One high quality study investigated the relationship between biofeedback interventions and the ability to perform activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis. post-stroke (Intiso et al. 1994). Using the Barthel Index as a measure of ADL performance, this study found no significant differences between groups. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More explored the use of biofeedback for standing balance training and its impact on ADL, as assessed by the Functional Independence Measure (Heller et al. 2005). There were significant improvements for both groups however no observed differences between the treatment and control group.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that biofeedback interventions in the lower extremity are not effective in the recovery of functional performance in activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis. post-stroke.

Two RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More have investigated the efficacy of biofeedback interventions for improving dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
strength post-stroke. One high quality study (Burnside et al. 1982) found a significant difference between groups, suggesting that biofeedback interventions in the lower extremity help to improve dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
strength post-stroke. One fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Basmajian et al. 1975) also tested strength of dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
and observed significant differences between groups.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
strength can be improved as a result of biofeedback treatment in the upper extremity post-stroke.

Two RCT studies investigated the relationship between biofeedback interventions and functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
post-stroke. One fair quality study (Mandel et al. 1990) found that walking speeds increased more rapidly for patients treated with a combination of biofeedback and conventional physical therapy. One high quality study (Intiso et al. 1994) also noted a significant improvement in walking ability for those who received biofeedback treatment. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More explored the use of biofeedback for standing balance training and its impact on functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
, as assessed by the Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Categories and walking speed (Heller et al. 2005). There were significant improvements for both groups on these assessments however no observed differences between the treatment and control group.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that biofeedback therapy in the lower extremity improves functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
post-stroke.

Two high quality RCTs investigated the use of biofeedback treatment in the lower extremity for enhancing gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
recovery post stroke and noted significant differences between groups. Both Morris et al.(1992) and Burnside et al. (1982) found gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
recovery was significantly improved for those who received biofeedback interventions. A high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Cozean et al. 1988) found greatest gains in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
cycle and stride length for the participants that had been exposed to biofeedback treatments in combination with functional electrical stimulation (FES) therapy. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More explored the use of biofeedback for standing balance training and its impact on gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
pattern, as assessed by the gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
spatiotemporal parameter using the Vicon© system (Heller et al. 2005). There were significant improvements for both groups however no observed differences between the treatment and control group.

Conclusion: There is strong evidence from three high quality RCTs (Level 1a) that biofeedback improves gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
recovery post-stroke.

One fair quality study (Engardt et al. 1993) investigated the effect of biofeedback interventions for improving postural control post-stroke, using measures of sit-to-stand and rising to sit-down as primary outcomes. Significant improvements were noted in favour of biofeedback treatment. Another fair quality study (Wong et al. 1997) found that biofeedback improved the ability to maintain stance post-stroke. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More explored the use of biofeedback for standing balance training and its impact on postural control, as assessed by the Postural Assessment Scale for StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More (PASS) (Heller et al. 2005). There were significant improvements for both groups on these assessments however no observed differences between the treatment and control group. One important finding was that the experimental group showed significant improvements in the duration of reception double stance on the paretic limb as compared to the control group.

Conclusion: There is limited (Level 2a) evidence to suggest that biofeedback interventions are effective in improving postural control post-stroke as noted in three fair quality studies.

Two high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More studies investigated the effect of biofeedback on range of motion in the lower extremity and all observed significant differences between groups. Burnside et al. (1982) noted significant improvements in range of motion for those who received biofeedback treatment. In a similar investigation, Bradley et al. (1998) found that active movement was significantly increased in patients that had received a combination of standard physiotherapy and biofeedback. One fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Basmajian et al. 1975) found a significant improvement in the range of motion of dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
in favour of the treatment group that received combined biofeedback with standard physical therapy. A recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More explored the use of biofeedback for standing balance training and its impact on motor recovery, as assessed by the Fugl-Meyer Motor Recovery Scale (Heller et al. 2005). There were significant improvements for both groups however no observed differences between the treatment and control group.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that biofeedback interventions improve range of motion (ROM) post-stroke.

One high quality study (Intiso et al. 1994) investigated the relationship between biofeedback interventions in the lower extremity and spasticity post-stroke. While the primary measure used to assess spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was the Ashworth Scale, no significant differences were noted between groups. Another recently published fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More explored the use of biofeedback for standing balance training and its impact on spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, as assessed by the Ashworth Scale (Heller et al. 2005). There were no significant improvements for both groups, as well as no observed differences between the treatment and control group.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
is not improved as a result of biofeedback interventions in the lower extremity.

Three high quality RCTs and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More have investigated the relationship between biofeedback treatment upper extremity function post-stroke. Two studies, Basmajian et al. (1982) and Basmajian et al. (1987) investigated the effect of biofeedback compared to physical therapy using the biofeedback approach. No significant differences were observed in upper extremity function, as assessed using the Upper Extremity Function Test. Similar results were found in a similar study by Prevo et al. (1982) as assessed using a non-standardized functional test.

One high quality RCT (Crow et al. 1989) compared the use of EMG biofeedback therapy to sham biofeedback. The treatment group scored significantly higher on the Action Research Arm Test and on the Brunnstrom-Fugl Meyer Test. However, these results were not maintained at follow up.

Conclusion: There is conflicting evidence (Level 4) from three high quality RCTs and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More, that biofeedback interventions are effective for improving upper extremity function post-stroke. However, at follow-up there is strong evidence that biofeedback interventions are not effective for improving upper extremity function post-stroke.

Two high quality RCTs investigated the relationship between biofeedback treatment and manual dexterity post-stroke. In the first, Basmajian et al. (1982) examined manual dexterity and biofeedback using the Minnesota Rate of Manipulation test. No improvements in manual dexterity were noted for either group. This finding was substantiated by another high quality RCTs Basmajian et al. (1987) that also investigated biofeedback interventions and manual dexterity. Results were similar to those found in the previous study, such that no significant differences were noted when the Finger Oscillation Test was used as a measure of manual dexterity.

Conclusion: There is strong (level 1a) evidence from two high quality RCTs, that biofeedback interventions are not effective for improving manual dexterity post-stroke.

Two RCTs have investigated the efficacy of biofeedback treatment for improving range of motion (ROM) in the upper extremity post-stroke. One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Hurd et al. 1980) investigated the relationship between biofeedback and range of motion using measures of active range of motion and muscle activity in the upper extremity. No significant differences were noted. One fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Greenberg and Fowler, 1980) also examined the use of biofeedback methods for improving the active elbow extension ROM. No significant improvements were reported in either group.

Conclusion: There is moderate evidence (Level 1b) from one high and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More, that biofeedback interventions are not effective for improving range of motion in the upper extremity post-stroke.

Two fair quality RCTs (MacDonell et al., 1994, Kojovic et al., 2009) and one quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Solopova et al., 2011) have investigated the effectiveness of FES on ADLs in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first fair quality RCT (MacDonell et al., 1994) investigated the effectiveness of FES for improving performance in activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living in 38 patients with acute stroke with weakness of dorsiflexion Grade 4 or less measured by the Medical Research Council Scale (MRC). The treatment group received FES five times a week for four weeks producing ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
of the affected leg in addition to standard physical therapy, while the control group received standard physical therapy alone. Outcomes were measured at four weeks (post-treatment) and at eight weeks. No significant between-group difference was found on performance of activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living at post-treatment (four weeks) or at the eight week follow-up as measured by the Barthel Index.

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Kojovic et al., 2009) investigated the effectiveness of FES for improving ADL in 13 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More who were able to ambulate with a single cane or hand support. The patients were randomly assigned to either the functional electrical therapy (FET) group, or a control group. Both FET and control groups participated in a standard rehabilitation program and walking sessions. During the walking sessions, patients used the tripod cane or were physically assisted by the therapist in addition to instructions given by the therapist on how to improve their walking pattern. The FET group used a sensor-driven electrical stimulator device to stimulate four muscle groups: quadriceps, hamstring, soleus and tibialis anterior of the paretic leg in order to improve knee flexion/extension and ankle flexion/extension during walking. Outcomes were assessed at post-treatment (four weeks). At the end of the four week intervention, the Barthel Index score was significantly higher (reflecting better functioning) in the FET group compared to the control group.

The quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Solopova et al., 2011) pseudo-randomized patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES with assisted passive/active locomotor-like leg movements and progressive limb loading (FES group) or conventional rehabilitation (control group). FES was applied to the soleus, tibialis anterior, hamstring, quadriceps, hip adductors, gluteus maximus and medial gastrocnemius muscles as participants performed leg movements while semi reclined on a tilt table. ADL function was measured by the Barthel Index. At post-treatment (2 weeks) a significant between-group difference in ADL function was seen in favour of the FES group compared to the control group.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT and 1 quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study that FES is more effective than conventional rehabilitation in improving ADL performance in patients with acute stroke.

Note: However, another fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that FES was not more effective than conventional rehabilitation alone in improving ADL performance among patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Both fair quality RCTs had small sample sizes, which may in part contribute to different results between studies.

One fair quality RCT (MacDonell et al., 1994) has investigated the effectiveness of FES for improving electrophysiological functioning in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (MacDonell et al., 1994) investigated the effectiveness of FES for improving electrophysiological functioning in 38 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and weakness of dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
Grade 4 or less as measured by the Medical Research Council Scale (MRC). The treatment group received FES producing ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
of the affected leg in addition to standard physical therapy and the control group received standard physical therapy alone. Outcomes were measured at post-treatment (four weeks) and at eight weeks. No significant between-group difference was found on any electrophysiological measure at post-treatment or at the eight week follow-up as measured by foot tap frequency, duration and frequency of electromyographic (EMG) burst activity in tibialis anterior, H max/ M max ratio in gastocnemius, degree of vibratory inhibitionThe ability to suppress automatic actions that are inappropriate in a given context that interfere with a certain behavior (Grieve & Gnanasekaran, 2008)
of the H reflex, and F mean/ M max ratio using responses from the flexor hallucis brevis.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES in combination with standard physical therapy is not more effective than standard physical therapy alone for improving electrophysiological functioning in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Ferrante et al., 2008, Yan et al., 2005) and one quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Solopova et al., 2011) investigated the effectiveness of FES for improving maximum isometric voluntary contraction in patients with acute stroke.

The first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Ferrante et al., 2008) investigated the use of FES for improving MIVC in 20 patients with acute stroke. The participants were randomized to receive either (1) standard rehabilitation and FES-cycling (5 minutes of passive cycling, 10 minutes of FES, 5 minutes of passive cycling, 10 minutes of FES and 5 minutes of passive cycling); or (2) standard rehabilitation alone. Outcomes were measured at post-treatment (four weeks). Following four weeks of treatment, a significant between-group difference in favour of the group receiving FES-cycling was found on the quadriceps isometric maximum force as measured by maximal voluntary contraction.

The second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Yan et al., 2005) investigated the effectiveness of FES on maximum isometric voluntary contraction (MIVC) of ankle dorsiflexors and planter flexors in 46 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Patients received either (1) standard rehabilitation and FES-cycling; (2) standard rehabilitation and placebo stimulation (placebo); or (3) standard rehabilitation alone (control) for three weeks. All participants were assessed on MIVC and EMG co-contraction ratio during ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
and plantarflexion at one, two, three and 8 weeks. During ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
, percent increases in MIVC torques and integrated EMG of the FES group were significantly larger than those of the control group from week one onward, and significantly larger than the placebo group at week three only. Also, the EMG co-contraction ratio during dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
of the affected ankle showed a significantly greater reduction in the FES group compared to the other groups from week one or two onward, reflecting greater improvement. For ankle plantarflexion, a significant difference was found in favour of the FES group only at week three only compared to the other groups. No significant between group difference was found on either measure at the 8 week follow-up.

The quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Solopova et al., 2011) pseudorandomized patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES with assisted passive/active locomotor-like leg movements and progressive limb loading (FES group) or conventional rehabilitation (control group). FES was applied to the soleus, tibialis anterior, hamstring, quadriceps, hip adductors, gluteus maximus and medial gastrocnemius muscles as participants performed leg movements while semi reclined on a tilt table. At post-treatment (2 weeks) there were significant between-group differences in maximum isometric voluntary contraction of the paretic flexor and extensor muscles and the nonparetic extensors, in favour of the FES group compared to the control group. There was also a significant between-group difference in EMG patterns of the rectus femoris and biceps femoris muscles during knee flexion of the ipsilateral leg, in favour of the intervention group compared to the control group.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and one quasi-experimental studyAn experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
that FES in addition to standard rehabilitation is more effective than standard rehabilitation alone for improving maximal isometric voluntary contraction in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Note:mprovements were not maintained beyond follow-up in one of the high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More.

One high quality RCT (Ferrante et al., 2008) has investigated the effectiveness of FES for improving mobility in patients with acute stroke.

The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Ferrante et al., 2008) examined the effectiveness of FES on mobility in 20 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Patients were randomized to receive either (1) standard rehabilitation and FES-cycling (5 minutes of passive cycling, 10 minutes of FES, 5 minutes of passive cycling, 10 minutes of FES and 5 minutes of passive cycling; or (2) standard rehabilitation alone. Outcomes were measured at post-treatment (four weeks). No significant between-group differences were found for mobility of the ankle, or knee and hip joint during voluntary movement, as measured by the Motricity Index (MI) following 4 weeks of treatment. Due to the small sample size, failure to find group differences may have occurred because of type 2 error.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES in addition to standard rehabilitation is not more effective than standard rehabilitation alone for improving mobility in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Ferrante et al., 2008) investigated the use of FES for improving motor control in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The high quality RCT (Ferrante et al., 2008), examined the effectiveness of FES on motor control in 20 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. The participants were randomized to receive either (1) standard rehabilitation and FES-cycling (5 minutes of passive cycling, 10 minutes of FES, 5 minutes of passive cycling, 10 minutes of FES and 5 minutes of passive cycling); or (2) standard rehabilitation alone. Patients were asked to perform sit to stand trials at 3 different speeds (patient selected, one slower than patient selected, and one faster than patient selected) to test motor control. Outcomes were measured at post-treatment (four weeks). Following four weeks of treatment, a significant between-group difference in favour of the FES-cycling group was found on the percentage ratio between the slow and self selected speeds. The percentage ratio between fast and self selected speed failed to reach significance.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES in addition to standard rehabilitation is more effective than standard rehabilitation alone for improving motor control in patients with acute stroke.

Two fair quality RCTs (MacDonell et al., 1994, Kojovic et al., 2009) and one quasi-experimental design study (Solopova et al., 2011) have examined the effectiveness of FES for improving motor function in patients with acute stroke.

The first fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (MacDonell et al., 1994) investigated the effectiveness of FES for improving motor function in 38 patients with acute stroke with weakness of dorsiflexion Grade 4 or less measured by the Medical Research Council Scale (MRC). The treatment group received FES five times a week for four weeks producing ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
of the affected leg in addition to standard physical therapy, while the control group received standard physical therapy alone. Outcomes were measured at post-treatment (four weeks) and at eight weeks. No significant between-group difference was found in motor function at post-treatment or at eight week follow-up measured by the Fugl-Meyer Lower Extremity Motor Assessment Scale.

