The purpose of this study was to assess the efficacy of surface neuromuscular electrical stimulation and placebo stimulation

in improving the upper extremity motor and functional recovery in acute hemiplegia. This study suggests that both surface neuromuscular electrical stimulation and cutaneous (placebo) stimulation are effective in improving upper extremity motor and functional recovery of stroke survivors. Neuromuscular electrical stimulation is seen to be better than placebo stimulation. The statistical analysis gives following results. The inter group comparison of Fugl Meyer scores in both groups, from 1st sit pre to 20 sit pre and 1 sit post to 20 sit post were carried out. For group A 1 sit pre shows a mean of 17.2, SD + 4.75(p=.647).20 sit pre shows a mean of 35.46 SD + 5.55, (p=.005).In group B 1 sit pre shows a mean of 16.4, S.D + 3.26 (p=.647). 20 sit pre shows a mean of 29.86, SD + 4.34, (p=.005).For group A1st sit post shows a mean of 17.4, SD + 4.56(p=.677) sit 20 post shows mean of 36.86, SD + 5.18, (p=.001). For group B sit 1 post shows a mean of 16.6, SD + 3.4, (p=.677) sit 20 post shows mean of 30.8, SD + 4.09, (p=.001). The result indicated that improvement in both groups. The intra group comparison of Fugl Meyer scores using paired sample test shows following result. In group A 1 sit pre and post shows a mean of -0.2000, SD + 0.41404, z=1.732, (p=.082). 20 sit pre and post shows a mean of -1.4000, SD + 0.63246, z=3.391, (p=.001).In group B 1 sit pre and post shows a mean of - .2667, SD + 0.45774, z=2, (p=.046) 20 sit pre and post shows a mean of-0.9333, SD + 0.70373.z =3.175, (p=001).the result shows there is improvement in both groups .but group A is showing better improvement than group B. The inter group comparison of FIM self-care scores of both groups, from 1 pre to and 20 sit post were carried out. FIM self-care scales having 6 components. Eating (A), grooming (B), bathing (C), dressing upper body (D), dressing lower body (E), toileting (F). The inter group comparison shows there is no significant change between group A and group B for 1 sit and 20 sit. The intra group comparison of FIM self-care scores using paired sample test shows following results. For group A1 pre to and 20 sit post, eating A shows a mean of -0.8667, SD + 0.35187, (.p=.001). B shows a mean of -.8000, S.D + 0.41404, (P=.001). C shows a mean of -0.7333, SD + 0.45774, (p=.001). D shows a mean of -0.7333, SD + 0.45774, (p=.001). E shows a mean of -0.9333, SD + 0.45774, (p=.001), F shows a mean of -0.9333, SD + 0.45774, (p=.001). In case of group B, eating (A) shows mean of -0.8000, SD + 0.67612, (p=.003). B shows a mean of - .8667, S.D + 0.35187, (P=.001). C shows a mean of -0.6667, SD + 0.72375, (p=0.008). D shows a mean of -0.9333, SD + 0.59362, (p=0.001). E shows a mean of 0.9333, SD + 0.59362, ( p=.001), F shows a mean of -0.8000, SD + 0.77460, (p=.006). The result shows there is improvement in both groups. But group A is showing better improvement than group B. This gain in Fugl Meyer scores supports a recent study on stroke survivors treated with surface neuromuscular electrical stimulation for their paretic arm who gained significantly greater upper extremity motor recovery than did control subjects. Outcome measured in the study were measured by Fugl Meyer upper extremity component44. A similar study concluded that motor recovery of the upper limb in hemiplegia can be improved significantly by additional sensory motor stimulation in the acute phase. The mean difference in improvement on the Fugl Meyer test at 6 and 12 month post stroke between control and experimental group was 7.3 and 6.5 respectively. This corresponds to11.1% and 9.8% of the total Brunnstrom Fugl Meyer score, a difference that clinically relevant11.

