Archive for category FES
Available from: https://www.researchgate.net/publication/321478935_EMG_based_FES_for_post-stroke_rehabilitation [accessed Dec 09 2017].
[ARTICLE] Arm rehabilitation in post stroke subjects: A randomized controlled trial on the efficacy of myoelectrically driven FES applied in a task-oriented approach – Full Text
Motor recovery of persons after stroke may be enhanced by a novel approach where residual muscle activity is facilitated by patient-controlled electrical muscle activation. Myoelectric activity from hemiparetic muscles is then used for continuous control of functional electrical stimulation (MeCFES) of same or synergic muscles to promote restoration of movements during task-oriented therapy (TOT). Use of MeCFES during TOT may help to obtain a larger functional and neurological recovery than otherwise possible.
Eighty two acute and chronic stroke victims were recruited through the collaborating facilities and after signing an informed consent were randomized to receive either the experimental (MeCFES assisted TOT (M-TOT) or conventional rehabilitation care including TOT (C-TOT). Both groups received 45 minutes of rehabilitation over 25 sessions. Outcomes were Action Research Arm Test (ARAT), Upper Extremity Fugl-Meyer Assessment (FMA-UE) scores and Disability of the Arm Shoulder and Hand questionnaire.
Sixty eight subjects completed the protocol (Mean age 66.2, range 36.5–88.7, onset months 12.7, range 0.8–19.1) of which 45 were seen at follow up 5 weeks later. There were significant improvements in both groups on ARAT (median improvement: MeCFES TOT group 3.0; C-TOT group 2.0) and FMA-UE (median improvement: M-TOT 4.5; C-TOT 3.5). Considering subacute subjects (time since stroke < 6 months), there was a trend for a larger proportion of improved patients in the M-TOT group following rehabilitation (57.9%) than in the C-TOT group (33.2%) (difference in proportion improved 24.7%; 95% CI -4.0; 48.6), though the study did not meet the planned sample size.
This is the first large multicentre RCT to compare MeCFES assisted TOT with conventional care TOT for the upper extremity. No adverse events or negative outcomes were encountered, thus we conclude that MeCFES can be a safe adjunct to rehabilitation that could promote recovery of upper limb function in persons after stroke, particularly when applied in the subacute phase.
Stroke is the leading cause of disability in adults in the world and can result in highly complex clinical situations. The insult often involves the sensory-motor system leading to hemiparesis and impairment of the upper limb in over 50% of survivors [1,2]. Although some structural recovery is possible, especially in the first months after stroke, only a small percentage of persons recover pre-morbid movement patterns and functionality .
Limitations in reaching and grasping have an important role in determining the level of independence of the person in their daily activities and the subsequent impact on their quality of life. Tailored goal oriented rehabilitation is therefore an essential factor in reducing impairment and augmenting functionality of a hemiplegic arm. A plurality of interventions may help the subject to restore participation and adapt to the new clinical status including task oriented therapy (TOT) that has been shown to be effective for motor recovery [4,5], as well as constraint induced movement therapy (CIMT) , biofeedback and robot assisted therapy [7–9]. Moreover, electrostimulation has been applied to improve muscle recruitment and aid motor recovery. Since resources and time in rehabilitation are limited it is important to identify and employ effective interventions .
The inability to use the arm in an efficient way may lead to non use of the arm and hand that can lead to changes also at the neural level . It is therefore essential that arm use is facilitated in meaningful activities. Approaches that assist the person during purposeful voluntarily activated movement could be important for inducing neuroplasticity and increasing function. Neuromuscular electrical stimulation (NMES) has been employed in rehabilitation of stroke patients either to generate muscle contraction or be a support during movements; however, with inconsistent results [11–20]. A prerequisite for neuroplasticity through training is the volitional intent and attention of the person and it therefore follows that the user should participate consciously in the rehabilitative intervention [21,22].
Through the use of EMG it is technically possible to register the myoelectric activity from voluntary contraction of a muscle while its motor nerve is being stimulated by electrical impulses . MeCFES is a method where the FES is directly controlled by volitional EMG activity. In contrast to EMG triggered FES, the controlling muscle is continuously controlling the stimulation intensity. Thus the resulting movement and intrinsic multisensory activation is synchronized with the active attention and intention of the subject and the muscle contraction can be gradually modulated by the subject himself facilitating motor learning and recovery of function. This has been demonstrated to be possible in spinal cord injured subjects [24,25] and a pilot study has shown that when the controlling and stimulated muscles are homologous or they are synergistic it may lead to a marked increase in motor function of the hemiparetic forearm of selected stroke patients . Motor learning principles required for CNS-activity-dependent plasticity, in fact, include task-oriented movements, muscle activation driving practice of movement, focused attention, repetition of desired movements, and training specificity [21,22,27]. The use of MeCFES during active challenging goal oriented movements should help the patient and the therapist overcome the effect of learned non use by turning attempts to move the arm into successful movements.
