[Abstract] Gait rehabilitation using functional electrical stimulation induces changes in ankle muscle coordination in stroke survivors: a preliminary study

Background: Previous studies have demonstrated that post-stroke gait rehabilitation combining functional electrical stimulation applied to the ankle muscles during fast treadmill walking (FastFES) improves gait biomechanics and clinical walking function. However, there is considerable inter-individual variability in response to FastFES. Although FastFES aims to sculpt ankle muscle coordination, whether changes in ankle muscle activity underlie observed gait improvements is unknown. The aim of this study was to investigate three cases illustrating how FastFES modulates ankle muscle recruitment during walking.

Methods: We conducted a preliminary case series study on three individuals (53-70y; 2M; 35-60 months post-stroke; 19-22 lower extremity Fugl-Meyer) who participated in 18 sessions of FastFES (3 sessions/week; ClinicalTrials.gov: NCT01668602). Clinical walking function (speed, six-minute walk test, and Timed-Up-and-Go test), gait biomechanics (paretic propulsion and ankle angle at initial-contact), and plantarflexor (soleus) / dorsiflexor (tibialis anterior) muscle recruitment were assessed pre- and post-FastFES while walking without stimulation.
Results: Two participants (R1, R2) were categorized as responders based on improvements in clinical walking function. Consistent with heterogeneity of clinical and biomechanical changes commonly observed following gait rehabilitation, how muscle activity was altered with FastFES differed between responders.R1 exhibited improved plantarflexor recruitment during stance accompanied by increased paretic propulsion. R2 exhibited improved dorsiflexor recruitment during swing accompanied by improved paretic ankle angle at initial-contact. In contrast, the third participant (NR1), classified as a non-responder, demonstrated increased ankle muscle activity during inappropriate phases of the gait cycle. Across all participants, there was a positive relationship between increased walking speeds after FastFES and reduced SOL/TA muscle coactivation.
Conclusion: Our preliminary case series study is the first to demonstrate that improvements in ankle plantarflexor and dorsiflexor muscle recruitment (muscles targeted by FastFES) accompanied improvements in gait biomechanics and walking function following FastFES in individuals post-stroke. Our results also suggest that inducing more appropriate (i.e., reduced) ankle plantar/dorsi-flexor muscle coactivation may be an important neuromuscular mechanism underlying improvements in gait function after FastFES training, suggesting that pre-treatment ankle muscle status could be used for inclusion into FastFES. The findings of this case-series study, albeit preliminary, provide the rationale and foundations for larger-sample studies using similar methodology.


via Frontiers | Gait rehabilitation using functional electrical stimulation induces changes in ankle muscle coordination in stroke survivors: a preliminary study | Neurology

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[Abstract] Home-based Technologies for Stroke Rehabilitation: A Systematic Review


-The types of technology of reviewed articles include games, telerehabilitation, robotic devices, virtual reality devices, sensors, and tablets.

-Two main human factors in designing home-based technologies for stroke rehabilitation are discussed: designing for engagement (including external and internal motivation) and designing for the home environment (including understanding the social context, practical challenges, and technical proficiency).



Many forms of home-based technology targeting stroke rehabilitation have been devised, and a number of human factors are important to their application, suggesting the need to examine this information in a comprehensive review.


The systematic review aims to synthesize the current knowledge of technologies and human factors in home-based technologies for stroke rehabilitation.


We conducted a systematic literature search in three electronic databases (IEEE, ACM, PubMed), including secondary citations from the literature search. We included articles that used technological means to help stroke patients conduct rehabilitation at home, reported empirical studies that evaluated the technologies with patients in the home environment, and were published in English. Three authors independently conducted the content analysis of searched articles using a list of interactively defined factors.


The search yielded 832 potentially relevant articles, leading to 31 articles that were included for in-depth analysis. The types of technology of reviewed articles included games, telerehabilitation, robotic devices, virtual reality devices, sensors, and tablets. We present the merits and limitations of each type of technology. We then derive two main human factors in designing home-based technologies for stroke rehabilitation: designing for engagement (including external and internal motivation) and designing for the home environment (including understanding the social context, practical challenges, and technical proficiency).


This systematic review presents an overview of key technologies and human factors for designing home-based technologies for stroke rehabilitation.


via Home-based Technologies for Stroke Rehabilitation: A Systematic Review – ScienceDirect

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[WEB SITE] VRHealth unveils VR software for hot flashes

The new technology will provide users with an AI guide that will lead them through CBT.

