The recommendations are graded by their level (I, II) and strength (A, B, C+, C, D, D+, D-) of evidence. Definitions for the level and strength of the recommendations are presented at the end of the "Major Recommendations" field.
Clinical Practice Guidelines for Electrical Stimulation
Functional electrical stimulation (FES) of quadriceps and rectus femoris combined with positional feedback stimulation training versus control for the knee, level I (randomized controlled trial [RCT]): Grade C+ for range of motion (ROM) (selective knee extension: extension of the knee without any help of the synergistic muscles) at end of treatment, 2 and 4 weeks, and knee extension torque and ROM (synergistic ROM extension: extension of the knee with possible help of synergistic muscles) at end of treatment, 1, 2, 3, and 4 weeks (clinically important benefit demonstrated without statistical significance); grade C was given for ROM (selective extension) at end of treatment, 1 week (no benefit demonstrated); grade D+ for ROM (selective extension) at end of treatment, 3 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with post-acute stroke.
Positional feedback stimulation training of wrist extensors versus control, level I (RCT): Grade A for torque and ROM at end of treatment, 2, 3, and 4 weeks. Patients with subacute and postacute stroke.
Neuromuscular electrical stimulation of the wrist and finger extensors versus control, level I (RCT): Grade A for grip strength (grip in kilograms) at end of treatment, 8 weeks, torque (moment of extension at 15º) at end of treatment, 8 weeks, and follow-up, 24 weeks, and motor function (Action Research Arm Test [ARAT] total) at end of treatment, 8 weeks (clinically important benefit demonstrated); grade C+ for ROM (resting wrist angle) at follow-up, 24 weeks, ROM (maximum active extension) at end of treatment, 8 weeks, and follow-up, 24 weeks, torque (moment of extension at 0°) at end of treatment, 8 weeks, and follow-up, 24 weeks, motor function (ARAT-grasp) at end of treatment, 8 weeks, and follow-up, 24 weeks, motor function (ARAT-grip, pinch, gross movement, and total score) at end of treatment, 8 weeks, functional status at follow-up, 24 weeks, and motor function (ARAT total) at follow-up, 24 weeks (clinically important benefit demonstrated without statistical significance); grade C was given for torque (moment of extension at 30°), ROM (maximum passive extension of the wrist and resting wrist angle), functional status at end of treatment, 8 weeks, motor function (ARAT-grip, pinch, and gross movement) at follow-up, 24 weeks, decrease of visuospatial neglect at end of treatment, 8 weeks, and follow-up, 24 weeks, decrease of spasticity at end of treatment, 8 weeks, and follow-up, 24 weeks (no benefit demonstrated); grade D was given for ROM (maximum passive extension of the wrist) at follow-up, 24 weeks (no benefit demonstrated but favoring control); grade D+ was given for grip strength at follow-up, 24 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute and post-acute stroke.
FES of anterior tibialis and gastrocnemius combined with electromyographic biofeedback (EMG-BFB) versus FES of anterior tibialis and gastrocnemius for gait training, level I (RCT): Grade A for stride length at end of treatment, 6 weeks (clinically important benefit demonstrated); grade C for ankle and knee angle at end of treatment, 6 weeks; grade D for gait cycle time at end of treatment, 6 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
Electromyographic-triggered electrical muscle stimulation training versus control, level I (RCT): Grade A for active ankle ROM at end of treatment, 5 weeks (clinically important benefit demonstrated); grade C+ for active wrist ROM and functional status at end of treatment, 5 weeks (clinically important benefit demonstrated without statistical significance); grade C for decrease in spasticity at end of treatment, 5 weeks (no benefit demonstrated). Patients with subacute stroke.
FES of the posterior deltoid and supraspinatus for the shoulder versus control, level I (RCT): Grade A for active ROM at end of treatment, 6 weeks, decrease in shoulder subluxation at end of treatment, 6 weeks, and difference in active ROM between affected and nonaffected shoulder at end of treatment, 6 weeks, and follow-up, 6 weeks (clinically important benefit demonstrated); grade C+ for active ROM at end of treatment, 3 weeks, and follow-up, 6 weeks, shoulder muscle tone at end of treatment, 3 and 6 weeks, and follow-up, 6 weeks (clinically important benefit demonstrated without statistical significance). Patients with chronic stroke.
