Contralaterally Controlled FES of Arm & Hand for Subacute Stroke Rehabilitation
Condition: Stroke; Hemiparesis; Hemiplegia
MeSH terms: Stroke; Hemiplegia; Paresis
Study type: Interventional

Summary: 
      Impaired arm and hand function is one of the most disabling and most common consequences of
      stroke. The Investigators have developed Contralaterally Controlled Functional Electrical
      Stimulation (CCFES), an innovative neuromuscular electrical stimulation (NMES) treatment for
      improving the recovery of hand function after stroke. The purpose of this study is to
      maximize the treatment effect of CCFES by adding stimulated elbow extension. The specific
      aims and hypotheses are as follows:

      AIM 1: Estimate the effect of Arm+Hand CCFES on upper limb motor impairment and activity
      limitation.

      Hypothesis 1: Stroke survivors treated with Arm+Hand CCFES have better outcomes on upper limb
      impairment and activity limitation measures than those treated with dose-matched Arm+Hand
      Cyclic NMES.

      AIM 2: Estimate the effect of adding stimulated elbow extension to Hand CCFES.

      Hypothesis 2: Stroke survivors treated with Arm+Hand CCFES will have greater reductions in
      upper limb impairment and activity limitation than those treated with Hand CCFES.

      AIM 3: Describe the relationship between treatment effect and time elapsed between stroke
      onset and start of treatment.

      Hypothesis 3: Patients who start Arm+Hand CCFES sooner after their stroke achieve better
      outcomes.
    

Detailed description: 
      Loss of arm and hand function is a severely disabling condition that occurs in nearly 75% of
      the estimated 795,000 Americans who have a new or recurrent stroke each year [Roger 2011].
      Upper limb impairment is often characterized by inability to extend the elbow and open the
      hand. The hope of regaining lost motor function after stroke has been fueled in recent years
      by the development of new rehabilitation therapies and devices that are aimed at promoting
      the brain's capacity to reorganize after injury in such a way that restores motor control of
      paretic limbs [Nudo 2001]. The Investigators' long-term objective is to develop stroke
      rehabilitation treatments for the hemiparetic upper limb that are optimized for
      effectiveness, applicability, and deployability.

      The primary objective of this project is to estimate the effect of Arm+Hand Contralaterally
      Controlled Functional Electrical Stimulation (CCFES) in reducing upper limb motor impairment
      and activity limitation in subacute hemiplegia. CCFES is a treatment aimed at improving
      recovery of volitional motor function in stroke survivors [Knutson 2007; Knutson 2009;
      Knutson 2010]. Hand CCFES activates finger and thumb extensors with an intensity of
      electrical stimulation that is proportional to the degree of opening of the contralateral
      unimpaired hand wearing an instrumented glove. Thus, volitional opening of the nonparetic
      hand produces stimulated opening of the paretic hand. The Hand CCFES system enables stroke
      patients to use their impaired hand to practice functional tasks in therapy sessions. CCFES
      incorporates the following features considered to be important to motor recovery and
      promoting neuroplasticity: synchronization of motor intent with motor execution of paretic
      hand opening [Rushton 2003; Kimberley 2004], bilateral symmetric movement [Luft 2004],
      intensive repetitive hand opening exercises [Lang 2009], and the practice of functional tasks
      [Nudo 2003]. In a pilot case series study of patients with chronic (> 6 months) post-stroke
      hemiplegia, all 6 participants experienced some reduction of upper limb motor impairment
      after several weeks of Hand CCFES [Knutson 2007; Knutson 2009]. The results of a Phase I
      randomized clinical trial (RCT) of Hand CCFES in 21 patients with subacute (≤ 6 months)
      hemiplegia suggested that Hand CCFES may be superior to cyclic neuromuscular electrical
      stimulation (NMES) in reducing upper extremity impairment and activity limitation [Knutson
      2011].

      In this study, added to the Hand CCFES treatment is stimulated elbow extension controlled by
      the contralateral elbow. This "next generation" CCFES treatment is called Arm+Hand CCFES.
      Arm+Hand CCFES therapy is intended to strengthen and improve the motor control of the
      proximal upper limb as well as the hand, to improve simultaneous reaching and hand opening, a
      functionally critical movement pattern that is often prevented by paresis and post-stroke
      flexor synergies. The secondary objective of this project is to evaluate the effect of adding
      elbow extensor stimulation to the Hand CCFES treatment.

      Stroke survivors who are ≤ 2 years post-stroke with upper limb hemiplegia will be randomly
      assigned to receive 12 weeks of either Arm+Hand CCFES (stimulates elbow extension and hand
      opening), Hand CCFES (stimulates hand opening), or Arm+Hand Cyclic NMES (stimulates elbow
      extension and hand opening but with pre-set timing and intensity, i.e., not
      intention-driven), plus lab-based therapist-guided task practice. Upper limb impairment and
      activity limitation will be assessed at baseline, 6, 12, 20, 28, and 36 weeks.

      This is the first randomized controlled trial of Arm+Hand CCFES in subacute upper extremity
      hemiplegia. Ultimately, the information learned in this study will serve to accelerate the
      development of a new treatment for reducing post-stroke disability.
    

Intervention name(s): Electrical Stimulator
Intervention type(s): Device
Intervention description(s): The 12-week treatment period consists of two components:
Therapist-guided task practice performed 70 minutes twice a week in the research laboratory. If Arm+Hand CCFES or Hand CCFES, the stimulator is used during task practice.
Self-administered muscle stimulation exercise performed 10 sessions per week at home using the device. If Arm+Hand CCFES or Hand CCFES, each session is 46 minutes. If Arm+Hand Cyclic NMES, each session is 60 minutes.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: hand; arm; stroke; hemiplegia; electrical stimulation; recovery; rehabilitation