Posts Tagged Neuromuscular electrical stimulation

[ARTICLE] Contralaterally controlled functional electrical stimulation improves wrist dorsiflexion and upper limb function in patients with early-phase stroke: A randomized controlled trial – Full Text HTML

Abstract

Objectives: To investigate the effectiveness of contra-laterally controlled functional

electrical stimulation (CCFES) on the recovery of active wrist dorsiflexion and upper limb function in patients with early-phase stroke (<15 days post-stroke).

Methods: Patients in the CCFES group were treated with routine rehabilitation combined with CCFES, while those in the conventional neuromuscular electrical stimulation (NMES) group were treated with routine rehabilitation combined with NMES. Time intervals from stroke onset to appearance of wrist dorsiflexion, and from onset of treatment to appearance of wrist dorsiflexion were recorded (in days). Functional assessments were also performed at baseline and endpoint.

Results: Nineteen out of 21 patients in the CCFES group and 12 out of 20 patients in the NMES group regained active wrist dorsiflexion during the treatment and follow-up period (90.5% vs 60%, p = 0.025). The mean time interval from onset of treatment to appearance of active wrist dorsiflexion was signifcantly shorter in the CCFES group than in the NMES

group (p < 0.001). The CCFES group had signifcantly higher scores for upper extremity

function (p = 0.001), strength of extensor carpi (p = 0.002), active ROM for wrist dorsiflexion (p = 0.003), activities of daily living score (p = 0.023) and ICF score (p < 0.001) than the NMES group at the endpoint.

Conclusion: CCFES signifcantly shortened the time for regaining wrist dorsiflexion, and improved the upper extremity function and general health of patients with early-phase stroke. CCFES therefore has potential as a clinical intervention.

 

Lay Abstract

After a stroke, it is essential that recovery of function of the upper limb is maximized in order to enable activities of daily living. The hand plays an important role in the function of the upper limb. This study examined the effectiveness of contralaterally controlled functional electrical stimulation (CCFES) on recovery of active dorsiflexion of the wrist and upper limb functioning in patients in the early-phase after stroke (<15 days post-stroke). CCFES significantly shortened the time for regaining wrist dorsiflexion, and improved the upper extremity function and general health of patients with early-phase stroke, compared with conventional neuro-muscular electrical stimulation. CCFES therefore has potential as a clinical intervention.

Introduction

Stroke is a leading cause of disability with high morbidity and mortality. Approximately 75% of patients with stroke have upper extremity dysfunction (1). Impaired motor function of the upper extremity is a major factor in preventing patients returning to their usual activities. In addition to routine medical treatment, early-phase rehabilitation helps improve motor function and activities of daily living (ADL) (2). Moreover, well-prescribed rehabilitation may shorten the course of recovery from stroke, help patients return to the community earlier, improve their quality of life, and reduce the cost of medication (3).

Recovery of upper extremity functioning is essential for improving ADL ability in patients with stroke (4). The hands play an important role in functioning of the upper extremities. Hand function and, in particular, extensor function, is difficult to recover once impaired, Therefore, specific rehabilitation interventions, which are considered the first step in re-gaining full extension of the hand, are essential in the recovery of wrist dorsiflexion (WD). Early recovery of active WD contributes not only to a better outcome for upper extremity functioning, but also to improved outcome for ADL.

Over the past decades, neuromuscular electrical stimulation (NMES), an electrical stimulation that provides passive training for the wrist dorsi-extensor, has been integrated into certain specific rehabilitation prescriptions (5–7). NMES triggers the movement using electrical stimulation. The frequency and amplitude of biphasic rectangular current pulses are pre-set and fixed during the whole training course.

In contrast, controlled functional electrical stimulation (CCFES) is an intervention technique developed recently to improve the function of the paretic upper extremity after stroke. One of the characteristics of CCFES is that it requires active participation from patients, and not merely electrical stimulation of the paretic muscle or extremity. As described by Knutson et al., “CCFES uses a control signal from the non-paretic side of the body to regulate the intensity of electrical stimulation delivered to the paretic muscles of the homologous limb on the opposite side of the body” (8). In separate studies, Knutson et al. (9) and Shen et al. (10) compared the effectiveness of CCFES and NMES in patients with sub-acute stoke, and found greater improvements with CCFES. Nonetheless, its effectiveness in the early-phase (i.e. within 15 days) after stroke is unclear. The aim of this study was therefore to investigate the effectiveness of CCFES compared with NMES on upper extremity function, particularly WD, in patients with early-phase stroke.

MATERIAL AND METHODS

Subjects

Patients admitted to the Department of Neurology, Jiangsu Province People’s Hospital, Nanjing, China, between March and September 2015 were recruited to this study. All subjects provided written informed consent prior to the study, and the ethics committee of the First Affiliated Hospital of Nanjing Medical University approved the study protocol.

Inclusion criteria were: (i) diagnosed with stroke using computed tomography (CT) or magnetic resonance imaging (MRI); (ii) stable vital signs 48 h post-stroke; (iii) single-side injury; (iv) age 20–80 years; (v) within 15 days post-stroke; (vi) Brunnstrom recovery stage of III or less; (vii) score of Fugl-Meyer assessment (FMA) for upper extremity ≤ 22; and (viii) no active WD detected.

Exclusion criteria were: (i) progressive stroke with non-stable condition; (ii) stroke-like symptoms due to subdural haematoma, tumour, encephalitis or trauma; (iii) unable to follow treatment instructions due to severe cognitive and communication deficiency; (iv) implanted with a pacemaker; and (v) no informed consent (11).

Randomization

Patients were assigned to either the NMES or the CCFES group based on a computer-generated randomization list and allocation (1:1) concealed by consecutively numbered, sealed opaque envelopes. An envelope was opened once a patient had consented to participate in the trial, the administrator then informed the doctor about the allocated intervention regimen via phone calls.

Electrical stimulation system

In the NMES group, 2 stimulating electrodes (4 × 4 cm) were placed at the motor points of the forearm extensor muscles (specifically the ulnar margin of the extensor aspect of the forearm) to produce WD (Fig. 1a). The stimulators (Weisi Corporation, Nanjing, China) used in this study delivered biphasic rectangular current pulses; the pulse frequency was set at 35 Hz, and the pulse amplitude was set at 40 mA. The electrical stimulation intensity was set at a sustainable level with full balanced WD with tetanic contraction.

