Tele-Supervised FES-Assisted Exercise for Hemiplegic Upper Limb

Effects of home-based neurostimulation on outcomes after stroke: a systematic review and meta-analysis

BACKGROUND

Home-based rehabilitation is a cost-effective means of making services available for patients. The aim of this study is to determine the evidence in the literature on the effects of home-based neurostimulation in patients with stroke.

METHOD

We searched PubMED, Embase, Web of Science, Scopus, and CENTRAL for randomized controlled trials on the subject matter using keywords such as stroke, electrical stimulation and transcranial direct current stimulation. Information on participants' characteristics and mean scores on the outcomes of interest were extracted. Risks of bias and methodological quality of the included studies were assessed using Cochrane Risks of bias tool and PEDro scale respectively. The data was analyzed using both narrative and quantitative syntheses. In the quantitative synthesis, meta-analysis was carried out using random effect model analysis.

RESULT

The results showed that, home-based neurostimulation is superior to the control at improving upper limb muscle strength (SMD = 0.72, 95% CI = 0.08 to 1.32, p = 0.03), functional mobility (SMD = -0.39, 95% CI = -0.65 to 0.14, p = 0.003) and walking endurance (SMD = 0.33, 95% CI = 0.08 to 0.59, p = 0.01) post intervention; and upper limb motor function (SMD = 0.9, 95% CI = 0.10 to 1.70, p = 0.03), functional mobility (SMD = -0.30, 95% CI = -0.56 to -0.05, p = 0.02) and walking endurance (SMD = 0.33, 95% CI = 0.08 to 0.59, p = 0.01) at follow-up.

CONCLUSIONS

Home-based neurostimulation can be used to improve upper and lower limb function after stroke.

Video Game-Based Trunk Exercises for Rehabilitation in Chronic Stroke Survivors: A Mixed-Methods Feasibility Study

Aim: To assess the feasibility of video game-based trunk exercises using the Valedo® system in a chronic stroke population. Method: Ten chronic stroke survivors (eight males and two females, mean age 63 ± 15 years) were asked to complete 18 intervention sessions, each lasting 45 min., over 6-8 weeks. Feasibility was evaluated quantitatively using the Psychosocial Impact of Assistive Devices Scale (PIADS) as well as through recruitment, retention, adherence, and safety measures. Qualitative data on feasibility were collected through post-intervention semi-structured interviews. Descriptive analysis was used to summarize participant characteristics, recruitment, retention, and adherence. Qualitative data were analyzed using thematic analysis of the interviews. Results: Twelve stroke survivors were recruited from Southampton (United Kingdom) and Riyadh (Kingdom of Saudi Arabia), with two participants dropping out after the baseline assessment session. The remaining ten participants completed the study with a mean adherence of 96.11% to the planned sessions. No serious adverse effects were reported, however, four participants did experience trunk muscle tightness and fatigue. Post-intervention interviews revealed that participants encountered some physical and cognitive challenges while playing the Valedo video games. However, they felt that the implementation of trunk exercises using video games was safe, as the exercises were performed in a secure environment and in safe positions. Conclusions: The findings suggest that the Valedo system is feasible for delivering trunk exercises to chronic stroke survivors. Several factors should be considered when implementing this type of intervention in the future.

The use of home-based digital technology to support post-stroke upper limb rehabilitation: A scoping review

OBJECTIVE

To identify, map and synthesize the extent and nature of existing studies on the use of home-based digital technology to support post-stroke upper limb rehabilitation.

DATA SOURCES

A comprehensive literature search was completed between 30 May 2022 and 05 April 2023, from seven online databases (CINAHL, Cochrane Library, PubMed, ScienceDirect, IEEExplore, Web of Science and PEDro), Google Scholar and the reference lists of already identified articles.

METHODS

A scoping review was conducted according to Arksey and O'Malley (2005), and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. All English-language studies reporting on the use of home-based digital technology to support upper limb post-stroke rehabilitation were eligible for inclusion.

RESULTS

The search generated a total of 1895 records, of which 76 articles met the inclusion criteria. Of these, 52 were experimental studies and the rest, qualitative, case series and case studies. Of the overall 2149 participants, 2028 were stroke survivors with upper limb impairment. The majority of studies were aimed at developing, designing and/or assessing the feasibility, acceptability and efficacy of a digital system for poststroke upper limb rehabilitation in home settings. The thematic analysis found six major categories: Tele-rehabilitation (n = 29), games (n = 45), virtual reality (n = 26), sensor (n = 22), mobile technology (n = 22), and robotics (n = 8).

