Posts Tagged Neurorehabilitation

[ARTICLE] Enhancing the alignment of the preclinical and clinical stroke recovery research pipeline: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable translational working group – Full Text

Stroke recovery research involves distinct biological and clinical targets compared to the study of acute stroke. Guidelines are proposed for the pre-clinical modeling of stroke recovery and for the alignment of pre-clinical studies to clinical trials in stroke recovery.

Introduction

Moving treatments from the preclinical to the clinical realms is notoriously difficult. For all diseases, only 10% of agents that enter phase 1 trials result in a clinically used drug.1,2 The success rate in stroke and traumatic brain injury is also low and well-documented.35 The translational failure in stroke has been attributed to the narrow therapeutic window and to mistakes such as very broad inclusion criteria, and imprecise, global outcome measures.35 On the preclinical side, depth and rigor of study design, analysis and interpretation have received special focus.

Stroke recovery involves distinct biological principles and a very different time window compared to stroke neuroprotection.68 Unlike acute stroke, post-stroke behavioral activity shapes recovery and can be manipulated to promote recovery, or to negatively interact with recovery.6,9 In addition, stroke recovery involves a unique biology of altered synaptic signaling, enhanced synaptic plasticity and changes in neuronal circuits that provide novel drug and cellular targets but also raise special considerations in clinical translation. The special considerations include: the animal stroke models, the tissue and behavioral outcome measures, imaging biomarkers and conceptual management of the full translational pipeline.

Recent conceptual and technological developments in neuroscience are bringing promising physical, pharmacological and cellular therapies to the field of neurorehabilitation and brain repair. This paper outlines a series of guidelines and recommendations specifically tailored to enhance the quality and rigor of preclinical stroke recovery research.

The task of the translational working group of the Stroke Recovery and Rehabilitation Roundtable (SRRR)10 was to develop a set of guidelines and recommendations appropriate for preclinical stroke recovery research. Existing preclinical stroke research recommendation papers (e.g. STAIR, STEPS) focus chiefly on acute stroke.11,12 Although cognitive impairments and depression are common after stroke,13 the SRRR working groups concluded that these topics require a subsequent roundtable discussion so the emphasis here is on preclinical sensorimotor recovery. The ultimate goal of the translational group was to align preclinical to clinical stroke recovery studies so as to avoid past mistakes and maximize clinical translation.

Continue —> Enhancing the alignment of the preclinical and clinical stroke recovery research pipeline: Consensus-based core recommendations from the Stroke Recovery and Rehabilitation Roundtable translational working groupInternational Journal of Stroke – Dale Corbett, S Thomas Carmichael, Timothy H Murphy, Theresa A Jones, Martin E Schwab, Jukka Jolkkonen, Andrew N Clarkson, Numa Dancause, Tadeusz Weiloch, Heidi Johansen-Berg, Michael Nilsson, Louise D McCullough, Mary T Joy, 2017

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[ARTICLE] Affordable stroke therapy in high-, low- and middle-income countries: From Theradrive to Rehab CARES, a compact robot gym – Full Text

 

Affordable technology-assisted stroke rehabilitation approaches can improve access to rehabilitation for low-resource environments characterized by the limited availability of rehabilitation experts and poor rehabilitation infrastructure. This paper describes the evolution of an approach to the implementation of affordable, technology-assisted stroke rehabilitation which relies on low-cost mechatronic/robot devices integrated with off-the-shelf or custom games. Important lessons learned from the evolution and use of Theradrive in the USA and in Mexico are briefly described. We present how a stronger and more compact version of the Theradrive is leveraged in the development of a new low-cost, all-in-one robot gym with four exercise stations for upper and lower limb therapy called Rehab Community-based Affordable Robot Exercise System (Rehab C.A.R.E.S). Three of the exercise stations are designed to accommodate versions of the 1 DOF haptic Theradrive with different custom handles or off-the-shelf commercial motion machine. The fourth station leverages a unique configuration of Wii-boards. Overall, results from testing versions of Theradrive in USA and Mexico in a robot gym suggest that the resulting presentation of the Rehab C.A.R.E.S robot gym can be deployed as an affordable computer/robot-assisted solution for stroke rehabilitation in developed and developing countries.

