The application of precisely controlled functional electrical stimulation to the shoulder, elbow and wrist for upper limb stroke rehabilitation: a feasibility study

Effect of functional electrical stimulation-based mirror therapy using gesture recognition biofeedback on upper extremity function in patients with chronic stroke: A randomized controlled trial

BACKGROUND

Mirror therapy (MT) is an intervention used for upper extremity rehabilitation in stroke patients and has been studied in various fields. Recently, effective MT methods have been introduced in combination with neuromuscular electrical stimulation or with electromyography (EMG)-triggered biofeedback. The purpose of this study was to investigate the effects of functional electrical stimulation (FES)-based MT incorporating a motion recognition biofeedback device on upper extremity motor recovery to chronic stroke patients.

METHODS

Twenty-six chronic stroke patients with onset of more than 6 months were randomly assigned into experimental group (n = 13) and control group (n = 13). Both groups participated in conventional rehabilitation program, while the control group received conventional MT intervention and the experimental group received FES-based MT with motion recognition biofeedback device. All interventions were conducted for 30 min/d, 5 d/wk, for 4 weeks. Upper limb motor recovery, upper limb function, active-range of motion (ROM), and activities of daily living independence were measured before and after the intervention and compared between the 2 groups.

RESULTS

The Fugl-Meyer assessment (FMA), manual function test (MFT), K-MBI, and active-ROM (excluding deviation) were significantly improved in both groups (P < .05). Only the experimental group showed significant improvement in upper extremity recovery, ulnar and radial deviation (P < .05). There was a significant difference of change in Brunstrom's recovery level, FMA, MFT, and active-ROM in the experimental group compared to the control group (P < .05).

CONCLUSION

FES-based MT using gesture recognition biofeedback is an effective intervention method for improving upper extremity motor recovery and function, active-ROM in patients with chronic stroke. This study suggests that incorporating gesture-recognition biofeedback into FES-based MT can provide additional benefits to patients with chronic stroke.

A systematic review on functional electrical stimulation based rehabilitation systems for upper limb post-stroke recovery

Background

Stroke is one of the most common neurological conditions that often leads to upper limb motor impairments, significantly affecting individuals' quality of life. Rehabilitation strategies are crucial in facilitating post-stroke recovery and improving functional independence. Functional Electrical Stimulation (FES) systems have emerged as promising upper limb rehabilitation tools, offering innovative neuromuscular reeducation approaches.

Objective

The main objective of this paper is to provide a comprehensive systematic review of the start-of-the-art functional electrical stimulation (FES) systems for upper limb neurorehabilitation in post-stroke therapy. More specifically, this paper aims to review different types of FES systems, their feasibility testing, or randomized control trials (RCT) studies.

Methods

The FES systems classification is based on the involvement of patient feedback within the FES control, which mainly includes "Open-Loop FES Systems" (manually controlled) and "Closed-Loop FES Systems" (brain-computer interface-BCI and electromyography-EMG controlled). Thus, valuable insights are presented into the technological advantages and effectiveness of Manual FES, EEG-FES, and EMG-FES systems.

Results and discussion

The review analyzed 25 studies and found that the use of FES-based rehabilitation systems resulted in favorable outcomes for the stroke recovery of upper limb functional movements, as measured by the FMA (Fugl-Meyer Assessment) (Manually controlled FES: mean difference = 5.6, 95% CI (3.77, 7.5), P < 0.001; BCI-controlled FES: mean difference = 5.37, 95% CI (4.2, 6.6), P < 0.001; EMG-controlled FES: mean difference = 14.14, 95% CI (11.72, 16.6), P < 0.001) and ARAT (Action Research Arm Test) (EMG-controlled FES: mean difference = 11.9, 95% CI (8.8, 14.9), P < 0.001) scores. Furthermore, the shortcomings, clinical considerations, comparison to non-FES systems, design improvements, and possible future implications are also discussed for improving stroke rehabilitation systems and advancing post-stroke recovery. Thus, summarizing the existing literature, this review paper can help researchers identify areas for further investigation. This can lead to formulating research questions and developing new studies aimed at improving FES systems and their outcomes in upper limb rehabilitation.

