Biofeedback – Lower Extremity

Evidence Reviewed as of before: 04-10-2011
Author(s)*: Robert Teasell, MD; Norine Foley, BASc; Sanjit Bhogal, MSc; Jeffrey Jutai, PhD Csych; Timothy Doherty, MD, PhD; Jamie Bitensky, MSc OT; Mark Speechley, PhD; Chelsea Hellings, BSc; Nicol Korner-Bitensky, PhD OT
Patient/Family Information Table of contents

Introduction

Biofeedback (BFB) has been practiced in clinical settings since the 1970’s, and has become a commonly used treatment in stroke rehabilitation. Normal regulation of muscle tone following a stroke is disrupted by central neuronal damage, which can result in decreased muscle functioning. Although the patient may have some preserved central motor pathways that remain relatively unaffected, these pathways are often unused. Individuals may learn how to use these preserved pathways with the help of electromyographic biofeedback (EMG-BFB). The use of EMG-BFB as an effective means of treatment for upper and lower extremity hemiparesis has been studied, given that hemiparesis of the lower extremity can result in functional disability following stroke and can affect important aspects of daily living (i.e. feeding and dressing).

Patient/Family Information

Author: Jamie Bitensky, MSc.OT

What is biofeedback for the lower extremity?

Biofeedback (BFB) has been practiced in clinical settings since the 1970’s, and has become a commonly used treatment in stroke rehabilitation. Normal regulation of muscle tone can be disrupted by central nerve damage caused by a stroke. This can prevent your muscles from functioning adequately. With the help of electromyographic biofeedback (EMG-BFB), you can get feedback concerning when your muscles are tense or relaxed. Electromyography or EMG is when a set of electrodes is placed on the skin over the chosen muscle or muscle group to detect the electrical signals that occur when a muscle is tense or contracted. This electrical signal will provide you with visual or auditory feedback on whether or not your muscle is contracting and the amount of force in the contraction.

Does it work for stroke?

Research studies have shown that biofeedback of the lower extremity can lead to improvements in the ability to walk, move your lower extremity to their full range, as well as improve the quality of lower extremity movements while walking. This intervention may also improve the ability to walk in a more natural, functional setting, such as on a sidewalk or street. However, these improvements do not seem to impact performance in daily activities or the muscle stiffness in your lower extremity that is commonly associated with a stroke. These studies did not mention if there are any adverse or harmful effects of biofeedback for the lower extremity in clients who have experienced a stroke, such that this therapy seems to be safe.

Who provides the treatment?

Biofeedback for the lower extremity is typically performed by a physiotherapist. Most rehabilitation centers and private clinics are equipped with EMG equipment.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Ten RCTs have investigated the efficacy of biofeedback in the lower extremity as a treatment intervention post-stroke. Specifically, biofeedback in the lower extremity has been examined in relation to gait recovery, range of motion (ROM), performance of activities of daily living (ADLs), functional ambulation, dorsiflexion strength, spasticity, and postural control. In eight of nine randomized controlled trials there were significant differences found for most of these outcome measures in favour of biofeedback therapy.

Results Table

View results table

Outcomes

Activities of daily living (ADL)
Not effective
1B

One high quality study investigated the relationship between biofeedback interventions and the ability to perform activities of daily living (ADL) 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 RCT 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 RCT and one fair quality RCT that biofeedback interventions in the lower extremity are not effective in the recovery of functional performance in activities of daily living (ADL) post-stroke.

Dorsiflexion strength
Effective
1b

Two RCT have investigated the efficacy of biofeedback interventions for improving dorsiflexion 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 dorsiflexion strength post-stroke. One fair quality RCT (Basmajian et al. 1975) also tested strength of dorsiflexion and observed significant differences between groups.

Conclusion: There is moderate (Level 1b) evidence from one high quality RCT that dorsiflexion strength can be improved as a result of biofeedback treatment in the upper extremity post-stroke.

Functional ambulation
Effective
1b

Two RCT studies investigated the relationship between biofeedback interventions and functional ambulation 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 RCT explored the use of biofeedback for standing balance training and its impact on functional ambulation, as assessed by the functional ambulation 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 RCT that biofeedback therapy in the lower extremity improves functional ambulation post-stroke.

Gait recovery
Effective
1a

Two high quality RCTs investigated the use of biofeedback treatment in the lower extremity for enhancing gait recovery post stroke and noted significant differences between groups. Both Morris et al.(1992) and Burnside et al. (1982) found gait recovery was significantly improved for those who received biofeedback interventions. A high quality RCT (Cozean et al. 1988) found greatest gains in gait 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 RCT explored the use of biofeedback for standing balance training and its impact on gait pattern, as assessed by the gait 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 gait recovery post-stroke.

Postural control
Effective
2a

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 RCT explored the use of biofeedback for standing balance training and its impact on postural control, as assessed by the Postural Assessment Scale for Stroke (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.

Range of motion (ROM)
Effective
1A

Two high quality RCT 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 RCT (Basmajian et al. 1975) found a significant improvement in the range of motion of dorsiflexion in favour of the treatment group that received combined biofeedback with standard physical therapy. A recently published fair quality RCT 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 RCT that biofeedback interventions improve range of motion (ROM) post-stroke.

Spasticity
Not effective
1B

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 spasticity was the Ashworth Scale, no significant differences were noted between groups. Another recently published fair quality RCT explored the use of biofeedback for standing balance training and its impact on spasticity, 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 RCT and one fair quality RCT that spasticity is not improved as a result of biofeedback interventions in the lower extremity.

References

Basmajian JV, Kukulka CG, Narayan MG, Takebe K. (1975). Biofeedback treatment of foot-drop after stroke compared with standard rehabilitation technique: effects on voluntary control and strength. Arch Phys Med Rehabil, 56, 231-236.

Bradley L, Hart BB, Mandana S, Flowers K, Riches M, Sanderson P. (1998). Electromyographic biofeedback for gait training after stroke. Clin Rehabil, 12, 11-22.

Burnside IG, Tobias HS, Bursill D. (1982). Electromyographic feedback in the remobilization of stroke patients: a controlled trial. Arch Phys Med Rehabil, 63, 217-222.

Cozean CD, Pease WS, Hubbell SL. Biofeedback and functional electric stimulation in stroke rehabilitation. Arch Phys Med Rehabil 1988; 69: 401-405

Engardt M, Ribbe T, Olsson E. (1993). Vertical ground reaction force feedback to enhance stroke patients’ symmetrical body-weight distribution while rising/sitting down. Scand J Rehabil Med, 25(1), 41-8.

Heller F., Beuret-Blanquart F., & Weber, J. (2005). [Postural biofeedback and locomotion reeducation in stroke patients]. Ann Readapt Med Phys, 48(4), 187-195.

Intiso D, Santilli V, Grasso MG, Rossi R, Caruso I. (1994). Rehabilitation of walking with electromyographic biofeedback in foot-drop after stroke. Stroke, 25, 1189-1192.

Mandel AR, Nymark JR, Balmer SJ, Grinnell DM, O’Riain MD. (1990). Electromyographic versus rhythmic positional biofeedback in computerized gait retraining with stroke patients. Arch Phys Med Rehabil 71, 649-654.

Morris ME, Matyas TA, Bach TM, Goldie PA. (1992). Electrogoniometric feedback: its effect on genu recurvatum in stroke. Arch Phys Med Rehabil, 73, 1147-1154.

Wong AM, Lee MY, Kuo JK, Tang FT.(1997).The development and clinical evaluation of a standing biofeedback trainer. J Rehabil Res Dev, 34, 322-327.

Biofeedback – Upper Extremity

Evidence Reviewed as of before: 26-10-2010
Author(s)*: Robert Teasell, MD; Norine Foley, BASc; Sanjit Bhogal, MSc; Jamie Bitensky, MSc OT; Mark Speechley, MD; Nicol Korner-Bitensky, PhD OT
Patient/Family Information Table of contents

Introduction

Biofeedback (BFB) is commonly used as a treatment intervention for stroke rehabilitation. Following a stroke, the main central motor pathways that regulate normal muscle tone and functioning can be disrupted or even damaged. However, some motor pathways that are often unused remain relatively unaffected by the stroke. Individuals may learn how to activate these unused pathways with the help of electromyographic biofeedback (EMG-BFB) and this may lead to improvements in their muscle tone and functioning. Given that hemiparesis of the upper extremity can result in functional disability following stroke and can affect important aspects of daily living (i.e. feeding and dressing), the use of EMG-BFB as an effective means of treatment for upper extremity hemiparesis has been carefully studied. Specifically, studies have examined the use of biofeedback to improve hand function as well as upper extremity range of motion and function.

Patient/Family Information

Author: Marc-André Roy, MSc.

What is biofeedback for the upper extremity?

A stroke can damage the central nervous system and disrupt normal regulation of muscle tone. This can prevent your muscles from functioning adequately. With the help of electromyographic biofeedback (EMG-BFB), you can receive feedback to know when your muscles are tense or relaxed. Electromyography (EMG) is when a set of electrodes is placed on the skin over the chosen muscle (or muscle group) to detect the electrical signals that occur when a muscle is tense (or contracted). This electrical signal will provide you with a visual or auditory feedback to know whether or not your muscle is contracting and indicate the amount of contraction. This biofeedback can help you re-educate your muscles to contract or relax at your own will in order to increase voluntary muscle control.

Does it work for stroke?

Research has shown that the main reason for functional impairment following a stroke is upper extremity hemiparesis which can affect important activities of daily living (e.g. feeding and dressing). Biofeedback (BFB) is commonly used as a treatment intervention for stroke rehabilitation. Following a stroke, the main central motor pathways that regulate normal muscle tone and functioning can be disrupted or even damaged. However, some motor pathways that are often unused remain relatively unaffected by the stroke. Individuals may learn how to activate these unused pathways with the help of electromyographic biofeedback (EMG-BFB) and this may lead to improvements in their muscle tone and functioning. Specifically, studies have examined the use of biofeedback to improve hand function as well as upper extremity range of motion and function. There is conflicting evidence that biofeedback interventions are effective for improving upper extremity function post-stroke. But, they are not effective for improving manual dexterity and for improving range of motion in the upper extremity post-stroke. At the follow-up evaluation, biofeedback interventions were not effective for improving upper extremity function.

Who provides the treatment?

Biofeedback for the upper extremity is typically performed by a physiotherapist. Most rehabilitation centers and private clinics are equipped with EMG equipment.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Six studies, four high quality RCTs and two of fair quality , have investigated the effect of biofeedback interventions on stroke rehabilitation. Specifically, studies have investigated the effectiveness of biofeedback to improve manual dexterity, upper extremity function and range of motion (ROM).