Non-communicable diseases, especially cardiovascular diseases, are the leading cause of death and disability in the world. An increase in their prevalence often leads to higher incidences of stroke and consequently, an increase in the number of persons living with permanent disability due to stroke.1,2 Stroke is the leading cause of disability worldwide. Over 6.8 million adults live in the USA with disabilities due to a stroke, and by 2030, this number will grow by 4 million.3,4Seventy-five percent of adults recovering from stroke have residual impairment in their limbs, with only about 25% achieving recovery with minor impairments, and only 10% achieving full recovery.57 Greater than 30% are unable to walk without some assistance and 26% remain dependent in activities of daily living.8

The issues influencing rehabilitation outcomes are complex; some examples of these issues are poverty, increase in health costs, short length of stays, insurance limitations, and physical constraints on rehabilitation services (e.g. time).3,6 In low- and middle-income countries (LMIC), rehabilitation outcomes are worse since a disproportionate number of the population is without easy access to rehabilitation technologies, services and skilled clinicians.1,3,9,10 Improved stroke rehabilitation approaches can maximize the functional independence of stroke survivors discharged after inpatient and outpatient services and improve access to rehabilitation for low-resource environments in USA or other LMICs.

Our long-term goal is to develop and use affordable robot technologies to improve access to rehabilitation and ultimately improve the health and function of persons with persistent motor deficits due to a stroke in the USA and worldwide, especially in LMICs where more than 80% of those living with a stroke reside. Specifically, we desire to target stroke survivors who are diagnosed with hemiparesis, are living with severe to moderate motor function impairment, and are without easy access to rehabilitation. Research efforts are needed to develop cost-effective robot devices that can do the above and function in harsher environments characterized by extreme economic hardship (per country), intermittent energy and limited expert supervisors.

Our main approach to delivering rehabilitation has always promoted robot/computer-assisted motivating rehabilitation systems for stroke therapy.31 We have proposed the use and development of mechatronic devices alone or within a suite of devices for upper limb stroke therapy. This paper summarizes lessons learned regarding the delivery of affordable and accessible stroke therapy in HICs and LMICs. We illustrate these lessons via the use of Theradrive, alone (TD-1),2832 its development into a 1DOF Haptic Robot called Haptic Theradrive,3638 a therapy gym in Mexico (TD-2),3335 where Theradrive was one of six devices aimed at improving motor function after stroke. The paper then presents how a stronger and more compact version of the Theradrive is re-designed and leveraged in the development of a new low-cost, all-in-one robot gym called Rehab Community-based Affordable Robot Exercise System (Rehab C.A.R.E.S) with four exercise stations for upper and lower limb therapy. The prototype of the system is described along with strategies for control and new results from testing on exercise station 2. Finally, we discuss implications for deploying such a system in LMICs. […]

Continue —> Affordable stroke therapy in high-, low- and middle-income countries: From Theradrive to Rehab CARES, a compact robot gymJournal of Rehabilitation and Assistive Technologies Engineering – Michelle Jillian Johnson, Roshan Rai, Sarath Barathi, Rochelle Mendonca, Karla Bustamante-Valles, 2017

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Figure 1. Theradrive (TD-1), Mexico Theradrive (TD-2), and Haptic Theradrive (TD-3). The Mexico Theradrive has a similar platform to TD-1. Note: Figure 1 used with permission from reference 37.

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[ARTICLE] Update on cell therapy for stroke – Full Text

Abstract

Ischaemic stroke remains a leading cause of death and disability. Current stroke treatment options aim to minimise the damage from a pending stroke during the acute stroke period using intravenous thrombolytics and endovascular thrombectomy; however, there are no currently approved treatment options for reversing neurological damage once a stroke is completed. Preclinical studies suggest that cell therapy may be safe and effective in improving functional outcomes. Several recent clinical trials have reported safety and some improvement in outcomes following cell therapy administration in ischaemic stroke, which are reviewed. Cell therapy may provide a promising new treatment for stroke reducing stroke-related disability. Further investigation is needed to determine specific effects of cell therapy and to optimise cell delivery methods, cell dosing, type of cells used, timing of delivery, infarct size and location of infarct that are likely to benefit from cell therapy.

