Posts Tagged Upper Extremity
More than 1.5 million people suffer a stroke in Europe per year and more than 70% of stroke survivors experience limited functional recovery of their upper limb, resulting in diminished quality of life. Therefore, interventions to address upper-limb impairment are a priority for stroke survivors and clinicians. While a significant body of evidence supports the use of conventional treatments, such as intensive motor training or constraint-induced movement therapy, the limited and heterogeneous improvements they allow are, for most patients, usually not sufficient to return to full autonomy. Various innovative neurorehabNIBSilitation strategies are emerging in order to enhance beneficial plasticity and improve motor recovery. Among them, robotic technologies, brain-computer interfaces, or noninvasive brain stimulation (NIBS) are showing encouraging results. These innovative interventions, such as NIBS, will only provide maximized effects, if the field moves away from the “one-fits all” approach toward a “patient-tailored” approach. After summarizing the most commonly used rehabilitation approaches, we will focus on and highlight the factors that limit its widespread use in clinical settings. Subsequently, we will propose potential biomarkers that might help to stratify stroke patients in order to identify the individualized optimal therapy. We will discuss future methodological developments, which could open new avenues for poststroke rehabilitation, toward more patient-tailored precision medicine approaches and pathophysiologically motivated strategies.
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Stroke survivor exhibits remarkable improvement in hand function more than two decades after stroke, disproving theories that recovery window is limited to 6 months.
Charlotte, N.C. – Tuesday, July 25, 2017 – Until recently, researchers believed that if a stroke survivor exhibited no improvement within the first 6 months, then he or she would have little to no chance of regaining motor function in the future. This assumed end of recovery is called a plateau. However, a groundbreaking new article published in the Journal of Neurophysiology discusses a stroke patient’s remarkable improvement decades after suffering a stroke at the age of 15. Doctors Peter Sörös, Robert Teasell, Daniel F. Hanley, and J. David Spence formally dismiss previous theories that stroke recovery occurs within 6 months, reporting that the patient experienced “recovery of hand function that began 23 years after the stroke.”
The patient’s stroke resulted in paralysis on the left side of his body, rendering his left hand completely nonfunctional, despite regular physical therapy. More than twenty years after his stroke, the patient took up swimming when his doctor recommended he lose weight. A year later, he began to show signs of movement on his affected side and returned to physical therapy. Therapists fitted the patient with the SaeboFlex, a mechanical device shown to improve hand function and speed up recovery, and, after only a few months of therapy, he began picking up coins with his previously nonfunctional hand. He also saw notable improvement in hand strength and control with the SaeboGlove, a low-profile hand device recently patented by Saebo.
Functional MRI studies showed the reorganization of sensorimotor neurons in both sides of the patient’s brain more than two decades after his stroke, resulting in a noticeable recovery in both hemispheres and improved motor function. “The marked delayed recovery in our patient and the widespread recruitment of bilateral areas of the brain indicate the potential for much greater stroke recovery than is generally assumed,” the doctors reported. “Physiotherapy and new modalities in development might be indicated long after a stroke.”
“This article highlights what we have seen for the last 15 years with many of our clients,” states Saebo co-founder, Henry Hoffman. “Oftentimes, stroke survivors are told that they have plateaued and no further progress is possible. We believe it is not the client that has plateaued but failed treatment options have plateaued them. In other words, traditional therapy interventions that lack scientific evidence can be ineffective and can actually facilitate the plateau.”
“The SaeboFlex device is a life-changing treatment designed for clients that lack motor recovery and function,” Hoffman continues. “Whether the client recently suffered a stroke or decades later, they can immediately begin using their hand with this device and potentially make significant progress over time. I agree with the authors that the neurorehabilitation community needs to take a hard look at traditional beliefs with respect to the window of recovery following stroke. It is my hope that this article will spark more interest by researchers to investigate upper limb function with clients at the chronic stage using Saebo’s hand technology.”
The abstract and article in its entirety can be viewed at the Journal of Neurophysiology’s website, jn.physiology.org.
To evaluate in the follow-up the sensory-motor recovery and quality of life patients 2 months after completion of the Nintendo Wii console intervention and determine whether learning retention was obtained through the technique.
