ISSN: 2320-5407 Int. J. Adv. Res.

12(05), 700-705

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/18774
DOI URL: http://dx.doi.org/10.21474/IJAR01/18774

RESEARCH ARTICLE
ADVANCES IN FUNCTIONAL ELECTRICAL STIMULATION FOR LOWER LIMB REHABILITATION
INSTROKE: A REVIEW ON PHYSIOLOGIC AND THERAPEUTIC PERSPECTIVE

Brammatha A.1, Nagarani R.2, Kannabiran B.2 and Franklin S.3

1. Ph.D. Scholar, RVS College of Physiotherapy / Professor, KMCH College of Physiotherapy,
Coimbatore,Affiliated to the Tamil Nadu Dr. M. G. R. Medical University, Chennai, India.
2. Professor / Ph.D Guide, Department of Neurological Physiotherapy, R.V.S College of Physiotherapy,
Coimbatore, The Tamil Nadu Dr. M. G. R. Medical University, Chennai, India.
3. Principal / Ph.D Guide, R.V.S College of Physiotherapy, Coimbatore, The Tamil Nadu Dr. M. G. R. Medical
University, Chennai, India.
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Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Stroke results in considerable impairment of lower limb (LL) function.
Received: 21 March 2024 The objective of rehabilitation is to restore pre-stroke motor skills
Final Accepted: 28 April 2024 through the promotion of neuroplasticity. Existing literature indicates
Published: May 2024 that mere movement of the impacted limb does not necessarily enhance
motor performance; instead, the movements should engage the patient
Key words:-
Functional Electrical Stimulation, Lower and activate the entire neuromuscular network responsible for the
Limb Rehabilitation, Stroke intended motion. Functional Electrical Stimulation (FES) stands out
among various rehabilitation strategies and is endorsed in numerous
stroke rehabilitation protocols as an adjunctive therapy alongside
standard care interventions. The aim of this research is to offer a
thorough examination of the use and physiological rationale of FES in
post-stroke rehabilitation. Many studies advocate for incorporating FES
into a contemporary stroke rehabilitation regimen, complemented by
activities such as cycling, treadmill exercises, and robotic interventions,
to optimize recovery outcomes in poststroke rehabilitation.

Copy Right, IJAR, 2024,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Stroke represents the most prevalent cause of fatality subsequent to coronary artery disease. Ramifications of a
stroke encompass changes in muscle tension, weakness, spasticity, abnormal force production,postural instability,
dysfunction in the upper extremities, challenges with walking, and diminished quality of life. The impediment or
struggle with locomotion stands out as one of the most severe consequences of a stroke, hence the restoration of
walking or gait frequently emerges as a central objective in the realm of rehabilitation. Activities linked to walking
or gait entail various tasks like moving while transitioning from sitting to standing, sitting down, climbing stairs,
turning, transferring (e.g., from wheelchair to bed or vice versa), walking at a brisk pace, and covering designated
distances. Restrictions in walking and its associated activities are correlated with an escalation in the likelihood of
falls.1

Numerous rehabilitation systems and physical exercises are available for individuals grappling with post-stroke or
hemiplegia, which denotes weakness on one side of the body. A contemporary and extensively utilized therapeutic
approach is Functional Electrical Stimulation (FES). The utilization of FES for therapeutic objectives within

Corresponding Author:- Brammatha A. 700

Address:- Ph.D. Scholar, RVS College of Physiotherapy / Professor, KMCH College of
Physiotherapy, Coimbatore,Affiliated to the Tamil Nadu Dr. M. G. R. Medical University,
Chennai, India.
ISSN: 2320-5407 Int. J. Adv. Res. 12(05), 700-705

rehabilitation environments traces back to the 1960s when Liberson et al. harnessed an FES system to stimulate the
peroneal nerve, rectifying foot drop by activating a foot switch. Through a singular-channel electrical stimulation
apparatus, the common peroneal nerve was stimulated via a surface electrode, inducing ankle dorsiflexion
throughout the swing phase of walking.2

