Posts Tagged chronic

[Abstract] Does adapted physical activity‑based rehabilitation improve mental and physical functioning? A randomized trial

BACKGROUND: Persons with chronic disabilities face a wide variety of problems with functioning that affect their level of physical activity and participation. We have limited knowledge about the effect of adapted physical activity (APA)-based rehabilitation on perceived mental and physical functioning.
AIM: The main aim of this study was to evaluate the effect of APA‑based rehabilitation compared to waiting‑list on perceived mental and physical functioning. Secondly, we wanted to assess whether improvement in self‑efficacy, motivation, pain and fatigue during rehabilitation was related to the effect of the intervention.
DESIGN: Randomized controlled trial.
SETTING: In‑patient rehabilitation Center.
POPULATION: All subjects above 17 years who were referred by their physician to BHC between July 1, 2010 and August 1, 2012 without major cognitive or language problems were eligible for the study (N.=321).
METHODS: Persons above 17 years (men and women) with chronic disabilities who applied for a rehabilitation stay, were randomized to an adapted physical activity‑based rehabilitation intervention (N.=304) or waiting‑list with delayed rehabilitation. A total of 246 consented and were allocated to four week intervention or a waiting‑list control group. The main outcome was physical and mental functioning evaluated four weeks after rehabilitation using the Medical Outcomes Study 12-Item Short‑Form Health Survey (SF-12).
RESULTS: Compared to waiting‑list the adapted physical activity‑based intervention improved physical and mental functioning. Improvement in physical functioning during rehabilitation was related to reduced pain, improved motivation and self‑efficacy.
CONCLUSIONS: The results indicate that an adapted physical activity‑based rehabilitation program improves functioning. Improved efficacy for managing disability may mediate the improvement in mental functioning.
CLINICAL REHABILITATION IMPACT: Adapted physical activity‑based rehabilitation should be considered during the development of rehabilitation strategies for people with chronic disabilities. Motivational and self‑efficacy aspects must be addressed when organizing and evaluating rehabilitation programs.

via Does adapted physical activity‑based rehabilitation improve mental and physical functioning? A randomized trial – European Journal of Physical and Rehabilitation Medicine 2018 June;54(3):419-27 – Minerva Medica – Journals


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[Abstract] EEG predicts upper limb motor improvement after robotic rehabilitation in chronic stroke patients


Robotic rehabilitation is known to be at least as effective as conventional training for upper limb motor recovery after stroke; nevertheless, which patients could benefit from this treatment is unknown and finding markers that could predict rehabilitation outcome is a challenge.

We aimed at understanding the neural mechanisms of motor function recovery after upper limb robotic rehabilitation in chronic stroke patients using neurophysiological markers obtained by electroencephalography recording (EEG).

Material and method

Fourteen chronic stroke patients (M/F: 11/3; 59.5 ± 13 yrs) with mild to moderate upper limb paresis were subjected to 10 sessions of upper limb rehabilitation with a planar mobile robotic device (MOTORE, Humanware). Fugl–Meyer Assessment Scale (FMAS) and Wolf Motor Function Test (WMFT) were administered before (t0), at the end (t1) and at 1 month follow-up (t2); at the same timing 64-channals EEG was recorded.

We analyzed power spectrum density in different frequency bands of the affected and unaffected hemispheres with 64-ch EEG and their correlation with motor impairment as measured by clinical scales. Correlation analyses were performed to identify the indicators of good rehabilitative outcome.


Clinical assessment indicated a significant functional improvement in upper limb motor function at the end of rehabilitation as assessed with FMAS and WMFT score that is maintained at follow-up. We found a positive correlation between global Alpha activity at t0 and WMFT score variation (t0–t1) and between global Beta activity at t0 and WMFT time variation (t0–t1) and a positive correlation between Beta activity at t0 in the unaffected hemisphere and FMAS variation (t0–t1 and t0–t2).