CONCLUSION

The digital technologies used in post-stroke upper limb rehabilitation were multimodal, and system-based comprising telerehabilitation, gamification, virtual reality, mobile technology, sensors and robotics. Furthermore, future research should focus to determine the effectiveness of these modalities.

Contralaterally EMG-triggered functional electrical stimulation during serious gaming for upper limb stroke rehabilitation: a feasibility study

Introduction

Virtual Reality/serious games (SG) and functional electrical stimulation (FES) therapies are used in upper limb stroke rehabilitation. A combination of both approaches seems to be beneficial for therapy success. The feasibility of a combination of SG and contralaterally EMG-triggered FES (SG+FES) was investigated as well as the characteristics of responders to such a therapy.

Materials and methods

In a randomized crossover trial, patients performed two gaming conditions: SG alone and SG+FES. Feasibility of the therapy system was assessed using the Intrinsic Motivation Inventory (IMI), the Nasa Task Load Index, and the System Usability Scale (SUS). Gaming parameters, fatigue level and a technical documentation was implemented for further information.

Results

In total, 18 patients after stroke (62.1 ± 14.1 years) with a unilateral paresis of the upper limb (MRC ≤4) were analyzed in this study. Both conditions were perceived as feasible. Comparing the IMI scores between conditions, perceived competence was significantly increased (z = -2.88, p = 0.004) and pressure/tension during training (z = -2.13, p = 0.034) was decreased during SG+FES. Furthermore, the task load was rated significantly lower for the SG+FES condition (z = -3.14, p = 0.002), especially the physical demand (z = -3.08, p = 0.002), while the performance was rated better (z = -2.59, p = 0.010). Responses to the SUS and the perceived level of fatigue did not differ between conditions (SUS: z = -0.79, p = 0.431; fatigue: z = 1.57, p = 0.115). For patients with mild to moderate impairments (MRC 3-4) the combined therapy provided no or little gaming benefit. The additional use of contralaterally controlled FES (ccFES), however, enabled severely impaired patients (MRC 0-1) to play the SG.

Discussion

The combination of SG with ccFES is feasible and well-accepted among patients after stroke. It seems that the additional use of ccFES may be more beneficial for severely impaired patients as it enables the execution of the serious game. These findings provide valuable implications for the development of rehabilitation systems by combining different therapeutic interventions to increase patients' benefit and proposes system modifications for home use.

Clinical trial registration

https://drks.de/search/en, DRKS00025761.

Coaching-Based Teleoccupational Guidance for Home-Based Stroke Survivors and Their Family Caregivers: Study Protocol for a Superior Randomized Controlled Trial

Background

Home-based rehabilitation has been shown to be useful for stroke survivors to participate in daily life activities and return to their families. However, many home-based stroke survivors face challenges in the lack of professional guidance, rational training plans, and insufficient motivation, which will affect their rehabilitation outcomes to varying degrees. Though occupational therapy and coaching are widely recommended for stroke rehabilitation, studies that combine these two interventions via telerehabilitation in home-based rehabilitation are limited. Hence, this study will explore whether coaching-based teleoccupational guidance (CTG) will help stroke survivors and caregivers obtain satisfactory outcomes.

Methods

This single-blind (assessor), two-arm parallel superior randomised controlled trial will be conducted in the Hebei General Hospital, Shijiazhuang, China. Ninety-two participant dyads in home-based rehabilitation will be recruited and randomised to either CTG (intervention group) or a standard telerehabilitation group (control group). Participant dyads in the intervention group will follow a 6-step circle procedure and receive 12 teleoccupational coaching sessions over 3 months via WeChat. Data will be collected at baseline, after the intervention (3 months), and follow-up (6 months). The Reintegration to Normal Living Index will be the primary outcome to assess the participation of stroke survivors. Secondary outcomes will not only involve an observation of changes in activities of daily living, intrinsic motivation, motor function, and quality of life of stroke survivors but also will focus on the caregivers' perceived benefit and care burden. Discussion. This trial will assess the effects of CTG compared with standard telerehabilitation. We believe that the results of this study will add to the understanding of occupational therapy for stroke survivors in home-based rehabilitation and provide a reference for developing health policy and facilitating other chronic management. Trial Registration Number. The Chinese Clinical Trial Registry ChiCTR2200061107.