We hypothesize that applying MeCFES in a task oriented paradigm to assist normal arm movements during rehabilitation of the upper limb in persons with stroke will improve the movement quality and success and thus induce recovery at the body functions level (impairment) and the activity level (disability) of the International Classification of Function, Disability and Health (ICF)  superior to that induced by usual care task-oriented rehabilitation.[…]
[ARTICLE] Functional Electrical Stimulation with Augmented Feedback Training Improves Gait and Functional Performance in Individuals with Chronic Stroke: A Randomized Controlled Trial – Full Text
Continue —> Functional Electrical Stimulation with Augmented Feedback Training Improves Gait and Functional Performance in Individuals with Chronic Stroke: A Randomized Controlled Trial (PDF Download Available)
[Abstract] Effectiveness of Functional Electrical Stimulation (FES) versus Conventional Electrical Stimulation in Gait Rehabilitation of Patients with Stroke.
PLACE AND DURATION OF STUDY: Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, from July to December 2016.
METHODOLOGY: Subjects with foot drop due to stroke were allotted randomly into 1 of 2 groups receiving standard rehabilitation with Functional Electrical Stimulation (FES) or Electrical Muscle Stimulation (EMS). FES was applied on tibialis anterior 30 minutes/day, five days/week for six weeks. EMS was also applied on the tibialis anterior five days/week for six weeks. Outcome measures included Fugl-Meyer Assessment Scale, Modified Ashworth Scale, Berg Balance Scale (BBS), Time Up and Go Test (TUG) and Gait Dynamic Index (GDI). They were recorded at baseline, after 3 and 6 weeks. Pre- and post-treatment scores were analyzed between two groups on SPSS-20.
RESULTS: After six weeks of intervention, significant improvement was recorded in Fugl-Meyer Assessment score (p<0.001), modified Ashworth Scale score (p=0.027), Berg Balance Scale score (p<0.001), Time Up and Go Test (p<0.001) and Gait Dynamic Index (p=0.012) of the group subjected to FES.
CONCLUSION: Gait training with FES is more effective than EMS in improving mobility, balance, gait performance and reducing spasticity in stroke patients. The research will help clinicians to select appropriate treatment of foot drop in stroke patients.
[ARTICLE] Hemiparetic Stroke Rehabilitation Using Avatar and Electrical Stimulation Based on Non-invasive Brain Computer Interface – Full Text
Brain computer interfaces (BCIs) have been employed in rehabilitation training for post-stroke patients. Patients in the chronic stage, and/or with severe paresis, are particularly challenging for conventional rehabilitation. We present results from two such patients who participated in BCI training with first-person avatar feedback. Five assessments were conducted to assess any behavioural changes after the intervention, including the upper extremity Fugl-Meyer assessment (UE-FMA) and 9 hole-peg test (9HPT). Patient 1 (P1) increased his UE-FMA score from 25 to 46 points after the intervention. He could not perform the 9HPT in the first session. After the 18th session, he was able to perform the 9HPT and reduced the time from 10 min 22 sec to 2 min 53 sec. Patient 2 (P2) increased her UE-FMA from 17 to 28 points after the intervention. She could not perform the 9HPT throughout the training session. However, she managed to complete the test in 17 min 17 sec during the post-assessment session.
These results show that the feasibility of this BCI approach with chronic patients with severe paresis, and further support the growing consensus that these types of tools might develop into a new paradigm for rehabilitation tool for stroke patients. However, the results are from only two chronic stroke patients. This approach should be furthe validated in broader randomized controlled studies involving more patients.
Innovative new technologies are helping patients who have suffered a stroke get back to performing everyday tasks like walking and drinking from a cup.
Watching someone who has suffered a stroke try to perform everyday actions such as walking down the sidewalk or even bringing a cup to their lips can serve as a sobering reminder of how fragile full and robust health is, and also serves as an inspiration for those dedicated to improving the lives of those patients.
