they will…

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Hi @gia! Wow, it sounds like you are having a great learning experience as a student. I’m realizing I didn’t make it super clear, but about 1/2 of the studies actually did look at chronic stroke. So if you are looking specifically on information on that stage of stroke, it would still be worth reading the article.

Also, I’m not sure how long you have been following the Club, but we looked at an AWESOME overview of stroke rehab last year, that broke down best practices by stages of stroke. It is still one of my favorite articles to date.

We have not looked at interventions that are specific to pediatric stroke, though pediatric stroke did come up when we discussed MELAS Syndrome. @lauren2, I wonder if you have anything to add, related to stroke care technologies that might be particularly well suited for pediatric clients…

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I am a pediatric OT and wonder about the use of FES in the pediatric population (brain tumor excision recovery, pediatric stroke). With all the changes occurring in the young brain at such a rapid rate, would the inclusion of FES improve their skills at an exponentially faster rate when compared to FES use with adults?

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Unfortunately devices like the Bioness haven’t reduced in cost over the years (maybe close to 10 years) that it’s been available to patients. There isn’t enough (or strong enough) evidence for FES devices like the BionessH200 to be covered by insurance. There is some (small) amount of coverage for these devices from very select plans. I think I’ve only had success in getting a Bioness device covered by Tricare insurance.

Until the cost to develop these technologies and run the companies that create them reduce enough, they’ll continue to be a challenge for patients to access.

There are several handheld FES devices on the market that are far less expensive (and just as useful for deploying FES in a functional manner in my opinion) such as a few provided by Saebo and other companies.

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@sanchala, I’m curious how you use FES paired with functional activities and task-based practice as the article suggests is most effective? Do you find it difficult to time opening and closing of the hand for pairing with task based activities? What is your placement typically for use of FES in the population you serve?

I’ve found, in my practice, that if I did send a patient home with an FES (handheld - typically not Bioness devices because of cost), they had a hard time setting it up to pair with function and would often put it on to “exercise” which meant letting it run while they did something else (not pairing it with activity). Have you been successful in teaching patients to pair FES with functional activities as part of a home program?

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Hi @tabitha! There aren’t any contraindications specific to children that are different than adults for use of FES that I’m aware of. (You mention tumor excision - if there’s active cancer it’s something that requires physician approval. Depending on the state of the cancer, it can be contraindicated.)
Of course since it’s artificial stimulation for muscle contraction, it can be uncomfortable and kids may have a more difficult time expressing that discomfort. It may also be scary to young kids so discretion should be used in choosing it for the right developmental stage and communication abilities.

In my clinical practice, I’ve primarily seen adults over the years but I did have an 8 year old post-stroke (in utero). One of the things that I think FES can assist with (in both adult and pediatric populations) is to provide a sensorimotor experience that a patient can’t always produce given their own motor activation. It can be so motivating for a patient to see their hand open for the first time after stroke (even if assisted by stimulation). Since FES paired with functional activity has some evidentiary support (based on the review), it can be used to elicit a variety of different movements (elbow extension for weight bearing, wrist/digit extension, activation of shoulder musculature, etc.). This is as much a fit for kids as adults as long as the other items (ability to understand the goal as well as ability to communicate discomfort) are considered and met. Young people have an easier time healing and making neuroplastic changes, so yes, they may recover more readily.

Here’s an article (that is an application of FES to hemiplegic CP) that might also be helpful: https://journals.sagepub.com/doi/pdf/10.1177/2055668318768402.

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Hey @lauren2, I’ve been digging a little deeper into options that are on the market. I found this recent video of an OT that is using a simple $40 electrical muscle stimulator in a functional way.


This seems much more in line with what the article was exploring— was that your understanding, @lauren2? (I wish the review would have outlined the specific devices being used!!!)

That being said, even though Bioness isn’t covered by insurance, it seems worth keeping in mind that there is a small section of the private pay market that is willing to invest in this kind of technology. (I think as therapists it is part of our role to help educate patients as to the potential benefits, but also the limitations of this type of purchase.)

Finally, the NMES market overall seems pretty confusing to me. I thought this guide from Saebo was really helpful in breaking down the different types of electrical stimulation.

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@SarahLyon, yes type of handhend unit is what I typically used in my practice. It’s a more versatile option for various placements of the electrodes for function and is just as useful (as a home device) as Bioness at far less cost.

Re: the private pay market - there is definitely a place for devices like Bioness for those that can get coverage or want to pay out of pocket. Handheld units can often do just the same from a functional standpoint and patients/caregivers can be educated on electrode placement for use of NMES at home. The idea of a unit like Bioness is that patients could wear it for a part of the day and use it to facilitate functional grasp and release. I think that opportunity is available but I haven’t seen the device used that way very often and rather more as an repetitive/task-practice device.

That’s a nice resource for patients/clinicians on electrical stimulation. I find that it’s something that many clinicians are not as comfortable with coming out of OT school.

OT students, have you had exposure to electrical stimulation in your programs or are you learning about it/seeing NMES applied on fieldwork?

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In my graduate seminar class, a rep from an NMES company came and spent a class session teaching us about electrical stimulation and demonstrating the equipment. I got a chance to feel what it is like, but that one day was all the exposure we had. I did not use electrical stimulation in fieldwork (just graduated in December).

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@abigail1 thanks for your insights! I find that it’s not something regularly covered or in the same amount of depth in the classroom between programs. Congrats on graduation!

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I did get the librarian to pull this article for me. It was a good read, it will be interesting to see where this tech goes from here. I just wondering if in the future is it still going to be saying as good of things that they are now. Right now the studies are coming back with positives for using this technology which is very promising for the future.

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