Hybrid Functional Electrical Stimulation and Robotic Assistance for Wrist Motion Training After Stroke: Preliminary Results

This work presents preliminary results of a clinical study with sub-acute stroke patients using a hybrid system for wrist rehabilitation. The patients trained their wrist flexion/extension motion through a target tracking task, where electrical stimulation and robotic torque assisted them proportionally to their tracking error. Five sub-acute stroke patients have completed the training for 3 sessions on separate days. The preliminary results show hybrid assistance improves tracking performance and motion smoothness in most participants. In each session, patients' tracking performances before and after training were evaluated in unassisted tracking trials, without assistance. Their unassisted performance was compared across sessions and the results suggest that moderately to severely impaired patients might benefit more from hybrid training with our system than mildly impaired patients. Subjective assessments from all sessions show that the patients found the use of the device very comfortable and the training enjoyable. More data is being collected and future work will aim at verifying these trends.

Parameter mapping of hemiplegic shoulder electrical stimulation for motor function: A scoping review

BACKGROUND

Electrical stimulation (ES) of the shoulder is effective in treating subluxation and shoulder pain. However, few studies have reported on ES of the hemiplegic shoulder with motor function as an outcome; thus, the method remains unclear.

OBJECTIVE

We aimed to map the existing evidence and identify the parameters for ES of the hemiplegic shoulder for motor function in stroke patients.

METHODS

A literature search was performed through PubMed and Scopus to retrieve original articles from 1975 to March 2023 using the terms "stroke", "shoulder", and "electricity". We selected studies in which ES was performed on hemiplegic shoulders after stroke, parameters were described, and upper extremity motor functional assessment was included as an outcome. The extracted data included study design, phase, sample size, electrode position, parameters, intervention period, evaluation frequency, outcomes, and results.

RESULTS

Of the 449 titles identified, 25 fulfilled the inclusion and exclusion criteria. Nineteen were randomized controlled trials. The most common electrode positions and parameters (frequency and pulse width) were over the posterior deltoid and the supraspinatus (upper trapezius) muscles, 30 Hz, and 250μs, respectively. The intervention period was 30-60 minutes per day, 5-7 days per week, for 4-5 weeks in over half of the studies.

CONCLUSION

Stimulation positions and parameters for electrical stimulation of the hemiplegic shoulder are inconsistent. Whether ES represents a significant treatment option remains unclear. Establishing universal ES methods is necessary to improve the motor function of hemiplegic shoulders.

The concepts of muscle activity generation driven by upper limb kinematics

BACKGROUND

The underlying motivation of this work is to demonstrate that artificial muscle activity of known and unknown motion can be generated based on motion parameters, such as angular position, acceleration, and velocity of each joint (or the end-effector instead), which are similarly represented in our brains. This model is motivated by the known motion planning process in the central nervous system. That process incorporates the current body state from sensory systems and previous experiences, which might be represented as pre-learned inverse dynamics that generate associated muscle activity.

METHODS

We develop a novel approach utilizing recurrent neural networks that are able to predict muscle activity of the upper limbs associated with complex 3D human arm motions. Therefore, motion parameters such as joint angle, velocity, acceleration, hand position, and orientation, serve as input for the models. In addition, these models are trained on multiple subjects (n=5 including , 3 male in the age of 26±2 years) and thus can generalize across individuals. In particular, we distinguish between a general model that has been trained on several subjects, a subject-specific model, and a specific fine-tuned model using a transfer learning approach to adapt the model to a new subject. Estimators such as mean square error MSE, correlation coefficient r, and coefficient of determination R² are used to evaluate the goodness of fit. We additionally assess performance by developing a new score called the zero-line score. The present approach was compared with multiple other architectures.

RESULTS

The presented approach predicts the muscle activity for previously through different subjects with remarkable high precision and generalizing nicely for new motions that have not been trained before. In an exhausting comparison, our recurrent network outperformed all other architectures. In addition, the high inter-subject variation of the recorded muscle activity was successfully handled using a transfer learning approach, resulting in a good fit for the muscle activity for a new subject.

CONCLUSIONS

The ability of this approach to efficiently predict muscle activity contributes to the fundamental understanding of motion control. Furthermore, this approach has great potential for use in rehabilitation contexts, both as a therapeutic approach and as an assistive device. The predicted muscle activity can be utilized to guide functional electrical stimulation, allowing specific muscles to be targeted and potentially improving overall rehabilitation outcomes.

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.

