Overcoming Ignorance and Ineptitude in 21st Century Rehabilitation

Metrology in sEMG and movement analysis: the need for training new figures in clinical rehabilitation

A new educational curriculum for the next generation of physical and occupational therapists is urgent in order to manage the recent fast advances in sensors, measurement technologies and related instrumentation. This is required by the growing role of STEM in rehabilitation, kinesiology, and sport sciences. Surface EMG technology is used in this work as a representative example of similar problems present in movement analysis, exoskeletons, and many other fields. A review of the most relevant articles and international projects in the field of interfacing physical therapy with measurement technology for quantitative assessment of outcome is presented. It is concluded that a new generation of educators is needed as well as a Ph.D. and/or a clinical doctorate degree in physical therapy, still lacking in many countries. It is urgent to consider knowledge translation since it will take many years before any recommended change in teaching will be accepted and show some effect. A call for a "white paper" on rehabilitation metrology is highly auspicable.

A scoping review of scientific concepts concerning motor recovery after stroke as employed in clinical trials

The scientific literature on poststroke rehabilitation is remarkably vast. Over the last decades, dozens of rehabilitation approaches have been investigated. However, sometimes it is challenging to trace new experimental interventions back to some of the known models of motor control and sensorimotor learning. This scoping review aimed to investigate motor control models' diffusion among the literature on motor recovery after stroke. We performed a literature search on Medline, Cochrane, Web of Science, Embase, and Scopus databases. The last search was conducted in September 2023. This scoping review included full-text articles published in English in peer-reviewed journals that provided rehabilitation interventions based on motor control or motor learning frameworks for at least one individual with stroke. For each study, we identified the theoretical framework the authors used to design the experimental treatment. To this aim, we used a previously proposed classification of the known models of motor control, dividing them into the following categories: neuroanatomy, robotics, self-organization, and ecological context. In total, 2,185 studies were originally considered in this scoping review. After the screening process, we included and analyzed 45 studies: 20 studies were randomized controlled trials, 12 were case series, 4 were case reports, 8 were observational longitudinal pilot studies, and 1 was an uncontrolled trial. Only 10 studies explicitly declared the reference theoretical model. Considering their classification, 21 studies referred to the robotics motor control model, 12 to the self-organization model, 8 to the neuroanatomy model, and 4 to the ecological model. Our results showed that most of the rehabilitative interventions purposed in stroke rehabilitation have no clear theoretical bases on motor control and motor learning models. We suggest this is an issue that deserves attention when designing new experimental interventions in stroke rehabilitation.

Advances in EMG measurement techniques, analysis procedures, and the impact of muscle mechanics on future requirements for the methodology

Muscular coordination enables locomotion and interaction with the environment. For more than 50 years electromyography (EMG) has provided insights into the central nervous system control of individual muscles or muscle groups, enabling both fine and gross motor functions. This information is available either at individual motor units (Mus) level or on a more global level from the coordination of different muscles or muscle groups. In particular, non-invasive EMG methods such as surface EMG (sEMG) or, more recently, spatial mapping methods (High-Density EMG - HDsEMG) have found their place in research into biomechanics, sport and exercise, ergonomics, rehabilitation, diagnostics, and increasingly for the control of technical devices. With further technical advances and a growing understanding of the relationship between EMG and movement task execution, it is expected that with time, especially non-invasive EMG methods will become increasingly important in movement sciences. However, while the total number of publications per year on non-invasive EMG methods is growing exponentially, the number of publications on this topic in journals with a scope in movement sciences has stagnated in the last decade. This review paper contextualizes non-invasive EMG development over the last 50 years, highlighting methodological progress. Changes in research topics related to non-invasive EMG were identified. Today non-invasive EMG procedures are increasingly used to control technical devices, where muscle mechanics have a minor influence. In movement science, however, the effect of muscle mechanics on the EMG signal cannot be neglected. This explains why non-invasive EMG's relevance in movement sciences has not developed as expected.

Translation of surface electromyography to clinical and motor rehabilitation applications: The need for new clinical figures

Advanced sensors/electrodes and signal processing techniques provide powerful tools to analyze surface electromyographic signals (sEMG) and their features, to decompose sEMG into the constituent motor unit action potential trains, and to identify synergies, neural muscle drive, and EEG-sEMG coherence. However, despite thousands of articles, dozens of textbooks, tutorials, consensus papers, and European and International efforts, the translation of this knowledge into clinical activities and assessment procedures has been very slow, likely because of lack of clinical studies and competent operators in the field. Understanding and using sEMG-based hardware and software tools requires a level of knowledge of signal processing and interpretation concepts that is multidisciplinary and is not provided by most academic curricula in physiotherapy, movement sciences, neurophysiology, rehabilitation, sport, and occupational medicine. The chasm existing between the available knowledge and its clinical applications in this field is discussed as well as the need for new clinical figures. The need for updating the training of physiotherapists, neurophysiology technicians, and clinical technologists is discussed as well as the required competences of trainers and trainees. Indications and examples are suggested and provide a basis for addressing the problem. Two teaching examples are provided in the Supplementary Material.