Robotic rehabilitation improves upper limb motor performance in stroke patients even in the chronic phase. The amount of Alpha and Beta band power at t0 is suggestive of rehabilitation-related motor outcome. Our results suggest that EEG recording preliminarily to robotic rehabilitation could help identifying good responders to treatment thus optimizing results.


via EEG predicts upper limb motor improvement after robotic rehabilitation in chronic stroke patients – ScienceDirect

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[Abstract] Combined effects of botulinum toxin type A and repetitive transcranial magnetic stimulation with intensive motor training immediately after injection in a patient with chronic stroke: A case report


  • 1-Hz repetitive transcranial magnetic stimulation with rehabilitation immediately after botulinum toxin type A injection in a stroke patient.
  • The spasticity, motor function, and usefulness of the paretic hand improved.
  • This is a possibility of shortening the intervention period of combined therapy.


Study Design

Single case report.


A previous study clarified that spasticity and motor function were improved by combined treatment with botulinum toxin type A (BTX) injection and 1-Hz repetitive transcranial magnetic stimulation (rTMS) with intensive motor training at 4 weeks after injection. However, it is not clear whether 1-Hz rTMS with intensive motor training immediately after BTX injection also improves spasticity and motor function in stroke patients.

Purpose of the Case Report

The purpose of this case report is to test the short- and long-term effects of BTX injection and rTMS with intensive motor training on the spasticity, motor function, and usefulness of the paretic hand in a stroke patient.


A 64-year-old male, who suffered from a right cerebral hemorrhage 53 months previously, participated in the present study. BTX was injected into the spastic muscles of the affected upper limb. He then received the new protocol for a total of 24 sessions. The Modified Ashworth Scale (MAS), Fugl-Meyer Assessment (FMA), and Motor Activity Log, consisting of the amount of use and quality of movement scales, were assessed before and immediately after BTX injection, at discharge, and monthly for up to 5 months after discharge.


For the short-term effects of the therapy, the MAS scores of the elbow and wrist, FMA score, and quality of movement score improved. For the long-term effects of the therapy, the MAS score of the fingers, FMA score, and amount of use score improved for up to 5 months after discharge.


The present case report showed the improvement of all assessments performed in the short and/or long term and suggest the possibility of shortening the intervention period of combined therapy of BTX and rTMS with intensive motor training.

via Combined effects of botulinum toxin type A and repetitive transcranial magnetic stimulation with intensive motor training immediately after injection in a patient with chronic stroke: A case report – Journal of Hand Therapy

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[Abstract] Sporadic distant neurotoxin effects in the chronic treatment of spasticity


Neurotoxin therapy is an effective component of comprehensive spasticity management. The two cases presented demonstrate adverse effects.

Material and method

Patient S is a 60-year-old female with right spastic hemiparesis due to left hemispheric stroke (age 46) treated with therapy, bracing, oral baclofen. Patient R is a 28-year-old female with left spastic hemiparesis due to hemispherectomy (age 6).


For patient S, onabotulinumtoxinA (ONA) was initiated at 300 units (u) to the right upper extremity (RUE), advanced to 500u. She received injections every 3–3.5 months for over 9 years and continued to function independently. At routine follow-up, she related left upper extremity (LUE) weakness that she noted but did not report with her two prior injections. She denied any other symptoms. Examination revealed mild, diffuse LUE weakness, imaging was unremarkable and EMG demonstrated a chronic LUE axonal polyradiculopathy. ONA was continued at 300u to the RUE with somewhat lesser but maintained benefit without adverse effects.

For patient R, ONA was initiated at 400u to the LUE every three months for 13 rounds, advanced to 500u. Contralateral (RUE) weakness developed after the second round of 500u dosing. Diagnostic evaluation was notable only for increased insertional activity, fibrillationpotentials and decreased recruitment with subsequent long duration polyphasic motor unitpotentials. Unchanged with high dose steroids, weakness improved with IVIG. Repeat ONA with 500u resulted in good local effect, recurrent contralateral upper and lower extremity weakness. EMG demonstrated contralateral cervical, thoracic and lumbosacral axonal polyradiculopathy. Symptoms improved with IVIG. Patient declined subsequent ONA.