Feasibility and significance of stimulating interscapular muscles using transcutaneous functional electrical stimulation in able-bodied individuals

OBJECTIVE

The study objective was to assess the feasibility of stimulating the lower trapezius (LT), the upper trapezius (UT) and serratus anterior (SA) muscles along with anterior or middle deltoid, using surface functional electrical stimulation (FES). The secondary aim was to understand the effects of LT, UT, and SA stimulation on maximum arm reach achieved in shoulder flexion and abduction.

DESIGN

Single arm interventional study.

SETTING

Inpatient Rehabilitation Hospital.

PARTICIPANTS

Ten healthy volunteers.

INTERVENTION

Participants completed 10 trials for each of the 3 conditions in flexion and abduction, i.e. (1) Active voluntary flexion or abduction, (2) FES for anterior deltoid for flexion or middle deltoid for abduction, and (3) FES for LT, UT, and SA along with anterior deltoid for flexion or middle deltoid for abduction.

OUTCOME MEASURES

Maximum arm reach and percent angle relative to the voluntary movement were computed from motion capture data for each condition. Wilcoxon signed-rank test was used to compare the maximum reach between two FES conditions.

RESULTS

The study results showed that all three interscapular muscles can be stimulated using surface FES. Maximum reach in abduction was greater for FES of middle deltoid along with the interscapular muscles (51.77° ± 17.54°) compared to FES for middle deltoid alone (43.76° ± 15.32°; Z = -2.701, P = 0.007). Maximum reach in flexion for FES of anterior deltoid, along with interscapular muscles, was similar to that during FES of anterior deltoid alone.

CONCLUSION

Interscapular muscles can be stimulated using surface FES devices and should be engaged during rehabilitation as appropriate.

Optimal multi-field functional electrical stimulation parameters for the "drinking task - reaching phase" and related upper limb kinematics repeatability in post stroke subjects

BACKGROUND

No specific guidelines for the management of functional electrical stimulation (FES) parameters in post stroke patients have been defined yet, despite its frequent use. The purpose of this study is to characterize the optimal FES parameters that assist the reaching phase of drinking task ("drinking task - reaching phase") on post stroke subjects and to analyze the related upper limb (UL) movement quality indicators repeatability.

METHODS

An observational study with a test and re-test design involving ten post stroke subjects with UL dysfunction was performed. End-point and joint kinematics of contralesional UL were assessed during the "drinking task - reaching phase" with FES through a test and retest design. FES parameters were adjusted to improve UL function according to a consensus between physiotherapists and patients' perspective.

FINDINGS

It was possible to establish reliable FES parameters that assisted the "drinking task - reaching phase". All FES parameters presented high to very high repeatability and led to moderate to very high repeatability in almost UL movement quality indicators during the "drinking task - reaching phase".

INTERPRETATION

These findings show that the main characteristics of FES parameters that improves patient perception of change are quite stable, which facilitate its implementation in clinical practice by allowing consistence between intervention sessions.

Convolutional neural network in upper limb functional motion analysis after stroke

In this work, implementation of Convolutional Neural Network (CNN) for the purpose of analysis of functional upper limb movement pattern was applied. The main aim of the study was to compare motion of selected activities of daily living of participants after stroke with the healthy ones (in similar age). The optical, marker-based motion capture system was applied for the purpose of data acquisition. There were some attempts made in order to find the existing differences in the motion pattern of the upper limb. For this purpose, the motion features of dominant and non-dominant upper limb of healthy participants were compared with motion features of paresis and non-paresis upper limbs of participants after stroke. On the basis of the newly collected data set, a new CNN application was presented to the classification of motion data in two different class label configurations. Analyzing individual segments of the upper body, it turned out that the arm was the most sensitive segment for capturing changes in the trajectory of the lifting movements of objects.

