Posts Tagged Neuromuscular electrical stimulation

[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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[WEB SITE] How Technology Is Changing Stroke Rehabilitation – Saebo

 

While everyday objects like clothespins and cups still play crucial roles in most patients’ journeys toward recovery, new technology is constantly changing the rehabilitation game. From video chats with doctors to robotic gloves and interactive video games, stroke recovery and rehabilitation tools have come a long way in the past decade. This new stroke recovery technology is helping link neuroplasticity and learning. A key part in recovery from a stroke.

This new stroke technology gives patients more repetitions, practice time and intensity compared to previous movement trainings. Not to mention this new technology is also more interactive, attention grabbing and really helps motivate the patient. These new technologies are really helping harness the brain’s ability to repair itself in ways that haven’t been seen before.

How Technology Kick-Starts Stroke Recovery

Just like the simple exercises that caregivers have used for years, the latest stroke recovery tools revolve around the concept of neuroplasticity. Though researchers have known about the brain’s ability to “retrain” itself for years, they now understand how crucial it is to begin this process as early as possible. That’s because the destruction of brain tissue during stroke is actually a temporary trigger for the rest of the brain.

“The tissue death that results from stroke appears to trigger a self-repair program in the brain,” says Karen Russell from The New Yorker.  

After stroke, healthy brain tissue reverts to a more malleable stage for one to three months. Neuroplasticity allows healthy brain tissue to create new connections to the affected muscles and nerves for years, but during these early months of recovery, the brain is especially open to forming these connections. Unfortunately, this is also when patients’ bodies face their most extreme limitations, preventing them from taking full advantage of their healthy brain tissue’s malleability.

neuroplasticity

That’s where modern technology comes in. Today’s stroke survivors have more recovery options than ever before, and many of them are designed to capitalize on this early recovery stage. Others allow doctors and caregivers to closely monitor patients’ progress and prevent common complications as they regain movement and retrain their brains in the months and years following stroke.

Video Games for Stroke Survivors

Perhaps one of the most innovative and exciting examples of stroke rehabilitation technology is in the video game space. Traditional low-tech stroke therapy options can be difficult and repetitive, making it less likely that patients follow through at home. Doctors are already noticing that video games are more engaging, exciting, and easy to incorporate into an at-home healing regimen.

One example of a new emerging video game gear toward stroke recovery is Bandit’s Shark Showdown. This is an interactive video game that allows players to control an animated dolphin’s movements. The version for stroke survivors incorporates a robotic sling, which patients wear to control the shark. This simulation synchronizes patients’ muscle movements with the dolphin’s leaps and dives, stimulating their brain and body simultaneously.

Stroke Technology, Video Games

(Source: Hub)

When you consider the brain itself, it’s not so unusual that a video game could recreate and reconnect key functions. John Krakauer, a neurologist who co-created the video game with a handpicked think tank, reminded The New Yorker that every simple muscle movement “requires an incredibly sophisticated set of computations“. His shark game is designed to break down “the physical-mental distinction” and restore function to impaired limbs.

“There’s no right and wrong when you’re playing as a dolphin,” John Krakauer told The New Yorker. “You’re learning the ABCs again—the building blocks of action. You’re not thinking about your arm’s limitations. You’re learning to control a dolphin. In the process, you’re going to experiment with many movements you’d never try in conventional therapy.”

Another example of this is a new therapeutic device that NYU Langone Medical Center has developed that creates an interactive canoe trip.

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Though the video game and device is still in the early stages of development and testing, doctors from NYU Langone say that they are seeing patients be more motivated and engaging that with current standard therapies. They also have shown to be another promising therapeutic option for stroke survivors who are too injured for traditional therapy.

 

Similar to the NYU Langone Medical Center’s device is the SaeboReJoyce workstation. Saebo’s ReJoyce workstation is a computerized task-oriented training system that involves a range of activity-based games that test speed, endurance, coordination, range of motion, strength, timing and cognitive demand. This helps patients practice repetitive gross motor and fine motor tasks with fun and motivating activities.

Because the games are customizable and incorporate a wide variety of grasp patterns, this workstation is useful for patients at each stage of recovery.