Introduction

Until recently, intravenous recombinant tissue plasminogen activator was the only proven effective treatment for acute stroke. Endovascular thrombectomy has now been added to our arsenal for acute stroke treatment following the publication of five randomised trials demonstrating highly significant treatment effects favouring endovascular therapy.1–6 Outcome data support advancements in acute stroke care and neurorehabilitation with a significant increase in stroke survivors over time.7 However, despite these advancements, stroke remains a leading cause of long-term disability.8 For patients with residual deficits after stroke, we have no currently approved therapy for restoring function.

Cell therapy is one approach to enhancing recovery after stroke. In animal models, delivery of several different types of stem cells reduce infarct size and improve functional outcomes.9 Clinical trials of cell therapy completed in the 2000s mostly treating small cohorts of patients with chronic stroke demonstrated adequate safety and a suggestion of efficacy with the use of cell therapy. Kondziolka and colleagues used N-Tera 2 cells derived from a lung metastasis of a human testicular germ cell tumour that when treated with retinoic acid generate postmitotic neurons that maintain a fetal neuronal phenotype indefinitely in vitro (LBS neurons). LBS neurons were stereotactically implanted around the stroke bed of chronic subcortical ischaemic stroke. This study demonstrated safety and feasibility of stereotactic cell implantation, although there was no significant improvement in functional outcomes.10 11 Using a similar stereotactic approach implanting cells into the basal ganglia, Savitz and colleagues transplanted LGE cells (fetal porcine striatum-derived cells, Genvec) in five patients. Two patients showed improvements, but two patients experienced adverse effects including delayed worsening of neurological symptoms and seizure resulting in early termination of the study.12 Bang and colleagues reported the safety and feasibility of intravenous infusion of autologous mesenchymal stem cells (MSCs) with no reported adverse effects in five patients treated with intravenous MSCs. Although they reported some initial motor improvements, at 12 months, there was no significant difference in motor scores.13 These early clinical trials mostly focused on chronic subcortical strokes, but more recent trials are now investigating cell therapy for treatment of both cortical and subcortical infarcts. This review discusses the considerations for design of cell therapy trials and summarises the results of more recent studies.

Continue —> Update on cell therapy for stroke | Stroke and Vascular Neurology

Table 1

Summary of recent human cell therapy trials for stroke

Clinical trial/sponsor Age Time after stroke Additional selection criteria Cell type Route Stroke location Patients (n) Safety results Efficacy results
MASTERS/Athersys 18–83 24–48 hours NIHSS 8–20, infarct 5-100cc, premorbid mRS 0–1 Multistem adult-derived stem cell product Intravenous Cortical 129 Similar SAE at 1 year 22(34%) versus 24 (39%) placebo,
Lower mortality—5 deaths (8%) versus 9deaths (15%) in placebo19
No effect on 90-day Global Stroke Recovery Assessment (mRS 0–2, NIHSS increase by 75%, Barthel Index >95) but trend towards improved outcome with earlier delivery of cells19
InveST/Department of Biotechnology, India 18–75 7–29 days NIHSS >7, GCS >8, BI <50, paretic arm or leg stable >48 hours Autologous marrow-derived stem cells Intravenous 120
(58 cell therapy)
61 AE (33%) and eight deaths versus 60 AEs (36%) and five deaths placebo22 No effect on 180-day Barthel Index Score, mRS shift or score >3, NIHSS, change of infarct volume22
RECOVER-Stroke/Aldagen 30–75 13–19 days NIHSS 7–22, mRS >3 ALDHbrautologous marrow-derived stem cells Intracarotid infusion distal to ophthalmic Anterior circulation ± subcortical 29 IA, 19 sham 12 SAE IA, 11 SAE sham; 0 cell-related SAE23 No difference in mRS, Barthel, NIHSS at 90 days or 1 year
PISCES-II/ReNeuron 40–89 2–13 months Paretic arm with NIHSS motor arm score 2–3 CTX0E03 DP allogeneic human fetal neural stem cells Stereotaxic infusion into ipsilateral putamen 21 Pending Pending
Sanbio 18–75 6–60 months NIHSS>7, mRS 3–4, stable symptoms>3 weeks SB623 allogeneic marrow-derived stem cells transiently transfected with plasmid encoding Notch122 Stereotaxic infusion peri-infarct Subcortical ± cortical component24 18 28 SAE, 0 cell-related SAE25 Improved ESS at 6 months (p<0.01) and 12 months (p<0.001)
Improved NIHSS at 6 months (p<0.01) and 12 months(p<0.001)
Improved Fugl-Meyer at 6 months (p<0.001) and 12 months(p<0.001)25
PISCES/ReNeuron >60, male only 6–60 months Persistent hemiparesis, Stable NIHSS over 4 weeks (Pt 2 CTX0E03 DP allogeneic human neural stem cells Stereotaxic infusion into putamen Subcortical 11 16 SAE (in nine patients), 0 cell-related SAE28 Improved NIHSS at 2 years (p=0.002), No change, Barthel Index, MMSE, Ashworth, mRS28 29
  • AE, Adverse Event; ARAT, Action Research Arm Test; BI, Barthel Index; DP, drug product; ESS, European Stroke Scale; IA, intra-arterially; MASTERS, Multistem Administration for Stroke Treatment and Enhanced Recovery Study; MMSE, Mini-Mental Status Examination; mRS, modified Rankin Score; NIHSS, National Institutes of Health Stroke Scale; PISCES, Pilot Investigation of Stem Cells in Stroke; SAE, Serious aAverse Events.