The Role of Robotic Path Assistance and Weight Support in Facilitating 3D Movements in Individuals With Poststroke Hemiparesis

Background. High-intensity repetitive training is challenging to provide poststroke. Robotic approaches can facilitate such training by unweighting the limb and/or by improving trajectory control, but the extent to which these types of assistance are necessary is not known. Objective. The purpose of this study was to examine the extent to which robotic path assistance and/or weight support facilitate repetitive 3D movements in high functioning and low functioning subjects with poststroke arm motor impairment relative to healthy controls. Methods. Seven healthy controls and 18 subjects with chronic poststroke right-sided hemiparesis performed 300 repetitions of a 3D circle-drawing task using a 3D Cable-driven Arm Exoskeleton (CAREX) robot. Subjects performed 100 repetitions each with path assistance alone, weight support alone, and path assistance plus weight support in a random order over a single session. Kinematic data from the task were used to compute the normalized error and speed as well as the speed-error relationship. Results. Low functioning stroke subjects (Fugl-Meyer Scale score = 16.6 ± 6.5) showed the lowest error with path assistance plus weight support, whereas high functioning stroke subjects (Fugl-Meyer Scale score = 59.6 ± 6.8) moved faster with path assistance alone. When both speed and error were considered together, low functioning subjects significantly reduced their error and increased their speed but showed no difference across the robotic conditions. Conclusions. Robotic assistance can facilitate repetitive task performance in individuals with severe arm motor impairment, but path assistance provides little advantage over weight support alone. Future studies focusing on antigravity arm movement control are warranted poststroke.

Long-Dose Intensive Therapy Is Necessary for Strong, Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke

Background. Effective treatment methods are needed for moderate/severely impairment chronic stroke. Objective. The questions were the following: (1) Is there need for long-dose therapy or is there a mid-treatment plateau? (2) Are the observed gains from the prior-studied protocol retained after treatment? Methods. Single-blind, stratified/randomized design, with 3 applied technology treatment groups, combined with motor learning, for long-duration treatment (300 hours of treatment). Measures were Arm Motor Ability Test time and coordination-function (AMAT-T, AMAT-F, respectively), acquired pre-/posttreatment and 3-month follow-up (3moF/U); Fugl-Meyer (FM), acquired similarly with addition of mid-treatment. Findings. There was no group difference in treatment response (P ≥ .16), therefore data were combined for remaining analyses (n = 31; except for FM pre/mid/post, n = 36). Pre-to-Mid-treatment and Mid-to-Posttreatment gains of FM were statistically and clinically significant (P < .0001; 4.7 points and P < .001; 5.1 points, respectively), indicating no plateau at 150 hours and benefit of second half of treatment. From baseline to 3moF/U: (1) FM gains were twice the clinically significant benchmark, (2) AMAT-F gains were greater than clinically significant benchmark, and (3) there was statistically significant improvement in FM (P < .0001); AMAT-F (P < .0001); AMAT-T (P < .0001). These gains indicate retained clinically and statistically significant gains at 3moFU. From posttreatment to 3moF/U, gains on FM were maintained. There were statistically significant gains in AMAT-F (P = .0379) and AMAT-T P = .003.

Prediction of setup times for an advanced upper limb functional electrical stimulation system

Introduction

Rehabilitation devices take time to don, and longer or unpredictable setup time impacts on usage. This paper reports on the development of a model to predict setup time for upper limb functional electrical stimulation.

Methods

Participants' level of impairment (Fugl Meyer-Upper Extremity Scale), function (Action Research Arm Test) and mental status (Mini Mental Scale) were measured. Setup times for each stage of the setup process and total setup times were recorded. A predictive model of setup time was devised using upper limb impairment and task complexity.

Results

Six participants with stroke were recruited, mean age 60 (±17) years and mean time since stroke 9.8 (±9.6) years. Mean Fugl Meyer-Upper Extremity score was 31.1 (±6), Action Research Arm Test 10.4 (±7.9) and Mini Mental Scale 26.1 (±2.7). Linear regression analysis showed that upper limb impairment and task complexity most effectively predicted setup time (51% as compared with 39%) (F(2,21) = 12.782, adjusted R² = 0.506; p < .05).

Conclusions

A model to predict setup time based on upper limb impairment and task complexity accounted for 51% of the variation in setup time. Further studies are required to test the model in real-world settings and to identify other contributing factors.

Functional electrical stimulation improves reaching movement in the shoulder and elbow muscles of stroke patients: A three-dimensional motion analysis

BACKGROUND

Recovery of motor function following stroke is essential to restore adequate functionality. The use of functional electrical stimulation (FES) technology as a neuroprosthesis to enhance the motor function of the UL, and thus facilitate the performance of ADL, could lead to a stroke patient's greater activity and participation in daily life.

