Annals of Physical and Rehabilitation Medicine 61 (2018) 339–344

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Review

Adding electrical stimulation during standard rehabilitation after stroke to

improve motor function. A systematic review and meta-analysis

a, b a
Sharareh Sharififar *, Jonathan J. Shuster , Mark D. Bishop
a Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
bDepartment of Health Outcomes and Policy, Biostatistics Epidemiology and Research Design, Clinical and Translational Science Institute, Biostatistician, UF Clinical Research Center, College of
Medicine, University of Florida, Gainesville, Florida, USA

ARTICLE INFO ABSTRACT

Article history: Background: Clinical studies have shown that sensory input improves motor function when added to active training after
Received 18 September 2017 neurological injuries in the spinal cord.
Accepted 10 June 2018
Objective: We aimed to determine the effect on motor function of extremities of adding an electrical sensory modality
without motor recruitment before or with routine rehabilitation for hemiparesis after stroke by a comprehensive systematic
Keywords: review and meta-analysis.
Sensory
Methods: We searched databases including MEDLINE via PubMed and the Cochrane Central Register of Controlled Trials
Stimulation
from 1978 to the end of November 2017 for reports of randomized controlled trials or controlled studies of patients with a
Stroke
clinical diagnosis of stroke who underwent 1) transcutaneous electrical nerve stimulation (TENS) or peripheral
Function
electromyography-triggered sensory stimulation over a peripheral nerve and associated muscles or 2) acupuncture to areas
that produced sensory effects, without motor recruitment, along with routine rehabilitation. Outcome measures were motor
impairment, activity, and participation outcomes defined by the International Classification of Functioning, Disability and
Health.

Results: The search yielded 11 studies with data that could be included in a meta-analysis. Electrical sensory inputs, when
paired with routine therapy, improved peak torque dorsiflexion (mean difference [MD] 2.44 Nm, 95% confidence interval
[CI] 0.26–4.63). On subgroup analysis, the combined therapy yielded a significant difference in terms of sensory stimulation
without motor recruitment only on the Timed Up and Go test in the chronic phase of stroke (MD 3.51 sec, 95% CI 3.05–
3.98). The spasticity score was reduced but not significantly (MD 0.83 points, 95% CI -1.77 0.10).

Conclusion: Electrical sensory input can contribute to routine rehabilitation to improve early post-stroke lower-extremity
impairment and late motor function, with no change in spasticity. Prolonged periods of sensory stimulation such as TENS
combined with activity can have beneficial effects on impairment and function after stroke.

C 2018 Elsevier Masson SAS. All rights reserved.

1. Introduction few months after brain insult reduces the individual’s potential to participate
in therapy [2,3]. The initial damage to the neuronal pathways followed by
Hemiparesis is one of the prominent impairments caused by stroke that functional reorganization halt the motor recovery; however, many stimuli
affects activities of daily living and quality of life [1]. Clinically, the failure to have shown potential therapeu-tic benefit to improve functional recovery after
recover motor deficits rapidly within a stroke. Tradition-ally, in stroke research, potential therapeutic strategies
targeting motor recovery emphasize motor stimulation associated with
massed motor practice for the recovery of motor skills [4].
* Corresponding author.
E-mail addresses: shararehsharififar@gmail.com (S. Sharififar), shusterj@ufl.edu Afferent motor stimulation leads to neurological improve-ments, but the
(J.J. Shuster), bish@phhp.ufl.edu (M.D. Bishop). recovery of function varies. The effects of increased