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Kojovic et al., 2009) investigated the effectiveness of FES for improving motor function in 13 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More who were able to ambulate with a single cane or hand support. The patients were randomly assigned to either the functional electrical therapy (FET) group, or a control group. Both FET and control groups participated in a standard rehabilitation program and walking sessions for four weeks. During the walking sessions, patients used the tripod cane or were physically assisted by the therapist in addition to instructions given by the therapist on how to improve their walking pattern. The FET group used a sensor-driven electrical stimulator device to stimulate four muscle groups: quadriceps, hamstring, soleus and tibialis anterior of the paretic leg in order to improve knee flexion/extension and ankle flexion/extension during walking. At the end of the 4 week intervention, the FET group had significantly higher scores on the Fugl-Meyer Lower Extremity Motor Assessment Scale compared to the control group.

The quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Solopova et al., 2011) pseudorandomized patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES with assisted passive/active locomotor-like leg movements and progressive limb loading (FES group) or conventional rehabilitation (control group). FES was applied to the soleus, tibialis anterior, hamstring, quadriceps, hip adductors, gluteus maximus and medial gastrocnemius muscles as participants performed leg movements while semi reclined on a tilt table. Motor function was measured by the Fugl Meyer Assessment. At post-treatment (2 weeks) a significant between-group difference in motor function was seen in favour of the FES group compared to the control group. Significant between-group differences in motor function were also seen among subgroups of patients with paralysis, severe hemiparesis and pronounced hemiparesis, in favour of the FES group compared to the control group.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and 1 quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study that FES is more effective than conventional rehabilitation in improving motor function in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Note: However, another fair quality RCT found that FES was not more effective than conventional rehabilitation alone in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Both fair quality RCTs had small sample sizes, which may in part contribute to different results between studies.

One high quality RCT (Ferrante et al., 2008) has investigated the use of FES for improving muscle strength in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Ferrante et al., 2008) examined the effectiveness of FES on muscle strength in 20 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Patients were randomized to receive either (1) standard rehabilitation and FES cycling FES-cycling (5 minutes of passive cycling, 10 minutes of FES, 5 minutes of passive cycling, 10 minutes of FES and 5 minutes of passive cycling); or (2) standard rehabilitation alone for four weeks. No significant between group difference was found for muscle strength of the hemiplegic limb, as measured by the Upright Motor Control Test following 4 weeks of treatment. Due to the small sample size, failure to find group differences may have occurred because of type 2 error.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that FES in addition to standard rehabilitation is not more effective than standard rehabilitation alone for improving muscle strength of the hemiplegic limb patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Solopova et al., 2011) has investigated the effectiveness of FES on severity of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More in patients with acute stroke.

The quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Solopova et al., 2011) pseudorandomized patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES with assisted passive/active locomotor-like leg movements and progressive limb loading (FES group) or conventional rehabilitation (control group). FES was applied to the soleus, tibialis anterior, hamstring, quadriceps, hip adductors, gluteus maximus and medial gastrocnemius muscles as participants performed leg movements while semi reclined on a tilt table. StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More severity was measured by the National Institutes of Health StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Scale (NIHSS) and European Stroke Scale (ESS). At post-treatment (2 weeks) a significant between-group difference in scores was seen in favour of the FES group compared to the control group.

Conclusion: There is limited evidence (level 2b) from 1 quasi-experimental studyAn experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
that FES is more effective than conventional rehabilitation in improving severity of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Yan et al., 2005, Yeh et al., 2010) have investigated the effectiveness of FES for improving spasticity in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Yan et al., 2005) randomized patients to receive (1) standard rehabilitation and FES (FES group); (2) standard rehabilitation and placebo stimulation (placebo group); or standard rehabilitation alone (control group) for 3 weeks. SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was measured by the Composite Spasticity Scale (CSS). At 3 weeks (post-treatment) a significant between-group difference was found in favour of the FES group compared to the placebo group and the control group. No significant between-group difference was found at the 8 week follow-up.

A high quality cross-over design study (Yeh et al., 2010) randomized patients to one 20-minute session of cycling with FES or one 20-minute session of cycling without FES. The groups performed the opposite treatment on the second intervention day. Hypertonicity was measured by the Modified Ashworth Scale (MAS) and the pendulum testThis is a test for spasticity. The patient sits on a table and the examiner holds the patient’s foot with the knee as fully extended as possible. The examiner drops the leg, and a computer records the motion and vibration.
(relaxation index and peak velocity). Both treatments were found to improve hypertonia, as seen by significantly reduced MAS scores and significantly improved pendulum testThis is a test for spasticity. The patient sits on a table and the examiner holds the patient’s foot with the knee as fully extended as possible. The examiner drops the leg, and a computer records the motion and vibration.
scores from pre- to post-testing. After the second intervention day there were significant between-group differences in all measures of hypertonia, in favour of the FES group compared to the non-FES group.

Conclusion: There is strong evidence (level 1a) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and one high quality randomized cross-over design study that FES is more effective than standard rehabilitation alone for improving spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More in the short term.

One high quality RCT (Ferrante et al., 2008) has investigated the effectiveness of FES for improving trunk movement and balance in patients with acute stroke.

The high quality RCT (Ferrante et al., 2008), examined the effectiveness of FES on trunk movements and balance in 20 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Patients were randomized to receive either (1) standard rehabilitation and FES-cycling (5 minutes of passive cycling, 10 minutes of FES), 5 minutes of passive cycling, 10 minutes of FES and 5 minutes of passive cycling; or (2) standard rehabilitation alone for four weeks. No significant between group differences were found for trunk movement and balance, as measured by the Trunk Control Test (TCT) following four weeks of treatment. Due to the small sample size failure to find group differences may have occurred because of type 2 error.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES in addition to standard rehabilitation is not more effective than standard rehabilitation alone for improving trunk movement and balance in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Ferrante et al., 2008, Yan et al., 2005), one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (MacDonell et al., 1994) and one quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Solopova et al., 2011) have investigated the effectiveness of FES for improving walking ability in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Ferrante et al., 2008) investigated the use of FES for improving walking ability in 20 patients with acute stroke. The participants were randomized to receive either (1) standard rehabilitation and FES-cycling (5 minutes of passive cycling, 10 minutes of FES, 5 minutes of passive cycling, 10 minutes of FES and 5 minutes of passive cycling); or (2) standard rehabilitation alone for four weeks. Following four weeks of treatment, the group that received FES – cycling showed more improvement in a 50m walk test than the control group, however, the between group difference failed to reach statistical significance.

The second high quality RCT (Yan et al., 2005) investigated the effectiveness of FES for improving walking ability in 46 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Patients received either (1) standard rehabilitation or FES; (2) standard rehabilitation and placebo stimulation (placebo); or (3) standard rehabilitation alone (control) for three weeks. Outcomes were measured at one, two, three and 8 weeks. No significant between group difference was found for walking ability, measured by the Timed Up and Go (TUG) test at all periods of assessment.

The fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (MacDonell et al., 1994) investigated the effectiveness of FES for improving walking ability in 38 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and weakness in dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
Grade 4 or less as measured by the Medical Research Council Scale (MRC). The treatment group received FES producing ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
of the affected leg in addition to standard physical therapy and the control group received standard physical therapy alone for four weeks. Outcomes were measured at post-treatment and at eight weeks. No significant between-group difference was found in walking ability at post-treatment or at eight week follow-up as measured by the Massachusetts General Hospital Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Categories (MGH FAC) scale.

The quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Solopova et al., 2011) pseudorandomized patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES with assisted passive/active locomotor-like leg movements and progressive limb loading (FES group) or conventional rehabilitation (control group). FES was applied to the soleus, tibialis anterior, hamstring, quadriceps, hip adductors, gluteus maximus and medial gastrocnemius muscles as participants performed leg movements while semi reclined on a tilt table. Walking ability was measured by movement in the knee and ankle joints. At post-treatment (2 weeks) a significant difference in ankle range of movement was found in favour of the FES group compared to the control group, however there were no differences between groups in knee joint motion.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs, one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and and one quasi-experimental studyAn experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
that FES in addition to standard rehabilitation is not more effective than standard rehabilitation alone for improving walking ability in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One fair quality RCT (Kojovic et al., 2009) has investigated the effectiveness of FES for improving walking efficiency in patients with acute stroke.

In the fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More, (Kojovic et al., 2009) investigated the effectiveness of FES for improving walking efficiency in 13 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More who were able to ambulate with a single cane or hand support. The patients were randomly assigned to either the functional electrical therapy (FET) group, or a control group. Both FET and control groups participated in a standard rehabilitation program and walking sessions for four weeks. During the walking sessions, patients used the tripod cane or were physically assisted by the therapist in addition to instructions given by the therapist on how to improve their walking pattern. The FET group used a sensor-driven electrical stimulator device to stimulate four muscle groups: quadriceps, hamstring, soleus and tibialis anterior of the paretic leg in order to improve knee flexion/extension and ankle flexion/extension during walking. At the end of the 4 week intervention, a statistically significant decrease in the Physiological Cost Index (PCI) was observed between groups in favour of the FET group, reflecting more efficient walking in the treatment group.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES in addition to standard therapy is more effective than standard therapy alone for improving walking efficiency in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One fair quality RCT (Kojovic et al., 2009) has investigated the effectiveness of FES for improving walking speed in patients with acute stroke.

In the fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More, (Kojovic et al., 2009) investigated the effectiveness of FES for improving walking efficiency in 13 patients with acute stroke who were able to ambulate with a single cane or hand support. The patients were randomly assigned to either the functional electrical therapy (FET) group, or a control group. Both FET and control groups participated in a standard rehabilitation program and walking sessions for four weeks. During the walking sessions, patients used the tripod cane or were physically assisted by the therapist in addition to instructions given by the therapist on how to improve their walking pattern. The FET group used a sensor-driven electrical stimulator device to stimulate four muscle groups: quadriceps, hamstring, soleus and tibialis anterior of the paretic leg in order to improve knee flexion/extension and ankle flexion/extension during walking. At the end of the 4 week intervention, a statistically significant increase in favour of the FES group was found on mean walking velocity over a 6 meter walkway.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES in addition to standard therapy is more effective than standard therapy alone for improving walking speed in patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Tong et al., 2006) and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Granat et al., 1996) have investigated the effectiveness of FES on ADL in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The high quality RCT (Tong et al., 2006) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive (1) gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training using an electromechanical gait trainer with functional electric stimulation (EGT-FES), (2) gait training using an electromechanical gait trainer (EGT), or (3) conventional gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training (CGT, control) for four weeks. Performance of ADLs was measured using the Barthel Index. At 4 weeks (post-treatment) no significant between-group differences in ADLs were found.

One fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Granat et al., 1996) assigned patients with subacute and chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive four weeks of standard rehabilitation followed by four weeks of FES intervention. ADLs were measured using the Barthel Index. A significant improvement in ADLs was seen following the intervention period but not following the control period.

Conclusion : There is moderate evidence (Level 1b) from one high quality RCT that FES is not more effective than conventional or electromechanical gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training for improving performance of ADLs in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Note: However, there is limited evidence (level 2a) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES is more effective than standard rehabilitation in improving performance of ADLs in patients with subacute and chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Tong et al., 2006) has investigated the effectiveness of FES on balance in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

In the high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Tong et al., 2006) has investigated the effectiveness of gait training using an electromechanical gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
trainer with and without functional electric stimulation for improving balance in 46 patients with sub-acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. The patients were randomly assigned to receive either: (1) gait training using an electromechanical gait trainer with functional electric stimulation (EGT-FES); (2) gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training using an electromechanical gait trainer (EGT), or (3) conventional gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training (CGT, control) for four weeks. At the end of the four week intervention, no significant between group difference was found on the Berg Balance Scale.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that FES not more effective than electromechanical or conventional gait training alone for improving balance in patients with sub-acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality cross-over RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Bogataj et al., 1995) and 2 fair quality RCTs (Newsam et al., 2004, Winchester et al., 1983) has investigated the effectiveness of FES on maximum isometric voluntary contraction (MIVC) and contraction force in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The high quality cross-over RCT (Bogataj et al., 1995) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and severe hemiplegia to receive either (1) 3 weeks of multi-channel functional electrical stimulation (MFES) followed by 3 weeks of conventional physiotherapy; or (2) 3 weeks of conventional therapy followed by 3 weeks of MFES. GaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
stability was measured by the vertical components of ground reaction force and the trajectories of center of pressure (TCP) for each foot in the stance phase. A significant between-group difference in TCP was found, in favour of FES compared to conventional therapy.

The first fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Newsam et al., 2004) assigned patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive physical therapy and an electric stimulation facilitation program of the quadriceps (FES group), or physical therapy alone (control group). A significant between-group difference in supramaximal contraction torque of the quadriceps was found at 3 weeks (post-treatment) in favour of the FES group compared to the control group. There was no significant difference in MIVC of the quadriceps.

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Winchester et al., 1983) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive either standard physiotherapy and FES (FES group) or standard physiotherapy alone (control group). Contraction force was measured by knee extension torque. A significant between-group difference in contraction force was seen at 3 weeks (during training) and 4 weeks (post-treatment) in favour of the FES group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from 1 high quality cross-over RCT and 2 fair quality RCTs that FES is more effective than standard rehabilitation for increasing contraction force in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Note: However, there is limited evidence (level 2a) from 1 fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES is not more effective than standard rehabilitation for improving MIVC in patients with subacute stroke.

Two high quality RCTs (Yavuzer et al., 2006; Yavuzer et al., 2007) and 2 fair quality RCTs (Sabut et al., 2010b, Granat et al., 1996) examined the effectiveness of FES on gait kinematics and parameter in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Yavuzer et al., 2006) randomly assigned patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive either (1) conventional rehabilitation and neuromuscular electric stimulation applied to the tibialis anterior for 10 minutes per session (NMES group) or (2) conventional rehabilitation alone (control group). Gait kinematics were measured by walking velocity, step length, percentage of stance phase at the paretic side, sagittal plane kinematics of the pelvis, hip, knee and ankle, maximum ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
at swing and maximum ankle plantar flexion angle at initial contact. No significant between-group differences in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics were found at 4 weeks (post-intervention).

The second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Yavuzer et al., 2007) randomly assigned patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive (1) conventional rehabilitation and sensory-amplitude electric stimulation (SES) to the paretic leg, or (2) standard rehabilitation alone (control group). Gait kinematics were measured by walking velocity, step length, percentage of stance phase at the paretic side, sagittal plane kinematics of the pelvis, hip, knee and ankle, maximum ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
at swing and maximum ankle plantar flexion angle at initial contact. No significant between-group differences in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics were found at 4 weeks (post-treatment).