OBJECTIVE

The aim of the present study was to establish whether the application of FES in patients who have suffered a stroke with UL motor impairment is able to modify and facilitate their reaching patterns, measured by a three-dimensional motion capture system.

METHODS

20 patients with chronic stroke participated in this study. For muscle stimulation, the electrical stimulator Compex® was used. Motion analysis was performed using the VICON Motion System®. Joint movements of the thorax, shoulder and elbow were analyzed in the sagittal plane, during the reaching movement under two different conditions of stimulation: FES condition and placebo condition.

RESULTS

Differences between FES condition and placebo condition were observed. In the FES condition it was recorded: an increased shoulder flexion and elbow extension in the reaching movement.

CONCLUSIONS

Functional electrical stimulation improved reaching movement in stroke patients with upper limb impairment.

Factors affecting rehabilitation and use of upper limb after stroke: views from healthcare professionals and stroke survivors

BACKGROUND

Training of the upper limb (UL) is limited in stroke rehabilitation, and about 50% of stroke survivors do not regain useful function in their upper limb.

OBJECTIVES

This study explored what factors affect rehabilitation and use of upper limb after stroke from a stroke survivor and healthcare professional perspective to better understand low engagement in UL rehabilitation in the chronic stages of stroke.

METHOD

Eight chronic stroke survivors and 21 healthcare professionals took part in semi-structured interviews or in one of three focus groups, respectively.

RESULTS

Thematic analysis revealed three main themes: Availability of resources, Healthcare professional-patient relationship, and Psychosocial factors. Availability of resources and Healthcare professional-patient relationship indicated that due to resource pressures and a lack of communication and education, positive upper limb rehabilitation behaviors (e.g. engaging and integrating the upper limb in daily activity) were not always established in the early stages post-stroke. Psychosocial factors illustrated the cognitive and psychological barriers to sustained engagement with upper limb rehabilitation.

CONCLUSION

The findings indicate that stroke survivors and healthcare professionals have very similar understandings of barriers to UL activity, and positive upper limb rehabilitation behaviors are not always established early in recovery post-stroke. Increased resources and healthcare professional-patient relationships seem key factors to establishing positive perceptions of UL rehabilitation. Addressing psychosocial issues and resource limitations may help sustain engagement with UL rehabilitation.

FES-UPP: A Flexible Functional Electrical Stimulation System to Support Upper Limb Functional Activity Practice

There is good evidence supporting highly intensive, repetitive, activity-focused, voluntary-initiated practice as a key to driving recovery of upper limb function following stroke. Functional electrical stimulation (FES) offers a potential mechanism to efficiently deliver this type of therapy, but current commercial devices are too inflexible and/or insufficiently automated, in some cases requiring engineering support. In this paper, we report a new, flexible upper limb FES system, FES-UPP, which addresses the issues above. The FES-UPP system consists of a 5-channel stimulator running a flexible FES finite state machine (FSM) controller, the associated setup software that guides therapists through the setup of FSM controllers via five setup stages, and finally the Session Manager used to guide the patient in repeated attempts at the activities(s) and provide feedback on their performance. The FSM controller represents a functional activity as a sequence of movement phases. The output for each phase implements the stimulations to one or more muscles. Progression between movement phases is governed by user-defined rules. As part of a clinical investigation of the system, nine therapists used the FES-UPP system to set up FES-supported activities with twenty two patient participants with impaired upper-limbs. Therapists with little or no FES experience and without any programming skills could use the system in their usual clinical settings, without engineering support. Different functional activities, tailored to suit the upper limb impairment levels of each participant were used, in up to 8 sessions of FES-supported therapy per participant. The efficiency of delivery of the therapy using FES-UPP was promising when compared with published data on traditional face-face therapy. The FES-UPP system described in this paper has been shown to allow therapists with little or no FES experience and without any programming skills to set up state-machine FES controllers bespoke to the patient's impairment patterns and activity requirements, without engineering support. The clinical results demonstrated that the system can be used to efficiently deliver high intensity, activity-focused therapy. Nevertheless, further work to reduce setup time is still required.

The use of functional electrical stimulation to improve upper limb function in children with hemiplegic cerebral palsy: A feasibility study

Background

Grasping and manipulating objects are common problems for children with hemiplegic cerebral palsy. Multichannel-functional electrical stimulation may help facilitate upper limb movements and improve function.