In the CCFES group, 3 recording electrodes (4 × 4 cm) were placed on the motor points of the forearm extensor muscles (the ulnar margin of the extensor aspect of the forearm) on the non-paretic side, while 2 stimulating electrodes (4 × 4 cm) were attached on the paretic side (Fig 1b). For each patient, the intensity of the electrical stimulation to WD of the paretic side was determined by the strength of contralateral forearm extensor muscles contraction. Subjects were asked to voluntarily extend their unaffected wrist to 10% of ROM or less and maintain that position without moving. The electromyography value of the movement was then recorded. Meanwhile, the therapist adjusted the electric intensity until the same degree of movement appeared on the paretic side. The intensity value was then recorded. The same practice and recording process was also applied, with the patients extending their unaffected wrist to 50% and 100% of ROM. The electrical stimulation intensity that produced balanced WD was determined empirically for each patient and programmed into the stimulator.

Fig. 1. Patients treated with different strategies. (a) The patient underwent neuromuscular electrical stimulation (NMES) with the stimulator in Model I; (b) the patient underwent contralaterally controlled functional electrical stimulation (CCFES) with the stimulator in Model II.

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Continue —> Journal of Rehabilitation Medicine – Contralaterally controlled functional electrical stimulation improves wrist dorsiflexion and upper limb function in patients with early-phase stroke: A randomized controlled trial – HTML

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[Abstract] Electromyogram-Related Neuromuscular Electrical Stimulation for Restoring Wrist and Hand Movement in Poststroke Hemiplegia: A Systematic Review and Meta-Analysis

Background. Clinical trials have demonstrated some benefits of electromyogram-triggered/controlled neuromuscular electrical stimulation (EMG-NMES) on motor recovery of upper limb (UL) function in patients with stroke. However, EMG-NMES use in clinical practice is limited due to a lack of evidence supporting its effectiveness.

Objective. To perform a systematic review and meta-analysis to determine the effects of EMG-NMES on stroke UL recovery based on each of the International Classification of Functioning, Disability, and Health (ICF) domains.

Methods. Database searches identified clinical trials comparing the effect of EMG-NMES versus no treatment or another treatment on stroke upper extremity motor recovery. A meta-analysis was done for outcomes at each ICF domain (Body Structure and Function, Activity and Participation) at posttest (short-term) and follow-up periods. Subgroup analyses were conducted based on stroke chronicity (acute/subacute, chronic phases). Sensitivity analysis was done by removing studies rated as poor or fair quality (PEDro score <6).

Results. Twenty-six studies (782 patients) met the inclusion criteria. Fifty percent of them were considered to be of high quality. The meta-analysis showed that EMG-NMES has a robust short-term effect on improving UL motor impairment in the Body Structure and Function domain. No evidence was found in favor of EMG-NMES for the Activity and Participation domain. EMG-NMES had a stronger effect for each ICF domain in chronic (≥3 months) compared to acute/subacute phases.

Conclusion. EMG-NMES is effective in the short term in improving UL impairment in individuals with chronic stroke.

 

via Electromyogram-Related Neuromuscular Electrical Stimulation for Restoring Wrist and Hand Movement in Poststroke Hemiplegia: A Systematic Review and Meta-Analysis – Katia Monte-Silva, Daniele Piscitelli, Nahid Norouzi-Gheidari, Marc Aureli Pique Batalla, Philippe Archambault, Mindy F. Levin, 2019

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

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

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

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

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

Introduction

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

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

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

 

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

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

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[WEB SITE] Breaking Down the Barriers of Stroke – Physical Therapy Products

A therapist and patient discuss features of a lower extremity functional electrical stimulation device. The patient’s understanding of the benefits advanced technology can provide is crucial to enhance the individual’s engagement in usage of these interventions.

by Justine Mamone, PT, DPT, and Michael Scarneo, PT, DPT, NCS

The World Health Organization (WHO) estimates that more than 1 billion people—about 15% of the world population—are living with some form of disability. The WHO has identified this as a global public health issue as it relates to barriers with accessing health services, education, and employment, and overall poorer health outcomes.1 Stroke has been identified as the leading cause of long-term disability in the United States, costing an estimated $34 billion each year per the Center for Disease Control and Prevention (CDC), with the prevalence only expected to increase as the aging population grows.

It has been shown that those who seek immediate medical care within 3 hours of identifying their first signs or symptoms of a stroke often demonstrate decreased disability 3 months post-stroke.2 Similarly, early rehabilitation for stroke survivors has been shown to improve functional outcomes and minimize the likelihood of long-term disability.2,3


Technology Snapshot:
Dynamic Stair Trainer and Body Weight Support
Today’s technology for locomotor training has advanced beyond what tools such as parallel bars and gait belts traditionally have provided. Part of this advance can be seen in devices such as the DST8000 Triple Pro Dynamic Stair Trainer from Clarke Health Care Products, Oakdale, Pa. DST8000 features include one side with electronically adjustable steps that can be controlled by push button in 1-centimeter increments, rising from flat plane up to 6½ inches. The other side has a walking surface that rises to 26º angled incline.Locomotor training has also benefitted from advances in partial body weight support systems, such as the LiteGait from Mobility Research, Tempe, Ariz,. The LiteGait supports the user with a harness suspended over a wheeled base to assist with over-ground walking. Therapists can use a handheld control with the LiteGait to adjust weight-bearing incrementally. The Andago from Hocoma, Norwell, Mass, is another advanced harness system over a wheeled base, which uses robotic technology to sense patient movement during over-ground gait therapy. For bigger budgets, ceiling-mounted systems that use an overhead trolley are part of the technology mix, including the SafeGait 360 from Gorbel Medical, Victor, NY, which can distinguish between a fall and movement that is initiated by a patient.