The first fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Sabut et al., 2010b) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive physical therapy and FES (FES group) or physical therapy alone (control) for 12 weeks. GaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics and parameters were taken as a measure of cadence, step length, step width, and toe-in toe-out. No significant between-group difference in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics and parameters were seen at 12 weeks (post-treatment).

The second fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Granat et al., 1996) assigned patients with subacute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive four weeks of conventional rehabilitation followed by four weeks of FES intervention. GaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics and parameters were taken as a measure of swing symmetry, heel strike and foot inversion. Group results at 11 weeks (post-treatment) revealed a significant improvement in foot inversion on linoleum, carpet and uneven ground, and swing symmetry on linoleum when receiving FES as compared to when not receiving FES.

Conclusion: There is strong evidence (Level 1a) from 2 high quality RCTs and 1 fair quality RCT that FES is not more effective than standard rehabilitation alone for improving gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics and parameters in patients with subacute stroke.

NOTE: However, 1 fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that FES was more effective than conventional rehabilitation in improving some aspects of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics and parameters in patients with subacute and chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One fair quality RCT (Winchester et al., 1983) has investigated the effect of FES on joint position sense in patients with subacute stroke.

The fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Winchester et al., 1983) investigated the effects of standard physiotherapy and FES (FES group) compared to standard physiotherapy alone (control group) in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. No significant between-group difference in joint position sense was found at 4 weeks (post-treatment).

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES and standard rehabilitation is not more effective than standard rehabilitation alone for improving joint position sense in patients with subacute stroke.

One pre-post design study (Sabut et al., 2010a) has investigated the effect of FES on metabolic function in patients with subacute and chronic stroke.

The pre-post design study (Sabut et al., 2010a) assigned patients with subacute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES and standard physical therapy. Metabolic function was measured by oxygen consumption, carbon dioxide production, heart rate and energy cost. A significant improvement in metabolic function was seen at 12 weeks (post-treatment).

Conclusion: There is limited evidence (level 2b) from one pre-post design study that FES and standard therapy is effective for improving measures of metabolic response in patients with subacute and chronic stroke.

One high quality RCT (Tong et al., 2006) investigated the effectiveness of FES on mobility in patients with sub-acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Tong et al., 2006) investigated the effectiveness of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training using an electromechanical gait trainer with and without functional electric stimulation for improving mobility in 46 patients with sub-acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. The patients were randomly assigned to receive either: (1) gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training using an electromechanical gait trainer with functional electric stimulation (EGT-FES), (2)gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training using an electromechanical gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
trainer (EGT), or (3) conventional gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training (CGT, control) for four weeks. At the end of the four week intervention, there was a significant between-group difference on the Elderly Mobility Scale (EMS) and on the Five-meter Walking Speed Test in the EGT and EGT-FES groups compared to controls, however no significant between-group differences were found on the Functional Independence Measure (FIM).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that FES in addition to gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training is more effective than gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training alone for improving mobility in patients with sub-acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Three high quality RCTs (Ambrosini et al., 2011; Bogataj et al., 1995; Tong et al., 2006) and 1 fair quality RCT (Sabut et al., 2010b) have investigated the effectiveness of FES for improving motor function in patients with subacute stroke.

The first high quality RCT (Ambrosini et al., 2011) randomized patients with subacute stroke or traumatic brain injury to either an FES-induced cycling group (FES group) or a placebo FES cycling group (control group). Function of the paretic limb was measured by the Upright Motor Control Test and by pedaling unbalance between the paretic and non-paretic legs, and motor power of the paretic limb was measured by the Motricity Index leg subscale. Significant between-group differences in all measures were seen at 4 weeks (post-treatment), in favour of the FES group compared to the control group. Results remained significant for the Upright Motor Control Test and the Motricity Index at follow-up (3-5 months post-treatment), in favour of the FES group.

The second high quality cross-over RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Bogataj et al., 1995) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and severe hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. to receive: (1) 3 weeks of multi-channel functional electrical stimulation (MFES) followed by 3 weeks of conventional physiotherapy; or (2) 3 weeks of conventional physiotherapy followed by 3 weeks of MFES. Functional motor status was assessed using the Fugl-Meyer Assessment. A significant improvement in motor function was seen at the middle of intervention (week 3), in favour of FES compared to conventional physiotherapy. However, no differences were seen at week 6.

The third high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Tong et al., 2006) investigated the effectiveness of gait training using an electromechanical gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
trainer with and without functional electric stimulation for improving motor impairmentLoss of strength and coordination, decrease in arm or leg movement
in 46 patients with sub-acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. The patients were randomly assigned to receive either: (1) gait training using an electromechanical gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
trainer with functional electric stimulation (EGT-FES), (2) gait training using an electromechanical gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
trainer (EGT), or (3) conventional gait training (CGT, control) for four weeks. At the end of the four week intervention, there was a significant between group difference on the Motricity Index Leg subscale (MI) in the EGT and EGT-FES groups compared to control group.

One fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Sabut et al., 2010b) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive physical therapy and FES (FES group) or physical therapy alone (control group) for 12 weeks. Motor function was measured by the Fugl-Meyer Assessment. No significant between-group differences were reported at 12 weeks (post-treatment), although the authors reported “better” improvement was made with FES.

Conclusion: There is strong evidence (level 1a) from 3 high quality RCTs that FES is more effective than control therapies (e.g. placebo intervention, conventional rehabilitation) in improving motor function in patients with subacute stroke. A fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More also reported improved motor function following FES, although between-group differences were not reported.

Two high quality RCTs (Yavuzer et al., 2007, Yavuzer et al., 2006) have investigated the effect of FES on motor recovery in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Yavuzer et al., 2007) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive either sensory amplitude electrical stimulation (SES group) or sham stimulation (control group). Motor recovery was measured using the Brunnstrom Stages of Motor Recovery. No significant between-group difference in motor recovery was seen at 4 weeks (post-treatment).

The second high quality RCT (Yavuzer et al., 2006) randomly assigned patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive either conventional stroke rehabilitation and neuromuscular electric stimulation to the tibialis anterior (NMES group) or conventional therapy alone (control group). Motor function was measured using the Brunnstrom Stages of Motor Recovery. No significant between-group difference in motor recovery was seen at 4 weeks (post-treatment).

Conclusion: There is strong (level 1a) evidence from 2 high quality RCTs that FES is not more effective than standard rehabilitation in improving motor recovery in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One fair quality RCT (Newsam et al., 2004) has investigated the effectiveness of FES on motor unit recruitment in patients with sub-acute stroke.

In the fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Newsam et al., 2004) investigated the effectiveness of FES on motor unit recruitment in 20 patients with sub-acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. The treatment group received an electric stimulation facilitation program of the quadriceps during gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training and weight-bearing activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
as well as standard physical therapy. The control group received standard physical therapy alone for three weeks. To measure the interpolated twitch and determine the motor unit recruitment, a short-duration, supramaximal electric stimulus was delivered at approximately three seconds into each of the maximal tests. After the three week intervention there was a significant between group difference in motor unit recruitment in favour of the patients that received FES.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that FES of the quadriceps in combination with standard physical therapy is more effective than standard physical therapy alone for increasing motor unit recruitment in the quadriceps in patients with sub-acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One fair quality RCT (Winchester et al., 1983) has investigated the effects of FES on muscle girth in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Winchester et al., 1983) investigated the effects of standard physiotherapy and FES (FES group) compared to standard physiotherapy alone in patients with subacute stroke. No significant between-group difference in quadriceps muscle girth was seen at 4 weeks (post-treatment).

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCT that FES is not more effective than standard rehabilitation in improving muscle girth of the quadriceps in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One fair quality RCT (Sabut et al., 2010b) and 1 pre-post design study (Sabut et al., 2010a) have investigated the effect of FES on muscle strength in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Sabut et al., 2010b) randomized patients with subacute stroke to receive physical therapy and FES (FES group) or physical therapy alone (control group) for 12 weeks. Muscle output was measured by the maximum value of the root mean square on electromyography analysis. No between-group comparisons in muscle strength were reported, however the authors state that the FES group showed a “better” improvement than the control group at 12 weeks (post-treatment).

The pre-post design study (Sabut et al., 2010a) assigned patients with subacute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES and standard physical therapy. Muscle strength was measured by the mean absolute value, root mean square, median frequency and median amplitude of the tibialis anterior muscle EMG signal. A significant effect of FES treatment on muscle strength was found at 12 weeks (post-treatment).

Conclusion: There is limited evidence (level 2b) from 1 fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and 1 pre-post design study that FES is effective improving muscle strength in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Note: Neither study reported between-group differences so it cannot be determined whether FES is more effective than control therapy in improving muscle strength in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two fair quality RCTs (Sabut et al., 2010b; Winchester et al., 1983) have investigated the effect of FES on range of motion in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first fair quality RCT (Sabut et al., 2010b) randomized patients with subacute stroke to receive physical therapy and FES (FES group) or physical therapy alone (control group) for 12 weeks. No between-group comparisons on ankle range of motion were made, however the authors state that the FES group showed “better” improvement than the control group at 12 weeks (post-treatment).

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Winchester et al., 1983) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive either standard physiotherapy and FES (FES group) or standard physiotherapy alone (control group). Range of motion was measured weekly during the 4-week intervention. A significant between-group difference in active range of motion was found at week 2 (during treatment) in favour of the FES group compared to the control group. No significant differences were found at week 1 or 3 of treatment, or at week 4 (post-treatment).

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES is not more effective than standard rehabilitation in improving range of motion in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More, although temporary gains were seen mid-treatment.

Note: One fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found improvement in ankle range of motion following FES, however these results are not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More as between-group differences were not reported.

Two fair quality RCTs (Sabut et al., 2010b; Winchester et al., 1983) have investigated the effectiveness of FES on spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first fair quality RCT (Sabut et al., 2010b) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive physical therapy and FES (FES group) or physical therapy alone (control group) for 12 weeks. SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was measured by the Modified Ashworth Scale. No between-group comparison in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was provided, however, the authors state that the FES group showed a “better” improvement than the control group at 12 weeks (post-treatment).

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Winchester et al., 1983) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive either standard physiotherapy and FES (FES group) or standard physiotherapy alone (control group). SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was measured on a scale of “none,” “minimal,” “moderate,” or “severe”. No significant between-group difference in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was seen at 4 weeks (post-treatment).

Conclusion: There is limited (level 2a) from 1 fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES and standard rehabilitation is not more effective than standard rehabilitation alone for decreasing spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Note: One fair quality RCT reported reduced spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
following FES, however these results are not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More as between-group differences were not reported.

One high quality RCT (Ambrosini et al., 2011) has investigated the effectiveness of FES on trunk control in patients with subacute stroke.

In the high quality RCT (Ambrosini et al., 2011) randomized patients with subacute stroke or traumatic brain injury to either an FES-induced cycling group (FES group) or a placebo FES cycling group (control group). Trunk control was measured by the Trunk Control Test. A significant between-group difference on trunk control was seen at 4 weeks (post-treatment) and follow-up, in favour of the FES group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCT that FES is more effective than placebo intervention in improving trunk control in patients with sub-acute stroke.

One high quality RCT (Tong et al., 2006) ), 1 fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Sabut et al., 2010b) and 1 pre-post design study (Sabut et al., 2010a) have investigated the effectiveness of FES on walking efficiency in patients with subacute and chronic stroke.

The high quality RCT (Tong et al., 2006) randomly assigned patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive: (1) gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training using an electromechanical gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
trainer with functional electric stimulation (EGT-FES); (2) gait training using an electromechanical gait trainer (EGT); or (3) conventional gait training (CGT, control) for four weeks. Walking efficiency was measured using the Functional Ambulatory Category (FAC). At four weeks (post-intervention), there was a significant between-group difference in walking efficiency in favour of the EGT and EGT-FES groups compared to the control group.

One fair quality RCT (Sabut et al., 2010b) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive physical therapy and FES (FES group) or physical therapy alone (control group) for 12 weeks. Walking efficiency was measured using the Physiological Cost Index. No significant between-group difference in walking efficiency was seen at 12 weeks (post-treatment).

One pre-post design study (Sabut et al., 2010a) assigned patients with subacute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES and standard physical therapy. Walking efficiency was measured using the Physiological Cost Index. A significant effect of FES treatment on walking efficiency was seen at 12 weeks (post-treatment).

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES is more effective than conventional gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training or standard rehabilitation in improving walking efficiency in patients with subacute stroke. One pre-post study also reported improved walking efficiency following FES in patients with subacute and chronic stroke.

NOTE: However, 1 fair quality RCT did not find FES to be more effective than standard rehabilitation in improving walking efficiency.

One high quality RCT (Ambrosini et al., 2011), 2 fair quality RCTs (Sabut et al., 2010b; Granat et al., 1996) and 1 pre-post design study (Sabut et al., 2010a) have investigated the effectiveness of FES on walking speed in patients with sub-acute and chronic stroke.

The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Ambrosini et al., 2011) randomized patients with subacute stroke or traumatic brain injury to either an FES-induced cycling group (FES group) or a placebo FES cycling group (control group). Self-selected gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed was measured by the 50m walking test. No significant between-group difference in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed was seen at 4 weeks (post-treatment) or follow-up. However, a subgroup analysis of patients with ischaemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More revealed a significant between-group difference in favour of the FES group compared to the control group.

The fair quality RCT (Sabut et al., 2010b) randomized patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive physical therapy and FES (FES group) or physical therapy alone (control group) for 12 weeks. Walking speed was measured using the 10 Meter Walk-Way Test. No significant between-group difference in walking speed was found at 12 weeks (post-treatment).

The fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Granat et al., 1996) assigned patients with subacute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive four weeks of standard rehabilitation followed by four weeks of FES intervention. Walking speed was measured by the walk-path length divided by the time to traverse the walk-path. No between-group comparisons in walking speed were made, however the authors reported improved speed following 4 weeks of FES intervention.

One pre-post design study (Sabut et al., 2010a) assigned patients with subacute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES and standard physical therapy. Walking speed was measured over 10 metres. A significant effect of FES treatment on walking speed was found at 12 weeks (post-treatment).

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES is more effective than placebo intervention in improving walking speed in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. One pre-post design study also reported improved walking speed following FES.

NOTE: However, one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More reported that FES is not more effective than standard rehabilitation alone in improving walking speed. Further, a second fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More did not find significant improvement in walking speed following FES, although these results are not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More as between-group differences were not reported.

Two fair quality crossover RCTs (Embrey et al., 2010; Granat et al., 1996) have investigated the effect of FES on ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of Daily Living (ADLs) and participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first fair quality crossover RCT (Embrey et al., 2010) randomized patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. to receive FES or no FES for 3 months (phase I). The groups performed the opposite treatment for the following 3 months (phase II). Function and participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More was measured using the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Impact Scale. Patients who received FES in phase I showed significantly improved function and participation compared with patients who received no FES, and retained these improvements following no FES in phase II. Patients who received FES in phase II demonstrated significantly improved function and participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More at 6 months (post-treatment) compared to baseline scores.