https://doi.org/10.1016/j.rehab.2018.06.005
1877-0657/ C 2018 Elsevier Masson SAS. All rights reserved.
340 S. Sharififar et al. / Annals of Physical and Rehabilitation Medicine 61 (2018) 339–344
sensory input on motor outcomes have been relatively neglected in the
rehabilitation literature as compared with those of other interventions, even
though a number of studies suggested clinical benefits. In 1915, Franz et al.
were the first to report success in recovering upper extremity motor function
by using simple rehabilitative techniques such as massage and vibration. [5]
In particular, cutaneous and proprioceptive afferent information facilitates the
improvement of motor performance and promotes effective motor learning
because it increases the cortico-motor excitability in areas representing the
stimulated body parts [6– 10]. Subsequent research has shown that electrical
sensory input alters the sensory and motor cortical maps [3,11–13] and
clinical studies have shown that sensory input improved motor function when
added to active training after neurological injuries in the spinal cord [14].
A recent systematic review and a meta-analysis of the effects of
augmenting rehabilitation with sensory stimulation were publis-hed in the
past 10 years [15,16]. The review by Laufer et al. did not lead to a meta-
analysis because of too few studies that met inclusion criteria and the meta-
analysis by Veerbeek et al. did not separate sensory stimulations that lead to
motor recruitment from pure sensory-level stimulation.
In the current analysis we expanded on these studies. In particular, we
used a newer method for the meta-analysis. The random-effects method is
commonly used, but it forces the distribution of effect sizes to be independent
of the study design, for no relation between a study’s effect size and the size
of study. This is a strong assumption, which is not necessarily true for all
studies, so the estimate of the between-studies variance will have poor
precision, limiting investigators’ and clinicians’ ability to apply the
commonly used random-effects method appropriately. Because of major
issues with this method [17,18], we used the approach proposed by Shuster et
al. to overcome the fundamental limitations of the empirical weighting
method. In this approach, ‘‘studies-at-random’’ assumes that studies are
drawn from a population of studies that are independent and implies that the
weight given to each study’s effect size is a random variable [19].
Thus, this current study extended the previous work by:
potentially broadening the available literature that could be reviewed;
using a method suitable for pooling a small number of studies with a small
number of participants;
examining the effects of electrical sensory stimulation without motor
recruitment across levels of function.
The primary questions driving this current analysis were as follows:
Is there evidence for the efficacy of augmenting rehabilitation with sensory
input using electrical stimulation (e-stim) to improve motor function in a
person after stroke?
What are the specific effects of adding an electrical sensory modality
before or along with routine rehabilitation on motor impairment, activity,
and participation outcomes after stroke?
2. Methods
2.1. Identification and selection of studies
We extracted key words associated from relevant articles and used
Medical Subject Heading (MeSH terms) and Major Headings to search for
human studies in any language in the databases MEDLINE via PubMed,
Cochrane Central Register of Controlled
Trials, Cochrane Database of Systematic Reviews, Web of Science,
SPORTDiscus, and Cumulative Index to Nursing and Allied Health Literature
(CINAHL), Google, and WorldCat from 1978 to the end of November 2017.
We also hand-searched the reference lists of published reviews and narrative
review articles. In addition, abstracts published in relevant conference
proceedings were polled.
The search terms included ‘‘cerebrovascular accident’’ OR ‘‘stroke’’ OR
‘‘hemiplegia’’ OR ‘‘hemiparesis’’ OR ‘‘hemiparetic,’’ AND ‘‘vibration,’’
‘‘pressure’’ OR ‘‘haptics,’’ ‘‘kinesthetic*,’’ ‘‘stretch,’’ ‘‘weight,’’ ‘‘joint
angle,’’ OR ‘‘tactile,’’ ‘‘touch,’’ OR ‘‘texture,’’ OR ‘‘transcutaneous
electrical nerve stimulation,’’ ‘‘TENS,’’ ‘‘neuro-muscular training,’’ AND
‘‘motor,’’ ‘‘movement,’’ OR ‘‘motion,’’ OR ‘‘mobility,’’ OR ‘‘function,’’
OR ‘‘performance’’. Although each database used differing syntax, this set of
search terms was the basis for the searches in each of those databases.
We included reports of randomized controlled trials or controlled trials
with parallel or crossover designs. In studies with more than 2 arms, the
values related to e-stim or placebo interventions combined with the routine
therapy were recorded.
All reports of sensory modalities investigated such as vibration, pressure,
haptics, stretch, weight, proprioception, tactile, touch, texture, thermal, and
transcutaneous electrical nerve stimulation (TENS) as adjunct therapy to
routine rehabilitation to improve post-stroke motor function were included.
However, the primarily sensory modality of interest was e-stim. Different e-
stim inter-ventions such as repetitive electrical nerve stimulation, acupunc-
