To investigate the effectiveness of neuromuscular electrical stimulation (NMES) with or without other interventions in improving lower limb activity after chronic stroke.
The rehabilitation effects of the NMES robotic hand and robotic hand were compared.
Both training systems could significantly improve the motor function of upper limb.
The NMES robot was more effective than the pure robot.
NMES applied on distal muscle could benefit the recovery in the entire upper limb.
Upper limb motor deficits are common after stroke, and observed in over 80% of stroke survivors [1,2]. Various rehabilitation devices have been purposed to assist human physical therapists to provide effective long-term rehabilitation programs [, , ]. Among them, rehabilitation robots and neuromuscular electrical stimulation (NMES) are most widely used in stroke rehabilitation practices. Rehabilitation robots have been recognized as efficient in such cases and could represent a cost-effective addition to conventional rehabilitation services because they provide highly intensive and repetitive training [, , , ]. It has been reported that the integration of voluntary effort (e.g. electromyography, EMG) into robotic design could contribute significantly to motor recovery in stroke patients [6,10]. This is because an EMG-driven strategy can maximize the involvement of voluntary effort in the training, and its effectiveness at improving upper limb voluntary motor functions have been proved by many EMG-driven robot-assisted upper-limb training systems [, , ]. However, rehabilitation robots are unable to directly activate the desired muscle groups, which may only assist, or even dominate limb movement such as continuous passive motions (CPM) . In addition, stroke patients usually cooperate with compensatory motions from other muscular activities to activate the target muscles, which may lead to ‘learned disuse’ . However, NMES can effectively limit compensatory motions by stimulating specific muscles via cyclic electrical currents, which provides repetitive sensorimotor experiences . With the advantage of precisely activating the target muscle, NMES has been reported to be effective in evoking sensory feedback, improving muscle force, and thus promoting motor function in stroke patients [17,18]. Nevertheless, training programs assisted by NMES alone are also suboptimal due to the difficulty of controlling movement trajectories and the early appearance of fatigue [19,20].
Accordingly, various NMES robot-assisted upper-limb training programs which combine these two unique techniques have been proposed to integrate the benefits and minimize the disadvantages [7,12,14,21,22]. The rehabilitation effectiveness of these combined systems has been investigated and reported to be effective in improving motor recovery. Several studies have compared the training outcomes of NMES robot-assisted training and other training programs. For example, Qian et al.  reported that NMES-robot-assisted upper-limb training could achieve better motor outcomes when compared with conventional therapies for subacute stroke patients. Meanwhile, another study which compared the training effects between robot-aided training with NMES and robot-aided training solely using the InMotion ARM™ Robot in the subacute period demonstrated that the active ranges of motion of the NMES robot-training group were significantly higher compared with the robot-training group . Coincidentally, investigations into applications in chronic stroke patients have also been carried out. For instance, Hu et al.  proposed an EMG-driven NMES robot system for wrist training; this combined device improved muscle activation levels related to the wrist and reduced compensatory muscular activities at the elbow, while these training outcomes were absent for the EMG-driven robot-assisted training alone. Indeed, a similar study by another research group also achieved better rehabilitation outcomes on some clinical assessments using the combined system compared to robot-assisted therapy alone .
In the literature, most studies on current rehabilitation devices combining the NMES and robotic systems targeted the elbow and wrist joints [7,, , ], while very few focused on the hand and fingers . In addition, a comparison of the training effects for hand rehabilitation between the NMES robot and other hand rehabilitation devices has not yet been adequately conducted. Indeed, the primary upper-limb disability post-stroke is the loss of hand function, and rehabilitation of the distal joints after stroke is much more difficult than the motor recovery of the proximal joints due to the compensatory motions from the proximal joints . Hence, developing effective rehabilitation devices to minimize compensatory movements for hand motor recovery is especially meaningful for stroke rehabilitation. In our previous work, we developed an EMG-driven NMES robotic hand and suggested it for use in hand rehabilitation after stroke . Our device provides fine control of hand movements and activates the target muscles selectively for finger extension/flexion, and its feasibility and effectiveness have been verified by a single group trial . However, whether the long-term rehabilitation effect of this EMG-driven NMES robotic hand is comparable or even better than other hand rehabilitation devices are still unclear and need to be investigated quantitively. Therefore, the objective of this study is to compare the training effects of hand rehabilitation assisted by an NMES robotic hand and by a pure robotic hand though a randomized controlled trial with a 3-month follow-up (3MFU).
