Long Term Effect of Contralaterally Controlled EMG-Modulated

Electrical Stimulation Combined with Training and Botulinum

Toxin A (BONT-A) Motor Point Block on Hand Function in Patients

with Stroke

Ratna Darjanti Haryadi

, Lydia Arfianti

, Meisy Andriana

Physical Medicine & Rehabilitation Department, Faculty of Medicine Universitas Airlangga,

Dr Soetomo Hospital Surabaya, Indonesia

Keywords: Contralaterally Controlled Electrical Stimulation, EMG-Modulated, Stroke, Hand Function, Motor Point

Block

Abstract: Objective: This study describes the long term effect of contralaterally controlled EMG modulated electrical

stimulation combined with Botulinum Toxin A (BONT-A) motor point block and hand function training in

stroke. Methods: Three stroke patients, onset ≥ 6 months, with paresis of wrist and fingers extensors (MRC

2/5), flexor spasticity >3 (MAS), were given BONT-A injections before training. The training consisted of

40 minutes electrical stimulation on the affected side, proportional to the EMG signal picked-up from the

unaffected side, simultaneously doing hand function training, for 3-5 days/ week. Outcome measures were

Box and Block Test (BBT) and Nine Hole Peg Test (NHPT) scored before, after training, and at follow-up of

4 and 9 months. After 18 sessions, grasp function (BBT) improved in 3 patients, pinch grip (NHPT)

improved in 2 patients. One patient was lost to follow-up. At 4 and 9 months, BBT improved further in 1

patient, deteriorated in 1 patient, while NHPT deteriorated in both patients. Conclusion: Grasp function

improved at long term follow-up in 1 chronic stroke patient who consistently used the affected dominant-

hand. No improvement was seen in 1 patient affected at the non-dominant hand. Improvement in pinch grip

was lost at long term follow-up.

1 INTRODUCTION

A stroke is often causing long term severe motor

disability due to hemiplegia. In many patients the

upper extremity does not recover to a functional

level (Yavuzer et al, 2008). The synergy pattern that

develops usually consist of flexion of the wrist &

fingers, causing inability to open the fingers. Flexors

muscle spasticity that occur after stroke can worsen

the inability to extend the wrist and fingers. The

effort to elicit active movement in the affected arm

tend to increase spasticity, and is therefore less

successful in producing an effective functional hand

movement. The condition together has been shown

to be one of the motor impairments responsible for

disability (Hara, 2008). Botulinum Toxin A (BONT-

A) motor point block injections showed efficacy to

reduce spasticity and allow more voluntary grasping.

Another study reported the efficacy of phenol motor

point block to reduce spasticity in stroke patients

(Hara et al, 2006).

Chronic stroke-related motor problems that begin

in the first year after a stroke may lead to learned

nonuse as individuals stop trying to move the

affected upper extremity voluntarily (Inobe, 2013).

Recent knowledge in the field of neuroplasticity and

functional recovery in brain lesion has contributed in

the development of several combinations of

functional training with the application of physical

modalities to enhance activity. Electromyography

(EMG)-initiated electrical stimulation is one novel

method of Functional Electrical Stimulation (FES).

A surface electrode picks up the EMG signal and

stimulates the target muscle in proportion to the

integrated signal. This device induces greater muscle

contraction because electrical stimulation is

proportional to the EMG signal (Yamaguchi et al,

124

Haryadi, R., Arﬁanti, L. and Andriana, M.

Long Term Effect of Contralaterally Controlled EMG-Modulated Electrical Stimulation Combined with Training and Botulinum Toxin A (BONT-A) Motor Point Block on Hand Function in Patients

with Stroke.

DOI: 10.5220/0009064901240129

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 124-129

ISBN: 978-989-758-409-1

2011). The efficacy of EMG-controlled electrical

stimulation was reported by Hara et al in a study of

combined Integrated Volitional Control Electrical

Stimulation (IVES) on the affected extensor

muscles, training, and motor point block using 5%

phenol for antagonist muscles in patients with

chronic stroke (Hara et al 2006).