The second fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Granat et al., 1996) assigned patients with sub-acute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive 4 weeks of standard rehabilitation followed by 4 weeks of FES intervention. Performance of ADLs was measured using the Barthel Index. A significant difference in ADLs was seen at 4 weeks (post-treatment) in favour of FES compared to standard rehabilitation.

Conclusion: There is limited evidence (level 2a) from 2 fair quality crossover RCTs that FES is more effective than standard rehabilitation for improving ADLs in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One fair quality RCT (Kottink et al., 2007) investigated the effectiveness of FES on physical activity in patients with chronic stroke.

The fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Kottink et al., 2007) investigated the effectiveness of using a 2-channel implantable peroneal nerve stimulator for improving physical activity in 29 patients with chronic stroke and foot drop. Participants were randomly assigned to receive either: (1) a 2-channel implantable peroneal nerve stimulator, (stimulation treatment group) or (2) a control group. Participants in the treatment group had the stimulator implanted under the epineurium of the peroneal nerve under general or spinal anesthesia. The control group was able to continue using their regular walking devices (ankle-foot orthosis, orthopedic shoes, or no device). Each participant was assessed on physical activity at baseline and at week 26. After 26 weeks, there was no significant between group difference in physical activity measured by the percentage of time spent stepping or standing, however there was a significant difference between the groups on time spent sitting/lying in favour of the stimulation group.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that FES is not more effective than standard therapy for increasing physical activity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Janssen et al., 2008) has investigated the effectiveness of FES on aerobic capacity in patients with chronic stroke.

The high quality RCT (Janssen et al., 2008) compared the effectiveness of cycling with and without FES on aerobic capacity in 12 patients with chronic stroke. Subjects were randomly assigned to either the treatment or control group in which both groups performed a cycling exercise. During cycling, the treatment group received electrical stimulation evoking muscle contractions and the control group received sensible stimulation not evoking muscle contractions for six weeks. After six weeks of treatment, there was no significant difference between the groups on VO2 peak scores.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES in addition to cycling is not more effective than cycling alone in improving aerobic capacity in patients with chronic stroke.

Two high quality RCTs (Daly et al., 2006, Janssen et al., 2008) have investigated the effectiveness of FES on improving balance in patients with chronic stroke.

The first high quality RCT (Daly et al., 2006) investigated the effectiveness of functional neuromuscular stimulation using intramuscular electrodes (FNS-IM) on balance in 32 patients with chronic stroke. The treatment group received functional neuromuscular stimulation using intramuscular electrodes, body-weight support treadmill training, coordination exercises, over ground walking (OG) and a home exercise program. The control group received the same treatment as the intervention group but without FNS for 12 weeks. No significant between group difference was reported for balance as measured by the Tinetti Balance (TB) after 12 weeks of treatment.

The second high quality RCT (Janssen et al., 2008) compared the effectiveness of cycling with and without FES on balance in 12 patients with chronic stroke. Participants were randomly assigned to either the treatment or control group in which both groups performed a cycling exercise. During cycling, the treatment group received electrical stimulation of the paretic leg evoking muscle contractions and the control group received sensible stimulation not evoking muscle contractions for six weeks. After the six week intervention, no significant difference between the groups was found on the Berg Balance Scale (BBS).

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that FES in addition to a gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training or a cycling program compared to a gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training or cycling program alone does not improve balance in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Daly et al., 2011, Daly et al., 2006) has investigated the effectiveness of FES for improving coordination in patients with chronic stroke.

The first high quality RCT (Daly et al., 2011) randomized patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive intramuscular FES or no FES. Participants performed strengthening exercises, overground gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training and body-weight supported treadmill training for 1.5 hours 4 times/week for 12 weeks. Lower extremity coordination was measured by the Fugl-Meyer Lower Limb Scale and by the Functional Independence Measure (FIM), Locomotion and Mobility subscales. Both groups demonstrated significant improvements in lower extremity coordination at post-treatment (12 weeks), however between-group differences were not reported for these measures.

The second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Daly et al., 2006) investigated the effectiveness of functional neuromuscular stimulation using intramuscular electrodes (FNS-IM) on coordination in 32 patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. The treatment group received functional neuromuscular stimulation using intramuscular electrodes, body-weight support treadmill training, coordination exercises, over ground walking (OG) and a home exercise program. The control group received the same treatment as the intervention group except without FNS for 12 weeks. After 12 weeks of treatment there was a significant between-group difference in favour of the treatment group on the Fugl-Meyer knee flexion coordination measure (FMKnFx). No statistically significant between group difference was found on the Fugl-Meyer lower extremity coordination (FMLE).

Conclusion: There is strong evidence (level 1a) from one high quality RCTs that FES is more effective than no FES in improving gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training program alone improves knee coordination but not general lower extremity coordination in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Another high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More also reported significantly improved coordination following FES, however these results are not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More as between-group differences were not reported.

One fair quality crossover study (Sheffler et al., 2006) has investigated the effectiveness of FES for improving functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The fair quality crossover study (Sheffler et al., 2006) investigated the effect of a transcutaneous peroneal nerve stimulation device on functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
in 14 patients with chronic stroke and a drop foot. The modified Emory Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Profile was used to measure functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
while the 14 patients underwent the test with the Odstock Dropped-Foot Stimulator (ODFS), with an Ankle-Foot Orthosis (AFO), or with no device. The order of use of the device was randomized, and all evaluations and training were completed over two days. After two days, there was a significant difference in favour of using the ODFS compared to no device as well as in favour of using an AFO compared to no device but there was no significant difference between using an AFO and the ODFS as measured by the modified Emory Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Profile.

Conclusion: There is limited evidence (Level 2a) from one fair quality crossover study that FES (via the ODFS) is more effective than using no device for improving functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Daly et al., 2011; Daly et al., 2006) have investigated the effectiveness of FES for improving gait component execution in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Daly et al., 2011) randomized patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive intramuscular FES or no FES. Participants performed strengthening exercises, overground gait training and body-weight supported treadmill training for 1.5 hours 4 times/week for 12 weeks. Gait component analysis was performed using the Gait Assessment and Intervention Tool (GAIT). A significant between-group difference was found in favour of the FES group compared to the no-FES group at post-treatment (12 weeks) and follow-up (6 months).

The second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Daly et al., 2006) investigated the effectiveness of functional neuromuscular stimulation using intramuscular electrodes (FNS-IM) on gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
component execution in 32 patients with chronic stroke. The treatment group received functional neuromuscular stimulation using intramuscular electrodes, body-weight support treadmill training, coordination exercises, over ground walking (OG) and a home exercise program. The control group received the same treatment as the intervention group except without FNS for 12 weeks. There was a significant between-group difference in favour of the treatment group after 12 weeks of treatment on the Tinetti Gait scale (TG) which measured: (1) gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
initiationThe ability to spontaneously start a task or activity (Grieve & Gnanasekaran, 2008)
; (2) walking path; (3) trunk alignment; (4) swing phase limb trajectory; (5) step continuity; (6) step symmetry; and (7) swing limb floor clearance and forward swing limb execution.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that FES is more effective than no FES in improving gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
component execution in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two fair quality RCTs (Daly et al., 2004, Granat et al., 1996) and 1 quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Kesar et al., 2011) have investigated the effectiveness of FES for improving gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics in patients with chronic stroke.

The first fair quality RCT (Daly et al., 2004) assigned patients with chronic stroke to: (1) a treatment group that received functional neuromuscular stimulation (FNS) with intramuscular electrodes during strengthening and coordination exercises, ground gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training, and weight supported treadmill training, or (2) a control group received the same treatment except for the FNS. Data was collected in three sessions: pre-treatment, post-treatment and follow-up (six months after the end of treatment). At each session gait kinematics were measured during volitional over-ground walking at a self-selected speed. Three limb flexion gait components were chosen as indicators of swing phase limb advancement in the sagittal plane: peak swing hip flexion, peak swing knee flexion and mid-swing ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
. Although the stimulation treatment group showed a significant gain in volitional peak swing knee flexion and volitional mid-swing ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
after treatment, no group comparisons were reported.

The second fair quality crossover RCT (Granat et al., 1996) assigned patients with sub-acute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive four weeks of standard rehabilitation followed by four weeks of FES intervention. GaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
parameters were measured by swing symmetry and foot inversion in stance. A significant difference in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
parameters in patients was seen at 4 weeks (post-treatment) in favour of FES compared to standard rehabilitation.

One quasi-experimental designA study in which subjects typically receive differing treatments and outcomes are then compared. No randomization is done in the assignment of treatment groups.
study (Kesar et al., 2011) measured gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics of patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More during four walking conditions: 1) self-selected speed without FES (SS); 2) self-selected speed with FES (SS-FES); 3) faster than self-selected speed without FES (FAST); and 4) faster than self-selected speed with FES (FAST-FES). GaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics were measured by peak anterior ground reaction force during paretic stance (AGRF) and trailing limb angle. Comparison of walking faster than self-selected speed conditions revealed significant differences on the AGRF in favour of FES (condition 4) compared to no FES (condition 3). Comparison of FES conditions at post-evaluation revealed significant differences on the AGRF, trailing limb angle and peak knee flexion in favour of condition 4 (walking faster than self selected speed with FES) compared to condition 2 (walking at a self selected speed with FES). Comparison of non-FES conditions revealed a significant difference in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
kinematics in favour of condition 3 (walking faster than self selected speed) compared to condition 1 (walking at self selected speed). No differences were found when comparing non-FES conditions (condition 3: walking at a faster than self selected speed vs. condition 1: walking at a self selected speed) on peak knee flexion. No differences were found when comparing FES conditions (condition 4: walking faster than self selected speed with FES vs. condition 2: walking at a self selected speed with FES) on trailing limb angle and peak knee flexion. No significant differences were found on any comparison on the percent paretic propulsion.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and 1 quasi-experimental designs study that FES is more effective than standard rehabilitation or no FES in improving gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
parameters and kinematics in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. A second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More reported improved gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
parameters following FES, however these results are not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More as between-group differences were not reported.

One high quality RCT (Janssen et al., 2008) has investigated the effectiveness of FES on maximal power output in patients with chronic stroke.

The high quality RCT (Janssen et al., 2008) compared the effectiveness of cycling with and without FES on maximal power output in 12 patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Subjects were randomly assigned to either the treatment or control group in which both groups performed a cycling exercise. During cycling, the treatment group received electrical stimulation evoking muscle contractions and the control group received sensible stimulation not evoking muscle contractions for six weeks. After six weeks of treatment, there was no significant difference between the groups on PO2max scores.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES in addition to cycling is not more effective than cycling alone in improving maximal power output in patients with chronic stroke.

One pre-post design study (Sabut et al., 2010a) has investigated the effect of FES on metabolic responses in patients with sub-acute and chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The pre-post design study (Sabut et al., 2010a) assigned patients with sub-acute or chronic stroke to receive FES and standard physical therapy. Metabolic responses were measured according to oxygen consumption, carbon dioxide production, heart rate and energy cost. A significant effect of FES treatment on metabolic responses was seen at 12 weeks (post-treatment) in patients with sub-acute and chronic stroke.

Conclusion: There is limited evidence (level 2b) from one pre-post design study that FES is effective in improving metabolic responses in patients with sub-acute and chronic stroke.

One high quality RCT (Janssen et al., 2008) has investigated the effectiveness of FES on maximum isometric voluntary contraction (MIVC) in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The high quality RCT (Janssen et al., 2008) compared the effectiveness of cycling with and without FES on maximum isometric voluntary contraction in 12 patients with chronic stroke. Subjects were randomly assigned to either the treatment or control group in which both groups performed a cycling exercise. During cycling, the treatment group received electrical stimulation evoking muscle contractions and the control group received sensible stimulation not evoking muscle contractions for six weeks. After six weeks of treatment, no significant difference was found between the groups on maximal voluntary knee extension.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that FES in addition to cycling is not more effective than cycling alone in improving maximum isometric voluntary contraction in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Daly et al., 2011, Janssen et al., 2008), one fair quality crossover RCT (Embrey et al., 2010), one meta-analysis (Glanz et al., 1996) and one pre-post design study (Sabut et al., 2010a) have investigated the effectiveness of FES on lower limb muscle strength in patients with chronic stroke.

The first high quality RCT (Daly et al., 2011) randomized patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive intramuscular FES or no FES. Participants performed strengthening exercises, overground gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training and body-weight supported treadmill training for 1.5 hours 4 times/week for 12 weeks. Muscle strength was measured by manual muscle testing. Both groups demonstrated significant improvements in muscle strength at post-treatment. Between-group differences were not reported for this outcome.

The second high quality RCT (Janssen et al., 2008) randomized patients to an intervention group that received FES to evoke muscle contractions during cycling exercises, or a control group that received sensible stimulation that did not evoke muscle contractions during cycling exercises. Muscle strength was measured by maximal knee extension torque. No significant difference in muscle strength was seen at 6 weeks (post-intervention).

A fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Embrey et al., 2010) randomized patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. to receive FES or no FES for 3 months (phase I). The groups performed the opposite treatment for the following 3 months (phase II). Isometric muscle strength was measured by dynamometer. Significant between-group differences in dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
strength in the paretic leg were seen in favour of the FES group compared to the no-FES group following phase I (3 months). Similar results were found in favour of FES compared to no-FES following phase II (6 months). There were no significant between-group differences in strength of plantar flexor muscles at either time point.

In the meta-analysisMethod in which the results of two or more studies are statistically combined. Typically used when studies have few subjects, but similar designs. By increasing the available number of subjects, more weight can be given to the findings.
(Glanz et al., 1996), four randomized controlled trials were analyzed to assess the effectiveness of functional electrical stimulation (FES) therapy for improving muscular strength in chronic patients post-stroke. The range of mean time since onset of symptoms for the individuals in the four studies included was 1.5 months to 29.2 months. The treatment group received FES for a muscle in their hemiparetic extremity (ankle, knee or wrist), along with standard physical therapy. The control group received physical therapy alone for all studies except one, where these patients received a sham treatment. All four studies generated a positive effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the “effect size correlation”.
(0.63), where patients who received FES had significant improvements in muscle strength of the hemiparetic extremity (ankle, knee or wrist) at post-treatment, in comparison to those who received standard physical therapy or sham treatment.

One pre-post design study (Sabut et al., 2010a) assigned patients with subacute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES and standard physical therapy. Muscle strength was measured by the mean absolute value, root mean square, median frequency and median amplitude of the tibialis anterior muscle EMG signal. A significant effect of FES treatment on muscle strength was seen at 12 weeks (post-treatment).

Conclusion: There is strong evidence (level 1a) from one meta-analysisMethod in which the results of two or more studies are statistically combined. Typically used when studies have few subjects, but similar designs. By increasing the available number of subjects, more weight can be given to the findings.
and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES is more effective than no FES, standard therapy, or no therapy for improving muscle strength in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. One high quality RCT and one pre-post study also found significant improvement in muscle strength following FES, although between-group differences were not reported.

