Posts Tagged Electric stimulation

[Abstract] Review on motor imagery based BCI systems for upper limb post-stroke neurorehabilitation: From designing to application


• BCI methods are among the most effective tool for designing rehabilitation systems

.• Use of virtual reality (VR) can increase the efficiency of BCI rehab systems

.• “FES,” “Robotics Assistance,” and “Hybrid VR based Models” are main BCI approaches.

• In the future, flexible electronics can be used for designing stroke rehab systems.


Strokes are a growing cause of mortality and many stroke survivors suffer from motor impairment as well as other types of disabilities in their daily life activities. To treat these sequelae, motor imagery (MI) based brain-computer interface (BCI) systems have shown potential to serve as an effective neurorehabilitation tool for post-stroke rehabilitation therapy. In this review, different MI-BCI based strategies, including “Functional Electric Stimulation, Robotics Assistance and Hybrid Virtual Reality based Models,” have been comprehensively reported for upper-limb neurorehabilitation. Each of these approaches have been presented to illustrate the in-depth advantages and challenges of the respective BCI systems. Additionally, the current state-of-the-art and main concerns regarding BCI based post-stroke neurorehabilitation devices have also been discussed. Finally, recommendations for future developments have been proposed while discussing the BCI neurorehabilitation systems.


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[ARTICLE] Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial – Full Text



Our group developed a rehabilitation robot to assist with repetitive, active reaching movement of a paretic upper extremity. The robot is equipped with a servo motor-controlled arm-weight support and works in conjunction with neuromuscular electrical stimulation and vibratory stimulation to facilitate agonist-muscle contraction. In this before-and-after pilot study, we assessed the feasibility of applying the robot to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke.


We enrolled 6 patients with chronic stroke and hemiparesis who, while sitting and without assistance, could reach 10 cm both sagitally and vertically (from a starting position located 10 cm forward from the patient’s navel level) with the affected upper extremity. The patients were assigned to receive reaching exercise intervention with the robot (Yaskawa Electric Co., Ltd. Fukuoka, Japan) for 2 weeks at 15 min/day in addition to regular occupational therapy for 40 min/day. Outcomes assessed before and after 2 weeks of intervention included the upper extremity component of the Fugl-Meyer Assessment (UE-FMA), the Action Research Arm Test (ARAT), and, during reaching movement, kinematic analysis.


None of the patients experienced adverse events. The mean score of UE-FMA increased from 44.8 [SD 14.4] to 48.0 [SD 14.4] (p = 0.026, r = 0.91), and both the shoulder–elbow and wrist–hand scores increased after 2-week intervention. An increase was also observed in ARAT score, from mean 29.8 [SD 16.3] to 36.2 [SD 18.1] (p = 0.042, r = 0.83). Kinematic analysis during the reaching movement revealed a significant increase in active range of motion (AROM) at the elbow, and movement time tended to decrease. Furthermore, trajectory length for the wrist (“hand path”) and the acromion (“trunk compensatory movement”) showed a decreasing trend.


This robot-assisted modality is feasible and our preliminary findings suggest it improved motor control and motor function of the hemiparetic upper extremity in patients with chronic stroke. Training with this robot might induce greater AROM for the elbow and decrease compensatory trunk movement, thus contributing to movement efficacy and efficiency.


Stroke is a leading cause of death and disability. In 2017, the number of patients treated for stroke in Japan was 1,115,000, with 109,844 deaths [12]. Many survivors of stroke require nursing care to some extent; in fact, patients with stroke account for the largest percentage of claims under the Japanese Long-term Care Insurance System [3]. In a previous review, about 90% of patients with stroke had hemiparesis on admission, and less than 15% of them experienced complete motor recovery [4]. In stroke rehabilitation, some principles are well accepted: high-intensity, task-specific, goal-setting, and multidisciplinary-team care are needed to be effective [5]. Among these principles, “task-specific” might be controversial, because some theories of motor control suggest that, on the contrary, motor learning improves, and acquires greater generalizability, when a training program offers variability [67]. The appropriate approach probably depends on the aim of rehabilitation (which can be subject-dependent): for example, a reaching movement with the arm is frequently needed in activities of daily living.

