Posts Tagged REHABILITATION

[ARTICLE] Functional Electrical Stimulation Controlled by Motor Imagery Brain-Computer Interface for Rehabilitation – Full Text HTML

Abstract

Sensorimotor rhythm (SMR)-based brain–computer interface (BCI) controlled Functional Electrical Stimulation (FES) has gained importance in recent years for the rehabilitation of motor deficits. However, there still remain many research questions to be addressed, such as unstructured Motor Imagery (MI) training procedures; a lack of methods to classify different MI tasks in a single hand, such as grasping and opening; and difficulty in decoding voluntary MI-evoked SMRs compared to FES-driven passive-movement-evoked SMRs. To address these issues, a study that is composed of two phases was conducted to develop and validate an SMR-based BCI-FES system with 2-class MI tasks in a single hand (Phase 1), and investigate the feasibility of the system with stroke and traumatic brain injury (TBI) patients (Phase 2). The results of Phase 1 showed that the accuracy of classifying 2-class MIs (approximately 71.25%) was significantly higher than the true chance level, while that of distinguishing voluntary and passive SMRs was not. In Phase 2, where the patients performed goal-oriented tasks in a semi-asynchronous mode, the effects of the FES existence type and adaptive learning on task performance were evaluated. The results showed that adaptive learning significantly increased the accuracy, and the accuracy after applying adaptive learning under the No-FES condition (61.9%) was significantly higher than the true chance level. The outcomes of the present research would provide insight into SMR-based BCI-controlled FES systems that can connect those with motor disabilities (e.g., stroke and TBI patients) to other people by greatly improving their quality of life. Recommendations for future work with a larger sample size and kinesthetic MI were also presented.

1. Introduction

Healthy individuals whose brains and neuromuscular systems enable normal motor functions can naturally perform Activities of Daily Living (ADLs). Nonetheless, for some people who have disabilities in these functions due to injury or disease, simple tasks become very difficult or impossible to do. To assist this population, researchers in many fields, from physical therapy to engineering, have developed various rehabilitation technologies that help them perform ADLs [1,2]. One such technology, Functional Electrical Stimulation (FES), delivers electrical impulses to either paralyzed or impaired limbs to generate artificial muscle contraction [3,4]. In this way, FES helps disabled people perform ADLs such as walking, reaching, and grasping [5,6]. Some FES devices are controlled by brain–computer interfaces (BCIs), sometimes called brain–machine interfaces.
In general, BCIs can help people communicate and control devices and applications without using peripheral nerves and muscle pathways [7]. BCIs are also a potential method to promote the independence of physically disabled people by means of the BCI’s ability to bypass non-functional neural pathways [8]. A sensorimotor rhythm (SMR)-based BCI-controlled FES system is a novel technology that combines the advantages of FES and BCI systems, and allows severely disabled patients to restore motor functions through the FES system by translating voluntary Motor Imagery (MI) to physical action [9]. There are many potential benefits of combining SMR-based BCIs and FES systems, such as the promotion of neuroplasticity [10], the restoration of motor functions by using voluntary motor intentions [9,11], and providing proprioceptive sensory feedback as a result of their intentions [12].
Although SMR-based BCI-controlled FES methods seem promising, current studies still have central issues: (1) ambiguous instruction of MI tasks during training under SMR-based BCI systems, and (2) difficulties in classifying voluntary MI-evoked SMRs and FES-driven passive-movement-evoked SMRs when FES is activated. Moreover, (3) only a few studies have examined the feasibility of classifying two different MI tasks of a single hand, such as grasping and opening, and (4) few studies have examined human factors and ergonomics (HF/E) perspectives such as subjective mental workload and user satisfaction in the use of SMR-based BCI-controlled FES systems. This research that is composed of two phases was conducted to address these issues by developing a new SMR-based BCI system with visual guidance during training to classify a 2-class MI task in a single hand, as well as voluntary and passive SMRs (Phase 1), and evaluating the feasibility of the proposed BCI-controlled FES system by performing sequential goal-oriented tasks with stroke and TBI patients (Phase 2).
The remainder of this article consists of five more sections (this introduction being Section 1): Section 2 describes a survey of current SMR-based BCI studies for FES systems to identify the limitations of current research and clarifies the current state of BCI-controlled FES technologies. Section 3 presents Phase 1, where an SMR-based BCI system to control FES was developed and validated to address the issues on current research studies. Section 4 describes Phase 2, which assessed the feasibility of the proposed BCI-FES system by conducting a sequential task with fixed order under a semi-asynchronous mode. Section 5 discusses the findings of the present research along with implications and future directions.[…]

Continue —-> Brain Sciences | Free Full-Text | Functional Electrical Stimulation Controlled by Motor Imagery Brain-Computer Interface for Rehabilitation | HTML

Figure 1. Schematic illustration of the experiment procedure. Text in the blue box indicates the auditory cue that played at the beginning of each period, and INI is an abbreviation of the Functional Electrical Stimulation (FES) initiation period. MI: Motor Imagery.