Saebo-Rejoyce

Robotics

Among the newest therapeutic tools used for stroke victims, those most commercially available are robotics and robotic exoskeletons, which attach directly to the affected part of the body to facilitate or enable movement. Therapeutic robotic devices include leg and arm supports that actually lift and support the limbs while reorganizing the pathways between the muscles, nerves, and healthy brain tissue. Like the robotic arm sling that researchers integrated into Bandit’s Shark Showdown robotic arm and leg devices contain sensors that track the limbs’ movements and monitor changes in force and terrain.

Bio Robotics

(Source: Bio Robotics)

 

The Wall Street Journal explains that robotic exoskeletons are especially useful because they are adjustable. As patients need less support, their therapists may adjust the robotic devices to let the patients’ muscles gradually resume more control. Because these exoskeletons can actually move the patients’ affected limbs until they regain movement, caregivers spend less time doing this themselves. When caregivers are free to observe patients’ movements – instead of manually moving their limbs – they can pay closer attention to the quality of each movement.

Body Weight Support Systems

Robots aren’t the only options for patients who need extra support for weak or paralyzed limbs. Because the force of gravity can turn patient’s’ own body weight into an obstacle, some of the most useful recovery devices like the SaeboMAS are designed to counteract this force. Support systems designed for the arms, legs and overall body, help support and facilitate movement to make task-oriented exercises possible. Motion that this is a much more affordable option as well.

Saebo-MAS

Support systems like the SaeboMAS aren’t used just to speed up the therapy process. One study found that stroke survivors who receive extra weight support actually walk better than patients who must support their own weight during rehabilitation. This makes sense, because gait training is more effective when patients are able to move their joints and muscles more quickly after stroke.

 

Neuromuscular Electrical Stimulation

Our everyday voluntary movements are made possible by connections between the brain and the body’s nerves, but after this connection is severed due to stroke, the affected nerves and muscles can no longer send or receive the sensory stimulation necessary to move. This is where neuromuscular electrical stimulation can be helpful. Neuromuscular electrical stimulation applies small electrical pulses to paralyzed muscles to restore or improve their function.

emg-triggered-stimulation

Devices  like the Saebo MyoTrac Infiniti uses EMG Triggered Stimulation which is a combination of biofeedback and electrical stimulation. Stimulation by devices like these are triggered to the desired muscle group (i.e., finger extensors, elbow extensors etc.) once the client deactivates or relaxes the opposite spastic muscle group (i.e., spastic finger flexors, elbow flexors etc.)

With Sensory Electrical Stimulation (SES), it is believed to enhance the neural plasticity and activate brain areas, helping with stroke rehabilitation. Studies show that providing SES to an impaired nervous system can prime the cortex ultimately leading to improve neuroplasticity, motor recovery and function. Using a Sensory Electrical Stimulation tool like the SaeboStim Micro is perfect for SES.

Saebo-stim

Research suggests that sensory electrical stimulation (SES) can be an effective treatment strategy for improving sensory and motor function. By providing low-level stimulation, increased signals are delivered to the brain and can lead to improved function and cortical reorgainzation.

Innovative Stroke Recovery Devices

Not all stroke recovery devices need electrical stimulation to aid in task-oriented training. Neurorehabilitation researchers have also incorporated mechanical features into lightweight gloves that simply ease the burden on the hands and fingers. For example, the SaeboGlove includes an innovative tension system that connects and controls the fingers, thumb, wrist, and forearm.

Saebo-Glove

(Source: Saebo)

Stroke P5glove-6sm

(Source: HWP)

Devices like the SaeboGlove and and the P5 Glove, a digital rehab glove designed to induce neural plasticity in the patient through specific and customized exercises with gamification, helps clients suffering from neurological and orthopedic injuries incorporate their hand functionally in therapy and at home.

Video Conferences with Doctors

Your odds of regaining movement after stroke are highly dependent on the speed with which you receive treatment. When stroke occurs, every second without proper diagnosis and treatment may cause more oxygen loss and damage to your brain cells. And after stroke, every moment of recovery is critical.

Ideally, all stroke patients would have immediate access to caregivers when stroke occurs, and then enjoy continuous access to rehabilitative and medical experts after they leave the hospital. In addition to caregivers who provide constant supervision, it’s important for patients’ healthcare providers to respond quickly to any concerns or questions as they monitor the patient’s progress.

Unfortunately, this isn’t always possible. Stroke is the country’s leading cause of long-term disability, and consistent, supervised therapy is one of the best ways to minimize complications and reduce a patient’s risks of suffering permanent mobility loss. But if patients can’t get to their therapist regularly – or get a proper diagnosis and treatment as soon as stroke occurs – they can face preventable setbacks. Now, the Internet is making it possible to maintain communication throughout the diagnosis, treatment, and recovery process.