Robotic rehabilitation is a novel intervention method, and several reviews have noted that it leads to improved muscle strength and motor control of the affected upper extremity [89]. A recent Cochrane review suggests that electromechanical and robot-assisted arm training might improve arm function, muscle strength of the upper extremity, and even activity of daily living after stroke [10]. Robotic devices can enable patients to perform task-specific, high-intensity rehabilitation due to increased repetition or amount of training.

At the same time, neuromuscular electrical stimulation (NMES) is widely employed as a rehabilitation technique. According to a previous study, NMES is effective at improving motor control and motor function of affected arms of patients with acute stroke [11], and the NMES system was more efficient when applied with a high-voltage pulsed current [12]. Although few studies have investigated untriggered NMES for the hemiparetic upper limb, continuous electrical stimulation with robotic training improved active range of motion and motor control [13], and we employed the NMES system without triggered electromyography (EMG) [14]. Continuous stimulation with NMES has been considered to be effective in facilitating contraction of paretic muscles [14]. Furthermore, the latest meta-analysis showed that electrical stimulation was effective for arm function and activity regardless of the stimulation type (NMES, EMG triggered, or sensory) [15].

Functional vibratory stimulation (FVS) is known to produce a favorable effect on spasticity, motor control, and gait after stroke [16]. Regarding hemiparetic upper extremities, previous studies have shown that focal vibration applied to paretic muscles is effective at decreasing spasticity with an amplitude of 91 Hz [17], and that it probably improves motor control with an amplitude of 120 Hz, especially in terms of smoothness of movement [18]. For the lower extremity, a previous study revealed that focal vibration improved gait by promoting contraction of the target muscle [19]. Moreover, not only did it promote contraction of the agonist muscle, low amplitude vibratory stimulation (80 Hz) also facilitated focused motorcortical activation [2021]. In addition, tendon or muscle vibration produces a tonic vibration reflex through both spinal and supraspinal pathways via repetitive activation of Ia afferent fibers [2223]. It is possible to artificially elicit the illusion of movement by vibrating the tendons or the muscles through the skin [24]; the illusion is probably mediated by the activation of muscle spindles [25]. This phenomenon indicates that vibration induces a strong proprioceptive feedback. On the other hand, it has been reported that the vastus lateralis muscle demonstrates a shift toward more appropriate muscle timing when vibration is applied during stance phase and transition to stance of the gait cycle in patients with spinal cord injury [26]. This indicates that strong sensory feedback from quadriceps vibration caused increased muscle excitation [26]. Thus, the combination of muscle vibration with NMES might help to recruit Ia afferent fibers and increase muscle force production. This phenomenon has already been demonstrated in healthy people in the plantar flexors [27]. To the best of our knowledge, however, the use of a robotic device equipped with electrical stimulation and vibration has not been reported.

Considering these facts, our group undertook to develop a rehabilitation robot to assist with repetitive, active reaching movement of the paretic upper extremity; patent acquisitions [28,29,30] and product development were accomplished with a medical–engineering collaboration within Kagoshima University and collaboration between industry (Yaskawa Electric Co., Ltd., Fukuoka, Japan) and academia (Kagoshima university). The robot is equipped with a servo motor-controlled arm-weight support via a wire—the system is programmed to assist the patient’s paretic arm to move between two switches (sensors) located at various three-dimensional positions, which provide a variety of reaching tasks—and works in conjunction with NMES and vibratory stimulation to facilitate agonist-muscle contraction, because the combination might strengthen proprioceptive feedback and tonic vibration reflex. Indeed, this device was applicable and beneficial for a patient with incomplete spinal cord injury [31]. In the before-and-after pilot study reported here, we assessed the feasibility of our novel approach of applying the robot equipped with electrical stimulation and vibration to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke.[…]

Continue —-> Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial | SpringerLink

Fig. 5

Fig.5 Setting for training with the robot. A wire (a) connecting the device to the forearm cuff adjusts the amount of arm-weight support. The patient repeats a reaching movement from the start button (b) to the target button (c), accompanied with the arm-weight support, electrical stimulation (d), and vibratory stimulation (e). Two video cameras (f) on the upper frame of the device record the reaching movement for kinematic analysis