This work was approved by the Human Subjects Ethics Sub-Committee of the Hong Kong Polytechnic University. A total of 53 stroke survivors were screened for the training from local districts. 30 participants with chronic stroke satisfied the following inclusion criteria: (1) The participants were at least 6 months after the onset of a singular and unilateral brain lesion due to stroke, (2) both the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints could be extended to 180° passively, (3) muscle spasticity during extension at the finger joints and the wrist joint was below 3 as measured by the Modified Ashworth Scale (MAS) , ranged from 0 (no increase in muscle tone) to 4 (affected part rigid), (4) detectable voluntary EMG signals from the driving muscle on the affected side (three times of the standard deviation (SD) above the EMG baseline), and (5) no visual deficit and able to understand and follow simple instructions as assessed by the Mini-Mental State Examination (MMSE > 21) .
This work involved a randomized controlled trial with a 3-month follow-up (3MFU). The potential participants were first told that the training program they would receive could be either NMES robotic hand training or pure robotic hand training, and all recruited participants submitted their written consent before randomization. Then, the recruited participants were randomly assigned into two groups according to a computer-based random number generator, i.e., the computer program generated either “1” (denoting the NMES robotic hand training group) or “2” (the pure robotic hand group) with an equal probability of 0.5 (Matlab, 2017, Mathworks, Inc.). Fig. 1 shows the Consolidated Standards of Reporting Trials flowchart of the training program.
For both groups, each participant was invited to attend a 20-session robotic hand training with an intensity of 3–5 sessions/week, completed within 7 consecutive weeks. The training setup of both groups is shown in Fig. 2. This robotic hand training system can assist with finger extension and flexion of the paretic limb for patients after stroke. In this work, real-time voluntary EMG detected from the abductor pollicis brevis (APB) and extensor digitorum (ED) muscles were used to control the respective hand closing and opening movements, and the threshold level of each motion phase was set at three times the SD above the EMG baseline at resting state . For example, during the motions of finger flexion, once the EMG activation level of the APB muscle reached a preset threshold, the robotic hand would provide mechanical assistance for hand closing. Similarly, during the motions of finger extension, the robotic hand would assist with hand opening when the EMG activation level of the ED muscle reached a preset threshold. For the NMES robot group, synchronized support from the NMES and the robot were both provided. The NMES electrode pair (30 mm diameter; Axelgaard Corp., Fallbrook, CA, USA) was attached over the ED muscle to provide stimulation during finger extension. The outputs of NMES were square pulses with a constant amplitude of 70 V, a stimulation frequency of 40 Hz, and a manually adjustable pulse width in the range 0–300 μs. Before the training, the pulse width was set at the minimum intensity, which achieved a fully extended position of the fingers in each patient. During the training, NMES would be triggered by the EMG from the ED muscle first and then provided stimulation to the ED muscle to assist hand-opening motions for the entire phase of finger extension, while no assistance from NMES was provided during finger flexion to avoid the possible increase of finger spasticity after stimulation . For the pure robot group, the difference between the two groups was that no NMES was applied in the pure robot group. A detailed account of the working principles of the robotic hand have been described in our previous work [12,30,31].
Continue —-> A comparison of the rehabilitation effectiveness of neuromuscular electrical stimulation robotic hand training and pure robotic hand training after stroke: A randomized controlled trial – ScienceDirect
This is an audio version of the Wikipedia Article: https://en.wikipedia.org/wiki/Functio…
00:01:21 1 Principles
00:09:14 2 History
00:10:01 3 Common applications
00:10:11 3.1 Spinal cord injury
00:11:09 3.1.1 Walking in spinal cord injury
00:15:01 3.2 Stroke and upper limb recovery
00:16:21 3.3 Drop foot
00:18:08 3.4 Stroke
00:18:58 3.5 Multiple sclerosis
00:20:06 3.6 Cerebral palsy
00:21:07 3.7 National Institute for Health and Care Excellence Guidelines (NICE) (UK)
00:21:47 4 In popular culture
00:22:10 5 See also
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Functional electrical stimulation (FES) is a technique that uses low-energy electrical pulses to artificially generate body movements in individuals who have been paralyzed due to injury to the central nervous system. More specifically, FES can be used to generate muscle contraction in otherwise paralyzed limbs to produce functions such as grasping, walking, bladder voiding and standing. This technology was originally used to develop neuroprostheses that were implemented to permanently substitute impaired functions in individuals with spinal cord injury (SCI), head injury, stroke and other neurological disorders. In other words, a person would use the device each time he or she wanted to generate a desired function. FES is sometimes also referred to as neuromuscular electrical stimulation (NMES).FES technology has been used to deliver therapies to retrain voluntary motor functions such as grasping, reaching and walking. In this embodiment, FES is used as a short-term therapy, the objective of which is restoration of voluntary function and not lifelong dependence on the FES device, hence the name functional electrical stimulation therapy, FES therapy (FET or FEST). In other words, the FEST is used as a short-term intervention to help the central nervous system of the person to re-learn how to execute impaired functions, instead of making the person dependent on neuroprostheses for the rest of her or his life.
