Bilateral upper limb training with functional electric stimulation in patients with chronic stroke

Portable robots for upper-limb rehabilitation after stroke: a systematic review and meta-analysis

BACKGROUND

Robot-assisted upper-limb rehabilitation has been studied for many years, with many randomised controlled trials (RCTs) investigating the effects of robotic-assisted training on affected limbs. The current trend directs towards end-effector devices. However, most studies have focused on the effectiveness of rehabilitation devices, but studies on device sizes are relatively few.

GOAL

Systematically review the effect of a portable rehabilitation robot (PRR) on the rehabilitation effectiveness of paralysed upper limbs compared with non-robotic therapy.

METHODS

A meta-analysis was conducted on literature that included the Fugl-Meyer Assessment (FMA) obtained from the PubMed and Web of Science (WoS) electronic databases until June 2023.

RESULTS

A total of 9 studies, which included RCTs, were completed and a meta-analysis was conducted on 8 of them. The analysis involved 295 patients. The influence on upper-limb function before and after treatment in a clinical environment is analysed by comparing the experimental group using the portable upper-limb rehabilitation robot with the control group using conventional therapy. The result shows that portable robots prove to be effective (FMA: SMD = 0.696, 95% = 0.099 to.293, p < 0.05).

DISCUSSION

Both robot-assisted and conventional rehabilitation effects are comparable. In some studies, PRR performs better than conventional rehabilitation, but conventional treatments are still irreplaceable. Smaller size with better portability has its advantages, and portable upper-limb rehabilitation robots are feasible in clinical rehabilitation.

CONCLUSION

Although portable upper-limb rehabilitation robots are clinically beneficial, few studies have focused on portability. Further research should focus on modular design so that rehabilitation robots can be decomposed, which benefits remote rehabilitation and household applications.

MEFFNet: Forecasting Myoelectric Indices of Muscle Fatigue in Healthy and Post-Stroke During Voluntary and FES-Induced Dynamic Contractions

Myoelectric indices forecasting is important for muscle fatigue monitoring in wearable technologies, adaptive control of assistive devices like exoskeletons and prostheses, functional electrical stimulation (FES)-based Neuroprostheses, and more. Non-stationary temporal development of these indices in dynamic contractions makes forecasting difficult. This study aims at incorporating transfer learning into a deep learning model, Myoelectric Fatigue Forecasting Network (MEFFNet), to forecast myoelectric indices of fatigue (both time and frequency domain) obtained during voluntary and FES-induced dynamic contractions in healthy and post-stroke subjects respectively. Different state-of-the-art deep learning models along with the novel MEFFNet architecture were tested on myoelectric indices of fatigue obtained during [Formula: see text] voluntary elbow flexion and extension with four different weights (1 kg, 2 kg, 3 kg, and 4 kg) in sixteen healthy subjects, and [Formula: see text] FES-induced elbow flexion in sixteen healthy and seventeen post-stroke subjects under three different stimulation patterns (customized rectangular, trapezoidal, and muscle synergy-based). A version of MEFFNet, named as pretrained MEFFNet, was trained on a dataset of sixty thousand synthetic time series to transfer its learning on real time series of myoelectric indices of fatigue. The pretrained MEFFNet could forecast up to 22.62 seconds, 60 timesteps, in future with a mean absolute percentage error of 15.99 ± 6.48% in voluntary and 11.93 ± 4.77% in FES-induced contractions, outperforming the MEFFNet and other models under consideration. The results suggest combining the proposed model with wearable technology, prosthetics, robotics, stimulation devices, etc. to improve performance. Transfer learning in time series forecasting has potential to improve wearable sensor predictions.

Investigation of Motor Learning Effects Using a Hybrid Rehabilitation System Based on Motion Estimation

Upper-limb paralysis requires extensive rehabilitation to recover functionality for everyday living, and such assistance can be supported with robot technology. Against such a background, we have proposed an electromyography (EMG)-driven hybrid rehabilitation system based on motion estimation using a probabilistic neural network. The system controls a robot and functional electrical stimulation (FES) from movement estimation using EMG signals based on the user's intention, enabling intuitive learning of joint motion and muscle contraction capacity even for multiple motions. In this study, hybrid and visual-feedback training were conducted with pointing movements involving the non-dominant wrist, and the motor learning effect was examined via quantitative evaluation of accuracy, stability, and smoothness. The results show that hybrid instruction was as effective as visual feedback training in all aspects. Accordingly, passive hybrid instruction using the proposed system can be considered effective in promoting motor learning and rehabilitation for paralysis with inability to perform voluntary movements.

Peripheral electrical stimulation on neuroplasticity and motor function in stroke patients: a systematic review and meta-analysis

INTRODUCTION

The use of electrotherapy has been presented as a great resource for the professional physiotherapist in the most diverse pathologies. Stroke is a neurological condition responsible for sequelae such as hemiplegia that directly impair the quality of life of patients.

OBJECTIVE

This study aimed to review the literature on the effects of electrotherapeutic resources on motor function and neuroplasticity in individuals with post-stroke sequelae.

MATERIALS AND METHODS

2427 articles were found in databases according to search criteria for each base according to the included descriptors (EndNote Web). After exclusion of duplicate articles, automatically and manually, Phase 1 was performed - reading of titles and abstracts of 1626 articles according to eligibility criteria by two blinded reviewers using the programme Rayyan QCRI (Qatar Computing Research Institute), conflicts were resolved in consensus between the two reviewers. Thus, 13 articles were selected for Phase 2-13 articles were selected for reading in full, leaving 8 articles in this review. To assess the quality of bias of the selected studies, the PEDro Scale was used.

RESULTS

In the assessment of neuroplasticity, statistically significant results were found in two studies (p < 0.05). However, the effects of electrostimulation stood out significantly in the motor function of these individuals (p < 0.05). It can be considered with neuroplasticity, since improved functionality can be related to electrostimulation-induced neuroplasticity. Conclusions Electrostimulation is able to promote neuroplasticity and increase motor function, generating positive effects in the treatment of individuals with post-stroke sequelae.

A scoping review on recent trends in wearable sensors to analyze gait in people with stroke: From sensor placement to validation against gold-standard equipment

The purpose of the review is to evaluate wearable sensor placement, their impact and validation of wearable sensors on analyzing gait, primarily the postural instability in people with stroke. Databases, namely PubMed, Cochrane, SpringerLink, and IEEE Xplore were searched to identify related articles published since January 2005. The authors have selected the articles by considering patient characteristics, intervention details, and outcome measurements by following the priorly set inclusion and exclusion criteria. From a total of 1077 articles, 142 were included in this study and classified into functional fields, namely postural stability (PS) assessments, physical activity monitoring (PA), gait pattern classification (GPC), and foot drop correction (FDC). The review covers the types of wearable sensors, their placement, and their performance in terms of reliability and validity. When employing a single wearable sensor, the pelvis and foot were the most used locations for detecting gait asymmetry and kinetic parameters, respectively. Multiple Inertial Measurement Units placed at different body parts were effectively used to estimate postural stability and gait pattern. This review article has compared results of placement of sensors at different locations helping researchers and clinicians to identify the best possible placement for sensors to measure specific kinematic and kinetic parameters in persons with stroke.