ture or muscle stimulation have common sensory nerve axon stimulation at
specific peripheral sites. The comparison groups included active treatment
(active or passive exercise, e-stim over different sites), placebo (sham, sub-
sensory threshold stimulus intensity), and no treatment.
The outcome measures were any measurable activity-based motor
function. To increase the generalizability of the results to the population of
interest, we included studies of participants with all durations of stroke-
related sequelae (acute, sub-acute, and chronic) and severity of stroke-induced
hemiparesis. The Interna-tional Classification of Functioning, Disability and
Health (ICF) allowed us to document functioning and disability outcomes
reported by the included studies across the levels of function (the body, the
person, the society).
2.2. Assessment of quality of studies
Two independent raters (SSh and MDB) assessed the methodo-logical
quality of the included articles by using the standardized validated PEDro
scale for the quality of controlled clinical trials [20], an 11-item scale [21]
previously used in systematic reviews [22], with total scores ranging from 0
to 10. Agreement in quality assessment on PEDro rating between evaluators
was measured by the Kappa statistic, with 95% confidence intervals (CIs). A
kappa of 1 ndicates perfect agreement, and a kappa of 0 indicates agree-ment
equivalent to chance.
2.3. Data analysis
The initial screening step involved examining the article title and major
key words, then abstracts and full texts.
One author (SSh) extracted the relevant data from each article and
recorded them on standardized Microsoft Excel spreadsheets. To ensure
accurate copying of the data, a second reviewer (MDB) independently
checked the information in the forms with the related articles. The data
recorded were the study design, participant characteristics, type of
intervention and co-interven-tion, region of the body to which the stimulus
was applied, and the mean pre-and post-intervention values for each measure.
 S. Sharififar et al. / Annals of Physical and Rehabilitation Medicine 61 (2018) 339–344
2.4. Statistical analysis
The meta-analysis involved use of SAS v9.4 (SAS Institute, Inc. Cary,
NC). We used a studies at random approach, which estimated the patient-level
effect size by assigning the weight of each point estimate based on the total
sample size [23]. We chose this method given limitations to the common used
random-effects model.
The mean effect sizes of the outcome measures were calculated by using
the information provided in the articles. When the number of trials was > 5,
the difference in means (MD; post-intervention mean values minus pre-
intervention mean values) in the experimental and comparison groups was
considered the effect size of each of the trials [23]. When the number of
studies was small (< 5), we used a conservative t-approximation method
[19,23]. Both periods of crossover trials were included in the analyses [24].
Secondary analyses stratified data by chronicity, comparing participants < 6
months post-stroke with those > 6 months post-stroke for all outcomes with
sufficient data. Two-sided P < 0.05 was considered statistically significant.
3. Results
The results of the systematic search are summarized in Fig. 1. Among the
676 articles identified, 189 were considered for potential inclusion; reports of
11 were finally included.
*
Fig. 1. Flow of studies in the review. Papers may have been excluded for failing to meet more than one inclusion criteria. rTMS, repetitive transcranial magnetic stimulation.
3.1. Characteristics of studies
The mean (SD) PEDro quality score for the 11 selected reports was
7.18/10 (1.32, range 5–9). The Kappa score was 0.36 (95% CI 0.05–0.67) (P
< 0.00).
Characteristics of the included studies are in Table 1. The meta-analysis
included 11 studies that investigated the effects of electrical sensory input
without motor recruitment across levels of function. These studies included
440 participants with stroke (the ratio of males to females 2:1). The mean
(SD) age of participants was 61.28 years (6.9, range 49–72), with mean (SD)
post-stroke period 34.99 months (32.84). Each study had a small sample size:
< 50 individuals in each group (range 14–67 total partici-pants). The single
controlled trial examined the effectiveness of e-stim using sock or glove
electrodes with an intensity that was sufficient for sensory level but
insufficient to produce a tetanic muscle contraction [25]. The remaining
studies used randomized controlled trial designs, repeated measures, or
crossover designs. Most of the studies usually validated and justified their
measu-rements and outcomes and described the intervention effectively. In
most studies, the description of the baseline characteristics was clear, and the
groups did not differ significantly in terms of certain characteristics.
However, the studies failed to screen for specific deficits such as type,
location, chronicity, and severity of stroke. The associated dysfunction in the
studies’ inclusion criteria resulted in non-tailored treatments and the treatment
of only one of the many deficits manifested in the population under the study.
342 S. Sharififar et al. / Annals of Physical and Rehabilitation Medicine 61 (2018) 339–344