More than 80% of stroke survivors worldwide suffer from permanent upper limb motor deficits. Restoration of upper limb motor functions in conventional rehabilitation remains challenging; the main difficulties are as follows: 1) lack of intensive, repetitive practice in manually delivered treatment; 2) lack of coordination management of upper limb motor tasks, particularly those involving the distal joints, e.g., the wrist and the hand; and 3) lack of understanding of the optimal joint supportive scheme in task-oriented upper limb training. More effective training strategies are necessary for upper limb rehabilitation following stroke. Robots have proved to be valuable assistants in labour-demanding post-stroke rehabilitation, with a controllable mechanical design and repeatable dynamic support in physical training. A series of rehabilitation robots for multi-joint practices were successfully designed in our previous works. In this work, we proposed a device-assisted multi-joint coordinated strategy for post-stroke upper limb training. The objectives of the study were as follows: 1) To evaluate the rehabilitation effectiveness of multi-joint coordinated upper limb practice assisted by an electromyography (EMG)-driven neuromuscular electric stimulation (NMES)-robot for stroke survivors in both the subacute and chronic stages. 2) To compare different joint supportive schemes using NMES-robots and identify the optimized scheme for upper limb rehabilitation. The objectives were achieved through three independent clinical trials using common clinical assessments, namely, the Fugl-Meyer Assessment (FMA), Modified Ashworth Scales (MAS), Action Research Arm Test (ARAT), and Functional Independence Measurement (FIM), and cross-session EMG evaluations to trace the recovery progress of individual muscle activities (i.e. EMG activation level) and muscular coordination (i.e. Co-contraction Index, CI) between a pair of muscles.
The first clinical randomized controlled trial (RCT) was conducted to investigate the clinical effects and rehabilitation effectiveness of the new training strategy in the subacute stroke period. Subjects were randomly assigned to two groups and received either 20 sessions of NMES-robot-assisted training (NMES-robot group, n=14) or time-matched conventional treatments (control group, n=10). Significant improvements were achieved in FMA (full score and shoulder/elbow), ARAT, and FIM for both groups [P<0.001, effect sizes (EFs)>0.279], whereas significant improvements in FMA (wrist/hand) and MAS (wrist) after treatment were only observed in the NMES-robot group (P<0.05, EFs>0.145), with the outcomes maintained for 3 months. In the NMES-robot group, CIs of the muscle pairs of biceps brachii and flexor carpi radialis (BIC&FCR) and biceps brachii and triceps brachii (BIC&TRI) were significantly reduced and the EMG activation level of the FCR decreased significantly. The result indicated comparable proximal motor improvements in both groups and better distal motor outcomes and more effective release of muscle spasticity across the whole upper limb in the NMES-robot group. The second part of the work was a clinical trial with a single-group design. Recruited chronic stroke patients (n=17) received 20 sessions of NMES-robot-assisted multi-joint coordinated upper limb training. Significant improvements were observed in FMA (full score and shoulder/elbow), ARAT, and FIM (P<0.05, EFs>0.157) and maintained for 3 months. CIs of the FCR&TRI and BIC&TRI muscle pairs and EMG activation levels of the FCR and BIC significantly decreased. The results indicated that the new training strategy was effective for upper limb recovery in the chronic stroke, with the long sustainability of the motor outcomes. In the third trial, another clinical RCT was conducted to investigate the training effects of different joint supportive schemes. The recruited chronic subjects were randomly assigned to receive task-oriented multi-joint practices with NMES-robotic support either to the finger-palm (hand group, n=15) or to the wrist-elbow (sleeve group, n=15). Significant improvements in FMA (full score and shoulder/elbow) and ARAT (P<0.05, EFs>0.147) were observed in both groups, whereas significant improvements in FMA (wrist/hand) and MAS (finger, wrist, and elbow) (P<0.05, EFs>0.149) were only observed in the hand group. These results indicated that the distal supportive scheme was more effective in distal motor recovery and whole arm spasticity control than the proximal supportive one under the same training strategy. In conclusion, NME-robot-assisted multi-joint coordinated training was able to achieve significant motor outcomes and effective muscle spasticity control in the entire upper limb, especially at the distal segments, i.e., the wrist and the fingers, in both subacute and chronic stroke patients. Moreover, the distal supportive scheme proved more effective than the proximal supportive scheme in multi-joint coordinated upper limb training.