Neuromuscular electrical stimulation (NMES) of chronic stroke patients for the hand versus placebo, level I (RCT): Grade C+ for strength, functional status, and motor function (turning pages, small objects, and stacking) at end of treatment, 3 weeks (clinically important benefit demonstrated without statistical significance); grade C for dexterity at end of treatment, 3 weeks (no benefit demonstrated); grade D+ for motor function (feeding, tracking accuracy) at end of treatment, 3 weeks (clinically important benefit favoring control, but demonstrated without statistical significance); grade D for motor function (light cans, heavy cans) at end of treatment, 3 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
FES of the finger thumb extensors and flexors for the hand versus control, level I (RCT): Grade A for functional status (average successful trials for higher and lower functioning groups) at end of treatment, 3 weeks, and follow-up, 3, 10, and 23 weeks, coordination for lower functioning group at follow-up, 3, 10, and 23 weeks, decrease in spasticity for higher functioning group at follow-up, 23 weeks, and functional status (% of maximum score for higher and lower functioning group) at follow-up, 23 weeks (clinically important benefit demonstrated); grade C+ for coordination for lower functioning group at end of treatment, 3 weeks; grade C for decrease in spasticity for lower functioning group at end of treatment, 3 weeks, and follow-up, 3, 10, and 23 weeks (no benefit demonstrated). Patients with subacute and post-acute stroke.
Blocked practice combined with NMES of the extensor communis digitorium/extensor carpiulnaris/triceps brachii/anterior and middle deltoid versus random practice combined with NMES of extensor communis digitorium/extensor carpi ulnaris/triceps brachii/anterior and middle deltoid, level I: Grade A for motor reaction time (time starting directly after pre-motor time and ended with movement initiation at bilateral peak force) favoring random practice at end of treatment, 2 weeks (clinically important benefit demonstrated); grade C+ for pre-motor reaction time (time from stimulus onset until the electromyographic activity of the muscles reaches 30% of unilateral peak reaction) favoring blocked practice at end of treatment, 2 weeks (clinically important benefit demonstrated without statistical significance); grade C for premotor bilateral reaction time and unilateral motor reaction time at end of treatment, 2 weeks, (no benefit demonstrated). Patients with chronic stroke.
Blocked practice combined with NMES of the extensor communis digitorium/extensor carpiulnaris/triceps brachii/anterior and middle deltoid versus passive/active ROM, level I (RCT): Grade C+ for unilateral pre-motor reaction time and bilateral motor reaction time at end of treatment, 2 weeks (clinically important benefit demonstrated without statistical significance); grade C for bilateral pre-motor reaction time at end of treatment, 2 weeks (no benefit demonstrated); grade D for unilateral motor reaction time at end of treatment, 2 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
Random practice combined with NMES of the extensor communis digitorium/extensor carpiulnaris/triceps brachii/anterior and middle deltoid versus passive/active ROM, level I (RCT): Grade C+ for bilateral motor reaction time at end of treatment, 2 weeks (clinically important benefit demonstrated without statistical significance); grade C for bilateral pre-motor reaction time and unilateral pre-motor reaction time at end of treatment, 2 weeks (no benefit demonstrated but favoring control). Patients with chronic stroke.
Electrical stimulation of extensors versus alternating electrical stimulation of flexors and extensors, level I (RCT): Grade A for decrease in spasticity at end of treatment, 6 weeks (clinically important benefit demonstrated); grade C for decrease in spasticity at follow-up, 6 weeks, and manual dexterity, motor impairment, grip muscle force, and wrist mobility at end of treatment, 6 weeks, and follow-up, 6 weeks (no benefit demonstrated). Patients with chronic stroke.
Definitions:
Level of Evidence
Level I: Randomized controlled trials
Level II: Nonrandomized studies
Grade of Recommendation
Grade A: Evidence from one or more randomized controlled trials (RCTs) of a statistically significant, clinically important benefit (>15%)
Grade B: Statistically significant, clinically important benefit (>15%), if the evidence was from observational studies or controlled clinical trials (CCTs)
Grade C+: Evidence of clinical importance (>15%) but not statistical significance
Grade C: Interventions where an appropriate outcome was measured in a study that met the inclusion criteria, but no clinically important difference and no statistical significance were shown
Grade D: Evidence from one or more randomized controlled trials of a statistically significant benefit favoring the control group (<0%: favors controls)
Grade D+: Evidence of clinical importance (<-15% for controls) without statistical significance
Grade D-: Evidence from one or more randomized controlled trials of a clinically important benefit (<-15% for controls) that was statistically significant, where the number of participants in the study is equal to or higher than 100
