CCFES in early-phase stroke rehabilitation
helpful in re-gaining motor function. Koyama et al.
reported that NMES can improve the function of the
upper extremity in patients with stroke (21).
Recently, CCFES has been developed as an active
training, involving repetitive stimulation of peripheral
neural activity, with bilateral symmetrical movement
on the non-paretic side, to produce symmetrical and
near-simultaneous movement of the paretic side. The
patients control the timing and degree of WD in a way
that does not interfere with the fluidity of task practice,
making it more conducive to complete task-oriented
functional hand activities (9, 10, 17). The effectiveness
of CCFES was investigated in a RCT study conducted
by Knutson et al. in 2016 (17). They randomized 80
patients with chronic stroke (> 6 months) into a CCFES
group or an NMES group and found the 12 weeks
of CCFES therapy improved manual dexterity more
than an equivalent dose of NMES (17). Furthermore,
Shen et al. compared the effectiveness of CCFES and
NMES on patients and found that CCFES was better
than NMES in the improvement of upper extremity
function (9); however, it was only tested in patients
with sub-acute stroke, not early-phase stroke.
The current study investigated the effectiveness of
CCFES compared with NMES in patients with early-
phase stroke. Although patients in both groups expe-
rienced improvement in each individual measurement,
the CCFES group showed better outcome. Within the
treatment and follow-up period, 19 patients in the CC-
FES group re-gained WD compared with 12 patients in
the NMES group. In addition, the time intervals from
the onset of stroke and the onset of treatment to the ap-
pearance of WD were significantly shorter in the CCFES
group than in the NMES group. Therefore, CCFES may
be more effective and efficient in the improvement of
hand function than NMES. For the FMA scores, the le-
vel of motor dysfunction was reduced from very severe
to severe in the NMES group (22). Although the same
situation was observed in the CCFES group, it scored
a mean of 7 higher, indicating that better upper limb
function was obtained compared with the NMES group.
This is not surprising, because this assessment captures
the most fundamental level of upper extremity function
and is therefore expected to be impacted largely by the
timing of WD appearance. Muscle strength was impro-
ved from 0 to 1.20 ± 1.06 in the NMES group and from
0 to 2.29 ± 0.78 in the CCFES group; the improvement
with NMES was limited for task-oriented movement,
while CCFES allows partial actions of the hand when
the effect of gravity is eliminated (23). At the endpoint,
active ROM of the WD (mean 14.76 (SD 13.81)) in the
CCFES group was approximately 15°, which is consi-
dered the lower threshold for basic hand movements,
while the improvement in the NMES group was limited
107
(24). The outcome of JHFT also indicated better hand
activity in the CCFES group than in the NMES group,
which indicated better hand function with CCFES. For
ADL measurement, patients in the CCFES group (mean
66.67 (SD 10.99)) could be classified as “Moderate
Dependence” after 2 weeks treatment according to the
criteria of mBI, while those in the NMES group (mean
58.25 (SD 11.73)) were classified as “Severe Depen-
dence” (15). This also demonstrated better ADL ability
in the CCFES group and could be considered clinically
important by patients and clinicians. Patients’ general
health was measured with the ICF Generic Set (25)
and greater improvement was observed in the CCFES
group. Although the mechanism of the improved upper-
limb function in the CCFES group remains unclear, the
possible explanation may be that linking movement of
the paretic side to the less-affected side increased the
corticospinal excitability of the stimulated muscles by
interhemispheric disinhibition, intracortical facilitation.
In addition, the short length of inpatient rehabilitation
in China requires patients to perform more self-admi-
nistered training at home with less assistance from a
therapist. This indicates that CCFES may be a promising
intervention with superior effectiveness compared with
NMES, since it further addresses the current clinical
needs of patients with early-phase stroke in China.
The major limitation of the current study was the
relatively small sample size, which may cause bias
when the findings are applied to specific patients
with impaired upper extremity. This limitation could
be overcome by enrollment of more patients. More-
over, the study focused only on the observation of the
outcome reflected by different scales after 2 specific
interventions (CCFES vs NMES), the real recovery
mechanism might be better understood using functio-
nal magnetic resonance imaging (fMRI) examinations
of the brain at the baseline and endpoint. A further
limitation was that there was no control group (without
NMES and CCFES) in the current study, therefore it
was difficult to identify whether the improvement was
due to the specific interventions or the natural history
of the disease. In addition, the appearance of WD was
reported by the patients and their family members af-
ter the patients were discharged from hospital, which
may lead to vulnerable and over- or under-estimated
results, since the patients and their family members
were not expected to be as precise as the medical staff.
The current study was not powered to detect changes
in the time to regain WD within the 2-week treatment;
however, this study provided estimates of the effect,
which can be used to power future studies.
In conclusion treating patients with early-phase
stroke at different levels. After 2 weeks of intervention,
improvements at the structural and functional level,
J Rehabil Med 51, 2019