Technology’s Role in Recovery

Early rehabilitation is crucial in not only minimizing long-term disability, but also in persevering independence and optimizing quality of life. The optimal time frame to begin rehabilitation is unclear. However, research supports that there is a window after a stroke occurs when there is enhanced neuroplasticity and the brain is the most susceptible to change.4 During that time, intensive and dynamic therapeutic interventions are implemented in an acute rehabilitation setting to maximize an individual’s rehabilitation potential.

The WHO developed a model of care, The International Classification of Function (ICF), to streamline the terminology and provide a comprehensive framework in providing care for individuals with various diagnoses, including stroke.5,6 The ICF model is used to identify the needs of everyone seen in an acute rehabilitation facility, such as Kessler Institute for Rehabilitation in New Jersey. Within that plan of care a vast number of interventions are functional and goal-oriented to address the specific needs of each individual, including the use of advanced technology. Technology can be included in a plan of care not only to drive recovery through task-specific training, but to prevent secondary complications that arise and to preserve the mobility of those affected by a neurological insult.

Neuromuscular Electrical Stimulation

Many of the stroke survivors seen in acute rehabilitation have impaired walking ability resulting in the need for physical assistance, the use of bracing and assistive devices, and concerns regarding joint integrity and overall safety. As a result, much of the technology used in rehabilitation has been studied to improve quality of movement, overall function, and independence. Additionally, the use of technology allows for the opportunity for functional, high-intensity mass practice under safe, controlled conditions where compensatory strategies can be minimized. One of the most commonly used pieces of technology is neuromuscular electrical stimulation (NMES) specifically used to stimulate the ankle dorsiflexors to assist in foot clearance during the swing phase of gait.

The option of using NMES is to obtain a neuroprosthetic effect which provides the therapist the opportunity to facilitate and train patients in exhibiting a more normal gait pattern as compared to gait training with the use of an ankle-foot orthosis. In addition, the use of NMES may also yield a neuro-therapeutic effect in which there is carryover in gait quality and mechanics when no longer in use.7 The literature has identified a neuro-therapeutic effect as noted in lower extremity motor function, improved gait mechanics when use acutely as compared to several weeks post-CVA, significant improvements on the Berg Balance Scale, Timed Up and Go (TUG), and decreased spasticity and subsequent improvements in range of motion.7,8


Product Resources

The following companies offer technologies that can be used for the rehabilitation of gait and balance disorders:

Accelerated Care Plus
www.acplus.com

APDM
www.apdm.com

Allard USA Inc
www.allardusa.com

Biodex
www.biodex.com

Clarke Health Care Products
www.clarkehealthcare.com

GAITRite/CIR Systems Inc
www.gaitrite.com

Gorbel Inc-Medical Division/SafeGait
www.safegait.com

Hocoma
www.hocoma.com

ICARE (SportsArt)
www.gosportsart.com

Micromedical
www.micromedical.com

Mobility Research
www.litegait.com

OPTP
www.optp.com

Perry Dynamics
www.perrydynamics.com

ProtoKinetics
www.protokinetics.com

Tekscan
www.tekscan.com

Vista Medical
www.boditrak.com


Robotic Technologies

Robotic-assisted gait training (RAGT) was researched and designed for utilization among the spinal cord injury population. In recent years, more and more studies have addressed the utilization of robotic exoskeletons with individuals post-stroke. This type of technology allows for increased training intensity and reduced demands on the therapists during locomotor training, allowing the therapist to address more specific impairments that would otherwise be difficult to complete in a safe and functional way.11 Additionally, RAGT provides the opportunity to minimize ineffective gait patterns, normalize gait speeds, and reduce the need for bracing in early gait training that would be difficult to control for with conventional interventions.

As expected, recent studies have shown that these devices have positive effects on gait recovery as compared to conventional gait training alone.12 Also, notably when utilized in a more acute phase of recovery, such as in an inpatient rehabilitation setting, there were more meaningful improvements.11 Improvements inclusive of increases in the individual’s self-selected walking speed and improvements in outcomes measures, such as the TUG and Functional Gait Assessment (FGA) when measured post-RAGT use.13There has also been evidence to improvements in spasticity management, bowel and bladder function, and bone density with varying populations in addition to improvements in balance, gait quality, and lower extremity strength.14

Locomotor Training

Functional Electrical Stimulation (FES) bicycle ergometers are utilized to improve aerobic capacity, neuromuscular recovery, and upper and/or lower extremity strength by increasing the intensity to a level not otherwise attainable and by stimulating plegic muscles, respectively. Safe and functional locomotor training requires the motor control, strength, and cardiovascular endurance to withstand the natural demands of walking, all of which can be addressed with the use of the aforementioned technology. Studies have identified that with the use of FES there is earlier onset of walking by 2 to 3 days, greater discharges to home as compared to conventional therapist, improvements in gait speed and walking distance tolerated, greater force production and limb symmetry.16-18

Breaking Down Barriers to Technology Acceptance

Advanced technologies have provided a greater number of options to physical therapists and increased possibilities of alternative interventions to provide to stroke survivors in an inpatient rehabilitation setting. The new and exciting interventions that the advent of technology has brought to the world of stroke rehabilitation continues to have increasing evidence to support utilization. An evidenced-based approach to identifying appropriate therapeutic interventions is the approach used when developing a physical therapy plan of care. Despite the amount of literature to support the use of advanced technology, there may be barriers and limitations to implementing some of these forms of technology.

For example, in a recent study, Auchstaetter et al found that barriers impacting the use of FES specifically included therapist preference for specific interventions, lack of knowledge/training/expertise, perception of intervention not being appropriate for specific patients, and lack of resources inclusive of time, equipment, and assistance.19 It can be inferred that, although these findings are specific to FES usage, that these may be barriers to utilization among many of the assistive technologies highlighted here. There are also patient-specific barriers that play a role in the utilization, including impaired cognition and communication limiting the individual’s ability to report pain and distress during use, behavioral issues, pre-morbid orthopedic issues, and hemodynamic instability which would result in poor tolerance.20

The limitations in knowledge and training may be directly related to the therapist’s ability to remain current with clinical advances and research which may prevent seamless integration of technology into daily practice. In a clinical setting, there may also be challenges with regard to access to these new technologies due to cost-effectiveness or benefits for populations served or with regard to clinical setting. Hughes et al stated that therapists take a pragmatic view when it comes to using assistive technologies and find these aspects of technology to be barriers to use. The Technology Acceptance Model developed by Hughes suggests that with any new technological advances several factors influence integration, including perceived usefulness and perceived ease of use.21 Taking these factors into consideration, stronger clinical evidence in various treatment environments, educational opportunities, and having a collaborative partnership with technology vendors will enhance knowledge transfer and increase usage of assistive technologies across all clinical settings.