via Investigation of multi-joint coordinated upper limb rehabilitation assisted with electromyography (EMG)-driven neuromuscular electrical stimulation (NMES)-robot after stroke | PolyU Institutional Research Archive
Stroke is the main cause of permanent and complex long-term disability in adults. RETRAINER S2 is a system able to recover and support person’s ability to perform Activities of Daily Living (ADL) in early stage after stroke. The system is based on exercises for hand and wrist performed using Neuro Muscular Electrical Stimulation (NMES). This work describes the preliminary results of a multi-center Randomized Controlled Trial (RCT) aimed at evaluating effectiveness of the system. The preliminary results were calculated on 18 patients who completed the protocol. Data is promising, the RETRANER S2 system seems to be a good tool for stroke rehabilitation. Data confirms also a general good usability of the system.
To investigate the effectiveness of neuromuscular electrical stimulation (NMES) with or without other interventions in improving lower limb activity after chronic stroke.
Electronic databases including PubMed, EMBase, Cochrane Library, PEDro (Physiotherapy Evidence Database) and PsycINFO were searched from the inception to January, 2017.
We selected the randomized controlled trials (RCTs) involving chronic stroke survivors with lower limb dysfunction and comparing NMES or combined with other interventions with control of no electrical-stimulated treatment.
The primary outcome was defined as lower limb motor function, and the secondary outcomes included gait speed, Berg Balance scale, Timed Up and Go, Six-Minute Walk Test, Modified Ashworth Scale and Range of Motion .
Twenty-one RCTs involving 1,481 participants were identified from 5,759 retrieved articles. Pooled analysis showed that NMES had a moderate but statistically significant benefits on lower limb motor function (SMD 0.42, 95% CI 0.26 to 0.58), especially when NMES combined with other interventions or treatment time within either 6 or 12 weeks. NMES also had significant benefits on gait speed, balance, spasticity and range of motion but had no significant difference in walking endurance after NMES.
NMES combined with or without other interventions has beneficial effects in lower limb motor function in chronic stroke survivors. These data suggest that NMES should be a promising therapy to apply in chronic stroke rehabilitation to improve the capability of lower extremity in performing activities.
The Christopher & Dana Reeve Foundation’s NeuroRecovery Network® (NRN) nine rehabilitation centers will receive 30 Restorative Therapies’ Xcite electrical stimulation systems.
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
Objective: To assess the efficacy of inhibitory repetitive transcranial magnetic stimulation (rTMS) and neuromuscular electrical stimulation (NMES) on upper extremity motor function in patients with acute/subacute ischemic stroke.
Methods: Twenty-five ischemic acute/subacute stroke subjects were enrolled in this randomized controlled trial. Experimental group 1 received low frequency (LF) rTMS to the primary motor cortex of the unaffected side + physical therapy (PT) including activities to improve strength, flexibility, transfers, posture, balance, coordination, and activities of daily living, mainly focusing on upper limb movements; experimental group 2 received the same protocol combined with NMES to hand extensor muscles; and the control group received only PT. Functional magnetic resonance imaging (fMRI) scan was used to evaluate the activation or inhibition of the affected and unaffected primary motor cortex.
Results: No adverse effect was reported. Most of the clinical outcome scores improved significantly in all groups, however no statistically significant difference was found between groups due to the small sample sizes. The highest percent improvement scores were observed in TMS + NMES group (varying between 48 and 99.3%) and the lowest scores in control group (varying between 13.1 and 28.1%). Hand motor recovery was significant in both experimental groups while it did not change in control group. Some motor cortex excitability changes were also observed in fMRI.