Results Table

View results table

Outcomes

Upper extremity function
Conflicting
4

Three high quality RCTs and one fair quality RCT 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 RCT, 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.

Upper extremity manual dexterity
Not Effective
1A

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.

Upper extremity range of motion
Not Effective
1b

Two RCTs have investigated the efficacy of biofeedback treatment for improving range of motion (ROM) in the upper extremity post-stroke. One high quality RCT (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 RCT (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 RCT, that biofeedback interventions are not effective for improving range of motion in the upper extremity post-stroke.

References

Basmajian JV, Gowland CA, Finlayson MA, Hall AL, Swanson LR, Stratford PW, Trotter JE, Brandstater ME. (1987). Stroke treatment: comparison of integrated behavioral-physical therapy vs traditional physical therapy programs. Arch Phys Med Rehabil, 68 (5 Pt 1), 267-272.

Basmajian, Gowland, Brandstater, Swanson, Trotter (1982). EMG feedback treatment of upper limb in hemiplegic stroke patients: a pilot study. Arch Phys Med Rehabil, 63(12), 613-616.

Crow, Lincoln, Nouri, De Weerdt (1989). The effectiveness of EMG biofeedback in the treatment of arm function after stroke. Int Disabil Stud, 11, 155-160.

Greenberg, Fowler (1980). Kinesthetic biofeedback: a treatment modality for elbow range of motion in hemiplegia. Am J Occup Ther, 34(11), 738-743.

Hurd, Pegram, Nepomuceno. (1980). Comparison of actual and simulated EMG biofeedback in the treatment of hemiplegic patients. Am J Phys Med, 59(2), 73-82.

Prevo, Visser, Vogelaar (1982). Effect of EMG feedback on paretic muscles and abnormal co-contraction in the hemiplegic arm, compared with conventional physical therapy. Scand J Rehabil Med, 14(3), 121-131.

Functional Electrical Stimulation – Lower Extremity

Evidence Reviewed as of before: 16-07-2012
Author(s)*: Émilie Comtois-Laurin, BSc PT; Catherine Kaley, BSc PT, BSc Exercise Science; Christopher Mares, BSc PT; Megan Robinson, BSc PT; Amy Henderson, PhD Student, Neuroscience; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc; Anita Petzold, BSc OT; Amy Henderson, PhD; Annabel McDermott, OT
Patient/Family Information Table of contents

Introduction

Functional electrical stimulation (FES), also sometimes called functional neuromuscular stimulation (FNS), is a technique used to elicit a voluntary muscle contraction during a functional task by applying low-level electrical current to the nerves that control muscles or directly over the motor end-plate of the muscle (just like a pacemaker makes a heart beat).

Neuromuscular electrical stimulation, or simply ‘electrical stimulation’ (ES), is a modality used primarily for strengthening muscles, without the purpose of integrating a functional task as done with FES. All three (FES, FNS, ES) basically focus on eliciting muscular contractions.

This module summarizes the scientific evidence on FES effectiveness in the treatment of the lower extremities post-stroke (FES of the shoulder and FES of the upper extremities are reviewed in separate modules). TENS and other therapeutic electrical stimulation that do not elicit muscular contraction are reviewed in other modules.

NOTE: Studies involving the use of medications such as Botox have not been included in our analyses.

Patient/Family Information

Authors*: Erica Kader; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT;

What is Functional Electrical Stimulation?

Functional electrical stimulation (FES) is a technique that causes a muscle to contract through the use of an electrical current. This might sound strange, but actually, the body naturally uses electrical currents to make muscles move. Normally, when a part of the body needs to move, the brain sends electrical signals through the nervous system. The nerves, acting like electrical wires, relay these signals to the muscles, directing them to contract. This contraction causes the body part – for example, the ankles, wrists, elbows – to move in a controlled, deliberate fashion. After a stroke, some of these electrical signals do not function as well as they should, causing patients to have trouble walking and coordinating movements. Pain and stiffness can result as well.

When using FES as an intervention after a stroke, the therapist applies an electrical current to either the skin over the nerve, or over the bulk of the muscle, and this will cause a muscle contraction.

The idea behind FES is that it allows the muscles that are paralyzed or partially paralyzed by stroke to move again. The electrical stimulation applied to the muscle is controlled so that the movement produced will provide useful function, and not random movement. FES devices translate input controlled by the patient into patterns that will produce the desired motion in the paralyzed muscles.

This module will look at the use of FES for loss of function, pain, or spasticity (stiffness) of the legs and feet. There is also an intervention using electrical stimulation that does not cause muscle contraction. This is called Transcutaneous Electrical Neuromuscular Stimulation (TENS) and it is described in another module of StrokEngine (soon to come).

Are there different kinds of FES?

Yes, and you will see different names, including functional electrical stimulation, functional neuromuscular stimulation, and electrical stimulation. But, they all have the same goal: to stimulate muscle contraction which in turn may lead to an increase in function, strength, and movement as well as a decrease in pain and spasticity. FES can be used on different parts of the body (arms, legs, shoulders, etc) and also on specific muscles in order to achieve different goals. For example, in FES of the lower extremities, a therapist may apply the stimulation to the quadriceps (muscles of the thighs) in order to help the patient to walk. Two other modules on StrokEngine focus on other kinds of FES, namely Functional Electrical Stimulation of the Hemiplegic Shoulder and Functional Electrical Stimulation of the Upper Extremities.

Why use FES on the legs after stroke?

Loss of leg function, movement, and strength are common after a stroke, and thus impair walking and standing. This occurs because muscles become paralyzed, and cannot receive electrical impulses from the brain. Pain and spasticity are also common after a stroke. FES may be useful for increasing leg function as well as for preventing pain and dysfunction after a stroke.

Does it work for stroke?

Researchers have studied how FES can help patients with stroke through its effects on the muscles in the legs and feet:

  • Strength of muscle contraction: In individuals 1-6 months post-stroke, FES was shown to strengthen muscle contractions.
  • Walking: In patients1-6 months post-stroke , FES showed some improvement in walking. However, FES is more useful in people more than 6 months post-stroke.
  • Perceived health status: Studies showed that FES for the lower extremities was not effective in improving the perceived health of patients more than 6 months post-stroke.
  • spasticity (stiffness): Research showed that when combined with other therapy, FES caused a reduction in spasticity when used for patients more than 6 months post-stroke.
  • Range of motion (movement of joints): FES was shown to be moderately effective in improving range of motion for individuals more than 6 months post-stroke, when combined with other therapy.
  • Functional Ambulation (mobility): There was some evidence that FES improved the ability of patients more than 6 months post-stroke to move around more easily.
  • Lower extremity coordination: There was improvement in knee coordination in patients more than 6 months post stroke, however coordination of the legs and feet in general did not show improvement.
  • Activity level: Studies did not show improvement in level of activity of patients more than 6 months post-stroke after using FES.
  • Balance: Research showed some evidence that FES did not improve the balance of individuals more than 6 months post stroke.

What can I expect?

Small square stickers (electrodes) are placed over the centre of the bulk of the muscle to be stimulated. Wires connect the electrodes to a stimulator, a small machine that produces the electrical current. The stimulation is usually started at a very low level, causing a tingling “pins and needles” feeling on the skin. The current will then slowly be increased after each stimulation until it is strong enough to make the muscle contract. This level (the smallest current necessary to make the muscle contract) will be used for the FES treatment.

Although some people find the treatment uncomfortable, it is usually well tolerated. FES may give some discomfort, but it is virtually painless. Treatment times may vary, however, the time is usually divided into a number of daily sessions. FES treatments are usually done for 30 – 45 minutes, but once you are set up, you can typically perform the treatments on your own or with a family member.

Are there any side effects/risks?

There are few risks that come with the use of functional electrical stimulation. The electrodes can irritate the skin they contact, but this is uncommon. Using non-latex hypoallergenic electrodes can often solve this problem. Some people may find that certain types of electrical stimulations are irritating, but this can be easily fixed by changing the level of the current. After the treatment, there may be pink marks left on the skin where the electrodes were placed, but these usually fade within an hour. Although very rare, this type of therapy can increase spasticity (muscle tightness).

NOTE: People with epilepsy, poor skin condition, hypersensitivity to the electrical stimulation, cancer, and cardiac pacemakers should not receive FES treatment.

Who provides the treatment?

Physical therapists or occupational therapists will usually provide the FES treatment. However, due to the long duration of the stimulation, it is possible for the treatment to be done at home after discharge from the hospital. This will require having a stimulator at home. If you are provided with a home stimulator, family members or friends will be given instructions on how to assist with treatments. Usually, once the electrodes are placed, the rest of the procedure is very simple. To operate an FES machine, you simply switch it on and increase (slowly and gradually) the intensity of the current on a knob – just like switching on a radio and increasing the volume.

NOTE: Consult with your therapist or medical professional on the exact use of specific models of FES equipment.

How many treatments?

Some patients continue to use FES for many years. To maximize the benefits after stroke, it should be used for at least 6 weeks.

How much does it cost? Does insurance pay for it?

Although the cost of an FES machine varies, some systems are relatively inexpensive. Rental or lease options bring the cost down to the equivalent of 1 or 2 clinical visits per month. Some insurance plans cover the purchase or rental of such equipment. Check with your insurance company.

Is FES for me?

There is clear evidence that there are benefits to using functional electrical stimulation in comparison to regular therapy. These benefits include increased force of contraction and improved walking. However, in terms of general activity level after stroke, balance, and perceived health status, FES was not shown to be more effective than conventional therapy. So, overall, FES is an effective treatment you may want to consider after a stroke. If you are interested in learning more about FES, speak to your rehabilitation provider about the possibility of using this treatment.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Thirty three studies (of which 13 high quality RCTs, 13 fair quality RCTs, two quasi-experimental design studies and two pre-post design studies) as well as two meta-analyses and one systematic review have examined the effectiveness of functional electrical stimulation (FES) as a means to improve lower extremity function post-stroke.

Results Table

View results table

Outcomes

Acute Phase

Activities of Daily Living
Effective
2A

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

The first fair quality RCT (MacDonell et al., 1994) investigated the effectiveness of FES for improving performance in activities 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 dorsiflexion 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 activities 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 RCT (Kojovic et al., 2009) investigated the effectiveness of FES for improving ADL 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. 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 design study (Solopova et al., 2011) pseudo-randomized patients with acute stroke 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 design study that FES is more effective than conventional rehabilitation in improving ADL performance in patients with acute stroke.

Note: However, another fair quality RCT found that FES was not more effective than conventional rehabilitation alone in improving ADL performance among patients with acute stroke. Both fair quality RCTs had small sample sizes, which may in part contribute to different results between studies.

Electrophysiology
Not Effective
2A

One fair quality RCT (MacDonell et al., 1994) has investigated the effectiveness of FES for improving electrophysiological functioning in patients with acute stroke.

