Electrical Stimulation & Visual Feedback for Stroke

Overseen By Kristin E Musselman, PhD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: University Health Network, Toronto

Must not be taking: Botulinum toxin

Disqualifiers: Lower extremity fracture, Peripheral nerve damage, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Approved in 1 Jurisdiction This treatment is already approved in other countries

Compensation: Varies

Number of Visits: 6

Duration: 3 weeks

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial tests a new method to assist individuals with balance issues resulting from spinal cord injuries or strokes. It combines electrical stimulation, which uses mild electrical currents to enhance muscle function, with visual feedback, where movement is guided by watching a screen. This method, known as Functional Electrical Stimulation Plus Visual Feedback Balance Training (FES+VFBT), aims to improve balance and prevent falls, which are common and costly problems. Individuals who experienced a stroke or spinal cord injury more than a year ago and can stand for 60 seconds without assistance might be suitable candidates for this study. As an unphased trial, this study provides an opportunity to explore innovative treatment options for improving balance and preventing falls.

Will I have to stop taking my current medications?

The trial protocol does not specify whether you need to stop taking your current medications. However, if you have had an injection of botulinum toxin to leg muscles in the past two weeks or plan to have one during the treatment period, you may not be eligible to participate.

What prior data suggests that this device is safe for improving balance in individuals with neurological conditions?

Research has shown that FES+VFBT, a treatment combining electrical stimulation with visual feedback balance training, is safe. In earlier studies, participants safely performed challenging balance exercises using this method, indicating it was well-received. Importantly, these studies reported no major negative side effects. Participants also highlighted the importance of safely incorporating these exercises into their routines. Overall, the evidence supports that FES+VFBT is a safe way to improve balance, especially for individuals with certain neurological conditions. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about FES+VFBT for stroke rehabilitation because it combines two innovative techniques: functional electrical stimulation (FES) and visual feedback balance training (VFBT). Unlike traditional therapies that might rely solely on physical therapy or medication to enhance recovery, FES+VFBT uses electrical impulses to stimulate muscles while providing real-time visual feedback to help patients improve their balance and coordination. This dual approach not only targets muscle activation but also engages the brain in a more interactive way, potentially speeding up recovery and improving outcomes for stroke survivors.

What evidence suggests that FES+VFBT is effective for improving balance in individuals post-stroke?

Research has shown that functional electrical stimulation (FES) combined with visual feedback balance training (VFBT) can help people stand more steadily. In this trial, participants will receive FES+VFBT, which integrates these methods. Studies have found that participants using this approach experienced better balance and increased stability. In one study, all participants improved in a test measuring how far they could lean without falling. This suggests that FES+VFBT helps retrain the brain and nervous system, enhancing movement and function. These improvements are especially promising for individuals with neurological conditions, such as those who have had a stroke, as they face a higher risk of falling. ^{1 4 6 7 8}

Who Is on the Research Team?

Kristin E Musselman, PhD

Principal Investigator

KITE-Toronto Rehabilitation Institute, UHN

Are You a Good Fit for This Trial?

This trial is for adults over 18 who can stand on their own for a minute, understand English, and have moderate trunk control. It's specifically for those with non-progressive spinal cord injury/disease or stroke that happened over a year ago and are not improving naturally anymore. People with other conditions affecting walking/balance or specific contraindications like recent fractures, botulinum toxin injections, nerve damage in legs, certain medical devices implanted, cancer treatments within six months, uncontrolled epilepsy or skin issues at electrode sites cannot join.

Inclusion Criteria

I have a spinal cord injury or stroke that hasn't worsened and can still move some muscles.

It's been over a year since my spinal cord injury/stroke, and my recovery has plateaued.

Able to understand spoken English

Exclusion Criteria

I do not have a history of epilepsy or seizures.

I have not had a botulinum toxin injection in my legs in the last two weeks and do not plan to during treatment.

I have had a fracture in my leg due to weak bones.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants receive FES+VFBT intervention, involving standing on a force plate with COP presented on a monitor and FES delivered to muscles

3 weeks

Multiple sessions per week

Follow-up

Participants are monitored for safety and effectiveness after treatment

12 weeks

Follow-up assessments at 6 and 12 weeks

What Are the Treatments Tested in This Trial?