Table 1
Summary of included studies.

Study Design Participants Intervention Outcome measures

a
Chen, Chen et al., RCT n = 24 All subjects received standard physical, Impairment = Fmax/Max (%) H-
b
2005 [35] Sex = 10F occupational, and speech therapy interventions reflex latency (ms)
Age (yr) = 57 as per routine of the inpatient stroke Activity = 10 m walking time (s)
Mean (SD) chronicity rehabilitation program. Exp = ES of paretic
(mo) = 23.5 (1.6) gastrocnemius
Max constant intensity without inducing
muscle contraction, 0.2 ms pulse width at 20 Hz
20 min (*)/day 6/wk 4 wk
Con = stimulation intensity at zero
Hui-Chan, Ng, and RCT home-based n = 52 Exp = TENS over paretic leg on 4 acupuncture Impairment = composite spasticity
Mak, 2009 [33] Sex = NR points scale, maximum voluntary
Age (yr) = 56 2-3 times sensory threshold, 0.2 ms square contraction for plantar and
Mean (SD) chronicity (yr) = 4.7 pulses at 100 Hz dorsiflexion
(3.4) 60 min (*)/day 5/wk 4 wk Activity = Timed Up and Go test,
Con = placebo 6 min walk test, gait velocity (m/s)
c
Both = FRE was followed by TENS/placebo Follow up = 0, 4 weeks
Mukherjee, McPeak RCT cross-over n = 14 Exp = Electro-acupuncture of paretic arm with Impairment = modified Ashworth
et al., 2007 [34] Mean (SD) age (yr) = 63.1 (1.7) unpleasant but tolerable intensity at 2 Hz for the wrist and the index finger
Sex = 6F 40 min (*)/day 2/wk 6 wk flexor and extensors, average speed
Mean (SD) chronicity (yr) = 9.4 Both = active-assisted, isokinetic, and isometric dependent reflex torque at the
(2.5) strengthening 4 different angular velocities:
30 min (*)/day 2/wk 20,45,60,75
Ng and Hui-Chan RCT home-based n = 41 Exp = TENS over paretic leg on 4 acupuncture Impairment = composite spasticity
2007 [26] Mean (SD) age (yr) = 55.9 (1.1) points scale, maximum voluntary
Sex = 8F 2-3 times sensory threshold, 0.2 ms square contraction for plantar and
Mean (SD) chronicity (yr) = 4.8 pulses at 100 Hz dorsiflexion
(0.5) 60 min (*)/day 5/wk 4 wk Activity = gait velocity (m/s)
Con = placebo Follow up = 0, 4 weeks
d
Both =TENS/placebo followed by FRE
Ng and Hui-Chan RCT home-based n = 52 Exp = TENS over paretic leg on 4 acupuncture Activity = Timed Up and Go test,
2009 [27] Mean (SD) age (yr) = 57.3 (1.1) points 6 min walk test, gait velocity (m/s)
Sex = 11F 2-3 times sensory threshold, 0.2 ms square Follow up = 0, 4 weeks
Mean (SD) chronicity (yr) = 4.5 pulses at 100 Hz
(0.4) 60 min (*)/day 5/wk 4 wk
Con = placebo
d
Both = FRE was followed by TENS/placebo
Park, Seo et al., RCT n = 29 Exp = ES of paretic leg over lateral and medial Impairment = modified-Ashworth