The fair quality RCT (MacDonell et al., 1994) investigated the effectiveness of FES for improving electrophysiological functioning in 38 patients with acute stroke and weakness of dorsiflexion Grade 4 or less as measured by the Medical Research Council Scale (MRC). The treatment group received FES producing ankle dorsiflexion 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 inhibition 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 RCT 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 stroke.

MIVC and EMG co-contraction
Effective
1a

Two high quality RCTs (Ferrante et al., 2008, Yan et al., 2005) and one quasi-experimental design 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 RCT (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 RCT (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 stroke. 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 dorsiflexion and plantarflexion at one, two, three and 8 weeks. During ankle dorsiflexion, 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 dorsiflexion 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 design study (Solopova et al., 2011) pseudorandomized patients with acute stroke 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 study that FES in addition to standard rehabilitation is more effective than standard rehabilitation alone for improving maximal isometric voluntary contraction in patients with acute stroke.

Note:mprovements were not maintained beyond follow-up in one of the high quality RCT.

Mobility
Not Effective
1b

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 RCT (Ferrante et al., 2008) examined the effectiveness of FES on mobility in 20 patients with acute stroke. 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 RCT that FES in addition to standard rehabilitation is not more effective than standard rehabilitation alone for improving mobility in patients with acute stroke.

Motor control
Effective
1B

One high quality RCT (Ferrante et al., 2008) investigated the use of FES for improving motor control in patients with acute stroke.

The high quality RCT (Ferrante et al., 2008), examined the effectiveness of FES on motor control 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. 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 RCT that FES in addition to standard rehabilitation is more effective than standard rehabilitation alone for improving motor control in patients with acute stroke.

Motor function
Effective
2A

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 RCT (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 dorsiflexion 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 RCT (Kojovic et al., 2009) investigated the effectiveness of FES for improving motor function 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, the FET group had significantly higher scores on the Fugl-Meyer Lower Extremity Motor Assessment Scale compared to the control group.

The quasi-experimental design study (Solopova et al., 2011) pseudorandomized patients with acute stroke 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 RCT and 1 quasi-experimental design study that FES is more effective than conventional rehabilitation in improving motor function in patients with acute stroke.

Note: However, another fair quality RCT found that FES was not more effective than conventional rehabilitation alone in patients with acute stroke. Both fair quality RCTs had small sample sizes, which may in part contribute to different results between studies.

Muscle strength
Not Effective
1B

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

The high quality RCT (Ferrante et al., 2008) examined the effectiveness of FES on muscle strength in 20 patients with acute stroke. 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 stroke.

Severity of stroke
Effective
2b

One quasi-experimental design study (Solopova et al., 2011) has investigated the effectiveness of FES on severity of stroke in patients with acute stroke.

The quasi-experimental design study (Solopova et al., 2011) pseudorandomized patients with acute stroke 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. stroke severity was measured by the National Institutes of Health stroke 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 study that FES is more effective than conventional rehabilitation in improving severity of stroke in patients with acute stroke.

Spasticity
Effective
1A

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 stroke.

The first high quality RCT (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. spasticity 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 test (relaxation index and peak velocity). Both treatments were found to improve hypertonia, as seen by significantly reduced MAS scores and significantly improved pendulum test 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 RCT and one high quality randomized cross-over design study that FES is more effective than standard rehabilitation alone for improving spasticity in patients with acute stroke in the short term.

Trunk movements and balance
Not Effective
1B

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 stroke. 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 RCT 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 stroke.

Walking ability
Not Effective
1a

Two high quality RCTs (Ferrante et al., 2008, Yan et al., 2005), one fair quality RCT (MacDonell et al., 1994) and one quasi-experimental design study (Solopova et al., 2011) have investigated the effectiveness of FES for improving walking ability in patients with acute stroke.

The first high quality RCT (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 stroke. 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 RCT (MacDonell et al., 1994) investigated the effectiveness of FES for improving walking ability in 38 patients with acute stroke and weakness in dorsiflexion Grade 4 or less as measured by the Medical Research Council Scale (MRC). The treatment group received FES producing ankle dorsiflexion 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 Ambulation Categories (MGH FAC) scale.

The quasi-experimental design study (Solopova et al., 2011) pseudorandomized patients with acute stroke 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 RCT and and one quasi-experimental study that FES in addition to standard rehabilitation is not more effective than standard rehabilitation alone for improving walking ability in patients with acute stroke.

Walking efficiency
Effective
2A

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 RCT, (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 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 RCT that FES in addition to standard therapy is more effective than standard therapy alone for improving walking efficiency in patients with acute stroke.

Walking speed
Effective
2A

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 RCT, (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 RCT that FES in addition to standard therapy is more effective than standard therapy alone for improving walking speed in patients with acute stroke.

Subacute Phase

Activities of Daily Living
Not Effective
1b

One high quality RCT (Tong et al., 2006) and one fair quality RCT (Granat et al., 1996) have investigated the effectiveness of FES on ADL in patients with subacute stroke.

The high quality RCT (Tong et al., 2006) randomized patients with subacute stroke to receive (1) gait training using an electromechanical gait 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. 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 RCT (Granat et al., 1996) assigned patients with subacute and chronic stroke 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 gait training for improving performance of ADLs in patients with subacute stroke.

Note: However, there is limited evidence (level 2a) from one fair quality RCT that FES is more effective than standard rehabilitation in improving performance of ADLs in patients with subacute and chronic stroke.

Balance
Not Effective
1B

One high quality RCT (Tong et al., 2006) has investigated the effectiveness of FES on balance in patients with subacute stroke.

In the high quality RCT (Tong et al., 2006) has investigated the effectiveness of gait training using an electromechanical gait trainer with and without functional electric stimulation for improving balance in 46 patients with sub-acute stroke. The patients were randomly assigned to receive either: (1) gait training using an electromechanical gait 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. 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 stroke.

Contraction force
Effective
1B

One high quality cross-over RCT (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 stroke.

The high quality cross-over RCT (Bogataj et al., 1995) randomized patients with subacute stroke 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. Gait 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 RCT (Newsam et al., 2004) assigned patients with subacute stroke 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 RCT (Winchester et al., 1983) randomized patients with subacute stroke 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 stroke.

Note: However, there is limited evidence (level 2a) from 1 fair quality RCT that FES is not more effective than standard rehabilitation for improving MIVC in patients with subacute stroke.

Gait kinematics and parameters
Not Effective
1A

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 stroke.

The first high quality RCT (Yavuzer et al., 2006) randomly assigned patients with subacute stroke 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 dorsiflexion at swing and maximum ankle plantar flexion angle at initial contact. No significant between-group differences in gait kinematics were found at 4 weeks (post-intervention).

The second high quality RCT (Yavuzer et al., 2007) randomly assigned patients with subacute stroke 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 dorsiflexion at swing and maximum ankle plantar flexion angle at initial contact. No significant between-group differences in gait kinematics were found at 4 weeks (post-treatment).

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) for 12 weeks. gait 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 gait kinematics and parameters were seen at 12 weeks (post-treatment).

The second fair quality crossover RCT (Granat et al., 1996) assigned patients with subacute or chronic stroke to receive four weeks of conventional rehabilitation followed by four weeks of FES intervention. gait 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 gait kinematics and parameters in patients with subacute stroke.

NOTE: However, 1 fair quality crossover RCT found that FES was more effective than conventional rehabilitation in improving some aspects of gait kinematics and parameters in patients with subacute and chronic stroke.

Joint position sense
Not Effective
2A

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 RCT (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 stroke. 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 RCT that FES and standard rehabilitation is not more effective than standard rehabilitation alone for improving joint position sense in patients with subacute stroke.

Metabolic function
Effective
2B

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 stroke 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.

Mobility
Effective
1B

One high quality RCT (Tong et al., 2006) investigated the effectiveness of FES on mobility in patients with sub-acute stroke.

The high quality RCT (Tong et al., 2006) investigated the effectiveness of gait training using an electromechanical gait trainer with and without functional electric stimulation for improving mobility in 46 patients with sub-acute stroke. The patients were randomly assigned to receive either: (1) gait training using an electromechanical gait 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. 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 gait training is more effective than gait training alone for improving mobility in patients with sub-acute stroke.

Motor function
Effective
1a

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 RCT (Bogataj et al., 1995) randomized patients with subacute stroke and severe hemiplegia 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 RCT (Tong et al., 2006) investigated the effectiveness of gait training using an electromechanical gait trainer with and without functional electric stimulation for improving motor impairment in 46 patients with sub-acute stroke. The patients were randomly assigned to receive either: (1) gait training using an electromechanical gait 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. 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 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. 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 RCT also reported improved motor function following FES, although between-group differences were not reported.

Motor recovery
Not Effective
1a

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 stroke.

The first high quality RCT (Yavuzer et al., 2007) randomized patients with subacute stroke 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 stroke 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 stroke.

Motor unit recruitment
Effective
2a

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 RCT (Newsam et al., 2004) investigated the effectiveness of FES on motor unit recruitment in 20 patients with sub-acute stroke. The treatment group received an electric stimulation facilitation program of the quadriceps during gait training and weight-bearing activities 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 stroke.

Muscle girth
Not Effective
2A

One fair quality RCT (Winchester et al., 1983) has investigated the effects of FES on muscle girth in patients with subacute stroke.

The fair quality RCT (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 stroke.

Muscle strength
Effective
2B

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 stroke.

The 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. 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 stroke 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 RCT and 1 pre-post design study that FES is effective improving muscle strength in patients with subacute stroke.

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 stroke.

Range of motion
Not Effective
2A

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 stroke.

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 RCT (Winchester et al., 1983) randomized patients with subacute stroke 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 RCT that FES is not more effective than standard rehabilitation in improving range of motion in patients with subacute stroke, although temporary gains were seen mid-treatment.

Note: One fair quality RCT found improvement in ankle range of motion following FES, however these results are not used to determine level of evidence as between-group differences were not reported.

Spasticity
Not Effective
2A

Two fair quality RCTs (Sabut et al., 2010b; Winchester et al., 1983) have investigated the effectiveness of FES on spasticity in patients with subacute stroke.

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. spasticity was measured by the Modified Ashworth Scale. No between-group comparison in spasticity 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 RCT (Winchester et al., 1983) randomized patients with subacute stroke to receive either standard physiotherapy and FES (FES group) or standard physiotherapy alone (control group). spasticity was measured on a scale of “none,” “minimal,” “moderate,” or “severe”. No significant between-group difference in spasticity was seen at 4 weeks (post-treatment).

Conclusion: There is limited (level 2a) from 1 fair quality RCT that FES and standard rehabilitation is not more effective than standard rehabilitation alone for decreasing spasticity in patients with subacute stroke.