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[REVIEW] CONTROL OF FUNCTIONAL ELECTRICAL STIMULATION FOR RESTORATION OF MOTOR FUNCTION – Full Text PDF

Abstract

An injury or disease of the central nervous system (CNS) results in significant limitations in the communication with the environment (e.g., mobility, reaching and grasping). Functional electrical stimulation (FES) externally activates the muscles; thus, can restore several motor functions and reduce other health related problems.

This review discusses the major bottleneck in current FES which prevents the wider use and better outcome of the treatment. We present a control method that we continually enhance during more than 30 years in the research and development of assistive systems. The presented control has a multi-level structure where upper levels use finite state control and the lower level implements model based control. We also discuss possible communication channels between the user and the controller of the FES. The artificial controller can be seen as the replica of the biological control. The principle of replication is used to minimize the problems which come from the interplay of biological and artificial control in FES. The biological control relies on an extensive network of neurons sending the output signals to the muscles. The network is being trained though many the trial and error processes in the early childhood, but staying open to changes throughout the life to satisfy the particular needs. The network considers the nonlinear and time variable properties of the motor system and provides adaptation in time and space.

The presented artificial control method implements the same strategy but relies on machine classification, heuristics, and simulation of model-based control. The motivation for writing this review comes from the fact that many control algorithms have been presented in the literature by the authors who do not have much experience in rehabilitation engineering and had never tested the operations with patients.

Almost all of the FES devices available implement only open-loop, sensory triggered preprogrammed sequences of stimulation. The suggestion is that the improvements in the FES devices need better controllers which consider the overall status of the potential user, various effects that stimulation has on afferent and efferent systems, reflexive responses to the FES and direct responses to the FES by non-stimulated sensory-motor systems, and the greater integration of the biological control.

Full Text: PDF

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R. Riener and T. Fuhr, “Patient-driven control of FES-supported standing up: a simulation study”, IEEE Trans. Rehabil.Eng., vol. 6, no. 2, pp. 113-124, 1998.

M. Ferrarin, F. Palazzo, R. Riener and J. Quintern, “Model-based control of FES-induced single joint movements”, IEEE Trans. Neural Syst. Rehabi. Eng., vol. 9, no. 3, pp. 245-257, 2001.

Z. Matjacic, K. Hunt, H. Gollee and T. Sinkjaer, “Control of posture with FES systems”, Med. Eng. Phys., vol. 25, no. 1, pp. 51-62, 2003.

D. B. Popović, M. Radulović, L. Schwirtlich and N. Jauković, “Automatic vs. hand-controlled walking of paraplegics”, Med, Eng, Phys., vol. 25, pp. 63-74, 2003.