Fundamental Concepts of Bipolar and High-Density Surface EMG Understanding and Teaching for Clinical, Occupational, and Sport Applications: Origin, Detection, and Main Errors

Surface electromyography (sEMG) has been the subject of thousands of scientific articles, but many barriers limit its clinical applications. Previous work has indicated that the lack of time, competence, training, and teaching is the main barrier to the clinical application of sEMG. This work follows up and presents a number of analogies, metaphors, and simulations using physical and mathematical models that provide tools for teaching sEMG detection by means of electrode pairs (1D signals) and electrode grids (2D and 3D signals). The basic mechanisms of sEMG generation are summarized and the features of the sensing system (electrode location, size, interelectrode distance, crosstalk, etc.) are illustrated (mostly by animations) with examples that teachers can use. The most common, as well as some potential, applications are illustrated in the areas of signal presentation, gait analysis, the optimal injection of botulinum toxin, neurorehabilitation, ergonomics, obstetrics, occupational medicine, and sport sciences. The work is primarily focused on correct sEMG detection and on crosstalk. Issues related to the clinical transfer of innovations are also discussed, as well as the need for training new clinical and/or technical operators in the field of sEMG.

Understanding Acceptability, Barriers, and Facilitators to Clinical Implementation of the on Track Developmental Monitoring System for Children with Cerebral Palsy: A Qualitative Study

AIMS

On Track Developmental Monitoring System (DMS) is a novel series of tools to assist in shared-decision making, guide rehabilitation intervention based on functional ability levels, and promote episodic care service models. Further understanding of the acceptability, feasibility, and appropriateness of On Track DMS in clinical settings is critical. The purpose of this study was to understand clinician perspectives of the acceptability of On Track DMS and to identify potential implementation barriers and facilitators within pediatric physical therapist practice.

METHODS

Three, day-long training workshops were conducted with 32 pediatric physical therapists across the US. Focus groups with 21 workshop participants were conducted following training. Results were audio recorded, transcribed verbatim, and coded into themes.

RESULTS

Three themes emerged from the data: (1) Valuing the On Track Approach to Intervention; (2) Setting-Specific Needs and Challenges to Implementation; and (3) Training Material/Tool Strengths and Limitations.

CONCLUSIONS

On Track DMS appears to have initial value and acceptability for pediatric physical therapists across practice settings. Perceived benefits include facilitation of data-driven practice and therapist/family collaboration to improve health outcomes for children with CP. Using this data to understand and assess barriers and facilitators to knowledge use are first steps in successfully implementing On Track DMS.

Robotic-assisted locomotor treadmill therapy does not change gait pattern in children with cerebral palsy

Although robotic-assisted locomotor treadmill therapy is utilized on children with cerebral palsy (CP), its impact on the gait pattern in childhood is not fully described. We investigated the outcome of robotized gait training focusing on the gait pattern modifications and mobility in individuals with CP. An additional intention is to compare our results with the previous literature advancing future solutions. Twenty-four children with diplegic CP (average age 6.4 years old with Gross Motor Functional Classification System range I-IV) received robotized gait training five times per week for 4 weeks. Gait analysis and Gross Motor Function Measurement (GMFM) assessments were performed before and at the end of the treatment. Gait analysis showed inconsistent modifications of the gait pattern. GMFM showed a mild improvement of the dimension D in all subjects, while dimension E changed only in the younger and more severely affected patients. In this study, a detailed investigation comprehensive of electromyography patterns, where previous literature reported only sparse data without giving information on the whole gait pattern, were conducted. We carried on the analysis considering the age of the participants and the severity of the gait function. The findings differentiate the concept of specific pattern recovery (no gait pattern changes) from the concept of physical training (mild GMFM changes).