By Laura Lovett, December 12, 2018

Photo credit: VRHealth


VRHealth has exclusively unveiled to MobiHealthNews a virtual reality product called Luna that was designed to help patients manage hot flashes.

The new VR product, which can be used by patients going through menopause or chemotherapy treatment, employs cognitive behavioral therapy (CBT). It also gives users a data analysis of their treatment.

When a user puts on the VR headset, they are greeted by an AI trainer called Luna who guides users through CBT and other coping mechanisms. The technology also lets users virtually travel to another environment.

“That trainer you can take to different places. One part of the app is called practice breathing in an environment. It [let’s you] see how you breath,” Eran Orr, CEO of VRHealth, told MobiHealthNews. “Users can actually see the environment and go into a lake or waterfall.”

While the technology will first be given to patients in a hospital setting, Orr said that the idea is for the system to go home with the patients.

“Patients will be introduced to it during chemotherapy or treatment in the hospital and will take [the] headset back home,” he said. “It is an AI that is basically a trainer that follows improvement and can be adjusted automatically.”

The idea for Luna came out of a personal connection. One of the members of the VRHealth team developed the idea for the technology after undergoing chemotherapy for breast cancer and experiencing hot flashes as a side effect.

Orr said that Luna will officially launch in January of 2019 at CES.

Why it matters

Hot flashes, which are often triggered by a hormone drop, are associated with breast cancer chemotherapy and surgery to remove the ovaries as well as menopause, according to the Cancer Treatment Centers of America (CTCA). While women are most likely to experience hot flashes, the CTCA said that men can also experience the condition.

Common treatment options include hormone therapy, antidepressants and other prescription medications, according to the Mayo Clinic. Alternative medicine including meditation, acupuncture and CBT are also used.

VRHealth is pitching this technology as another avenue to treat the condition, and Orr hinted that in yet-to-be-released clinical trials Luna outperformed medications for hot flash treatment.

What’s the trend

VRHealth was in the news in September when it teamed up with Facebook’s Oculus, which makes VR hardware and other related products, on a range of healthcare-focused VR applications to be delivered on the latter’s hardware.

VR as a whole is growing. Many in healthcare are looking to the technology to help with pain, discomfort and anxiety. Clinicians are deploying it in a wide range of settings including obstetricspediatrics and rehabilitation.

On the record 

“We believe VR can be an amazing replacement for opiates or any kind of nonnatural hormone and the most common treatments that have a lot of side effects,” Orr said. “We believe VR could be a good solution.”

via VRHealth unveils VR software for hot flashes | MobiHealthNews

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[ARTICLE] Variation of Finger Activation Patterns Post-stroke Through Non-invasive Nerve Stimulation – Full Text

Purpose: A transcutaneous proximal nerve stimulation technique utilizing an electrode grid along the nerve bundles has previously shown flexible activation of multiple fingers. This case study aimed to further demonstrate the ability of this novel stimulation technique to induce various finger grasp patterns in a stroke survivor.

Methods: An individual with chronic hemiplegia and severe hand impairment was recruited. Electrical stimulation was delivered to different pairs of an electrode grid along the ulnar and median nerves to selectively activate different finger flexor muscles, with an automated electrode switching method. The resultant individual isometric flexion forces and forearm flexor high-density electromyography (HDEMG) were acquired to evaluate the finger activation patterns. A medium and low level of overall activation were chosen to gauge the available finger patterns for both the contralateral and paretic hands. All the flexion forces were then clustered to categorize the different types of grasp patterns.

Results: Both the contralateral and paretic sides demonstrated various force clusters including single and multi-finger activation patterns. The contralateral hand showed finger activation patterns mainly centered on median nerve activation of the index, middle, and ring fingers. The paretic hand exhibited fewer total activation patterns, but still showed activation of all four fingers in some combination.

Conclusion: Our results show that electrical stimulation at multiple positions along the proximal nerve bundles can elicit a select variety of finger activation patterns even in a stroke survivor with minimal hand function. This system could be further implemented for better rehabilitative training to help induce functional grasp patterns or to help regain muscle mass.


Following a stroke, a majority of individuals have paresis due to a loss of excitatory input and subsequent complications, such as disuse atrophy (1) and altered spinal organization (24). This loss of voluntary control of muscle activation often limits activities of daily living. Neuromuscular electrical stimulation (NMES) has been widely utilized both in the clinic and in research settings to help restore atrophied muscle and lost functions (57). Electrical stimulation has been particularly successful with post-stroke survivors for functional recovery (810). Research in NMES also aims to restore functional activation of muscles, such as the restoration of hand grasps (11).