 

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[Abstract] DESC glove: Prototyping a novel wearable device for post-stroke hand rehabilitation

Abstract

The human brain integrates tactile sensory information from the fingertips to efficiently manipulate objects. Sensory impairments due to neurological disorders, e.g. stroke, largely reduce hand dexterity and the ability to perform daily living activities. Several feedback augmentation techniques have been investigated for rehabilitative purposes with promising outcomes. However, they often require the use of unpractical, expensive, or complex devices. In this work we propose the delivery of vibrotactile feedback based on the Discrete Event-driven Sensory feedback Control (DESC) to promote motor learning in post stroke rehabilitation. For this purpose, we prototyped a novel wearable device, namely the DESC glove. It consisted of a soft glove instrumented with PolyVinylidene Fluoride (PVDF) sensors at the fingertips and eccentric-mass vibration actuators to be worn on the forearm. We proceeded with the characterization of the device, which resulted in promising outcomes. The DESC glove was tested with ten healthy participants subsequently in a pick and lift timed task. The effects of augmented vibrotactile feedback were assessed comparing it to a baseline, consisting of wearing the device unpowered. The results of this pilot study showed a decrease in the time necessary to perform the task, a reduction in the time delay from load force to grip force activation and a diminishing of the grip force applied on the object, which led to a lower breakage rate in the intervention condition. These promising outcomes encourage further experiments with stroke survivors to validate the effectiveness of the device to improve hand dexterity and promote stroke rehabilitation.

via DESC glove | TU Delft Repositories

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[ARTICLE] Persons post-stroke improve step length symmetry by walking asymmetrically – Full Text

Abstract

Background and purpose

Restoration of step length symmetry is a common rehabilitation goal after stroke. Persons post-stroke often retain the ability to walk with symmetric step lengths (“symmetric steps”); however, the resulting walking pattern remains effortful. Two key questions with direct implications for rehabilitation have emerged: 1) how do persons post-stroke generate symmetric steps, and 2) why do symmetric steps remain so effortful? Here, we aimed to understand how persons post-stroke generate symmetric steps and explored how the resulting gait pattern may relate to the metabolic cost of transport.

Methods

We recorded kinematic, kinetic, and metabolic data as nine persons post-stroke walked on an instrumented treadmill under two conditions: preferred walking and symmetric stepping (using visual feedback).

Results

Gait kinematics and kinetics remained markedly asymmetric even when persons post-stroke improved step length symmetry. Impaired paretic propulsion and aberrant movement of the center of mass were evident during both preferred walking and symmetric stepping. These deficits contributed to diminished positive work performed by the paretic limb on the center of mass in both conditions. Within each condition, decreased positive paretic work correlated with increased metabolic cost of transport and decreased walking speed across participants.

Conclusions

It is critical to consider the mechanics used to restore symmetric steps when designing interventions to improve walking after stroke. Future research should consider the many dimensions of asymmetry in post-stroke gait, and additional within-participant manipulations of gait parameters are needed to improve our understanding of the elevated metabolic cost of walking after stroke.

Introduction

Gait dysfunction is common after stroke [1]. Persons post-stroke exhibit slow walking speeds [2,3,4], gait asymmetry [45], and an elevated metabolic cost of transport (i.e., energy expended per meter walked) [6,7,8]. Gait training is a key component of stroke rehabilitation, as persons post-stroke frequently list gait improvement among their most desired rehabilitation goals [9].

Many rehabilitation approaches aim to restore step length symmetry [10,11,12,13,14,15,16]. The rationale for restoring step length symmetry is multifaceted: 1) asymmetric stepping increases the cost of transport in healthy adults [17], 2) persons post-stroke who walk with more asymmetric step lengths also tend to exhibit poorer balance [18] and more effortful gait patterns [19], 3) step length asymmetry is a simple metric that manifests from complex kinematic and kinetic asymmetries that can be difficult to treat in isolation, and 4) step length is easy to measure and manipulate in clinical settings (e.g., “step to the lines on the floor”). Consequently, there has been increasing interest in restoring step length symmetry after stroke, especially after recent intervention studies showed that improved step length symmetry coincided with improvements in gait speed [15] and cost of transport [19].

However, it is not clear that restoration of step length symmetry alone should lead to improvements in gait speed or cost of transport. Persons post-stroke often retain the capacity to walk with improved step length symmetry, even within a single testing session [162021]. But unlike the intervention studies mentioned above, single-session studies have shown cost of transport to be similar whether persons post-stroke walk with asymmetric or symmetric step lengths [1621]. These findings suggest that improvements in gait speed and cost of transport likely arise from changes in kinematic or kinetic parameters that more directly influence gait speed or energetics and also affect step length symmetry. From this perspective, interventions that aim to restore step length symmetry but do not affect these critical underlying factors may not result in meaningful gait improvement. The ability to lessen cost of transport with an intervention aiming to restore step length symmetry likely depends on 1) the underlying causes of the asymmetry (which vary among patients [2122]), and 2) the mechanics used to generate the symmetric step lengths.

Here, we aimed to understand how persons post-stroke changed their walking patterns to restore step length symmetry and how these gait mechanics related to the cost of transport. We asked: do persons post-stroke restore step length symmetry by restoring symmetric gait mechanics or by relying on asymmetric compensatory mechanics? We hypothesized that persons post-stroke would restore step length symmetry using asymmetric walking patterns. We then aimed to explain why these asymmetric gait patterns cost so much energy despite improved step length symmetry.