Alabama’s Madison Hospital is one of many healthcare facilities that now use computers and cameras to connect neurologists with stroke patients. Patients who may be suffering a stroke – or complications during recovery – can now seek diagnosis and treatment through live conference calls with stroke experts at other hospitals. This makes incorrect diagnoses less likely, and ensures that stroke patients get the help they need immediately instead of waiting while more damage is done and experts are called in.

patient-exam-local-physician

(Source: Froedtert)

 

After patients return home, they may also conduct video chats with their physical therapists as they perform at-home stroke exercises. Virtual supervision may not be a substitute for the real thing, but it’s far more useful than unsupervised exercises that could do more harm than good, and it keeps patients accountable and their progress consistent. In fact, video conferencing is so useful that some insurance companies now cover virtual checkups.

Technology for The Greater Good

As video conferencing, video games, virtual reality, and robotics take off in the consumer sphere, medicine continues to come along for the ride, and our solutions for battling debilitating disabilities grow stronger. Whether our latest technology is infused into wearables, or whether it creates new categories of products, dollars spent researching, development, testing and distributing new solutions is a major key to improving healthcare in the 21st century.


 

Whether you are a caregiver, occupational therapist or a stroke survivor yourself, Saebo provides stroke survivors young or old, access to transformative and life changing products. We pride ourselves on providing affordable, easily accessible, and cutting-edge solutions to people suffering from impaired mobility and function. We have several products to help with the stroke recovery and rehabilitation process. From the SaeboFlex, which allows clients to incorporate their hand functionally in therapy or at home, to the SaeboMAS, an unweighting device used to assist the arm during daily living tasks and exercise training, we are commitment to helping create innovative products for stroke recovery. Check out all of our product offerings or let us help you find which product is right for you.

Source: How Technology Is Changing Stroke Rehabilitation | Saebo

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[Abstract] BCI controlled neuromuscular electrical stimulation enables sustained motor recovery in chronic stroke victims – PDF

R. Leeb1,2,#, A. Biasiucci2,#, T. Schmidlin1 , T. Corbet2 , P. Vuadens3 , JdR. Millán2,*

  1. Center for Neuroprosthetics (CNP), École Polytechnique Fédérale de Lausanne, Sion, Switzerland;
  2. Chair in Brain-Machine Interface (CNBI), École Polytechnique Fédérale de Lausanne, Geneva, Switzerland;
  3. SUVACare – Clinique Romande de Réadaptation, Sion, Switzerland

Equal contributions; * Campus Biotech, Chemin des Mines 9, CH-1202 Geneva, Switzerland; E-mail: jose.millan@epfl.ch

Introduction: Recently, it has been shown that brain-computer interfaces (BCI) can be used in stroke rehabilitation to decode motor attempts from brain signals and to trigger movements of the paralyzed limb [1]. Among other available practices in rehabilitation, neuromuscular electrical stimulation (NMES) is often used to directly engage muscles on the affected parts of the body during physical therapy. Nevertheless, the benefits of a combined approach, to directly link the brain intention with a muscular response, are not yet fully validated. In this abstract, we report first results of a BCI-NMES system for stroke rehabilitation.

Material and Methods: Up to now, we enrolled 18 chronic stroke victims (minimum 10 months past the incident) suffering from an impairment of the upper limb in a randomized controlled clinical trial. Half of the subjects were assigned to the BCI group and half to a “sham” group, whereby the criteria such as motor impairment –measured via the Fugl-Meyer scale for upper extremity (FM) score–, age, time since incident and lesion location were balanced. Generally, the experimental protocol consisted of three different phases: (i) patients underwent a preevaluation to check the motor capabilities, to characterize the initial state of the brain and to calibrate the BCI classifier (see BCI details in [2]). (ii) In the following weeks, they were trained with an online BCI twice a week for 10 sessions (45 to 90 minutes including setup). (iii) Finally, they performed a post-experimental screening to determine changes in EEG patterns and in motor functions following the treatment, and a 6-month follow-up to evaluate the sustainment. Patients in the BCI group received NMES of the extensor digitorum muscles triggered by the BCI detecting the intention of movement at the cortical level (modulation of the sensorimotor rhythm in the contralateral motor cortex). For patients in the sham group the NMES was not correlated with the brain activity. All subjects were asked to attempt to open their paretic hand (full sustained finger extension) with the aim of activating the NMES upon detection of a suitable sensorimotor rhythms (Fig. 1-a). Subjects in the two groups (BCI and sham) received comparable amount of NMES.

