A study entitled “ The Effect of Neuromuscular Electrical Nerve Stimulation in the Management of Post-stroke Spasticity: A Scoping Review ” conducted by Athanasios Chasiotis, Vasileios Giannopapas, Marianna Papadopoulou, Maria Chondrogianni, Dimitrios Stasinopoulos, Sotirios Giannopoulos, Daphne Bakalidou , published November 29, 2022 .
Stroke is a cerebrovascular disorder characterized by the sudden onset of symptoms and clinical signs caused by either vascular infarction or hemorrhage .
It is considered one of the leading causes of death due to cardiovascular disease (CVD) worldwide, reaching a mortality rate of 33% of CVD patients in 2020 .
Spasticity is considered a “positive” feature of UMNS due to the loss of inhibition of the lower motor neuron pathways resulting from a sensory-motion control disorder in the muscle regulation system.
In addition, a significant percent of pSps exhibits a high degree of disability, thus needing around-the-clock assistance from a caregiver (usually a family member) .
Since the electrical excitability of lower motor units (and their respective innervated muscles) is usually intact, NMES can be used to stimulate the neuromuscular activity of the affected limbs with either direct stimulation of the affected muscles or the stimulation of their antagonists solo or in parallel with robotic assistive devices .
The aim of this systematic review was to examine the efficacy of NMES as a treatment modality in the management of post-stroke spasticity on the upper or lower hemiplegic limb and to identify the different electrical parameters (waveform, pulse duration, frequency, on/off time, site of application, intensity) that are being used.
A scoping review of clinical trials and randomized control trials regarding the use and effectiveness of NMES in the mobility and/or functionality of the affected upper and/or lower limb in pSps was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . Three authors independently performed the literature search and assessed the results before the synthesis. Studies reporting intervention with NMES on spastic upper or lower limbs were included while protocols presenting NMES treatments combined with physiotherapeutic and/or pharmacological techniques were excluded from the literature search. The studies included were based on spasticity and the thorough investigation of its therapeutic approach. Most included studies based their design and the sample stratification using the modified Ashworth scale (MAS), hence the database search was adjusted accordingly. A MESH search was performed using the PubMed Medline database with the terms: electrical neuromuscular stimulation AND stroke AND spasticity Filters: Clinical Trial, Randomized Controlled Trial, from 01-01- 2010 – 01-01-2022. The corresponding flowchart is presented in Figure 1 .
- Spasticity was measured through the modified Ashworth scale (MAS) and electromyographic recordings (EMG). In most cases, spasticity was decreased for at least two weeks post-intervention. In conclusion, NMES can be used either solo or in combination with different physical therapy modalities in order to produce optimal results, taking into consideration the specific needs and limitations of each individual patient.
- One of the main things highlighted by this systematic review is the heterogeneity of the electrical parameters.
- Even though there is a variety of possible NMES protocols for the management of post-stroke spasticity, there is an urgent need for a standarized, validated protocol.
- Based on the literature review and clinical experience, the frequency and waveform used for the management of post-stroke spasticity are commonly set in the specified range (0-100 Hz and biphasic symmetrical, respectively).
Future Studies #
Future studies should focus on examining the effect of a higher and/or lower pulse duration (specifically lower than 100 μs and higher than 450 μs) with a variation in the treatment duration in order to avoid any negative impact on pSps. Furthermore, it would be beneficial to maintain the homogeneity of all other electrical parameters and the heterogeneity of the sample in the domains of gender, age, and socio-economic status.
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