Encoder-Controlled Functional Electrical Stimulator for Bilateral Wrist Activities—Design and Evaluation

Upper limb impairment following stroke is often characterized by limited voluntary control in the affected arm. In addition, significant motor coordination problems occur on the unaffected arm due to avoidance of performing bilateral symmetrical activities. Rehabilitation strategies should, therefore, not only aim at improving voluntary control on the affected arm, but also contribute to synchronizing activity from both upper limbs. The encoder-controlled functional electrical stimulator, described in this paper, implements precise contralateral control of wrist flexion and extension with electrical stimulation. The stimulator is calibrated for each individual to obtain a table of stimulation parameters versus wrist angle. This table is used to set stimulation parameters dynamically, based on the difference in wrist angle between the set and stimulated side, which is continuously monitored. This allows the wrist on the stimulated side to follow flexion and extension patterns on the set side, thereby mirroring wrist movements of the normal side. This device also gives real-time graphical feedback on how the stimulated wrist is performing in comparison to the normal side. A study was performed on 25 normal volunteers to determine how closely wrist movements on the set side were being followed on the stimulated side. Graphical results show that there were minor differences, which were quantified by considering the peak angles of flexion and extension on the set and stimulated side for each participant. The mean difference in peak flexion and extension range of movement was 2.3 degrees and 1.9 degrees, respectively, with a mean time lag of 1 s between the set and the stimulated angle graphs.

A Co-driven Functional Electrical Stimulation Control Strategy by Dynamic Surface Electromyography and Joint Angle

Functional electrical stimulation (FES) is widely used in neurorehabilitation to improve patients’ motion ability. It has been verified to promote neural remodeling and relearning, during which FES has to produce an accurate movement to obtain a good efficacy. Therefore, many studies have focused on the relationship between FES parameters and the generated movements. However, most of the relationships have been established in static contractions, which leads to an unsatisfactory result when applied to dynamic conditions. Therefore, this study proposed a FES control strategy based on the surface electromyography (sEMG) and kinematic information during dynamic contractions. The pulse width (PW) of FES was determined by a direct transfer function (DTF) with sEMG features and joint angles as the input. The DTF was established by combing the polynomial transfer functions of sEMG and joint torque and the polynomial transfer functions of joint torque and FES. Moreover, the PW of two FES channels was set based on the muscle synergy ratio obtained through sEMG. A total of six healthy right-handed subjects were recruited in this experiment to verify the validity of the strategy. The PW of FES applied to the left arm was evaluated based on the sEMG of the right extensor carpi radialis (ECR) and the right wrist angle. The coefficient of determination (R²) and the normalized root mean square error (NRMSE) of FES-included and voluntary wrist angles and torques were used to verify the performance of the strategy. The result showed that this study achieved a high accuracy (R² = 0.965 and NRMSE = 0.047) of joint angle and a good accuracy (R² = 0.701 and NRMSE = 0.241) of joint torque reproduction during dynamic movements. Moreover, the DTF in real-time FES system also had a nice performance of joint angle fitting (R² = 0.940 and NRMSE = 0.071) and joint torque fitting (R² = 0.607 and NRMSE = 0.303). It is concluded that the proposed strategy is able to generate proper FES parameters based on sEMG and kinematic information for dynamic movement reproduction and can be used in a real-time FES system combined with bilateral movements for better rehabilitation.

Usability of Functional Electrical Stimulation in Upper Limb Rehabilitation in Post-Stroke Patients: A Narrative Review

Stroke leads to significant impairment in upper limb (UL) function. The goal of rehabilitation is the reestablishment of pre-stroke motor stroke skills by stimulating neuroplasticity. Among several rehabilitation approaches, functional electrical stimulation (FES) is highlighted in stroke rehabilitation guidelines as a supplementary therapy alongside the standard care modalities. The aim of this study is to present a comprehensive review regarding the usability of FES in post-stroke UL rehabilitation. Specifically, the factors related to UL rehabilitation that should be considered in FES usability, as well a critical review of the outcomes used to assess FES usability, are presented. This review reinforces the FES as a promising tool to induce neuroplastic modifications in post-stroke rehabilitation by enabling the possibility of delivering intensive periods of treatment with comparatively less demand on human resources. However, the lack of studies evaluating FES usability through motor control outcomes, specifically movement quality indicators, combined with user satisfaction limits the definition of FES optimal therapeutical window for different UL functional tasks. FES systems capable of integrating postural control muscles involving other anatomic regions, such as the trunk, during reaching tasks are required to improve UL function in post-stroke patients.

A review on magnetic and spintronic neurostimulation: challenges and prospects

In the treatment of neurodegenerative, sensory and cardiovascular diseases, electrical probes and arrays have shown quite a promising success rate. However, despite the outstanding clinical outcomes, their operation is significantly hindered by non-selective control of electric fields. A promising alternative is micromagnetic stimulation (μMS) due to the high permeability of magnetic field through biological tissues. The induced electric field from the time-varying magnetic field generated by magnetic neurostimulators is used to remotely stimulate neighboring neurons. Due to the spatial asymmetry of the induced electric field, high spatial selectivity of neurostimulation has been realized. Herein, some popular choices of magnetic neurostimulators such as microcoils (μcoils) and spintronic nanodevices are reviewed. The neurostimulator features such as power consumption and resolution (aiming at cellular level) are discussed. In addition, the chronic stability and biocompatibility of these implantable neurostimulator are commented in favor of further translation to clinical settings. Furthermore, magnetic nanoparticles (MNPs), as another invaluable neurostimulation material, has emerged in recent years. Thus, in this review we have also included MNPs as a remote neurostimulation solution that overcomes physical limitations of invasive implants. Overall, this review provides peers with the recent development of ultra-low power, cellular-level, spatially selective magnetic neurostimulators of dimensions within micro- to nano-range for treating chronic neurological disorders. At the end of this review, some potential applications of next generation neuro-devices have also been discussed.

Rehabilitation of Upper Limb Motor Impairment in Stroke: A Narrative Review on the Prevalence, Risk Factors, and Economic Statistics of Stroke and State of the Art Therapies

Stroke has been one of the leading causes of disability worldwide and is still a social health issue. Keeping in view the importance of physical rehabilitation of stroke patients, an analytical review has been compiled in which different therapies have been reviewed for their effectiveness, such as functional electric stimulation (FES), noninvasive brain stimulation (NIBS) including transcranial direct current stimulation (t-DCS) and transcranial magnetic stimulation (t-MS), invasive epidural cortical stimulation, virtual reality (VR) rehabilitation, task-oriented therapy, robot-assisted training, tele rehabilitation, and cerebral plasticity for the rehabilitation of upper extremity motor impairment. New therapeutic rehabilitation techniques are also being investigated, such as VR. This literature review mainly focuses on the randomized controlled studies, reviews, and statistical meta-analyses associated with motor rehabilitation after stroke. Moreover, with the increasing prevalence rate and the adverse socio-economic consequences of stroke, a statistical analysis covering its economic factors such as treatment, medication and post-stroke care services, and risk factors (modifiable and non-modifiable) have also been discussed. This review suggests that if the prevalence rate of the disease remains persistent, a considerable increase in the stroke population is expected by 2025, causing a substantial economic burden on society, as the survival rate of stroke is high compared to other diseases. Compared to all the other therapies, VR has now emerged as the modern approach towards rehabilitation motor activity of impaired limbs. A range of randomized controlled studies and experimental trials were reviewed to analyse the effectiveness of VR as a rehabilitative treatment with considerable satisfactory results. However, more clinical controlled trials are required to establish a strong evidence base for VR to be widely accepted as a preferred rehabilitation therapy for stroke.