Materials and methods

General methods

Ten persons post-stroke were recruited for the study. Data accrued from nine persons were retained for analysis (6 M/3F, age (mean ± SEM): 54 ± 4 years, lower extremity Fugl-Meyer [23]: 26 ± 1, body mass: 93 ± 6 kg, all > 6 months post-stroke). Inclusion criteria for recruitment included a step length difference of at least 2 cm during over-ground walking. One participant was excluded from analysis because they unexpectedly reduced the asymmetry below 2 cm during treadmill walking. All other participants showed a > 2 cm step length difference during both over-ground and treadmill walking and reduced their step length asymmetry from the preferred walking trial to the symmetric stepping trial. Participants reported no additional neurological, musculoskeletal, or cardiovascular conditions. We determined preferred walking speed as the average speed of three over-ground 10-meter walk tests (0.81 ± 0.09 m/s, range: 0.40–1.25 m/s). Seven participants held onto the treadmill handrails, two wore ankle-foot orthoses, and one received functional electrical stimulation of the tibialis anterior. We asked participants who held onto the handrails to hold onto them as little as possible and avoid gripping the handrail if at all possible. All participants wore a safety harness that did not provide body weight support, provided written informed consent in accordance with the Johns Hopkins Medicine Institutional Review board prior to participation, and received monetary compensation.

We recorded kinematic (100 Hz) and kinetic (1000 Hz) data using a three-dimensional motion capture system (Vicon, Oxford, UK) and instrumented split-belt treadmill (Motek, Amsterdam, NL; Fig. 1a, left). We placed retroreflective markers over the seventh cervical vertebrae, tenth thoracic vertebrae, jugular notch, xiphoid process, and bilaterally over the second and fifth metatarsal heads, calcaneus, medial and lateral malleoli, shank, medial and lateral femoral epicondyles, thigh, greater trochanter, iliac crest, and anterior and posterior superior iliac spines. We filtered marker trajectories and ground reaction forces (GRFs) with fourth order low-pass Butterworth filters (6 Hz and 15 Hz cut-off frequencies, respectively). GRFs were set to zero for vertical GRF magnitudes < 32 N. Participants wore comfortable shoes and form-fitting clothing.

Fig. 1

a Experimental setup (left). Example participant walking with asymmetric step lengths (center) and resulting visual display showing step length feedback bilaterally (right). b Step lengths (mean ± SE curves) for the limbs that took longer (blue) and shorter (red) steps at baseline during preferred walking (left) and symmetric stepping (right). The data shown have been truncated to number of strides for the participant that took the fewest strides for the same duration of the trial. c Step length asymmetry decreases significantly during symmetric stepping (green) as compared to preferred walking (purple). d The net metabolic cost of transport is similar between preferred walking and symmetric stepping

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Continue —-> Persons post-stroke improve step length symmetry by walking asymmetrically | Journal of NeuroEngineering and Rehabilitation | Full Text

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[Abstract] Understanding the multidimensional nature of sexuality after traumatic brain injury

Abstract

Objective

To investigate the association of sexuality with sociodemographic (age, sex, education), medical (injury severity, time since injury), physical (fatigue, pain, independence), neuropsychological (memory, attention, executive function), psychological (depression, anxiety, self-esteem), and social participation factors after traumatic brain injury (TBI).

Design

Survey. Individuals with TBI completed measures at a mean average of 2.78 years post-injury (range = 1-10.3 years).

Setting

All participants were community based at the time of data collection.

Participants

Eighty-four individuals with TBI consecutively recruited after discharge from rehabilitation and 88 age-, sex- and education-matched controls recruited from the general community.

Interventions

Not applicable.

Main Outcome Measure

Brain Injury Questionnaire of Sexuality (BIQS).

Results

Individuals with TBI performed significantly worse on sexuality, mood and self-esteem measures compared to the healthy control group, supporting previous findings. Research findings highlighted a range of significant correlations between sociodemographic, physical, neuropsychological, psychological and social participation factors and sexuality outcomes after TBI. In the multiple regression model, older age, greater depression and lower self-esteem were significant predictors of poorer sexuality post-injury. Further analyses indicated that depression mediated the independent relationships between lower social participation and greater fatigue with a decline in sexuality after TBI.

Conclusions

These findings support sexuality changes after TBI as a multidimensional construct, highlighting depression as a key mechanism through which other factors may impact sexual functioning. Further research is needed to target assessment and intervention services for sexuality problems after TBI.

via Understanding the multidimensional nature of sexuality after traumatic brain injury – Archives of Physical Medicine and Rehabilitation

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[Abstract] Robot-assisted gait training promotes brain reorganization after stroke: A randomized controlled pilot study

Abstract

Background: Robot-assisted gait training (RAGT) can improve walking ability after stroke but the underlying mechanisms are unknown.

Objective: We evaluated the changes in the injured brain after RAGT and compared the effects of early start and late start of RAGT.