2014 [28] Mean (SD) age (yr) = 71.2 (0.6) quadriceps and gastrocnemius 0.01 mA up to for calf muscles, balance; anterior-
Sex = 9F 90% amplitude using sub sensory threshold, posterior and mediolateral sway,
Mean (SD) chronicity 200 ms at 100 Hz gait analysis using Opto-gait,
(mo) = 18.6 (0.4) 30 min (*)/day 5/wk 6 wk cadence, paretic step and stride
Con = placebo lengths
Both = general exercise program (ROM training, Activity = Timed Up and Go test
functional mat training, gait training each
10 min)
Peurala, Pitkanen CT n = 67 Exp = ES of paretic hand or foot Impairment = modified Ashworth,
et al., 2002 [25] Mean (SD) age (yr) = 54.4 (1.1) glove or sock electrode monophasic constant limb skin sensation somatosensory
Sex = 18F cutaneous twin pulses just below sensory evokes potentials
Mean (SD) chronicity (yr) = 3.3 threshold at 50 Hz Activity = walking speed (m/s)
(1.1) 20 min 2(*)/day 3 wk
Con = placebo
Both = individual PT without any specific
approach
Tekeoglu, Adak RCT n = 60 Exp = ES of the paretic hand over triceps brachii Impairment = Ashworth for the
et al., 1998 [29] Mean (SD) age (yr) = 54.1 (0.8) and the paretic leg over common peroneal elbow flexors, knee and ankle
Sex = 29F nerve Activity = Barthel index
Mean (SD) chronicity Sensory threshold at the bearable pain level
(mo) = 42.5 (1.5) with square pulses of 0.2 ms at 100 Hz
30 min (*)/day 5 day/wk 8 wk
Con = placebo
Both = Todd-Davis exc for 40 min in the
morning and afternoon
Yan 2002 [30] RCT n = 33 Exp = ES of the paretic lower extremity Impairment = max voluntary
Mean (SD) age (yr) = 70.8 (0.9) 20-30 mA at 2 to 3 times sensory threshold contraction and torque of ankle
Sex = 17F 0.3 ms at 30 Hz dorsi/plantar flexion,
Chronicity (wk) = 5.6 60 min (*)/day 5/wk 3 wk proprioception threshold of the
Con = placebo or no treatment knee joint
Both = standard rehabilitation including both Activity = Timed Up and Go test
PT and OT each lasting 60 min Follow up = 0, 5 weeks
Yan and Hui-Chan RCT n = 38 Exp = ES of the paretic lower extremity Impairment = max voluntary
2009 [31] Mean (SD) age (yr) = 70.6 (1.3) 0.2 ms at 100 Hz within the subject’s tolerance contraction torque (Nm),
Sex = 19F level on 3 lower-extremity acupuncture points Composite spasticity score
Mean (SD) chronicity 60 mins (*)/day 5/wk 3 wk Activity = Timed Up and Go Test
(day) = 9.5 (0.6) Con = placebo or no treatment Follow up = 0, 5 weeks
Both = standard rehabilitation including both
PT and OT each lasting 60 min
 S. Sharififar et al. / Annals of Physical and Rehabilitation Medicine 61 (2018) 339–344 343

Table 1 (Continued )

