A ground-breaking ’bicycle’ which simulates muscle movements is helping a range of patients with long-term mobility problems caused by head or spinal injuries, stroke or MS. Julie Blackburn watched a demonstration.
One morning in April last year Jason Moffatt from Peel woke up with a headache.
And not just any normal headache, as he recalls: ’I don’t usually do headaches and this one was the worst: it felt like my head was about to explode out of the top.’
He put up with it for a while then decided it ’might be worth popping into the A&E’. It was lucky he did because an examination and subsequent scan revealed dried blood on his brain. He had suffered a bleed.
Jason was flown off the island to Walton Hospital in Liverpool for an operation but during surgery he suffered a stroke which left him paralysed down the left side of his body.
’I then spent three months in Liverpool, learning to walk again and do everyday tasks,’ he says.
While there, Jason realised that strokes do not just happen to older people, but to plenty of younger ones too.
Back on the island his rehabilitation programme has included sessions on a Functional Electrical Stimulation (FES) bicycle.
FES is a technique that uses low energy electrical pulses and has been found to be effective in restoring voluntary functions.
These pulses artificially generate body movements in specific muscle groups through electrodes placed on the patient’s body.
Jason’s physiotherapist is Christine Wright, from the Community Adult Therapy Services team. She specialises in helping patients with long-term neurological conditions and she demonstrated how the machine works.
Once the electrodes are positioned on the muscle groups which Jason needs to get working, he sits in a chair which is attached to the machine with his legs strapped onto the ’pedals’.
His session starts with a warm-up of around one and a half minutes before the resistance increases and he is working hard, concentrating on putting in more effort on his left leg.
Having started his treatments with around 10 to 15 minutes on the bike, Jason has now built up to 30 minutes in each session.
’I’ll be sweating at the end of this,’ he says.
As she keeps an eye on his progress, Christine explains: ’Although it’s a bike, the pattern of movement is simulating walking: each turn of the bike gives Jason a step.
’Numbers of repetitions lead to changes in the brain and the development of new neural pathways.
’The bike also strengthens the muscles so that, when those connections in the brain reform, those muscles are there, ready to be used.’
It has probably served Jason well that he was a keen cyclist before he became ill, having done the End2End mountain bike race, as well as the Parish Walk to Peel and the End to End walk.
He knows that he is also fortunate to have the use of the FES bicycle. When he was doing rehab in Liverpool, at a large, dedicated 30-bed rehab centre there, they didn’t have one: ’It was basically just a gym,’ he recalls. This is true of most rehab units where FES simulators are not part of the standard kit.
’We’re incredibly lucky to have this,’ Christine says.
This machine was purchased for the Community Physiotherapy Department two years ago with £11,695 provided by the Henry Bloom Noble Healthcare Trust.
The Trust’s main remit is to provide equipment over and above what the DHSC in the island would be able to buy.
It has been a great success for Christine and the other physiotherapists, Graihagh Betteridge and Rosie Callow, who are also trained to use the machine.
As well as working on patients’ lower limbs, the simulator can be detached from the bicycle element and used as a portable machine.
It can then be taken to people’s homes and used to help them regain shoulder and arm movement.
At the moment the department has to ration the machine’s use.
They take around 25 to 30 patients at a time, usually for a six-eight week course, with a session once a week on the bike.
They have a waiting list, both with new patients and patients who have had a course already and need further treatment. Because of this the Henry Bloom Noble Healthcare Trust has agreed to purchase a second bicycle so more patients will have the chance to use one.
Chairman of the Trust, Terry Groves, said: ’Jason’s story, and many others, have shown the value of this FES bicycle in managing differing conditions and rehabilitation.
’Recognising the continuing donations made to our Healthcare Trust we are delighted to fund the acquisition of this second FES bicycle from our funds so that continuing strides in this important area of aftercare can be made.’
Jason himself is delighted with the progress he has made using the bicycle: ’I can see an improvement. I can walk further and with a better balance,’ he says.
His aim now is to get back on his (real) bike.
Christine smiles when he says this. ’You will do it,’ she assures him.
Each year, 795,000 stroke patients suffer a new or recurrent stroke and 235,000 severe traumatic brain injuries (TBIs) occur in the US. These patients are susceptible to a combination of significant motor, sensory, and cognitive deficits, and it becomes difficult or impossible for them to perform activities of daily living due to residual functional impairments. Recently, sensorimotor rhythm (SMR)-based brain–computer interface (BCI)-controlled functional electrical stimulation (FES) has been studied for restoration and rehabilitation of motor deficits. To provide future neuroergonomists with the limitations of current BCI-controlled FES research, this chapter presents the state-of-the-art SMR-based BCI-controlled FES technologies, such as current motor imagery (MI) training procedures and guidelines, an EEG-channel montage used to decode MI features, and brain features evoked by MI.