Methods: Eleven patients with hemiplegia after stroke undergoing inpatient rehabilitation were examined within 3 months of stroke onset and were randomly assigned into two groups. Group 1 started RAGT with conventional physiotherapy immediately after enrollment, whereas Group 2 underwent conventional physiotherapy for 4 weeks before starting RAGT. We acquired diffusion tensor imaging data after enrollment and at 4 and 8 weeks after treatment. Fractional anisotropy (FA) and mean diffusivity (MD) maps were used to analyze the neural changes.

Results: Repeated measures analysis of variance of the data at 4 weeks after treatment showed a significant interaction between time and groups (RAGT versus control) for the FA and MD values in the non-lesioned hemisphere, indicating that the non-lesioned hemisphere was significantly reorganized by RAGT compared with conventional physiotherapy. Analysis of the data at 8 weeks after treatment showed a significant interaction between time and groups (early and late start of RAGT) for the MD values in the motor-related areas bilaterally, indicating that early start of RAGT significantly accelerated bi-hemispheric reorganization as compared with late start of RAGT.

Conclusions: Our findings indicate that RAGT can facilitate reorganization in the intact superior temporal, cingulate, and postcentral gyri. Furthermore, early start of RAGT can accelerate bi-hemispheric reorganization in the motor-related brain regions.

via Robot-assisted gait training promotes brain reorganization after stroke: A randomized controlled pilot study – PubMed

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[Abstract + References] Resistance training in stroke rehabilitation: systematic review and meta-analysis

This systematic review and meta-analysis investigates the effects of resistance training in supporting the recovery in stroke patients.

PubMed, the Cochrane Central Register of Controlled Trials and the PEDro databases were reviewed up to 30 April 2020.

Randomized controlled trials were included, who compared: (i) resistance training with no intervention, (ii) resistance training with other interventions and (iii) different resistance training protocols in stroke rehabilitation.

Overall 30 trials (n = 1051) were enrolled. The parameters evaluated were: (1) gait, (2) muscular force and motor function, (3) mobility, balance and postural control, (4) health related quality of life, independence and reintegration, (5) spasticity and hypertonia, (6) cardiorespiratory fitness, (7) cognitive abilities and emotional state and (8) other health-relevant physiological indicators. The data indicates that: (i) resistance training is beneficial for the majority of parameters observed, (ii) resistance training is superior to other therapies on muscular force and motor function of lower and upper limbs, health related quality of life, independence and reintegration and other health-relevant physiological indicators, not significantly different from other therapies on walking ability, mobility balance and postural control and spasticity and hypertonia, and inferior to ergometer training on cardiorespiratory fitness and (iii) the type of resistance training protocol significantly impacts its effect; leg press is more efficient than knee extension and high intensity training is superior than low intensity training.

Current data indicates that resistance training may be beneficial in supporting the recovery of stroke patients. However, the current evidence is insufficient for evidence-based rehabilitation.

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via Resistance training in stroke rehabilitation: systematic review and meta-analysis – Jitka Veldema, Petra Jansen, 2020

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[Abstract] Understanding the multidimensional nature of sexuality after traumatic brain injury

Abstract

Objective

To investigate the association of sexuality with sociodemographic (age, sex, education), medical (injury severity, time since injury), physical (fatigue, pain, independence), neuropsychological (memory, attention, executive function), psychological (depression, anxiety, self-esteem), and social participation factors after traumatic brain injury (TBI).

Design

Survey. Individuals with TBI completed measures at a mean average of 2.78 years post-injury (range = 1-10.3 years).

Setting

All participants were community based at the time of data collection.

Participants

Eighty-four individuals with TBI consecutively recruited after discharge from rehabilitation and 88 age-, sex- and education-matched controls recruited from the general community.

Interventions

Not applicable.

Main Outcome Measure

Brain Injury Questionnaire of Sexuality (BIQS).

Results

Individuals with TBI performed significantly worse on sexuality, mood and self-esteem measures compared to the healthy control group, supporting previous findings. Research findings highlighted a range of significant correlations between sociodemographic, physical, neuropsychological, psychological and social participation factors and sexuality outcomes after TBI. In the multiple regression model, older age, greater depression and lower self-esteem were significant predictors of poorer sexuality post-injury. Further analyses indicated that depression mediated the independent relationships between lower social participation and greater fatigue with a decline in sexuality after TBI.

Conclusions

These findings support sexuality changes after TBI as a multidimensional construct, highlighting depression as a key mechanism through which other factors may impact sexual functioning. Further research is needed to target assessment and intervention services for sexuality problems after TBI.

via Understanding the multidimensional nature of sexuality after traumatic brain injury – ScienceDirect

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[ARTICLE] In-Home Rehabilitation Using a Smartphone App Coupled With 3D Printed Functional Objects: Single-Subject Design Study – Full Text

ABSTRACT

Background: Stroke is a major cause of long-term disability. While there is potential for improvements long after stroke onset, there is little to support functional recovery across the lifespan. mHealth solutions can help fill this gap. mRehab was designed to guide individuals with stroke through a home program and provide performance feedback.