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[ARTICLE] Neurotechnology-aided interventions for upper limb motor rehabilitation in severe chronic stroke – Full Text


Upper limb motor deficits in severe stroke survivors often remain unresolved over extended time periods. Novel neurotechnologies have the potential to significantly support upper limb motor restoration in severely impaired stroke individuals. Here, we review recent controlled clinical studies and reviews focusing on the mechanisms of action and effectiveness of single and combined technology-aided interventions for upper limb motor rehabilitation after stroke, including robotics, muscular electrical stimulation, brain stimulation and brain computer/machine interfaces. We aim at identifying possible guidance for the optimal use of these new technologies to enhance upper limb motor recovery especially in severe chronic stroke patients. We found that the current literature does not provide enough evidence to support strict guidelines, because of the variability of the procedures for each intervention and of the heterogeneity of the stroke population. The present results confirm that neurotechnology-aided upper limb rehabilitation is promising for severe chronic stroke patients, but the combination of interventions often lacks understanding of single intervention mechanisms of action, which may not reflect the summation of single intervention’s effectiveness. Stroke rehabilitation is a long and complex process, and one single intervention administrated in a short time interval cannot have a large impact for motor recovery, especially in severely impaired patients. To design personalized interventions combining or proposing different interventions in sequence, it is necessary to have an excellent understanding of the mechanisms determining the effectiveness of a single treatment in this heterogeneous population of stroke patients. We encourage the identification of objective biomarkers for stroke recovery for patients’ stratification and to tailor treatments. Furthermore, the advantage of longitudinal personalized trial designs compared to classical double-blind placebo-controlled clinical trials as the basis for precise personalized stroke rehabilitation medicine is discussed. Finally, we also promote the necessary conceptual change from ‘one-suits-all’ treatments within in-patient clinical rehabilitation set-ups towards personalized home-based treatment strategies, by adopting novel technologies merging rehabilitation and motor assistance, including implantable ones.


Stroke constitutes a major public health problem affecting millions of people worldwide with considerable impacts on socio-economics and health-related costs. It is the second cause of death (Langhorne et al., 2011), and the third cause of disability-adjusted life-years worldwide (Feigin et al., 2014): ∼8.2 million people were affected by stroke in Europe in 2010, with a total cost of ∼€64 billion per year (Olesen et al., 2012). Due to ageing societies, these numbers might still rise, estimated to increase 1.5–2-fold from 2010 to 2030 (Feigin et al., 2014).

Improving upper limb functioning is a major therapeutic target in stroke rehabilitation (Pollock et al., 2014Veerbeek et al., 2017) to maximize patients’ functional recovery and reduce long-term disability (Nichols-Larsen et al., 2005Veerbeek et al., 2011Pollock et al., 2014). Motor impairment of the upper limb occurs in 73–88% first time stroke survivors and in 55–75% of chronic stroke patients (Lawrence et al., 2001). Constraint-induced movement therapy (CIMT), but also standard occupational practice, virtual reality and brain stimulation-based interventions for sensory and motor impairments show positive rehabilitative effects in mildly and moderately impaired stroke victims (Pollock et al., 2014Raffin and Hummel, 2018). However, stroke survivors with severe motor deficits are often excluded from these therapeutic approaches as their deficit does not allow easily rehabilitative motor training (e.g. CIMT), treatment effects are negligible and recovery unpredictable (Byblow et al., 2015Wuwei et al., 2015Buch et al., 2016Guggisberg et al., 2017).

Recent neurotechnology-supported interventions offer the opportunity to deliver high-intensity motor training to stroke victims with severe motor impairments (Sivan et al., 2011). Robotics, muscular electrical stimulation, brain stimulation, brain computer/machine interfaces (BCI/BMI) can support upper limb motor restoration including hand and arm movements and induce neuro-plastic changes within the motor network (Mrachacz-Kersting et al., 2016Biasiucci et al., 2018).

