The effects of cycling with and without functional electrical stimulation on lower limb dysfunction in patients post-stroke: A systematic review with meta-analysis

What is it about?

One of the leading causes of disability in the world is stroke (Feigin et al., 2014; Lehmann et al., 2015). People who have sustained a stroke experience activity limitations such as a decreased ability to walk, and decreased participation in everyday life tasks (e.g., property maintenance, managing household chores, self-care, etc) (Billinger et al., 2014; Shariat et al., 2018; Timmermans et al., 2016). These functional limitations are often related to the hemiplegia that occurs as a result of the stroke (Kwakkel, Veerbeek, van Wegen, & Wolf, 2015). The levels of disability associated with stroke result in an enormous economic burden (Wang et al., 2014). Identifying strategies to maximize function and reduce the societal burden associated with stroke is of utmost importance. In the first few weeks after a stroke, neurological deficits may improve as a result of brain plasticity. This brain plasticity may result from recruitment of different pathways, facilitation of existing but dormant synaptic junctions, aboritzation of dendrites and synaptogenesis (Rossini, Calautti, Pauri, & Baron, 2003). The magnitude of recovery differs greatly among individuals with similar clinical severity in the acute phase. The understanding of the mechanisms which prevent or promote recovery is critical to optimize therapeutic management strategies and maximize function. During treatment, sensory feedback and motor activity is essential (Rossini et al., 2003). Numerous studies have identified a relationship between afferent stimulation and changes in brain activity, such as repetition (Jones, 2000), efficient goal-directed activity (Nudo, Wise, SiFuentes, & Milliken, 1996), and functional electrical stimulation (FES) (Ambrosini, Ferrante, Pedrocchi, Ferrigno, & Molteni, 2011; de Sousa, Harvey, Dorsch, Leung, & Harris, 2016; Popovic,´ Sinkjær, & Popovic, 2009). Outcomes after a stroke can potentially be enhanced through interventions focused on improving impairments, functional limitations and restrictions of participation (Billinger et al., 2014). One such intervention that may address these outcomes is cycling with/without electrical stimulation which has the potential to improve motor capacity and hypothetically result in greater participation and activity performance after a stroke (Barbosa, Santos, & Martins, 2015; Bauer, Krewer, Golaszewski, Koenig, & Muller, 2015). In comparison with conventional train- ¨ ing modes, cycling is a low-cost and simple-to-use rehabilitation approach following a stroke (Mazzocchio, Meunier, Ferrante, Molteni, & Cohen, 2008). Patients with a stroke who participate in daily cycle training have achieved major enhancements in their lower extremity (LE) muscle strength, balance ability and aerobic capacity (Yang et al., 2014). Furthermore, participants who suffer from chronic stroke and participate in 10–12-weeks of cycling have been shown to experience improvements in cardiorespiratory fitness (Janssen et al., 2008). Even though multiple systems are affected by a stroke, such as motor control, balance, upper-extremity function, endurance, and gait, the majority of studies have only reported data on functional outcomes post stroke (Duncan et al., 2003). Most studies have used a simple form of cycling with/without FES (Bauer et al., 2015; de Sousa et al., 2016; M. Lee et al., 2008; S. Y. Lee et al., 2013; Yang et al., 2014). However, the optimal cycling protocol to maximize outcomes is not known for this population. An increasing number of physical therapists throughout the world are using cycling to treat lower limb dysfunction for patients post stroke (Billinger et al., 2014; Valles et al., 2016). As physical therapists use cycling more frequently, it is essential to continually evaluate the current evidence to refute or support its effectiveness. Therefore, the purpose of this systematic review and meta-analysis was to quantify the effectiveness of different protocols of cycling with/without FES on the lower limbs after stroke and to make recommendations for clinicians currently treating this population. The specific research question is as follow: Is cycling with FES more effective than cycling alone and if so, for which outcome measures?

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Photo by Sincerely Media on Unsplash

Photo by Sincerely Media on Unsplash

Why is it important?

One of the leading causes of disability in the world with enormous economic burden is stroke. To quantify the effectiveness of different protocols of cycling with/without functional electrical stimulation on functional mobility after stroke.

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