Neuromuscular Stimulation as an Intervention Tool for Recovery from Upper Limb Paresis after Stroke and the Neural Basis

Neuromodulators at the periphery, such as neuromuscular electrical stimulation (NMES), have been developed as add-on tools to regain upper extremity (UE) paresis after stroke, but this recovery has often been limited. To overcome these limits, novel strategies to enhance neural reorganization and functional recovery are needed. This review aims to discuss possible strategies for enhancing the benefits of NMES. To date, NMES studies have involved some therapeutic concerns that have been addressed under various conditions, such as the time of post-stroke and stroke severity and/or with heterogeneous stimulation parameters, such as target muscles, doses or durations of treatment and outcome measures. We began by identifying factors sensitive to NMES benefits among heterogeneous conditions and parameters, based on the “progress rate (PR)”, defined as the gains in UE function scores per intervention duration. Our analysis disclosed that the benefits might be affected by the target muscles, stroke severity and time period after stroke. Likewise, repetitive peripheral neuromuscular magnetic stimulation (rPMS) is expected to facilitate motor recovery, as already demonstrated by a successful study. In parallel, our efforts should be devoted to further understanding the precise neural mechanism of how neuromodulators make UE function recovery occur, thereby leading to overcoming the limits. In this study, we discuss the possible neural mechanisms.

Effectiveness of a Novel Contralaterally Controlled Neuromuscular Electrical Stimulation for Restoring Lower Limb Motor Performance and Activities of Daily Living in Stroke Survivors: A Randomized Controlled Trial

Background

Contralaterally controlled neuromuscular electrical stimulation (CCNMES) is a novel electrical stimulation treatment for stroke; however, reports on the efficacy of CCNMES on lower extremity function after stroke are scarce.

Objective

To compare the effects of CCNMES versus NMES on lower extremity function and activities of daily living (ADL) in subacute stroke patients.

Methods

Forty-four patients with a history of subacute stroke were randomly assigned to a CCNMES group and a NMES group (n = 22 per group). Twenty-one patients in each group completed the study per protocol, with one subject lost in follow-up in each group. The CCNMES group received CCNMES to the tibialis anterior (TA) and the peroneus longus and brevis muscles to induce ankle dorsiflexion motion, whereas the NMES group received NMES. The stimulus current was a biphasic waveform with a pulse duration of 200 μs and a frequency of 60 Hz. Patients in both groups underwent five 15 min sessions of electrical stimulation per week for three weeks. Indicators of motor function and ADL were measured pre- and posttreatment, including the Fugl–Meyer assessment of the lower extremity (FMA-LE) and modified Barthel index (MBI). Surface electromyography (sEMG) assessments included average electromyography (aEMG), integrated electromyography (iEMG), and root mean square (RMS) of the paretic TA muscle.

Results

Values for the FMA-LE, MBI, aEMG, iEMG, and RMS of the affected TA muscle were significantly increased in both groups after treatment (p < 0.01). Patients in the CCNMES group showed significant improvements in all the measurements compared with the NMES group after treatment. Within-group differences in all post- and pretreatment indicators were significantly greater in the CCNMES group than in the NMES group (p < 0.05).

Conclusion

CCNMES improved motor function and ADL ability to a greater extent than the conventional NMES in subacute stroke patients.

Effectiveness of Contralaterally Controlled Functional Electrical Stimulation versus Neuromuscular Electrical Stimulation on Upper Limb Motor Functional Recovery in Subacute Stroke Patients: A Randomized Controlled Trial

Purpose

To compare the effectiveness of contralaterally controlled functional electrical stimulation (CCFES) versus neuromuscular electrical stimulation (NMES) on motor recovery of the upper limb in subacute stroke patients.

Materials and Methods

Fifty patients within six months poststroke were randomly assigned to the CCFES group (n = 25) and the NMES group (n = 25). Both groups underwent routine rehabilitation plus 20-minute stimulation on wrist extensors per day, five days a week, for 3 weeks. Fugl-Meyer Assessment of upper extremity (FMA-UE), action research arm test (ARAT), Barthel Index (BI), and surface electromyography (sEMG) were assessed at baseline and end of intervention.

Results

After a 3-week intervention, FMA-UE and BI increased in both groups (p < 0.05). ARAT increased significantly only in the CCFES group (p < 0.05). The changes of FMA-UE, ARAT, and BI in the CCFES group were not greater than those in the NMES group. The improvement in sEMG response of extensor carpi radialis by CCFES was greater than that by NMES (p = 0.026). The cocontraction ratio (CCR) of flexor carpi radialis did not decrease in both groups.

Conclusions

CCFES improved upper limb motor function, but did not show better treatment effect than NMES. CCFES significantly enhanced the sEMG response of paretic extensor carpi radialis compared with NMES, but did not decrease the cocontraction of antagonist.

A New Socially Assistive Robot with Integrated Serious Games for Therapies with Children with Autism Spectrum Disorder and Down Syndrome: A Pilot Study

This work introduces a new socially assistive robot termed MARIA T21 (meaning “Mobile Autonomous Robot for Interaction with Autistics”, with the addition of the acronym T21, meaning “Trisomy 21”, which is used to designate individuals with Down syndrome). This new robot is used in psychomotor therapies for children with Down syndrome (contributing to improve their proprioception, postural balance, and gait) as well as in psychosocial and cognitive therapies for children with autism spectrum disorder. The robot uses, as a novelty, an embedded mini-video projector able to project Serious Games on the floor or tables to make already-established therapies funnier to these children, thus creating a motivating and facilitating effect for both children and therapists. The Serious Games were developed in Python through the library Pygame, considering theoretical bases of behavioral psychology for these children, which are integrated into the robot through the robot operating system (ROS). Encouraging results from the child–robot interaction are shown, according to outcomes obtained from the application of the Goal Attainment Scale. Regarding the Serious Games, they were considered suitable based on both the “Guidelines for Game Design of Serious Games for Children” and the “Evaluation of the Psychological Bases” used during the games’ development. Thus, this pilot study seeks to demonstrate that the use of a robot as a therapeutic tool together with the concept of Serious Games is an innovative and promising tool to help health professionals in conducting therapies with children with autistic spectrum disorder and Down syndrome. Due to health issues imposed by the COVID-19 pandemic, the sample of children was limited to eight children (one child with typical development, one with Trisomy 21, both female, and six children with ASD, one girl and five boys), from 4 to 9 years of age. For the non-typically developing children, the inclusion criterion was the existence of a conclusive diagnosis and fulfillment of at least 1 year of therapy. The protocol was carried out in an infant psychotherapy room with three video cameras, supervised by a group of researchers and a therapist. The experiments were separated into four steps: The first stage was composed of a robot introduction followed by an approximation between robot and child to establish eye contact and assess proxemics and interaction between child/robot. In the second stage, the robot projected Serious Games on the floor, and emitted verbal commands, seeking to evaluate the child’s susceptibility to perform the proposed tasks. In the third stage, the games were performed for a certain time, with the robot sending messages of positive reinforcement to encourage the child to accomplish the game. Finally, in the fourth stage, the robot finished the games and said goodbye to the child, using messages aiming to build a closer relationship with the child.