NOTE: One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More, published after the meta-analysisMethod in which the results of two or more studies are statistically combined. Typically used when studies have few subjects, but similar designs. By increasing the available number of subjects, more weight can be given to the findings.
, found no significant difference between FES treatment and sensible stimulation during cycling.

One high quality RCT (Kottink et al., 2010) has investigated the effectiveness of FES on quality of life in patients with chronic stroke.

The high quality RCT (Kottink et al., 2010) randomized patients with stroke and chronic hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. with foot drop to a group that received FES by an implantable two-channel peroneal nerve stimulator for correction of their foot drop, or to a control group who continued using conventional walking devices (e.g. ankle-foot orthoses, orthopedic shoes or no device). Health status was measured using the Short Form-36 (SF-36), Disability Impact Profile (DIP), and mean preference-based summary indexes of the SF-36 and EuroQoL (EQ-5D). At 26 weeks there was a significant between-group difference in favour of the intervention group compared to the control group on the SF-36 (physical functioning, general health and physical component summary scores), the DIP (mobility, self-care and psychological status scores), and the EQ-5D preference-based summary index. There were no differences in other domains of the DIP (symptoms, social activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
, communication), the SF-36 (physical role functioning, bodily pain, social functioning, mental health, emotional role functioning, vitality, mental component summary) or the SF-36 mean preference-based summary index.

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES is more effective than control therapies (no FES, orthotic devices) in improving aspects of quality of life in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Cozean et al., 1988) has investigated the effectiveness of FES for improving range of motion in patients with chronic stroke.

The high quality RCT (Cozean et al., 1988) examined the effectiveness of FES on range of motion in 32 patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More who demonstrated a dynamic gait problem of spastic equinus posturing of the affected leg. Patients received either (1) a combination of electromyographic biofeedback (BFB) and functional electrical stimulation (FES), (2) BFB only, (3) FES only, or (4) control therapy (standard physical therapy only). At four weeks post-treatment, statistically significant differences were seen in the improvement indices of knee flexion and ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
in the combined treatment group compared to the control group who received standard physical therapy only.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that FES combined with BFB and physiotherapy compared to physiotherapy alone improves range of motion (knee flexion and ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
) in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Janssen et al., 2008) has investigated the effectiveness of FES on self-reported functional mobility in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Janssen et al., 2008) compared the effectiveness of cycling with and without FES on self-reported functional mobility in 12 patients with chronic stroke. Subjects were randomly assigned to either the treatment or control group in which both groups performed a cycling exercise. During cycling, the treatment group received electrical stimulation evoking muscle contractions and the control group received sensible stimulation not evoking muscle contractions for six weeks. After six weeks of treatment, no significant difference was found between the groups on the Rivermead Mobility Index (RMI).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES in addition to cycling is not more effective than cycling alone in improving self-reported functional mobility in patients with chronic stroke.

One high quality RCT (Chen et al., 2005) and one fair quality RCT (Embrey et al., 2010) have investigated the effect of FES on spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with chronic stroke.

The high quality RCT (Chen et al., 2005) randomized patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive electrical stimulation (ES) or placebo ES. Spasticity was measured using the Modified Ashworth Scale and electrophysiological evaluation of lower limb responses (tibial Fmax/Mmax ratio, H-reflex latency and H-reflex recovery curve). Patients who received ES demonstrated a significant decrease in electrophysiology measures of spasticity (Fmax/Mmax ratio, H-reflex latency). More patients from the ES group than the placebo group demonstrated decreased spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
on the modified Ashworth scale, although between-group differences were not reported.

A fair quality crossover RCT (Embrey et al., 2010) randomized patients with chronic stroke and hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. to receive FES or no FES for 3 months (phase I). The groups performed the opposite treatment for the following 3 months (phase II). SpasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was measured by the Modified Ashworth Scale. No significant between-group differences in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
were seen following phase I or phase II.

Conclusion: There is limited evidence (level 2a) from 1 fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES is not more effective than no stimulation in reducing spasticity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Note: 1 high quality RCT reported significantly reduced spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
following FES, although between-group differences were not reported.

Two high quality RCTs (Daly et al., 2006, Janssen et al., 2008) have investigated the effectiveness of FES on walking distance in patients with chronic stroke.

The first high quality RCT (Daly et al., 2006) investigated the effectiveness of functional neuromuscular stimulation using intramuscular electrodes (FNS-IM) on walking distance in 32 patients with chronic stroke. The treatment group received functional neuromuscular stimulation using intramuscular electrodes, body-weight support treadmill training, coordination exercises, over ground walking (OG) and a home exercise program. The control group received the same treatment as the intervention group but without FNS for 12 weeks. No significant between group difference was found for walking distance measured by the 6 minute walking test (6MWT) after 12 weeks of treatment.

The second high quality RCT (Janssen et al., 2008) compared the effectiveness of cycling with and without FES on walking distance in 12 patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Subjects were randomly assigned to either treatment or control group in which both groups performed a cycling exercise. During cycling, the treatment group received electrical stimulation evoking muscle contractions and the control group received sensible stimulation not evoking muscle contractions for six weeks. After six weeks of treatment, no significant difference was found between the groups on the 6 minute walking test (6MWT).

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that FES in addition to a gait training or cycling program is not more effective than a gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
training or cycling program alone for improving walking distance in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two fair quality RCTs (Burridge and McLellan, 2000, Burridge et al., 1997), two pre-post designed studies (Sabut et al., 2010a, Stein et al., 2006) and one systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
(Kottink et al., 2004) examined the effectiveness of FES on walking efficiency in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first fair quality RCT (Burridge and McLellan, 2000) assigned patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and age-matched controls to receive FES to the common peroneal nerve during swing phase of walking, for a period of 3 months. Walking efficiency was measured by the Physiological Cost Index. Subjects were assessed with and without stimulation. Comparison of scores from baseline to post-intervention revealed a significant improvement in walking efficiency, both with and without stimulation. Note: this study did not provide between-group differences, so is not used to determine level of evidence1a (Strong) : Well-designed meta-analysis, or 2 or more high quality RCTs (PEDro ≥ 6) showing similar findings 1b(Moderate): 1 RCT of high quality (PEDro ≥ 6) 2a (Limited): At least 1 fair quality RCT (PEDro = 4-5) 2b (Limited): At least one poor quality RCT (PEDro < 4) or well-designed non-experimental study (non-randomized controlled trial, quasi-experimental studies, cohort studies with multiple baselines, single subject series with multiple baselines, etc.) 3 (Consensus): Agreement by an expert panel or a group of professionals in the field or a number of pre-post studies all with similar results 4 (Conflicting): Conflicting evidence of 2 or more equally well-designed studies 5 (No evidence): No well-designed studies – only case studies/case descriptions or cohort studies/single subject series with no multiple baselines) More in the conclusion below.

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Burridge et al., 1997)randomized patients to a group that received FES and physiotherapy (FES group) or a group that received physiotherapy alone (control group). Assessment of the Physiological Cost Index (PCI) was done at the start of the trial, between four and five weeks, and between 12 and 13 weeks. Subjects in the treatment group were assessed with and without stimulation. A statistically significant difference was found between the change in PCI in the control group and change in PCI in the FES group (measured without stimulation at the start of the trial and with stimulation at the end).

The first pre-post design study (Sabut et al., 2010a) assigned patients with subacute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive FES and standard physical therapy. Walking efficiency was measured by the Physiological Cost Index. A significant effect of FES treatment on walking efficiency was seen at 12 weeks (post-treatment).

The second pre-post design study (Stein et al., 2006) investigated the use of FES to the peroneal nerve and tibialis anterior for improving walking efficiency in 26 individuals with drop foot as a result of various central nervous system disorders, including 12 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.. Physiological Cost Index (PCI) was measured before the subjects took the device home and at approximately monthly intervals for at least three months. At the end of treatment, a trend was seen in the PCI toward lower values (from 1.06 to 1.01) however these results were not significant.

The systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
(Kottink et al., 2004) examined the literature on the effectiveness of FES for improving walking efficiency in eight studies of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Only one of these studies was an RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and has been reviewed above (Burridge et al., 1997). A second pre-post designed study by the same authors reported a significant decrease in PCI with and without stimulation after three months in 56 individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Overall this systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
suggests a positive impact of FES on improving walking efficiency in individuals with chronic stroke.

Conclusion: There is limited evidence (level 2a) from 1 fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that FES is more effective than standard rehabilitation alone for improving walking efficiency in patients with sub-acute and chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. A second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More, a pre-post design study and a systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
also reported significant improvements in walking efficiency following FES, and a second pre-post design study reported a non-significant trend towards improved walking efficiency.

One meta-analysis (Robbins et al., 2006) has investigated the effectiveness of FES for improving walking speed once the FES therapy has ended. Six of the studies included in the meta-analysis (Alon & Ring, 2003; Bogataj et al., 1995; Burridge et al., 1997; Burridge & MacLellan, 2000; Chen et al., 2005; Granat et al., 1996) have been reviewed in this StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Engine module.

The meta-analysisMethod in which the results of two or more studies are statistically combined. Typically used when studies have few subjects, but similar designs. By increasing the available number of subjects, more weight can be given to the findings.
(Robbins et al., 2006) which included three controlled trials examined changes in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed that had occurred after a series of FES treatments over a period of weeks or months. The main outcome was gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed. Time since strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More was 3.9 to 59 months with a mean of 34 months. All studies examined differences in gait speed in subjects who had received training with FES for weeks or months compared to those that did not receive FES training. A fixed-effects model of three studies produced a mean difference that was significant, indicating the effectiveness of FES treatment at increasing gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed in subjects post-stroke.

Conclusion: There is strong evidence (Level 1a) from one meta-analysisMethod in which the results of two or more studies are statistically combined. Typically used when studies have few subjects, but similar designs. By increasing the available number of subjects, more weight can be given to the findings.
that FES is more effective even after the sessions have ended for improving walking speed compared to conventional therapy.

Note:Due to the small number of controlled trials, the authors also included in their discussion the results of 1 pre-post design and 1 crossover study to provide a more comprehensive review. In total three of the five FES studies showed a real improvement in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed (defined in this article as a minimal improvement of 7.9% in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed). This meta-analysis showed that previous training using FES produces sustained improvements in gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed even after the FES is turned off (therapeutic effect).

Three high quality RCTs (Cozean et al., 1988; Chen et al., 2005; Daly et al., 2011), four fair quality RCTs (Burridge et al., 1997; Kottink et al., 2007; Alon and Ring, 2003; Burridge and McLellan, 2000), two fair quality crossover RCT (Granat et al., 1996; Embrey et al., 2010), two pre-post designed studies (Sabut et al., 2010a; Stein et al., 2006) and one systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
(Kottink et al., 2004) investigated the effectiveness of FES on walking speed in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCT (Cozean et al., 1988) randomized (1) a combination of electromyographic biofeedback (BFB) and functional electrical stimulation (FES), (2) BFB only, (3) FES only, or (4) control therapy (standard physical therapy only). At four weeks post-treatment a statistically significant improvement in the velocity of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
was observed in the combined treatment group, however no group comparisons were made.

The second high quality RCT (Chen et al., 2005) randomized patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive electrical stimulation (ES) for 20 minutes/day, 6 days/week for 1 month, or placebo ES. Walking speed was measured by a 10m walking time assessment. Patients who received ES demonstrated significant improvements in walking time at post-treatment, while patients who received placebo ES did not demonstrate a significant improvement. Between-group differences were not reported.

The third high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Daly et al., 2011) randomized patients with chronic stroke to receive intramuscular FES or no FES. Participants performed strengthening exercises, overground gait training and body-weight supported treadmill training for 1.5 hours 4 times/week for 12 weeks. Walking speed was measured using the 6-Minute Walk Test (6MWT). Both groups demonstrated significant improvements in walking speed at post-treatment.

The first fair quality RCT (Burridge et al., 1997) examined the effectiveness of FES and physical therapy on walking speed in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More whose walking was impaired by a drop foot. The participants were randomized into a treatment group that received FES and physiotherapy or to a control group which received physiotherapy alone. The Odstock Dropped Foot Stimulator provided FES. Walking speed was measured over a 10-meter walkway. Treatment group subjects were asked to perform the walk three times with stimulation and three times without. Control subjects completed the walk three times without stimulation. At the first assessment there was no significant difference between the walking speed of the control and the FES group with stimulation. However, there was a significant difference between the groups when the mean change in walking speed was compared (measured without stimulation at the start of the trial and with stimulation at the end for the FES group).

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Kottink et al., 2007) investigated the effectiveness of using a 2-channel implantable peroneal nerve stimulator for improving walking speed in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and foot drop. Participants were randomly assigned to receive either: (1) a 2-channel implantable peroneal nerve stimulator, (stimulation treatment group) or (2) a control group. Participants in the treatment group had the stimulator implanted under the epineurium of the peroneal nerve under general or spinal anesthesia. The implanted device communicates with an external transmitter, and applied continual stimulation to the nerve. The control group was able to continue using their regular walking devices (ankle-foot orthosis, orthopedic shoes, or no device). Each participant was assessed on this measure at baseline, week 12 and week 26. After 12 weeks, there was no significant difference between the groups on the 6MWT or 10-meter walkway test, however, after 26 weeks, there was a significant improvement in walking speed in the stimulation group compared to the control group measured by the 6MWT and the 10-meter walkway test.

The third fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Alon and Ring, 2003) assigned patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive either FES (electrically augmented stimulation training) or a control treatment consisting of the same exercises without stimulation. Walking speed was measured by the 10 Meter Walk Test: time and cadence. A significant between-group difference in walking speed was seen at 2 months (post-treatment) in favour of FES and standard rehabilitation compared to standard rehabilitation only.

The fourth fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Burridge and McLellan, 2000) assigned patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and age-matched controls to receive 3 months of FES to the common peroneal nerve. Walking speed was measured by the 10 Meter Walk Test. Comparison of scores from baseline to post-intervention revealed a significant improvement in walking speed when the stimulator was turned on.

The first fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Granat et al., 1996) assigned patients with sub-acute or chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive four weeks of standard rehabilitation followed by four weeks of FES intervention. Walking speed was measured by the walk-path length divided by the time to traverse the walk-path. A significant improvement in walking speed was seen after 4 weeks of FES intervention, although between-group comparisons were not reported.

A second fair quality crossover RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Embrey et al., 2010) randomized patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More and hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. to receive FES or no FES for 3 months (phase I). The groups performed the opposite treatment for the following 3 months (phase II). Walking speed was measured by the 6-Minute Walk Test (6MWT) and the Emory Functional Ambulatory Profile (EFAP). At 3 months (phase I), participants who had received FES demonstrated a statistically significant improvement in walking speed. At 6 months (phase II) the group that received FES in phase I retained significant improvements from baseline and the group that received FES in phase II demonstrated significantly improved walking speed compared to baseline scores.