FES commonly denotes the act of synchronously or sporadically pairing electrical stimulation with a functional task.
A stimulation tool is employed to dispatch electrical signals to nerves, prompting muscle contractions. This form of
input can bolster muscle strength and range of motion, counteracting the consequences of physical inactivity
frequently observed in individuals encountering post-stroke challenges. It is frequently employed to recondition or
rehabilitate muscles for improved functionality, encompassing activities such as walking or utilizing an arm for
reaching. Among the lower limb issues, foot drop emerges as a prevalent complication following a stroke,
potentially leading to reduced walking speed, modified step length, or even falls. By applying FES to the dorsiflexor
muscles responsible for raising the foot at the appropriate timingor during the walking cycle, not only can foot
clearance and safety be enhanced, but there can also be an augmentation in muscular strength and ankle joint
flexibility.3

Therapeutic Vs. Prosthetic effect of Functional electrical stimulation (FES)

The two principal applications of Functional Electrical Stimulation (FES) entail the substitution of function, such as
acting as an orthotic device and the retraining of function, exemplified by its therapeutic use. When individuals who
have experienced a stroke utilize a FES motor relearning system to rehabilitate lower limb movements and activities,
the primary objective is focused on training to ensure sustained enhancement in the functional utilization of the
hemiparetic limb even during periods of non-use. The enduring enhancement in lower limb function or mobility
subsequent to undergoing FES training or utilizing the device is identified as a therapeutic outcome. For individuals
in the chronic phase of stroke with depleted motor relearning options, FES can serve as a neuroprosthesis. The
central goal in this context is to empower patients to perform daily functional tasks using the affected lower limb or
to walk while incorporating the device into their routine activities. The enhanced functionality observed while
employing an FES device is denoted as a neuroprosthetic or orthotic benefit. An evaluation of the existing literature
regarding the advancement in walking abilities among stroke patients with foot drop when employing peroneus
stimulation indicates a favorable orthotic impact of Functional Electrical Stimulation on walking speed. 4,5

Physiologic effect of FES

It has been found that therapies that temporally link motor output and sensory feedback from the affected limb may
facilitate neurophysiologic changes leading to motor recovery.The peripheral mechanism of FES involves enhancing
the paralyzed limbs muscle flexibility, strength, range of motion, and reducing spasticity. 9FES can help restore
muscle strength, particularly in the dorsiflexors and hip abductors, aiding in weight-bearing, postural support, and
balance improvement.Several studies indicate that the rehabilitation potential of Functional electrical stimulation can
range from the modulation of motor function in various levels of motor recovery of individuals to reduction in
impairment severity .7,8

Neuroplasticity and FES

Functional electrical stimulation can improve neuroplasticity by increase in synaptic efficacy within existing neural
circuits or formation of new synapses. FES assisted movement causes cortical reorganization by acting as
proprioceptive inputs to the brain and reinforcing network connection patterns through the creation of new
synapses.10FES maximizes the motor output (peripheral efferent activation) and corresponding muscle and joint
proprioceptive feedback (afferent activation) that are tightly coupled and coordinated with movement by
FES.TheHebbian mechanisms related to activity dependent cortical reorganization suggest that rehabilitation
therapies that repeatedly generate synchronous presynaptic and postsynaptic neural activity along motor and sensory
pathways might facilitate synaptic remodeling, leading to neural reorganization and motor recovery.6

Therapeutic applications of Functional Electrical Stimulation (FES)

The utilization of FES has been endorsed by the Clinical Guidelines for Stroke Management and Guidelines for
Adult Stroke Rehabilitation and Recovery as an adjunctive intervention alongside standard care modalities.11, 12

Various Systematic reviews and Meta-analysis, as demonstrated in table 1, have indicated that the incorporation of
FES into a conventional rehabilitation regimen yields favorable therapeutic outcomes concerning enhancements in

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tone, gait recovery, motor function, energy expenditure, and functional capacity among stroke patients. These
reviews have highlighted the beneficial impact of FES on lower limb motor impairments and functional results. 13-19

A substantial body of literature substantiates the efficacy of FES in ameliorating lower limb motor control through a
variety of outcome measures such as Functional Ambulation Category, Berg balance test, 10-m walk test, timed-up-
and-go (TUG) test, Fugl-Meyer lower extremity, Motricity Index, Barthel index, and Six-minute walk test.20-32

