The goal of this clinical trial is to learn if neuromuscular electrical stimulation combined with upper limb neural mobilization works to improve hand grip and upper limb function in post-stroke patients.
Literature Review: In previous studies researcher compared Dynamic Neural Mobilization and Proprioceptive Neuromuscular Facilitation (PNF) in 30 sub-acute stroke patients, divided into two groups (15 each). Both groups received 30-minute sessions, 5 days/week for 4 weeks. Pre-test FMA-UE scores were 33.60±7.13 (Group A) vs. 32.60±9.85 (Group B), and grip strength 2.92±1.07 kg vs. 1.70±0.68 kg. Post-test scores improved to 41.00±7.07 and 5.12±2.03 kg (Group A), and 34.13±10.40 and 3.32±0.82 kg (Group B). Dynamic Neural Mobilization showed significantly better improvements in both outcomes. A randomised controlled experiment with forty-three stroke patients who had hemiplegia in order to evaluate the impact of neural mobilisation in conjunction with shoulder control training,. The additional effect of neural mobilisation in stroke rehabilitation was supported by the treatment group's considerably higher improvements in upper limb motor function (FMA-UE) and shoulder pain (NRS) after four weeks when compared to the control group that received only shoulder training. A qualitative review of 16 studies on neurodynamics in stroke patients, including 9 RCTs, 3 clinical trials, 3 systematic reviews, and 1 case study. Most studies reported that neurodynamics improved range of motion, flexibility, tone reduction, pain, nerve conduction, cortical activity, and post-stroke function. Only one RCT reported no effect on spasticity. Despite these benefits, the review concluded that evidence remains limited and more high-quality research is needed to validate neurodynamic techniques in stroke rehabilitation. A case study of a 68-year-old male post-stroke patient with right-sided hemiparesis. The patient received Neuromuscular Electrical Stimulation combined with Proprioceptive Neuromuscular Facilitation (PNF) therapy for 4 sessions over 2 weeks. Post-treatment, improvements were noted in muscle strength and reduction of pain during passive flexion of the shoulder, elbow, and knee. The study concluded that Neuromuscular Electrical Stimulation and Proprioceptive Neuromuscular Facilitation (PNF) effectively promote muscle growth, strength, and pain relief in hemiparetic stroke patients. A systematic review on the effectiveness of Neuromuscular Electrical Stimulation (NMES) for post-stroke spastic hemiparetic limbs. A total of 26 studies were screened, and 9 clinical studies were included (7 upper limb, 2 lower limb). Spasticity was assessed using Modified Ashworth Scale (MAS) and Electromyography. Most studies reported a decrease in spasticity lasting at least two weeks post-intervention. The authors concluded Neuromuscular Electrical Stimulation (NMES) is effective both alone or combined with physical therapy, while recommending further studies on Neuromuscular Electrical Stimulation (NMES) parameters. A parallel two-arm open-label trial on 26 sub-acute stroke patients using an interactive grasp rehabilitation system (S2) combining smart objects, orthoses, and forearm Neuromuscular Electrical Stimulation (NMES). Participants were block-randomized into experimental (n=14) and control (n=12) groups, receiving 30-minute sessions over 27 sessions. In patients with ARAT scores \<35 (n=11), the experimental group showed greater improvement (+14.9 points on ARAT; p=0.0494). The study confirmed the feasibility and effectiveness of enriched Neuromuscular Electrical Stimulation (NMES)-based grasp rehabilitation. A case study on three first-incident stroke survivors in South Africa to assess the effects of activity-based Neuromuscular Electrical Stimulation (NMES) during short inpatient care. Patients received two 30-minute Neuromuscular Electrical Stimulation (NMES) sessions daily along with occupational therapy for five days. Significant improvements were observed in motor function (FMA, p=0.002) and activities of daily living (MBI, p\<0.001), particularly in toilet transfer, hygiene, and washing. Better cognitive function (MMSE scores) was associated with greater outcomes, while age and dominance had less impact. A randomized controlled trial on 20 tetraplegic patients with upper limb spasticity (C5-C8 level). Participants were randomized into neurodynamic mobilization (n=11) and conventional therapy (n=9) groups, receiving treatment 5 days/week for 4 weeks. Neurodynamic mobilization showed significant improvements: MAS for wrist flexors (-1.64±0.67), finger flexors (-1.00±0.63), F-wave amplitude (-154.09±220.86), F/M ratio (-0.18±0.24), and CUE scores (+17.82±13.49), indicating