Clinical Relevance of State-of-the-Art Analysis of Surface Electromyography in Cerebral Palsy

Surface electromyography (sEMG) can be used to assess the integrity of the neuromuscular system and its impairment in neurological disorders. Here we will consider several issues related to the current clinical applications, difficulties and limited usage of sEMG for the assessment and rehabilitation of children with cerebral palsy. The uniqueness of this methodology is that it can determine hyperactivity or inactivity of selected muscles, which cannot be assessed by other methods. In addition, it can assist for intervention or muscle/tendon surgery acts, and it can evaluate integrated functioning of the nervous system based on multi-muscle sEMG recordings and assess motor pool activation. The latter aspect is especially important for understanding impairments of the mechanisms of neural controllers rather than malfunction of individual muscles. Although sEMG study is an important tool in both clinical research and neurorehabilitation, the results of a survey on the clinical relevance of sEMG in a typical department of pediatric rehabilitation highlighted its limited clinical usage. We believe that this is due to limited knowledge of the sEMG and its neuromuscular underpinnings by many physiotherapists, as a result of lack of emphasis on this important methodology in the courses taught in physical therapy schools. The lack of reference databases or benchmarking software for sEMG analysis may also contribute to the limited clinical usage. Despite the existence of educational and technical barriers to a widespread use of, sEMG does provide important tools for planning and assessment of rehabilitation treatments for children with cerebral palsy.

Surface Electromyography in Clinical Practice. A Perspective From a Developing Country

Surface electromyography (sEMG) has long been used in research, health care, and other fields such as ergonomics and brain-machine interfaces. In health care, sEMG has been employed to diagnose as well as to treat musculoskeletal disorders, pelvic floor dysfunction, and post-stroke motor deficits, among others. Despite the extensive literature on sEMG, the clinical community has not widely adopted it. We believe that in developing countries, such as Chile, this phenomenon may be explained by several interacting barriers. First, the socioeconomics of the country creates an environment where only high cost-effective treatments are routinely applied. Second, the majority of the sEMG literature on clinical applications has not extensively translated into decisive outcomes, which interferes with its applicability in low-income contexts. Third, clinical training on rehabilitation provides inadequate instruction on sEMG. And fourth, accessibility to equipment (i.e., affordability, availability, portability) may constitute another barrier, especially among developing countries. Here, we analyze socio-economic indicators of health care in Chile and comment on current literature about the use of sEMG in rehabilitation. Then we analyze the curricula of several physical therapy schools in Chile and report some estimations of the training on sEMG. Finally, we analyze the accessibility of some available sEMG devices and show that several match predefined criteria. We conclude that in developing countries, the insufficient use of sEMG in health might be explained by a shortage of evidence showing a crucial role in specific outcomes and the lack of training in rehabilitation-related careers, which interact with local socioeconomic factors that limit the application of these techniques.

Analysis and Biophysics of Surface EMG for Physiotherapists and Kinesiologists: Toward a Common Language With Rehabilitation Engineers

Recent decades have seen a move toward evidence-based medicine to inform the clinical decision-making process with reproducible findings from high-quality research studies. There is a need for objective, quantitative measurement tools to increase the reliability and reproducibility of studies evaluating the efficacy of healthcare interventions, particularly in the field of physical and rehabilitative medicine. Surface electromyography (sEMG) is a non-invasive measure of muscle activity that is widely used in research but is under-utilized as a clinical tool in rehabilitative medicine. Other types of electrophysiological signals (e.g., electrocardiography, electroencephalography, intramuscular EMG) are commonly recorded by healthcare practitioners, however, sEMG has yet to successfully transition to clinical practice. Surface EMG has clear clinical potential as an indicator of muscle activation, however reliable extraction of information requires knowledge of the appropriate methods for recording and analyzing sEMG and an understanding of the underlying biophysics. These concepts are generally not covered in sufficient depth in the standard curriculum for physiotherapists and kinesiologists to encourage a confident use of sEMG in clinical practice. In addition, the common perception of sEMG as a specialized topic means that the clinical potential of sEMG and the pathways to application in practice are often not apparent. The aim of this paper is to address barriers to the translation of sEMG by emphasizing its benefits as an objective clinical tool and by overcoming its perceived complexity. The many useful clinical applications of sEMG are highlighted and examples provided to illustrate how it can be implemented in practice. The paper outlines how fundamental biophysics and EMG signal processing concepts could be presented to a non-technical audience. An accompanying tutorial with sample data and code is provided which could be used as a tool for teaching or self-guided learning. The importance of observing sEMG in routine use in clinic is identified as an essential part of the effective communication of sEMG recording and signal analysis methods. Highlighting the advantages of sEMG as a clinical tool and reducing its perceived complexity could bridge the gap between theoretical knowledge and practical application and provide the impetus for the widespread use of sEMG in clinic.