S. Jezernik, R,G. Wassink and T. Keller, “Sliding mode closed-loop control of FES controlling the shank movement”, IEEE Trans. Biomed. Eng., vol. 51, no. 2, pp. 163-172, 2004.

D. Graupe, “EMG pattern analysis for patient-responsive control of FES in paraplegics for walker-supported walking”, IEEE Trans.Biomed. Eng., vol. 36, no. 7, pp. 711-919, 1989.

C. T Freeman, A. M. Hughes, J. H. Burridge, P. H. Chappell, P. L. Lewin ans E. Rogers, “Iterative learning control of FES applied to the upper extremity for rehabilitation”, Control Engineering Practice, vol. 17, no. 3, pp. 368-381, 2009.

Source: CONTROL OF FUNCTIONAL ELECTRICAL STIMULATION FOR RESTORATION OF MOTOR FUNCTION | Popović | Facta Universitatis, Series: Electronics and Energetics

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[Abstract] Bilateral sequential motor cortex stimulation and skilled task performance with non-dominant hand

Highlights

  • Both, contralateral M1 iTBS and ipsilateral M1 cTBS improved non-dominant skilled-task performance.
  • Bilateral sequential M1 TBS (contralateral cTBS followed by ipsilateral iTBS) improved skilled-task performance more than unilateral or sham TBS.
  • Bilateral sequential M1 TBS may be particularly effective in improving motor learning, also in the neurorehabilitation setting.

Abstract

Objective

To check whether bilateral sequential stimulation (BSS) of M1 with theta burst stimulation (TBS), using facilitatory protocol over non-dominant M1 followed by inhibitory one over dominant M1, can improve skilled task performance with non-dominant hand more than either of the unilateral stimulations do. Both, direct motor cortex (M1) facilitatory non-invasive brain stimulation (NIBS) and contralateral M1 inhibitory NIBS were shown to improve motor learning.

Methods

Forty right-handed healthy subjects were divided into 4 matched groups which received either ipsilateral facilitatory (intermittent TBS [iTBS] over non-dominant M1), contralateral inhibitory (continuous TBS [cTBS] over dominant M1), bilateral sequential (contralateral cTBS followed by ipsilateral iTBS), or placebo stimulation. Performance was evaluated by Purdue peg-board test (PPT), before (T0), immediately after (T1), and 30 min after (T2) an intervention.

Results

In all groups and for both hands, the PPT scores increased at T1 and T2 in comparison to T0, showing clear learning effect. However, for the target non-dominant hand only, immediately after BSS (at T1) the PPT scores improved significantly more than after either of unilateral interventions or placebo.

Conclusion

M1 BSS TBS is an effective intervention for improving motor performance.

Significance

M1 BSS TBS seems as a promising tool for motor learning improvement with potential uses in neurorehabilitation.

Source: Bilateral sequential motor cortex stimulation and skilled task performance with non-dominant hand – Clinical Neurophysiology

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[ARTICLE] Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis – Full Text

Abstract

Background

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

Methods

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

Results

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).

Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

Conclusions

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

Background

Stroke is defined as a clinical syndrome characterised by rapidly developing focal or global disturbance in cerebral function lasting more than 24 h or leading to death due to a presumed vascular cause [1]. Globally, approximately 16 million people have a stroke each year [2] and in the UK, first-ever stroke affects about 230 people per 100,000 population each year [3]. Stroke represents a cost to the UK economy of approximately £9 billion annually, of which £1.33 billion results from productivity losses [4].

Stroke often leads to significant impairment of upper limb function and is associated with decreased quality of life in all domains except for mobility [5]. Few patients attain complete functional recovery [6]; this deficit impairs performance of activities of daily living (ADL), including self-care and social activities [7, 8]. ADL reflect the level of functional impairment in daily life and are therefore the most clinically relevant outcome measures in assessing recovery after stroke [9].

Functional electrical stimulation (FES) was well established as an intervention for motor rehabilitation. FES is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract and create/augment a moment about a joint [2]. Transcutaneous electrodes offer the most immediate and clinically viable treatment option as they are non-invasive and may permit home-based treatment.