reduced spasticity and improved upper limb function. A randomized controlled trial evaluating the effects of neuromuscular electrical stimulation combined with mirror therapy. They reported significant improvements in hand function, motor control, and cortical excitability compared to conventional therapy alone in chronic stroke patients. In a review of innovative neurotechnologies, that the effect of neuromuscular electrical stimulation (NMES) in regaining motor function following a stroke. According to the study, Neuromuscular Electrical Stimulation (NMES) enhances muscle strength and neuroplasticity, especially when paired with voluntary movement and task-specific training. The authors also go over the advantages of combining Neuromuscular Electrical Stimulation (NMES) with closed-loop systems and brain-machine interfaces to improve the accuracy and results of motor rehabilitation. A systematic review to assess the status of peripheral neural mechanics and the effect of neural mobilization in stroke rehabilitation. The search across multiple databases identified 22 studies, out of which 12 were included (7 RCTs, 3 quasi-experimental, 1 case report, 1 systematic review). Most studies reported positive therapeutic benefits of neural mobilization, but due to limited methodological quality, the evidence remains weak. The review emphasized the need for further high-quality research on neural mobilization in stroke patients. Study Gap: Despite the proven benefits of Neuromuscular Electrical Stimulation and neural mobilization in stroke rehabilitation, current literature largely examines these interventions in isolation. To date, up to the researcher's knowledge, no study has directly assessed the combined effects of Neuromuscular Electrical Stimulation and neural mobilization on hand grip strength and upper limb function in post-stroke patients. Additionally, there is limited evidence on standardized protocols for their integration in upper limb rehabilitation. Given that Neuromuscular Electrical Stimulation targets muscle activation and neural mobilization addresses nerve mobility, combining both may produce synergistic improvements in motor function of upper limb and hand grip. This study aims to fill this gap by evaluating the effectiveness of a combined approach, providing evidence-based strategies for optimizing stroke rehabilitation outcomes.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
44
Neural mobilization for median, radial, and ulnar nerves. 3 sets of 10 repetitions per nerve for 15 mins with 30 sec rest. Progressed based on tolerance and Range of Motion. Conventional rehabilitation consisted of standardized upper limb exercises, including ROM activities, strengthening exercises, stretching and tsk oriented training. Each treatment session was conducted for 45 minutes.
Neuromuscular Electrical Stimulation (NMES) applied to wrist extensors and finger flexors. Frequency: 35 Hz. Pulse width: 250 µs. Duty cycle: 10s on / 20s off. Intensity: Visible muscle contraction, within patient tolerance. Duration: 30 min Neuromuscular Electrical Stimulation (NMES) + 15 min rest/cool-down. Neural mobilization for median, radial, and ulnar nerves. 3 sets of 10 repetitions per nerve with 30 sec rest.
Handheld dynamometer
The standard Jamar hydraulic handgrip dynamometer with reliability (ICC = 0.95-0.98) was used according to established ASHT (American Society of Hand Therapists) protocols for the measurement of hand grip strength. The patient was seated with shoulder adducted, elbow flexed at 90°, forearm neutral, and wrist 0-30° extension. A total of three trials (kg) with a 1-minute rest between trials was done, and the mean of the 3 values was recorded.
Time frame: Baseline and 6th week
Goniometer
A clinically accepted instrument with high reliability (ICC: 0.85 - 0.99), in accordance with standardised assessment protocols. Each movement was measured across three trails with a 1-minute rest period between trails, and the average of the three readings (in degrees) was used for statistical analysis.
Time frame: baseline and 6th week
Fugl-Meyer Assessment - Upper Extremity
The scale assesses motor recovery by observing movement patterns that advance from proximal to distal joints and from mass synergistic actions to more selective, isolated movements following a stroke. It consists of 4 sections: shoulder-arm, wrist, hand, and coordination and speed. It comprises 33 test items, each scored on a three-point ordinal scale (0-2) with a maximum achievable score of 66. In stroke patients the scale has revealed high reliability (ICC: 0.993 - 0.997).
Time frame: Baseline and 6th week
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