The first pre-post design study (Sabut et al., 2010a) assigned patients with sub-acute or chronic stroke to receive FES and standard physical therapy. Walking speed was measured over 10 metres. A significant effect of FES treatment on walking speed was found at 12 weeks (post-treatment).

The second pre-post designed study (Stein et al., 2006) investigated the use of a peroneal nerve and tibialis anterior FES for improving walking efficiency in individuals with drop foot as a result of various central nervous system disorders including 12 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Walking speed was measured over a straight distance of 10 meters as well as by walking around a continuous 10 meter figure of eight. Measurements were taken before the subject took the device home and at approximately monthly intervals for at least three months. Subjects were asked to perform the 10 meter straight walking test twice with FES and twice without FES at each subsequent visit. The average increase in walking speed from the initial measure without FES to the final measure with FES was 12%, which was not a significant difference.

The systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
(Kottink et al., 2004), investigated the results of eight studies (including only one RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More, Burridge et al., 1997) on the relationship between FES and walking speed. Walking speed was measured in six of the eight studies analyzed for the review, and it was concluded that FES interventions improved walking speed post-stroke.

Conclusion: There is limited evidence (level 2a) from 5 fair quality RCTs (one which using a cross-over design) that FES is more effective than control therapies (physiotherapy, conventional rehabilitation, no FES) in improving walking speed in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Two high quality RCTs, one fair quality cross-over RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More, one pre-post design study and one systematic reviewA systematic review is a summary of available research on a given topic that compares studies based on design and methods. It summarizes the findings of each, and points out flaws or potentially confounding variables that may have been overlooked. A critical analysis of each study is done in an effort to rate the value of its stated conclusions. The research findings are then summarized, and a conclusion is provided.
found significant improvements in walking speed following FES, although between-group differences were not reported.

Note: One high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More reported significant improvements in walking speed at post-treatment in both groups whereas 1 pre-post design study reported no significant improvement in walking speed following FES.

One fair quality RCT (Mohan et al., 2013) investigated the effect of lower extremity mirror therapy on balance in patients with acute stroke. This fair quality RCT randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups also received conventional strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More rehabilitation. Balance was measured by the Brunnel Balance Assessment at post-treatment (2 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity mirror therapy is not more effective than a comparison therapy (sham mirror therapy) for improving balance in patients with acute stroke.

One fair quality RCT (Mohan et al., 2013) investigated the effect of lower extremity mirror therapy on mobility in patients with acute stroke. This fair quality RCT randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups also received conventional stroke rehabilitation. Mobility was measured by the Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Categories at post-treatment (2 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that lower extremity mirror therapy is more effective than a comparison therapy (sham mirror therapy) for improving mobility in patients with acute stroke.

One fair quality RCT (Mohan et al., 2013) investigated the effect of lower extremity mirror therapy on motor function in patients with acute stroke. This fair quality RCT randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups also received conventional stroke rehabilitation. Lower extremity motor function was measured by the Fugl-Meyer Assessment (Lower Extremity score) at post-treatment (2 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity mirror therapy is not more effective than a comparison therapy (sham therapy) for improving lower extremity motor function in patients with acute stroke.

One high quality RCT (Sutbeyaz et al., 2007) investigated the effect of lower extremity mirror therapy on functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This high quality RCT randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Functional ambulation was measured by the Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Categories at post-treatment (4 weeks) and follow-up (6 months). No significant between-group difference was found at follow-up.
Note: Post-treatment results were not reported.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mirror therapy is not more effective than a comparison intervention (sham mirror therapy) for improving functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCTs (Sutbeyaz et al., 2007) investigated the effect of lower extremity mirror therapy on functional independence in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This high quality RCT randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (Motor score) at post-treatment (4 weeks) and follow-up (6 months). A significant difference was seen at follow-up, in favour of mirror therapy vs. sham mirror therapy.
Note: Post-treatment results were not reported.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving functional independence in patients with subacute stroke.

One high quality RCT (Ji & Kim, 2014) investigated the effect of lower extremity mirror therapy on gait in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Temporospatial gait characteristics (single stance, step length, stance phase, swing phase, velocity, cadence, stride length, step width) were measured by a motion analysis device at post-treatment (4 weeks). Significant between-group differences were found in 3 measures (single stance, step length, stride length), in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving some gait measures in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Xu et al., 2017) investigated the effect of lower extremity mirror therapy on mobility in patients with subacute stroke. This high quality RCT randomized patients with foot drop to receive lower extremity mirror therapy, mirror therapy and neuromuscular electrical stimulation (NMES), or sham mirror therapy. Mobility was measured by the 10 meter Walk Test at post-treatment (4 weeks). Significant between-group difference was found, in favour of lower extremity mirror therapy vs. sham mirror therapy.

Note: Significant between-group differences were also found in favour of mirror therapy + NMES vs. lower extremity mirror therapy and vs. sham mirror therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving mobility in patients with subacute stroke.

Two high quality RCTs (Sutbeyaz et al., 2007; Xu et al., 2017) investigated the effect of lower extremity mirror therapy on lower extremity motor recovery in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCT (Sutbeyaz et al., 2007) randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Lower extremity motor recovery was measured by Brunnstrom stages of motor recovery (Lower extremity score) at post-treatment (4 weeks) and follow-up (6 months). A significant between-group difference was found at follow-up, in favour of mirror therapy vs. sham mirror therapy.

Note: post-treatment results were not reported.

The second high quality RCT (Xu et al., 2017) randomized patients with foot drop to receive lower extremity mirror therapy, mirror therapy and neuromuscular electrical stimulation (NMES), or sham mirror therapy. Lower extremity motor recovery was measured by Brunnstrom stages of motor recovery (Lower extremity score) at post-treatment (4 weeks). A significant between-group difference was found, in favour of lower extremity mirror therapy vs. sham mirror therapy.

Note: A significant between-group difference was found in favour of mirror therapy + NMES vs. sham mirror therapy. There were no significant differences between lower extremity mirror therapy vs. mirror therapy + NMES.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that lower extremity mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving lower extremity motor recovery in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Xu et al., 2017) investigated the effect of lower extremity mirror therapy on range of motion in patients with subacute stroke . This high quality RCT randomized patients with foot drop to receive lower extremity mirror therapy, mirror therapy and neuromuscular electrical stimulation (NMES), or sham mirror therapy. Passive range of motion on ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
was measured by a goniometer at post-treatment (4 weeks). A significant between-group difference was found, in favour of lower extremity mirror therapy vs. sham mirror therapy.

Note: A significant between-group difference was found in favour of mirror therapy + NMES vs. sham mirror therapy. There were no significant differences between lower extremity mirror therapy vs. mirror therapy + NMES.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving range of motion (ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
) in patients with subacute stroke.

Two high quality RCTs (Sutbeyaz et al., 2007; Xu et al., 2017) investigated the effect of lower extremity mirror therapy lower extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCT (Sutbeyaz et al., 2007) randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Lower extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was measured by the Modified Ashworth Scale at post-treatment (4 weeks) and follow-up (6 months). No significant between-group difference was found at follow-up.
Note: Post-treatment results were not reported.

The second high quality RCT (Xu et al., 2017) randomized patients with foot drop to receive lower extremity mirror therapy, mirror therapy and neuromuscular electrical stimulation (NMES), or sham mirror therapy. Lower extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
was measured by the Modified Ashworth Scale (plantar flexion) at post-treatment (4 weeks). No significant between-group difference was found when comparing lower extremity mirror therapy vs. sham mirror therapy.
Note: Significant between-group difference was found in favour of mirror therapy + NMES vs. sham mirror therapy. There were no significant differences between lower extremity mirror therapy vs. mirror therapy + NMES.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mirror therapy is not more effective than a comparison intervention (sham mirror therapy) for reducing lower extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Arya, Pandian & Kumar, 2017) investigated the effect of lower extremity mirror therapy on gait in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This high quality RCT randomized patients to receive lower extremity mirror therapy or time-matched conventional rehabilitation. Gait was measured by the Rivermead visual gait assessment at post-treatment (3 months). A significant between-group difference was found, in favour of mirror therapy vs. conventional rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mirror therapy is more effective than a comparison intervention (conventional rehabilitation) for improving gait in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Arya, Pandian & Kumar, 2017) investigated the effect of lower extremity mirror therapy on lower extremity motor function in patients with chronic stroke. This high quality RCT randomized patients to receive lower extremity mirror therapy or time-matched conventional rehabilitation. Lower extremity motor function was measured by the Fugl-Meyer Assessment (Lower extremity score) at post-treatment (3 months). A significant between-group difference was found, in favour of mirror therapy vs. conventional rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mirror therapy is more effective than a comparison intervention (conventional rehabilitation) for improving lower extremity motor function in patients with chronic stroke.

One high quality RCT (Arya, Pandian & Kumar, 2017) and one fair quality RCT (Abo Salem & Huang, 2015) investigated the effect of lower extremity mirror therapy on motor recovery in patients with chronic stroke.

The high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Arya, Pandian & Kumar, 2017) randomized patients to receive lower extremity mirror therapy or time-matched conventional rehabilitation. Lower extremity motor recovery was measured by the Brunnstrom stages of motor recovery (Lower extremity score) at post-treatment (3 months). No significant between-group difference was found.

The fair quality RCT (Abo Salem & Huang, 2015) randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Lower extremity motor recovery was measured by the Brunnstrom stages of motor recovery (Lower extremity score) at post-treatment (4 weeks). A significant between-group difference was found, in favour of lower extremity mirror therapy vs. sham mirror therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mirror therapy is not more effective than a comparison intervention (conventional rehabilitation) for improving motor recovery in the chronic phase of strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More recovery.

Note: However, a fair quality RCT found that lower extremity mirror therapy was more effective than sham mirror therapy for improving motor recovery. The studies differed in the intensity and duration of intervention, as well as the type of mirror therapy and comparison intervention provided.

One fair quality RCT (Abo Salem & Huang, 2015) investigated the effect of lower extremity mirror therapy on range of motion in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This fair quality RCT randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Passive range of motion on ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
was measured by a goniometer at post-treatment (4 weeks). A significant between-group difference was found, in favour of lower extremity mirror therapy vs. sham mirror therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving range of motion (ankle dorsiflexionTurning an appendage in an upward direction, for example turning the foot so that the angle between the foot and the leg decreases.
) in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One fair quality RCT (Abo Salem & Huang, 2015) investigated the effect of lower extremity mirror therapy on spasticity in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. This fair quality RCT randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Spasticity (ankle plantarflexion) was measured by the Modified Ashworth Scale at post-treatment (4 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity mirror therapy is not more effective than a comparison intervention (sham mirror therapy) for reducing spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
(ankle plantarflexion) in patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Arya, Pandian & Kumar, 2017) and one fair quality RCT (Abo Salem & Huang, 2015) investigated the effect of lower extremity mirror therapy on walking speed in patients with chronic stroke.

The high quality RCT (Arya, Pandian & Kumar, 2017) randomized patients to receive mirror therapy or time-matched conventional rehabilitation. Walking speed was measured by the 10 Meter Walk Test (10MWT -Comfortable speed, Maximum speed) at post-treatment (3 months). No significant between-group differences were found.

The fair quality RCT (Abo Salem & Huang, 2015) randomized patients to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Walking speed was measured by the 10MWT at post-treatment (4 weeks). A significant between-group difference was found, in favour of lower extremity mirror therapy vs. sham mirror therapy.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that lower extremity mirror therapy is not more effective than a comparison intervention (conventional rehabilitation) for improving walking speed in patients with chronic stroke.

Note: However, a fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that lower extremity mirror therapy was more effective than sham mirror therapy for improving walking speed. The studies differed in the intensity and duration of intervention, as well as the type of mirror therapy and comparison intervention provided.

One fair quality RCT (Wang et al., 2017) investigated the effect of lower extremity mirror therapy on balance in patients with stroke. This fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients with acute/subacute stroke to receive lower extremity mirror therapy or sham mirror therapy; both groups received conventional rehabilitation. Balance was measured by the Berg Balance Scale at post-treatment (6 weeks). No significant between-group difference was found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity mirror therapy is not more effective than a comparison intervention (sham mirror therapy) for improving balance in patients with stroke.

One fair quality RCT (Ji et al., 2014) investigated the effect of lower extremity mirror therapy on gait in patients with stroke. This fair quality RCT randomized patients with subacute / chronic stroke to receive lower extremity mirror therapy, lower extremity mirror therapy + functional electrical stimulation (FES), or sham mirror therapy; all participants received additional rehabilitation. Gait was measured by a three-dimensional motion capture system (velocity, cadence, step length and stride length) at post-treatment (6 weeks). A significant between-group difference in one measure (velocity) was found, in favour of lower extremity mirror therapy vs. sham mirror therapy.
Note: There were significant between-group differences in three measures of gait (velocity, step length, stride length), in favour of mirror therapy + FES vs. sham mirror therapy. There were no significant differences between lower extremity mirror therapy vs. mirror therapy + FES.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity mirror therapy is not more effective than a comparison intervention (sham mirror therapy) for improving gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
in patients with stroke.

Note: Mirror therapy with FES was more effective than sham mirror therapy for improving gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
following stroke.

One poor quality RCT (Kawakami et al., 2015) investigated the effect of mirror therapy on lower extremity motor function in patients with stroke. This poor quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients with acute/subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More to receive (i) lower extremity mirror therapy, (ii) integrated volitional-control electrical stimulation, (iii) therapeutic electrical stimulation, (iv) repetitive facilitative exercises, or (v) facilitated movement. Lower extremity motor function was measured by the Stroke Impairment Assessment Set (Hip flexion test, Knee extension test, Foot pad test) at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that mirror therapy is not more effective than comparison interventions (integrated volitional-control electrical stimulation, therapeutic electrical stimulation, repetitive facilitative exercises, facilitated movement) for improving lower extremity motor function in patients with stroke.

One fair quality RCT (Wang et al., 2017) investigated the effect of lower extremity mirror therapy on motor recovery in patients with stroke. This fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More randomized patients with acute/subacute stroke to receive lower extremity mirror therapy or lower extremity sham mirror therapy; both groups received conventional rehabilitation. Motor recovery was measured by the Brunnstrom stages of motor recovery at post-treatment (6 weeks). A significant between-group difference was found, in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that lower extremity mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving lower extremity motor recovery in patients with stroke.

One fair quality RCT (Wang et al., 2017) investigated the effect of lower extremity mirror therapy on walking in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive lower extremity mirror therapy or lower extremity sham mirror therapy; both groups received conventional rehabilitation. Walking was measured by the Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Categories and the Functional Independence Measure (Locomotion subtest) at post-treatment (6 weeks). Significant between-group differences were found on both measures, in favour of mirror therapy vs. sham mirror therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that lower extremity mirror therapy is more effective than a comparison intervention (sham mirror therapy) for improving walking in patients with stroke.

