Task-oriented bilateral upper extremity rehabilitation using functional electrical stimulation in a patient with hemiplegia: a case study

Functional recovery of the hemiplegic upper extremity after stroke is a great challenge faced by medical and rehabilitation professionals. In this case study, three approaches including task-oriented model of practice, bilateral training, and functional electrical stimulation were utilized with patient care. These three approaches have been preliminarily confirmed to be effective in stroke rehabilitation. The patient in this case study is a 57 year-old male. He sustained right middle cerebral artery stroke on January 1, 2012. This study included this patient’s intensive inpatient rehabilitation and outpatient therapy. At the beginning of his therapy, the patient did not have any movement in his left hand due to lack of motor control and hypotonicity; his active range of motion (AROM) of his left upper extremity (UE) was 0 -70° for shoulder flexion and 0 70° for shoulder abduction; and he had decreased independence with his occupations of daily living secondary to left UE hemiparesis. Based on the patient’s goals and occupational therapy evaluation, a series of therapy goals were established to improve AROM and strength in his left UE with the ultimate goals to be independent with his occupations of daily living (ODLs), get back to driving, return to work, and be able to play guitar. A various interventions were used during his rehabilitation based on these three effective approaches. After more than 3 months of therapy, the patient had made excellent recovery and his occupational performance has substantially improved. He is using his left hand independently with majority of ODLs. His AROM in his left UE has returned to within functional limit. The grip strength for his left hand has improved from 0 to 14 pounds; the pinch strength for the left hand has improved from 0 – 10 pounds (tip pinch), 0 – 6 pounds (palmar pinch), and 0 – 11 pounds respectively. He is still participating occupational therapy and speech therapy at present time. The implication for practice and research was discussed in this case study. FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 3 Introduction Heart disease and stroke statistics--2010 update: a report from the American Heart Association (Writing group members, Lloyd-Jones, Adams, Brown, Carnethon, Dai, et al., 2010) reported that stroke was the leading cause of disability and the third leading cause of death in the United States. Each year approximately 795,000 individuals experience stroke with 610,000 sustaining an initial event and the remaining 185,000 a reoccurrence of stroke. The indirect and directs costs of stroke for 2010 was $73.7 billion. The projected cost from 2005 through 2050 is expected to surpass 2.2 trillion dollars. Stroke is the leading cause of long-term disability in western countries and one third of patients with stroke need help in at least one occupation of daily living (ODL) (Bonita, Solomon, & Broad, 1997). Upper extremity impairment occurs in 85% of patients at the beginning of their stroke, and at 3 months, 55–75% of patients still have upper extremity paresis (Thorngren & Westling, 1990). According to the Framingham study, older patients have been observed to have the following disabilities at 6 months after stroke: 50% had some hemiparesis, 30% were unable to walk without some assistance, 26% were dependent in the ODL, 19% had aphasia, 35% had depressive symptoms, 26% were institutionalized in a nursing home (Kelley-Hayes, Beiser, Kase, Scaramucci, D’Agostino, & Wolf, 2003). These disabilities severely affect patients’ quality of life. Functional recovery of the hemiplegic upper extremity after stroke is a great challenge faced by medical and rehabilitation professionals. Over 60% of chronic stroke patients have motor dysfunction in their affected upper extremity, while only 5% recover their upper extremity dysfunction completely (Dobkin, 2005). Stroke rehabilitation represents a considerable workload for occupational therapists. It is one of the most important goals for occupational therapists to FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 4 help patients to recover their upper extremity function during stroke rehabilitation and regain their independence as much as possible. During the history of stroke rehabilitation, rehabilitation professionals have used various techniques to manipulate elements of the central and peripheral nervous system, which include neurodevelopmental techniques, proprioceptive neuromuscular facilitation, biofeedback, repetitive task training, robot-assisted therapy, mirror therapy, bilateral training, task-oriented approach, constraint intensive movement therapy, and electrical stimulation, etc. The superiority or effectiveness of majority of these techniques or approaches has not been confirmed or established. As it is known, rehabilitation professionals are in the middle of a paradigm shift from empirical to evidence-based practice. It is important to choose the best and effective intervention techniques during clinical practice. It is the profession’s ethical responsibility for these patients. In this case study, three approaches including task-oriented model of practice, bilateral training, and functional electrical stimulation will be utilized with patient care. These three approaches have been preliminarily