Interventions

• FES+VFBT

Trial Overview The study tests an intervention called FES+VFBT designed to improve balance and prevent falls in people affected by neurological diseases or injuries like spinal cord injury/disease (SCI/D) or stroke. Participants will use a system combining functional electrical stimulation (FES) with visual feedback balance training (VFBT), standing on a force plate while responding to visual cues that help train muscle response through electrical stimulation.

How Is the Trial Designed?

Group I: FES+VFBT Experimental Treatment 1 Intervention

Functional electrical stimulation combined with visual feedback balance training

FES+VFBT is already approved in Canada for the following indications:

Approved in Canada as FES+VFBT for:

• Balance training for individuals with neurological disease or injury
• Prevention of falls in individuals with spinal cord injury or disease (SCI/D) and stroke

Who Is Running the Clinical Trial?

University Health Network, Toronto

Lead Sponsor

Trials

1,555

Recruited

526,000+

Published Research Related to This Trial

In a study involving 15 adults with chronic stroke, functional electrical stimulation (FES) applied during gait training led to small but significant improvements in balance function and toe clearance, although gait speed did not change.

Despite physical improvements, over half of the participants reported decreased balance confidence while using the FES device, indicating that while FES can enhance balance, it may also create challenges in confidence for stroke survivors.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The effect of functional electrical stimulation on balance function and balance confidence in community-dwelling individuals with stroke. Robertson, JA., Eng, JJ., Hung, C.[2021]

In a study of 38 stroke patients, functional electrical stimulation (FES) combined with physical therapy showed a significant improvement in functional deficits after 4 weeks (p < 0.01).

While there were no significant differences in overall outcomes between the FES and control groups at 4 and 8 weeks, FES-treated patients demonstrated a better rate of recovery in ambulation scores (p < 0.05), suggesting potential additional benefits in stroke rehabilitation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Functional electrical stimulation to the affected lower limb and recovery after cerebral infarction. Macdonell, RA., Triggs, WJ., Leikauskas, J., et al.[2015]

Functional electrical stimulation (FES) combined with conventional therapy significantly improves balance in post-stroke patients, as shown by better scores on the Berg Balance Scale and Timed Up and Go Scale in a review of 9 studies involving 255 participants.

No adverse effects were reported in the studies, indicating that FES is a safe intervention for enhancing balance in stroke rehabilitation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The Effects of Electrical Stimulation of Lower Extremity Muscles on Balance in Stroke Patients: A Systematic Review of Literatures. Mahmoudi, Z., Mohammadi, R., Sadeghi, T., et al.[2021]

Functional electrical stimulation (FES) can help restore movement in stroke patients by using a portable neuroelectric stimulator that the patient can control, particularly effective for conditions like dropfoot.

While lower extremity FES systems have been successfully developed to aid walking, creating effective upper extremity systems for hand and finger movements remains a challenge.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Recent applications of functional electrical stimulation to stroke patients in Ljubljana. Vodovnik, L., Kralj, A., Stanic, U., et al.[2005]

Functional electrical stimulation (FES) combined with voluntary movement (FESVOL) enhances cerebellar activity and may improve rehabilitation outcomes for post-stroke hemiplegia, suggesting a synergistic effect between electrical stimulation and voluntary effort.

The study indicates that FESVOL leads to reduced activity in secondary somatosensory areas, which may reflect a more accurate internal model of movement, potentially improving the effectiveness of rehabilitation strategies.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Interaction of electrical stimulation and voluntary hand movement in SII and the cerebellum during simulated therapeutic functional electrical stimulation in healthy adults. Iftime-Nielsen, SD., Christensen, MS., Vingborg, RJ., et al.[2021]

The developed feedback-controlled functional electrical stimulation (FES) system provides real-time muscle stimulation for hemiplegic patients, helping to prevent drop-foot and quadriceps weakness during gait training.

The FES system uses tilt sensors and footswitches to automatically adjust stimulation parameters, ensuring optimal support for patients as they walk.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Clinical evaluation of the tilt sensors feedback controlled FES for hemiplegia. Chen, YL., Shih, YY., Chen, WL., et al.[2020]

Functional electrical stimulation (FES) can enhance sensory-motor processing, as indicated by changes in theta band coherence in the brain during tasks involving electrical stimulation of the hand.