Steven Plymale, recently named CEO of Toronto-based MyndTec, said his reaction to watching videos of patients using the company’s MyndMove functional electrical stimulation (FES) rehabilitation system was one of the reasons he joined MyndTec.
“They are very compelling,” Plymale said of the demonstration videos, “and, to be honest with you, were one of the visceral reasons why I took this job. It really is technology we have to get out there.”
MyndMove’s potential market just increased exponentially with recent 510(k) marketing clearance from the U.S. Food and Drug Administration. Plymale said MyndTec has already sent several units of the MyndMove system—which uses an eight-channel electrode array programmable with more than 30 protocols to specifically target muscles in the arm—to a partner institution in the U.S. for a pilot.
“Meanwhile, we have had lots of facilities reach out once they heard of the FDA clearance actively trying to get us to work with them both in terms of further research and also in the commercial setting,” Plymale said.
The MyndMove technology, which received Health Canada approval for clinical use in 2014, is based on repeated stimulation of targeted muscles by the FES system (activated by a therapist who has asked a patient to try a specific movement, such as lifting a cup to the mouth or grasping a pen). The stimulation causes muscles to contract and the movement sends a signal from the muscle to the brain.
Based on the concept of neuroplasticity, this coordinated effort trains a new neural pathway that enables improvement and recovery of voluntary movement. The technology was born nearly a decade ago in the research lab of Milos Popovic at the University of Toronto; it is just one example of cutting-edge technology aiding stroke patients, plus some with spinal cord and traumatic brain injuries, to regain more normal function in everyday movements.
From Battlefield To Rehab
While MyndMove aims to improve arm and hand function, another emerging, early-stage technology, is attempting to help stroke patients regain a more natural walking gait. The technology, a soft “exosuit” from Marlborough, Mass.-based ReWalk Robotics, will be entering pre-clinical trials early in 2018.
The exosuit is the product of a collaborative agreement between ReWalk and Harvard University’s Wyss Institute for Biologically Inspired Engineering, and a salient example of how publicly-funded research for one idea can be re-purposed in other areas. The exosuit research began in 2012 as a Defense Advanced Research Projects Agency (DARPA) project intended for the battlefield.
“We started to call it the exosuit because there is no rigid component,” Kathleen O’Donnell, the program lead for Wyss Institute’s medical exosuit program, said. “It does not restrict movement like an exoskeleton might. The first suits were developed to help able-bodied soldiers carry heavy loads and walk long distances. The purpose was to reduce the metabolic burden on them. They often carry 100 or more pounds of equipment on long marches and the goal was to make them less fatigued when they got to their destination.
“About a year or so into that program, we started looking at where we could find more medical applications of this same technology. We talked to clinicians in the Boston area, and it seemed like stroke was a really good application area that could benefit from this type of technology. The reason for that is that a stroke patient who could benefit from this has some residual walking capacity – it’s not somebody who requires total support in order to walk, but they need a little help in learning how to walk better.”
The exosuit is powered by a motor unit worn on a waist belt, which activates sheathed Bowden cables anchored in two spots: one in a calf-worn fabric sleeve and one in the insole of the shoe the unit is activating to achieve a more natural gait.
ReWalk already markets a rigid exoskeleton for people who have suffered a spinal cord injury who are unable to walk unassisted, and O’Donnell said the exosuit collaboration is meant for a different market—”with the exosuit we’re taking somebody with some underlying ability to walk and we are injecting small levels of assistance at critical times in their gait cycle to improve their walking ability and coordination rather than taking over for them.”
ReWalk CEO Larry Jasinski said the upcoming trial is not expected to enroll a large number of patients – comparable trials have consisted of 40 patients or so – and also said the trial is in the middle of IRB approval at four top research institutions nationwide.
Jasinski said the Wyss Institute researchers had shown the device worked, but didn’t have a product that would meet commercial requirements.
“It could not have gotten past the FDA, would not have been durable enough for a rehab lab and use by 100 patients, and it wasn’t really designed for home use,” he said. “And that’s why this relationship is so ideal. They are doing a high level of fundamental research that, generally, small companies can not afford to do. They are making it work for that individual situation. We are going to be able to take it through the FDA, through the reimbursement processes, and manufacture it at a price point with the quality control and functional level that can meet a mass audience. That is why it’s a good marriage.”