confirmed to be effective in stroke rehabilitation. Literature review Task-oriented model of practice: This model of practice is based on motor control, motor learning, and motor development (Mathiowetz & Bass-Haugen, 1994; Flinn, 1995). It assumes that “The nervous system itself is organized heterarchically such that higher centers interact with the lower centers but do not control them. Closed-loop and open-loop system work cooperatively and both feedback and feed-forward control are used to achieve task goals.” (BassHaugen, Mathiowetz, & Flinn, 2008, p599). The central nervous system needs to interact with personal and environmental factors as a person pursues a functional goal. When using this model of practice, therapists should simulate natural environment as much as possible and use FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 5 functional tasks or daily occupations that patients identify as important or meaningful to them. The therapists should help and encourage patients to try their own ways to perform these functional tasks effectively and efficiently. Varied practice should be used to help clients discover optimal strategies for achieving functional performance (Higgins, 1991). Flinn (1995) studied the task-oriented approach using a case study in post-stroke rehabilitation. The patient was a 34-year old female with hemiplegia. The patient received a onehour occupational therapy and 3 sessions per week over a period of six months. The focus of treatment was meeting the participant’s functional goals including childcare, homemaking occupations, and work-related occupations. Throughout the treatment, the therapists tried to revise the treatment plan by identifying the critical control parameters and working on them under the purpose of evoking functional performance improvements. The treatment was directed toward the client’s affected UE strength, ROM, and incorporation into daily use under controlled degrees of freedom (simplifying the tasks’ requirements by reducing the variables needed to be controlled). As the participants’ motor abilities were improved, she was getting more challenging functional tasks that required more degrees of freedom. The therapists tried to give as many repetitions of functional tasks with contextual variability to simulate real world contextual variability. At discharge, the patient’ affected UE was improved substantially; she was independent in all self-care tasks, was able to perform her housekeeping and childcare tasks, and was able to ambulate independently. The author concluded that the use of task-oriented approach have potential benefits in post-stroke rehabilitation. In a randomized clinical trial by Dean and Shepherd (1997), twenty subjects at least 1 year after stroke were randomized into an experimental or control group. The experimental group participated in a standardized training program involving practice of reaching beyond arm's FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 6 length. These participants performed the reaching tasks in different conditions, for examples, distance and direction were varied by changing the location of the object; seat height, movement speed, object weight, and extent of thigh support on the seat were also varied. The control group received sham training involving completion of cognitive-manipulative tasks within arm's length. Performance of reaching in sitting was measured before and after training using electromyography, videotaping, and two force plates. Movement time, distance reached, vertical ground reaction forces through the feet, and muscle activity were measured. The training was done in a 2-week period. After training, experimental subjects were able to reach faster and further, increase load through the affected foot, and increase activation of affected leg muscles compared with the control group (P<.01). In comparison, the control group did not improve in reaching. This study suggests that task-oriented motor training can improve the ability of balance during seating reaching occupations after stroke. Bilateral training: Bilateral arm training has emerged as an approach that leads to preliminary positive outcomes in upper extremity rehabilitation after stroke. Bilateral training is based on three principles: 1. What we do every day involves the use of both arms, for examples, both arms and hands are used for occupations of daily living and instrumental occupations of daily living such as dressing, feeding, bathing, toileting, driving, and cooking, etc. Therefore, bilateral re-training is necessary. 2. Bilateral training is based on bimanual coordination (Cardoso de Oliveira, 2002, Turvey, 1990). Both arms were centrally linked as a coordinative structure unit, hands and fingers function in a homologous coupling of muscle groups on both sides of the body. Bilateral training emphasizes the inherent characteristics of muscles as important for muscle control. 