Study Design Participants Intervention Outcome measures

Yavuzer, Oken RCT n = 30 Exp = ES of the paretic lower extremity Impairment = modified-Ashworth,
et al., 2007 [32] Mean (SD) age (yr) = 63.1 (1.7) 10 mA below palpable contraction, duty cycle gait kinematics
Sex = 14F 10 s on/10 s off 240 ms pulse width 240 ms pulse Activity = lower extremity motor
Mean (SD) chronicity (mo) = 3.4 width asymmetric biphasic rectangular at recovery, walking velocity (m/s)
(0.4) 35 Hz Participation = FIM
30 min(*)/day 5/wk 4 wk
Con = placebo
Both = Conventional stroke rehabilitation
program 2 to 5 hr (*)/day 5/wk 4 wk
CT: controlled trial; BL: baseline; Con: control group; ES: electrical stimulation; Exp: experiment group; F: female; FIM: functional independence measure; FRE: functional
resistance exercise; NA: not applicable; max: maximum; mo: months; ROM: range of motion; OT: occupational therapy; PT: physiotherapy; wk: week; yr: year; TENS:
transcutaneous electrical nerve stimulation.
a Standard stroke rehabilitation interventions such as neuromuscular re-education, RCT, randomized controlled trial; ROM, strengthening, neuromuscular facilitation, functional training, and use of
physical modalities and adaptive equipment as indicated.
b
Amount of the inhibition of the H reflex during vibration, excitability of soleus stretch reflex in terms of latency, onset angles and magnitude.
c
FRE included (1) loading exercise on the affected leg; (2) stepping-up exercise with the affected leg; (3) stepping-down exercise with the unaffected leg; (4) heel lifts from a dorsiflexed position in
standing and 2 functional training; (5) standing up from a chair, walking a short distance, and returning to the chair; and 6) walking with rhythmic
auditory cues generated by a metronome.
d
The physiotherapist provided standardized progression by using higher wooden blocks when subjects could perform the weight-bearing exercises 20 times without compensatory movement and
by increasing the number of repetitions completed within 10 min. Walking was progressed by increasing its speed.

Table 2
Summary effect sizes of combined sensory and motor inputs.

ICF level Outcomes N/n MD 95% CI P-values

Activity Timed Up and Go test (sec) 4/171 7.87* 7.08 to 22.82 0.19
Timed Up and Go test (sec), chronic 3/133 3.51 3.05 to 3.98 0.00
Walking ability (m/s) 7/266 0.04 0.02 to 0.11 0.14
Walking ability (m/s), chronic 5/184 0.03 0.05 to 0.11 0.28
Body impairment Ashworth/modified Ashworth/CSS 8/487 0.83 1.77 to 0.10 0.07
Ashworth/modified Ashworth/CSS, chronic 6/182 0.17 0.85 to 0.51 0.53

Dorsiflexion torque (N.m) 4/158 2.44 0.26 to 4.63 0.03

Peak plantarflexion torque (N.m) 3/126 1.05 4.52 to 6.62 0.50
ICF: International classification of functioning; disability and health; CSS: Composite Spasticity Scale; MD: mean difference; N: number of studies; n: number of participants.
* P < 0.05
treatment. A common problem in all these studies was the small sample size:
< 30 participants in each group. Thus, the studies lacked the power necessary
The methods, amount of exposure to the e-stim, and associated exercise to assess the statistical significance of the sensory inputs.
protocols (passive versus active) varied among studies. Three of the included
studies investigated TENS, and the remaining studies investigated peripheral,
sensory level stimulation modali-ties over a peripheral nerve and its A wide range of outcome measures was used, so we considered the effects
distributed muscle supply, or acupuncture areas. of sensory input by grouping 5 outcome measures in terms of impairment on
the ICF: the activity (Timed Up and Go test
Ten studies investigated electrical sensory input with routine therapy or
active treatment of specific standardized isotonic training with routine
therapy. The participants received e-stim for a median of 20 sessions (range
12–61; interquartile range 6.75) over 3 to 8 weeks. The comparator group was
placebo with routine therapy or active treatment of specific standardized
isotonic training [26–33]. One study used routine therapy alone in the
comparison group [34]. One study used routine therapy before e-stim
compared to placebo [35]. Another study compared the effects of adding
electrical sensory input to routine therapy before active treatment of specific
standardized isotonic training [27].

None of the included studies performed blinded or concealed allocations.