Among the advanced technologies at Kessler Institute for Rehabilitation is the EKSO GT, a robotic assisted gait trainer used to promote upright posture while modifying parameters to facilitate safe gait training.

Understanding the Path to Improved Outcomes

Greater understanding yielding greater clinician acceptance is critical to usage of assistive technologies. Additionally, the patient’s understanding of the benefit that technology can provide is crucial to enhance the individual’s engagement in usage of these interventions. As clinicians, we are limited in identifying the individual’s perception of their improvement or their adherence to interventions and with few outcome measures that address these areas.22 Psychology of the individual receiving the intervention, engagement and participation are key factors in rehabilitation performance, neuroplasticity, and ultimate recovery.23 Integration of technology has become standard in every daily life, and as the cultural gap between our treatment population and assistive technology usage closes, patients will be more eager in seeking out these interventions.23

It is anticipated that with greater understanding of the enhanced benefits that technology can provide by the entire therapy team inclusive of the patient, there will be improved patient outcomes. Despite the few barriers to use, technology has shown a great deal of promise with regard to functional outcomes and psycho-social benefits. Continued research and advances in technology will aid in providing our patients with a greater number of options and interventions to maximize function and minimize long-term disability. PTP

Justine Mamone, PT, DPT, is a board-certified clinical specialist in Neurologic Physical Therapy, and an inpatient clinical specialist physical therapist, at Kessler Institute for Rehabilitation.

Michael Scarneo, PT, DPT, NCS, is a senior physical therapist at Kessler Institute for Rehabilitation. For more information, contact PTPEditor@medqor.com.

References

  1. World Health Organization. Summary: World report on disability, 2011. Geneva, Switzerland: World Health Organization; 2011.
  2. Benjamin EJ, Blaha MJ, Chiuve SE, et al, on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146-e603.
  3. Stroke Facts | cdc.gov. https://www.cdc.gov/stroke/facts.htm. Published 2018. Accessed May 24, 2018.
  4. Lynch E, Hillier S, Cadilhac D. When should physical rehabilitation commence after stroke: a systematic review. Int J Stroke. 2014;9(4):468-478.

  5. Silva S, Corrêa F, Faria C, Buchalla C, Silva P, Corrêa J. Evaluation of post-stroke functionality based on the International Classification of Functioning, Disability, and Health: a proposal for use of assessment tools. J Phys Ther Sci. 2015;27(6):1665-1670.

  6. Brewer L, Horgan F, Hickey A, Williams D. Stroke rehabilitation: recent advances and future therapies. QJM. 2012;106(1):11-25.

  7. Knutson JS, Fu MJ, Sheffler LR, Chae J. Neuromuscular electrical stimulation for motor restoration in hemiplegia. Phys Med Rehabil Clin N Am. 2015;26(4):729-745.

  8. Howlett OA, Lannin NA, Ada L, McKinstry C. Functional electrical stimulation improves activity after stroke: a systematic review with meta-analysis. Arch Phys Med Rehabil. 2015:96(5):934-943.

  9. Louie DR, Eng JJ. Powered robotic exoskeletons in post-stroke rehabilitation of gait: a scoping review. J Neuroeng Rehabil. 2016;13(1):53.

  10. Nilsson A, Vreede KS, Häglund V, Kawamoto H, Sankai Y, Borg J. Gait training early after stroke with a new exoskeleton – the hybrid assistive limb: a study of safety and feasibility. J Neuroeng Rehabil. 2014;11:92.

  11. Srivastava S, Kao PC, Reisman DS, Scholz JP, Agrawal SK, Higginson JS. Robotic assist-as-needed as an alternative to therapist-assisted gait rehabilitation. Int J Phys Med Rehabil. 2016;4(5):370.

  12. Bruni MF, Melegari C, De Cola MC, Bramanti A, Bramanti P, Calabrò RS. What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and meta-analysis. J Clin Neurosci. 2018;48:11-17.

  13. Chang WH, Kim Y-H. Robot-assisted therapy in stroke rehabilitation. J Stroke. 2013;15(3):174-181.

  14. Ambrosini E, Ferrante S, Ferrigno G, Molteni F, Pedrocchi A. Cycling induced by electrical stimulation improves muscle activation and symmetry during pedaling in hemiparetic patients. IEEE Trans Neural Syst Rehabil Eng. 2012;20(3):320-330.

  15. Aaron SE, Vanderwerker CJ, Embry AE, Newton JH, Lee SCK, Gregory CM. FES-assisted cycling improves aerobic xapacity and locomotor function postcerebrovascular accident. Med Sci Sports Exerc. 2018;50(3):400-406.

  16. Yan T, Hui-Chan CW, Li LS. Functional electrical stimulation improves motor recovery of the lower extremity and walking ability of subjects with first acute stroke: a randomized placebo-controlled trial. Stroke. 2005;36(1):80-85.

  17. Auchstaetter N, Luc J, Lukye S, Lynd K, Schemenauer S, Whittaker M, Musselman KE. Physical therapists’ use of functional electrical stimulation for clients with stroke: frequency, barriers, and facilitators. Phys Ther. 2016:96(7):995-1005.

  18. Chua KSG, Kuah CWK. Innovating with rehabilitation technology in the real world. Am J Phys Med Rehabil. 2017;96(10 Suppl 1):S150-S156.

  19. Hughes AM, Burridge JH, Demain SH, et al. Translation of evidence-based assistive technologies into stroke rehabilitation: users’ perceptions of the barriers and opportunities. BMC Health Serv Res. 2014;14:124.

  20. Meadmore KL, Hughes AM, Freeman CT, Benson V, Burridge JH. Participant feedback in the evaluation of novel stroke rehabilitation technologies. J Rehab Robotics. 2013;1:82-92.