Objective: To examine if individuals with chronic stroke can use mRehab at home to improve upper limb mobility. The secondary objective was to examine if changes in limb mobility transferred to standardized clinical assessments.

Methods: mRehab consists of a smartphone coupled with 3D printed household items: mug, bowl, key, and doorknob. The smartphone custom app guides task-oriented activities and measures both time to complete an activity and quality of movement (smoothness/accuracy). It also provides performance-based feedback to aid the user in self-monitoring their performance. Task-oriented activities were categorized as (1) object transportation, (2) prehensile grip with supination/pronation, (3) fractionated finger movement, and (4) walking with object. A total of 18 individuals with stroke enrolled in the single-subject experimental design study consisting of pretesting, a 6-week mRehab home program, and posttesting. Pre- and posttesting included both in-laboratory clinical assessments and in-home mRehab recorded samples of task performance. During the home program, mRehab recorded performance data. A System Usability Scale assessed user’s perception of mRehab.

Results: A total of 16 participants completed the study and their data are presented in the results. The average days of exercise for each mRehab activity ranged from 15.93 to 21.19 days. This level of adherence was sufficient for improvements in time (t15=2.555, P=.02) and smoothness (t15=3.483, P=.003) in object transportation. Clinical assessments indicated improvements in functional performance (t15=2.675, P=.02) and hand dexterity (t15=2.629, P=.02). Participant’s perception of mRehab was positive.

Conclusions: Despite heterogeneity in participants’ use of mRehab, there were improvements in upper limb mobility. Smartphone-based portable technology can support home rehabilitation programs in chronic conditions such as stroke. The ability to record performance data from home rehabilitation offers new insights into the impact of home programs on outcomes.

Introduction

Background

Stroke is a major cause of disability, leading to restriction of occupational performance for stroke survivors [1,2]. It is estimated that 30%-60% of stroke survivors continue to have residual limitations in upper extremity movements after traditional rehabilitation services [3]. At the end of rehabilitation services, survivors are commonly given a written home exercise program to guide recovery in chronic stages of stroke [4]. Shortcomings of the written home exercise program include complaints of being unengaging and patients not continuing the program [4]. Knowing that upper limb motor deficits can reduce quality of life [5], it is important to support survivors to recover as much function as possible. Upper limb recovery after stroke is identified as a research priority by survivors of stroke, caregivers, and health professionals [6].

Research demonstrates that individuals with chronic stroke are capable of making gains in performance with continued practice. The research so far has focused on interventions led by therapists [7,8]. It is improbable that direct oversight by a therapist is a feasible solution for long-term recovery. For chronic conditions such as stroke, better supporting the individual’s ability to self-manage their long-term recovery could offer a more sustainable approach. Use of mHealth (ie, mobile technology to manage health) offers the opportunity for individuals to engage in rehabilitative activities while monitoring their performance and managing their health behaviors [9,10]. mHealth apps can assist users in meeting basic needs, thereby giving a sense of autonomy and competence [11]. In addition, participants have reported that it is enjoyable to use apps [12]. Smart devices are equipped with interactive components (eg, sensors, cameras, speakers, and vibrators) capable of measuring human movement and providing feedback [13]. Readily available smartphone technology can be the basis of a home rehabilitation system.

There has been an increase in app development for stroke rehabilitation. A review of apps designed for stroke survivors or their caregivers found that 62% of apps addressed language or communication [14]. Other apps addressed stroke risk calculation, identifying acute stroke, atrial fibrillation, direction to emergency room or nearest certified stroke center, visual attention therapy, and a mere 4% addressed physical rehabilitation [14]. Importantly, apps for rehabilitation did not focus on upper limb function [14]. Use of technology to guide and measure performance in task-specific training of the upper extremity after stroke has primarily included clinical or laboratory-based interventions [15,16]. Task-specific programs are function based, with practice of tasks relevant to activities of daily life, and have been shown to be efficacious [17,18]. Use of instrumented objects in a laboratory setting has resulted in patients reporting they enjoyed the experience [15]. There has been less research on the use of portable technology for upper limb rehabilitation in a home setting for individuals with chronic arm/hand deficits after stroke.

Previous Work

mRehab (mobile Rehab) was created to better support in-home upper limb rehabilitation programs (Figure 1) [13]. It incorporates a task-oriented approach and immediate performance-based feedback. Exercise programs that include feedback have resulted in better outcomes compared with programs without feedback [19,20]. mRehab consists of 3D printed household objects (a mug, bowl, key, and doorknob) integrated with a smartphone and an app. The app guides participants through practice of activities of daily living, for example, sipping from a mug. It can also consistently measure time to complete an activity and quality of movement (smoothness/accuracy) during the performance of activities of daily living. The system is described in more detail in previous articles that have evaluated it in primarily laboratory-based settings [13,21].

Figure 1. In-home use of mRehab: (A) selecting an activity in mRehab; (B) turning key activity; and (C) vertical mug transfer activity.