Conclusion: LF-rTMS with or without NMES seems to facilitate the motor recovery in the paretic hand of patients with acute/subacute ischemic stroke. TMS or the combination of TMS + NMES may be a promising additional therapy in upper limb motor training. Further studies with larger numbers of patients are needed to establish their effectiveness in upper limb motor rehabilitation of stroke.
Source: Effects of low-frequency repetitive transcranial magnetic stimulation and neuromuscular electrical stimulation on upper extremity motor recovery in the early period after stroke: a preliminary study: Topics in Stroke Rehabilitation: Vol 24, No 5
It is a challenge to reduce the muscular discoordination in the paretic upper limb after stroke in the traditional rehabilitation programs.
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.
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).
The EMG-driven NMES-robotic system could improve the muscular coordination at the elbow, wrist and fingers.
Stroke is a main cause of long-term disability in adults . Approximately 70 to 80% stroke survivors experienced impairments in their upper extremity, which greatly affects the independency of their daily living [2, 3]. 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 [4, 5]. 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 . 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 [2, 6]. 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 . Post-stroke rehabilitation assisted with NMES has been found to effectively prevent muscle atrophy and improve muscle strength , and the stimulation also evokes sensory feedback to the brain during muscle contraction to facilitate motor relearning . 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 . 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 . 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 . Furthermore, faster muscular fatigue would be experienced when using NMES with intensive stimuli, in comparison with the muscle contraction by biological neural stimulation .
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 . 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 [12, 13]. 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 . 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 [10, 14]. In our previous studies, we designed a series of voluntary intention-driven rehabilitation robotics for physical training at the elbow, the wrist and fingers [14, 15, 16, 17, 18]. 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 [15, 17]. 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 [16, 19]. 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 . 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 . 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.
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
Hybrid Assistive Neuromuscular Dynamic Stimulation (HANDS) therapy is one of the neurorehabilitation therapeutic approaches that facilitates the use of the paretic upper extremity (UE) in daily life by combining closed-loop electromyography- (EMG-) controlled neuromuscular electrical stimulation (NMES) with a wrist-hand splint. This closed-loop EMG-controlled NMES can change its stimulation intensity in direct proportion to the changes in voluntary generated EMG amplitudes recorded with surface electrodes placed on the target muscle. The stimulation was applied to the paretic finger extensors. Patients wore a wrist-hand splint and carried a portable stimulator in an arm holder for 8 hours during the daytime. The system was active for 8 hours, and patients were instructed to use their paretic hand as much as possible. HANDS therapy was conducted for 3 weeks. The patients were also instructed to practice bimanual activities in their daily lives. Paretic upper extremity motor function improved after 3 weeks of HANDS therapy. Functional improvement of upper extremity motor function and spasticity with HANDS therapy is based on the disinhibition of the affected hemisphere and modulation of reciprocal inhibition. HANDS therapy may offer a promising option for the management of the paretic UE in patients with stroke.
Stroke is a common health-care problem that causes physical impairment, disability, and problems in social participation. The most common impairment caused by stroke is motor impairment. Motor impairment affects the control of the unilateral upper and lower extremities. Recovery of function in the hemiparetic upper extremity is noted in fewer than 15% of patients after stroke .
Patients often compensate for their paretic upper extremity by using their intact upper extremity in the performance of everyday tasks . It is supposed that strong reliance on compensatory overuse of the intact upper extremity inhibits functional recovery of the impaired upper extremity. This may explain the limited improvement of the functional capability of the paretic upper extremity in activities of daily living (ADL).
Principles of motor rehabilitation following stroke have been described as being dose-dependent and task-specific . High-intensity practice and task-specific training are recommended for functional recovery. Several systematic reviews [4, 5] have explored whether high-intensity therapy improves recovery, and the principle that increased intensive training is helpful is widely accepted. Task-specific training is a well-accepted principle in motor rehabilitation. Training should target the goals that are relevant for the needs of the patients and preferably be given in the patient’s own environment.
The goal of upper extremity rehabilitation is to improve the capability of the paretic upper extremity for ADL. Constraint-induced movement therapy (CIMT) has been developed to enhance the forced use of the paretic hand in ADL with reduction of the compensatory overuse of the intact upper extremity. However, to participate in CIMT, the candidates must be able to voluntary extend their fingers and wrist at least 10 degrees, practice for 6 hours daily in a 2-week course, and spend waking hours with their nonparetic hand in a mitt .