  21. Morone G, Paolucci S, Cherubini A, et al. Robot-assisted gait training for stroke patients: current state of the art and perspectives of robotics. Neuropsychiatr Dis Treat. 2017;13:1303-1311.

 

Objective Data for Evaluating Gait & Balance

An expanding category of tech-enabled devices is helping gait evaluation stay on the straight and narrow.

Compiled by Physical Therapy Products staff

Once restricted to observational analysis, today’s clinicians now have access to technologies that provide objective data for developing an accurate picture of a patient’s recovery. To spotlight the latest features and benefits of systems that collect objective gait measurements, Physical Therapy Products profiles four solutions that provide data-driven insight into patients who are affected by a movement impairment.

---BodiTrak logo RGB

Vista Medical / BodiTrak
(800) 822-3553
www.boditrak.com

Vista Medical, Winnipeg, Manitoba, Canada, introduces the BodiTrak Balance Mat, which is designed to assess steadiness, symmetry, and dynamic stability as an aid for fall prevention, concussion evaluation and recovery, athlete rehabilitation, and general postural/sway.

The BodiTrak Balance Mat measures weight-bearing, like a force plate, but also pressure-maps each foot individually, including heel/toe segmentation. Additionally, the BodiTrak Balance Mat tracks center-of-pressure (COP) total distance moved, maximum COP displacement, and velocity of COP movement.

The Mat brings quantification and objectivity to balance tests such as mCTSIB, which have historically been observational and subjective. By displaying and reporting detailed data about various balance-related metrics, it is designed to enable the detection of even slight improvements in outcomes over time—thereby enhancing the quality and value of reports for both physicians and insurers.

GAITRITE-LOGO

GAITRite / CIR Systems Inc
(888) 482-2362
www.gaitrite.com

GAITRite from CIR Systems Inc, Franklin, NJ, a leader in temporo-spatial gait analysis for the past 26 years, is engineered to capture with unsurpassed accuracy the objective data necessary to reliably document patient condition and progression. Measurement of stride-to-stride variability has shown to be an invaluable tool in evaluating or monitoring interventions aimed at improving balance and gait with numerous patient conditions. Built to be durable, GAITRite walkways may be left in place permanently or can be moved easily and set up in less than 75 seconds.

Robust reporting options allow for tailorable reports with multiple export functions available. The software identifies, through a multitude of specific spatial-temporal gait parameters, asymmetries and deviations from normal time and distance values. These objective numbers allow for an informed assessment of targeted interventions such as gait training or use of assistive devices or sensory aids.

The company reports that GAITRite walkways and modular systems have been cited in many peer-reviewed publications worldwide, across multiple disciplines that include geriatrics, neurology, orthopedics, orthotics, prosthetics, pediatrics, physiotherapy, and rehabilitation, from educational and research institutes to hospital and other clinical settings. GAITRite walkways and modular systems are reported to have been widely used in 54 countries for the past 26 years.

TK_Logo_cmyk

Tekscan
(800) 248-3669
www.tekscan.com/strideway

The Strideway is a modular system from Tekscan, South Boston, Mass, that calculates spatial, temporal, and kinetic parameters essential for a comprehensive gait analysis. The system is engineered so that data is presented in easy-to-understand tables and graphs for quick comparison of patient progress between visits. Symmetry tables can provide quick insights into differences between left and right sides, a key indicator in the rehabilitation process. The pressure data provided by the Strideway is useful to identify asymmetries, potential problem areas, pain points, or areas of ulceration.

With a smooth, flush surface, the Strideway is designed to be ideal for patients of all ages, and its width can easily accommodate individuals who use walking aids. The Strideway is a tile-based system, built to be quickly assembled and disassembled for greater mobility. It is available in multiple lengths and provides flexibility to add or subtract length at any time. This design allows for reduction or expansion based on need, and greater capabilities with a longer walkway.

With a quick set-up time, full data collection can be completed in minutes. A downloadable data sheet on the company’s website shares extensive details about platform dimensions and technical specifications.

ProtoKinetics

ProtoKinetics
(610) 449-4879
www.protokinetics.com

Michael Rowling, COO of ProtoKinetics LLC, Havertown, Pa, reportedly is credited by some in the rehab industry with putting gaitmat technology on the map. According to Jacquelyn Perry, MD, one of Rowling’s mentors described as a “pillar of clinical gait analysis”: “the wide range of initial disability following an acute stroke and the seeming inconsistency of recovery, …, continue to challenge therapeutic planning.”1

Clinical scales have predictive value in assessment of walking potential at an early recovery state. However, the sensitivity of these clinical measures is questioned for more advanced stages of recovery.2 More valid and reliable measures are essential to evaluate the many walking and balance strategies acquired by patients.

The Zeno Walkway from ProtoKinetics has a wide surface that allows for the capture of assistive device performance in addition to the loading patterns of the patient’s footsteps. PKMAS software automatically eliminates walker tracks, while expertly identifying overlapping steps, which is crucial for implementation in clinical care.

ProtoKinetics is reported to consistently review updates in the literature for valuable measures and protocols that will improve data output and interpretability. Recent implementation of the enhanced GVI3 and automated Four Square Step Test are just two examples of rehabilitation-related outcomes which may assist in clinical decisions about balance control to plan therapy and discharge from the hospital.

References

  1. Perry J, Burnfield J. Gait Analysis: Normal and Pathological Function. 2nd ed. Thorofare: Slack Incorporated; 2010.
  • Richards CL, Olney SJ. Hemiparetic gait following stroke. Part II: Recovery and physical therapy. Gait & Posture. 1996;4(2):149-162.
  • Gouelle A, Rennie L, Clark DJ, Mégrot F, Balasubramanian CK. Addressing limitations of the Gait Variability Index to enhance its applicability: The enhanced GVI (EGVI). PLoS ONE. 2018;13(6):e0198267.

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    [Abstract] Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study

     

    To investigate the effectiveness of mirror therapy combined with neuromuscular electrical stimulation in promoting motor recovery of the lower limbs and walking ability in patients suffering from foot drop after stroke.

    Randomized controlled study.

    Inpatient rehabilitation center of a teaching hospital.

    Sixty-nine patients with foot drop.