The main hurdle for an improvement of the status quo of stroke rehabilitation is the fragmentary knowledge about the physiological, psychological and social mechanisms, their interplay and how they impact on functional brain reorganization and stroke recovery. Positive stimulating and negatively blocking adaptive brain reorganization factors are insufficiently characterized except from some more or less trivial determinants, such as number and time of treatment sessions, pointing towards the more the better (Kwakkel et al., 1997). Even the long accepted model of detrimental interhemispheric inhibition of the overactive contralesional brain hemisphere on the ipsilesional hemisphere is based on an oversimplification and lack of differential knowledge and is thus called into question (Hummel et al., 2008Krakauer and Carmichael, 2017Morishita and Hummel, 2017).

Here, we take a pragmatic approach of comparing effectiveness data, keeping this lack of knowledge of mechanisms in mind and providing novel ideas towards precision medicine-based approaches to individually tailor treatments to the characteristics and needs of the individual patient with severe chronic stroke to maximize rehabilitative outcome.[…]

Continue —>   Neurotechnology-aided interventions for upper limb motor rehabilitation in severe chronic stroke | Brain | Oxford Academic

Conceptualization of longitudinal personalized rehabilitation-treatment designs for patients with severe chronic stroke. Ideally, each patient with severe chronic stroke with a stable motor recovery could be stratified based on objective biomarkers of stroke recovery in order to select the most appropriate/promising neurotechnology-aided interventions and/or their combination for the specific case. Then, these interventions can be administered in the clinic and/or at home in sequence, moving from one to another only when patient’s motor recovery plateaus. In this way, comparisons of the efficacy of each intervention (grey arrows) are still possible, and if the selected interventions and/or their combination are suitable, motor recovery could increase.

Conceptualization of longitudinal personalized rehabilitation-treatment designs for patients with severe chronic stroke. Ideally, each patient with severe chronic stroke with a stable motor recovery could be stratified based on objective biomarkers of stroke recovery in order to select the most appropriate/promising neurotechnology-aided interventions and/or their combination for the specific case. Then, these interventions can be administered in the clinic and/or at home in sequence, moving from one to another only when patient’s motor recovery plateaus. In this way, comparisons of the efficacy of each intervention (grey arrows) are still possible, and if the selected interventions and/or their combination are suitable, motor recovery could increase.

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[NEWS] Researchers propose new approach for post-stroke rehabilitation

The existing approach for brain stimulation to rehabilitate patients after a stroke does not take into account the diversity of lesions and the individual characteristics of patients’ brains, a study has found.

In recent decades, non-invasive neuromodulation methods such as electric and magnetic stimulation of various parts of the nervous system have been increasingly used to rehabilitate patients after a stroke.

Stimulation selectively affects different parts of the brain, which allows you to functionally enhance activity in some areas while suppressing unwanted processes in others that impede the restoration of brain functions.

This is a promising mean of rehabilitation after a stroke. However, its results in patients remain highly variable.

Authors of the study, which was published in the journal ‘Frontiers in Neurology’, argued that the main reason for the lack of effectiveness in neuromodulation approaches after a stroke is an inadequate selection of patients for the application of a particular brain stimulation technique.

They said the existing approach does not take into account the diversity of lesions after a stroke and the variability of individual responses to brain stimulation as a whole.

The researchers have proposed two criteria for selecting the optimal brain stimulation strategy.

The first is an analysis of the interactions between the hemispheres. Now, all patients, regardless of the severity of injury after a stroke, are offered a relatively standard treatment regimen. This approach relies on the idea of interhemispheric competition.

“For a long time, it was believed that when one hemisphere is bad, the second, instead of helping it, suppresses it even more,” said

Maria Nazarova, researcher at the HSE Institute of Cognitive Neurosciences.

“In this regard, the suppression of the activity of the “unaffected” hemisphere should help restore the affected side of the brain. However, the fact is that this particular scheme does not work in many patients after a stroke. Each time it is necessary to check what the impact of the unaffected hemisphere is — whether it is suppressive or activating,” she said.

According to the researchers, the second criterion is the neuronal phenotype.

This is an individual characteristic of the activity of the brain, which is ‘unique to each person like their fingerprints’.

Such a phenotype is determined, firstly, by the ability of the brain to build effective structural and functional connections between different areas (connectivity).