Traditionally, NMES uses large electrode pads, targeting the distal branches of the nerve, known as the motor point stimulation (12). Although stimulation of the motor point is straightforward methodologically, NMES is limited to localized muscle activation, which limits its functional efficacy and also leads to rapid muscle fatigue (13). Advances in NMES techniques to alleviate these issues involve various multi-electrode techniques, which can stimulate multiple small regions of the muscle to help distribute the current and potentially activate more muscle fibers (1415). Crema et al. has also demonstrated flexible activation of multiple fingers using a multi-electrode array across the forearm and hand (16). Other approaches to NMES involve stimulation of the nerve bundle prior to branching and innervating a muscle, which has shown to allow for a larger area of muscle activation and potentially reduce long-term fatigue effects (1719).

Recent developments have demonstrated the capabilities of an alternative non-invasive transcutaneous electrical nerve stimulation method targeting the ulnar and median nerves proximal to the elbow to flexibly activate individual and multiple fingers (2021). In addition, this technique shows the ability to delay the force decline (2223). A stimulation electrode grid placed along the two nerves allows us to activate different muscles or muscle portions to elicit varied desired movements, but manually switching between different electrode pairs is time-consuming. To shorten this process, an automated electrode pair searching method has been developed and tested on intact control subjects (24). This new method can further categorize the total available sets of finger activation patterns across the entire electrode grid, providing valuable information on electrode selection and the force generation capacity of stroke muscles. However, the efficiency of this method has not been tested on stroke survivors. Therefore, this case study recruited a control subject and a stroke survivor with severe weakness of the right arm, and evaluated the available finger activation patterns of the subjects. Our results showed varied activation of multiple fingers from both subjects. Further development of this stimulation technique can provide valuable alternatives to current rehabilitation for the restoration of hand movements.[…]


Continue —> Frontiers | Variation of Finger Activation Patterns Post-stroke Through Non-invasive Nerve Stimulation | Neurology

Figure 1. Experimental Setup and Data Samples. (A) Stimulation Electrode Array and Force/HDEMG Setup. Processed Data samples are displayed adjacent to the setup figure. (B) The EMG map is the spatial map of calculated AUC values from each EMG channel’s CMAP and (C) the Force Profile is the smoothed force of each finger. (D) Sample Depiction of Automated Stimulation Procedure. Each stimulation pair can be paired with an EMG activity map and a force profile, which is the repetition of 3 stimulations.

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[BOOK] Person Centered Approach to Recovery in Medicine – Luigi Grassi – Google Books

Bibliographic information

via Person Centered Approach to Recovery in Medicine – Luigi Grassi – Google Books

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[Abstract] Acceptance of Tele-Rehabilitation by Stroke Patients: Perceived Barriers and Facilitators



To explore the perceived barriers and facilitators of tele-rehabilitation (TR) by stroke patients, caregivers and rehabilitation therapists in an Asian setting.


Qualitative study involving semi-structured in-depth interviews and focus group discussions.


General community.


Participants (N=37) including stroke patients, their caregivers, and tele-therapists selected by purposive sampling.


Singapore Tele-technology Aided Rehabilitation in Stroke trial.

Main Outcome Measures

Perceived barriers and facilitators for TR uptake, as reported by patients, their caregivers, and tele-therapists.


Thematic analysis was used to inductively identify the following themes: facilitators identified by patients were affordability and accessibility; by tele-therapists, was filling a service gap and common to both was unexpected benefits such as detection of uncontrolled hypertension. Barriers identified by patients were equipment setup–related difficulties and limited scope of exercises; barriers identified by tele-therapists were patient assessments, interface problems and limited scope of exercises; and common to both were connectivity barriers. Patient characteristics like age, stroke severity, caregiver support, and cultural influence modified patient perceptions and choice of rehabilitation.


Patient attributes and context are significant determinants in adoption and compliance of stroke patients to technology driven interventions like TR. Policy recommendations from our work are inclusion of introductory videos in TR programs, provision of technical support to older patients, longer FaceTime sessions as re-enforcement for severely disabled stroke patients, and training of tele-therapists in assessment methods suitable for virtual platforms.

via Acceptance of Tele-Rehabilitation by Stroke Patients: Perceived Barriers and Facilitators – Archives of Physical Medicine and Rehabilitation

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[Abstract] Effects of Home-Based Versus Clinic-Based Rehabilitation Combining Mirror Therapy and Task-Specific Training for Patients With Stroke: A Randomized Crossover Trial



We investigated the treatment effects of a home-based rehabilitation program compared with clinic-based rehabilitation in patients with stroke.