One high quality RCT (Yang et al., 2006) and one single case study (Sullivan et al., 2006) investigated the effect of lower extremity strength training on biomechanical gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
parameters in patients with stroke.

The high quality RCT found that a progressive task-oriented resistance program for the lower extremity improved gait cadence and stride length compared to no treatment.

The single case study (Sullivan et al., 2006) found that body-weight supported treadmill walking combined with limb loaded cycling improved hip and knee extension motions throughout stance and swing while walking, however ankle motion showed no noticeable change. As well, a strong correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
improvement and magnitude of paretic leg gluteus maximus and gluteus medius activation during gait (measured by EMG).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that lower extremity strength training is more effective than no treatment in improving gait cadence and stride length in patients with stroke. One single case study also found an improvement for hip and knee extension while walking, but no change in ankle motion.

One fair quality RCT (Glasser et al., 1986) investigated the relationship between strength training and functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
(as measured by the Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Profile) in patients with stroke. No significant differences were found between a group of patients who received therapeutic exercise combined with isokinetic exerciseExercise performed with a specialized apparatus that provides variable resistance to a movement, so that no matter how much effort is exerted, the movement takes place at a constant speed. Such exercise is used to test and improve muscular strength and endurance, especially after injury.
therapy and a group who received therapeutic exercise alone. However, this study may not have been sufficiently powered to find significant between group differences.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that strength training is not more effective than therapeutic exercise alone in improving functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
Note: The fair quality study may not have been sufficiently powered to find significant between-group differences.

One high quality RCT (Cooke et al., 2010) examined the efficacy of lower extremity strength training for improving temperospatial gait parameters (as measured by symmetry of step length and step time) in patients with subacute stroke and found no significant difference at 6 weeks (outcome) or 18 weeks (follow-up) between patients who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that lower extremity functional strength training is not more effective than conventional physiotherapy alone in improving temperospatial gait parameters in patients with subacute stroke.

One high quality RCT (Mead et al., 2007) studied the effect of lower extremity strength training on walking economy in patients with stroke. Immediately post intervention, there was a significant improvement in walking economy, as measured by oxygen uptake, in favour of the group of patients who received a progressive endurance and resistance training program for the lower extremity, compared to a group of patients who received relaxation training only (control). However, at a 4-month follow-up the difference was no longer significant.

Conclusion: There is moderate (level 1b) evidence from one high quality RCT that lower extremity strength training is more effective than control therapies (e.g. relaxation training) in improving walking economy immediately post intervention, but not at a 4-month follow-up, in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Five high quality RCTs (Moreland et al., 2003, Ouellette et al., 2004, Yang et al., 2006, Sullivan et al., 2007, Lee et al., 2008), two fair quality RCTs (Dean et al., 2000, Bourbonnais et al., 2002) and one single case study (Sullivan et al., 2006) have investigated the effectiveness of lower extremity strength training for improving walking endurance in patients with stroke.

The first high quality RCT (Moreland et al., 2003) reported no significant change in walking endurance, as assessed by the 2-minute walk test, following a program of progressive resistance exercises compared to the control group who performed the same exercises without resistance.

The second high quality RCT (Ouellette et al., 2004) found no significant change in walking endurance, as measured by the 6-minute walk test, between a group of patients who received lower-extremity progressive resistance training and a group who received upper extremity stretching (control).

The third high quality RCT (Yang et al., 2006) found that a task-oriented endurance-resistance program did improve endurance as measured by the 6-minute walk test compared to no treatment.

The fourth high quality RCT (Sullivan et al., 2007) found no significant difference between non-gait-specific strength training of the lower extremity (limb loaded cycling) compared to gait-specific ambulation exercise that had no strength training component (body-weight supported treadmill walking), as measured by the 6-minute walk test.

The fifth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More by Lee et al. (2008) found no improvement on the 6-minute walk test, following progressive resistance training for the lower extremity compared to a sham strength-training program (control).

The first fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Dean et al., 2000), reported significant improvements in walking endurance, as assessed by the 6-minute walk test, following a program focused on strengthening the affected lower limb combined with practicing functional tasks involving the lower limbs, compared to practicing upper limb tasks only (control).

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Bourbonnais et al., 2002), reported significant improvements in walking endurance, as assessed by the 2-minute walk test, in favour of a group of patients who received a force feedback program for the lower paretic limb compared to a group who received a force feedback program for upper paretic limb (control).

A single case study (Sullivan et al., 2006) found that body-weight supported treadmill walking combined with limb loaded cycling improved walking endurance, as measured by the 6-minute walk test, for one patient with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Conclusion: There is conflicting evidence (Level 4) regarding the effectiveness of lower extremity strength training in improving walking endurance in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. While four high quality RCTs found that lower extremity strength training is not more effective than control therapies (e.g. resistance-free exercises, upper extremity stretching program, exercises without strength training component or sham strength-training program) in improving walking endurance in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More, one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and two fair quality RCTs found that lower extremity strength training is more effective than control therapies (e.g. no treatment, the practice of upper limb tasks only and a force feedback program for upper paretic limb) in improving walking endurance in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
Note: The one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that did find improvements in walking endurance used task-oriented strength training with some components that involved gait-related strength training movements (i.e. stepping exercises). Furthermore, one single case study found improvements in walking endurance for non-gait-specific strength training (limb loaded cycling) combined with gait-specific training that had no strength component (body-weight supported treadmill walking).

Seven high quality RCTs (Cooke et al., 2010, Kim et al., 2001, Lee et al., 2008, Mead et al., 2007, Ouellette et al., 2004, Sullivan et al., 2007, Yang et al., 2006), three fair quality RCTs (Bourbonnais et al., 2002, Dean et al., 2000, Teixeria-Salmela et al., 1999), two pre-post studies (Sharp & Brouwer, 1997, Cramp et al., 2006) and one single case study (Sullivan et al., 2006) have investigated the efficacy of lower extremity strength training for improving walking speed in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

The first high quality RCT (Cooke et al., 2010) reported no significant difference in walking speed (as measured by the 10 minute walking test or VICON movement analysis system) or community mobility (as measured by walking speed of 0.8m/sec) at 6 weeks (outcome) or 18 weeks (follow-up) between patients with subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

The second high quality RCT (Kim et al., 2001) found no difference in habitual walking speed between a group of patients who received maximal isokinetic strength training compared to a group who received a program of passive range of motion exercises (control).

The third high quality RCT (Lee et al., 2008) found no difference in maximal or habitual walking speed following progressive resistance training for the lower extremity compared to a sham strength-training program.

The fourth high quality RCT (Mead et al., 2007) found no difference in habitual walking speed between a group of patients who received a progressive endurance and resistance training program for the lower extremity compared to the control group who received a relaxation program only.

The fifth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Ouellette et al., 2004) found no difference in self-selected and maximal walking speed (as measured by maximal gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
velocities) between a group of patients who received lower-extremity progressive resistance training and a group who received upper extremity stretching (control).

Interestingly, the sixth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Sullivan et al., 2007) found that non-gait-specific strength training of the lower extremity (resistance cycling) was less effective for improving self-selected walking speed than ambulation exercise that had little or no strength training component (body-weight supported treadmill walking), and that when strength training of the lower-extremity was added to the gait-oriented training, there was no additional benefit.

The seventh high quality RCT (Yang et al., 2006) found that a task-oriented endurance-resistance program for the lower extremity did improve habitual walking speed compared to no treatment (control).

The first fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Bourbonnais et al., 2002) reported a significant improvement in habitual walking speed in favour of a group of patients who received a force feedback program of the lower paretic limb compared to a group who received a force feedback program of the upper paretic limb (control).

The second fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Dean et al., 2000) found significant improvements in self-selected walking speed following a program focused on strengthening the affected lower limb combined with practicing functional tasks involving the lower limbs, compared to practicing upper limb tasks only (control).

The third fair quality RCT (Teixeria-Salmela et al., 1999) found an improvement in habitual walking speed following an aerobic-strength training program compared to no training.

The first pre-post study (Sharp & Brouwer, 1997) found a significant within-group improvement in habitual walking speed for a group of patients who received an isokinetic exerciseExercise performed with a specialized apparatus that provides variable resistance to a movement, so that no matter how much effort is exerted, the movement takes place at a constant speed. Such exercise is used to test and improve muscular strength and endurance, especially after injury.
program consisting of knee extension and flexion.

The second pre-post study (Cramp et al., 2006) found a significant within-group improvement in habitual walking speed for patients who received a low intensity progressive strength program.

A single case study (Sullivan et al., 2006) found that body-weight supported treadmill walking combined with limb loaded cycling improved habitual walking speed for one patient with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Conclusion: There is conflicting evidence (level 4) regarding the effectiveness of lower limb strength training in improving walking speed in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. Six high quality RCTs report that lower limb strength training (conducted during functional strength training, maximal isokinetic strength training, progressive endurance and/or resistance training programs, resistance cycling, gait-oriented training or body-weight supported treadmill training) is not more effective than control therapies (e.g. conventional physiotherapy, passive range of motion exercises, sham strength-training programs, relaxation programs or upper extremity stretching) in improving self-selected, maximal or habitual walking speed in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. However, one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and three fair quality RCTs found that lower limb strength training (conducted during aerobic strength training programs or force-feedback programs) was more effective than control therapy (e.g. upper limb programs) or no therapy in improving habitual or self-selected walking speed. Furthermore, two pre-post studies and one case study also reported improved habitual walking speed following lower extremity strength training programs.
Note: Programs that were successful in improving ambulation skills often included elements such as gait-related training tasks.

Three high quality RCTs (Mead et al., 2007, Lee et al., 2008, Cooke et al., 2010) investigated the effects of strength training on self-reported functional mobility in patients with stroke.

The first high quality RCT (Mead et al., 2007) found no significant between-group differences in self-reported functional mobility, as measured by the Rivermead Mobility Index, between a group of patients who received a progressive task-oriented resistance program for the lower extremity compared to the control group who received a relaxation program.

The second high quality RCT (Lee et al. (2008), found no improvement in perceived self-efficacy in functional mobility (measured by the Ewart Self-Efficacy Scales for stair climbing and walking) following a progressive strength-training program, compared to a sham strength-training program.

The third high quality RCT (Cooke et al., 2010) found no significant differences in functional mobility (as measured by the Rivermead Mobility Index) at 6 weeks (outcome) or 18 weeks (follow-up) between patients with subacute stroke who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that lower extremity strength training is not more effective than other control treatments (e.g. relaxation program, sham strength-training or conventional physiotherapy) for improving self-reported measures of functional mobility in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Yang et al., 2006, Mead et al., 2007), one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Bourbonnais et al., 2002) and one pre-post study (Sharp & Brouwer, 1997) investigated the effect of lower extremity strength training on ability to transition from sitting to ambulating in patients with stroke.

The first high quality RCT (Yang et al., 2006) found a significant between-group difference in transition from sitting to ambulating (as measured by the Timed Up and Go test) immediately post treatment in favour of a group of patients who received an endurance-resistance program compared to a group that received no treatment (control).

The second high quality RCT (Mead et al., 2007) also found a significant between-group difference in transition from sitting to ambulating (as measure by the Timed Up and Go test) immediately post treatment for participants who received a progressive task-oriented resistance program for the lower extremity compared to the control group who received a relaxation program (control), however the difference was no longer significant at a 4-month follow up.

The fair quality RCT (Bourbonnais et al., 2002) found no significant difference for the Timed Up and Go test between a group of patients who received a force feedback program of the lower paretic limb compared to a group who received a force feedback program for the upper paretic limb (control).

The pre-post study (Sharp & Brouwer, 1997) found no improvement in transition from sitting to ambulating (as measured by the Timed Up and Go) following an isokinetic exerciseExercise performed with a specialized apparatus that provides variable resistance to a movement, so that no matter how much effort is exerted, the movement takes place at a constant speed. Such exercise is used to test and improve muscular strength and endurance, especially after injury.
program consisting of knee extension and flexion.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that lower extremity strength training is more effective than control therapies (e.g. no treatment, relaxation) in improving the time it takes to transition from sitting to ambulating in patients post stroke. However, one fairquality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and one pre-post study found no improvement following a strength training program.

One fair quality RCT (Dean et al., 2000 ) investigated the effect of lower extremity strength training on force production during sit-to-stand in patients with stroke. This fair quality RCT found a significant increase in force production through the affected leg during sit-to-stand, following a program focused on strengthening the affected lower limb combined with practicing functional tasks involving the lower limbs compared to a program of upper limb tasks only (control).

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that lower extremity strength training is more effective than upper limb exercises in improving force production during sit-to-stand in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Ouellette et al., 2004, Mead et al., 2007) investigated the effect of lower extremity strength training on the time it takes to transition from sitting to standing in patients with stroke.

The first high quality RCT (Ouellette et al., 2004) found no significant difference in ‘repeated chair rise time’ between a group of patients who received lower extremity progressive resistance training compared to a group who received upper extremity stretching (control).

The second high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Mead et al., 2007) found no significant differences immediately post-intervention (3 months) or at follow-up (4 months) for ‘timed sit to stand’ between a group of participants who received a progressive endurance and resistance training program (that involved a sit-to-stand strength exercise) for the lower extremity, and the control group who received a relaxation program.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that lower extremity strength training is not more effective than control therapies (e.g. upper extremity stretching or relaxation program) in improving the time it takes to transition from sitting to standing in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Three high quality RCTs (Kim et al., 2001, Ouellette et al., 2004, Lee et al., 2008), one fair quality RCT (Teixeria-Salmela et al., 1999) and one pre-post study (Sharp & Brouwer, 1997) studied the effect of lower extremity strength training on stair climbing in patients with stroke.

The first high quality RCT (Kim et al., 2001) found that maximal isokinetic strength training did not improve stair climbing speed compared to a program of passive range of motion exercises (control).

The second high quality RCT (Ouellette et al., 2004) found no significant difference for stair climbing speed between a group of patients who received lower-extremity progressive resistance training and a group who received upper extremity stretching (control).

The third high quality RCT (Lee et al., 2008) found a significant improvement in stair climbing power following progressive resistance training for the lower extremity compared to a sham strength-training program.

The one fair quality RCT by Teixeria-Salmela et al. (1999) found an improvement in stair climbing following a strength training program compared to no training.

The pre-post study (Sharp & Brouwer, 1997) found no improvement in stair climbing following an isokinetic exerciseExercise performed with a specialized apparatus that provides variable resistance to a movement, so that no matter how much effort is exerted, the movement takes place at a constant speed. Such exercise is used to test and improve muscular strength and endurance, especially after injury.
program consisting of knee extension and flexion.

Conclusion: There is conflicting evidence (Level 4) regarding the effectiveness of lower extremity strength training in improving parameters of stair climbing in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. While two high quality RCTs and one pre-post study found that lower extremity strength training is not more effective than control therapies (e.g. passive range of motion exercises or upper extremity stretching program) in improving stair climbing in patients with stroke, one high quality RCT reported an improvement in stair climbing power and one fair quality RCTs reported an improvement in rate of stair climbing following strength training.