Daniel Becker, MD | The Johns Hopkins University School of Medicine and INI October 21, 2017
[ARTICLE] Functional electrical stimulation and ankle foot orthoses provide equivalent therapeutic effects on foot drop: A meta-analysis providing direction for future research – Full Text PDF
Objective: To compare the randomized controlled trial evidence for therapeutic effects on walking of functional electrical stimulation and ankle foot orthoses for foot drop caused by central nervous system conditions.
Data sources: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, REHABDATA, PEDro, NIHR Centre for Reviews and Dissemination, Scopus and clinicaltrials.gov.
Study selection: One reviewer screened titles/abstracts. Two independent reviewers then screened the full articles.
Data extraction: One reviewer extracted data, another screened for accuracy. Risk of bias was assessed by 2 independent reviewers using the Cochrane Risk of Bias Tool.
Data synthesis: Eight papers were eligible; 7 involving participants with stroke and 1 involving participants with cerebral palsy. Two papes reporting different measures from the same trial were grouped, resulting in 7 synthesized randomized controlled trials (n= 464). Meta-analysis of walking speed at final assessment (p = 0.46), for stroke participants (p = 0.54) and after 4–6 weeks’ use (p = 0.49) showed equal improvement for both devices.
Conclusion: Functional electrical stimulation and ankle foot orthoses have an equally positive therapeutic effect on walking speed in non-progressive central nervous system diagnoses. The current randomized controlled trial evidence base does not show whether this improvement translates into the user’s own environment or reveal the mechanisms that achieve that change. Future studies should focus on measuring activity, muscle activity and gait kinematics. They should also report specific device details, capture sustained therapeutic effects and involve a variety of central nervous system diagnoses.
[Abstract] Sensing motion and muscle activity for feedback control of functional electrical stimulation: Ten years of experience in Berlin
SMARTmove is a £1.1 million Medical Research Council research project running for 30 months from September 2016 to February 2019, funded under the Development Pathway Funding Scheme (DPFS). The project brings together a multidisciplinary team with expertise in functional materials, direct printing fabrication, control algorithms, wireless electronics, sensors, and end user engagement to address stroke rehabilitation. Working together with the advisory board members from six institutions, we will deliver a personalised wearable device for home-based stroke upper limb rehabilitation.
Current commercial devices using functional electrical stimulation (FES) have large electrodes that only stimulate a limited number of muscles, resulting in simple, imprecise movements and the rapid onset of fatigue. In addition, current commercial devices do not employ feedback control to account for the movement of patients, only reducing the level of precision in the resulting movements. In addition, devices are either bulky and expensive, or difficult to set-up due to trailing wires.
Our project uses bespoke screen printable pastes to print electrode arrays directly onto everyday fabrics, such as those used in clothing. The resulting garments will have cutting-edge sensor technologies integrated into them. Advanced control algorithms will then adjust the stimulation based on the patients’ limb motion to enable precise functional movements, such as eating, washing or dressing.
This project will deliver a fabric-based wearable FES for home based stroke rehabilitation. The beneficiaries include:
- Persons with stroke (PwS) and other neurological conditions. Stroke survivors are the direct beneficiaries of our research. The FES clothing can be adapted to also treat hand/arm disabilities resulting from other neurological conditions such as cerebral palsy, head injury, spinal cord injury, and multiple sclerosis. The use of the wearable training system increases the intensity of rehabilitation without an increase in clinical contact time. This leads to better outcomes such as reduced impairment, greater restoration of function, improved quality of life and increased social activity.
- The NHS. FES-integrated clothing is comfortable to wear and convenient to use for rehabilitation, enabling impaired people to benefit from FES at home. It will transfer hospital based professional care to home based self-care, and therefore will reduce NHS costs by saving healthcare professionals’ time and other hospital resources.
- Industry. Benefits include: bringing business to the whole supply chain; increasing the FES market demand by improving performance; benefiting other industry sectors such as rehabilitation for other neurological conditions.
- Research communities in related fields. Specifically, the fields of novel fabrication, control systems, design of medical devices, rehabilitation, smart fabrics, and remote healthcare will benefit from the highly transformative platform technology (e.g. direct write printing, fabric electrodes, iterative learning control systems) developed in this work.
Functional electrical stimulation (FES) is a technique used to facilitate the practice of therapeutic exercises and tasks. Intensive movement practice can restore the upper limb function lost following stroke. However, stroke patients often have little or no movement, so are unable to practice. FES activates muscles artificially to facilitate task practise and improve patients’ movement.