Five hemiplegics patients participated in the study, of whom 3 were male with an average age of 54.8 years (SD = 4.6). Everyone practiced Nintendo Wii therapy for 2 months (50 minutes/day, 2 times/week, during 16 sessions). Each session lasting 60 minutes, under a protocol in which only the games played were changed, plus 10 minutes of stretching. In the first session, tennis and hula hoop games were used; in the second session, football (soccer) and boxing were used. For the evaluation, the Fulg-Meyer and Short Form Health Survey 36 (SF-36) scales were utilized. The patients were immediately evaluated upon the conclusion of the intervention and 2 months after the second evaluation (follow-up).
Values for the upper limb motor function sub-items and total score in the Fugl–Meyer scale evaluation and functional capacity in the SF-36 questionnaire were sustained, indicating a possible maintenance of the therapeutic effects.
The results suggest that after Nintendo Wii therapy, patients had motor learning retention, achieving a sustained benefit through the technique.
HOCOMA REVOLUTIONIZING REHABILITATION
Conventional therapy today is limited—by time, by number of repetitions, by
the lack of reproducible movement quality and by the fact that it is strenuous for both therapists and patients. In other words: there is a disbalance between the therapy we know we should provide according to motor learning principles and all the factors that prevent us from reaching this goal.[…]
[ARTICLE] Is two better than one? Muscle vibration plus robotic rehabilitation to improve upper limb spasticity and function: A pilot randomized controlled trial – Full Text
Even though robotic rehabilitation is very useful to improve motor function, there is no conclusive evidence on its role in reducing post-stroke spasticity. Focal muscle vibration (MV) is instead very useful to reduce segmental spasticity, with a consequent positive effect on motor function. Therefore, it could be possible to strengthen the effects of robotic rehabilitation by coupling MV. To this end, we designed a pilot randomized controlled trial (Clinical Trial NCT03110718) that included twenty patients suffering from unilateral post-stroke upper limb spasticity. Patients underwent 40 daily sessions of Armeo-Power training (1 hour/session, 5 sessions/week, for 8 weeks) with or without spastic antagonist MV. They were randomized into two groups of 10 individuals, which received (group-A) or not (group-B) MV. The intensity of MV, represented by the peak acceleration (a-peak), was calculated by the formula (2πf)2A, where f is the frequency of MV and A is the amplitude. Modified Ashworth Scale (MAS), short intracortical inhibition (SICI), and Hmax/Mmax ratio (HMR) were the primary outcomes measured before and after (immediately and 4 weeks later) the end of the treatment. In all patients of group-A, we observed a greater reduction of MAS (p = 0.007, d = 0.6) and HMR (p<0.001, d = 0.7), and a more evident increase of SICI (p<0.001, d = 0.7) up to 4 weeks after the end of the treatment, as compared to group-B. Likewise, group-A showed a greater function outcome of upper limb (Functional Independence Measure p = 0.1, d = 0.7; Fugl-Meyer Assessment of the Upper Extremity p = 0.007, d = 0.4) up to 4 weeks after the end of the treatment. A significant correlation was found between the degree of MAS reduction and SICI increase in the agonist spastic muscles (p = 0.004). Our data show that this combined rehabilitative approach could be a promising option in improving upper limb spasticity and motor function. We could hypothesize that the greater rehabilitative outcome improvement may depend on a reshape of corticospinal plasticity induced by a sort of associative plasticity between Armeo-Power and MV.
Spasticity is defined as a velocity-dependent increase in muscle tone due to the hyper-excitability of muscle stretch reflex . Spasticity of the upper limb is a common condition following stroke and traumatic brain injury and needs to be assessed carefully because of the significant adverse effects on patient’s motor functions, autonomy, and quality of life .
Different pharmacological and non-pharmacological approaches are currently available for upper limb spasticity management, as physiotherapy (including magnetic stimulation, electromagnetic therapy, sensory-motor techniques, and functional electrical stimulation treatment) and robot-assisted therapy [3–4]. In this regard, several studies suggest robotic devices, including the Armeo® (a robotic exoskeleton for the rehabilitation of upper limbs), may help reducing spasticity by modifying spasticity-related synaptic processes at either the brain or spinal level [5–13], resulting in spasticity reduction in antagonist muscles through, e.g., a strengthening of spinal reciprocal inhibition mechanisms .