A Survey on the Use and Barriers of Surface Electromyography in Neurorehabilitation

Historical, educational, and technical barriers have been reported to limit the use of surface electromyography (sEMG) in clinical neurorehabilitation settings. In an attempt to identify, review, rank, and interpret potential factors that may play a role in this scenario, we gathered information on (1) current use of sEMG and its clinical potential; (2) professional figures primarily dealing with sEMG; (3) educational aspects, and (4) possible barriers and reasons for its apparently limited use in neurorehabilitation. To this aim, an online 30-question survey was sent to 52 experts on sEMG from diverse standpoints, backgrounds, and countries. Participants were asked to respond to each question on a 5-point Likert scale or by ranking items. A cut-off of 75% agreement was chosen as the consensus threshold. Thirty-five invitees (67%) completed the electronic survey. Consensus was reached for 77% of the proposed questions encompassing current trends in sEMG use in neurorehabilitation, educational, technical, and methodological features as well as its translational utility for clinicians and patients. Data evidenced the clinical utility of sEMG for patient assessment, to define the intervention plan, and to complement/optimize other methods used to quantify muscle and physical function. The aggregate opinion of the interviewed experts confirmed that sEMG is more frequently employed in technical/methodological than clinical research. Moreover, the slow dissemination of research findings and the lack of education on sEMG seem to prevent prompt transfer into practice. The findings of the present survey may contribute to the ongoing debate on the appropriateness and value of sEMG for neurorehabilitation professionals and its potential translation into clinical settings.

Surface EMG in Clinical Assessment and Neurorehabilitation: Barriers Limiting Its Use

This article addresses the potential clinical value of techniques based on surface electromyography (sEMG) in rehabilitation medicine with specific focus on neurorehabilitation. Applications in exercise and sport pathophysiology, in movement analysis, in ergonomics and occupational medicine, and in a number of related fields are also considered. The contrast between the extensive scientific literature in these fields and the limited clinical applications is discussed. The "barriers" between research findings and their application are very broad, and are longstanding, cultural, educational, and technical. Cultural barriers relate to the general acceptance and use of the concept of objective measurement in a clinical setting and its role in promoting Evidence Based Medicine. Wide differences between countries exist in appropriate training in the use of such quantitative measurements in general, and in electrical measurements in particular. These differences are manifest in training programs, in degrees granted, and in academic/research career opportunities. Educational barriers are related to the background in mathematics and physics for rehabilitation clinicians, leading to insufficient basic concepts of signal interpretation, as well as to the lack of a common language with rehabilitation engineers. Technical barriers are being overcome progressively, but progress is still impacted by the lack of user-friendly equipment, insufficient market demand, gadget-like devices, relatively high equipment price and a pervasive lack of interest by manufacturers. Despite the recommendations provided by the 20-year old EU project on "Surface EMG for Non-Invasive Assessment of Muscles (SENIAM)," real international standards are still missing and there is minimal international pressure for developing and applying such standards. The need for change in training and teaching is increasingly felt in the academic world, but is much less perceived in the health delivery system and clinical environments. The rapid technological progress in the fields of sensor and measurement technology (including sEMG), assistive devices, and robotic rehabilitation, has not been driven by clinical demands. Our assertion is that the most important and urgent interventions concern enhanced education, more effective technology transfer, and increased academic opportunities for physiotherapists, occupational therapists, and kinesiologists.

"Look, Your Muscles Are Firing!": A Qualitative Study of Clinician Perspectives on the Use of Surface Electromyography in Neurorehabilitation

OBJECTIVE

To examine the perceived value, benefits, drawbacks, and ideas for technology development and implementation of surface electromyography recordings in neurologic rehabilitation practice from clinical stakeholder perspectives.

DESIGN

A qualitative, phenomenological study was conducted. In-depth, semistructured interviews and focus groups were completed. Sessions included questions about clinician perspectives and demonstrations of surface electromyography systems to garner perceptions of specific system features.

SETTING

The study was conducted at hospital systems in a large metropolitan area.

PARTICIPANTS

Adult and pediatric physical therapists, occupational therapists, and physiatrists from inpatient, outpatient, and research settings (N=22) took part in the study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Interviews and focus groups were audio-recorded, transcribed verbatim, then coded for analysis into themes.

RESULTS

Four major themes emerged: (1) low-tech clinical practice and future directions for rehabilitation; (2) barriers to surface electromyography uptake and potential solutions; (3) benefits of surface electromyography for targeted populations; and (4) essential features of surface electromyography systems.

CONCLUSIONS

Surface electromyography systems were not routinely utilized for assessment or intervention following neurologic injury. Despite recognition of potential clinical benefits of surface electromyography use, clinicians identified limited time and resources as key barriers to implementation. Perspectives on design and surface electromyography system features indicated the need for streamlined, intuitive, and clinically effective applications. Further research is needed to determine feasibility and clinical relevance of surface electromyography in rehabilitation intervention.