Blinding participants to the exercise intervention is difficult in rehabilitation
studies. Almost all studies used sham or sub-sensory threshold stimuli in
controls. In half of the studies, evaluators who were blinded to the groups’
assignment evaluated the baseline and post-intervention outcomes. Only a
few studies included a therapist blinded to the groups’ assignment to deliver
[TUG] and walking ability) and the body impairment (Ashworth/ modified
Ashworth scale or Composite Spasticity Score, dorsi-flexion and peak plantar
flexion torque) (Table 2). An insufficient number of studies reported common
outcomes during the participation. The additional benefit of using sensory
input as an adjunct to routine therapy appeared seemed to be relatively high
for lower- extremity impairment (t = 2.44, P = 0.03) and functional mobility (t
= 3.51, P = 0.0009). We found significant effects associated with increased
dorsiflexion torque and decreased time to complete the TUG in a chronic
subgroup of patients post-stroke. The sapsticity score was reduced but not
significantly (

4. Discussion

Our findings from this systematic review and meta-analysis show that
electrical sensory stimulation without muscle contrac-tion can help improve
post-stroke lower-extremity muscle function and functional mobility before or
with routine rehabili-tation for hemiparesis after stroke. An insufficient
number of studies reported common outcome measures. We used the t-
approximation method to calculate the effect sizes for 5 of 13 of the reported
outcomes, which were pooled from more than 3 studies per outcome measure.
The variability in methodology, in addition to the low power to find real
effects in many of the trials, may have contributed to these limited findings.

Two studies showed enhanced dorsiflexion torque production with e-stim

applied to the peripheral nerve and acupuncture points as compared with
placebo during the acute and chronic stages after stroke. Patients in both
studies received 60 min of e-stim with active exercise 4 to 6 hr/day every
weekday for 3 to 4 weeks. Increases in primary somatosensory cortical area
by
344 S. Sharififar et al. / Annals of Physical and Rehabilitation Medicine 61 (2018) 339–344
[8] Ridding MC, et al. Changes in muscle responses to stimulation of the motor cortex
sensory stimulation may have been caused by sensory cortical long-term induced by peripheral nerve stimulation in human subjects. Exp Brain Res 2000;131:135–43.
potentiation processes that led to skill development [36,37]. This is a [9] Tinazzi M, et al. Long-lasting modulation of human motor cortex following prolonged
relatively short duration of e-stim applied to the peripheral nerve and transcutaneous electrical nerve stimulation (TENS) of forearm
acupuncture points that can be easily used in patients post-stroke in the
therapy setting or at their homes.
Two studies showed beneficial effects of the TUG of sensory input
combined with passive and active exercises or routine therapy as compared
with placebo. The TUG includes a series of motor tasks that also demand
muscle strength and movement coordination in addition to balance control.
Improvements in TUG time have practical significance. For people in the
chronic phase after stroke who received TENS in addition to active exercises,
the mean time to get up from a chair and walking speed changed from 25 to
19 sec. These participants were more likely independent in the transfer tasks
needed for activities of daily living [38]. Because TENS could be taught
easily, it represents a low-cost treatment modality that could be readily
applied to patients after stroke and help in promoting this treatment.

The placebo protocols in the included studies involved the use of

electrodes placed over acupuncture points or non-motor areas and delivered
no or subliminal stimuli. Although this is encourag-ing evidence to support
the benefits of sensory input, we cannot definitively conclude that the
addition of e-stim to rehabilitation was a superior intervention given that no
study evaluated the believability of the placebo or determined the
expectations of the effectiveness of the intervention. Studies of other
rehabilitation interventions indicate that baseline differences in the
believability of a placebo or expectations for treatment effectiveness have
potential to confound the results [39,40].

Several problems were identified, such as variability in how researchers

delivered somatosensory stimulations with the associated exercise protocols
(passive versus active) and variabili-ty in the reported outcomes. The optimal
dosage needs to be addressed in future studies. Also, researchers and
clinicians should use measurements that are specific to both the residual
deficits of the post-stroke patient and adjust treatment parameters based on
augmenting motor learning and motor function.

In summary, our systematic review and meta-analysis of 11 studies that

augmented rehabilitation with electrical sensory stimulation without motor
recruitment showed benefits for improving lower-extremity impairment and
function. Future studies could consider measures of impairment and function
with stronger, more direct associations between the two.

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