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This paper presents a novel omnidirectional platform for gait rehabilitation of people with hemiparesis after stroke. The mobile platform, henceforth the “walker”, allows unobstructed pelvic motion during walking, helps the user maintain balance and prevents falls. The system aids mobility actively by combining three types of therapeutic intervention: forward propulsion of the pelvis, controlled body weight support, and functional electrical stimulation (FES) for compensation of deficits in angular motion of the joints. FES is controlled using gait data extracted from a set of inertial measurement units (IMUs) worn by the user. The resulting closed-loop FES system synchronizes stimulation with the gait cycle phases and automatically adapts to the variations in muscle activation caused by changes in residual muscle activity and spasticity. A pilot study was conducted to determine the potential outcomes of the different interventions. One chronic stroke survivor underwent five sessions of gait training, each one involving a total of 30 minutes using the walker and FES system. The patient initially exhibited severe anomalies in joint angle trajectories on both the paretic and the non-paretic side. With training, the patient showed progressive increase in cadence and self-selected gait speed, along with consistent decrease in double-support time. FES helped correct the paretic foot angle during swing phase, and likely was a factor in observed improvements in temporal gait symmetry. Although the experiments showed favorable changes in the paretic trajectories, they also highlighted the need for intervention on the non-paretic side.
In this paper, we present the development of a hybrid system which supports an active rehabilitation of the closing and the opening of the hand. The particularity of this system is to combine a soft exoskeleton glove, the SEM Glove™, and functional electrical stimulations (FES) to perform both types of hand movements. The created system is also a suggestion of improvement for the SEM Glove™ that is already commercialized by the BIOSERVO company and usable for hand closing rehabilitation only. In our study, a FES system was associated to this glove in order to provide the missing hand opening rehabilitation. To engage the patient in his rehabilitation, our system is electromyogram (EMG)-controlled and is activated according to the patient movement intentions. EMG signals of the muscles involved in the extension and flexion of the fingers were recorded and then processed in order to detect muscle activations. The control of the different elements of the system was then executed based on the results of this detection. The preliminary results demonstrated that the designed hybrid system shows good performances in detecting correctly the intention of a healthy user. Some improvements could still be made in the signal processing to increase the sensitivity of detection, but we proved that the hybrid system is already operational to assist the hand movements of a healthy user.
Functional electrical stimulation (FES) for Walking its important training for Improvement the waking in Stroke patient, FES is guide training for patient foot to pick up from ground. It’s also showed improvement in walking after training with FES. I am thankful to my patient for giving me consent for this Video. I am want to thank MGM MCRI Hospital and MGM Physiotherapy Rehabilitation and Fitness Centre, Aurangabad, Maharashtra for constant support. Neuro Physiotherapist: Dr. Gaurav C. Mhaske (PT)
One of the prevalent disabilities after stroke is the loss of upper extremity motor function, leading survivors to suffer from an increased dependency in their activities of daily living and a general decrease in their overall quality of life. Therefore, the restoration of upper extremity function to improve survivors’ independency is crucial. Conventional stroke rehabilitation interventions, while effective, fall short of helping individuals achieve maximum recovery potential. Functional Electrical Stimulation (FES), both with passive and active approaches, has been found to moderately increase function in the affected limbs. This paper discusses a novel EEG-Based BCI-FES system that provides FES stimulation to the affected limbs based on the brain activity patterns of the patient specifically in the sensory motor cortex, while the patient imagines moving the affected limb. This system allows the synchronization of brain activity with peripheral movements, which may lead to brain reorganization and restoration of motor function by affecting motor learning or re-learning, and therefore induce brain plasticity to restore normal-like brain function.
Stroke is one of the leading causes of severe motor disability, with approximately 800,000 individuals each year are experiencing a new or recurrent stroke in the US alone (1). Advances in healthcare and medical technology, and the high incidence of stroke and its increasing rate in the growing elderly population, have contributed to a relatively large population of stroke survivors currently estimated at 4 million individuals in the United States alone (1). These survivors are left with several devastating long-term neurological impairments.
The most apparent defect after a stroke is motor impairments, with impairment of upper extremity (UE) functions standing as the most disabling motor deficit. Approximately 80% of survivors suffering from UE paresis, and only about one-tenth of the them regain complete functional recovery (2). Stroke survivors generally suffer from a decrease in their quality of life, and an increase dependency in their activities of daily living. Statistically, close to one quarter of the stroke survivors become dependent in activities of daily living (3). Thus, the optimal restoration of arm and hand function is crucial to improve their independence.