Secondly, the individual characteristics of neuronal dynamics, including its ability to reach a critical state. This is the state of the neuronal system in which it is the most plastic and capable of change.

(This story has not been edited by Business Standard staff and is auto-generated from a syndicated feed.

First Published: Fri, June 28 2019. 15:20 IST


via Researchers propose new approach for post-stroke rehabilitation | Business Standard News

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[ARTICLE] Effect of high-frequency alternating current transcutaneous stimulation over muscle strength: a controlled pilot study – Full Text



High-frequency alternating currents of greater than 1 kHz applied on peripheral nerves has been used in animal studies to produce a motor nerve block. It has been evidenced that frequencies higher than 5 kHz are necessary to produce a complete peripheral nerve block in primates, whose nerve thickness is more similar to humans. The aim of the study was to determine the effect on muscle strength after the application of a high-frequency stimulation at 5 and 10 kHz compared to sham stimulation in healthy volunteers.


Transcutaneous stimulation at 5 kHz, 10 kHz and sham stimulation were applied to eleven healthy volunteers over the ulnar and median nerves for 20 min. Maximal handgrip strength was measured before, during, immediately after the intervention, and 10 min after the end of intervention. The 10 kHz stimulation showed a lower handgrip strength during the intervention (28.1 N, SEM 3.9) when compared to 5 kHz (31.1 N, SEM 3.6; p < 0.001) and to sham stimulation (33.7 N, SEM 3.9; p < 0.001). Furthermore, only stimulation at 10 kHz decreased handgrip strength when compared to baseline.


These findings suggest high-frequency stimulation has an inhibitory effect over muscle strength. Future studies are required in patients that are characterized by motor hyperactive such as spasticity or tremors.


Previous studies in animals have shown that high-frequency alternating current (HFAC) of greater than 1 kHz applied on exposed peripheral nerves can produce a motor nerve block (Bhadra and Kilgore [12]). An in vivo study, [3] showed that frequencies higher than 5 kHz were able to block nerve conduction of motor fibers. One study [4] in non-injured subjects showed an incomplete block when transcutaneous HFAC applied to the radial nerve at 5 kHz increased somatosensory thresholds. It has been evidenced [5] that frequencies higher than 5 kHz are necessary to produce a complete peripheral nerve block in primates, whose nerve diameter is similar to humans, however, there is not any human study that apply HFAC transcutaneously with frequencies higher than 5 kHz. It is believed that the nerve conduction block produced by application of HFAC could be a useful tool for the treatment of patients with pain or with an exaggerated increase of nerve activity, such as hypertonia or spasms.

The purpose of this study was to determine the effects on maximal handgrip strength (MHS) of a non-invasive HFAC at 5 kHz and 10 kHz applied to the ulnar and median nerves in healthy subjects, compared to a sham stimulation.[…]


Continue —> Effect of high-frequency alternating current transcutaneous stimulation over muscle strength: a controlled pilot study | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 1

Fig. 1Stimulation effect on maximal handgrip strength. Sham stimulation (circle), 5 kHz (square), and 10 kHz (triangle). Data are represented as mean and standard error. * Indicates significantly different compared to sham stimulation (***p < 0.001; **p < 0.01). + Indicates a significant difference compared to 5 kHz stimulation (++p < 0.01). # Indicates significantly different from baseline (###p < 0.001)

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[BOOK Chapter] Overview of FES-Assisted Cycling Approaches and Their Benefits on Functional Rehabilitation and Muscle Atrophy – Abstract + References

Part of the Advances in Experimental Medicine and Biology book series (AEMB, volume 1088)


Central nervous system diseases include brain or spinal cord impairments and may result in movement disorders almost always manifested by paralyzed muscles with preserved innervations and therefore susceptible to be activated by electrical stimulation. Functional electrical stimulation (FES)-assisted cycling is an approach mainly used for rehabilitation purposes contributing, among other effects, to restore muscle trophism. FES-assisted cycling has also been adapted for mobile devices adding a leisure and recreational benefit to the physical training. In October 2016, our teams (Freewheels and EMA-trike) took part in FES-bike discipline at the Cybathlon competition, presenting technologies that allow pilots with spinal cord injury to use their paralyzed lower limb muscles to propel a tricycle. Among the many benefits observed and reported in our study cases for the pilots during preparation period, we achieved a muscle remodeling in response to FES-assisted cycling that is discussed in this chapter. Then, we have organized some sections to explore how FES-assisted cycling could contribute to functional rehabilitation by means of changes in the skeletal muscle disuse atrophy.