    Patients were randomly divided into three groups: control, mirror therapy, and mirror therapy + neuromuscular electrical stimulation. All groups received interventions for 0.5 hours/day and five days/week for four weeks.

    10-Meter walk test, Brunnstrom stage of motor recovery of the lower limbs, Modified Ashworth Scale score of plantar flexor spasticity, and passive ankle joint dorsiflexion range of motion were assessed before and after the four-week period.

    After four weeks of intervention, Brunnstrom stage (P = 0.04), 10-meter walk test (P < 0.05), and passive range of motion (P < 0.05) showed obvious improvements between patients in the mirror therapy and control groups. Patients in the mirror therapy + neuromuscular electrical stimulation group showed better results than those in the mirror therapy group in the 10-meter walk test (P < 0.05). There was no significant difference in spasticity between patients in the two intervention groups. However, compared with patients in the control group, patients in the mirror therapy + neuromuscular electrical stimulation group showed a significant decrease in spasticity (P < 0.001).

    Therapy combining mirror therapy and neuromuscular electrical stimulation may help improve walking ability and reduce spasticity in stroke patients with foot drop.

    via Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study – Qun Xu, Feng Guo, Hassan M Abo Salem, Hong Chen, Xiaolin Huang, 2017

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    [Abstract] Effectiveness of Neuromuscular Electrical Stimulation on Lower Limb Hemiplegic Patients following Chronic Stroke: A Systematic Review

    Abstract

    Objective

    To investigate the effectiveness of neuromuscular electrical stimulation (NMES) with or without other interventions in improving lower limb activity after chronic stroke.

    Data Source

    Electronic databases including PubMed, EMBase, Cochrane Library, PEDro (Physiotherapy Evidence Database) and PsycINFO were searched from the inception to January, 2017.

    Study Selection

    We selected the randomized controlled trials (RCTs) involving chronic stroke survivors with lower limb dysfunction and comparing NMES or combined with other interventions with control of no electrical-stimulated treatment.

    Data Extraction

    The primary outcome was defined as lower limb motor function, and the secondary outcomes included gait speed, Berg Balance scale, Timed Up and Go, Six-Minute Walk Test, Modified Ashworth Scale and Range of Motion .

    Data Synthesis

    Twenty-one RCTs involving 1,481 participants were identified from 5,759 retrieved articles. Pooled analysis showed that NMES had a moderate but statistically significant benefits on lower limb motor function (SMD 0.42, 95% CI 0.26 to 0.58), especially when NMES combined with other interventions or treatment time within either 6 or 12 weeks. NMES also had significant benefits on gait speed, balance, spasticity and range of motion but had no significant difference in walking endurance after NMES.

    Conclusion

    NMES combined with or without other interventions has beneficial effects in lower limb motor function in chronic stroke survivors. These data suggest that NMES should be a promising therapy to apply in chronic stroke rehabilitation to improve the capability of lower extremity in performing activities.

    via Effectiveness of Neuromuscular Electrical Stimulation on Lower Limb Hemiplegic Patients following Chronic Stroke: A Systematic Review – Archives of Physical Medicine and Rehabilitation

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    [Abstract] Effectiveness of Functional Electrical Stimulation (FES) versus Conventional Electrical Stimulation in Gait Rehabilitation of Patients with Stroke.

    Abstract

    OBJECTIVE: To compare the effectiveness of functional electrical stimulation (FES) versus conventional electrical stimulation in gait rehabilitation of patients with stroke for finding the most appropriate problem-oriented treatment for foot drop patients in a shorter time period.STUDY DESIGN: Randomized controlled trial.
    PLACE AND DURATION OF STUDY: Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, from July to December 2016.
    METHODOLOGY: Subjects with foot drop due to stroke were allotted randomly into 1 of 2 groups receiving standard rehabilitation with Functional Electrical Stimulation (FES) or Electrical Muscle Stimulation (EMS). FES was applied on tibialis anterior 30 minutes/day, five days/week for six weeks. EMS was also applied on the tibialis anterior five days/week for six weeks. Outcome measures included Fugl-Meyer Assessment Scale, Modified Ashworth Scale, Berg Balance Scale (BBS), Time Up and Go Test (TUG) and Gait Dynamic Index (GDI). They were recorded at baseline, after 3 and 6 weeks. Pre- and post-treatment scores were analyzed between two groups on SPSS-20.
    RESULTS: After six weeks of intervention, significant improvement was recorded in Fugl-Meyer Assessment score (p<0.001), modified Ashworth Scale score (p=0.027), Berg Balance Scale score (p<0.001), Time Up and Go Test (p<0.001) and Gait Dynamic Index (p=0.012) of the group subjected to FES.
    CONCLUSION: Gait training with FES is more effective than EMS in improving mobility, balance, gait performance and reducing spasticity in stroke patients. The research will help clinicians to select appropriate treatment of foot drop in stroke patients.

     

    via Effectiveness of Functional Electrical Stimulation (FES) versus Conventional Electrical Stimulation in Gait Rehabilitation of Patients with Stroke. – PubMed – NCBI

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    [Abstract] Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study 

    To investigate the effectiveness of mirror therapy combined with neuromuscular electrical stimulation in promoting motor recovery of the lower limbs and walking ability in patients suffering from foot drop after stroke.

    Randomized controlled study.

    Inpatient rehabilitation center of a teaching hospital.

    Sixty-nine patients with foot drop.

    Patients were randomly divided into three groups: control, mirror therapy, and mirror therapy + neuromuscular electrical stimulation. All groups received interventions for 0.5 hours/day and five days/week for four weeks.

    10-Meter walk test, Brunnstrom stage of motor recovery of the lower limbs, Modified Ashworth Scale score of plantar flexor spasticity, and passive ankle joint dorsiflexion range of motion were assessed before and after the four-week period.

    After four weeks of intervention, Brunnstrom stage (P = 0.04), 10-meter walk test (P < 0.05), and passive range of motion (P < 0.05) showed obvious improvements between patients in the mirror therapy and control groups. Patients in the mirror therapy + neuromuscular electrical stimulation group showed better results than those in the mirror therapy group in the 10-meter walk test (P < 0.05). There was no significant difference in spasticity between patients in the two intervention groups. However, compared with patients in the control group, patients in the mirror therapy + neuromuscular electrical stimulation group showed a significant decrease in spasticity (P < 0.001).