Results: Remarkably, subjects in the BCI group improved their motor function (post minus pre) by 8.6±5.0 FM points (which is more than the minimal clinical change of 5.25 FM points), while those in the sham group improved only by 2.4±3.4 FM points (Fig. 1-b). As expected, the features used by the BCI classifier were mostly located over the affected hemisphere and the motor cortex (see topographic presentation in Fig. 1-c).

Discussion: We hypothesize that the motor improvement in the BCI group (in contrast to the sham group) is triggered by the tight timed and functional link between the intended action in the brain, and the executed and perceived motor action, through the activation of the body’s natural efferent and afferent pathways.

Significance: In our randomized controlled trial, we demonstrate that the modulation of sensorimotor rhythms driving contingent neuromuscular stimulation is more effective than sham stimulation with active motor attempt, and that the proposed therapy dosage produces a clinically important recovery in chronic stroke survivors having a moderate-to-severe motor impairment.

References: [1] Ramos-Murguialday A, et al. Brain-machine interface in chronic stroke rehabilitation. Ann Neurol, 74(1):100-108, 2013. [2] Leeb R, et al. Transferring brain-computer interfaces beyond the laboratory: Successful application control for motor-disabled users. Artif Intell Med, 59: 121-132, 2013.

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[ARTICLE] Multi-contact functional electrical stimulation for hand opening: electrophysiologically driven identification of the optimal stimulation site | Journal of NeuroEngineering and Rehabilitation – Full Text

Abstract

Background

Functional Electrical Stimulation (FES) is increasingly applied in neurorehabilitation. Particularly, the use of electrode arrays may allow for selective muscle recruitment. However, detecting the best electrode configuration constitutes still a challenge.

Methods

A multi-contact set-up with thirty electrodes was applied for combined FES and electromyography (EMG) recording of the forearm. A search procedure scanned all electrode configurations by applying single, sub-threshold stimulation pulses while recording M-waves of the extensor digitorum communis (EDC), extensor carpi radialis (ECR) and extensor carpi ulnaris (ECU) muscles. The electrode contacts with the best electrophysiological response were then selected for stimulation with FES bursts while capturing finger/wrist extension and radial/ulnar deviation with a kinematic glove.

Results

The stimulation electrodes chosen on the basis of M-waves of the EDC/ECR/ECU muscles were able to effectively elicit the respective finger/wrist movements for the targeted extension and/or deviation with high specificity in two different hand postures.

Conclusions

A subset of functionally relevant stimulation electrodes could be selected fast, automatic and non-painful from a multi-contact array on the basis of muscle responses to subthreshold stimulation pulses. The selectivity of muscle recruitment predicted the kinematic pattern. This electrophysiologically driven approach would thus allow for an operator-independent positioning of the electrode array in neurorehabilitation.

Continue – Multi-contact functional electrical stimulation for hand opening: electrophysiologically driven identification of the optimal stimulation site | Journal of NeuroEngineering and Rehabilitation | Full Text

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[ARTICLE] Combination of Transcranial Direct Current Stimulation and Neuromuscular Electrical Stimulation Improves Gait Ability in a Patient in Chronic Stage of Stroke – Full Text HTML/PDF

Abstract

Background: Walking ability is important in stroke patients to maintain daily life. Nevertheless, its improvement is limited with conventional physical therapy in chronic stage. We report the case of a chronic stroke patient showing a remarkable improvement in gait function after a new neurorehabilitation protocol using transcranial direct current stimulation (tDCS) and neuromuscular electrical stimulation (NMES). Case Presentation: A 62-year-old male with left putaminal hemorrhage suffered from severe right hemiparesis. He could move by himself with a wheelchair 1 year after the ictus. Anodal tDCS at the vertex (2 mA, 20 min) with NMES at the anterior tibialis muscle had been applied for 3 weeks. The Timed Up and Go test and 10-meter walk test improved after the intervention, which had been maintained for at least 1 month. Conclusion: This single case suggests the possibility that tDCS with NMES could be a new rehabilitation approach to improve the gait ability in chronic stroke patients.