Recently a device of EMG-modulated electrical

stimulation enables to pick up EMG signal from

active voluntary contraction of the contralateral non-

affected arm, and send it as a trigger electrical

stimuli to the muscle at the affected arm. The trigger

delivered to the affected arm then should be

followed by voluntary effort to increase the activity

of the recipient muscle. This method requires active

participation from patients to perform bilateral

symmetrical movement on both arms or wrists.

Several studies have reported the effectiveness of

contralaterally controlled electrical stimulation alone

in patients with early-phase stroke (< 15 days post

stroke), subacute, and chronic stroke (> 6 months,

but less than 2 years) (Zheng et al, 2019). None of

these studies used combined electrical stimulation

with motor point block injections. This study,

therefore, aims to demonstrate the long term effect

of contralaterally controlled EMG-modulated

electrical stimulation combined with training, and

Botulinum Toxin A (BONT-A) motor point block,

to improve functional hand movement in stroke

patients.

2 METHODS

The study participants were 3 patients with first

episode unilateral stroke, onset ≥ 6 months. Two

patients had chronic stroke (> 6 months), and one

patient had a stroke 6 months before intervention.

All 3 patients had hemiparesis of wrist and fingers,

difficulty in extension movements (MRC scale 2/5),

with flexor spasticity graded ≥ 3 (Modified

Ashworth Scale). Patient 1 was a 40-year-old male

with left hemiparesis after a hemorrhagic stroke 4

years ago. Patient 2 was a 50-year-old male with left

hemiparesis after a thrombotic stroke 6 months ago.

Patient 3 was 50-year-old female with right

hemiparesis after a thrombotic stroke 3 years ago.

Botulinum toxin A (BONT-A) motor point block

injections were given by an-experienced physiatrist

to the flexor wrist and fingers muscles 7-10 days

before start of training. All 3 patients received

training that consisted of 40 minutes integrated

volitional control electrical stimulation of extensor

wrist and fingers on the affected side, in proportion

to the voluntary EMG signal picked-up at the non-

affected side, while doing therapist-supervised

activities with the affected hand. Electrodes

placement were on extensor carpi radialis longus and

brevis, and extensor digitorum communis. The

equipment Integrated Volitional Control Electrical

Stimulation (IVES) GD-611 by OG Wellness

Technologies Co, Ltd. was used in this study.

The combined contralaterally controlled EMG-

modulated electrical stimulation with training is

depicted in Figure 1. Treatment frequency was 3-5

days a week, up to 18 sessions. Subjects were

dropped out from this study if they missed

consecutively 2 therapy session in 1 week, or if they

wished to stop the therapy.

The outcome measures were Box and Block Test

(BBT) and Nine Hole Peg Test (NHPT) scored

before training, after training, and at follow-up of 4

and 9 months. All patients were given detailed

information about the procedure, and informed

consent was obtained.

3 RESULTS

All 3 patients were successfully completed 18

sessions of training. Baseline scores of BBT were <

4, and NHPT were 0. All 3 patients showed

improvement in grasp function starting from session

6 and achieved peak performance at session 12, as

shown by the BBT results. Compared to session 12,

session 18 did not show further improvement. Pinch

performance as shown by the NHPT showed peak

performance in session 18 in Patient 1 and Patient 3.

Patient 2 was never able to perform the NHPT.

Table 1 summarizes the changes in outcome

measurement scores over the sessions, and at long

term follow-up of 4 and 9 months.

Only Patient 1 and Patient 3 were assessed for

long term follow-up at 4 and 9 months. Patient 2

was lost to follow-up because he worked in a

different city. Hand function at follow-up of 4 and 9

months improved further as shown by the BBT score

in Patient 3, while it deteriorated in Patient 1. The

NHPT score deteriorated in both Patient 1 and

Patient 3 at follow-up of 4 and 9 months. Figure 2

shows the progress in the NHPT and BBT scores of

all 3 patients after 18 sessions, and at long-term

follow-up of 4 and 9 months.