There are various terms used in the literature to describe different forms of electrical stimulation, often inconsistently. Some authors define FES as electrical stimulation applied to a subject which causes muscle contraction. This passive modality is also referred to as neuromuscular electrical stimulation [10]. Others define FES as electrical stimulation applied during a voluntary movement [4]. This definition acknowledges the volitional component of physical rehabilitation and was used in this systematic review. The distinction is important because neuroimaging studies have identified different cortical mechanisms according to stimulation type [11, 12, 13]. Indeed, perfusion to the ipsilesional sensory-motor cortex and cortical excitability were increased with FES when compared to passive modalities of electrical stimulation [12, 13, 14]. These findings could indicate greater potential for volitional FES to induce neuroplasticity. This is believed to play an important role in neurorehabilitation [15] and is a key objective of post-stroke functional recovery [16].

FES has been widely researched for post-stroke lower limb rehabilitation; several systematic reviews [17, 18, 19] and national guidelines [20, 21] exist. Improvement in upper limb function is central to post-stroke rehabilitation as it positively affects ADL and quality of life [22]. Yet, there is still a lack of clarity on the effectiveness of FES in post-stroke upper limb rehabilitation [23] despite systematic reviews having been undertaken [24, 25, 26, 27, 28]. In part, this is due to methodological limitations [27, 28] or the outdated nature of some existing reviews [24, 25, 26]. The latter was highlighted by a recent Cochrane overview of reviews calling for an up-to-date review and meta-analysis of randomised controlled trials (RCTs) related to electrical stimulation [29]. A more recent systematic review found a significant improvement in motor outcomes with upper limb FES [27]. However, this was based on a single meta-analysis that combined ADLs with upper limb-specific measures of functional motor ability, including studies where results were at risk of performance bias (intervention groups receiving greater duration of treatment than control groups) [27]. Another found no improvement in motor function when FES was applied within 6 months of stroke [28]. However, this predominantly included studies that applied electrical stimulation in the absence of volitional muscle contraction, confounding interpretation of the results. This inconsistency is reflected in the 2016 guidelines set by the Royal College of Physicians which recommends FES only in the context of clinical trials as an adjunct to conventional therapy [21].

This systematic review aims to elucidate the effectiveness of upper limb FES compared to standard therapy in improving ADL, in addition to motor outcomes, post-stroke. It represents an important addition to the literature that focuses on the use of volitional FES and, for the first time, distinguishes its effect on clinically relevant patient outcomes from surrogate markers of patient rehabilitation. This includes analyses based on patient sub-groups defined by the time after stroke at which FES was initiated.

Fig. 1 Flow diagram for included studies

Continue —> Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis | Systematic Reviews | Full Text

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[Systematic Review] Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis – Full Text

Abstract

Background

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

Methods

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

Results

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [−0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD −0.10; CI [−0.59, 0.38], n = 35).

Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

Conclusions

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

Background

Stroke is defined as a clinical syndrome characterised by rapidly developing focal or global disturbance in cerebral function lasting more than 24 h or leading to death due to a presumed vascular cause [1]. Globally, approximately 16 million people have a stroke each year [2] and in the UK, first-ever stroke affects about 230 people per 100,000 population each year [3]. Stroke represents a cost to the UK economy of approximately £9 billion annually, of which £1.33 billion results from productivity losses [4].

Stroke often leads to significant impairment of upper limb function and is associated with decreased quality of life in all domains except for mobility [5]. Few patients attain complete functional recovery [6]; this deficit impairs performance of activities of daily living (ADL), including self-care and social activities [7, 8]. ADL reflect the level of functional impairment in daily life and are therefore the most clinically relevant outcome measures in assessing recovery after stroke [9].

Functional electrical stimulation (FES) was well established as an intervention for motor rehabilitation. FES is the electrical stimulation of motor neurons such that muscle groups are stimulated to contract and create/augment a moment about a joint [2]. Transcutaneous electrodes offer the most immediate and clinically viable treatment option as they are non-invasive and may permit home-based treatment.