3. Bilateral training has neurophysiological justification. According to McCombe Waller & Whitall (2008), bilateral training led to reduced intracortical inhibition and increased FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 7 intracortical facilitation in both hemispheres, while unilateral training, no matter it is dominant or nondominant, produced increased ICF and reduced ICI only the contralateral hemispheres. This neurophysiological basis may encourage recruitment of undamaged neurons to construct new task-related neural network or lead to neuroplasticity. Stewart, Cauraugh, & Summers (2006) did a meta-analysis on the effectiveness of bilateral movement in rehabilitation. They searched PubMed and Cochrane databases to find research on bilateral motor recovery and included 11 stroke rehabilitation studies for their systematic review. Their inclusion criteria included 1). Bilateral training protocols involved either functional tasks or repetitive arm movements; 2) Each study had one of three common arm and hand functional outcome measures: Fugl-Meyer, Box and Block, and kinematic performance. These meta-analysis findings suggest that bilateral movements alone or in combination with auxiliary sensory feedback are effective in stroke rehabilitation during the subacute and chronic phases of recovery. Functional Electrical Stimulation: Electrical stimulation (Popovic, Sinkjærc, & Popovic, 2009) is the latest technology in stroke rehabilitation and it is a method to activate sensory-motor systems by delivering electrical charge in the form of bursts of electrical pulses to induce specific muscle contraction. Functional electrical stimulation involves the use of multiple channel electrical stimulation systems and it is a kind of designed neural prostheses for therapy. FES will help patients with stroke recover their voluntary movement and function and return them to independent life. In this case study, BIONESS H200 (http://www.bioness.com/H200_for_Hand_Paralysis) was used for functional electrical stimulation. It is an electrical stimulation hand unit that has five surface electrodes integrated into the system to stimulate and activate muscle flexion or FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 8 extension in the hand and facilitate neuromuscular re-education. Therapy programs and function modes are pre-programmed, providing the clinician and the patient control over hand activation. In the past 10 years, there have many research, case studies, and clinical trials done on BIONESS H200 system. It has been confirmed that it has many benefits for patients with stroke, spinal cord injury, and traumatic brain injury, such as improving hand active range of motion and function such as grasping, releasing, and opening and closing the hand, reducing muscle spasticity, re-educating muscles, preventing contractures, and increasing local blood circulation. Functional electrical stimulation usually is not the only approach used during rehabilitation. It is commonly utilized with bilateral training or with task-oriented approach or with both. This combination will further improve the efficacy of stroke rehabilitation. The following evidence will demonstrate their effectiveness. Chan, Tong, & Chung (2009) studied the effectiveness of functional electrical stimulation and bilateral occupations training on the recovery of upper extremity function in patients with stroke. They used a double-blinded randomized controlled trial design and recruited twenty patients who were 6 months after the onset of stroke. Patients were randomly assigned to the functional electrical stimulation group or to the control group. For the functional electrical stimulation group, each session consisted of stretching occupations (10 minutes), functional electrical stimulation with bilateral tasks (20 minutes), and occupational therapy treatment (60 minutes). The functional electrical stimulation was synchronized with the bilateral upper limb occupations during the training; while patients in the control group received the same duration of stretching and occupational therapy training except that they just received placebo stimulation (sensation only) with the bilateral tasks. All patients underwent 15 session treatments. Functional Test for the Hemiplegic Upper Extremity (FTHUE), Fugl–Meyer Assessment (FMA), grip FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 9 power, forward reaching distance, active range of motion of wrist extension, Functional Independence Measure, and Modified Ashworth Scale were measured for all these patients. Their results showed that, at baseline comparison, there was no significant difference in both groups for these measurements. After completing these treatment sessions, the functional electrical stimulation and bilateral training group had significant improvement in FMA (P = .039), FTHUE (P = .001), and active range of motion of wrist extension (P = .020) when compared with the control group. Their results suggest that the functional electrical stimulation and bilateral training could be an effective method for upper limb rehabilitation for patients with stroke. In a study by Ring & Rosenthal’s group (2005), they investigated the effects of daily neuroprosthetic (BIONESS H200) functional electrical stimulation in sub-acute stroke. There were total of 22 patients with moderate to severe upper limb paralysis 3–6 months post-stroke participating this clinical study. Their experimental design is controlled randomized study. Patients were first clinically stratified to two groups: no active finger movement (10 patients, type I patients), and partial active finger movements (12 patients, type II patients), and then were randomized into control and neuroprosthesis groups. At baseline and completion of the 6-week study, the evaluator was blinded about patient group. All patients attended day hospital rehabilitation, receiving physical