Long Term Effect of Contralaterally Controlled EMG-Modulated Electrical Stimulation Combined with Training and Botulinum Toxin A

(BONT-A) Motor Point Block on Hand Function in Patients with Stroke

125

Figure 1: The EMG signal was picked up from active voluntary contraction of the contralateral non-affected arm (muscle 2)

and delivered to the muscle in the affected arm (muscle 1). Integrated volitional control electrical stimulation on the

affected side was in proportion to the voluntary EMG signal picked up on the non-affected side. The trigger delivered to the

affected arm should then be followed by voluntary effort to increase the activity of the recipient muscle (Hara, 2008).

4 DISCUSSION

This study showed that after 18 sessions of

combined contralaterally controlled EMG-

modulated electrical stimulation, therapist-guided

training, and Botulinum toxin A (BONT-A) motor

point block, the grasp function represented by BBT

score, optimally improved after 12 sessions in all 3

patients. No further improvement was seen after 12

sessions in Patient 1 and Patient 2, while Patient 3

showed further improvement at long-term follow up

of 4 and 9 months. Improvement of the pinch started

to emerge later than the grasp. Pinch grip

performance, assessed by NHPT score, showed

improvement after 18 sessions in two patients

(Patient 1 and Patient 3), both who had chronic

stroke (> 6 months). One patient who had stroke 6

months before intervention (Patient 2) did not show

any improvement. These findings indicated that to

improve the pinch grip more sessions are necessary

compared to the grasp function. This can be

explained because the pinch grip is a more selective

and precise movement than the grasp. At long-term

follow up of 4 and 9 months, the NHPT deteriorated

in two patients, while one patient was lost to follow-

up.

Patients who had chronic stroke still have a

chance of recovery. A study by Hara et al in 16

chronic (more than 1 year) stroke patients showed

improvement in motor performances of upper

extremity with combined of power-assisted FES,

training, and phenol motor point block injections

(Hara et al, 2006). Lewinsky et al reported in a study

of 9 chronic stroke patients, that BBT result at the

time of inception (before training) has predictive

value potential. There was no significant gain if the

BBT score was below 4, even after 8 weeks of

combined training and EMG-triggered electrical

stimulation (Lewinsky et al, 2009).

Table 1: The Nine Hole Peg Test (NHPT) and the Box and Block Test (BBT) scored before treatment, after treatment, and at

follow-up of 4 months and 9 months.

Sessions

Baseline 6 12 18

4 months

follow-up

9 months

follow-up

BBT

NHP

BBT NHPT

NHPT BBT NHPT BBT

Patie

nt 1

0 1 0 1 0 10 3 10 0 0 0 0

Patie

nt 2

0 0 0 0 0 3 0 2 - - - -

Patie

nt 3

0 2 0 5 4 6 5 5 2 10 0 16

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

126

 

A B

Figure 2: (a) The Nine Hole Peg Test (NHPT) and (b) the Box and Block Test (BBT) scored before treatment, after

treatment, and at follow-up of 4 and 9 months.

In this study, all 3 patients had BBT scores <4 at

baseline measurement. Only one patient who had

chronic stroke, with an initial BBT score 2, gained

significant improvement (BBT score 16) after 18

sessions, and improved further at long term follow-

up of 4 and 9 months. The other two patients, who

had chronic stroke and stroke at 6 months before

intervention, with initial BBT score 1 and 0, showed

improvement (BBT score 10 and 2) after 18

sessions, and then deteriorated at long term follow-

up of 4 and 9 months.

Stroke affecting dominant or non-dominant hand

also plays a role in recovery. If the dominant hand is

affected, the patient can be motivated to actively use

the hand for daily activities. In this study, two

patient (Patient 2 and Patient 3) were affected in the

dominant hand. Patient 2, who had subacute stroke

showed improvement in grasp function showed by

BBT score, after 12 sessions of combined treatment.