There is little information on in-home use of technology for rehabilitation in chronic stroke. While technology-based systems designed for rehabilitation have been developed, they have typically been examined in laboratory or clinical settings [22,23]. The results of this study will provide much needed evidence of the ability of individuals with chronic stroke to use technology in a home-based program with oversight only upon request. This mimics clinical practice, in which patients are discharged from rehabilitation with a home program and then need to self-manage their recovery. We examine the individual’s adherence to exercise and if they required support with the technology. The impact of the home-based mRehab program on functional mobility was also examined. While individuals with chronic stroke were selected for the first examination of mRehab in a home-based setting, the system has the potential to be used by individuals that have arm/hand deficits due to other underlying pathology.[…]

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[Abstract + References] sEMG-biofeedback armband for hand motor rehabilitation in stroke patients: a preliminary pilot longitudinal study – IEEE Conference Publication

Abstract

Upper limb motor impairment is one of the most debilitating sequelae after stroke, thus the aim of rehabilitation is to promote functional recovery and improve quality of life. Surface Electromyography Biofeedback (sEMG-BFB) is a therapeutic tool based on providing amplified neuromuscular information on motor performance to the patient, for enhancing motor learning and driving to a successful recovery. A preliminary pilot longitudinal study was carried out to preliminarily investigate any clinical and instrumental effect due to an innovative treatment based on sEMG-BFB, in stroke survivors. Fifteen stroke patients with impairment of hand function were enrolled for a 3-weeks- training with REcognition MOvement (REMO®), a sEMG-BFB armband, clinical and instrumental assessments were administered before and after the training. After training, statistically significant differences were observed at the Box and Block Test (BBT) and in the relation between changes at BBT and chMAX-chMIN of wrist extension movement. Our results indicated that improvement in the device control is associated to a better hand function. Further studies need to be conducted to investigate the feasibility of using REMO® to study motor behavior in both healthy and diseased subjects.
1. R. L. Sacco et al., “AHA / ASA Expert Consensus Document An Updated Definition of Stroke for the 21st Century A Statement for Healthcare Professionals From the American Heart Association / American Stroke Association”, Stroke, pp. 2064-89, 2013.

3. A. Italiana et al., “SPREAD – Stroke Prevention and Educational Awareness Diffusion”, 2016.

4. P. Langhorne, F. Coupar and A. Pollock, “Motor recovery after stroke : a systematic review”, Lancet Neurol, vol. 8, no. 8, pp. 741-754, 2009.

5. S. Balasubramanian, J. Klein and E. Burdet, “Robot-assisted rehabilitation of hand function”, Curr. Opin. Neurol, pp. 661-670, Dec. 2010.

6. F. E. Buma, E. Lindeman, N. F. Ramsey and G. Kwakkel, “Functional Neuroimaging Studies of Early Upper Limb Recovery After Stroke : A Systematic Review of the Literature”, Neurorehabil Neural Repair, pp. 589-608, Sep. 2010.

7. A. Pollock et al., “Interventions for improving upper limb function after stroke (Review)”, The Cochrane Database of Systematic Reviews, no. 11, pp. 1-172, Nov. 2014.

8. J. A. Kleim and T. A. Jones, “Principles of Experience-Dependent Neural Plasticity : Implications for Rehabilitation After Brain Damage”, J. Speech Lang. Hear. Res, vol. 51, pp. 225-240, Feb. 2008.

9. J. W. Krakauer and P. Mazzoni, “Human sensorimotor learning : adaptation skill and beyond”, Curr. Opin. Neurobiol, vol. 21, no. 4, pp. 636-644, Aug. 2011.

10. O. M. Giggins, U. M. Persson and B. Caulfield, “Biofeedback in rehabilitation”, J. Neuroeng. Rehabil, pp. 1-11, Jun. 2013.

11. D. Farina et al., “The Extraction of Neural Information from the Surface EMG for the Control of Upper-Limb Prostheses : Emerging Avenues and Challenges”, IEEE Trans Neural Syst Rehabil Eng, vol. 22, no. 4, pp. 797-809, Feb. 2014.

12. O. Armagan, F. Tascioglu and C. Oner, “Electromyographic Biofeedback in the treatment of the Hemiplegic Hand: A placebo-controlled study”, Am J Phys Med Rehabil, vol. 82, pp. 856-861, Nov. 2003.

13. M. Lyu et al., “Training wrist extensor function and detecting unwanted movement strategies in an EMG-controlled visuomotor task”, Int Conf Rehabil Robot, pp. 1549-1555, 2017.

14. W. Hj and P. Cim, “EMG biofeedback for the recovery of motor function after stroke ( Review )”, pp. 1-19, 2009.

15. R. Neblett, “Surface Electromyographic (SEMG) Biofeedback for Chronic Low Back Pain”, Healthcare, 2016.

16. M. Di Girolamo, A. Favetto, M. Paleari, N. Celadon and P. Ariano, “A comparison of sEMG temporal and spatial information in the analysis ofcontinuous movements”, Informatics in Medicine Unlocked, vol. 9, pp. 255-263, 2017.

17. V. Mathiowetz, G. Volland, N. Kashman and K. Weber, “Adult norms for the Box and Block Test of Manual Dexterity”, Am J Occup Ther, vol. 39, pp. 386-391, Jun. 1985.