Recently, several remarkable advancements in the medical management of stroke have been made. However, a widely applicable or effective medical treatment is still missing, and most post-stroke care will continue to depend on rehabilitation interventions (4). The available UE stroke rehabilitation interventions can be categorized as: conventional physical and occupational therapy, constraint-induced movement therapy (CIT), functional electrical stimulation (FES), and robotic-aided and sensor-based therapy systems (5). Although an increased effort has been made to enhance the recovery process following a stroke, survivors generally do not reach their full recovery potential. Thus, the growing population of stroke survivors is in a vital need for innovative strategies in stroke rehabilitation, especially in the domain of UE motor rehabilitation. This paper presents an innovative integration of a brain-computer interface (BCI) system to actively control the delivery of FES. Early research and product development activities are advancing the reality of this becoming a mainstream intervention option.
PASSIVE VS. ACTIVE DELIVERY OF FES
The use of FES on the impaired arm is an accepted intervention for stroke rehabilitation aiming to improve motor function. A systematic review with meta-analysis of 18 randomized control trials found that FES had a moderate effect on activity compared with no intervention or placebo and a large effect on UE activity compared to control groups, suggesting that FES should be used in stroke rehabilitation to improve the ability to perform activities (6). Specifically, improvements in UE motor function after intensive FES intervention can be ascribed to the increased ability to voluntarily contract impaired muscles, the reduction in spasticity and improved muscle tone in the stimulated muscles, and the increased range of motion in all joints (7). These improvements in UE after FES could be attributable to multiple neural mechanisms, with one mechanism suggesting that proprioceptive sensory input and visual perception of the movement could promote neural reorganization and motor learning (8). A potential limiting factor to the application of FES is that the stimulation is administered manually, usually from a therapist, without any regard to the concurrent brain activity of the patient. This makes the delivery a passive process with no to minimal coordination with the mental task required to happen concurrently from the patient.
On the other hand, electromyography (EMG)-triggered FES systems made the delivery of FES an active process. Such systems are activated through detecting a preset electrical threshold in certain muscles, which provide the user (patient) the ability to actively control the delivery of FES and make the delivery concurrent with the patient’s brain activity. However, a systematic review of 8 randomized controlled trials (n=157) that assessed the effects of EMG-triggered neuromuscular electrical stimulation for improving hand function in stroke patients found no statistically significant differences in effects when compared to patients receiving usual care (9). A possibility to explain the shortcoming of EMG-triggered FES systems, is that the ability of the brain to generate and send efficient neural signals to the peripheral nervous system is disrupted after stroke, which could affect the control mechanism of these systems. Thus, the synchronization of FES with brain activity maybe critical for the optimization of recovery.
AN ACTIVE EEG-BASED BCI-FES SYSTEM
BCI technology can be used to actively control the FES application through detecting the brain neural activity directly when imagining or attempting a movement. Performing or mentally imagining (or as it commonly called motor imagery) a movement results in the generation of neurophysiological phenomena called event-related desynchronization or synchronization (ERD or ERS). ERD or ERS can be observed from Mu (9–13 Hz) or Beta rhythms (22–29 Hz) over the primary sensorimotor area contralateral to the imagined part of the body (10). These rhythms can be detected using electroencephalography (EEG). Therefore, an EEG based BCI system can be utilized to provide automated FES neurofeedback through detecting either actual movement or motor imagery (MI) and can be used to train the voluntary modulation of these rhythms. The ability to modulate these rhythms alongside the real-time neurofeedback from the FES application may induce neuroplastic change in a disrupted motor system to allow for more normal motor-related brain activity, and thus promote functional recovery. Figure 1 provides an overview of the BCI-FES system.
Any BCI-FES intervention session includes two screening tasks: an open-loop screening followed by a closed-loop task. The open-loop screening task is used to identify appropriate EEG-based control features to guide all subsequent closed-loop tasks. In the open-loop screening task, subjects are instructed to perform attempted movement of either hand by following on-screen cues of “right”, “left”, and “rest”. The attempted movement can vary across subjects, depending on the subject’s baseline abilities and recovery goals. For example, subjects can perform opening and closing of the hand or wrist flexion/extension movements. During this screening task, no feedback is provided to the subject.