Both patients were treated with neurotoxin therapy for 3–9 years with good clinical response before developing the adverse reaction. Weakness distant to the injection sites is supported by electrodiagnostic findings of contralateral axonal polyradiculopathy. The clinical presentations suggest the possibility that the adverse effect of distant weakness may be immune-mediated and dose-related.


via Sporadic distant neurotoxin effects in the chronic treatment of spasticity – ScienceDirect

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[Abstract] Recovery in the Severely Impaired Arm Post-stroke after Mirror Therapy – a Randomized Controlled Study



This study aimed to examine the effectiveness of mirror therapy (MT) on recovery in the severely impaired arm after stroke.


Using single-blind randomized controlled design, patients with severely impaired arm within 1-month post-stroke were assigned to received MT (n=20) or control therapy (CT) (n=21), 30min. twice daily for 4 weeks in addition to conventional rehabilitation. During MT and CT, subjects practiced similar structured exercises in both arms, except that mirror reflection of the unaffected arm was the visual feedback for MT, but mirror was absent for CT so that subjects could watch both arms in exercise. Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) were the outcome measurements.


After the intervention, both MT and CT groups had significant arm recovery similarly in FMA (p=0.867), WMFT-Time (p=0.947) and WMFT-Functional Ability Scale (p=0.676).


MT or CT which involved exercises concurrently for the paretic and unaffected arms during subacute stroke promoted similar motor recovery in the severely impaired arm.


via Recovery in the Severely Impaired Arm Post-stroke after Mirror Therapy – a Randomized Controlled Study. – PubMed – NCBI

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[BLOG POST] Repetition Improves Stroke Recovery Time – Saebo

In all stages of growth and development, repetition is key to successful long-term learning and information retention. Repetition is especially beneficial for stroke survivors who seek to regain motor function, strength, and coordination. Consistent repetition that re-establishes communication between the damaged parts of the brain and the body is crucial in stroke rehabilitation.

The brain is our most complex organ and scientists still don’t fully understand it, but we have extensive evidence of one amazing capability called “neuroplasticity.” Neuroplasticity is the brain’s ability to form new synapses, or connections between neurons, especially in response to a brain injury. The nervous system compensates for damage by reorganizing the neurons that remain intact. To form new connections, the involved neurons must be stimulated through consistent activity. Fully understanding this process—and why it works—motivates and clarifies the essential role of repetition in post-stroke rehabilitation.

Neuroplasticity Is The Ability To Heal

For our bodies to perform even the simplest tasks, networks of nerve cells, or neurons, must act in tandem to stimulate the correct parts of our bodies. However, when a stroke causes damage to an area of the brain, damaged neurons become unable to send out signals to the corresponding regions of the body. Although a stroke survivor may appear to have suffered damage to an area of the body—for example, the right arm and leg might be paralyzed—the issue actually stems from damage in the brain.

Amazingly, the brain compensates for these losses through various regenerative strategies. A common process, neuroplasticity, is something that the brain undergoes whenever we learn a new piece of information. As our environments and daily routines change throughout life, we create new synapses, or neural connections. During a healing process, the brain is even more engaged when building these new networks. Synaptic pathways are restructured to work around damaged neurons and may even relocate to entirely different areas of the brain.

Under the right circumstances, the brain can even create new neurons in a process known as neurogenesis. Any healing process requires a healthy body, to support the regeneration of cells, and neurogenesis is no different—the regenerating areas of the brain must be healthy, with the proper blood and oxygen supply, and must be activated consistently. Stroke survivors can encourage neurogenesis through frequent therapy, as well as at-home practice. Careful, diligent practice also ensures that new synapses and neurons do not lead to additional issues or symptoms.

Research has shown that stroke survivors who use repetition to promote neuroplasticity enjoy significant progress in their recovery. In one study, patients who initially struggled with grasp-and-release exercises demonstrated increased cortical reorganization after adhering to a repetitive rehabilitation regimen.