18. J. Inglis, M.W. Donald, TN Monga, M. Sproule and MJ Young, “Electromyographic biofeedback and physical therapy of the hemiplegic upper limb”, Arch Phys Med Rehabil, vol. 65, pp. 756-759, Dec. 1984.

19. C.E. Lang et al., “Assessment of upper extremity impairment function and activity after stroke: foundations for clinical decision making”, J. Hand Ther, vol. 26, no. 2, pp. 104-115, Apr. 2013.

20. L.A. Connell and S.F. Tyson, “Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review”, Arch Phys Med Rehabil, vol. 93, pp. 221-228, Feb. 2012.

via sEMG-biofeedback armband for hand motor rehabilitation in stroke patients: a preliminary pilot longitudinal study – IEEE Conference Publication

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[ARTICLE] Feasibility of single and combined with other treatments using transcranial direct current stimulation for chronic stroke: A pilot study – Full Text

This pilot study aimed to investigate the safety and efficacy of transcranial direct current stimulation (tDCS) for chronic stroke in adult and pediatric patients. We also aimed to verify the efficacy of botulinum toxin A and peripheral neuromuscular electrical stimulation combined therapy involving bilateral tDCS in adult patients with chronic stroke.

We conducted a pilot study applying an unblinded, non-randomized design. Eleven patients were recruited, and classified into three groups. Group I-a involved bilateral transcranial direct current stimulation and intensive occupational therapy for chronic stroke in adult patients. Group I-b involved bilateral tDCS and intensive occupational therapy for chronic stroke in pediatric patients. Group II involved bilateral tDCS, peripheral neuromuscular electrical stimulation, and intensive occupational therapy after botulinum toxin A injection for chronic stroke in adult patients. Clinical evaluations to assess motor function and spasticity were performed at baseline as well as in 2-week and 4-month follow-up visits. The questionnaire included questions regarding the presence of tDCS side effects, such as headache, redness, pain, itching, and fever.

There were clinically meaningful changes in total Fugl–Meyer Assessment Upper Extremity (FMA-UE) scores at the 2-week follow-up and in the Action Research Arm Test (ARAT) scores at 4-month follow-up in Group I-b. In addition, Group II showed significant improvement in total FMA-UE scores in the 2-week follow-up (p < 0.05) but not on the ARAT scores (p > 0.05). However, Group II showed improvements in total Motor Activity Log scores at both follow-up visits (p < 0.05). No serious adverse events were reported.

The results of this study indicate that tDCS therapy is a potential treatment in pediatric patients with chronic stroke. Furthermore, our data indicate that botulinum toxin A and peripheral neuromuscular electrical stimulation combined therapy may enhance the efficacy of tDCS on motor function.

Previous longitudinal studies have reported that between 30% and 66% of patients experience upper limb paralysis 6 months after suffering from a stroke.13 Recent studies have demonstrated the efficacy of various treatments for patients with chronic stroke, who experience upper limb paralysis, including botulinum toxin A (BTX-A) treatment, functional electrical stimulation therapy, and robotic therapy for functional motor recovery.46 In addition, repetitive transcranial magnetic stimulation and transcranial direct current stimulation (tDCS), have been reported to induce long-term effects on cortical excitability, lasting for months after the intervention.7,8

tDCS modulates cortical excitability which influences neural plasticity.9 Anodal tDCS (anodal electrode placed over standard scalp coordinates for motor ipsilesional M1, the cathodal electrode over the contralesional supraorbital ridge) also modulates cortical excitability in motor areas within affected hemisphere.9,10 Furthermore, bilateral tDCS, which stimulates both hemispheres simultaneously, could affect excitatory and inhibitory synaptic transmission in the bilateral motor cortex in patients with chronic stroke.9,1113 By modulating cortical excitability, tDCS may alter maladaptive neural plasticity after stroke.9 Moreover, peripheral neuromuscular electrical stimulation (PNMES) enhances the effects of tDCS on cortical excitability, relative to tDCS alone.14,15 Furthermore, rehabilitation therapy using PNMES combined with BTX-A has been shown to be an effective treatment in chronic stroke or spinal cord injury.16

However, no studies have examined the efficacy of the use of bilateral tDCS with PNMES and BTX-A therapy in patients with stroke and upper limb paralysis. Therefore, based on the results of each combination therapy effect from previous studies, we predicted that a new multiple combination of adding BTX-A to existing tDCS and PNMES combination therapy would result in more effective results. In addition, tDCS may help improve upper limb paralysis in pediatric patients with chronic stroke. Since tDCS alone has been rarely used in pediatrics, our pilot study aimed to investigate the safety and efficacy of tDCS in adult and pediatric patients with chronic stroke. We also aimed to verify the efficacy of BTX-A and PNMES combined therapy involving bilateral tDCS in adult patients with chronic stroke.

Study design

We conducted a pilot study applying an unblinded, non-randomized design. This study included patients with chronic stroke (>6 months from stroke onset) experiencing paralysis in an upper limb. Patients between 6 and 85 years old were included. We also excluded patients with epilepsy, complete paralysis, and/or severe pain, as well as those who were unable to follow directions due to cognitive impairment and/or aphasia. All participants provided written informed consent. Our institutional review board approved the study. Patient characteristics are summarized in Table 1.