Objective

To evaluate the feasibility of multichannel-functional electrical stimulation to improve grasp and upper limb function in children with hemiplegic cerebral palsy to inform the development of a clinical trial.

Methods

A prospective pre-/post-test/follow-up (six months) design with three children, aged 6–13 years, was used. Multichannel-functional electrical stimulation (mFES) was applied to the hemiplegic upper limb for up to 48 sessions over 16 weeks. Feasibility indicators included recruitment of participants and adherence rates, safety, and discomfort/pain. Effectiveness was assessed using the grasp domain of the Quality of Upper Extremity Skills Test, and other secondary clinical outcome measures with “success” criteria set a priori.

Results

Participant recruitment target was not met but adherence was high, and multichannel-functional electrical stimulation was found to be safe and comfortable. Of the three participants, two improved in grasp at post-test, whereas one child’s ability deteriorated. Only one child met success criteria on most outcomes at post-test.

Conclusions

Feasibility indicators met success criteria, except for participant recruitment. Treatment effectiveness was mixed. A future case comparison investigation with a larger but more selected sample is suggested.

Person-Generated Health Data in Simulated Rehabilitation Using Kinect for Stroke: Literature Review

BACKGROUND

Person- or patient-generated health data (PGHD) are health, wellness, and clinical data that people generate, record, and analyze for themselves. There is potential for PGHD to improve the efficiency and effectiveness of simulated rehabilitation technologies for stroke. Simulated rehabilitation is a type of telerehabilitation that uses computer technologies and interfaces to allow the real-time simulation of rehabilitation activities or a rehabilitation environment. A leading technology for simulated rehabilitation is Microsoft's Kinect, a video-based technology that uses infrared to track a user's body movements.

OBJECTIVE

This review attempts to understand to what extent Kinect-based stroke rehabilitation systems (K-SRS) have used PGHD and to what benefit.

METHODS

The review is conducted in two parts. In part 1, aspects of relevance for PGHD were searched for in existing systematic reviews on K-SRS. The following databases were searched: IEEE Xplore, Association of Computing Machinery Digital Library, PubMed, Biomed Central, Cochrane Library, and Campbell Collaboration. In part 2, original research papers that presented or used K-SRS were reviewed in terms of (1) types of PGHD, (2) patient access to PGHD, (3) PGHD use, and (4) effects of PGHD use. The search was conducted in the same databases as part 1 except Cochrane and Campbell Collaboration. Reference lists on K-SRS of the reviews found in part 1 were also included in the search for part 2. There was no date restriction. The search was closed in June 2017. The quality of the papers was not assessed, as it was not deemed critical to understanding PGHD access and use in studies that used K-SRS.

RESULTS

In part 1, 192 papers were identified, and after assessment only 3 papers were included. Part 1 showed that previous reviews focused on technical effectiveness of K-SRS with some attention on clinical effectiveness. None of those reviews reported on home-based implementation or PGHD use. In part 2, 163 papers were identified and after assessment, 41 papers were included. Part 2 showed that there is a gap in understanding how PGHD use may affect patients using K-SRS and a lack of patient participation in the design of such systems.

CONCLUSIONS

This paper calls specifically for further studies of K-SRS-and for studies of technologies that allow patients to generate their own health data in general-to pay more attention to how patients' own use of their data may influence their care processes and outcomes. Future studies that trial the effectiveness of K-SRS outside the clinic should also explore how patients and carers use PGHD in home rehabilitation programs.

Virtual Reality Rehabilitation With Functional Electrical Stimulation Improves Upper Extremity Function in Patients With Chronic Stroke: A Pilot Randomized Controlled Study

OBJECTIVE

To compare virtual reality (VR) combined with functional electrical stimulation (FES) with cyclic FES for improving upper extremity function and health-related quality of life in patients with chronic stroke.

DESIGN

A pilot, randomized, single-blind, controlled trial.

SETTING

Stroke rehabilitation inpatient unit.

PARTICIPANTS

Participants (N=48) with hemiplegia secondary to a unilateral stroke for >3 months and with a hemiplegic wrist extensor Medical Research Council scale score ranging from 1 to 3.

INTERVENTIONS

FES was applied to the wrist extensors and finger extensors. A VR-based wearable rehabilitation device was used combined with FES and virtual activity-based training for the intervention group. The control group received cyclic FES only. Both groups completed 20 sessions over a 4-week period.