Growing research is proposing segmental muscle vibration (MV) as being a powerful tool for the treatment of focal spasticity in post-stroke patients [14–15]. Mechanical devices deliver low-amplitude/high-frequency vibratory stimuli to specific muscles [16–17], thus offering strong proprioceptive inputs by activating the neural pathway from muscle spindle annulospiral endings to Ia-fiber, dorsal column–medial lemniscal pathway, the ventral posterolateral nucleus of the thalamus (and other nuclei of the basal ganglia), up to the primary somatosensory area (postcentral gyrus and posterior paracentral lobule of the parietal lobe), and the primary motor cortex [18–19]. At the cortical network level, proprioceptive inputs can alter the excitability of the corticospinal pathway by modulating intracortical inhibitory and facilitatory networks within primary sensory and motor cortex, and affecting the strength of sensory inputs to motor circuits [20–22]. In particular, periods of focal MV delivered alone can modify sensorimotor organization within the primary motor cortex (i.e., can increase or decrease motor evoked potential—MEP—and short intracortical inhibition (SICI) magnitude in the vibrated muscles, while opposite changes occur in the neighboring muscles), thus reducing segmental hyper-excitability and spasticity [20–22].
While focal MV is commonly used to reduce upper limb post-stroke spasticity, there is no conclusive evidence on the role of robotic rehabilitation in such a condition [14–17,23–27]. A strengthening of the effects of neurorobotics and MV on spasticity could be achieved by combining MV and neurorobotics. The rationale for combining Armeo-Power and MV to reduce spasticity could lie in the summation and amplification of their single modulatory effects on corticospinal excitability . Specifically, it is hypothesizable that MV may strengthen the learning-dependent plasticity processes within sensory-motor areas that are in turn triggered by the intensive, repetitive, and task-oriented movement training offered by Armeo-Power [29–30]. Such an amplification may depend on a sort of associative plasticity (i.e., the one generated by timely coupling two different synaptic inputs) between MV and Armeo-Power [31–33].
To the best of our knowledge, this is the first attempt to investigate such approach. Indeed, a previous study combining MV with conventional physiotherapy used Armeo only as evaluating tool .
The aim of our study was to assess whether a combined protocol employing MV and Armeo-Power training, as compared to Armeo-Power alone, may improve upper limb spasticity and motor function in patients suffering from a hemispheric stroke in the chronic phase. To this end, we compared the clinical and electrophysiological after-effects of Armeo-Power with or without MV on upper limb spasticity. We also assessed the effects on upper limb motor function and muscle activation, disability burden, and mood, given that spasticity may have significant negative consequences on these outcomes. Further, it is important to evaluate mood, as it may negatively affect functional recovery [34–36], increase mortality , and weaken the compliance of the patient to the rehabilitative training [38–39].[…]
[ARTICLE] Design and Interaction Control of a New Bilateral Upper-Limb Rehabilitation Device – Full Text
This paper proposed a bilateral upper-limb rehabilitation device (BULReD) with two degrees of freedom (DOFs). The BULReD is portable for both hospital and home environment, easy to use for therapists and patients, and safer with respect to upper-limb robotic exoskeletons. It was implemented to be able to conduct both passive and interactive training, based on system kinematics and dynamics, as well as the identification of real-time movement intention of human users. Preliminary results demonstrate the potential of the BULReD for clinical applications, with satisfactory position and interaction force tracking performance. Future work will focus on the clinical evaluation of the BULReD on a large sample of poststroke patients.
In the United States, more than 700,000 people suffer from stroke each year, and approximately two-thirds of these individuals survive and require rehabilitation . In New Zealand (NZ), there are an estimated 60,000 stroke survivors, and many of them have mobility impairments . Stroke is the third reason for health loss and takes the proportion of 3.9 percent, especially for the group starting on middle age, suffering the stroke as a nonfatal disease in NZ . Professor Caplan who studies Neurology at Harvard Medical School describes stroke as a term which is a kind of brain impairment as a result of abnormal blood supply in a portion of the brain . The brain injury is most likely leading to dysfunctions and disabilities. These survivors normally have difficulties in activities of daily living, such as walking, speaking, and understanding, and paralysis or numbness of the human limbs. The goals of rehabilitation are to help survivors become as independent as possible and to attain the best possible quality of life.