Concurrent impact of bilateral multiple joint functional electrical stimulation and treadmill walking on gait and spasticity in post-stroke survivors: a pilot study

Background: Stroke causes multi-joint gait deficits, so a major objective of post-stroke rehabilitation is to regain normal gait function. Design and Setting: A case series completed at a neuroscience institute. Aim: The aim of the study was to determine the concurrent impact of functional electrical stimulation (FES) during treadmill walking on gait speed, knee extensors spasticity and ankle plantar flexors spasticity in post-stroke survivors. Participants: Six post-stroke survivors with altered gait patterns and ankle plantar flexors spasticity (4 = male; age 56.8 ± 4.8 years; Body Mass Index (BMI) 26.2 ± 4.3; since onset of stroke: 30.8 ± 10.4 months; side of hemiplegia [L/R]: 3:3) were recruited. Intervention: Nine treatment sessions using FES bilaterally while walking on a treadmill. Main Outcome Measures: Primary outcome measures included the Modified Modified Ashworth Scale (MMAS), Timed Up and Go test (TUG), 10-m walking test, gait speed, and Functional ambulation category (FAC). Secondary outcome measures included the Step Length Test (SLT), and active range of motion (ROM) of the affected ankle and the knee. Measurements were taken at baseline (T0), at the end of last treatment (T1), and 1 month after the final treatment session (T2). Results: The TUG, 10-m walking test, gait speed, FAC, active ROM, and SLT all significantly improved following treatment (P< .05), while ankle plantar flexors spasticity (P = .135), and knee extensors spasticity (P = .368) did not show any significant decrease. Conclusions: A short duration of bilateral FES in conjugation with treadmill walking contributed to significant improvement in gait speed, functional mobility, functional ambulation, range of motion and step length in post-stroke survivors. In contrast, no significant decreases were identified in the spasticity of the ankle plantar flexors and knee extensors muscles.

A randomised clinical trial comparing 35 Hz versus 50 Hz frequency stimulation effects on hand motor recovery in older adults after stroke

More solid data are needed regarding the application of neuromuscular electrical stimulation (NMES) in the paretic hand following a stroke. A randomised clinical trial was conducted to compare the effects of two NMES protocols with different stimulation frequencies on upper limb motor impairment and function in older adults with spastic hemiparesis after stroke. Sixty nine outpatients were randomly assigned to the control group or the experimental groups (NMES with 50 Hz or 35 Hz). Outcome measures included motor impairment tests and functional assessment. They were collected at baseline, after 4 and 8 weeks of treatment, and after a follow-up period. NMES groups showed significant changes (p < 0.05) with different effect sizes in range of motion, grip and pinch strength, the Modified Ashworth Scale, and the muscle electrical activity in the extensors of the wrist. The 35 Hz NMES intervention showed a significant effect on Barthel Index. Additionally, there were no significant differences between the groups in the Box and Block Test. Both NMES protocols proved evidence of improvements in measurements related to hand motor recovery in older adults following a stroke, nevertheless, these findings showed that the specific stimulation frequency had different effects depending on the clinical measures under study.

Smart Protocols for Physical Therapy of Foot Drop Based on Functional Electrical Stimulation: A Case Study

Functional electrical stimulation (FES) is used for treating foot drop by delivering electrical pulses to the anterior tibialis muscle during the swing phase of gait. This treatment requires that a patient can walk, which is mostly possible in the later phases of rehabilitation. In the early phase of recovery, the therapy conventionally consists of stretching exercises, and less commonly of FES delivered cyclically. Nevertheless, both approaches minimize patient engagement, which is inconsistent with recent findings that the full rehabilitation potential could be achieved by an active psycho-physical engagement of the patient during physical therapy. Following this notion, we proposed smart protocols whereby the patient sits and ankle movements are FES-induced by self-control. In six smart protocols, movements of the paretic ankle were governed by the non-paretic ankle with different control strategies, while in the seventh voluntary movements of the paretic ankle were used for stimulation triggering. One stroke survivor in the acute phase of recovery participated in the study. During the therapy, the patient’s voluntary ankle range of motion increased and reached the value of normal gait after 15 sessions. Statistical analysis did not reveal the differences between the protocols in FES-induced movements.

Generalizability of Results from Randomized Controlled Trials in Post-Stroke Physiotherapy

Purpose: The randomized controlled trial (RCT) is considered a reliable experimental design, able to detect the effect of an intervention. However, a criticism frequently levelled at RCTs by clinicians is their lack of generalizability. This study aimed to evaluate the generalizability of findings from RCTs of physiotherapy interventions for individuals with stroke. Method: A sample of RCTs of physiotherapy interventions after stroke indexed in the PEDro database was selected, and the reported inclusion and exclusion criteria were analyzed. Results: We reviewed 100 articles, which included 7,366 participants (41.6% women, with a mean weighted age of 65.5 years). The most frequent criteria for exclusion were comorbidity (83%), cognitive impairments (69%), communication skills (55%), recurrent stroke (53%), low functional level (47%) and being elderly (25%). Conclusions: A variety of cohorts of individuals who have had a stroke are excluded from RCTs published in the field of physiotherapy. Because they represent a substantial proportion of the real-world population with stroke, and consequently treated in clinical practice, more vulnerable cohorts of participants should be included in RCTs.

Home-Based Functional Electrical Stimulation-Assisted Hand Therapy Video Games for Children With Hemiplegia: Development and Proof-of-Concept

We describe the development and three case reports of a home-based intervention for children with hand hemiplegia that integrates custom video games with contralaterally controlled functional electrical stimulation (CCFES). With CCFES, stimulated opening of the more-affected hand is modulated by volitional opening of the less-affected hand. Video games that solicit goal-oriented, skill-requiring movement have shown promise for treating hemiplegia, but they have not previously been combined with electrical stimulation in children. Three children ages 8, 9, and 11 with moderate-to-severe hand hemiplegia were assigned six weeks of therapy in lab and at home. The goal was to determine if children could tolerate 9 lab treatment sessions and administer up to 7.5 hrs/wk of CCFES video game therapy at home. The feasibility of this intervention for home use was assessed by device logs, end-of-treatment interviews, and motor function/impairment assessments. With caregiver help, the children were all able to attend 9 lab sessions and built up to 7.5 hrs/wk of therapy by week 3. They averaged 5-7 hrs/wk of home intervention overall. Motor outcomes improved for all three participants at treatment end, but mostly regressed at 4-weeks follow-up. Individual improvements at treatment end exceeded minimum detectable or clinically important thresholds for Assisting Hands Assessment, Fugl-Meyer Assessment, and Melbourne Motor Assessment 2. We found preliminary indications that CCFES-integrated video game therapy can provide a high dose of hand motor control therapy at home and in the lab. Improvements in motor outcomes were also observed, but more development and study is needed.

Motor neuroprosthesis for promoting recovery of function after stroke

BACKGROUND

Motor neuroprosthesis (MN) involves electrical stimulation of neural structures by miniaturized devices to allow the performance of tasks in the natural environment in which people live (home and community context), as an orthosis. In this way, daily use of these devices could act as an environmental facilitator for increasing the activities and participation of people with stroke.