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via Overview of FES-Assisted Cycling Approaches and Their Benefits on Functional Rehabilitation and Muscle Atrophy | SpringerLink

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[Abstract] The effect of peripheral nerve electrical stimulation on corticomotor excitability and motor function of the paretic hand in stroke


Electrical stimulation to the stroke-affected paretic upper limb (UL) has been a treatment to promote its motor recovery. Despite its efficacy in promoting muscle strength and enhancing motor training, the underlying neurophysiological mechanism for such motor improvement has not been clear. It is crucial to delineate the corticomotor plasticity effects of electrical stimulation when it is applied as a single entity and as an adjunct to other forms of therapies, since the knowledge would support formulation of effective treatment for the paretic UL in stroke rehabilitation.

This dissertation incorporated 4 studies to examine the corticomotor excitability modulation and motor function effects of electrical stimulation on the paretic UL due to stroke. Study 1 reviewed randomized controlled trials published before 2012 to scrutinize the efficacy of electrical stimulation on motor function improvement as well as corticomotor excitability for muscles in the paretic hand. Results of the meta-analysis showed that electrical stimulation could improve UL motor impairment but not its ability in functional task performance measured with the Action Research Arm Test. The corticomotor excitability changes associated with electrical stimulation could not be concluded because of diverse outcomes reported in only 3 studies. Study 2 was a randomized cross-over sham-controlled experiment (n = 32) set to determine a single session of 1-hour electrical stimulation delivered to the ulnar and radial nerves (PNS) of the paretic UL at an intensity of 2 to 3 sensory thresholds in modulating the corticomotor excitability in both brain hemispheres. The results confirmed that PNS could increase corticomotor excitability in terms of the recruitment curve (RC) slope and peak amplitude of motor-evoked potentials (pMEP) for the corticospinal projections to the contralateral first dorsal interosseous hand muscle (FDI) measured in both hemispheres. The PNS also enhanced better hand pincer dexterity scored by the Purdue pegboard test than the sham stimulation (PNSsham). Then Study 3 was conducted to examine if PNS could condition the corticomotor pathways for another treatment targeting motor improvement in the paretic UL. This pilot randomized cross-over study involved 20 subjects to receive 1-hour PNS paired with observation of movement demonstration in videos (termed action observation, AO) that was introduced during the last 30 minutes of PNS. PNS+AO improved the Purdue dexterity score of the paretic hand, but the change in corticomotor excitability for the contralateral FDI in the lesioned hemisphere was not significant. The control intervention PNSsham+AO did not change any of the outcome measurements. Study 4 further tested the hypothesis that PNS and/or jointly with AO might effectively condition motor training of the paretic UL in enhancing corticomotor plastic changes and hand dexterity. In this randomized sham-controlled cross-over study, 20 subjects in chronic stage of stroke were exposed to 3 separate sessions of different interventions composed of 1-hour PNS or PNSsham paired with 30 minutes of AO or sham AO (AOsham), all followed by 30-minute training of index finger abduction. The results revealed that PNS+AO+Training led to significantly increased corticomotor excitability in terms of RC slope and pMEP amplitude localized in the lesioned hemisphere but that of the intact hemisphere was not altered. This neuroplastic modulation was accompanied by enhanced hand dexterity at 24 hours post-intervention better than the control with PNSsham+AOsham+Training. On the other hand, PNS+AOsham+Training did not modulate corticomotor excitability functions but hand dexterity was increased immediately after the intervention better than after PNSsham+AOsham+Training. Training after PNSsham+AOsham conditioning was not effective on the outcome measurements.
Results of the series of studies supported that (1) one-hour PNS could increase the excitability of corticomotor pathways for the contralateral hand muscle in both the lesioned and intact hemispheres similarly; (2) one-hour PNS alone, or applied as a conditioning treatment in the presence of AO or AOsham prior to movement training in the paretic hand could lead to better hand dexterity than training after sham controls; (3) Up-regulation of corticomotor excitability specifically confined to the stroke-lesioned hemisphere was evident after a session of PNS paired with AO and Training.