Note: One fair quality RCT reported reduced spasticity following FES, however these results are not used to determine level of evidence as between-group differences were not reported.

Trunk control
Effective
1B

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.

Walking efficiency
Effective
1B

One high quality RCT (Tong et al., 2006) ), 1 fair quality RCT (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 stroke to receive: (1) gait training using an electromechanical gait 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 stroke 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 stroke 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 RCT that FES is more effective than conventional gait 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.

Walking speed
Effective
1B

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 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). Self-selected gait speed was measured by the 50m walking test. No significant between-group difference in gait speed was seen at 4 weeks (post-treatment) or follow-up. However, a subgroup analysis of patients with ischaemic stroke 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 stroke 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 RCT (Granat et al., 1996) assigned patients with subacute or chronic stroke 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 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).

Conclusion: There is moderate evidence (level 1b) from 1 high quality RCT that FES is more effective than placebo intervention in improving walking speed in patients with subacute stroke. One pre-post design study also reported improved walking speed following FES.

NOTE: However, one fair quality RCT reported that FES is not more effective than standard rehabilitation alone in improving walking speed. Further, a second fair quality crossover RCT did not find significant improvement in walking speed following FES, although these results are not used to determine level of evidence as between-group differences were not reported.

Chronic Phase

Activities of Daily Living and participation
Effective
2A

Two fair quality crossover RCTs (Embrey et al., 2010; Granat et al., 1996) have investigated the effect of FES on Activities of Daily Living (ADLs) and participation in patients with chronic stroke.

The first fair quality crossover RCT (Embrey et al., 2010) randomized patients with chronic stroke and hemiplegia 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 participation was measured using the stroke 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 participation at 6 months (post-treatment) compared to baseline scores.

The second fair quality crossover RCT (Granat et al., 1996) assigned patients with sub-acute or chronic stroke 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 stroke.

Activity level
Not Effective
2a

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

The fair quality RCT (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 stroke.

Aerobic capacity
Not Effective
1B

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 RCT that FES in addition to cycling is not more effective than cycling alone in improving aerobic capacity in patients with chronic stroke.

Balance
Not Effective
1A

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 gait training or a cycling program compared to a gait training or cycling program alone does not improve balance in patients with chronic stroke.

Coordination
Not Effective
1A

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 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. 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 RCT (Daly et al., 2006) investigated the effectiveness of functional neuromuscular stimulation using intramuscular electrodes (FNS-IM) on coordination 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. 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 gait training program alone improves knee coordination but not general lower extremity coordination in patients with chronic stroke. Another high quality RCT also reported significantly improved coordination following FES, however these results are not used to determine level of evidence as between-group differences were not reported.

Functional ambulation
Effective
2A

One fair quality crossover study (Sheffler et al., 2006) has investigated the effectiveness of FES for improving functional ambulation in patients with chronic stroke.

The fair quality crossover study (Sheffler et al., 2006) investigated the effect of a transcutaneous peroneal nerve stimulation device on functional ambulation in 14 patients with chronic stroke and a drop foot. The modified Emory functional ambulation Profile was used to measure functional ambulation 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 ambulation 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 ambulation in patients with chronic stroke.

Gait component execution
Effective
1A

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 stroke.

The first high quality RCT (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. 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 RCT (Daly et al., 2006) investigated the effectiveness of functional neuromuscular stimulation using intramuscular electrodes (FNS-IM) on gait 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) gait initiation; (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 gait component execution in patients with chronic stroke.

Gait kinematics and parameters
Effective
2A

Two fair quality RCTs (Daly et al., 2004, Granat et al., 1996) and 1 quasi-experimental design study (Kesar et al., 2011) have investigated the effectiveness of FES for improving gait 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 gait 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 dorsiflexion. Although the stimulation treatment group showed a significant gain in volitional peak swing knee flexion and volitional mid-swing ankle dorsiflexion after treatment, no group comparisons were reported.

The second fair quality crossover RCT (Granat et al., 1996) assigned patients with sub-acute or chronic stroke to receive four weeks of standard rehabilitation followed by four weeks of FES intervention. gait parameters were measured by swing symmetry and foot inversion in stance. A significant difference in gait parameters in patients was seen at 4 weeks (post-treatment) in favour of FES compared to standard rehabilitation.

One quasi-experimental design study (Kesar et al., 2011) measured gait kinematics of patients with chronic stroke 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). gait 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 gait 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 RCT and 1 quasi-experimental designs study that FES is more effective than standard rehabilitation or no FES in improving gait parameters and kinematics in patients with chronic stroke. A second fair quality RCT reported improved gait parameters following FES, however these results are not used to determine level of evidence as between-group differences were not reported.

Maximal power output
Not Effective
1b

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 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 PO2max scores.

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 maximal power output in patients with chronic stroke.

Metabolic responses
Effective
2b

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 stroke.

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.

MIVC
Not Effective
1B

One high quality RCT (Janssen et al., 2008) has investigated the effectiveness of FES on maximum isometric voluntary contraction (MIVC) in patients with chronic stroke.

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 stroke.

Muscle strength
Effective
1A

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 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. 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 RCT (Embrey et al., 2010) randomized patients with chronic stroke and hemiplegia 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 dorsiflexion 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-analysis (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 size (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 stroke 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-analysis and one fair quality RCT that FES is more effective than no FES, standard therapy, or no therapy for improving muscle strength in patients with chronic stroke. 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 RCT, published after the meta-analysis, found no significant difference between FES treatment and sensible stimulation during cycling.

Quality of life
Effective
1B

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 hemiplegia 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 activities, 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 RCT that FES is more effective than control therapies (no FES, orthotic devices) in improving aspects of quality of life in patients with chronic stroke.

Range of motion
Effective
1B

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 stroke 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 dorsiflexion 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 dorsiflexion) in patients with chronic stroke.

Self-reported functional mobility
Not Effective
1B

One high quality RCT (Janssen et al., 2008) has investigated the effectiveness of FES on self-reported functional mobility in patients with chronic stroke.

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 RCT that FES in addition to cycling is not more effective than cycling alone in improving self-reported functional mobility in patients with chronic stroke.

Spasticity
Not Effective
2A

One high quality RCT (Chen et al., 2005) and one fair quality RCT (Embrey et al., 2010) have investigated the effect of FES on spasticity in patients with chronic stroke.

The high quality RCT (Chen et al., 2005) randomized patients with chronic stroke 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 spasticity 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 hemiplegia to receive FES or no FES for 3 months (phase I). The groups performed the opposite treatment for the following 3 months (phase II). spasticity was measured by the Modified Ashworth Scale. No significant between-group differences in spasticity were seen following phase I or phase II.

Conclusion: There is limited evidence (level 2a) from 1 fair quality crossover RCT that FES is not more effective than no stimulation in reducing spasticity in patients with chronic stroke.

Note: 1 high quality RCT reported significantly reduced spasticity following FES, although between-group differences were not reported.

Walking distance
Not Effective
1a

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 stroke. 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 gait training or cycling program alone for improving walking distance in patients with chronic stroke.

Walking efficiency
Effective
2A

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 review (Kottink et al., 2004) examined the effectiveness of FES on walking efficiency in patients with chronic stroke.

The first fair quality RCT (Burridge and McLellan, 2000) assigned patients with chronic stroke 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 evidence in the conclusion below.

The second fair quality RCT (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 stroke 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 stroke.. 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 review (Kottink et al., 2004) examined the literature on the effectiveness of FES for improving walking efficiency in eight studies of patients with stroke. Only one of these studies was an RCT 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 stroke. Overall this systematic review 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 RCT that FES is more effective than standard rehabilitation alone for improving walking efficiency in patients with sub-acute and chronic stroke. A second fair quality RCT, a pre-post design study and a systematic review 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.

Walking speed post-FES (therapeutic effect)
Effective
1A

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 Stroke Engine module.

The meta-analysis (Robbins et al., 2006) which included three controlled trials examined changes in gait speed that had occurred after a series of FES treatments over a period of weeks or months. The main outcome was gait speed. Time since Stroke 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 gait speed in subjects post-stroke.

Conclusion: There is strong evidence (Level 1a) from one meta-analysis 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 gait speed (defined in this article as a minimal improvement of 7.9% in gait speed). This meta-analysis showed that previous training using FES produces sustained improvements in gait speed even after the FES is turned off (therapeutic effect).

Walking speed with FES
Effective
2A

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 review (Kottink et al., 2004) investigated the effectiveness of FES on walking speed in patients with chronic stroke.

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 gait 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 stroke 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 RCT (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 stroke 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 RCT (Kottink et al., 2007) investigated the effectiveness of using a 2-channel implantable peroneal nerve stimulator for improving walking speed in 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 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 RCT (Alon and Ring, 2003) assigned patients with chronic stroke 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 RCT (Burridge and McLellan, 2000) assigned patients with stroke 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 RCT (Granat et al., 1996) assigned patients with sub-acute or chronic stroke 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 RCT (Embrey et al., 2010) randomized patients with chronic stroke and hemiplegia 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 stroke. 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 review (Kottink et al., 2004), investigated the results of eight studies (including only one RCT, 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 stroke. Two high quality RCTs, one fair quality cross-over RCT, one pre-post design study and one systematic review found significant improvements in walking speed following FES, although between-group differences were not reported.

Note: One high quality RCT 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.

References

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Mirror Therapy – Lower Extremity

Evidence Reviewed as of before: 01-11-2018
Author(s)*: Annabel McDermott, OT; Adam Kagan, B.Sc; Samuel Harvey-Vaillancourt, PT U3; Shahin Tavakol, PT U3; Dan Moldoveanu, PT U3; Phonesavanh Cheang, PT U3; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT
Table of contents

Introduction

Mirror therapy is a type of motor imagery whereby the patient moves his unaffected limb while watching the movement in a mirror; this in turn sends a visual stimulus to the brain to promote movement in the affected limb. Some of the effects of mirror therapy on the brain have already been demonstrated. A crossover study on healthy individuals by Garry, Loftus & Summers (2004) showed that viewing the mirror image of an individual’s active hand increased the excitability of neurons in the ipsilateral primary motor cortex significantly more than viewing the inactive hand directly (no mirror). The study also found a trend toward significance in favour of viewing a mirror image of the active hand compared to viewing the active hand directly (no mirror).

While numerous studies have investigated the use of mirror therapy on the upper extremity following stroke, there is a limited body of evidence regarding lower extremity mirror therapy. As more studies become available, the benefits and use of mirror therapy with the lower extremity can be better understood. In order to gain a clearer appreciation for the effect of mirror therapy on lower extremity outcomes, this review includes studies where mirror therapy is provided to the intervention group in isolation rather than as a combined treatment (e.g. mirror therapy with repetitive transcranial magnetic stimulation).