Wearable myoelectric interface enables high-dose, home-based training in severely impaired chronic stroke survivors

Background

High‐intensity occupational therapy can improve arm function after stroke, but many people lack access to such therapy. Home‐based therapies could address this need, but they don’t typically address abnormal muscle co‐activation, an important aspect of arm impairment. An earlier study using lab‐based, myoelectric computer interface game training enabled chronic stroke survivors to reduce abnormal co‐activation and improve arm function. Here, we assess feasibility of doing this training at home using a novel, wearable, myoelectric interface for neurorehabilitation training (MINT) paradigm.

Objective

Assess tolerability and feasibility of home‐based, high‐dose MINT therapy in severely impaired chronic stroke survivors.

Methods

Twenty‐three participants were instructed to train with the MINT and game for 90 min/day, 36 days over 6 weeks. We assessed feasibility using amount of time trained and game performance. We assessed tolerability (enjoyment and effort) using a customized version of the Intrinsic Motivation Inventory at the conclusion of training.

Results

Participants displayed high adherence to near‐daily therapy at home (mean of 82 min/day of training; 96% trained at least 60 min/day) and enjoyed the therapy. Training performance improved and co‐activation decreased with training. Although a substantial number of participants stopped training, most dropouts were due to reasons unrelated to the training paradigm itself.

Interpretation

Home‐based therapy with MINT is feasible and tolerable in severely impaired stroke survivors. This affordable, enjoyable, and mobile health paradigm has potential to improve recovery from stroke in a variety of settings.

Clinicaltrials.gov: NCT03401762.

Home Activity-based Interventions for the Neurologically Impaired Upper Extremity: A Scoping Review

Background:

Activity-based therapy (ABT) for the upper extremity (UE) enables neurologic recovery with tasks that are functional, intense, and highly repetitive. A large proportion of rehabilitation occurs in the home and there is a gap in literature on the application of ABT within the home. The objective of this scoping review was to describe ABT in the home-setting for the neurologically-impaired UE.

Methods:

A systematic scoping review included searches of: MEDLINE, CINAHL, Cochrane, and OTSeeker.

Results:

A systematic search yielded 51 final studies. About 61% of ABT studies were exclusively within the home, others included outpatient visits (37%). Telerehabilitation was used in 37% of the studies with live-video and store forward techniques equally represented. ABT supported by technology was used in 61% of studies. Dosing of intervention ranged from 7 to 120 hours, with a mean of 34.5 hours of practice. Adherence with intended dosing was reported in 27% of studies and subjects completed a mean of 86% of the intended practice time. Sixty-seven percent of studies reported some degree of practice without therapist supervision.

Conclusions:

The results showed wide variability in the intervention methods, dosing and technology used in homebased settings. The high rate of adherence with dosing is encouraging for the application of homebased neurologic UE interventions. This scoping review highlights feasibility of UE ABT within the home and need for further research.

Perseverance with technology-facilitated home-based upper limb practice after stroke: a systematic mixed studies review

Background

Technology is being increasingly investigated as an option to allow stroke survivors to exploit their full potential for recovery by facilitating home-based upper limb practice. This review seeks to explore the factors that influence perseverance with technology-facilitated home-based upper limb practice after stroke.

Methods

A systematic mixed studies review with sequential exploratory synthesis was undertaken. Studies investigating adult stroke survivors with upper limb disability undertaking technology-facilitated home-based upper limb practice administered ≥ 3 times/week over a period of ≥ 4 weeks were included. Qualitative outcomes were stroke survivors’ and family members’ perceptions of their experience utilising technology to facilitate home-based upper limb practice. Quantitative outcomes were adherence and dropouts, as surrogate measures of perseverance. The Mixed Methods Appraisal Tool was used to assess quality of included studies.

Results

Forty-two studies were included. Six studies were qualitative and of high quality; 28 studies were quantitative and eight were mixed methods studies, all moderate to low quality. A conceptual framework of perseverance with three stages was formed: (1) getting in the game; (2) sticking with it, and; (3) continuing or moving on. Conditions perceived to influence perseverance, and factors mediating these conditions were identified at each stage. Adherence with prescribed dose ranged from 13 to 140%. Participants were found to be less likely to adhere when prescribed sessions were more frequent (6–7 days/week) or of longer duration (≥ 12 weeks).