Physical therapy is conventionally delivered by the therapist. While this has been demonstrated as an effective way for motor rehabilitation , it is time-consuming and costly. Treatments manually provided by therapists require to take place in a specific environment (in a hospital or rehabilitation center) and may last several months for enhanced rehabilitation efficacy . A study by Kleim et al.  has shown that physical therapy like regular exercises can improve plasticity of a nervous system and then benefits motor enrichment procedures in promoting rehabilitation of brain functional models. It is a truth that physical therapy should be a preferable way to take patients into regular exercises and guided by a physical therapist, but Chang et al.  showed that it is a money-consuming scheme. Robot-assisted rehabilitation solutions, as therapeutic adjuncts to facilitate clinical practice, have been actively researched in the past few decades and provide an overdue transformation of the rehabilitation center from labor-intensive operations to technology-assisted operations . The robot could also provide a rich stream of data from built-in sensors to facilitate patient diagnosis, customization of the therapy, and maintenance of patient records. As a popular neurorehabilitation technique, Liao et al.  indicated that robot-assisted therapy presents market potential due to quantification and individuation in the therapy session. The quantification of robot-assisted therapy refers that a robot can provide consistent training pattern without fatigue with the given parameter. The characterization of individuation allows therapists to customize a specific training scheme for an individual.
Many robotic devices have been developed in recent years for stroke rehabilitation and show great potential for clinical applications [11, 12]. Typical upper-limb rehabilitation devices are MIME, MIT-Manus, ARM Guide, NeReBot, and ARMin [5, 13–21]. Relevant evidences demonstrated that these robots are effective for upper-limb rehabilitation but mostly for the one side of the human body. Further, upper-limb rehabilitation devices can be unilateral or bilateral [22–24]. Despite the argument between these two design strategies, bilateral activities are more common than unilateral activities in daily living. Liu et al.  pointed that the central nervous system dominates the human movement with coordinating bilateral limb to act in one unit instead of independent unilateral actions. From this point, bilateral robots are expected to be more potential than unilateral devices. Robotic devices for upper-limb rehabilitation can be also divided into two categories in terms of structure: the exoskeleton and the end-effector device . Two examples of upper-limb exoskeletons are the arm exoskeleton  and the RUPERT IV . In addition, Lum et al.  incorporated a PUMA 560 robot (Staubli Unimation Inc., Duncan, South Carolina) to apply forces to the paretic limbs in the MIME system. This robotic device can be made for both unilateral and bilateral movements in a three-dimensional space. To summarize, existing robotic exoskeletons for upper-limb rehabilitation are mostly for unilateral training.
There are some devices that have been specially designed for bilateral upper-limb training for poststroke rehabilitation. van Delden et al.  conducted a systematic review to provide an overview and qualitative evaluation of the clinical applications of bilateral upper-limb training devices. A systematic search found a total of six mechanical devices and 14 robotic bilateral upper-limb training devices, with a comparative analysis in terms of mechanical and electromechanical characteristics, movement patterns, targeted part, and active involvement of the upper limb, training protocols, outcomes of clinical trials, and commercial availability. Obviously, these mechanical devices require the human limbs to actively move for training, while the robotic ones can be operated in both passive and active modes. However, few of these robotic bilateral upper-limb training devices have been commercially available with current technology. For example, the exoskeleton presented in  requires the development of higher power-to-weight motors and structural materials to make it mobile and more compact.
The University of Auckland developed an end-effector ReachHab device to assist bilateral upper-limb functional recovery . However, this device suffered from some limitations, such as deformation of the frame leading to significant vibration, also hard to achieve satisfactory control performance. This paper presents the design and interaction control of an improved bilateral upper-limb rehabilitation device (BULReD). This device is portable for both hospital and home environment, easy to use for therapists and patients, and safer with respect to upper-limb robotic exoskeletons. This paper is organized as follows. Following Introduction, a detailed description of the BULReD is given, including mechanical design, electrical design, kinematics, and dynamics. Then, the control design is presented for both passive training and interactive training, as well as the fuzzy-based adaptive training. Experiments and Results is introduced next and the last is Conclusion.[…]
SMARTmove is a £1.1 million Medical Research Council research project running for 30 months from September 2016 to February 2019, funded under the Development Pathway Funding Scheme (DPFS). The project brings together a multidisciplinary team with expertise in functional materials, direct printing fabrication, control algorithms, wireless electronics, sensors, and end user engagement to address stroke rehabilitation. Working together with the advisory board members from six institutions, we will deliver a personalised wearable device for home-based stroke upper limb rehabilitation.
Current commercial devices using functional electrical stimulation (FES) have large electrodes that only stimulate a limited number of muscles, resulting in simple, imprecise movements and the rapid onset of fatigue. In addition, current commercial devices do not employ feedback control to account for the movement of patients, only reducing the level of precision in the resulting movements. In addition, devices are either bulky and expensive, or difficult to set-up due to trailing wires.
Our project uses bespoke screen printable pastes to print electrode arrays directly onto everyday fabrics, such as those used in clothing. The resulting garments will have cutting-edge sensor technologies integrated into them. Advanced control algorithms will then adjust the stimulation based on the patients’ limb motion to enable precise functional movements, such as eating, washing or dressing.