Please also see our Mirror Therapy – Upper Extremity module for studies that have investigated the use of mirror therapy with the upper limbs.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Nine randomized trials (four high quality RCTs, four fair quality RCTs and one poor quality RCT) have studied the use of lower extremity mirror therapy following stroke. Of these:

  • One fair quality study investigated the effect of mirror therapy on balance, mobility and motor function in the acute phase of stroke recovery;
  • Three high quality RCTs involved patients in the subacute phase of recovery and outcomes included functional ambulation, gait and mobility, functional independence, motor recovery, spasticity and range of motion;
  • One high quality RCT and one fair quality RCT involved patients in the chronic phase of recovery and included outcomes of gait and walking speed, motor function and motor recovery, range of motion and spasticity; and
  • The remaining two fair quality RCTs and one poor quality RCT included patients across the recovery continuum and outcomes included balance, gait and walking, motor function and motor recovery.

Comparison interventions included sham mirror therapy, conventional rehabilitation, electrical stimulation and facilitated movement/exercises.

Results Table

View results table

Outcomes

Acute Phase

Balance
Not Effective
2A

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 stroke 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.

Mobility
Effective
2A

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 Ambulation 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 RCT that lower extremity mirror therapy is more effective than a comparison therapy (sham mirror therapy) for improving mobility in patients with acute stroke.

Motor function
Not Effective
2A

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.

Subacute Phase

Functional ambulation
Not Effective
1B

One high quality RCT (Sutbeyaz et al., 2007) investigated the effect of lower extremity mirror therapy on functional ambulation 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. functional ambulation was measured by the functional ambulation 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 ambulation in patients with subacute stroke.

Functional independence
Effective
1B

One high quality RCTs (Sutbeyaz et al., 2007) investigated the effect of lower extremity mirror therapy on functional independence 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. 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.

Gait
Effective
1B

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 stroke.

Mobility
Effective
1B

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.

Motor recovery
Effective
1A

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 stroke.

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 stroke.

Range of motion
Effective
1B

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 dorsiflexion 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 dorsiflexion) in patients with subacute stroke.

Spasticity
Not Effective
1A

Two high quality RCTs (Sutbeyaz et al., 2007; Xu et al., 2017) investigated the effect of lower extremity mirror therapy lower extremity spasticity in patients with subacute stroke.

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 spasticity 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 spasticity 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 spasticity in patients with subacute stroke.

Chronic Phase

Gait
Effective
1b

One high quality RCT (Arya, Pandian & Kumar, 2017) investigated the effect of lower extremity mirror therapy on gait in patients with chronic stroke. 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 stroke.

Motor function
Effective
1B

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.

Motor recovery
Not Effective
1B

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 RCT (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 stroke 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.

Range of motion
Effective
2a

One fair quality RCT (Abo Salem & Huang, 2015) investigated the effect of lower extremity mirror therapy on range of motion in patients with chronic stroke. 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 dorsiflexion 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 dorsiflexion) in patients with chronic stroke.

Spasticity
Not Effective
2A

One fair quality RCT (Abo Salem & Huang, 2015) investigated the effect of lower extremity mirror therapy on spasticity in patients with chronic stroke. 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 spasticity (ankle plantarflexion) in patients with chronic stroke.

Walking speed
Not Effective
1B

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 RCT 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 RCT 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.

Phase of stroke recovery not specific to one period

Balance
Not Effective
2A

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 RCT 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.

Gait
Not Effective
2A

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 gait in patients with stroke.

Note: Mirror therapy with FES was more effective than sham mirror therapy for improving gait following stroke.

Motor function
Not Effective
2B

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 RCT randomized patients with acute/subacute stroke 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.

Motor recovery
Effective
2A

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 RCT 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 RCT 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.

Walking
Effective
2A

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 Ambulation 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.

References

Abo Salem, H.M. & Huang, X. (2015). The effects of mirror therapy on clinical improvement in hemiplegic lower extremity rehabilitation in subjects with chronic stroke. International Journal of Biomedical and Biological Engineering, 9(2), 163-6. DOI: 10.1177/0269215518766642

Arya, K.N., Pandian, S., & Kumar, S.P. (2017, September 26). Effect of activity-based mirror therapy on lower limb motor-recovery and gait in stroke: a randomised controlled trial. Neuropsychological Rehabilitation, DOI: 10.1080/09602011.2017.1377087.

Ji, S.G., Cha, H.-G., Kim, M.-K., & Lee, C.-R. (2014). The effect of mirror therapy integrating functional electrical stimulation on the gait of stroke patients. Journal of Physical Therapy Science, 26(4), 497-9. DOI: 10.1589/jpts.26.497

Ji, S.G. & Kim, M.K. (2014). The effects of mirror therapy on the gait of subacute stroke patients: a randomized controlled trial. Clinical Rehabilitation, 29(4), 348-54. DOI: 10.1177/0269215514542356.

Kawakami, K., Miyasaka, H., Nonoyama, S., Hayashi, K., Tonogai, Y., Tanino, G., Wada, Y., Narukawa, A., Okuyama, Y., Tomita, Y., & Sonoda, S. (2015). Randomized controlled comparative study on effect of training to improve lower limb motor paralysis in convalescent patients with post-stroke hemiplegia. Journal of Physical Therapy Science, 27(9), 2947-50. DOI: 10.1589/jpts.27.2947

Mohan, U., Babu, S.K., Kumar, K.V., Suresh, B.V., Misri, Z.K., Chakrapani, M. (2013). Effectiveness of mirror therapy on lower extremity motor recovery, balance and mobility in patients with acute stroke: a randomized sham-controlled pilot trial. Annals of Indian Academy of Neurology, 16(4), 634-9. DOI: 10.4103/0972-2327.120496

Sütbeyaz S., Yavuzer G., Sezer N., Koseoglu B. F. (2007). Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 88, 555-559. DOI: 10.1016/j.apmr.2007.02.034

Wang, H., Zhao, Z., Jiang, P., Li, X., Lin, Q., & Wu, Q. (2017). Effect and mechanism of mirror therapy on rehabilitation of lower limb motor function in patients with stroke hemiplegia. Biomedical Research, 28(22), 10165-70.

Xu, Q., Guo, F., Salem, H.M.A., Chen, H., & Huang, X. (2017). Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study. Clinical Rehabilitation, 31(12), 1583-91. DOI: 10.1177/0269215517705689

Excluded Studies

Cha, H.-G. & Kim, M.K. (2015). Therapeutic efficacy of low frequency transcranial magnetic stimulation in conjunction with mirror therapy for sub-acute stroke patients. Journal of Magnetics, 20(1), 52-6.
Reason for exclusion: Study compared mirror therapy + rTMS vs. sham mirror therapy + sham rTMS, limiting the ability to compare mirror therapy vs. sham mirror therapy alone.

Cha, H.G. & Oh, D.W. (2016). Effects of mirror therapy integrated with task-oriented exercise on the balance function of patients with poststroke hemiparesis: a randomized-controlled pilot trial. International Journal of Rehabilitation Research, 39(1), 70-6. DOI: 10.1097/MRR.0000000000000148
Reason for exclusion: Participants performed movements in front of mirrors with full view of both sides of the body simultaneously.

Motor Imagery / Mental Practice

Evidence Reviewed as of before: 01-06-2017
Author(s)*: Tatiana Ogourtsova, MSc BSc OT; Annabel McDermott, OT; Angela Kim, B.Sc.; Adam Kagan, B.Sc.; Emilie Belley B.A. Psychology, B.Sc PT; Mathilde Parent-Vachon Bsc PT; Josee-Anne Filion; Alison Nutter; Marie Saulnier; Stephanie Shedleur, Bsc PT; Tsz Ting Wan, BSc PT; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Stephen Page, PhD (C)
Patient/Family Information Table of contents

Introduction

Motor imagery or mental practice/mental imagery/mental rehearsal involves activation of the neural system while a person imagines performing a task or body movement without actually physically performing the movement. Motor imagery has been used after a stroke to attempt to treat loss of arm, hand and lower extremity movement, to help improve performance in activities of daily living, to help improve gait, and to minimize the effects of unilateral spatial neglect. Motor imagery can be used in the acute phase, subacute phase or chronic phase of rehabilitation. It has been shown that while motor imagery is beneficial by itself, it is most effective when used in addition to physical practice. In fact, many of the first studies on motor imagery were designed to investigate whether motor imagery improved motor performance in athletes. Brain scanning techniques have shown that similar areas of the brain are activated during motor imagery and physical movement. In addition, motor imagery has been shown in one study to help the brain reorganize its neural pathways, which may help promote learning of motor tasks after a stroke.

Patient/Family Information

Authors: Tatiana Ogourtsova, MSc BSc OT, Annabel McDermott, OT, Erica Kader; Emilie Belley, BA Psychology, BSc PT; Josee-Anne Filion; Alison Nutter; Mathilde Parent-Vachon; Marie Saulnier; Stephanie Shedleur, Bsc PT; Tsz Ting Wan, BSc PT; Elissa Sitcoff, BA BSc; Nicol Korner-Bitensky, PhD OT

What is motor imagery?

Motor imagery is a form of therapy that can be used to strengthen the arms, hands, feet and legs which may be weakened by stroke. In motor imagery, we mentally rehearse the movement of the affected body parts, without ever actually attempting to perform the movement. In other words, you imagine doing the motion in your mind. For example, you may imagine hitting a golf ball or drinking a cup of tea. Researchers have shown that this “mental rehearsal” actually works, as it stimulates the brain areas responsible for making the weaker arm or leg move.

Courtesy of Dr. Stephen Page and his team at Drake Center and University of Cincinnati

What is motor imagery used for?

It has been used to improve strength, increase hip movements, and improve postural control in the elderly, as well as treat people who have health problems, including injury to the spinal cord, Parkinson’s disease, or fibromyalgia (general muscle pain). It is especially useful for people with problems with the arms, legs, and hands.

Are there different types of motor imagery?

There are two distinct types of motor imagery:

  • Kinaesthetic motor imagery – imagining the feeling associated with performing a movement.
  • Visual motor imagery – imagining the movement itself.

What can I expect from a motor imagery session?

An example of a motor imagery session for a person with a weakened arm might include:

  • 5 minutes of listening to a tape recording of relaxation techniques
  • 20 minutes of exercises related to motor imagery. In week one the mental imagery training involves using computer images and movies to analyze steps and sequences required to successfully complete a task ie. reaching for a cup or turning a page in a book. In week two, patients are trained to identify problems they are having with the tasks and correct them using mental imagery. In the third week, they practice the corrected tasks mentally as well as perform the actual tasks.
  • The session concludes with time given to the individual to refocus on the room around them.