A single-blinded, 2-sequence, 2-period, crossover-designed study.


Rehabilitation clinics and participant’s home environment.


Individuals with disabilities poststroke.


During each intervention period, each participant received 12 training sessions, with a 4-week washout phase between the 2 periods. Participants were randomly allocated to home-based rehabilitation first or clinic-based rehabilitation first. Intervention protocols included mirror therapy and task-specific training.

Main Outcome Measures

Outcome measures were selected based on the International Classification of Functioning, Disability and Health. Outcomes of impairment level were the Fugl-Meyer Assessment, Box and Block Test, and Revised Nottingham Sensory Assessment. Outcomes of activity and participation levels included the Motor Activity Log, 10-meter walk test, sit-to-stand test, Canadian Occupational Performance Measure, and EuroQoL-5D Questionnaire.


Pretest analyses showed no significant evidence of carryover effect. Home-based rehabilitation resulted in significantly greater improvements on the Motor Activity Log amount of use subscale (P=.01) and the sit-to-stand test (P=.03) than clinic-based rehabilitation. The clinic-based rehabilitation group had better benefits on the health index measured by the EuroQoL-5D Questionnaire (P=.02) than the home-based rehabilitation group. Differences between the 2 groups on the other outcomes were not statistically significant.


The home-based and clinic-based rehabilitation groups had comparable benefits in the outcomes of impairment level but showed differential effects in the outcomes of activity and participation levels.

via Effects of Home-Based Versus Clinic-Based Rehabilitation Combining Mirror Therapy and Task-Specific Training for Patients With Stroke: A Randomized Crossover Trial – Archives of Physical Medicine and Rehabilitation

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[Proceeding] Investigation of Upper Arm Muscle Activation for the Progress Monitoring in Stroke Rehabilitation – Full Text PDF


This paper investigates the muscle activation of the upper arm for the progress monitoring of post-stroke rehabilitation. The performance measure is an indicator to monitor the progress of the rehabilitation exercise. The aim is for the fast recovery from the lost function of the upper limb as a result of the paralyzed patients. The investigation results will be employed in virtual reality (VR) game technology in the stroke rehabilitation exercise. It can solve the problem of the conventional stroke therapy which some prove inefficient and even some fail to regain patients’ upper arm. The rehabilitation task requires the muscle activity measurement and monitoring of the progress that involve both fundamental and functional movements. By consistently do the rehabilitation exercise, patients can slowly develop the motor functions, which enables them to slowly regain the movement of the affected limb. In the experiments, five healthy subjects were selected. The experimental results show that deltoid has a significant activation compared with the bicep. In the VR systems, these two muscles will be used to monitor the progress of the rehabilitation.


Stroke is one of the main five driving reasons for death and one of the best 10 foundations for hospitalization in Malaysia. World Health Organization (WHO) statistical profile for Malaysia stated that the stroke was at second position for causes of deaths in Malaysia, killing 15.5 thousand people in 2012. Based on study by Burke and Venketasubramanian [1], it was stated that Malaysia was at third position for stroke mortality and at fourth placed among causes of death after 1991. Stroke can cause a long-term disability. The major cause of this disability is due to Traumatic Brain Injury (TBI), Spinal Cord Injury (SCI), and Cerebrovascular Accident (CVA) [2]. The outcomes of these ailments are impact on patient’s personal satisfaction as well as likewise confined their execution of everyday life exercises. Motor deficits following stroke are most obvious in the contralesional (inverse of the injury side of the cerebrum) limbs, and may include muscle shortcoming, fatigue, abnormal muscle tone, and joint and muscle contracture [2-4]. In order to recover from this disability, hospitals and clinics had conducted the rehabilitation proses of training with the goals to heal or improve lost function of human motor due to the stroke disease [5-7].

This research is conducted to select the most activated muscle on human body specifically for upper arm muscle in case of measuring the performance of post stroke patient in rehabilitation. The objective of this research is to investigate the motion features of the functional movement by using electromyography (EMG). The significant muscle for the performance measure of the stroke rehabilitation will be proposed. Not to forget the functional pattern or motion pattern will be design to get the better muscle activation performance.

The organization of the paper is as follows. Introduction is given in the first section of this paper. Then, literature review regarding EMG and post stroke rehabilitation will be presented in the following section. Methodology and flow of this work will be explained in detail in the third section. Results of this work can be seen in the fourth section.