© 2016 The Author(s). Published by S. Karger AG, Basel

Introduction

Stroke is a leading cause of life-long disability. Conventional physical, occupational and speech therapies are established means of recovery from such disabilities, which are commonly used in the worldwide rehabilitation settings. However, the recovery of motor function after stroke is usually incomplete. Persistent neurological deficits impair activities of daily living (i.e. dressing, eating, self-care and personal hygiene), which underlie the need for the development of a novel neurorehabilitation approach.

Transcranial direct current stimulation (tDCS) is one of the noninvasive brain stimulation approaches that increasingly gather attention as a means for increasing or decreasing cortical excitability, depending on the delivery of anodal or cathodal stimulation to the cerebral cortex [1]. This method has advantages over other transcranial stimulation techniques, such as its ease of application, the lower cost and more prolonged modulating effect on the cerebral cortex. Although the efficacy of tDCS on hand function and aphasia has been widely evaluated, studies investigating the effects of tDCS on lower limb function have been limited [2,3,4]. In those studies, only tDCS was used as a neuromodulation method to improve leg function.

It can be assumed that other additional peripheral input might enhance the effect of tDCS and rehabilitation. In fact, tDCS combined with peripheral nerve stimulation improved the motor sequence task with a paretic hand as compared to the two interventions alone [5]. However, studies investigating the improvement of gait ability by the combination of tDCS and peripheral stimulation have never been reported.

Here, we show a patient in chronic stage of hemorrhagic stroke who experienced a surprising improvement in gait ability after the implementation of 3 weeks of combination therapy with tDCS and neuromuscular electrical stimulation (NMES).

Patient and Method

Case Presentation

A 62-year-old, right-handed male with a history of hypertension was referred to our hospital for the treatment of left putaminal hemorrhage (fig. 1). On admission, he was stuporous and showed complete hemiparesis on the right side. During the acute period of this hemorrhagic stroke, glyceol was given to control intracranial pressure, and his systolic blood pressure was maintained between 120 and 130 mm Hg with continuous infusion of nicardipine. Without enlargement of the hematoma, he gradually recovered from consciousness disturbance 1 week after the ictus. Conventional rehabilitation including physical, occupational and speech therapies was initiated under cardiorespiratory monitoring. However, deep venous thrombosis occurred, which required anticoagulation and inferior vena cava filter placement. Then, a carcinoma of the kidney was discovered incidentally, and the patient underwent surgical removal of the tumor in the Department of Urology of our hospital. Such treatment prevented him from intensive neurorehabilitation during the acute period and resulted in disuse syndrome. At 4 months after admission, he was readmitted to the Neurosurgery ward to restart rehabilitation.

Fig. 1

CT of the brain on admission, showing left putaminal hemorrhage.

http://www.karger.com/WebMaterial/ShowPic/493893

He was bed-ridden, and his right upper and lower extremities showed contracture. Physical and occupational therapy gradually made him sit and stand, which established his ability to operate a wheelchair by himself at 8 months after admission. Then, he could walk slowly in parallel bars with long leg braces at 1 year after the ictus.

For the further improvement of his gait ability, he underwent a new rehabilitation protocol combining tDCS and NMES.

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Continue —> Combination of Transcranial Direct Current Stimulation and Neuromuscular Electrical Stimulation Improves Gait Ability in a Patient in Chronic Stage of Stroke – FullText – Case Reports in Neurology 2016, Vol. 8, No. 1 – Karger Publishers

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[ARTICLE] Effects of repetitive facilitative exercise with neuromuscular electrical stimulation, vibratory stimulation and repetitive transcranial magnetic stimulation of the hemiplegic hand in chronic stroke patients

Abstract

Aim: Repetitive facilitative exercise (RFE) is a developed approach to the rehabilitation of hemiplegia. RFE can be integrated with neuromuscular electrical stimulation (NMES), direct application of vibratory stimulation (DAVS) and repetitive transcranial magnetic stimulation (rTMS). The aims of the present study were to retrospectively compare the effects of RFE and NMES, DAVS with those of RFE and rTMS, and to determine the maximal effect of the combination of RFE with NMES, DAVS, rTMS and pharmacological treatments in stroke patients.