Does it Work for Stroke?

Experts have done experiments to compare mental imagery with other treatments, to see if mental imagery helps people who have had a stroke.

In individuals with ACUTE stroke (up to 1 month after stroke), 1 high quality study and one fair quality study found that mental imagery:

  • Was more helpful than the usual treatment alone for improving self-care skills (e.g. dressing and shopping);
  • Was as helpful as other treatments for improving thinking skills (e.g. attention) and motor function of the arms and legs.

In individuals with SUBACUTE stroke (1 month to 6 months after stroke), 2 high quality studies and 1 fair quality study found that mental imagery:

  • Was more helpful than the usual treatment alone for improving walking speed;
  • Was as helpful as other treatments for improving self-care skills (e.g. dressing) and physical skills of the arms and legs, including mobility, dexterity and grip strength.

In individuals with CHRONIC stroke (more than 6 months after stroke), 10 high quality studies, 6 fair quality studies in 1 poor quality study found that mental imagery:

  • Was more helpful than the usual treatment alone for improving balance, walking speed, and motor function of the arms and legs;
  • Was as helpful as other treatments for improving self-care skills (e.g. dressing and shopping) and spasticity.

When can motor imagery be used after stroke?

Motor imagery techniques can be started at any time following a stroke. However, it is believed that the treatments would be most useful in the first 6 to 18 months after a stroke when the majority of post-stroke recovery occurs.

Are there any risks to me?

There are no specific risks involved in participating in motor imagery. Motor imagery is actually quite easy to do at home, and many people find it a fun and relaxing way of having additional therapy.

How do I begin?

Your rehabilitation therapist should be able to provide you with a program to meet your individual needs. She/He can guide you as to:

  • how many times a week you should do motor imagery exercises,
  • what specific activities and movements you should do,
  • what activities you should not do,
  • how long each motor imagery session should be,
  • how to change activities as you improve.

How much does it cost? Do I need special equipment?

Motor imagery is inexpensive and accessible. Insurance will cover the services that you will receive in the hospital or rehabilitation centre. Once you are home you can continue this treatment on your own. No special equipment is required.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The present module compiled results from 30 RCTs – 16 high quality RCTs, 12 fair quality RCTs and two low quality RCTs – and one non-randomized quasi experimental study. A Cochrane review by Barclay-Goddard et al. (2011) and three systematic reviews by Harris & Hebert (2015), Nilsen, Gillen & Gordon (2010), and Braun et al. (2006) were also reviewed to ensure completeness of results.

Studies were excluded if: (1) they were not RCTs and outcomes within those studies could be found in RCTs; (2) both groups were receiving a form of mental imagery training; and/or (3) no between-group analyses were performed.

Studies included in this review used mental imagery across all stages of stroke recovery, although most studies included individuals in the chronic phase or mixed phases of recovery (acute/subacute/chronic). Overall, mental imagery was often provided in combination with other interventions (e.g. conventional rehabilitation, physical therapy, occupational therapy, electrical stimulation or modified-Constraint Induced Movement Therapy – mCIMT). While in many instances it was found to achieve similar results to other interventions, mental imagery was shown to be more effective than comparison interventions in improving outcomes such as:

  • Acute stroke – functional independence and instrumental activities of daily living;
  • Subacute strokegait speed;
  • Chronic stroke – balance, gait speed, lower extremity motor function, mobility and stroke outcomes.

Note: Mental imagery, motor imagery or mental rehearsal are used interchangeably in this module.

Results Table

View results table

Outcomes

Acute phase

Functional independence
Effective
1b

One high quality RCT (Liu et al., 2004) investigated the effect of mental imagery on functional independence in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Functional independence of trained and untrained tasks was measured by a 7-point Likert Scale at post-treatment (3 weeks) and at follow-up (1 month). Significant between-group differences in functional independence (trained and untrained tasks) were found at post-treatment, favoring mental imagery + ADL training vs. ADL training alone. Significant between-group differences in functional independence (trained tasks only) were found at follow-up, favoring mental imagery + ADL training vs. ADL training alone.
Note: In this study, mental imagery training was aimed at creating a strategy to correct ADLs in general, rather than to improve a particular movement.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is more effective than a comparison intervention (ADL training alone) in improving functional independence in patients with acute stroke.

Instrumental activities of daily living (IADLs)
Effective
2a

One fair quality RCT (Liu et al., 2009) investigated the effect of mental imagery on instrumental activities of daily living (IADLs) in patients with acute stroke. This fair quality RCT randomized patients to receive mental imagery training or conventional functional rehabilitation. IADLs (trained: sweeping, tidying, cooking, going outdoors, going to a shop; untrained: cooking, cleaning, visiting a resource center) were measured at post-treatment (3 weeks). There were significant between-group differences in performance of 3/5 trained tasks (tidying, cooking, going outdoors) and 2/3 untrained tasks (cleaning, visiting a resource center) at post-treatment, favoring mental imagery training vs. conventional functional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mental imagery training is more effective than a comparison intervention (conventional functional rehabilitation) in improving IADLs in patients with acute stroke.

Motor function - lower extremity
Not effective
1b

One high quality RCT (Liu et al., 2004) investigated the effect of mental imagery on lower extremity motor function in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training alone) in improving lower extremity motor function in patients with acute stroke.

Motor function - upper extremity
Not effective
1b

One high quality RCT (Liu et al., 2004) investigated the effects of mental imagery on upper extremity motor function in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training alone) in improving upper extremity motor function in patients with acute stroke.

Sensation
Not effective
1b

One high quality RCT (Liu et al., 2004) investigated the effect of mental imagery on sensation in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Sensation was measured by the Fugl-Meyer Assessment – Sensation subtest at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training) in improving sensation in patients with acute stroke.

Sustained visual attention
Not effective
1b

One high quality RCT (Liu et al., 2004) investigated the effects of mental imagery on sustained visual attention in patients with acute stroke. This high quality RCT randomized patients to receive mental imagery + activity of daily living (ADL) training or ADL training alone. Sustained attention was measured by the Color Trails Test at post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + ADL training is not more effective than a comparison intervention (ADL training alone) in improving sustained attention in patients with acute stroke.

Subacute phase

Dexterity
Not effective
1b

One high quality RCT (Ietswaart et al., 2011) investigated the effect of mental imagery on dexterity in patients with subacute stroke. This high quality RCT randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Dexterity was measured by a timed manual dexterity task at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving dexterity in patients with subacute stroke.

Functional independence
Not effective
1b

One high quality RCT (Ietswaart et al., 2011) investigated the effect of mental imagery on functional independence in patients with subacute stroke. This high quality RCT randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Functional independence was measured by the Barthel Index and the Modified Functional Limitations Profile at post-treatment (4 weeks). No significant between-group differences were found on any of the measures.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving functional independence in patients with subacute stroke.

Gait speed
Effective
1b

One high quality RCT (Oostra et al., 2015) investigated the effect of mental imagery on gait speed in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mental imagery practice or muscle relaxation. gait speed was measured by the 10 Meter Walking Test at post-treatment (6 weeks). Significant between-group differences were found at post-treatment, favoring lower extremity mental imagery practice vs. muscle relaxation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mental imagery practice is more effective than a comparison intervention (muscle relaxation) in improving gait speed in patients with subacute stroke.

Grip strength
Not effective
1b

One high quality RCT (Ietswaart et al., 2011) investigated the effect of mental imagery on grip strength in patients with subacute stroke. This high quality RCT randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Grip strength was measured with a dynamometer at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving grip strength in patients with subacute stroke.

Motor function - lower extremity
Not effective
1b

One high quality RCT (Oostra et al., 2015) investigated the effect of mental imagery on lower extremity motor function in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mental imagery practice or muscle relaxation. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity (far transfer) at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mental imagery practice is not more effective than a comparison intervention (muscle relaxation) in improving lower extremity motor function in patients with subacute stroke.

Motor function - upper extremity
Not effective
1b

One high quality RCT (Ietswaart et al., 2011) and one fair quality RCT (Riccio et al., 2010) investigated the effect of mental imagery on upper extremity motor function in patients with subacute stroke.

The high quality RCT (Ietswaart et al., 2011) randomized patients to receive mental rehearsal training, non-motor mental rehearsal training or conventional rehabilitation. Upper extremity motor function was measured by the Action Research Arm Test at post-treatment (4 weeks). No significant between-group differences were found.

The fair quality RCT (Riccio et al., 2010) randomized patients to receive mental rehearsal training + conventional rehabilitation or conventional rehabilitation alone, in a cross-over design study. Upper extremity motor function was measured by the Motricity Index – Upper Extremity subscale (MI-UE) and the Arm Functional Test – Functional Ability Scale and Time score (AFT-FAS, AFT-T) score at post-treatment of Phase 1 (3 weeks) and post-treatment of Phase 2 (6 weeks). Significant between-group differences were found on all measures of upper extremity motor function at both time points, in favour of the group that had just undergone mental rehearsal training + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental rehearsal training is not more effective than comparison interventions (non-motor mental rehearsal training, conventional rehabilitation) in improving upper extremity motor function in patients with subacute stroke.
Note:
However, one cross-over fair quality RCT found that mental rehearsal training + conventional rehabilitation was more effective than conventional rehabilitation alone in improving upper extremity motor function in patients with subacute stroke.

Motor imagery ability
Not effective
1b

One high quality RCT (Oostra et al., 2015) investigated the effect of mental imagery on motor imagery ability in patients with subacute stroke. This high quality RCT randomized patients to receive lower extremity mental imagery practice or muscle relaxation. Motor imagery ability was measured by the Movement Imagery Questionnaire Revised – Visual and Kinesthetic scales, and the Walking Trajectory Test (imagery/actual walking time) at post-treatment (6 weeks). There was a significant between-group difference on only one measure (Movement Imagery Questionnaire Revised – kinesthetic scale) at post-treatment, favoring lower extremity mental imagery practice vs. muscle relaxation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that lower extremity mental imagery practice is not more effective than a comparison intervention (muscle relaxation) in improving motor imagery ability in patients with subacute stroke.
Note:
However, there was a significant difference in kinaesthetic motor imagery, in favour of lower extremity mental imagery practice vs. muscle relaxation.

Chronic phase

Balance
Effective
1a

Four high quality RCTs (Hwang et al., 2010; Cho et al., 2012; Hosseini et al., 2012; Kim & Lee, 2013) investigated the effect of mental imagery on balance in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Balance was measure by the Berg Balance Scale (BBS) at post-treatment (4 weeks). Significant between-group differences were found in balance, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Cho et al., 2012) randomized patients to receive mental imagery + gait training or gait training alone. Balance was measured by the Functional Reach Test (FRT) at post-treatment (6 weeks). Significant between-group differences were found in balance, favoring mental imagery + gait training vs. gait training alone.