OBJECTIVES

To assess the effects of MN for improving independence in activities of daily living (ADL), activities involving limbs, participation scales of health-related quality of life (HRQoL), exercise capacity, balance, and adverse events in people after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (searched 19 August 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (August 2019), MEDLINE (1946 to 16 August 2019), Embase (1980 to 19 August 2019), and five additional databases. We also searched trial registries, databases, and websites to identify additional relevant published, unpublished, and ongoing trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and randomized controlled cross-over trials comparing MN for improving activities and participation versus other assistive technology device or MN without electrical stimulus (stimulator is turned off), or no treatment, for people after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed risk of bias of the included studies. Any disagreements were resolved through discussion with a third review author. We contacted trialists for additional information when necessary and performed all analyses using Review Manager 5. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included four RCTs involving a total of 831 participants who were more than three months poststroke. All RCTs were of MN that applied electrical stimuli to the peroneal nerve. All studies included conditioning protocols to adapt participants to MN use, after which participants used MN from up to eight hours per day to all-day use for ambulation in daily activities performed in the home or community context. All studies compared the use of MN versus another assistive device (ankle-foot orthosis [AFO]). There was a high risk of bias for at least one assessed domain in three of the four included studies. No studies reported outcomes related to independence in ADL. There was low-certainty evidence that AFO was more beneficial than MN on activities involving limbs such as walking speed until six months of device use (mean difference (MD) -0.05 m/s, 95% confidence interval (CI) -0.10 to -0.00; P = 0.03; 605 participants; 2 studies; I² = 0%; low-certainty evidence); however, this difference was no longer present in our sensitivity analysis (MD -0.07 m/s, 95% CI -0.16 to 0.02; P = 0.13; 110 participants; 1 study; I² = 0%). There was low to moderate certainty that MN was no more beneficial than AFO on activities involving limbs such as walking speed between 6 and 12 months of device use (MD 0.00 m/s, 95% CI -0.05 to 0.05; P = 0.93; 713 participants; 3 studies; I² = 17%; low-certainty evidence), Timed Up and Go (MD 0.51 s, 95% CI -4.41 to 5.43; P = 0.84; 692 participants; 2 studies; I² = 0%; moderate-certainty evidence), and modified Emory Functional Ambulation Profile (MD 14.77 s, 95% CI -12.52 to 42.06; P = 0.29; 605 participants; 2 studies; I² = 0%; low-certainty evidence). There was no significant difference in walking speed when MN was delivered with surface or implantable electrodes (test for subgroup differences P = 0.09; I² = 65.1%). For our secondary outcomes, there was very low to moderate certainty that MN was no more beneficial than another assistive device for participation scales of HRQoL (standardized mean difference 0.26, 95% CI -0.22 to 0.74; P = 0.28; 632 participants; 3 studies; I² = 77%; very low-certainty evidence), exercise capacity (MD -9.03 m, 95% CI -26.87 to 8.81; P = 0.32; 692 participants; 2 studies; I² = 0%; low-certainty evidence), and balance (MD -0.34, 95% CI -1.96 to 1.28; P = 0.68; 692 participants; 2 studies; I² = 0%; moderate-certainty evidence). Although there was low- to moderate-certainty evidence that the use of MN did not increase the number of serious adverse events related to intervention (risk ratio (RR) 0.35, 95% CI 0.04 to 3.33; P = 0.36; 692 participants; 2 studies; I² = 0%; low-certainty evidence) or number of falls (RR 1.20, 95% CI 0.92 to 1.55; P = 0.08; 802 participants; 3 studies; I² = 33%; moderate-certainty evidence), there was low-certainty evidence that the use of MN in people after stroke may increase the risk of participants dropping out during the intervention (RR 1.48, 95% CI 1.11 to 1.97; P = 0.007; 829 participants; 4 studies; I² = 0%).

AUTHORS' CONCLUSIONS

Current evidence indicates that MN is no more beneficial than another assistive technology device for improving activities involving limbs measured by Timed Up and Go, balance (moderate-certainty evidence), activities involving limbs measured by walking speed and modified Emory Functional Ambulation Profile, exercise capacity (low-certainty evidence), and participation scale of HRQoL (very low-certainty evidence). Evidence was insufficient to estimate the effect of MN on independence in ADL. In comparison to other assistive devices, MN does not appear to increase the number of falls (moderate-certainty evidence) or serious adverse events (low-certainty evidence), but may result in a higher number of dropouts during intervention period (low-certainty evidence).

Endothelin-1-Induced Ischemic Damage and Functional Impairment Is Mediated Primarily by NR2B-Containing NMDA Receptors

Ischemic stroke accounts for 70-80% of stroke cases worldwide and survivors are frequently left with compromising sensorimotor deficits localized to one or more body regions. Most animal models of stroke involve transient or permanent occlusion of one or more major vessels such as the middle cerebral artery and are characterized by widespread damage to cortical and subcortical structures that result in deficits that can confound studies of neuroprotection and neurorehabilitation. Localized microinjections of the vasoconstricting peptide endothelin-1 (ET-1) into specific brain regions are becoming increasingly popular for such studies, but the pharmacology of endothelin-induced ischemic damage is poorly understood. To test the hypothesis that NMDA receptors, and particularly those containing the NR2B subunit, are involved in ET-1-mediated excitotoxicity and functional impairment, male CD1 rats (N = 32) were pre-treated with either the non-competitive NMDA antagonist MK-801 or the NR2B-selective antagonist Ro25-6981 (or vehicle) prior to unilateral microinjections of endothelin-1 into the somatosensory cortex and striatum. Rats were then tested using 4 established tests of sensory and/or motor function over 14 days. Lesion volumes were quantified post-mortem using standard histology and image analysis. Results confirmed reproducible lesions and significant deficits in all tests in vehicle-treated rats that were significantly reduced in both drug groups but were not different between drugs, providing evidence that endothelin-induced ischemic damage is mediated almost exclusively by NR2B-containing NMDA receptors.

The effect of motor imagery and mirror therapy on upper extremity function according to the level of cognition in stroke patients

This study was conducted to investigate the effects of motor imagery (MI) and mirror therapy (MT) on upper extremity function according to the level of cognition in stroke patients. Twenty-four participants who were diagnosed with stroke were divided into a mild cognitive group (n = 12) and a severe cognitive group (n = 12). Then, the two groups were again divided into MI group (n = 6) and MT group (n = 6). The participants were evaluated for function of upper extremity using the Box and Block Test (BBT), the Jebsen-Taylor Hand Function Test (JTHFT), and Manual Function Test (MFT). There were significant differences between the two groups of cognitive function of mild level in the post-test of JTHFT (p < 0.05). In the MI group, significant differences were found in the pre- and post-test scores for all variance (p < 0.05). In the MT group, significant differences were found in the pre- and post-test scores for JTHFT and MFT (p < 0.05). There were significant differences between the two groups of cognitive function of severe level in the post-test of all variances (p < 0.05). Furthermore, in the MT group, significant differences were found in the pre- and post-test scores for all variances (P < 0.05). The results of this study suggest that applying MI to the mild cognitive group is effective and that applying MT to the severe cognitive group is effective.

Effects of 8-week sensory electrical stimulation combined with motor training on EEG-EMG coherence and motor function in individuals with stroke

The peripheral sensory system is critical to regulating motor plasticity and motor recovery. Peripheral electrical stimulation (ES) can generate constant and adequate sensory input to influence the excitability of the motor cortex. The aim of this proof of concept study was to assess whether ES prior to each hand function training session for eight weeks can better improve neuromuscular control and hand function in chronic stroke individuals and change electroencephalography-electromyography (EEG-EMG) coherence, as compared to the control (sham ES). We recruited twelve subjects and randomly assigned them into ES and control groups. Both groups received 20-minute hand function training twice a week, and the ES group received 40-minute ES on the median nerve of the affected side before each training session. The control group received sham ES. EEG, EMG and Fugl-Meyer Assessment (FMA) were collected at four different time points. The corticomuscular coherence (CMC) in the ES group at fourth weeks was significantly higher (p = 0.004) as compared to the control group. The notable increment of FMA at eight weeks and follow-up was found only in the ES group. The eight-week rehabilitation program that implemented peripheral ES sessions prior to function training has a potential to improve neuromuscular control and hand function in chronic stroke individuals.