Visualize Progress And Challenge Yourself

We are only just beginning to discover the magnitude of the brain’s capabilities. Not only can the brain heal itself through proper support and repetitive exercises, but it can also respond positively to diligent and focused visualization of those same exercises. People who visualize a process can strengthen the involved synapses without performing the actual, physical motion. Visualization is a great introduction to rehabilitation for those who cannot physically complete the motions. In the early stages of regaining motor function or range-of-motion in an affected limb, it is important for stroke survivors to apply themselves to visualization with the same commitment as they would a physical exercise.

Ia 1995 study, synapses strengthened in participants who imagined completing a particular piano exercise. Even though they were not performing any physical motions, their brains still registered and retained the musical information. This principle is vital for those in the early stages of stroke recovery. Visualization bridges the gap between the motivational difficulties inherent to the early stages of rehabilitation and the more physically intense practices later on in recovery.

The transition between visualization and physical performance can be challenging. Supportive tools such as the SaeboMAS provide support to the affected limb while relieving stress from the joints and muscles involved in the exercise. By guiding the arm through its first physical motions, SaeboMAS helps the brain transition from visualization to independent task completion. Tools like SaeboMAS also encourage consistency in motion, a crucial factor when attempting such intensely repetitive action.

Once you master a repetitive action, it’s important to continue challenging yourself with an exercise routine. This is against human nature because once a task feels easy, we feel that we have succeeded; however, repetitions while on autopilot are far less beneficial than when the individual is actively focused on performing each repetition. It takes self-discipline to continue increasing the difficulty of an exercise but you can derive motivation from the support of a therapist, friends or family.

CIMT—or Constraint Induced Movement Therapy— allows for personal adjustments to the difficulty of an exercise. It’s common for those healing from motor function difficulties to avoid challenging the affected limb, overcompensating with the healthy limb to the point that the affected limb begins to deteriorate further due to non-use. Once the patient can comfortably rely on the affected limb, CIMT introduces “shaping” or “adaptive task practice”: the deconstruction of complex physical tasks into manageable steps that are added one at a time. This gradual addition of challenges deters the patient from switching to autopilot during long, repetitive sets.

A motivated and clear mindset is crucial, therefore the exercises themselves must follow a natural progression to become more challenging, while not being too frustrating. This balance comes from respecting each motion—no matter how small—as an important building block in the healing process. By remaining present in the repetitions, the brain picks up on more detailed messages from the body about what it needs. Any associated soreness or pain should be discussed with professionals to ensure that exercises are promoting healing and not inadvertently causing further damage.

Practice With Purpose

As mindfulness increases, it will become clearer which exercises are right for each particular day, depending on how the body feels. By honoring your body as your guide, you will improve your motivation and the physical progression of neuroplasticity. However, sensing what is best for the body is a tricky practice. Harder tasks may challenge a wider variety of neural networks, speeding up the healing process even when the exercise itself feels less successful.

Overall, it’s better to challenge the brain by moving beyond repetition that no longer inspires further improvement. Start small by mastering simpler tasks and skills, then immediately move on to slightly harder versions of those actions. Always maintain the same level of consistency, but with added restraint or weight. Without added challenges, the progress made through rehabilitation can be lost. It may help to view this healing process as a long-term, ongoing journey with the goal of fully rebuilding and re-strengthening connections that would otherwise be lost.

Canadian psychologist Dr. Donald Hebb claimed that “neurons that fire together, wire together,” in his 1949 book, “The Organization of Behavior.” Long before today’s societal focus on mindfulness, Dr. Hebb recognized the occurrence of neurological regrowth when an activity or thought process is repeated diligently. This observation is pertinent to unlearning less helpful habits or thought patterns, as well. If someone in rehabilitation develops a bad habit, such as injuring a healthy limb through overuse, the brain can unlearn these habits through careful repetition.

Mindfulness Leads To Motivation

The benefits of mindfulness are open to all kinds of learning. Intentional focus during practice is the only way to ensure the brain is fully present and supported for neuroplasticity and neurogenesis. During visualization, each movement should be imagined with extreme specificity as well; awareness that is too unspecific can lead to apathy and lack of concentration. Visualization can be motivating, pushing the person in rehabilitation past the plateau stage—a dispiriting time in the process in which progress stalls. Overall, the trick is to keep exercises from becoming routine. When each day is different or challenging in a new way, the brain stays engaged in ways more conducive to synaptic rehabilitation.