There are various terms used in the literature to describe different forms of electrical stimulation, often inconsistently. Some authors define FES as electrical stimulation applied to a subject which causes muscle contraction. This passive modality is also referred to as neuromuscular electrical stimulation [10]. Others define FES as electrical stimulation applied during a voluntary movement [4]. This definition acknowledges the volitional component of physical rehabilitation and was used in this systematic review. The distinction is important because neuroimaging studies have identified different cortical mechanisms according to stimulation type [11, 12, 13]. Indeed, perfusion to the ipsilesional sensory-motor cortex and cortical excitability were increased with FES when compared to passive modalities of electrical stimulation [12, 13, 14]. These findings could indicate greater potential for volitional FES to induce neuroplasticity. This is believed to play an important role in neurorehabilitation [15] and is a key objective of post-stroke functional recovery [16].

FES has been widely researched for post-stroke lower limb rehabilitation; several systematic reviews [17, 18, 19] and national guidelines [20, 21] exist. Improvement in upper limb function is central to post-stroke rehabilitation as it positively affects ADL and quality of life [22]. Yet, there is still a lack of clarity on the effectiveness of FES in post-stroke upper limb rehabilitation [23] despite systematic reviews having been undertaken [24, 25, 26, 27, 28]. In part, this is due to methodological limitations [27, 28] or the outdated nature of some existing reviews [24, 25, 26]. The latter was highlighted by a recent Cochrane overview of reviews calling for an up-to-date review and meta-analysis of randomised controlled trials (RCTs) related to electrical stimulation [29]. A more recent systematic review found a significant improvement in motor outcomes with upper limb FES [27]. However, this was based on a single meta-analysis that combined ADLs with upper limb-specific measures of functional motor ability, including studies where results were at risk of performance bias (intervention groups receiving greater duration of treatment than control groups) [27]. Another found no improvement in motor function when FES was applied within 6 months of stroke [28]. However, this predominantly included studies that applied electrical stimulation in the absence of volitional muscle contraction, confounding interpretation of the results. This inconsistency is reflected in the 2016 guidelines set by the Royal College of Physicians which recommends FES only in the context of clinical trials as an adjunct to conventional therapy [21].

This systematic review aims to elucidate the effectiveness of upper limb FES compared to standard therapy in improving ADL, in addition to motor outcomes, post-stroke. It represents an important addition to the literature that focuses on the use of volitional FES and, for the first time, distinguishes its effect on clinically relevant patient outcomes from surrogate markers of patient rehabilitation. This includes analyses based on patient sub-groups defined by the time after stroke at which FES was initiated.

Continue —> Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis | Systematic Reviews | Full Text

Fig. 1 Flow diagram for included studies

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[ARTICLE] Weight compensation characteristics of Armeo®Spring exoskeleton: implications for clinical practice and research – Full Text

Abstract

Background

Armeo®Spring exoskeleton is widely used for upper extremity rehabilitation; however, weight compensation provided by the device appears insufficiently characterized to fully utilize it in clinical and research settings.

Methods

Weight compensation was quantified by measuring static force in the sagittal plane with a load cell attached to the elbow joint of Armeo®Spring. All upper spring settings were examined in 5° increments at the minimum, maximum, and two intermediate upper and lower module length settings, while keeping the lower spring at minimum. The same measurements were made for minimum upper spring setting and maximum lower spring setting at minimum and maximum module lengths. Weight compensation was plotted against upper module angles, and slope was analyzed for each condition.

Results

The Armeo®Spring design prompted defining the slack angle and exoskeleton balance angle, which, depending on spring and length settings, divide the operating range into different unloading and loading regions. Higher spring tensions and shorter module lengths provided greater unloading (≤6.32 kg of support). Weight compensation slope decreased faster with shorter length settings (minimum length = −0.082 ± 0.002 kg/°; maximum length = −0.046 ± 0.001 kg/°) independent of spring settings.

Conclusions

Understanding the impact of different settings on the Armeo®Spring weight compensation should help define best clinical practice and improve fidelity of research.