Effect of EMG-triggered neuromuscular electrical stimulation with bilateral arm training on hemiplegic shoulder pain and arm function after stroke: a randomized controlled trial

BACKGROUND

Hemiplegic shoulder pain is a frequent complication after stroke, leading to limited use of the affected arm. Neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS) are two widely used interventions to reduce pain, but the comparative efficacy of these two modalities remains uncertain. The purpose of this research was to compare the immediate and retained effects of EMG-triggered NMES and TENS, both in combination with bilateral arm training, on hemiplegic shoulder pain and arm function of stroke patients.

METHODS

A single-blind, randomized controlled trial was conducted at two medical centers. Thirty-eight patients (25 males and 13 females, 60.75 ± 10.84 years old, post stroke duration 32.68 ± 53.07 months) who had experienced a stroke more than 3 months ago at the time of recruitment and hemiplegic shoulder pain were randomized to EMG-triggered NMES or TENS. Both groups received electrical stimulation followed by bilateral arm training 3 times a week for 4 weeks. The primary outcome measures included a vertical Numerical Rating Scale supplemented with a Faces Rating Scale, and the short form of the Brief Pain Inventory. The secondary outcome measures were the upper-limb subscale of the Fugl-Meyer Assessment, and pain-free passive shoulder range of motion. All outcomes were measured pretreatment, post-treatment, and at 1-month after post-treatment. Two-way mixed repeated measures ANOVAs were used to examine treatment effects.

RESULTS

Compared to TENS with bilateral arm training, the EMG-triggered NMES with bilateral arm training was associated with lower pain intensity during active and passive shoulder movement (P =0.007, P =0.008), lower worst pain intensity (P = 0.003), and greater pain-free passive shoulder abduction (P =0.001) and internal rotation (P =0.004) at follow-up. Both groups improved in pain at rest (P =0.02), pain interference with daily activities, the Fugl-Meyer Assessment, and pain-free passive shoulder flexion and external rotation post-treatment (P < 0.001) and maintained the improvement at follow-up (P < 0.001), except for resting pain (P =0.08).

CONCLUSIONS

EMG-triggered NMES with bilateral arm training exhibited greater immediate and retained effects than TENS with bilateral arm training with respect to pain and shoulder impairment for chronic and subacute stroke patients with hemiplegic shoulder pain.

TRIAL REGISTRATION

NCT01913509 .

Neuromuscular Electrical Stimulation for Treatment of Muscle Impairment: Critical Review and Recommendations for Clinical Practice

Purpose: In response to requests from physiotherapists for guidance on optimal stimulation of muscle using neuromuscular electrical stimulation (NMES), a review, synthesis, and extraction of key data from the literature was undertaken by six Canadian physical therapy (PT) educators, clinicians, and researchers in the field of electrophysical agents. The objective was to identify commonly treated conditions for which there was a substantial body of literature from which to draw conclusions regarding the effectiveness of NMES. Included studies had to apply NMES with visible and tetanic muscle contractions. Method: Four electronic databases (CINAHL, Embase, PUBMED, and SCOPUS) were searched for relevant literature published between database inceptions until May 2015. Additional articles were identified from bibliographies of the systematic reviews and from personal collections. Results: The extracted data were synthesized using a consensus process among the authors to provide recommendations for optimal stimulation parameters and application techniques to address muscle impairments associated with the following conditions: stroke (upper or lower extremity; both acute and chronic), anterior cruciate ligament reconstruction, patellofemoral pain syndrome, knee osteoarthritis, and total knee arthroplasty as well as critical illness and advanced disease states. Summaries of key details from each study incorporated into the review were also developed. The final sections of the article outline the recommended terminology for describing practice using electrical currents and provide tips for safe and effective clinical practice using NMES. Conclusion: This article provides physiotherapists with a resource to enable evidence-informed, effective use of NMES for PT practice.

Effectiveness of neuromuscular electrical stimulation for management of shoulder subluxation post-stroke: a systematic review with meta-analysis

Objectives:

To examine the effectiveness of neuromuscular electrical stimulation (NMES) for the management of shoulder subluxation after stroke including assessment of short (1 hour or less) and long (more than one hour) daily treatment duration.

Data sources:

MEDLINE, CENTRAL, CINAHL, WOS, KoreaMed, RISS and reference lists from inception to January 2017

Review methods:

We considered randomized controlled trials that reported neuromuscular electrical stimulation for the treatment of shoulder subluxation post-stroke. Two reviewers independently selected trials for inclusion, assessed trial quality, and extracted data.

Results:

Eleven studies were included (432 participants); seven studies were good quality, four were fair. There was a significant treatment effect of neuromuscular electrical stimulation for reduction of subluxation for persons with acute and subacute stroke (SMD:–1.11; 95% CI:–1.53, –0.68) with either short (SMD:–0.91; 95% CI:–1.43, –0.40) or long (SMD:–1.49; 95% CI:–2.31, –0.67) daily treatment duration. The effect for patients with chronic stroke was not significant (SMD:–1.25; 95% CI:–2.60, 0.11). There was no significant effect of neuromuscular electrical stimulation on arm function or shoulder pain.

Conclusion:

This meta-analysis suggests a beneficial effect of neuromuscular electrical stimulation, with either short or long daily treatment duration, for reducing shoulder subluxation in persons with acute and subacute stroke. No significant benefits were observed for persons with chronic stroke or for improving arm function or reducing shoulder pain.

Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis

BACKGROUND

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

METHODS

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

RESULTS

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [-0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD -0.10; CI [-0.59, 0.38], n = 35). Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

CONCLUSIONS

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

TRIAL REGISTRATION

PROSPERO: CRD42015025162 , Date:11/08/2015.

Asking New Questions with Old Data: The Centralized Open-Access Rehabilitation Database for Stroke

BACKGROUND

This paper introduces a tool for streamlining data integration in rehabilitation science, the Centralized Open-Access Rehabilitation database for Stroke (SCOAR), which allows researchers to quickly visualize relationships among variables, efficiently share data, generate hypotheses, and enhance clinical trial design.

METHODS

Bibliographic databases were searched according to inclusion criteria leaving 2,892 titles that were further screened to 514 manuscripts to be screened by full text, leaving 215 randomized controlled trials (RCTs) in the database (489 independent groups representing 12,847 patients). Demographic, methodological, and statistical data were extracted by independent coders and entered into SCOAR.

RESULTS

Trial data came from 114 locations in 27 different countries and represented patients with a wide range of ages, 62 year [41; 85] [shown as median (range)] and at various stages of recovery following their stroke, 141 days [1; 3372]. There was considerable variation in the dose of therapy that patients received, 20 h [0; 221], over interventions of different durations, 28 days [10; 365]. There was also a lack of common data elements (CDEs) across trials, but this lack of CDEs was most pronounced for baseline assessments of patient impairment and severity of stroke.

CONCLUSION

Data integration across hundreds of RCTs allows clinicians and researchers to quickly visualize data from the history of the field and lays the foundation for making SCOAR a living database to which researchers can upload new data as trial results are published. SCOAR is a useful tool for clinicians and researchers that will facilitate data visualization, data sharing, the finding of relevant past studies, and the design of clinical trials by enabling more accurate and comprehensive power analyses. Furthermore, these data speak to the need for CDEs specific to stroke rehabilitation in randomized controlled trials.

PROSPERO 2014

CRD42014009010.