The third high quality RCT (Hosseini et al., 2012) randomized patients to receive mental imagery + occupational therapy or occupational therapy alone. Balance was measured by the BBS at post-treatment (5 weeks) and at follow-up (7 weeks). Significant between-group differences were found in balance at post-treatment, favoring mental imagery + occupational therapy vs. occupational therapy alone. Differences did not remain significant at follow-up.

The forth high quality RCT (Kim & Lee, 2013) randomized patients to receive mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone. Balance was measured by the FRT at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that mental imagery training is more effective than comparison interventions (sham imagery training, gait training alone, occupational therapy alone) in improving balance in patients with chronic stroke. However, a fourth high quality RCT reported no significant between-group differences when comparing mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone in improving balance in patients with chronic stroke.

Balance confidence
Conflicting
4

Two high quality RCTs (Hwang et al., 2010 Dickstein et al., 2013) investigated the effect of mental imagery on balance confidence in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Balance confidence was measure by the Activities Specific Balance Confidence Scale at post-treatment (4 weeks). Significant between-group differences were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Dickstein et al., 2013) randomized patients to receive mental imagery training or physical therapy. Balance confidence was measured by the Falls Efficacy Scale at post-treatment (4 weeks) and at follow-up (6 weeks). No significant between-group differences were found at either time point.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery on balance confidence in patients with chronic stroke. While one high quality RCT found that videotape-based locomotor imagery training was more effective than sham mental imagery training, one second high quality RCT found that mental imagery training was not more effective than physical therapy in improving balance confidence in patients with chronic stroke.
Note:
Studies used different measures of balance confidence.

Functional independence
Not effective
1a

Two high quality RCTs (Bovend’Eerdt et al., 2010; Hong et al., 2012) investigated the effect of mental imagery on functional independence in patients with chronic stroke.

The first high quality RCT (Bovend’Eerdt et al., 2010) randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Functional independence was measured by the Barthel Index (BI) at post-treatment (6 weeks). No significant between-group differences were found.

The second high quality RCT (Hong et al., 2012) randomized patients to receive mental imagery with electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Functional independence was measured by the modified BI at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, functional electric stimulation) in improving functional independence in patients with chronic stroke.

Gait parameters
Conflicting
4

Two high quality RCTs (Hwang et al., 2010 Kim & Lee, 2013) and one fair quality RCT (Lee et al., 2011) investigated the effect of mental imagery on gait parameters in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. gait parameters (cadence, joint motion, stride length) were measured by a 3D motion capture system at post-treatment (4 weeks). Significant between-group differences in some gait parameters (joint motion, stride length) were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Kim & Lee, 2013) randomized patients to receive mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone. gait parameters (cadence, speed, single/double limb support, step/stride length) were measured by the GAITRite system at post-treatment (4 weeks). There were significant between-group differences in three gait parameters (cadence, speed, single limb support) at post-treatment, favoring action observation training + physical therapy vs. physical therapy alone.

The fair quality RCT (Lee et al., 2011) randomized patients to receive mental imagery + treadmill training or treadmill training alone. gait parameters (cadence, speed, single/double limb support, step/stride length) were measured at post-treatment (2 weeks following a 6-week treatment block). No significant between-group differences were found.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery training on gait parameters in patients with chronic stroke. While one high quality RCT found that videotape-based locomotor imagery training is more effective than a comparison intervention (sham mental imagery training) in improving some gait parameters in patients with chronic stroke, another high quality RCT and one fair quality RCT found that mental imagery training is not more effective than comparison interventions (action observation training with physical therapy, physical therapy alone, treadmill training alone) in improving gait parameters in patients with chronic stroke.

Gait speed
Effective
1a

Three high quality RCTs (Hwang et al., 2010; Cho et al., 2012;Dickstein et al., 2013) investigated the effect of mental imagery on gait speed in patients with chronic stroke.

The first high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. gait speed was measured by the 10 Meter Walk Test (10MWT) at post-treatment (4 weeks). Significant between-group differences were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The second high quality RCT (Cho et al., 2012) randomized patients to receive mental imagery + gait training or gait training alone. gait speed was measured by the 10MWT at post-treatment (6 weeks). Significant between-group differences were found in gait speed at post-treatment, favoring mental imagery + gait training vs. gait training alone.

The third high quality RCT (Dickstein et al., 2013) randomized patients to receive mental imagery training or physical therapy. gait speed was measured by the 10MWT at post-treatment (4 weeks) and at follow-up (6 weeks). Significant between-group differences were found at both time points, favoring mental imagery training vs. physical therapy.
Note: Further, all participants who received physical therapy crossed-over to receive mental imagery training for 4 weeks. A significant improvement in gait speed was reported among those participants at both time points.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that mental imagery training is more effective than comparison interventions (sham imagery training, gait training alone, physical therapy) in improving gait speed in patients with chronic stroke.

Goal attainment
Not effective
1b

One high quality RCT (Bovend’Eerdt et al., 2010) investigated the effect of mental imagery training on goal attainment in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Goal attainment was measured by the Goal Attainment Scale at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (conventional rehabilitation alone) in improving goal attainment in patients with chronic stroke.

Instrumental activities of daily living (IADLs)
Not effective
1b

One high quality RCT (Bovend’Eerdt et al., 2010) investigated the effect of mental imagery training on instrumental activities of daily living (IADLs) in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. IADLs were measured by the Nottingham Extended activities of Daily Living at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (conventional rehabilitation alone) in improving IADLs in patients with chronic stroke.

Mobility
Conflicting
4

Seven high quality RCTs (Malouin et al., 2009Bovend’Eerdt et al., 2010Hwang et al., 2010; Cho et al., 2012Hosseini et al., 2012Dickstein et al., 2013Kim & Lee, 2013) investigated the effect of mental imagery training on mobility in patients with chronic stroke.

The first high quality RCT (Malouin et al., 2009) randomized patients to receive mental imagery + physical practice, cognitive training + physical practice, or no training. Mobility was measured by the change scores in leg loading of the affected leg as a percent of body weight during the rising-to-sitting action at baseline, post-treatment (4 weeks) and follow-up (7 weeks). Significant between-group differences in change scores from baseline to post-treatment were found, favoring mental imagery training + physical practice vs. cognitive training + physical practice; and favoring mental imagery training + physical practice vs. no training. Significant between-group differences were not maintained at follow-up.

The second high quality RCT (Bovend’Eerdt et al., 2010) randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Mobility was measured by the Timed Up and Go Test (TUGT) and the Rivermead Mobility Index at post-treatment (6 weeks). No significant between-group differences were found on any of the measures.

The third high quality RCT (Hwang et al., 2010) randomized patients to receive videotape-based locomotor imagery training or sham imagery training. Mobility was measured by the Dynamic Gait Index and the Modified Emory Functional Ambulation Profile at post-treatment (4 weeks). Significant between-group differences in both measures of mobility were found, favoring videotape-based locomotor imagery training vs. sham imagery training.

The forth high quality RCT (Cho et al., 2012) randomized patients to receive mental imagery + Gait training or Gait training alone. Mobility was measured by the TUGT at post-treatment (6 weeks). Significant between-group differences were found, favoring mental imagery + Gait training vs. Gait training alone.

The fifth high quality RCT (Hosseini et al., 2012) randomized patients to receive mental imagery + occupational therapy or occupational therapy alone. Mobility was measured by the TUGT at post-treatment (5 weeks) and at follow-up (7 weeks). Significant between-group differences were found at post-treatment, favoring mental imagery + occupational therapy vs. occupational therapy alone. Significant between-group differences were not maintained at follow-up.

The sixth high quality RCT (Dickstein et al., 2013) randomized patients to receive mental imagery training or physical therapy. Mobility was measured by step activity monitor (community ambulation) and number of steps/minute at post-treatment (4 weeks) and at follow-up (6 weeks). There were no significant between-group differences in both measures of mobility at either time point.

The seventh high quality RCT (Kim & Lee, 2013) randomized patients to receive mental imagery + physical therapy, action observation training + physical therapy or physical therapy alone. Mobility was measured by the TUGT, Walking Ability Questionnaire, and Functional Ambulation Category at post-treatment (4 weeks). A significant between-group difference in one measure of mobility (TUGT) was found at post-treatment, favoring action observation training + physical therapy vs. physical therapy alone.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery on mobility in patients with chronic stroke. While four high quality RCTs found that mental imagery training is more effective than comparison interventions (cognitive training + physical practice, no training, sham imagery training, Gait training alone, occupational therapy alone) in improving mobility in patients with chronic stroke; three other high quality RCTs found that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, physical therapy, action observation training + physical therapy) in improving mobility in patients with chronic stroke.

Motor activity - upper extremity
Not effective
1b

One high quality RCT (Hong et al., 2012) and one fair quality RCT (Page et al., 2005) investigated the effect of mental imagery on upper extremity motor activity among patients with chronic stroke.

The high quality RCT (Hong et al., 2012) randomized patients to receive mental imagery + electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Upper extremity motor activity was measured by the Motor Activity Log – Amount of Use and Quality of Movement (MAL-AOU, MAL-QOM) at post-treatment (4 weeks). No significant between-group differences were found.

The fair quality RCT (Page et al., 2005) randomized patients to receive mental imagery training or relaxation training. Upper extremity motor activity was measured by the MAL at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fair quality RCT that mental imagery training is not more effective than comparison interventions (functional electrical stimulation to the affected forearm, relaxation training) in improving upper extremity motor activity in patients with chronic stroke.

Motor function - lower extremity
Effective
1b

One high quality RCT (Cho et al., 2012) investigated the effect of mental imagery on lower extremity motor function in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + gait training or gait training alone. Lower extremity motor function was measured by the Fugl-Meyer Assessment – Lower Extremity at post-treatment (6 weeks). Significant between-group differences were found, favoring mental imagery + gait training vs. gait training alone.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + gait training is more effective than a comparison intervention (gait training alone) in improving lower extremity motor function in patients with chronic stroke.

Motor function - upper extremity
Conflicting
4

Four high quality RCTs (Bovend’Eerdt et al., 2010Page et al., 2011;Hong et al., 2012Nilsen et al., 2012) and five fair quality RCTs (Page, 2000Page et al., 2005Ertelt et al., 2007Page et al., 2007Page et al., 2009) investigated the effect of mental imagery on upper extremity motor function in patients with chronic stroke.

The first high quality RCT (Bovend’Eerdt et al., 2010) randomized patients to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Upper extremity motor function was measured by the Action Research Arm Test (ARAT) at post-treatment (6 weeks). No significant between-group differences were found.