To conclude, one session of PNS or PNS-associated interventions for the paretic UL could effectively improve dexterity of the paretic hand in people with chronic stroke. PNS might have primed the corticomotor pathways for AO and motor training to result in corticomotor excitability enhancement specifically confined to the stroke-lesioned hemisphere.

Source: The effect of peripheral nerve electrical stimulation on corticomotor excitability and motor function of the paretic hand in stroke | PolyU Institutional Research Archive

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[ARTICLE] Effects of Electrical Stimulation in Spastic Muscles After Stroke


Background and Purpose—Neuromuscular electric stimulation (NMES) has been used to reduce spasticity and improve range of motion in patients with stroke. However, contradictory results have been reported by clinical trials. A systematic review of randomized clinical trials was conducted to assess the effect of treatment with NMES with or without association to another therapy on spastic muscles after stroke compared with placebo or another intervention.

Methods—We searched the following electronic databases (from inception to February 2015): Medline (PubMed), EMBASE, Cochrane Central Register of Controlled Trials and Physiotherapy Evidence Database (PEDro). Two independent reviewers assessed the eligibility of studies based on predefined inclusion criteria (application of electric stimulation on the lower or upper extremities, regardless of NMES dosage, and comparison with a control group which was not exposed to electric stimulation), excluding studies with ❤ days of intervention. The primary outcome extracted was spasticity, assessed by the Modified Ashworth Scale, and the secondary outcome extracted was range of motion, assessed by Goniometer.

Results—Of the total of 5066 titles, 29 randomized clinical trials were included with 940 subjects. NMES provided reductions in spasticity (−0.30 [95% confidence interval, −0.58 to −0.03], n=14 randomized clinical trials) and increase in range of motion when compared with control group (2.87 [95% confidence interval, 1.18–4.56], n=13 randomized clinical trials) after stroke.

Conclusions—NMES combined with other intervention modalities can be considered as a treatment option that provides improvements in spasticity and range of motion in patients after stroke.

via Effects of Electrical Stimulation in Spastic Muscles After Stroke.

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[Supplement] It Takes Two: Noninvasive Brain Stimulation Combined With Neurorehabilitation- Full Text

The goal of postacute neurorehabilitation is to maximize patient function, ideally by using surviving brain and central nervous system tissue when possible. However, the structures incorporated into neurorehabilitative approaches often differ from this target, which may explain why the efficacy of conventional clinical treatments targeting neurologic impairment varies widely.

Noninvasive brain stimulation (eg, transcranial magnetic stimulation [TMS], transcranial direct current stimulation [tDCS]) offers the possibility of directly targeting brain structures to facilitate or inhibit their activity to steer neural plasticity in recovery and measure neuronal output and interactions for evaluating progress. The latest advances as stereotactic navigation and electric field modeling are enabling more precise targeting of patient’s residual structures in diagnosis and therapy.

Given its promise, this supplement illustrates the wide-ranging significance of TMS and tDCS in neurorehabilitation, including in stroke, pediatrics, traumatic brain injury, focal hand dystonia, neuropathic pain, and spinal cord injury. TMS and tDCS are still not widely used and remain poorly understood in neurorehabilitation. Therefore, the present supplement includes articles that highlight ready clinical application of these technologies, including their comparative diagnostic capabilities relative to neuroimaging, their therapeutic benefit, their optimal delivery, the stratification of likely responders, and the variable benefits associated with their clinical use because of interactions between pathophysiology and the innate reorganization of the patient’s brain. Overall, the supplement concludes that whether provided in isolation or in combination, noninvasive brain stimulation and neurorehabilitation are synergistic in the potential to transform clinical practice.

