Effect of Functional Electrical Stimulation on Upper Limb Motor Functions in Patient with Chronic Stroke-A Case Report

Background: Literature shows that intensive Functional Electrical Stimulation facilitates upper limb motor recovery after Stroke. Aim: To assess the effects of 4 weeks of FES therapy on right upper limb motor functions in patient with Chronic Stroke. Materials and Methods: The participant was thirty year old male Right Hemiparesis who had experienced Chronic Ischemic Stroke. FES therapy was given for forty five minutes per session, three sessions a week for complete four weeks. The pre and post intervention score were measured with Fugl Meyer Assessment, Voluntary Control Grading and MAS. Results: The Fugl Meyer Assessment score for right upper limb showed improvement with progression in stage of VCG for right upper limb and hand. Also improved MAS score was noted for right shoulder, elbow and hand muscles. Conclusion: The current study confirms that application of FES therapy improves upper limb motor functions in Chronic stage of Stroke after 4 weeks. Case study Zanwar et al.; JPRI, 33(29B): 199-203, 2021; Article no.JPRI.68845 200


INTRODUCTION
Stroke is defined as a clinical syndrome of presumed vascular origin, typified by rapidly developing signs of focal or global disturbances of cerebral function lasting for more than twenty four hours or leading to death (World Health Organization) [1].
Stroke is classified into Anterior cerebral artery infarct (ACA), Middle cerebral artery infract (MCA) and Posterior cerebral artery infarct (PCA) [2]. The blockage in Middle cerebral artery is the most common type in stroke. The most common impairments of MCA infarct are spastic hemiparesis and sensory loss with the face and upper extremity more involved than lower extremity and is associated with lesions in Motor and Sensory Cortex [3,4] FES is the recent advancement in the field of Neurophysiotherapy.The Functional Electrical Stimulation is the utilization of electrical current for Contractile tissue to facilitate the function that is lost in Neurological patients. FES therapy stimulates afferent nerves which increases nerve Excitability in paretic area and provides Neuroplasticity changes [5].
Various studies found that FES is successful for improving upper limb functions such as reaching, holding, grasping, moving and releasing objects. FES therapy is also helpful in reducing spasticity, increasing range of motion and motor control. Therefore, we aimed to examine the effect of Functional Electrical Stimulation Therapy in Upper Limb Motor functions in patient with Chronic Stroke [6].

CASE DESCRIPTION
The study subject was a thirty year old male Right Hemiparesis and Flexion Synergy of Right Upper Limb who had experienced an Ischaemic Stroke in the left Frontal, Parietal and Temporal lobes, secondary to obstruction in Middle cerebral artery, sixteen months before the study. According to practice guideline endorsed by American Heart Association and American stroke Association, he can be considered as a Chronic Stroke patient (the guidelines define Chronic Stroke as >six months post-stroke). Prior to study, patient's Motor recovery status of Upper Extremity was measured by FMA [7,8,9] which was 6 (of 66 possible) with shoulder movements, elbow flexion and extension, supination and pronation of forearm, flexion, But extension of wrist, fingers movements was impossible. The Voluntary Control Grading of upper limb grade 3 and hand was grade 2. The MAS score for muscles of shoulder 2+, elbow 2+ and wrist 3+.
Functional electrical stimulation: FES therapy was given with MEGAXP electrical stimulator which is multichannel fully programmed FES system with surface electrodes used to deliver stimulation pulses secured on skin with adhesive tapes. The muscles that were stimulated are as follow: Deltoid, Biceps and triceps brachialis, extensor carpi radialis, extensor carpi ulnaris, flexor carpi radialis and flexor carpi ulnaris Fig. 1. The Muscles were stimulated with Symmetrical Biphasic pulsed current with pulse duration of 250 microseconds. The ramp-up and ramp-down period was for 2 seconds with frequency of 35 Hz was used.

FES Therapy Protocol:
The therapy includes preprogrammed coordinated muscular stimulation and Active range of motion of upper limb to produce Functional movements. Patient performs following movements during FES therapy: 1) reaching for a bottle of water 2) grasping a bottle of water 3) bringing a bottle of water to mouth Fig. 2. Total treatment duration was 45 minutes per session for 3 alternate days in a week. FES therapy was given for 4 complete weeks. Each task was performed 20 times during single treatment session.

RESULTS
After 4 weeks of FES therapy, we found that FES therapy has positive effects on upper limb motor recovery in Chronic Stroke patient. After therapy, patient showed improvement in MAS score for muscles of shoulder, elbow and wrist. Prior to therapy FMA-UL score was 6 and post -therapy score improved to 16 and VCG for upper limb (grade 3 to 4b) and hand changed from grade3 to grade 3c. Table 1.

DISCUSSION
This study assessed the effectiveness of FES therapy on Upper Limb Motor functions in the management of Chronic Stroke patient. After application of FES therapy improvement in outcome measures was seen that was attributed to ability to flex and extend the elbow , ability to grasp object of different shapes (cylindrical, spherical, etc) and ability to elevate (flexion and abduction) the shoulder within the synergy pattern. The patient's pre-treatment FMA Upper limb score was 6 and Post-treatment score was increased to 16. The pre-treatment VCG of upper limb was grade 3 which changed to 4b and hand changed from grade3 to grade 3c. The result also showed improvement in MAS score for muscles of shoulder, elbow and hand. Limitation of the study there was no follow after the intervention.

CONCLUSION
The current study confirms that application of FES therapy improves upper limb Motor functions in chronic stage of Stroke, which supports previous studies.

CONSENT
The written informed consent was taken by the patient for enrollement, Images and Publication of the article.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).