This study documents the effects of neuromuscular electrical stimulation on the complex aspect of neurofunctional recovery as reflected by the Fugl Meyer motor assessment and FIM self-care assessment. The study suggests that active repetitive exercises induced by NMES enhance motor recovery after stroke. This is consistent with the evolving basic and clinical data on central motor neuroplasticity that support the use of active repetitive training of the paretic limb to maximize motor recovery after stroke A clinical study of sub-acute stroke survivors also emphasized the importance of frequent active movement repetition for motor rehabilitation of the centrally paretic hand and challenges conventional physiotherapeutic strategies that focus on tone modification and functional compensation, instead of early initiation of active movements .Among stroke survivors who are beyond 6 months from their stroke, forced active repetitive movement of paretic limb also appear to enhance recovery12. The Fugl Meyer motor assessment is based on the observation, that motor recovery occurs according to predictable stages, each evaluated by a set of items36. An improvement of 10% on this test implies that the patient achieved the next stage in the recovery process. There are a variety of possible reasons that, patient were given NMES showed benefit. Electrical stimulation may have direct effect leading to muscle strength and improved motor control, resulting in reduced upper limb disability47. Electrical stimulation has a combination of effects including those at the level of the muscle, and also a central effect associated with motor learning the result of present study indicate that motor recovery of upper limb in stroke patients can be improved significantly by additional sensory motor stimulation in the acute phase. This study did not demonstrate a significant result that neuromuscular electrical stimulation enhances the upper extremity related functional recovery of acute stroke survivors. Previous studies demonstrated that motor and functional recovery roughly parallel to one another. The relation between Fugl Meyer motor assessment and self-care component of FIM is modest at the best43. This is due to the nature of FIM. The self-care component of FIM measures general disability and is not arm disability specific. Stroke survivors with severe upper extremity hemiplegics can score high on the self-care component of FIM, as long as they are able to learn compensatory single handed technique to perform activity. The items in the self-care component are basic in nature and patients are not restricted for using a single handed versus a bimanual strategy. Future studies should use a functional outcome measure that is specific to the arm and is more sensitive to the degree of arm paresis. At with any treatment there may be placebo effect. Recent studies show that cutaneous stimulation had a positive effect in the motor performance and limb sensation. A general increase in awareness of hemi paretic limb may occur as an effect of placebo stimulation.

Limitations of the study

1. Study was done only for a short period of time. 2. The sample size was small. 3. The upper extremity-related disability measure used in this study may have Been inadequate. 4. Pain from stimulation was the most common discomfort.

Scope for further studies

1. Large scale studies will be required to determine whether NMES of specific muscle group after stroke will lead to improved self-care 2. Properly controlled studies also required of cutaneous electrical stimulation (at intensity below that required for muscle contraction) In patients with motor deficits

Conclusion
The subjects were treated with neuromuscular electrical stimulation and placebo stimulation for 5 days in a week for 4 weeks were found to have an improvement in the upper extremity motor and functional recovery in both groups. The subjects in group A, who received NMES showed better improvement in motor and functional recovery of paretic arm than group B, who received placebo stimulation. In conclusion the treatment program consisting of NMES may be more effective in improving motor and functional recovery of acute hemiplegics than placebo stimulation. The study results favour the hypothesis of this study and it is accepted.
SUMMARY The study was conducted on 30 subjects with a mean age of 59.9 and SD + 5.50, who were diagnosed as having acute hemiplegia. The study was done to compare the efficacy of NMES and placebo stimulation in improving the upper extremity motor and functional recovery in acute hemiplegia. The subjects were divided into 2 groups, group A and group B, consisting of 15 subjects each. Subjects selected randomly irrelevant of sex and side affected. Group A received NMES for the wrist extensor muscles of forearm to produce full wrist and finger extension. Group B received placebo stimulation over the paretic arm without motor activation. All subjects were treated 1 hour per day, 5 days in a week for 4 weeks (total 20 sessions). The main outcome measures were assessed in a blinded manner with upper extremity component of Fugl-Meyer motor assessment scale and self-care component of Functional Independence Measure. Upper extremity component of Fugl-Meyer motor assessment scale was used to evaluate motor recovery. The test was performed before and after treatment for both groups. FIM evaluation was performed on the 1st sitting day before treatment and 20th sitting day after treatment. The scores were tabulated and subjected to statistical analysis.

The analyses of data lead to the following interferences

1. Both groups showed improvement in motor and functional outcome. 2. The group of which subjects received NMES showed better improvement in the motor and functional recovery compared to placebo stimulation.

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ANNEXURE - I NEUROLOGICAL ASSESSMENT PROFORMA

NAME: OCCUPATION: ADDRESS: INCOME:

AGE:

GENDER: M.F.

HOSPITAL NO:

CHIEF COMPLAINTS WITH DURATION: I. HISTORY: PRESENT: PAST: MEDICAL: OCCUPATIONAL: PERSONAL: II. ON OBSERVATION: 1. ATTITUDE OF LIMBS 2. POSTURE: 1-

Normal 2-Stooping 3-Kyphosis 4-Sculiosis 5-Lordosis 6-Others (Specify) 3. GAIT: 1-Nomal 2-Affected