The study found that different conditions of electrostimulation affected brain coherence in specific areas, suggesting that FES may improve memory functions related to motor tasks, with implications for rehabilitation strategies.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effects of functional electro-stimulation in the theta-band coherence: a quantitative electroencephalograph study. Santos, J., Velasques, B., Paes, F., et al.[2011]

The hybrid functional electrical stimulation (FES) orthosis combines a rigid brace with a multi-channel FES system to provide stability for patients with spinal cord injuries, allowing them to maintain standing postures without muscle fatigue during prolonged use.

Preliminary tests on two spinal cord injured subjects indicate that the FES controller effectively responds to destabilizing shifts, stimulating the necessary muscles to maintain balance and support leg movement during walking.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Hybrid FES orthosis incorporating closed loop control and sensory feedback. Andrews, BJ., Baxendale, RH., Barnett, R., et al.[2019]

In a study involving 21 hemiplegic stroke patients, those who received visual feedback training with visual targets showed significantly greater improvements in muscle activation and balance compared to those who only received visual feedback training without targets.

The experimental group demonstrated enhanced gluteus medius muscle activation and better weight-bearing ability on the affected side, suggesting that incorporating visual targets can be an effective strategy in rehabilitation for stroke patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effects of visual feedback training and visual targets on muscle activation, balancing, and walking ability in adults after hemiplegic stroke: a preliminary, randomized, controlled study. Pak, NW., Lee, JH.[2021]

Combining functional electrical stimulation (FES) with standing frame training significantly improved standing balance in stroke patients compared to separate treatments, as shown by better scores on the Berg Balance Scale and stability indices after 3 weeks of therapy.

The study involved 60 patients with hemiparesis and postural instability, demonstrating that this combined approach is not only effective but also practical for clinical use, making it a promising option for rehabilitation in subacute stroke patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Combined Therapy With Functional Electrical Stimulation and Standing Frame in Stroke Patients. Lee, JB., Kim, SB., Lee, KW., et al.[2023]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC7390869/

Functional Electrical Stimulation Plus Visual Feedback ... These results suggest that FES+VFBT has potential as an intervention for standing balance after iSCI. Keywords: visual feedback, balance training, functional ...

2. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/32793101/

Functional Electrical Stimulation Plus Visual Feedback ... These results suggest that FES+VFBT has potential as an intervention for standing balance after iSCI. Keywords: balance training; functional ...

3. researchgate.net researchgate.net/publication/343166564_Functional_Electrical_Stimulation_Plus_Visual_Feedback_Balance_Training_for_Standing_Balance_Performance_Among_Individuals_With_Incomplete_Spinal_Cord_Injury_A_Case_Series

Functional Electrical Stimulation Plus Visual Feedback ... All participants showed greater maximal COP excursion area during the limits of stability test after the training intervention, whereas only one ...

4. bmjopen.bmj.com bmjopen.bmj.com/content/15/4/e090791

Combining functional electrical stimulation with visual ... One intervention that targets balance control—functional electrical stimulation with visual feedback balance training (FES+VFBT)—may improve balance control but ...

5. researchgate.net researchgate.net/publication/322012948_Development_of_Visual_Feedback_Training_Using_Functional_Electrical_Stimulation_Therapy_for_Balance_Rehabilitation

Development of Visual Feedback Training Using ... Development of a closed-loop controller for functional electrical stimulation therapy plus visual feedback balance training for standing balance training.

6. frontiersin.org frontiersin.org/journals/neurology/articles/10.3389/fneur.2020.00680/full

Functional Electrical Stimulation Plus Visual Feedback ... Specific components of FES+VFBT, including the ability to safely practice challenging balance exercises, were deemed important by the participants. These ...

7. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC11969585/

Combining functional electrical stimulation with visual ... One intervention that may improve standing balance control is visual feedback balance training (VFBT); it is thought to improve balance control ...

8. dam-oclc.bac-lac.gc.ca dam-oclc.bac-lac.gc.ca/download?id=125d796f-cdbc-42ca-bd0f-837879e86781&fileName=Houston_David_J_201911_MSc_thesis.pdf

The Effects of Functional Electrical Stimulation and Visual This concurrent, multi-methods study investigated the effect of combining functional electrical stimulation (FES) with visual feedback balance training (VFBT) ...