One high quality RCT (Mead et al., 2007) and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Inaba et al., 1973) examined the ability to resume activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis. following strength training in patients with stroke.

The high quality RCT (Mead et al., 2007) found that lower-extremity strength training does not improve the ability to perform ADLs, as measured by the Nottingham Extended ADL Scale, for a group of patients who received an endurance-resistance training program compared to a group of patients who received relaxation training (control).

The fair quality RCT (Inaba et al. 1973) found that patients who received progressive resistance training combined with selective stretching significantly improved their ability to perform ADL tasks, as measured by 8 items representing functional ability, compared to a group of patients who received functional training and selective stretching only (control) and a group of patients who received active exercises combined with functional training and selective stretching.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that strength training is not more effective than control therapies (e.g. relaxation training) in improving performance of ADLs in patients with stroke. However, one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that a progressive resistance program may be effective in improving ADL performance in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

One high quality RCT (Lee et al., 2008) found that strength training had no effect on peak VO2 or peak heart rate in patients with stroke following progressive strength training, compared to sham strength training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More that lower extremity strength training is not more effective than sham treatment in improving aerobic capacity in patients with stroke.

One high quality RCT (Mead et al., 2007) studied the effects of lower extremity strength training on anxiety and depression in patients with stroke. The study found no significant differences for anxiety and depression as measured by the Hospital Anxiety And DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Scale between a group of patients who received an endurance-resistance training program and a group of patients who received relaxation training (control).

Conclusion: There is moderate (level 1b) evidence from one high quality RCT that lower extremity strength training is not more effective than control treatments (e.g. relaxation training) in improving depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and anxiety in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Yang et al., 2006, Mead et al., 2007), one fair quality RCT (Dean et al., 2000), one fair quality randomized crossover study (Page et al., 2008), one pre-post study (Weiss et al., 2000) and one single case study (Sullivan et al., 2006) studied the effect of lower extremity strength training on balance in patients with stroke.

The first high quality RCT (Yang et al., 2006) found no significant difference in balance (as measured by a step test) between a group of patients who received a progressive task-oriented resistance program for the lower extremity and a group that received no treatment (control).

The second high quality RCT (Mead et al., 2007) found no significant difference in balance (as measured by the Functional Reach Test) between a group of patients who received an endurance-resistance training program and a group of patients who received relaxation training (control).

The one fair quality RCT (Dean et al., 2000) found an improvement on the step test following a program focused on strengthening the affected lower limb combined with practicing functional tasks involving the lower limbs (including stepping exercises), compared to practicing upper limb tasks only.

The one fair quality randomized crossover study (Page et al., 2008) found a marked pre-post improvement in balance (as measured by the Berg Balance Scale), following resistance-based locomotive training. In contrast, following a home exercise program that had no strength-training component, there was no improvement on the Berg Balance Scale. No statistical analysis was done between groups for this measure.

The pre-post study (Weiss et al., 2000) found that lower extremity strength gains from a resistance program were correlated with increases in balance as measured by the Berg Balance Scale.

The single subject study (Sullivan et al., 2006) found lower extremity strength training had no effect on balance as measured by the Berg Balance Scale.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs and one single subject study that strength training is not more effective than control therapies (e.g. no treatment or relaxation training) in improving balance in patients with stroke. However, one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More and one fair quality crossover study (without between-group analysis) reported an improvement in balance following a strength-training program, and one pre-post study suggests that lower limb strength improvement is associated with balance improvement.

One high quality RCT (Mead et al., 2007) investigated the effects of strength training on functional independence (as measured by the Functional Independence Measure) in patients with stroke. The study found no significant difference between a group of patients who received an endurance-resistance training program as compared to a group of patients who received relaxation training (control).

Conclusion: There is moderate (level 1b) evidence from one high quality study that lower extremity strength training is not more effective than control therapies (e.g. relaxation training) in improving functional independence in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Five high quality RCTs (Cooke et al., 2010, Ouellette et al., 2004, Yang et al., 2006, Mead et al., 2007, Lee et al., 2008,), three fair quality RCTs (Inaba et al., 1973, Teixeria-Salmela et al., 1999, Bourbonnais et al., 2002) and three pre-post studies (Sharp & Brouwer, 1997, Badics et al., 2002, Cramp et al., 2006) examined the effect of strength training on lower extremity strength in patients with stroke.

The first high quality RCT (Cooke et al., 2010) found no significant difference in knee flexion or knee extension peak torque (as measured by an isokinetic dynamometer) at 6 weeks (outcome) or 18 weeks (follow-up) between patients with subacute stroke who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

The second high quality RCT (Ouellette et al., 2004) found a significant improvement in lower extremity strength, as measured by leg press strength and knee extension strength, in favour of a group of patients who received lower-extremity progressive resistance training program compared to a group who received upper extremity stretching (control).

The third high quality RCT (Yang et al., 2006) found a significant between-group difference in leg strength as measured by a hand-held dynamometer in favour of a group of patients who received a progressive task-oriented resistance program for the lower extremity compared to no treatment (control).

The fourth high quality RCT (Mead et al., 2007) found no significant improvement in lower extremity strength as measured by leg extensor power between a group of patients who received an endurance-resistance training program compared to a group of patients who received relaxation training (control).

The fifth high quality RCT (Lee et al., 2008) found an improvement in peak power output on a cycle ergometer, as well as lower extremity strength (1 rep max, power and endurance tests) in both legs following progressive strength training compared to sham strength training (control).

The first fair quality RCT (Inaba et al., 1973) found a significant improvement in lower extremity strength in favour of a group of patients who received progressive resistance training combined with selective stretching compared to a group who received functional training combined with selective stretching (control) and a group who received active exercises combined with selective stretching.

The second fair quality RCT (Teixeria-Salmela et al., 1999) also found a significant improvement in lower extremity strength following a lower limb-training program compared to no intervention.

The third fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Bourbonnais et al., 2002) found a significant improvement in lower extremity strength following a force feedback program for the lower paretic limb compared to a force feedback program for upper paretic limb.

The first pre-post study (Sharp & Brouwer, 1997) found a significant improvement in paretic muscle strength following an isokinetic exerciseExercise performed with a specialized apparatus that provides variable resistance to a movement, so that no matter how much effort is exerted, the movement takes place at a constant speed. Such exercise is used to test and improve muscular strength and endurance, especially after injury.
program consisting of knee extension and flexion.

The second pre-post study (Badics et al., 2002) found a significant within group increase in leg extensor and supporting strength of the legs following a strength-training program aimed at restoring the extensor strength of the legs and the supporting strength of the arms.

The third pre-post study (Cramp et al., 2006) found a significant within-group improvement in isometric and concentric strength of knee extensor muscles in patients who received a low intensity progressive strength program. However, no improvement in knee flexor muscle strength was found.

Conclusion: There is conflicting evidence (level 4) as to whether lower extremity strength training is more effective than various control treatments (e.g. relaxation, upper extremity programs, no treatment, sham strength training and conventional physiotherapy) in improving lower extremity strength in patients with stroke. While three high quality RCTs, three fairquality RCTs and three pre-post studies found an improvement in lower extremity strength following lower extremity strength training, two high quality RCTs did not find an improvement.
Note: The studies used different methods for evaluating strength.

Two high quality RCTs (Moreland et al., 2003, Ouellette et al., 2004), one fair quality RCT (Bourbonnais et al., 2002), one fair quality randomized crossover study (Page et al., 2008), two pre-post studies (Nugent et al., 1994, Weiss et al., 2000) and one single case study (Sullivan et al., 2006) have investigated the effectiveness of strength-training interventions for the improvement of motor function in patients with stroke.

The first high quality RCT (Moreland et al., 2003) found no significant differences in motor function between patients who received strength training and patients who received conventional therapy (control), as assessed using the disability inventory of the Chedoke-McMaster Scale Assessment (CMSA).

The second high quality RCT (Ouellette et al., 2004) found a significant difference in motor function (as measured by self-reported changes in function and disability using the Late Life Function and Disability Instrument) in favour of patients who received a lower-extremity progressive resistance training program as compared to patients who received an upper extremity stretching program (control).

The one fair quality RCT (Bourbonnais et al., 2002) found no significant difference in motor function (as measured by the lower extremity section of the Fugl-Meyer Assessment) between a group of patients who received lower extremity strength training and a group of patients who received upper-extremity strength training.

The one fair quality randomized crossover study (Page et al., 2008) found a marked pre-post improvement in motor function (as measured by lower extremity section of the Fugl-Meyer Assessment), following resistance-based locomotive training . In contrast, following a home exercise program that had no strength training component, there was only a negligible improvement on the lower extremity section of the FMA. No statistical analysis was done between groups.

Two pre-post studies used the Motor Assessment Scale (MAS) as a primary outcome measure to explore the relationship between strength-training interventions and motor function. Nugent et al. (1994) reported a significant improvement in MAS score following a set regimen of weight bearing leg extensor exercise (WBE). Similarly, Weiss et al. (2000) noted significant improvements in MAS scores following a 12-week program of resistance training.

The single case study by Sullivan et al. (2006) found an improvement in motor ability as measured by the lower extremity section of the Fugl-Meyer Assessment immediately post intervention, however this difference was no longer notable 6 months after baseline.

Conclusion: There is conflicting evidence (level 4) as to whether strength training improves motor function in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More. While one high quality RCT, one fair quality crossover (without between-group analysis) and two pre-post studies reported improved motor function, another high quality RCT and one fair quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More found that strength training was not more effective than control therapies (e.g. conventional therapy, upper extremity strength training) in improving motor function in patients with stroke. Further, while the single case study found an improvement immediately post intervention, the improvement was no longer notable 6 months post intervention.
Note: Because of the variations in the intervention times and exercise programs, future studies are warranted to better understand the effect of the different strength training regiments on motor function. It should also be noted that all studies used different functional assessments.

One fair quality RCT (Teixeria-Salmela et al., 1999) examined the use of strength training to improve physical activity (as measured by the Human Activity Profile and the Adjusted Activity Scale) in patients with stroke. Significant improvements were found for those who had received the intervention compared to those who had not received strength training.

Conclusion: There is limited (level 2a) evidence from one fair quality RCT that strength training interventions may be effective in increasing physical activity in patients with stroke.

Four high quality RCTs (Cooke et al., 2010, Kim et al., 2001, Mead et al., 2007, Lee et al., 2008, ) and one single case study (Sullivan et al., 2006) investigated the effects of lower extremity strength training on quality of life in patients with stroke.

The first high quality RCT (Cooke et al., 2010) found no significant difference in health status or health-related quality of life (as measured by the EuroQuoL) at 6 weeks (outcome) or 18 weeks (follow-up) between patients with subacute stroke who received physiotherapy and functional strength training using progressive resistive exercise vs. conventional physiotherapy alone.

The second high quality RCT (Kim et al., 2001) found no improvement on the mental or physical health items of the Medical Outcomes Short Form-36 (SF-36) for patients who received a maximal isokinetic strengthening program compared to patients who received a passive range of motion intervention (control).

The third high quality RCT (Mead et al., 2007) found that lower extremity strength training significantly improved the role-physical items of the SF-36 for patients who received an endurance-resistance training program compared to a group of patients who received relaxation training (control). However, no significant between-group difference was found for the physical functioning, general health, vitality and mental health items of the SF-36.

The fourth high quality RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness. More (Lee et al., 2008) found no improvement in quality of life, as measured by the SF-36, following a progressive strength training of the lower extremities compared to a sham strength training program.

The single case study (Sullivan et al., 2006) found that a patient who received lower extremity strength training improved on the strength, mobility, emotion, and social participationAs defined by the International Classification of Functioning, Disability and Health, participation is an individual’s involvement in life situations in relation to health conditions, body functions or structures, activities, and contextual factors. Participation restrictions are problems an individual may have in the manner or extent of involvement in life situations. More sub-scales of the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More Impact Scale (SIS), however no improvement was found for the hand function, activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis., communication, memory and thinking subscales of the SIS.

Conclusion: There is strong evidence (level 1a) from three high quality RCTs that lower extremity strength training is not more effective than a variety of control treatments (e.g. conventional physiotherapy, passive ROM, or sham strength training) in improving quality of life in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.
Note: However, one high quality RCT found a significant difference in the role-physical items of the Medical Outcomes Short Form-36 (SF-36), in favour of patients who received the lower extremity strength training program as compared to the control group who received relaxation training. As well, one single case study found an improvement in some aspects of quality of life following strength training post-stroke.

One high quality RCT (Moreland et al., 2003), two fair quality RCTs (Teixeria-Salmela et al., 1999, Bourbonnais et al., 2002) and three pre-post studies (Sharp & Brouwer, 1997, Badics et al., 2002, Cramp et al., 2006) examined the effect of strength training on spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with stroke.

The one high quality RCT (Moreland et al (2003), found no change in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
(as measured by the Ashworth Scale) following progressive resistance exercises compared to the control group who performed the same exercises without resistance.

The first fair quality RCT (Teixeria-Salmela et al., 1999) found no change in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, as measured by the pendulum testThis is a test for spasticity. The patient sits on a table and the examiner holds the patient’s foot with the knee as fully extended as possible. The examiner drops the leg, and a computer records the motion and vibration.
for the knee and controlled resistance to passive stretch for the ankle, following a lower limb training program compared to no intervention. However this study may not have been sufficiently powered to find significant results.

The second fair quality RCT (Bourbonnais et al., 2002) found no change in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
(no measure specified) following a force feedback program for the lower paretic limb compared to a force feedback program for the upper paretic limb.

The first pre-post study (Sharp & Brouwer, 1997) found no change in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, as measured by the pendulum test, following an isokinetic exerciseExercise performed with a specialized apparatus that provides variable resistance to a movement, so that no matter how much effort is exerted, the movement takes place at a constant speed. Such exercise is used to test and improve muscular strength and endurance, especially after injury.
program consisting of knee extension and flexion.

The second pre-post study (Badics et al., 2002) found no change in spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, as measured by the Ashworth scale, following an exercise program aimed at restoring the extensor strength of the legs and the supporting strength of the arms, possibly due to an unusually high level of spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
at baseline.

The third pre-post study (Cramp et al., 2006) found no change in lower extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, as measured by the Ashworth scale, in patients who received a low intensity progressive strength program.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT, two fair quality RCTs and three pre-post studies that lower extremity strength training is not more effective than control therapies in improving lower extremity spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More.

Two high quality RCTs (Richards et al., 1993; Langhammer & Stanghelle, 2000) and one quasi-experimental studyAn experimental study in which the participants are not randomized to receive treatments and as such the investigators lack control over allocation to interventions. This study design is inferior to a randomized controlled trial (RCT) but is valuable in answering research questions when an RCT is not possible either because of ethical constraints or logistic restraints.
(Rose et al., 2011) investigated the effect of lower extremity task-oriented training on balance in patients with acute stroke.