Subjects and methods: Thirty-three stroke patients were enrolled and divided into three groups: 15 who received RFE with rTMS (4 min) (TMS4 alone), 9 who received RFE with NMES, DAVS (NMES, DAVS alone) and 9 who received RFE with NMES, DAVS and rTMS (10 min) (rTMS10 + NMES, DAVS). The subjects performed the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT) before and after the 2-week session. The 18 patients in the NMES, DAVS alone and rTMS10 + NMES, DAVS group underwent the intervention for 4 weeks.

Result: There were no significant differences in the increases in the FMA, ARAT scores in the three groups. The FMA or ARAT scores in the NMES, DAVS alone and the rTMS10 + NMES, DAVS group were increased significantly. The FMA and ARAT scores were significantly improved after 4 weeks in the NMES, DAVS alone group.

Discussion: RFE with NMES, DAVS may be more effective than RFE with rTMS for the recovery of upper-limb function. Patients who received RFE with NMES, DAVS and pharmacological treatments showed significant functional recovery.

Source: Taylor & Francis Online

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[ARTICLE] Wrist Rehabilitation Assisted by an Electromyography-Driven Neuromuscular Electrical Stimulation Robot After Stroke

Abstract

Background: Augmented physical training with assistance from robot and neuromuscular electrical stimulation (NMES) may introduce intensive motor improvement in chronic stroke.

Objective: To compare the rehabilitation effectiveness achieved by NMES robot–assisted wrist training and that by robot-assisted training.

Methods: This study was a single-blinded randomized controlled trial with a 3-month follow-up. Twenty-six hemiplegic subjects with chronic stroke were randomly assigned to receive 20-session wrist training with an electromyography (EMG)-driven NMES robot (NMES robot group, n = 11) and with an EMG-driven robot (robot group, n = 15), completed within 7 consecutive weeks. Clinical scores, Fugl-Meyer Assessment (FMA), Modified Ashworth Score (MAS), and Action Research Arm Test (ARAT) were used to evaluate the training effects before and after the training, as well as 3 months later. An EMG parameter, muscle co-contraction index, was also applied to investigate the session-by-session variation in muscular coordination patterns during the training.

Results: The improvement in FMA (shoulder/elbow, wrist/hand) obtained in the NMES robot group was more significant than the robot group (P < .05). Significant improvement in ARAT was achieved in the NMES robot group (P < .05) but absent in the robot group. NMES robot–assisted training showed better performance in releasing muscle co-contraction than the robot-assisted across the training sessions (P < .05).

Conclusions: The NMES robot–assisted wrist training was more effective than the pure robot. The additional NMES application in the treatment could bring more improvements in the distal motor functions and faster rehabilitation progress.

Source: Wrist Rehabilitation Assisted by an Electromyography-Driven Neuromuscular Electrical Stimulation Robot After Stroke

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[ARTICLE] Comparing the Effects of Functional Electrical Stimulation Versus Somatosensory Stimulation on Increasing Corticospinal Excitability for a Muscle of the Hand – Full Text PDF

Abstract

The electrically-evoked afferent volley generated during NeuroMuscular Electrical Stimulation (NMES) can increase the excitability of CorticoSpinal (CS) pathways. Over time, NMES can strengthen damaged CS pathways and result in enduring improvements in function for persons with central nervous system injury or disease. NMES-induced increases in CS excitability have been studied using a variety of NMES parameters, yet the influence of these stimulation parameters on increasing CS excitability is not well understood.

NMES is commonly delivered at intensities sufficient to generate repeated functional contractions for relatively short durations (30-40 min) or at low intensities, near motor threshold, for long durations (2 h).

For the purpose of this study, these different stimulation protocols are termed Functional Electrical Stimulation (FES) and Somatosensory Stimulation (SS), respectively. A direct comparison of increases in CS excitability induced by such protocols has not been conducted. Thus, the present experiments were designed to compare changes in CS excitability for Abductor Pollicis Brevis (APB) in the hand following FES and SS of the median nerve.

We hypothesized that due to the generation of a larger afferent volley, the FES would increase CS excitability more than the SS. Ten Motor Evoked Potentials (MEPs) were evoked in APB using transcranial magnetic stimulation before and after each type of NMES. MEP amplitude increased significantly following both the FES (by 66 ± 7%, mean ± standard error) and SS (49 ± 6%), but the amplitude of these increases was not significantly different.

These results suggest that just 40 min of FES can increase CS excitability, and potentially provide rehabilitative benefits, to the same extent as 2 h of SS.

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