The second high quality RCT (Page et al., 2011) randomized patients to receive mental imagery or sham audio therapy. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE) and the ARAT at post-treatment (10 weeks). No significant between-group differences were found on any of the measures.

The third high quality RCT (Hong et al., 2012) randomized patients to receive mental imagery + electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. Upper extremity motor function was measured by the FMA-UE at post-treatment (4 weeks). Significant between-group differences in upper extremity motor function were found at post-treatment, favoring mental imagery + electromyogram-triggered electric stimulation vs. functional electric stimulation to the affected forearm.

The forth high quality RCT (Nilsen et al., 2012) randomized patients to receive mental imagery training using an internal perspective (internal group), mental imagery training using an external perspective (external group), or relaxation imagery; all groups received occupational therapy. Upper extremity motor function was measured by the FMA-UE and the Jebsen-Taylor Test of Hand Function at post-treatment (6 weeks). Significant between-group differences were found on both measures, favoring both styles of mental imagery training (internal group, external group) vs. relaxation imagery.

The first fair quality RCT (Page, 2000) randomized patients to receive mental imagery training + occupational therapy or occupational therapy alone. Upper extremity motor function was measured by the FMA-UE at post-treatment (4 weeks). Significant between-group differences were found at post-treatment, favoring mental imagery training + occupational therapy vs. occupational therapy alone.

The second fair quality RCT (Page et al., 2005) randomized patients to receive mental imagery training or relaxation training. Upper extremity motor function was measured by the ARAT at post-treatment (6 weeks). Significant between-group differences were found, favoring mental imagery training vs. relaxation training.

The third fair quality RCT (Ertelt et al., 2007) randomized patients to receive action observation therapy or conventional rehabilitation. Upper extremity motor function was measured by the Frenchay Arm Test and the Wolf Motor Function Test at post-treatment (18 days); participants in the action observation group were reassessed 8 weeks later (follow-up). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment, favoring action observation therapy vs. conventional rehabilitation. Significant within-group gains were maintained at follow-up.

The forth fair quality RCT (Page et al., 2007) randomized patients to receive mental imagery training or relaxation training. Upper extremity motor function was measured by the ARAT and the FMA-UE at post-treatment (1 week following a 6-week treatment). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment, favoring mental imagery training vs. relaxation training.

The fifth fair quality RCT (Page et al., 2009) randomized patients to receive mental imagery + modified-constraint induced therapy (mCIMT) or mCIMT alone. Upper extremity motor function was measured by the ARAT and the FMA-UE at post-treatment (10 weeks) and follow-up (3 months). Significant between-group differences were found on both measures of upper extremity motor function at post-treatment and at follow-up, favoring mental imagery training + mCIMT vs. mCIMT alone.

Conclusion: There is conflicting evidence (Level 4) regarding the effect of mental imagery on upper extremity motor function. While two high quality RCTs found that mental imagery was not more effective than comparison interventions (conventional rehabilitation alone, sham audio therapy) in improving upper extremity motor function in patients with chronic stroke; two other high quality RCTs found that mental imagery was more effective than comparison interventions (functional electric stimulation to the affected forearm, relaxation imagery) in improving upper extremity motor function in patients with chronic stroke.
Note:
Five fair quality RCTs found that mental imagery training is more effective than comparison interventions (occupational therapy alone, relaxation training, conventional rehabilitation, mCIMT alone) in improving upper extremity motor function in patients with chronic stroke.

Occupational performance
Not effective
1b

One high quality RCT (Nilsen et al., 2012) investigated the effect of mental imagery on occupational performance in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery training using an internal perspective (internal group), mental imagery training using an external perspective (external group), or relaxation imagery; all groups received occupational therapy. Occupational performance was measure by the Canadian Occupational Performance Measure at post-treatment (6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery training using an internal or external perspective is not more effective than a comparison intervention (relaxation imagery) in improving occupational performance in patients with chronic stroke.

Pain
Not effective
2b

One poor quality RCT (Cacchio et al., 2009) investigated the effect of mental imagery on pain in patients with chronic stroke. This poor quality RCT randomized patients with Complex Regional Pain Syndrome (CRPS) to receive mental imagery, mirror therapy or covered mirror practice. Pain was measured by Visual Analogue Scale at post-treatment (4 weeks). Significant between-group differences were found, favoring mirror therapy vs. mental imagery and favouring mirror therapy vs. covered mirror practice.
Note: Following 4 weeks, some participants crossed-over to the mirror therapy group. A significant reduction in pain was reported among participants who crossed-over from the mental imagery and covered mirror practice groups to the mirror therapy group.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that mental imagery is not more effective than comparison interventions (mirror therapy, covered mirror practice) in improving pain in patients with chronic stroke and CRPS. In fact, mirror therapy was more effective than mental imagery in reducing pain.

Spasticity
Not effective
1b

One high quality RCT (Hong et al., 2012) investigated the effect of mental imagery training on spasticity in patients with chronic stroke. This high quality RCT randomized patients to receive mental imagery + electromyogram-triggered electric stimulation or functional electric stimulation to the affected forearm. spasticity was measured by the Modified Ashworth Scale at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + electromyogram-triggered electric stimulation is not more effective than a comparison intervention (functional electric stimulation to the affected forearm) in improving spasticity in patients with chronic stroke.

Stroke outcomes
Effective
2a

One fair quality RCT (Ertelt et al., 2007) investigated the effect of mental imagery on stroke outcomes in patients with chronic stroke. This high quality RCT randomized patients to receive action observation therapy or conventional rehabilitation. stroke outcomes were measured by the stroke Impact Scale at post-treatment (18 days); participants in the action observation group were reassessed 8 weeks later (follow-up). Significant between-group differences were found at post-treatment, favoring action observation therapy vs. conventional rehabilitation. Significant within-group gains were maintained at follow-up.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that action observation training is more effective than a comparison intervention (conventional rehabilitation) in improving stroke outcomes in patients with chronic stroke.

Phase not specific to one period

Balance
Not effective
1a

Two high quality RCTs (Braun et al., 2012; Schuster et al., 2012) investigated the effect of mental imagery on balance in patients with stroke.

The first high quality RCT (Braun et al., 2012) randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Balance was measured by the Berg Balance Scale (BBS) at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point. 

The second high quality RCT (Schuster et al., 2012) randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training or time-matched stroke education tapes; all groups received physical therapy. Balance was measured by the BBS at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, time-matched stroke education tapes) in improving balance in patients with stroke.

Balance confidence
Not effective
1b

One high quality RCT (Schuster et al., 2012) investigated the effect of mental imagery training on balance confidence in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive embedded mental imagery training or added mental imagery training or time-matched stroke education tapes; all groups received physical therapy. Balance confidence was measured by the Activities-Specific Balance Confidence Scale at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that embedded or added mental imagery is not more effective than a comparison intervention (time-matched stroke education tapes) in improving balance confidence in patients with subacute/chronic stroke.

Dexterity
Not effective
1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery on dexterity in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Dexterity was measured by the Nine Hole Peg Test at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery is not more effective than a comparison intervention (conventional rehabilitation alone) in improving dexterity in patients with acute/subacute stroke.

Functional independence
Not effective
1a

Three high quality RCTs (Braun et al., 2012Schuster et al., 2012Timmermans et al., 2013), one fair quality RCT (Ferreira et al., 2011) and one poor quality RCT (Park et al., 2015) investigated the effect of mental imagery on functional independence in patients with stroke.

The first high quality RCT (Braun et al., 2012) randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Functional independence was measured by the Barthel Index (BI); patients’ and therapists’ perception of performance of daily activities (e.g. drinking, walking) was measured by a 10-point numeric rating scale at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found on either measure at either time point.

The second high quality RCT (Schuster et al., 2012) randomized patients with subacute/chronic stroke to receive embedded mental imagery training, added mental imagery training, or time-matched stroke education tapes; all groups received physical therapy. Functional independence was measured by the BI at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

The third high quality RCT (Timmermans et al., 2013) randomized patients with acute/subacute stroke to receive mental imagery or neurodevelopmental therapy; both groups received conventional rehabilitation. Functional independence was measured by the BI at post-treatment (6 weeks) and at follow-up (6 and 12 months). No significant between-group differences were found at any time point.

The fair quality RCT (Ferreira et al., 2011) randomized patients with subacute/chronic stroke to receive mental imagery + conventional rehabilitation, visual scanning training + conventional rehabilitation, or conventional rehabilitation alone. Functional independence was measured by the Functional Independence Measure (FIM) at post-treatment (5 weeks) and at follow-up (3 months). There were no significant differences between mental imagery + conventional rehabilitation and other treatment groups at either time point.
Note: Significant between-group differences in functional independence (FIM – self-care items only) were found at post-treatment, favoring visual scanning + conventional rehabilitation vs. conventional rehabilitation alone. Differences did not remain significant at follow-up.

The poor quality RCT (Park et al., 2015) randomized patients with subacute/chronic stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. Functional independence was measured by the modified BI at post-treatment (2 weeks). Significant between-group differences were found, favoring mental imagery + conventional rehabilitation vs. conventional rehabilitation alone.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs and one fair quality RCT that mental imagery is not more effective than comparison interventions (conventional rehabilitation alone, time-matched stroke education tapes, neurodevelopmental therapy, visual scanning training + conventional rehabilitation) in improving functional independence in patients with stroke.
Note
: One poor quality RCT found that mental imagery training + conventional rehabilitation is more effective than a comparison intervention (conventional rehabilitation alone) in improving functional independence in patients with subacute/chronic stroke.

Gait speed
Not effective
1b

One high quality RCT (Braun et al., 2012) investigated the effect of mental imagery on gait speed in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive mental imagery + conventional rehabilitation or conventional rehabilitation alone. gait speed was measured by the 10 Meter Walk Test at post-treatment (6 weeks) and at follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that mental imagery + conventional rehabilitation is not more effective than a comparison intervention (conventional rehabilitation alone) in improving gait speed in patients with acute/subacute stroke.

Grip strength
Effective
2a

One fair quality RCT (Muller et al., 2007) investigated the effect of mental imagery on grip strength in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive mental imagery training, motor practice training or conventional physical therapy. Grip strength was measured by a force transducer at post-treatment (4 weeks). Significant between-group differences were found, favoring mental imagery vs. physical therapy l rehabilitation and favoring motor practice vs. physical therapy rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that mental imagery training is more effective than a comparison intervention (conventional physical therapy) in improving grip strength in patients with acute/subacute stroke.

Instrumental activities of daily living (IADLs)
Not effective
1b

One high quality RCT (Timmermans et al., 2013) investigated the effect of mental imagery on instrumental activities of daily living (IADLs) in patients with stroke. This high quality RCT