Evoked Electromyographically Controlled Electrical Stimulation

Time-variant muscle responses under electrical stimulation (ES) are often problematic for all the applications of neuroprosthetic muscle control. This situation limits the range of ES usage in relevant areas, mainly due to muscle fatigue and also to changes in stimulation electrode contact conditions, especially in transcutaneous ES. Surface electrodes are still the most widely used in noninvasive applications. Electrical field variations caused by changes in the stimulation contact condition markedly affect the resulting total muscle activation levels. Fatigue phenomena under functional electrical stimulation (FES) are also well known source of time-varying characteristics coming from muscle response under ES. Therefore, it is essential to monitor the actual muscle state and assess the expected muscle response by ES so as to improve the current ES system in favor of adaptive muscle-response-aware FES control. To deal with this issue, we have been studying a novel control technique using evoked electromyography (eEMG) signals to compensate for these muscle time-variances under ES for stable neuroprosthetic muscle control. In this perspective article, I overview the background of this topic and highlight important points to be aware of when using ES to induce the desired muscle activation regardless of the time-variance. I also demonstrate how to deal with the common critical problem of ES to move toward robust neuroprosthetic muscle control with the Evoked Electromyographically Controlled Electrical Stimulation paradigm.

Development of network-based multichannel neuromuscular electrical stimulation system for stroke rehabilitation

Neuromuscular electrical stimulation (NMES) is a promising assistive technology for stroke rehabilitation. Here we present the design and development of a multimuscle stimulation system as an emerging therapy for people with paretic stroke. A network-based multichannel NMES system was integrated based on dual bus architecture of communication and an H-bridge current regulator with a power booster. The structure of the system was a body area network embedded with multiple stimulators and a communication protocol of controlled area network to transmit muscle stimulation parameter information to individual stimulators. A graphical user interface was designed to allow clinicians to specify temporal patterns and muscle stimulation parameters. We completed and tested a prototype of the hardware and communication software modules of the multichannel NMES system. The prototype system was first verified in nondisabled subjects for safety, and then tested in subjects with stroke for feasibility with assisting multijoint movements. Results showed that synergistic stimulation of multiple muscles in subjects with stroke improved performance of multijoint movements with more natural velocity profiles at elbow and shoulder and reduced acromion excursion due to compensatory trunk rotation. The network-based NMES system may provide an innovative solution that allows more physiological activation of multiple muscles in multijoint task training for patients with stroke.

Pain syndromes in hemiplegic patients and their effects on rehabilitation results

[Purpose] The aim of this study was to determine the frequency, type, and location of pain in hemiplegic patients and the effects on rehabilitation results in our inpatient rehabilitation unit. [Subjects and Methods] Patients rehabilitated between January 2010 and July 2012 were investigated retrospectively. Properties of pain were recorded. Pre- and post-rehabilitation motor evaluation and achievement in daily activities were considered, and differences in scores between groups classified as with and without pain were examined. [Results] The number of patients included in the study was 156. The mean age was 64.28 ± 12.45 years, the mean disease duration was 11.10 months, and the gender distribution was 75 males (48%) and 81 females (52%). Fortysix (29.5%) patients had pain complaints. The nociceptive pain ratio was 86.7%, and the neuropathic pain ratio was 13.3%. Pain was mostly localized at the shoulder joint, with the proportion being 86.9%. In the pain group, statistically significant improvement was found in pain scores after the treatment. There was no significant difference between groups in the pre- and post-rehabilitation Brunnstrom motor evaluation and functional independence measurement scores. [Conclusion] Nociceptive pain is more common than neuropathic pain in patients with hemiplegia, and the shoulder joint is the most frequent location of nociceptive pain.

Effectiveness of Constraint induced movement therapy as compared to bimanual therapy in Upper motor function outcome in child with hemiplegic Cerebral palsy

Objective:

This study aims at determining the effectiveness of constraint induced movement therapy as compared to bimanual therapy for improving functional status in children with hemiplegic cerebral palsy.

Methods:

This study was a randomized control trial, children (n = 20) with spastic hemiplegic cerebral palsy was randomly allocated to CIMT (constraint induced movement therapy) and BMT (bimanual therapy) group. The children with spastic hemiplegia, age between 1.5 and 12 year and having 10 degrees of wrist extension and 10 degrees of finger extension were included in study. Treatment regime was two hours of daily training six days a week for two weeks. Constraint was applied to CIMT group for six hours. The outcome tool QUEST was used for baseline and post treatment assessment.

Result:

CIMT had superior outcome as compared to BMT in improving functional status (p=0.007). On QUEST tool grasp and dissociated movements results were significant (p=0.005) and (p=0.028) respectively. Weight bearing and protective extension resulted in no significant outcome (p=0.080) and (p=0.149) respectively. Dissociated movements and grasp are significantly improved but there is no difference for weight bearing and protective extension in CIMT treated group as compared to BMT treated group.

Conclusion:

CIMT approach is better in improving functional status of child with cerebral palsy as compared to BMT. Significant improvement in grasp and dissociated movement is noted in group of CIMT while there was no significant improvement in weight bearing and protective extension in CIMT group when compared to BMT. CIMT is considered the appropriate treatment approach for unilateral conditions while BMT for bilateral conditions.

Effects of Electrical Stimulation in Spastic Muscles After Stroke

Background and Purpose—

Neuromuscular electric stimulation (NMES) has been used to reduce spasticity and improve range of motion in patients with stroke. However, contradictory results have been reported by clinical trials. A systematic review of randomized clinical trials was conducted to assess the effect of treatment with NMES with or without association to another therapy on spastic muscles after stroke compared with placebo or another intervention.

Methods—

We searched the following electronic databases (from inception to February 2015): Medline (PubMed), EMBASE, Cochrane Central Register of Controlled Trials and Physiotherapy Evidence Database (PEDro). Two independent reviewers assessed the eligibility of studies based on predefined inclusion criteria (application of electric stimulation on the lower or upper extremities, regardless of NMES dosage, and comparison with a control group which was not exposed to electric stimulation), excluding studies with <3 days of intervention. The primary outcome extracted was spasticity, assessed by the Modified Ashworth Scale, and the secondary outcome extracted was range of motion, assessed by Goniometer.

Results—

Of the total of 5066 titles, 29 randomized clinical trials were included with 940 subjects. NMES provided reductions in spasticity (−0.30 [95% confidence interval, −0.58 to −0.03], n=14 randomized clinical trials) and increase in range of motion when compared with control group (2.87 [95% confidence interval, 1.18–4.56], n=13 randomized clinical trials) after stroke.

Conclusions—

NMES combined with other intervention modalities can be considered as a treatment option that provides improvements in spasticity and range of motion in patients after stroke.

Clinical Trial Registration Information—

URL: http://www.crd.york.ac.uk/PROSPERO . Unique identifier: CRD42014008946.

Standing with electrical stimulation and splinting is no better than standing alone for management of ankle plantarflexion contractures in people with traumatic brain injury: a randomised trial

QUESTION

Is a combination of standing, electrical stimulation and splinting more effective than standing alone for the management of ankle contractures after severe brain injury?

DESIGN

A multi-centre randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

Thirty-six adults with severe traumatic brain injury and ankle plantarflexion contractures.

INTERVENTION

All participants underwent a 6-week program. The experimental group received tilt table standing, electrical stimulation and ankle splinting. The control group received tilt table standing alone.

OUTCOME MEASURES

The primary outcome was passive ankle dorsiflexion with a 12Nm torque. Secondary outcomes included: passive dorsiflexion with lower torques (3, 5, 7 and 9Nm); spasticity; the walking item of the Functional Independence Measure; walking speed; global perceived effect of treatment; and perceived treatment credibility. OUTCOME MEASURES were taken at baseline (Week 0), end of intervention (Week 6), and follow-up (Week 10).