Table

Table 1. Demographics and clinical characteristics.

We included 11 patients (four males and seven females; mean age 43.5 ± 5.1 years) including 7 cases of hemorrhagic stroke and 4 cases of ischemic stroke. All study participants were right handed. There were six cases of right upper limb paralysis and five cases of left upper limb paralysis. All of four ischemic stroke cases had a lesion in the middle cerebral arterial territtory, and three hemorrhagic stroke patients had a lesion in the putamen, two stroke patients had a lesion in the subcortical, and other two patients had lesions were in the thalamus and pontine. These treatment programs were initiated on 54.9 ± 23.2 days from stroke onset. Of the included cases, data from 1 patient (Case 1) was published previously.13

Five patients, included in Group I, underwent bilateral tDCS therapy alongside intensive occupational therapy (OT) (Group I-a: two adults; Group I-b: three children). Group II included six adult patients in chronic stroke who underwent BTX-A and PNMES combined therapy involving bilateral tDCS.

Each rehabilitation session lasted 60 min. Sessions were performed twice daily for 10 days so that all patients completed 20 sessions for the 2-week intervention period in the hospital. In Group I, tDCS started at the same time as the intensive OT for 25 min; and a 45-min only intensive OT was performed after the tDCS. In Group II, patients were given a BTX-A injection. Following this, patients simultaneously underwent intensive OT for 25 min using tDCS, and PNMES (25 min). Meanwhile, intensive OT was continued as well, and finally alone intensive OT (10 minutes) was performed (Figure 1). Intensive OT involved task-oriented training. The content of the task-oriented training mainly consisted of the task on the desk. The difficulty of the task was adjusted for each patient depending on the extent of their upper limb paralysis and their rehabilitation goals. Examples of activities included gripping or picking up blocks or pegs, varying in size; as well as using a keyboard and playing cards. The activities performed by each patient were recorded. In addition, patients were instructed to increase their use of upper limb paralysis. After the 2-week intervention period, patients presented as outpatients and were given exercises to complete at home. Patients were encouraged to use their paralyzed upper limbs depending on their individual rehabilitation needs. Daily activities involved tasks related to their own rehabilitation goals from the activities of daily living (ADL) and instrumental activities of daily living (IADL) tasks.


                        figure

Figure 1. Study protocol in Groups I, bilateral tDCS started at the same time as the intensive occupational therapy for 25 min; and a 45-min-only intensive occupational therapy was performed after bilateral tDCS. Study protocol for combined therapy involving bilateral tDCS. Patients in Group II received BTX-A therapy 25 min prior to bilateral tDCS, which was immediately followed by a 25-min PNMES. Intensive occupational therapy was also provided simultaneously and performed alone for 10 min.

BTX-A: botulinum toxin A; tDCS: transcranial direct current stimulation; PNMES: peripheral neuromuscular electrical stimulation.

Clinical evaluations were performed at baseline and in 2-week and 4-month follow-up visits conducted after the intervention. We used the following clinical outcome measures to evaluate upper limb function, including the Fugl–Meyer Assessment Upper Extremity (FMA-UE; range: 0–66) and the Action Research Arm Test (ARAT; range: 0–57).17,18 Limb functioning used during daily activities were assessed using the Motor Activity Log (MAL; range: 0–5).19 The severity of spasticity symptoms were evaluated using the Disability Assessment Scale (DAS; range: 0–12).20 DAS evaluations were conducted with patients who had received BTX-A injections. The questionnaire included questions regarding the presence of tDCS side effects, such as headache, redness, pain, itching, and fever.

The effective change in this pilot study was defined as the minimal clinically important difference (MCID) for endpoints with established values, and the MCID for FMA-UE, ARAT and MAL were 4.25, 5.7 and 0.5 points, respectively.21,22 Furthermore, the statistically significant difference in the amount of change from the baseline within the group and the presence or absence of serious adverse events were used as reference indicators of feasibility.

Statistical analysis

Within-group comparisons were conducted to investigate changes in clinical symptoms (FMA-UE, ARAT, and MAL) before and after treatment using the Wilcoxon signed-rank test. All analyses were performed using SPSS, version 21.0 (IBM Corp., Armonk, NY, USA). The significance threshold was set to p < 0.05.

tDCS-supported rehabilitation

We used the DC-STIMULATOR PLUS system (neuroConn GmbH, Germany) to perform tDCS. The anodal electrode was placed over standard scalp coordinates for the ipsilesional M1; whereas the cathodal electrode was placed over standard scalp coordinates for the contralesional M1 (C3 or C4 points according to the 10–20 system). Bilateral tDCS using electrodes (size of 5 × 7 cm; 35 cm2) using a constant current intensity of 2.5 mA for 25 min (Figure 2). Our protocol used current densities below 25 mA/cm2 which should not induce damage even when high-frequency stimulation is applied for several hours.23,24 The tDCS protocol that we used has been described previously (Figure 3).13,25

                        figure

Figure 2. Bilateral tDCS with intensive occupational therapy: (1) DC-STIMULATOR PLUS system (neuroConn GmbH, Germany) for transcranial direct current stimulation.

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