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    Source: Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled studyClinical Rehabilitation – Qun Xu, Feng Guo, Hassan M Abo Salem, Hong Chen, Xiaolin Huang, 2017

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    [WEB SITE] NeuroRecovery Network clinical rehabilitation centers adopt Restorative Therapies’ Xcite System for Neuromuscular Electrical Stimulation (NMES)

     

    The Christopher & Dana Reeve Foundation’s NeuroRecovery Network® (NRN) nine rehabilitation centers will receive 30 Restorative Therapies’ Xcite electrical stimulation systems.

    Xcite multichannel electrical stimulation for neuro re-education

    BALTIMORE, MD (PRWEB) JUNE 28, 2017

    The Christopher & Dana Reeve Foundation’s NeuroRecovery Network® (NRN) supports cutting-edge Clinical Rehabilitation Centers and Community Fitness and Wellness Facilities (CFWs) that make up two branches of care for people living with spinal cord injury and other physical disabilities.

    The nine NRN rehabilitation centers and CFWs will receive 30 Restorative Therapies’ Xcite systems which will be used to implement NRN’s cutting edge NMES rehabilitation program for patients across the US. The acquisition was funded by the Reeve NRN Network and the University of Louisville in conjunction with the rehabilitation centers and CFWs.

    NMES is a physical therapy rehabilitation modality used to evoke sensory feedback, functional movements and exercise not otherwise possible for individuals with a neurological impairment such as a spinal cord injury, stroke, multiple sclerosis or cerebral palsy.

    The Xcite system delivers up to 12 channels of electrical stimulation to nerves which activate core, leg and arm muscles. Easy to use sequenced stimulation evokes functional movement enabling a patient’s paralyzed or weak muscles to move through dynamic task specific movement patterns.

    “Xcite is the first truly practical electrical stimulation rehabilitation system of this kind that I have seen. In addition to combining several valuable neuro-rehabilitation interventions, task-specific electrical stimulation, mass practice and neuromuscular re-education, Xcite is portable and easy enough to use that it could be used in the patient’s home,” said Prof. Susan Harkema of the Kentucky Spinal Cord Injury Research Center, University of Louisville. “In the context of rehabilitation influencing neural plasticity as a means for neural restoration, training in the home is an essential component of progress and I see Xcite as a great tool in achieving this,” concludes Harkema.

    “The NRN clinical rehabilitation centers and CFWs played a key role during the development of the Xcite system.” says Andrew Barriskill, CEO of Restorative Therapies. “Xcite is designed to be integrated into the cutting edge therapy programs being developed and utilized by the Reeve Foundation’s NRN while at the same time being easy to use within any physical therapy or occupational therapy.”

    About Restorative Therapies
    Restorative Therapies is the designer of medical devices providing clinic and in-home restoration therapy. Xcite is the next in the series of FES powered physical therapy systems that started with the company’s hugely successful RT300 FES cycle.

    Restorative Therapies mission is to help people with a neurological impairment or in critical care achieve their full recovery potential. Restorative Therapies combines activity-based physical therapy and Functional Electrical Stimulation as a rehabilitation therapy for immobility associated with paralysis such as stroke, multiple sclerosis and spinal cord injury or for patients in critical care.

    Restorative Therapies is a privately held company headquartered in Baltimore. To learn more about Restorative Therapies please visit us at http://www.restorative-therapies.com

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    [ARTICLE] A Neuromuscular Electrical Stimulation (NMES) and robot hybrid system for multi-joint coordinated upper limb rehabilitation after stroke – Full Text

    Abstract

    Background

    It is a challenge to reduce the muscular discoordination in the paretic upper limb after stroke in the traditional rehabilitation programs.

    Method

    In this study, a neuromuscular electrical stimulation (NMES) and robot hybrid system was developed for multi-joint coordinated upper limb physical training. The system could assist the elbow, wrist and fingers to conduct arm reaching out, hand opening/grasping and arm withdrawing by tracking an indicative moving cursor on the screen of a computer, with the support from the joint motors and electrical stimulations on target muscles, under the voluntary intention control by electromyography (EMG). Subjects with chronic stroke (n = 11) were recruited for the investigation on the assistive capability of the NMES-robot and the evaluation of the rehabilitation effectiveness through a 20-session device assisted upper limb training.

    Results

    In the evaluation, the movement accuracy measured by the root mean squared error (RMSE) during the tracking was significantly improved with the support from both the robot and NMES, in comparison with those without the assistance from the system (P < 0.05). The intra-joint and inter-joint muscular co-contractions measured by EMG were significantly released when the NMES was applied to the agonist muscles in the different phases of the limb motion (P < 0.05). After the physical training, significant improvements (P < 0.05) were captured by the clinical scores, i.e., Modified Ashworth Score (MAS, the elbow and the wrist), Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Wolf Motor Function Test (WMFT).

    Conclusions

    The EMG-driven NMES-robotic system could improve the muscular coordination at the elbow, wrist and fingers.

    Background

    Stroke is a main cause of long-term disability in adults [1]. Approximately 70 to 80% stroke survivors experienced impairments in their upper extremity, which greatly affects the independency of their daily living [23]. In the upper limb rehabilitation, it also has been found that the recovery of the proximal joints, e.g., the shoulder and the elbow, is much better than the distal, e.g., the wrist and fingers [45]. The main possible reasons are: 1) The spontaneous motor recovery in early stage after stroke is from the proximal to the distal; and 2) the proximal joints experienced more effective physical practices than the distal joints throughout the whole rehabilitation process, since the proximal joints are easier to be handled by a human therapist and are more voluntarily controllable by most of stroke survivors [2]. However, improved proximal functions in the upper limb without the synchronized recovery at the distal makes it hard to apply the improvements into meaningful daily activities, such as reaching out and grasping objects, which requires the coordination among the joints of the upper limb, including the hand. More effective rehabilitation methods which may benefit the functional restoration at both the proximal and the distal are desired for post-stroke upper limb rehabilitation.