Conclusion

From the mixed methods findings, we propose a framework for perseverance with technology-facilitated home-based upper limb practice. The framework offers opportunities for clinicians and researchers to design strategies targeting factors that influence perseverance with practice, in both the clinical prescription of practice and technology design. To confirm the clinical utility of this framework, further research is required to explore perseverance and the factors influencing perseverance.

Registration: PROSPERO CRD42017072799—https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=72799

Automated functional electrical stimulation training system for upper-limb function recovery in poststroke patients

BACKGROUND

This paper describes the design and test of an automated functional electrical stimulation (FES) system for poststroke rehabilitation training. The aim of automated FES is to synchronize electrically induced movements to assist residual movements of patients.

METHODS

In the design of the FES system, an accelerometry module detected movement initiation and movement performed by post-stroke patients. The desired movement was displayed in visual game module. Synergy-based FES patterns were formulated using a normal pattern of muscle synergies from a healthy subject. Experiment 1 evaluated how different levels of trigger threshold or timing affected the variability of compound movements for forward reaching (FR) and lateral reaching (LR). Experiment 2 explored the effect of FES duration on compound movements.

RESULTS

Synchronizing FES-assisted movements with residual voluntary movements produced more consistent compound movements. Matching the duration of synergy-based FES to that of patients could assist slower movements of patients with reduced RMS errors.

CONCLUSIONS

Evidence indicated that synchronization and matching duration with residual voluntary movements of patients could improve the consistency of FES assisted movements. Automated FES training can reduce the burden of therapists to monitor the training process, which may encourage patients to complete the training.

Functional Electrical Stimulation Therapy for Retraining Reaching and Grasping After Spinal Cord Injury and Stroke

Neurological conditions like hemiplegia following stroke or tetraplegia following spinal cord injury, result in a massive compromise in motor function. Each of the two conditions can leave individuals dependent on caregivers for the rest of their lives. Once medically stable, rehabilitation is the main stay of treatment. This article will address rehabilitation of upper extremity function. It is long known that moving the affected limb is crucial to recovery following any kind of injury. Overtime, it has also been established that just moving the affected extremities does not suffice, and that the movements have to involve patient’s participation, be as close to physiologic movements as possible, and should ideally stimulate the entire neuromuscular circuitry involved in producing the desired movement. For over four decades now, functional electrical stimulation (FES) is being used to either replace or retrain function. The FES therapy discussed in this article has been used to retrain upper extremity function for over 15 years. Published data of pilot studies and randomized control trials show that FES therapy produces significant changes in arm and hand function. There are specific principles of the FES therapy as applied in our studies: (i) stimulation is applied using surface stimulation electrodes, (ii) there is minimum to virtually no pain during application, (iii) each session lasts no more than 45–60 min, (iv) the technology is quite robust and can make up for specificity to a certain extent, and (v) fine motor function like two finger precision grip can be trained (i.e., thumb and index finger tip to tip pinch). The FES therapy protocols can be successfully applied to individuals with paralysis resulting from stroke or spinal cord injury.

IoT-Enabled Dual-Arm Motion Capture and Mapping for Telerobotics in Home Care

With the paradigm shift from hospital-centric healthcare to home-centric healthcare in Healthcare 4.0, healthcare robotics has become one of the fastest growing fields of robotics. The combination of robot capabilities with human intelligence, for example, telerobotics for home care, is gradually showing promising potentials. In this paper, the Home-TeleBot system, a generalized IoT-enabled telerobotic architecture designed to support home-centric healthcare system, is proposed. In particular, the implementation of it is realized by integrating human-motion-capture subsystem with robot-control subsystem. The dual-arm cooperative robot, YuMi, imitates human motion captured by a set of wearable inertial motion capture devices to complete tasks. The proposed approach using workspace mapping and path planning of robot manipulators, facilitates telerobot to execute tasks in a natural and human-like way. Based on the constant of proportionality calculated by comparing the human original workspace with the robot original workspace, the workspace mapping is achieved by making assumptions of the distance between end-effectors (human hands, robot's grippers) and shoulders. Additionally, robot manipulators' path is planned by setting virtual obstacles to constrain robot motion, which aims to improve the performance of robot's human-like motion. As a specific example of application, we apply the proposed architecture to a fetching task based on dual-arm motion capture and mapping for telerobotics in home care.