Few Studies found AFOs to have positive combined-orthotic effects on walking that are equivalent to FES for foot-
drop caused by stroke.5,33 Also FES is effective in improving the temporal-spatial gait and activities of daily living
in hemiplegic stroke patients.34
TABLE 1 : SYSTEMATIC REVIEWS AND METAANALYSIS ON EFFECTS OF FES FOR LOWERLIMB
REHABILITATION FOR POST STROKE RECOVERY
Authors Endpoints Findings
14
Glanz et al, 1996 Muscle strength/Torque
17
Robbins SM et al, 2006 Gait speed/ Walking
Pereira S et al, 201216 Gait speed/ Walking Positive therapeutic effects found on
Sabut S.K et al, 2013 40 gait, motor function,energy expenditure various outcome measures
Stein C et al, 201541 Spasticity/Range of Motion
Howlett O et al, 201513 Gait speed
Prenton S et al, 20165 Gait speed/Orthotic effect Less orthotic effect
Francisco L et al, 201642 Quality of life, motor abilities and gait
Mahmoudi Z et al,202118 Balance /BBS/ TUG Positive therapeutic effect
Kang et al, 202133 Implantable FES/ Gait performance Superior gait parameters
Fang Y et al,202319 Motor, Balance and ADL Superior to other electrical stimulation

Various methods of application

In hemiplegia multichannel stimulation systems have been investigated for therapeutic effects. Surface electrodes
are used with a 6-channel surface system to activate ankle dorsiflexion , plantar flexion, knee flexion, knee
extension, hip flexion and extension. However, as the number of electrodes increases, surface systems become
increasingly difficult to implement due to difficulty of donning and doffing of multiple electrodes, pain of
stimulation, difficulty in electrode placement and muscle contractions. Therefore, multichannel percutaneous
systems have also been explored for motor relearning. 23,33, 35

Hybrid FES
New FES techniques for lower limb stroke rehabilitation continue to be developed, especially those that use sensors
to trigger stimulation when patients achieve some minimum volitional movement. EMG-controlled Functional
Electrical Stimulation (FES) induces greater muscle contraction by electrical stimulation that is in proportion to
voluntary integrated EMG signals. There is a growing trend toward combining FES with other emerging therapeutic
strategies. Examples include combining FES with Brain Cortical Interface (BCI), repetitive trans cranial magnetic
stimulation (rTMS), constraint induced movement therapy (CIMT) robot-assisted movement therapy, motor
imagery, bilateral movement training, virtual reality games, trans cranial direct current stimulation (tDCS), and
body-weight-supported treadmill training(BWSTT).36,39

Discussion:-
It was previously believed that the central nervous system, had no ability to regenerate or change, So compensatory
strategies were focus of stroke rehabilitation. However, with the increasing awareness that brain plasticity, neural
regeneration, and rehabilitation therapy can promote recovery, the focus has shifted toward treatments that
maximize neurological recovery. So now -a -day’s rehabilitation therapy using a restorative approach is the main
focus to reduce impairments and improve functional activity.

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Therapeutic FES assists functional tasks in a synergic way and encourages user effort. In addition, recent
evidence supports the assumption that BCI-based FES could improve motor recovery after stroke. Also, evidence
are there for improving lower extremity motor function in patients with early stroke through combining magnetic
resonance diffusion tensor imaging (DTI) technology and functional electrical stimulation (FES) based on human
walking patterns.37 Most trials to date have stroke patients in the subacute and chronic stage of stroke recovery. 38
Studies now are examining the effects of FES therapy in early recovery stages. In addition, current research is
focusing on FEST dosage parameters to improve the trial methodology.

Conclusion:-
Evidences from the literature suggest that FES is beneficial in improving lower limb motor impairments and
functional activity performance after stroke. Better understanding of both neurophysiology and the clinical
applications of FES therapy would increase its therapeutic effects and become a component of routine clinical
practice in addition to conventional modalities in post stroke rehabilitation.

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