The incidence of many neurologic diseases is rising partly because of an increasingly aged population and improved delivery and timing of acute care for neurologic disorders. As a result, more survivors are emerging from acute care, with most exhibiting life-altering impairments that require neurorehabilitation. One prominent example of this trend is stroke; taking into account both the years of potential life lost from premature death and long-term disability, stroke is also one of the most costly diseases, with 36% of this growing population exhibiting a discernable disability 5 years poststroke,1 and almost half of survivors remaining dependent on others 6 years poststroke because of the severity of their disability.2

The focus of medical teams during hyperacute and acute neurologic care is usually 3-fold: ensure survival/reduce mortality; manage and prevent medical complications; and when possible, salvage existing central nervous system tissue (eg, through the use of thrombolytics in stroke).3 In contrast, the goal of postacute neurorehabilitation is to maximize patient function, ideally by using surviving brain and central nervous system tissue when possible. However, despite their widely appreciated importance, the efficacy of conventional clinical treatments targeting specific neurologic impairments and sequelae vary widely. Again in the case of stroke, conventional rehabilitative strategies targeting upper extremity hemiparesis in adults offer negligible or no efficacy.4, 5

Recently developed neurorehabilitative strategies offer slightly more promise but remain limited because of the considerable time and resources that they require to administer. Perhaps the most notable example is constraint-induced movement therapy (CIMT), which has been applied to the affected upper extremity after stroke and other neurologic disorders (eg, multiple sclerosis, aphasia, traumatic brain injury [TBI]). One of the hallmarks of CIMT is long-duration training using an affected body part (eg, paretic upper extremity) or capacity (eg, speaking) that lasts up to 6 hours per day and is administered over multiple days (usually 10 consecutive weekdays). Although results have been promising,6 several studies7, 8 have found that most patients with stroke do not wish to participate in CIMT because of these long-duration treatment parameters, have reported high attrition rates,9 have reported poor compliance with the CIMT restrictive device wear,10, 11 and have reported on patient inability to participate in the entire 6-hour regimen as a result of fatigue.12 As a result of the required time, financial resources, and human resources, CIMT has not realized widespread clinical application.13, 14

Other new neurorehabilitative approaches being taught by training programs and/or adopted by clinics worldwide (eg, partial weight-supported treadmill training, certain automated and splinting approaches) offer negligible efficacy when compared with more conventional strategies15, 16, 17 and/or only work on patients displaying a particular level of impairment. As a result, there remains a gap centering on the need for techniques that extend the efficacy, duration of treatment effect, and/or number of patients who may benefit from promising neurorehabilitative therapies. Noninvasive brain stimulation offers the ability to meet all of these needs and offers efficacy as a stand-alone treatment approach for many neurologic impairments.

Continue –>  It Takes Two: Noninvasive Brain Stimulation Combined With Neurorehabilitation – Archives of Physical Medicine and Rehabilitation.

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[ARTICLE] Invited Commentary on Comparison of Robotics, FES, and Motor Learning Methods for Treatment of Persistent Upper Extremity Dysfunction after Stroke


In this issue of Archives of Physical Medicine and Rehabilitation, Jessica McCabe and colleagues report findings from their methodologically sound dose-matched clinical trial in 39 patients beyond 6 months post stroke. In this phase II trial, the effects of 60 treatment sessions, each involving 3.5 hours of intensive practice plus either 1.5 hours of functional electrical stimulation (FES) or a shoulder-arm robotic therapy, were compared with 5 hours of intensive daily practice alone. Although no significant between-group differences were found on the primary outcome measure of Arm Motor Ability Test (AMAT) and the secondary outcome measure of Fugl Meyer Arm (FMA) motor score, 10 to 15% within-group therapeutic gains were observed regarding AMAT and FMA. These gains are clinically meaningful for patients with stroke. However, the underlying mechanisms that drive these improvements remain poorly understood. The approximately 1000 dollar cost reduction per patient calculated for the use of motor learning (ML) methods alone or combined with FES, compared to the combination of ML and shoulder arm-robotics, further emphasizes the need for cost considerations when making clinical decisions about selecting the most appropriate therapy for the upper paretic limb in clients suffering from chronic stroke.

via Invited Commentary on Comparison of Robotics, FES, and Motor Learning Methods for Treatment of Persistent Upper Extremity Dysfunction after Stroke: a Randomized Controlled Trial – Archives of Physical Medicine and Rehabilitation.

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