You Need To Move

The most important mantra for post-stroke recovery is to keep moving. Once an intention or goal has been set, consistent movement is the key to warding off muscular atrophy. As mentioned earlier, even before physical movement is possible, exercises can be completed in the brain through visualization. Begin as soon as possible after the injury to take full advantage of early neurogenesis before entering the plateau phase. Whether visualizing or physically completing an action, repetition  is the most important factor in long-term recovery.

How Much Is Enough?

The question remains, how many repetitions are enough to regain full health during stroke rehabilitation? The number of repetitions required to establish a neural pathway depends on multiple factors:

  • the type of exercise
  • the area of the body
  • the current health of the muscles, nerves, and joints

Consistent, dedicated repetition is the most important priority. Without this, the brain cannot complete the rebuilding of the neurons, networks, and capabilities it lost during the stroke.

Quality of repetitions is just as important as quantity. Practice is helpful only while remaining mindful and fully present. Concentration also bolsters motivation, especially when progress plateaus.

Together, mindfulness and repetition move those in rehabilitation past initial discomfort more quickly by strengthening the affected muscles and neurons. We now know that visualization and drive have a psychosomatic effect, speeding up rehabilitation while the brain is most susceptible to healing. Visit the Saebo blog for more information about healing after a stroke.

All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.

via Repetition Improves Stroke Recovery Time | Saebo

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[Case Report] Case report on the use of a functional electrical orthosis in rehabilitation of upper limb function in a chronic stroke patient – Full Text PDF


Introduction. The increasing incidence of strokes and their occurrence in younger active people require the development of solutions that allow participation, despite the debilitating deficit that is not always solved by rehabilitation. The present report shows
such a potential solution.
Objective. In this presentation we will show the effects of using a functional electric orthosis, the high number of repetitions and daily electrostimulation in a young stroke patient with motor deficit in the upper limb, the difficulties encountered in attempting to
use orthosis, the results and the course of its recovery over the years.
Materials and Methods. The present report shows the evolution of a 31-year-old female patient with hemiplegia, resulting from a hemorrhagic stroke, from the moment of surgery to the moment of purchasing a functional electrical orthosis and a few months
later, highlighting a 3-week period when the training method focused on performing a large number of repetitions of a single exercise helped by the orthosis – 3 weekly physical therapy sessions, with a duration of one hour and 15 minutes, plus 2 electrostimulation sessions lasting 20 minutes each and 100 elbow extension, daily, 6 times a week. The patient was evaluated and filmed at the beginning and end of the 3 week period. The patient’s consent was obtained for the use of the data and images presented.
Results. Invalidating motor deficiency and problems specific to the use of upper limb functional electrostimulation in patients with stroke sequelae (flexion synergy, exaggeration of reflex response, wrist position during stimulation, etc.) made it impossible to use orthosis in functional activities within ADL although it allowed the achievement of a single task. Evaluation on the FuglMayer assessment does not show any quantifiable progress, although it is possible to have slightly improved the control of the
shoulder and elbow and increased the speed of task execution.
Conclusions. The use of functional orthoses of this type may be useful in patients who still have a significant functional rest in the shoulder, elbow and hand, and where the orthosis can produce an effective grasp. However for some patients, perhaps those who
would have been desirable to benefit most from this treatment, the benefit of using this orthosis is minimal.[…]

Full Text PDF

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[Abstract] Bilateral Motor Cortex Plasticity in Individuals With Chronic Stroke, Induced by Paired Associative Stimulation

Background: In the chronic phase after stroke, cortical excitability differs between the cerebral hemispheres; the magnitude of this asymmetry depends on degree of motor impairment. It is unclear whether these asymmetries also affect capacity for plasticity in corticospinal tract excitability or whether hemispheric differences in plasticity are related to chronic sensorimotor impairment.

