Electrical Stimulation for Recovery of Hand Function in Chronic Stroke Survivors

Hemiparesis of the upper limb is one of the most serious and most common impairments
resulting from stroke. Approximately 75% of the over 750,000 strokes that occur annually in
the United States cause some degree of upper extremity paralysis. Approximately 65% of stroke
survivors still cannot use their affected hand to assist with activities of daily living 6
months after their stroke. The impact of upper extremity impairments on disability and health
is great, yet there are relatively few rehabilitation interventions designed to restore
function to the impaired upper limb. Therefore, our long-term objective is to develop upper
extremity rehabilitation therapies that are effective at restoring arm and hand function,
that are applicable across a wide range of impairment severity, and that are readily
implemented in the present healthcare environment.

The purpose of this study is to estimate the efficacy of Contralataterally Controlled
Functional Electrical Stimulation (CCFES) in reducing upper extremity impairment and activity
limitation in chronic upper extremity hemiplegia. CCFES is a rehabilitation intervention in
which neuromuscular electrical stimulation (NMES) is applied to the finger and thumb extensor
muscles of the paretic upper limb to open the hand. The stroke survivor controls the
stimulation intensity, and consequent degree of hand opening, by modulating the degree of
opening of the contralateral unimpaired hand, which is detected by an instrumented glove.
Thus, volitional opening of the unaffected hand produces stimulated opening of the affected
hand. The stimulation paradigm is used to assist the stroke survivor in practicing functional
tasks with their affected hand. We will conduct a randomized controlled trial in which
chronic stroke survivors (>6 months post-stroke) will be randomly assigned to receive 12
weeks of CCFES or cyclic NMES, an intervention that provides electrical stimulation of the
hand extensors, but with preprogrammed timing and intensity. Randomization will be stratified
on two levels of baseline hand impairment defined by the degree of voluntary finger extension
present. Assessments of upper extremity impairment and activity limitation will be made every
3 weeks during the treatment period and every 2 months during a 6-month follow-up period.

This study is the first randomized controlled trial of CCFES in chronic upper extremity
hemiplegia. Ultimately, the information learned in this study will serve to accelerate the
development of treatments for reducing post-stroke disability.

Inclusion Criteria:

- Age 18-80

- > 6 months of first hemorrhagic or nonhemorrhagic stroke

- Able to recall 2 of 3 items after 30 minutes

- MRC ≤ 4 for finger extensors on paretic side

- Able to follow 3-stage commands

- Functional movement of shoulder and elbow (e.g., can reach ¾ hand-to- mouth movement)
of paretic side

- Caregiver available to assist with device and compliance if needed

- Skin intact on hemiparetic arm

- Medically stable

- Surface NMES trial opens hand without pain

- Full volitional hand opening/closing of contralateral hand

- Upper extremity hand section of FMA < 11/14

- Able to hear and respond to stimulator/cue box auditory cues

- Completed occupational therapy (no concomitant OT)

Exclusion Criteria:

- Lack of functional PROM of the wrist or fingers of affected side

- Severe shoulder or hand pain (unable to position hand in the workspace without pain)

- Uncontrolled seizure disorder

- Insensate forearm and/or hand

- Uncompensated hemi-neglect (extinguishing to double simultaneous stimulation)

- Edema of the affected forearm and/or hand

- History of cardiac arrhythmias with hemodynamic instability

- Cardiac pacemaker or other implanted electronic system

- Pregnant

- IM Botox injections in any UE muscle in the last 3 months

- Parkinson's disease, SCI, TBI, or MS

- Ipsilateral motor neuron lesion