    Besides the weakness and spasticity of muscles in the paretic upper limb, discoordination among muscles is also one of the major impairments after stroke, mainly reflected as abnormal muscular co-activating patterns and loss of independent joint control [26]. Stereotyped movements of the entire limb with compensation from the proximal joints are commonly observed in most of persons with chronic stroke who have passed six months after the onset of the stroke, during which abnormal motor synergies were gradually developed. Neuromuscular electrical stimulation (NMES) is a technique that can generate limb movements by applying electrical current on the paretic muscles [7]. Post-stroke rehabilitation assisted with NMES has been found to effectively prevent muscle atrophy and improve muscle strength [7], and the stimulation also evokes sensory feedback to the brain during muscle contraction to facilitate motor relearning [8]. It has been found that NMES can improve muscular coordination in a paralysed limb by limiting ‘learned disuse’ that stroke survivors are gradually accustomed to managing their daily activities without using certain muscles, which has been considered as a significant barrier to maximizing the recovery of post-stroke motor function [9]. However, difficulties have been found in NMES alone to precisely activate groups of muscles for dynamic and coordinated limb movements with desired accuracy in kinematics, for example, speeds and trajectories. It is because most of the NMES systems adopted transcutaneous stimulation with surface electrodes only recruiting muscles located closely to the skin surface with limited stimulation channels [8]. Therefore, the muscular force evoked may not be enough to achieve the precise limb motions. However, limb motions with repeated and close-to-normal kinematic experiences are necessary to enhance the sensorimotor pathways in rehabilitation, which has been found to contribute to the motor recovery after stroke [10]. Furthermore, faster muscular fatigue would be experienced when using NMES with intensive stimuli, in comparison with the muscle contraction by biological neural stimulation [11].

    The use of rehabilitation robots is one of the solutions to the shortage of affordable professional manpower in the industry of physical therapy, to cope with the long-term and labour-demanding physical practices [10]. In comparison with the NMES, robots can well control the limb movements with electrical motors. Various robots have been proposed for upper limb training after stroke [1213]. Among them, the robots with the involvement of voluntary efforts from persons after stroke demonstrated better rehabilitation effects than those with passive limb motions, i.e., the limb movements are totally dominated by the robots [10]. Physical training with passive motions only contributed to the temporary release of muscle spasticity; whereas, voluntary practices could improve the motor functions of the limb with longer sustainability [1014]. In our previous studies, we designed a series of voluntary intention-driven rehabilitation robotics for physical training at the elbow, the wrist and fingers [1415161718]. Residual electromyography (EMG) from the paretic muscles was used to control the robots to provide assistive torques to the limb for desired motions. The results of applying these robots in post-stroke physical training showed that the target joint could obtain motor improvements after the training; however, more significant improvements usually appeared at its neighbouring proximal joint mainly due to the compensatory exercises from the proximal muscles [1517]. In order to improve the muscle coordination during robot-assisted training, we integrated NMES into the EMG-driven robot as an intact system for wrist rehabilitation [1619]. It has been found that the combined assistance with both robot and NMES could reduce the excessive muscular activities at the elbow and improve the muscle activation levels related to the wrist, which was absent in the pure robot assisted training [16]. More recently, combined treatment with robot and NMES for the wrist by other research group also demonstrated more promising rehabilitation effectiveness in the upper limb functions than pure robot training [20]. However, most of the proposed devices are for single joint treatment, and cannot be used for multi-joint coordinated upper limb training. Furthermore, the training tasks provided by these devices are not easy to be directly translated into daily activities. We hypothesized that multi-joint coordinated upper limb training assisted by both NMES and robot could improve the muscular coordination in the whole upper limb and promote the synchronized recovery at both the proximal and distal joints. In this work, we designed a multi-joint robot and NMES hybrid system for the coordinated upper limb physical practice at the elbow, wrist and fingers. Then, the rehabilitation effectiveness with the assistance of the device was evaluated by a pilot single-group trial. EMG signals from target muscles were used for voluntary intention control for both the robot and NMES parts.

    Methods

    The NMES-robot system

    The system developed is a wearable device as shown in Fig. 1. It can support a stroke subject to perform sequencing limb movements, i.e., 1) elbow extension, 2) wrist extension associated with hand open, 3) wrist flexion and 4) elbow flexion, with the purpose of simulating the coordination of the joints in arm reaching out, hand open for grasping, and withdrawing in daily activities. The starting position of the motion cycle was set at the elbow joint extended at 180° and the wrist extended at 45°, which is also the end point for a motion cycle. In each phase of the motion, visual guidance on a computer screen was provided to a subject by following a moving cursor on the computer screen with a constant angular velocity at 10°/s for the movement of the wrist and the elbow. The subject was asked to minimize the target and actual joint positions during the tracking. In the limb tasks, assistances would be provided from the mechanical motors and NMES at the same time related to the wrist and elbow flexion/extension. NMES alone was applied for finger extension, and there was no assistance from the system for finger flexion (hand grasp). It is because that the main impairment in the hand for persons with chronic stroke is hand open, and the hand grasp can be achieved passively due to spasticity in finger flexors, and one channel NMES has demonstrated the capacity to achieve the gross open of the hand with finger extensions in clinical practices [2]. With the attempt to reduce the overall weight of the system, especially at the distal joints, for the coordinated multi-joint training of the whole upper limb, finger motions were only supported by the NMES in this work. The robot and NMES combined effects on individual finger motions in chronic stroke have been investigated in our previous work [21]. A hanging system was used to lift up the testing limb to a horizontal level (Fig. 1), to compensate the limb gravity and the weight of the wearable part of the system (totally 895 g).

    Fig. 1 a The schematic diagram of the experimental setup, b a photo of a subject who is conducting the tracking task with the NMES-robot, c a photo of a subject wearing the mechanical parts of the system, d the configuration of the NMES electrodes and EMG electrodes on a driving muscle. The driving muscles in the study are BIC, TRI, FCR and the muscle union of ECU-ED

    Continue —> A Neuromuscular Electrical Stimulation (NMES) and robot hybrid system for multi-joint coordinated upper limb rehabilitation after stroke | Journal of NeuroEngineering and Rehabilitation | Full Text

     

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