To counter potential problems inherent in the intensive services needed for CIMT, we developed an alternative therapeutic approach that provides high-intensity training to facilitate the use of the paretic upper extremity in daily living by combining closed-loop electromyography- (EMG-) controlled neuromuscular electrical stimulation (NMES) with a wrist-hand splint for patients with moderate to severe hemiparesis. Fujiwara et al. called this hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy .
A PubMed literature search was conducted using the MeSH terms stroke, rehabilitation, upper extremity function, and neuromuscular electrical stimulation, and 71 articles were identified. A further search of PubMed with the terms stroke, rehabilitation, upper extremity function, neuromuscular electrical stimulation, and splint identified 4 articles, all regarding HANDS therapy.
HANDS therapy facilitates the use of the paretic upper extremity in daily living by combining closed-loop EMG-controlled NMES with a wrist-hand splint for patients with moderate to severe hemiparesis. This HANDS system is active for 8 hours, and patients are instructed to use their paretic hand as much as possible while wearing the HANDS system. Their nonparetic upper extremity is not restrained. The patients are also instructed to practice bimanual activities in their ADL. All participants in HANDS therapy are admitted, and the length of the intervention is 21 days. They receive 90 minutes of occupational therapy per day, 5 days a week. Each session of occupational therapy consists of gentle stretching exercise of the paretic upper extremity and active muscle reeducation exercise. All participants are instructed how to use their paretic hand in ADL with the HANDS system. Occupational therapists are directed toward participants’ goals and focused on their particular impairments and disabilities; thus, the specific therapy that each patient receives varies [7, 8].
Fujiwara et al. [7, 8] reported the indications for HANDS therapy as follows: () no cognitive deficits; () no pain in the paretic upper extremity; () passive extension range of motion (ROM) greater than 0 degrees of the affected wrist and −10 degrees of the metacarpophalangeal joints; () detectable surface EMG signals in the affected extensor digitorum communis (EDC) or extensor pollicis longus (EPL) when the patient intends to extend their fingers; () ability to raise the paretic hand to the height of the nipple; () scores of Fugl-Meyer test position sense of joints in the glenohumeral joint, elbow, wrist, and thumb of 1 or more; and () the ability to walk without physical assistance in daily life (e.g., including patients who can walk independently with a cane and/or an orthosis). The exclusion criteria were () history of major psychiatric or previous neurological disease, including seizures; () cognitive impairment precluding appropriately giving informed consent or the patient’s Mini Mental Examination Scale score was below 25; () patients with severe pain in the paretic upper extremity; () patients with a pacemaker or other implanted stimulator; and () patients with visuospatial neglect or apraxia.
Previous reports showed that none of the patients experienced any discomfort or significant disability with the HANDS therapy.
Twenty-nine articles were found in PubMed using the terms stroke, electromyography, neuromuscular electrical stimulation, and upper extremity. Thirteen of 29 articles were on EMG-triggered NMES. Six of 29 articles were on EMG-controlled NMES. Two involved contralaterally controlled electrical stimulation.
EMG-triggered NMES applies preset electrical stimulation when EMG activity reaches a target threshold. The stimulus intensity and duration are determined and not changeable. EMG-controlled NMES applies electrical stimulation during voluntary contraction and changes the stimulation intensity in proportion to the changes in EMG amplitude.
For assistive stimulation, HANDS therapy used closed-loop EMG-controlled NMES, which was developed by Muraoka  and commercially available with MURO stimulation (Pacific Supply, Osaka, Japan). This closed-loop EMG-controlled NMES is portable and attaches to the arm (Figure 1). The surface electrodes pick up EMG signals at the target muscle and simultaneously stimulate it in direct proportion to the picked-up EMG signal, with the exception of the 25 ms after delivering each stimulation pulse, in which stimulation artifacts and M wave are observed. The external adjustment unit sets () range of stimulus intensity; () sensitivity of the EMG; () threshold of EMG amplitude that starts stimulation; and () gradient of stimulus intensity change to the change of EMG amplitude. Once these parameters were set with the external adjustment unit, the stimulator memorized these parameters.
R. Leeb1,2,#, A. Biasiucci2,#, T. Schmidlin1 , T. Corbet2 , P. Vuadens3 , JdR. Millán2,*
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 . 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 ). (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:  Ramos-Murguialday A, et al. Brain-machine interface in chronic stroke rehabilitation. Ann Neurol, 74(1):100-108, 2013.  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.