In the closed-loop screening task, a real-time visual feedback is given to the subject in a form of a game. A ball appears on the center of a computer monitor with a vertical rectangle (target) to either the right or left side of the screen (Figure 2). The movement of the ball is controlled by the BCI system in which the detection of an attempted movement in either hand will be translated into moving the ball toward the same side. For example, if the target appeared on the left side of the screen and the BCI system detected a movement attempt of the user’s left hand, the ball then moves toward the left. Users are instructed to perform or attempt the same movement that they used during the open-loop task. The FES electrodes are placed on the subject’s affected side over a specific muscle of the forearm. The selection of which muscle to be innervated with FES is dependent on the rehabilitation goal for the subject. For example, if a subject is having a difficulty extending his/her wrist, the FES electrodes are placed over the extensor muscles of the impaired forearm.
The FES neurofeedback is triggered when cortical activity related to attempted movement of the impaired limb is detected by the BCI system, and the subject is cued to attempt movement of the impaired hand. Thus, since both ball movement and FES are controlled by the same set of EEG signals, FES is only applied when the ball moves correctly toward the target on the affected side of the body. This triggering of the FES ensures that only consistent, desired patterns of brain activity associated with attempted movement of the impaired hand are rewarded with feedback from the FES device.
The growing population of stroke survivors constitutes an increasing need for new strategies in stroke rehabilitation. Thus, it is imperative to explore novel intervention technologies that present promise to aid in the recovery process of this population. Some studies suggest that noninvasive EEG-based BCI systems hold a potential for facilitating upper extremities motor recovery after stroke (12,13). Although several groups had gave up on the idea of using non-invasive EEG-based BCI systems for control, there might be several implementations of these systems in the context of rehabilitation that yet need to be explored. The active EEG-based BCI-FES system is one example. However, more research and clinical studies are needed to investigate the efficacy of the system in order to be accepted and integrated into regular stroke rehabilitation practice.
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This project is supported in part by UW-Madison Institute for Clinical and Translational Research, and College of Health Sciences, UW-Milwaukee.
Saebo, Inc. is a medical device company primarily engaged in the discovery, development and commercialization of affordable and novel clinical solutions designed to improve mobility and function in individuals suffering from neurological and orthopedic conditions. With a vast network of Saebo-trained clinicians spanning six continents, Saebo has helped over 100,000 clients around the globe achieve a new level of independence.
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Stroke rehabilitation researchers test new electrical stimulation therapy for improving for hand function after stroke, as part of multi-site study headed by the MetroHealth System and Case Western Reserve University
East Hanover, NJ. November 26, 2019. Kessler Foundation is participating in a phase II multi-site study of an innovative treatment to improve hand function in stroke survivors. Olga Boukrina, PhD, research scientist in the Center for Stroke Rehabilitation Research, is the site’s principal investigator. The study is funded through a five-year $3.2 million grant from the National Institutes of Health awarded to the principal investigator, Jayme S. Knutson, PhD, director of Research and associate professor of Physical Medicine and Rehabilitation at the MetroHealth System and Case Western Reserve University.
This is the first multi-site clinical trial of contralaterally controlled functional electrical stimulation (CCFES), a new rehabilitation intervention for hand recovery following stroke developed by Knutson and colleagues. With CCFES, electrical stimulation is applied to the muscles of the weak hand through surface electrodes, causing the weak hand to open, a function that is often lost in stroke survivors. The patient controls the stimulation to their weak hand through a glove with sensors worn on their opposite, unaffected hand. Opening their unaffected hand delivers a proportional intensity of electrical stimulation that opens their weak hand, and enables them to practice using their hand in therapy. Researchers will enroll 129 patients who are 6 to 24 months post stroke who have upper extremity hemiparesis and limited hand movement.
The effectiveness of CCFES will be compared with two other treatments — cyclic neuromuscular electrical stimulation (CNMES), which has pre-set duration and intensity of stimulation and operates independent of patient control, and traditional task-based training without stimulation. Participants will be randomly assigned to one of the three treatment options for 12 weeks. The research teams will administer the treatments and conduct blinded outcome assessments. The durability of functional improvements will be evaluated at 6-month follow-up. Study sites include the MetroHealth System (Jayme Knutson, PhD), the Cleveland Clinic (Ela Plow, PT, PhD), Emory University (A.M. Barrett, MD), and Johns Hopkins University (Preeti Raghavan, MD).
“Because hand function is integral to so many activities of daily living, advances that improve function can have significant effect on the lives of stroke survivors,” said Dr. Boukrina. “This study will help determine the optimal method for restoring hand function. We anticipate that putting the patients in control of stimulating their weak hand with CCFES may activate neuroplastic changes that lead to greater and longer lasting functional gains.”