He consciously used his right (dominant) hand in

activities of daily living, such as holding a cup and

picking up objects. Patient 3, who had chronic

stroke, showed further improvement in grasp

function after 12 sessions and even at long-term

follow-up of 4 and 9 months after BONT-A

injections. This is because the patient actively used

her right hand for daily household activities. She

could use her right hand for cooking, such as cutting

tofu and vegetables, holding saucepan and frying

tofu. While Patient 1, who had chronic stroke, did

not show improvement in grasp function. This can

be explained because he did not actively use his left

(non-dominant) hand for daily activities. He only

used the left hand to open the door. This will worsen

or deteriorate the learned nonuse as individuals stop

trying to move the affected extremity voluntarily

(Inobe, 2013).

The current study used contralaterally controlled

(from the non-affected side) EMG-modulated

electrical stimulation in chronic stroke patients. It is

considered as novel method of FES, that requires

active participation from patients to perform

bilateral symmetrical movement, and not only

electrical stimulation of the affected side (Zheng et

al, 2019). Because this technique uses a control

signal from the non-affected side, EMG signal will

still be picked-up even when the target-affected

muscles display no muscle contraction at all. With

the non-contralaterally EMG-controlled electrical

stimulation, the stimulator will not work when there

was no contraction at all on the target-affected

muscles (Chuang et al, 2017). The mechanism of

contralaterally controlled EMG-modulated electrical

stimulation on motor recovery after stroke remains

unclear. The possible explanation may be that

movement of the non-affected side can increase the

corticospinal excitability of the stimulated muscles

by interhemispheric disinhibition and intracortical

facilitation (Zheng et al, 2019). Zhou et al reported

that because patients could control the timing and

degree of movements during training with EMG

bridge detects surface electromyographic signals

from the non paretic limb, may induce synaptic

remodelling and cortical reorganization. In addition,

because patients were more willing and more able to

use their affected hand actively, it might enhance

further the treatment effects (Zhou et al, 2017).

In stroke patients, good balance of movement

between flexion and extension in the wrist and

fingers should be obtained to achieve effective hand

Long Term Effect of Contralaterally Controlled EMG-Modulated Electrical Stimulation Combined with Training and Botulinum Toxin A

(BONT-A) Motor Point Block on Hand Function in Patients with Stroke

127

function. For patients who had stroke with

significant flexor muscles spasticity in upper

extremity, NMES or FES alone does not produce

satisfactory improvement (Hara et al, 2006). Some

authors have reported the efficacy of a phenol motor

point block which is more cost-effective than

Botulinum toxin A (BONT-A) (Hara et al 2006). We

use motor point block with BONT-A to reduce

spasticity in this study, because of technical

constraints to obtain phenol for injection. Studies

have shown the efficacy of BONT-A to reduce

spasticity, thus allowing more voluntary grasping.

For the long term follow-up assessment 4 and 9

months were the time points chosen because the

average duration of the BONT-A effect is said to

wear off within 3-6 months (Ambrose et al, 2018).

Longer duration of training seemed to have

better results in chronic stroke. Hara et al evaluated

the hand function after 4 months (2 times per week,

total of 32 sessions) of combined treatment in

chronic stroke. In this study, we have difficulty in

maintaining patients’ compliance for more than 18

sessions. The number of visits as well as frequency

in an outpatient-based treatment plan is often limited

by several technical factors, such as transportation

and availability of family members to bring the

patient to a rehabilitation facility. This condition is

quite common in developing countries such as

Indonesia.

5 STUDY LIMITATION

A limitation of this study is that we only had 3

patients as study participants, and the study was

ended after 18 sessions.

6 CONCLUSIONS

Improved grasp function was seen as long-term

effect of contralaterally controlled EMG-modulated

electrical stimulation combined with training and

Botulinum Toxin A (BONT-A) motor point block

injections, in 1 chronic stroke patient who

consistently use the affected dominant-hand. No

improvement was seen in 1 chronic stroke patient

affected at the non-dominant hand. Improvement in

pinch grip performance was lost at long term follow-

up.

ACKNOWLEDGEMENTS

Equipment Integrated Volitional Control Electrical

Stimulation (IVES) GD-611 was provided on loan

during this study by OG Wellness Technologies Co,

Ltd. This study was funded by a grant from OG

Wellness Technologies Co, Ltd.

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