Finally, conclusions and future recommendation is also given in the end of this paper.[…]

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[BOOK Chapter] Application of a Robotic Rehabilitation Training System for Recovery of Severe Plegie Hand Motor Function after a Stroke – Full Text PDF


We have developed a rehabilitation training system (UR-System-PARKO: Useful
and Ultimate Rehabilitation System-PARKO) for patients after a stroke to promote
recovery of motor function of the severe plegic hand with hemiplegia. A clinical
test with six patients for the therapeutic effect of the UR-System-PARKO for severe
plegic hand was performed. For all patients, the active ranges of motion (total
active motion) of finger extension improved after training with the UR-SystemPARKO. Moreover, the modified Ashworth scale (MAS) scores of finger extension
increased. Thus, the training reduced the spastic paralysis. These results suggest the
effectiveness of training with the UR-System-PARKO for recovery of motor function as defined by finger extension in the severe plegic hand.

1. Introduction

Stroke is the leading cause of disability in Japan, with more than 1 million people
in Japan living with a disability as a result of stroke. Therefore, interventions that
address the sensorimotor impairments resulting from stroke are important. Motor
function may be restored more than 6 months after a stroke [1, 2], but these studies
included patients with only moderate poststroke hemiplegia, whereas most stroke
survivors have a severely plegic hand with difficulty extending the fingers [3]. This
suggests that a method is needed for treatment of these severely affected cases.
However, although a few studies on rehabilitation therapy for severe plegic hands
have been reported, no marked recovery of ability in extension of the fingers of
the plegic hands was achieved in any study [4, 5]. Proprioceptive neuromuscular
facilitation (PNF) is a therapeutic method that was reported to increase the muscle
strength of the plegic extremities in patients with stroke-induced hemiplegia [6].
However, since PNF is indicated for patients with a certain level of joint motion,
this method has not been used for severe plegic hands where the fingers cannot
extend. Thus, the first author developed a method to build up the extensor digitorum muscle strength using PNF [7, 8] for stroke patients with severe hemiplegia.

With this therapy, he has performed repeated facilitation training using his hands
on stroke patients with a severe plegic hand to help them recover their motor function, and a good treatment outcome was achieved [9, 10] (Figure 1).
Facilitation training uses extension of the elbow joint with resistance applied to
the tips of the fully extended hemiplegic fingers to increase the force of the extensor digitorum muscle. However, this approach is time-consuming for the therapist.
Therefore, development of a training system is required instead of repeated
facilitation training by a therapist. The objectives of this study were to develop
a training system to increase the output of the extensor digitorum muscle force
and to verify the effect of training with the developed system on a severe plegic
hand. The training system is called the UR-System-PARKO (a useful and ultimate
rehabilitation support system for PARKO). The UR-System-PARKO was developed
by remodeling the simplified training system, which developed previously for
resistance training of hemiplegic upper limbs [11]. A brace for securing the plegic
hand to the UR-System-PARKO was developed on the basis of repeated facilitation
training by a therapist.[…]

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[BLOG POST] Brain Injury, Social Skills, and the Holidays – BrainLine

Ask the Expert: Social Skills and the HolidaysQuestion:

My husband fell off a ladder almost a year ago now and sustained a brain injury. I’ve noticed that his communication and social skills tend to get worse at parties, especially during the holiday season. Why is this? And what can I do to help


The holidays can be fraught with pitfalls for someone with a brain injury. The fact that your husband’s communication and social skills worsen at parties is not unusual. For starters, routines are disrupted and there can be an increased number of social functions with less time to rest in between.

TBI related fatigue could cause a decline in social skills. Things can get even more challenging if alcohol is added to the mix. And for individuals prone to seizure activity, holiday lighting — particularly flashing lights — could increase the risk of a seizure.

A social setting, like a party with many people engaged in conversation, eating, and drinking, can easily become over-stimulating and even upsetting to a person with TBI. To help your husband deal with all these issues, you might try limiting the number of engagements during the holidays. And when in a social setting, help support your husband’s conversations by introducing easy topics, and repeating or rephrasing questions asked by others.

You know your husband better than anyone else, and when you hear him having difficulty using the right words, or even slurring his speech, it’s time to go home. All the activity has probably tired him out. For someone with TBI, it can be exhausting trying to converse in crowds, with strangers, and in over-stimulating settings.


via Brain Injury, Social Skills, and the Holidays | BrainLine

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