Garments for functional electrical stimulation: Design and proofs of concept

Introduction

Repeated use of functional electrical stimulation can promote functional recovery in individuals with neurological paralysis. We designed garments able to deliver functional electrical stimulation.

Methods

Shirts and pants containing electrodes knitted with a conductive yarn were produced. Electrodes were moistened with water before use. Stimulation intensity at four thresholds levels (sensory, movement, full range of motion, and maximal), stimulation comfort, and electrical properties of the interface were tested in one able-bodied subject with garment electrodes and size-matched conventional gel electrodes. The pants and shirt were then used to explore usability and design limitations.

Results

Compared to gel electrodes, fabric electrodes had a lower sensory threshold (on forearm muscles) but they had a higher maximal stimulation threshold (for all tested muscles). The stimulation delivery was comfortable when the garment electrodes were recently moistened; however, as the electrodes dried (within 9 to 18 min) stimulation became unpleasant. Inconsistent water content in the fabric electrodes caused inconsistent intensity thresholds and inconsistent voltage necessary to apply a desired stimulation current. Garments’ tightness and impracticality of electrode lead necessitate further design improvement.

Conclusions

Fabric electrodes offer a promising alternative to gel electrodes. Further work involving people with paralysis is required to overcome the identified challenges.

Development of an Activity-Dependent Epidural Stimulation System in Freely Moving Spinal Cord Injured Rats: A Proof of Concept Study

Purpose: Extensive pre-clinical and clinical experimentation has yielded data on the robustness and versatility of epidural stimulation (ES) strategies to activate spinal neural circuitry to produce functional benefits. Increasing studies are now reporting that closed-loop electrical stimulation delivery methods significantly enhance the neuromodulation effects of stimulation, to in turn, improve physiological outcomes of the intervention. No studies have yet explored the feasibility and usage of closed-loop systems to neuromodulate the cervical spinal cord using ES. Methods: We developed an activity-dependent system that utilizes electromyography (EMG) activity to trigger epidural stimulation (tES) of the cervical spinal cord in awake, freely moving rats. Experiments were performed on rats that were implanted with chronic forelimb EMG and cervical epidural implants, with (n = 7) and without (n = 2) a complete C4 spinal hemisection. Results: Our results show that the EMG triggered activity-dependent system can be reliably applied and reproduced for: (i) stimulating multiple rats simultaneously throughout the night during free home-cage activity and (ii) use as a mobile system for testing and training during various short-term behavioral testing conditions. The system was able to consistently generate stimulation pulse trains in response to attempted EMG activity that crossed a user-defined threshold in all rats for all experiments, including the overnight experiments that lasts for 7 h/session for 6 days/week through the 3-month period. Conclusion: The developed closed-loop system can be considered to represent a class of bidirectional neural prostheses via a circuit that enables two-way interactions between neural activity (real-time processing of EMG activity) and external devices (such as a stimulator). It can operate autonomously for extended periods of time in unrestrained rats, allowing its use as a long-term therapeutic tool. It can also enable us to study the long-term physiological effects of incorporating electrical stimulation techniques into the nervous system. The system can also be experimented for connecting several neural systems into a Brainet by combining neural signals from multiple rats dynamically and in real-time so as to enhance motor performance. Studies are ongoing in our laboratory to test the usefulness of this system in the recovery of hand function after cervical spinal cord injuries.

Neurophysiology and neural engineering: a review

Neurophysiology is the branch of physiology concerned with understanding the function of neural systems. Neural engineering (also known as neuroengineering) is a discipline within biomedical engineering that uses engineering techniques to understand, repair, replace, enhance, or otherwise exploit the properties and functions of neural systems. In most cases neural engineering involves the development of an interface between electronic devices and living neural tissue. This review describes the origins of neural engineering, the explosive development of methods and devices commencing in the late 1950s, and the present-day devices that have resulted. The barriers to interfacing electronic devices with living neural tissues are many and varied, and consequently there have been numerous stops and starts along the way. Representative examples are discussed. None of this could have happened without a basic understanding of the relevant neurophysiology. I also consider examples of how neural engineering is repaying the debt to basic neurophysiology with new knowledge and insight.