Continue —> Weight compensation characteristics of Armeo®Spring exoskeleton: implications for clinical practice and research | Journal of NeuroEngineering and Rehabilitation | Full Text

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[ARTICLE] Using Biophysical Models to Understand the Effect of tDCS on Neurorehabilitation: Searching for Optimal Covariates to Enhance Poststroke Recovery – Full Text

Stroke is a leading cause of worldwide disability, and up to 75% of survivors suffer from some degree of arm paresis. Recently, rehabilitation of stroke patients has focused on recovering motor skills by taking advantage of use-dependent neuroplasticity, where high-repetition of goal-oriented movement is at times combined with non-invasive brain stimulation, such as transcranial direct current stimulation (tDCS). Merging the two approaches is thought to provide outlasting clinical gains, by enhancing synaptic plasticity and motor relearning in the motor cortex primary area. However, this general approach has shown mixed results across the stroke population. In particular, stroke location has been found to correlate with the likelihood of success, which suggests that different patients might require different protocols. Understanding how motor rehabilitation and stimulation interact with ongoing neural dynamics is crucial to optimize rehabilitation strategies, but it requires theoretical and computational models to consider the multiple levels at which this complex phenomenon operate. In this work, we argue that biophysical models of cortical dynamics are uniquely suited to address this problem. Specifically, biophysical models can predict treatment efficacy by introducing explicit variables and dynamics for damaged connections, changes in neural excitability, neurotransmitters, neuromodulators, plasticity mechanisms and repetitive movement, which together can represent brain state, effect of incoming stimulus and movement-induced activity. In this work, we hypothesize that effects of tDCS depend on ongoing neural activity, and that tDCS effects on plasticity may be also related to enhancing inhibitory processes. We propose a model design for each step of this complex system, and highlight strengths and limitations of the different modeling choices within our approach. Our theoretical framework proposes a change in paradigm, where biophysical models can contribute to the future design of novel protocols, in which combined tDCS and motor rehabilitation strategies are tailored to the ongoing dynamics that they interact with, by considering the known biophysical factors recruited by such protocols and their interaction.

Source: Frontiers | Using Biophysical Models to Understand the Effect of tDCS on Neurorehabilitation: Searching for Optimal Covariates to Enhance Poststroke Recovery | Stroke

Figure 1. Diagram of top-down and bottom-up stroke neurorehabilitation strategies. Sensory–motor training and brain stimulation contribute to rehabilitation protocols that exploit neural plasticity. The bottom-up approach includes sensory–motor training, which can be aided by robots, electrical stimulation of the periphery, and constrains. The top-down approaches include methods to stimulate the brain non-invasively.

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[Abstract] Contracture of Finger and Hand and Disturbance in Speech After Stroke were Improved in a Short Duration by Grasping a High Repulsion Cushion Grip

Abstract

Stroke is a common disease especially for elders and it is often followed by unpleasant aftereffects: muscle rigidity, contracture, stiff joint and speech disturbance. Extensive neurorehabilitation is useful for these aftereffects but it sometimes doesn’t work enough. Thus there are many persons who are obligated to spend a low quality of life after the attack. Here we made a cushion grip that has a strong repulsion power against the outer pressure. Once the grip was held continuously for 24 h, the aftereffects lasted for years were ameliorated in about one month. However, voluntary movements of digits have not recovered yet. Continuous, normal, pleasant sensorimotor stimuli due to the strong repulsion power would be the base of the amelioration. We believe the grip is a useful item producing a prompt amelioration of aftereffects of stroke. Data suggest that extensive neurorehabilitation in association with sensorimotor stimuli to hand is a key procedure for treatment of aftereffects of stroke.

We recommend

Vibration Selectively Modulates Corticomotor Excitability in Hand Muscles Following StrokeYang, Bing-Shiang et al., Journal of Neuroscience and Neuroengineering, 2013

Assessment to Aesthetic Shape Using the Stability of GrippingWidiyati, Khusnun et al., Advanced Science Letters,2013

Force Closure Analysis for the Forging Gripping Mechanisms,Li, Qunming et al., Advanced Science Letters, 2011

Low-Cost Design and Fabrication of an Anthropomorphic Robotic Hand,Ali Bin Junaid et al., Journal of Nanoscience and Nanotechnology, 2014

Analysis of Human Hand Kinematics: Forearm Pronation and Supination,Rahman, Hisyam Abdul et al., Journal of Medical Imaging and Health Informatics, 2014

Source: Contracture of Finger and Hand and Disturbance in Speech After St…: Ingenta Connect

 

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