Methods: Response to paired associative stimulation (PAS) was assessed bilaterally in 22 individuals with chronic hemiparesis. Corticospinal excitability was measured as the area under the motor-evoked potential (MEP) recruitment curve (AUC) at baseline, 5 minutes, and 30 minutes post-PAS. Percentage change in contralesional AUC was calculated and correlated with paretic motor and somatosensory impairment scores.

Results: PAS induced a significant increase in AUC in the contralesional hemisphere (P = .041); in the ipsilesional hemisphere, there was no significant effect of PAS (P = .073). Contralesional AUC showed significantly greater change in individuals without an ipsilesional MEP (P = .029). Percentage change in contralesional AUC between baseline and 5 m post-PAS correlated significantly with FM score (r = −0.443; P = .039) and monofilament thresholds (r = 0.444, P = .044).

Discussion: There are differential responses to PAS within each cerebral hemisphere. Contralesional plasticity was increased in individuals with more severe hemiparesis, indicated by both the absence of an ipsilesional MEP and a greater degree of motor and somatosensory impairment. These data support a body of research showing compensatory changes in the contralesional hemisphere after stroke; new therapies for individuals with chronic stroke could exploit contralesional plasticity to help restore function.


via Bilateral Motor Cortex Plasticity in Individuals With Chronic Stroke, Induced by Paired Associative Stimulation – Jennifer K. Ferris, Jason L. Neva, Beatrice A. Francisco, Lara A. Boyd, 2018

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[ARTICLE] Translation of robot-assisted rehabilitation to clinical service: a comparison of the rehabilitation effectiveness of EMG-driven robot hand assisted upper limb training in practical clinical service and in clinical trial with laboratory configuration for chronic stroke – Full Text



Rehabilitation robots can provide intensive physical training after stroke. However, variations of the rehabilitation effects in translation from well-controlled research studies to clinical services have not been well evaluated yet. This study aims to compare the rehabilitation effects of the upper limb training by an electromyography (EMG)-driven robotic hand achieved in a well-controlled research environment and in a practical clinical service.


It was a non-randomized controlled trial, and thirty-two participants with chronic stroke were recruited either in the clinical service (n = 16, clinic group), or in the research setting (n = 16, lab group). Each participant received 20-session EMG-driven robotic hand assisted upper limb training. The training frequency (4 sessions/week) and the pace in a session were fixed for the lab group, while they were flexible (1–3 sessions/week) and adaptive for the clinic group. The training effects were evaluated before and after the treatment with clinical scores of the Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), Functional Independence Measure (FIM), and Modified Ashworth Scale (MAS).


Significant improvements in the FMA full score, shoulder/elbow and wrist/hand (P < 0.001), ARAT (P < 0.001), and MAS elbow (P < 0.05) were observed after the training for both groups. Significant improvements in the FIM (P < 0.05), MAS wrist (P < 0.001) and MAS hand (P < 0.05) were only obtained after the training in the clinic group. Compared with the lab group, higher FIM improvement in the clinic group was observed (P < 0.05).


The functional improvements after the robotic hand training in the clinical service were comparable to the effectiveness achieved in the research setting, through flexible training schedules even with a lower training frequency every week. Higher independence in the daily living and a more effective release in muscle tones were achieved in the clinic group than the lab group.


Stroke is a major cause of permanent disability in adults [1]. By 2014, the number of stroke survivors in Hong Kong was approximately 300,000, and more than 7 million in Mainland China, with an average of 2 million new cases per year and an annual increase of 8% from 2009 to 2014 in Mainland China [23]. Approximately 80% of stroke survivors experience upper extremity impairment and disability in activities of daily living (ADLs) [45]. However, fewer than 25% of these can regain limited recovery on their paretic arms even after post-stroke rehabilitation [6]. Physical treatment can result in more significant recovery of arm function during the subacute period (i.e., before 6 months after stroke onset) than in the chronic stage (i.e., more than 6 months after the stroke onset) [7]. In current clinical practice, the professional manpower of post-stroke rehabilitation is much more concentrated on the in-patient period in the subacute stage, compared with that in the long-term service for chronic stroke. However, recent studies have demonstrated that with intensive training, significant motor improvements could also be achieved during the chronic period after stroke [89]. The challenge, however, is that rehabilitation manpower is insufficient, even in developed countries with the fast-expanding stroke populations. Hence, effective techniques and services for long-term rehabilitation after stroke are in urgent need.