and occupational therapy 3 times per week. The neuroprosthesis group used the device at home, type II patients in neuroprosthesis group engaged functional occupations while using BIONESS H200. Their results showed as follows. For type I patients, there was greater improvement in active motion in the proximal upper extremity in the neuroprosthesis group, however, the difference did not reach a level of statistical significance. For type II patients in the neuroprosthesis group, there had significantly greater improvements in FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 10 spasticity, active range of motion and hand function. They concluded that supplementing standard outpatient rehabilitation with daily home neuroprosthetic stimulation and functional occupations improves upper extremity outcomes in voluntary movement and functional use of the hand. A pilot study by Alon, Levitt, & McCarthy (2007) tried to test whether functional electrical stimulation can Improve the recovery of upper extremity function during early stroke rehabilitation. It included 15 patients who had stroke more than 2 weeks and less than 4 weeks. These patients were stratified into blocks of 10 points (11-20, 21-30, 31-40) based on the modified Fugl-Meyer score for the upper extremity, and then randomized into a functional electrical stimulation group combined (n= 7 patients) or a control group (n= 8 patients). The patients begun their therapy at inpatient rehabilitation and continued at the patients’ home. Patients in functional electrical stimulation group received electrical stimulation combined with task-specific upper extremity occupations while the control group received task-specific therapy alone over 12 weeks. Hand function was measured by Box & Blocks and Jebsen-Taylor light object lift test and motor control was measured by modified Fugl-Meyer test, These measurements were video-recorded for both upper extremities at baseline, 4, 8, and 12 weeks. Their results showed that the patients in both groups improved their hand function; however, functional electrical stimulation combined with task-oriented occupations resulted in significant improvement over task-specific therapy alone. They concluded that upper extremity taskoriented training incorporating with functional electrical stimulation could help recover upper extremity function in patients with mild/moderate paralysis during early rehabilitation more than task-oriented training only. FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 11 Some effective evidences are presented in aforementioned studies or meta-analysis; however, the latest authoritative meta-analyses (Coupar, Pollock, van Wijck, Morris, & Langhorne, 2010; Pomeroy, King, Pollock, Baily-Hallam, Langhorne, 2009) had not confirmed that bilateral training and electrical stimulation were more (or less) effective than usual care or other upper limb interventions for functional movement of the upper extremity. Looking at all these studies, there were many limitations in these studies, for examples, all studies had small sample size; different studies used different protocol (treatment time, treatment length, or occupations, etc.); and there were differences among the patients (time after stroke, level of functional deficit, severity of stroke, etc.). It is very possible there is selection and detection bias in these studies. For the meta-analysis on bilateral training (Stewart, Cauraugh, & Summers , 2006), it reported a significant overall effect in favor of bilateral movement training alone or in combination with auxiliary sensory feedback for improving motor recovery post-stroke. However, its search strategy was limited and it included studies that were not randomized controlled trials. At present, there are insufficient robust data or good quality evidence to confirm their claims. More well-designed, large sample size, and multiple-site randomized controlled trials are needed to determine their effectiveness. Two specific outcome measurements were used in this case study. One was Action Research Arm Test (Carroll, 1965; Crow, Lincoln, Nouri, & De Weerdt, 1989; De Weerdt, & Harrison, 1985; Lyle, 1981). It is an observational test used to determine upper extremity function and assess functional recovery in upper extremity after brain insult. The test consists of 19 items grouped in subtests (grasp, grip, pinch, and gross arm movement) and performance of each item is rated on a 4-point scale ranging from 0 (no movement possible), 1 (performs test partially), 2 (completes test, but takes abnormally long or has great difficulty), and 3 (movement FUNCTIONAL E-STIM & TASK-ORIENTED UE REHAB 12 performed normally). Another test is Motor Activity Log (Uswatte, Taub, Morris, Light, Thompson, 2006). This log is used to evaluate actual use of the impaired arm outside of the treatment setting and in patient’s real life. Each item evaluates on how much the client uses the affected arm and how well he/she uses the affected arm. Administration of the MAL before and after treatment provides valuable data for rehabilitation professionals to tracks a patient's progress during the therapy process. This case study is innovative because 1) its intervention is evidence-based; 2) its intervention combines three effective approaches: task-oriented, bilateral training, and functional electrical stimulation; and 3) it provides effective evidence for stroke rehabilitation.