This project will deliver a fabric-based wearable FES for home based stroke rehabilitation. The beneficiaries include:
- Persons with stroke (PwS) and other neurological conditions. Stroke survivors are the direct beneficiaries of our research. The FES clothing can be adapted to also treat hand/arm disabilities resulting from other neurological conditions such as cerebral palsy, head injury, spinal cord injury, and multiple sclerosis. The use of the wearable training system increases the intensity of rehabilitation without an increase in clinical contact time. This leads to better outcomes such as reduced impairment, greater restoration of function, improved quality of life and increased social activity.
- The NHS. FES-integrated clothing is comfortable to wear and convenient to use for rehabilitation, enabling impaired people to benefit from FES at home. It will transfer hospital based professional care to home based self-care, and therefore will reduce NHS costs by saving healthcare professionals’ time and other hospital resources.
- Industry. Benefits include: bringing business to the whole supply chain; increasing the FES market demand by improving performance; benefiting other industry sectors such as rehabilitation for other neurological conditions.
- Research communities in related fields. Specifically, the fields of novel fabrication, control systems, design of medical devices, rehabilitation, smart fabrics, and remote healthcare will benefit from the highly transformative platform technology (e.g. direct write printing, fabric electrodes, iterative learning control systems) developed in this work.
Functional electrical stimulation (FES) is a technique used to facilitate the practice of therapeutic exercises and tasks. Intensive movement practice can restore the upper limb function lost following stroke. However, stroke patients often have little or no movement, so are unable to practice. FES activates muscles artificially to facilitate task practise and improve patients’ movement.
[ARTICLE] The Relationship between Poststroke Depression and Upper Limb Recovery in Patients Admitted to a Rehabilitation Unit – Full Text PDF
Objective: We sought to determine the relationship between poststroke depression and upper limb recovery in a cohort of patients admitted to a rehabilitation center in Singapore.
Method: We conducted a secondary analysis of an interventional study of 105 patients with a stroke. Depression was diagnosed using the Centre for Epidemiological Studies Depression Scale (CES-D) and this was correlated with the following measures: Fugl-Meyer Assessment of Upper Limb (FMA), Action Research Am Test (ARAT), Stroke Impact Scale – Upper Limb Items (SIS) and Functional Independence Measure-Selfcare (FIM-Selfcare) at 3, 7 and 15 weeks after admission to rehabilitation.
Results: Poststroke depression was present in 20% of patients on admission to rehabilitation. It was negatively correlated to SIS and FIM-Selfcare at 7 weeks and to FMA, ARAT, SIS and FIM-Selfcare at 15 weeks after rehabilitation admission. Depression on rehabilitation admission did not influence upper limb recovery at 3 weeks, 7 weeks, and 15 weeks after admission to rehabilitation.
Conclusion: Given the negative impact of depression on upper limb impairment, function and performance of selfcare, routine screening of depression should be considered in subacute stroke patients, especially in those with poorer upper limb function.
[ARTICLE] Effect of repetitive wrist extension with electromyography-triggered stimulation after stroke: a preliminary randomized controlled study – Full Text PDF
Objective: The purpose of this study was to explore the effect of repetitive wrist extension task training with electromyography (EMG)-triggered neuromuscular electrical stimulation (NMES) for wrist extensor muscle recovery in patients with stroke.
Design: Randomized controlled trial.
Methods: Fifteen subjects who had suffered a stroke were randomly assigned to an EMG-triggered NMES group (n=8) or control group (n=7); subjects in both groups received conventional therapy as usual. Subjects in the experimental group received application of EMG-triggered NMES to the wrist extensor muscles for 20 minutes, twice per day, five days per week, for a period of four weeks, and were given a task to make a touch alarm go off by activity involving extension of their wrist. In the control group, subjects
performed wrist self-exercises for the same duration and frequency as those in the experimental group. Outcome measures included muscle reaction time and spectrum analysis. Assessments were performed during the pre- and post-treatment periods.
Results: In the EMG-triggered NMES group, faster muscle reaction time was observed, and median frequency also showed improvement, from 68.2 to 75.3 Hz, after training (p<0.05). Muscle reaction time was significantly faster, and median frequency was significantly higher in the experimental group than in the experimental group after training.
Conclusions: EMG-triggered NMES is beneficial for patients with hemiparetic stroke in recovery of upper extremity function.