Rehabilitation robots have been valuable for human therapists in delivering the labor-demanding physical training with the advantages of higher repetition and lower cost than professional manpower [10]. Various robots have been proposed for the upper limb rehabilitation after stroke, and the robots’ effectiveness has been evaluated by clinical trials [111213]. Among them, robot-assisted rehabilitation controlled by the voluntary inputs of the user exhibited more significant efficacy than that with continuous passive motions, i.e., no voluntary input was required from a user and the robots dominated the motion of a paralyzed limb [14]. In a voluntary intention driven robot designed by Song et al. [15], electromyography (EMG) from the residual muscle of the upper limb was used as the indicator of the voluntary motor intention from a stroke survivor. In the related randomized clinical trial, it was found that patients with chronic stroke obtained more significant motor gain when assisted with the EMG-driven robot than with passive motion assistance alone [16]. Another representative study was the large randomized multi-center trial by Lo et al. which compared the MIT-Manus robotic system for upper limb training with the conventional physical treatments by a human therapist [17]. The results suggested that the robot could achieve the equivalent motor improvements to those of the conventional treatment [17]. Thus, according to the findings, robot-assisted post-stroke training could be a cost-effective alternative to the conventional rehabilitation service when human manpower is insufficient.

However, almost all positive reports on robot-assisted rehabilitation were obtained through research-oriented clinical trial studies and not in a real clinical service configuration, with the assumption that the positive improvements reported in the trial studies would be naturally carried on into the real services after commercialization. Differences, or even discounts, in the rehabilitation effectiveness during the translation from well-controlled research studies to more flexible services have not yet been intensely evaluated. Actually, the feasibility and effectiveness of rehabilitation robots in the clinical service setting have been questioned when trial-quality management was difficult to achieve in a real long-term service [1819202122]. There are several factors that increase the difficulty of head-to-head comparison on the training effectiveness in robot-assisted rehabilitation services with the clinical trials. For instance: (1) In a real service setting, the rehabilitation schedule is relatively flexible with payment from a client. In contrast, trial studies have restricted training schedules (are usually free of charge, or in some cases, participants are even paid for their involvement in the trial); (2) Participant (client) variability is large in the service. In the trials, participant inclusion criteria are usually targeted, and therefore, are difficult to replicate and implement exactly in the service management (particularly in the private sectors) due to the financial sustainability required; (3) In a clinical trial, the participants would usually not be allowed to receive other treatments that might interfere with the prescribed physical program under investigation. However, in a service setting, it is impossible to restrict a client and stop him/her from receiving other physical treatments he/she considers useful. An EMG-driven robotic hand was designed in our previous work, and its rehabilitation effectiveness on the upper limb functions in chronic stroke has been reported by a single group clinical trial [23]. From 2011, the EMG-driven robotic hand service open to local communities has been available in a self-financed university clinic in a private sector. The purpose of this work was to quantitatively evaluate the difference between the rehabilitation effects of an EMG-driven robot hand-assisted upper limb training program conducted as a research trial in a laboratory configuration and as real clinical practice in a private clinic, with minimum disturbance to the routine clinical management and service provided to the clients.