RESULTS

The mean between-group differences (95% CI) for passive ankle dorsiflexion at Week 6 and Week 10 were -3 degrees (-8 to 2) and -1 degrees (-6 to 4), respectively, in favour of the control group. There was a small mean reduction of 1 point in spasticity at Week 6 (95% CI 0.1 to 1.8) in favour of the experimental group, but this effect disappeared at Week 10. There were no differences for other secondary outcome measures except the physiotherapists' perceived treatment credibility.

CONCLUSION

Tilt table standing with electrical stimulation and splinting is not better than tilt table standing alone for the management of ankle contractures after severe brain injury.

TRIAL REGISTRATION

ACTRN12608000637347. [Leung J, Harvey LA, Moseley AM, Whiteside B, Simpson M, Stroud K (2014) Standing with electrical stimulation and splinting is no better than standing alone for management of ankle plantarflexion contractures in people with traumatic brain injury: a randomised trial.Journal of Physiotherapy60: 201-208].

Pain management of hemiplegic shoulder pain post stroke in patients from Nanjing, China

We selected 106 hemiplegic patients with shoulder pain hospitalized after stroke from three hospitals in Nanjing, China between February 2007 and January 2012. All patients had complete clinical data sets and accounted for 45.5% of the inpatients because of stroke. Results showed that the number of patients with hemiplegic shoulder pain post stroke increased yearly, attacking mainly males 50-69 years of age. Of 106 patients, there were 60 cases (56.6%) of adhesive capsulitis, 19 (17.9%) of shoulder subluxation, 14 (13.2%) of complex regional pain syndrome, and 13 (12.6%) of central pain. The main symptoms were shoulder pain (100%), limit of shoulder mobility (98.1%), and adhesion of the scapula (56.6%). MRI of the shoulder showed tendon and ligament lesions (57.1%) and rotator cuff tear (38.1%). 53.8% of central pain was related to the thalamus, in addition to the basal ganglia, brain stem, and cerebellopontine angle. Shoulder pain, upper limb motor function, and function independence were significantly improved after comprehensive rehabilitation. In particular, electroacupuncture based on basic physical therapy exhibited efficacy on shoulder tion and complex regional pain syndrome. Multiple linear regression results showed a negative relationship of efficacy of pain management with the attack period of shoulder pain, involvement of the posterior limb of the internal capsule, and duration between onset and rehabilitation treatment, but a positive correlation with pain-related education, pain regression period, and pain diagnosis.

Chronic stroke survivors achieve comparable outcomes following virtual task specific repetitive training guided by a wearable robotic orthosis (UL-EXO7) and actual task specific repetitive training guided by a physical therapist

Survivors post stroke commonly have upper limb impairments. Patients can drive neural reorganization, brain recovery and return of function with task specific repetitive training (TSRT). Fifteen community independent stroke survivors (25-75 years, >6 months post stroke, Upper Limb Fugl Meyer [ULFM] scores 16-39) participated in this randomized feasibility study to compare outcomes of upper limb TSRT guided by a robotic orthosis (bilateral or unilateral) or a physical therapist. After 6 weeks of training (18 h), across all subjects, there were significant improvements in depression, flexibility, strength, tone, pain and voluntary movement (ULFM) (p < 0.05; effect sizes 0.49-3.53). Each training group significantly improved ULFM scores and range of motion without significant group differences. Virtual or actual TSRT performed with a robotic orthosis or a physical therapist significantly reduced arm impairments around the shoulder and elbow without significant gains in fine motor hand control, activities of daily living or independence.

Community-based exercise for upper limb paresis: a controlled trial with telerehabilitation

BACKGROUND

Arm paresis remains a major impairment after stroke despite the best conventional rehabilitation. Randomized, controlled trials of intensive exercise programs have demonstrated improvements in arm function for patients with chronic stroke. However, the gains achieved have been relatively modest for the large investments in patient and therapist time.

OBJECTIVE

To evaluate the safety, acceptance, adherence, and effectiveness of a community-based exercise program for upper limb paresis in patients with chronic stroke and the effects of telerehabilitation monitoring in kiosks distributed through the community.

METHODS

Longitudinal cohort with geographic control group. The experimental group received devices needed for a home exercise program based on the Carr and Shepherd "Motor Learning Program" and were instructed to practice the exercises at least twice a week at the kiosk and at least 3 more days a week at home. The control group received usual care.

RESULTS

Compared with the control group, patients in the experimental group demonstrated significant gains in arm function as measured by the Wolf Motor Function Test, 9-Hole Peg Test, Motricity Index, and Nottingham Extended Activities of Daily Living Questionnaire. The intervention received high satisfaction ratings and produced no adverse events. Only 30% of the subjects attended kiosks regularly. Outcomes for this group did not differ significantly from those who only practiced at home.

CONCLUSIONS

Home- and community-based exercise for arm paresis is safe and effective. Telerehabilitation interventions will need additional enhancements to improve effectiveness. The optimal upper extremity exercise prescription poststroke remains to be established.

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

BACKGROUND

Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

METHODS AND FINDINGS

Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

CONCLUSIONS

There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.

Changes in the electrical properties of the electrode-skin-underlying tissue composite during a week-long programme of neuromuscular electrical stimulation

Particular neuromuscular electrical stimulation (NMES) applications require the use of the same electrodes over a long duration (>1 day) without having access to them. Under such circumstance the quality of the electrode-skin contact cannot be assessed. We used the NMES signal itself to assess the quality of the electrode-skin contact and the electrical properties of the underlying tissues over a week. A 14% decrease in the skin's stratum corneum resistance (from 20 to 17 kΩ) and a 15% decrease in the resistance of the electrodes and underlying tissues (from 550 to 460 Ω) were observed in the 14 healthy subjects investigated. A follow-on investigation of the effect of exercise-induced sweating on the electrical properties of the electrode-skin-underlying tissue composite during NMES indicated a correlation between the decrease in the resistance values observed over the course of the week and the accumulation of sweat at the electrode-skin interface. The value of the capacitance representing the dielectric properties of the skin's stratum corneum increased after exercise-induced sweating but did not change significantly over the course of the week. We conclude that valuable information about the electrode-skin-underlying tissue composite can be gathered using the NMES signal itself, and suggest that this is a practical, safe and relatively simple method for monitoring these electrical properties during long-term stimulation.

Median nerve fascicular anatomy as a basis for distal neural prostheses

INTRODUCTION

Functional electrical stimulation (FES) serves as a possible therapy to restore missing motor functions of peripheral nerves by means of cuff electrodes. FES is established for improving lower limb function. Transferring this method to the upper extremity is complex, due to a lack of anatomical data on the physiological configuration of nerve fascicles. Our study's aim was to provide an anatomical basis for FES of the median nerve in the distal forearm and hand.

METHODS

We investigated 21 distal median nerves from 12 body donors. The peripheral fascicles were traced back by removing the external and interfascicular epineurium and then assigned to 4 quadrants.

RESULTS

A distinct motor and sensory distribution was observed. The fascicles innervating the thenar eminence and the first lumbrical muscle originated from the nerves' radial parts in 82%. The fascicle supplying the second lumbrical muscle originated from the ulnar side in 78%. No macroscopically visible plexus formation was observed for the distal median nerve in the forearm.

CONCLUSIONS

The findings on the distribution of the motor branches of the median nerve and the missing plexus formation may likely serve as an anatomical basis for FES of the distal forearm. However, due to the considerable variability of the motor branches, cuff electrodes will need to be adapted individually in FES. Taking into account the sensory distribution of the median nerve, FES may also possibly be applied in the treatment of regional pain syndromes.