EMG-driven robotic hand

The EMG-driven robotic hand system used in this study is shown in Fig. 1. The system can aid with finger extension and flexion of the paretic limb in stroke patients. The robotic hand consisted of five linear actuators (Firgelli L12, Firgelli Technologies Inc.), and provided individual mechanical assistance to the five fingers [23]. The proximal and distal section of the index, middle, ring and little fingers were rotated around the virtual centers located at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP). The thumb was rotated around the virtual center of its MCP joint. The finger assembly provided two degrees of freedom (DOF) for each finger and offered a range of motion (ROM) of 55° and 65° for the MCP and PIP joints, respectively. The angular rotation speeds of the two joints were set as 22° and 26°/s at the MCP and PIP joints, respectively, during hand open/close.[…]
Figure 1

Fig. 1 The electromyography (EMG)-driven robotic hand system: A The wearable system consisting of a mechanical exoskeleton of the robotic hand and EMG electrodes; B, C the illustration of the configuration of the EMG electrodes attached to the extensor digitorum (ED) and abductor pollicis brevis (APB) muscles. The reference electrode was attached on the olecranon


Continue —> Translation of robot-assisted rehabilitation to clinical service: a comparison of the rehabilitation effectiveness of EMG-driven robot hand assisted upper limb training in practical clinical service and in clinical trial with laboratory configuration for chronic stroke | BioMedical Engineering OnLine | Full Text


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[BLOG POST] A Dual-Therapy Approach to Boost Motor Recovery After a Stroke

Stroke victims have a reason to finally smile as a new therapy approach promises to help them recover greater use of their paralyzed leg and/or arm. In a recent study, researchers managed to demonstrate that indeed, broken sensory nerve connections can be reconstructed without surgery, but using two therapies at the same time.

The technique combines functional electrical stimulation (FES) and brain-computer interface BCI to help “resurrect” the use of paralyzed limb (arm/leg). In most cases, paralysis happens to be the most general but hard to bear effects of a stroke. Fortunately, research now seems to have a solution for treating this effect.

Communication Between Nerve Pathways

While the approach may not be something completely out of the horizon, this is the first time experts considered deploying two therapies at the same time on stroke effects (FES + BCI). The therapy works to help reestablish communication between nerve pathways, which ideally corrects how signals come in and go out of the nerve segment endings.

“The goal is to stimulate those nerves thought to have been silenced by the paralysis. This should be the work of the brain. But as the part of the brain tasked to do this may no longer be active enough, the therapy steps in to help reestablish the links between (the brain) and the nerve pathways,” explains Jose del R. Millan, one of the scientists involve in the research, which was pioneered by the Defitech Foundation Brain and Machine Interface.

Degrees of Paralysis

The work, which also appears in the latest issue of Nature Communications focused on mid-age and aged adults of between 36 to 76, and involved 27 volunteers with varying stroke effects. A section of the patients had moderate paralysis, while for the rest the cases were considered as severe arm paralysis occurring less than a year prior to the dual-therapy.

Representing half of the volunteering team, 14 of the patients took the dual-therapy and the results found a significant lasting improvement in the ability to initiate control of their affected arms. The other half of the volunteers took the functional electrical stimulation (FES) treatment only and acted as a control team to help monitor progress.

Hunting for the Brain Signals

Now, the scientists introduced the BCI system to access the patient’s brain response, linking the same to computers via electrodes. The exact task was to pinpoint the specific areas the electrical signals showed up in the brain as the patient tried to pick something using the affected arm.

When the electrical activity was spotted the system immediately stimulated the concerned muscle in the wrist and finger to have it respond to the signal. Patients in the “control” group had their muscles stimulated but not as often as the first team. That was done on purpose to help establish the motor-function improvement that could directly be attributed to the BCI system and the reliability of the same.

Reactivated Tissue and How this Changes Stroke Effect Therapy

Source: braceworks

What makes the research outstanding is that some patients in the first group registered a significant improvement in arm mobility within the first ten one-hour therapy sessions. Using a special test that evaluates motor recovery on post-stroke hemiplegia, called the Fugl-Meyer Assessment, a good number of the patients in the first group improved in their mobility twice in score compared to their counterparts.

The scientists also found an overall increase in connection among the motor cortex areas of their damaged brain, which corresponded with the overall ease in undertaking the associated tasks.

This might, without doubt, be the complete game changer of the way effects of stroke should be treated, because, even after 6 and 12 months – looking at the progress of the patients, their recovered mobility from the dual-therapy was maintained.


via A Dual-Therapy Approach to Boost Motor Recovery After a Stroke – Sanvada

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