MAIN OUTCOME MEASURES

Primary outcome measures were changes in Fugl-Meyer Assessment-Upper Extremity and Wolf Motor Function Test scores. Secondary outcome measures were changes in Box and Block Test, Jebsen-Taylor Hand Function Test, and Stroke Impact Scale scores. Assessments were performed at baseline (t0) and at 2 weeks (t1), 4 weeks (t4), and 8 weeks (t8). Between-group comparisons were evaluated using a repeated-measures analysis of variance.

RESULTS

Forty-one participants were included in the analysis. Compared with FES alone, VR-FES produced a substantial increase in Fugl-Meyer Assessment-distal score (P=.011) and marginal improvement in Jebsen-Taylor Hand Function Test-gross score (P=.057). VR-FES produced greater, although nonsignificant, improvements in all other outcome measures, except in the Stroke Impact Scale-activities of daily living/instrumental activities of daily living score.

CONCLUSIONS

FES with VR-based rehabilitation may be more effective than cyclic FES in improving distal upper extremity gross motor performance poststroke.

Adaptive hybrid robotic system for rehabilitation of reaching movement after a brain injury: a usability study

Background

Brain injury survivors often present upper-limb motor impairment affecting the execution of functional activities such as reaching. A currently active research line seeking to maximize upper-limb motor recovery after a brain injury, deals with the combined use of functional electrical stimulation (FES) and mechanical supporting devices, in what has been previously termed hybrid robotic systems. This study evaluates from the technical and clinical perspectives the usability of an integrated hybrid robotic system for the rehabilitation of upper-limb reaching movements after a brain lesion affecting the motor function.

Methods

The presented system is comprised of four main components. The hybrid assistance is given by a passive exoskeleton to support the arm weight against gravity and a functional electrical stimulation device to assist the execution of the reaching task. The feedback error learning (FEL) controller was implemented to adjust the intensity of the electrical stimuli delivered on target muscles according to the performance of the users. This control strategy is based on a proportional-integral-derivative feedback controller and an artificial neural network as the feedforward controller. Two experiments were carried out in this evaluation. First, the technical viability and the performance of the implemented FEL controller was evaluated in healthy subjects (N = 12). Second, a small cohort of patients with a brain injury (N = 4) participated in two experimental session to evaluate the system performance. Also, the overall satisfaction and emotional response of the users after they used the system was assessed.

Results

In the experiment with healthy subjects, a significant reduction of the tracking error was found during the execution of reaching movements. In the experiment with patients, a decreasing trend of the error trajectory was found together with an increasing trend in the task performance as the movement was repeated. Brain injury patients expressed a great acceptance in using the system as a rehabilitation tool.

Conclusions

The study demonstrates the technical feasibility of using the hybrid robotic system for reaching rehabilitation. Patients’ reports on the received intervention reveal a great satisfaction and acceptance of the hybrid robotic system.

Trial registration

Retrospective trial registration in ISRCTN Register with study ID ISRCTN12843006.

Analysis of muscle synergy for evaluation of task-specific performance in stroke patients

Muscle synergy represents a central neural module that organizes and activates a group of muscles when performing a certain task. However, whether muscle synergy is a good physiological indicator of motor ability in task performance for patients suffering stroke is not clear. The purpose of this study is to understand how information of task-specific muscle synergy in healthy subjects and patients post stroke can be used to evaluate their motor ability, and further to assist motor rehabilitation for stroke patients. Electromyography (EMG) signals and movement kinematics in reaching tasks were recorded in 5 healthy subjects and 4 stroke patients. Muscle synergies were extracted from EMGs and compared cross healthy and stroke subjects. Normal synergies displayed a characteristic pattern common in healthy subjects. But pathological synergies in stroke subjects lacked the characteristics of normal synergy without a common component, implicating varying extent of damage to the motor module due to lesion in cerebral circuits. Further analysis in stroke subjects showed that pathological patterns of synergy in stroke subjects corresponded to the abnormality in their movement control compared with healthy subjects. Data showed that task-specific muscle synergy did reveal a positive correlation to the ability of neural control of tasks. It was further observed that task-specific synergy was changed towards the normal pattern after intervention with functional electrical stimulation in patients post stroke.

Upper limb and eye movement coordination during reaching tasks in people with stroke

PURPOSE

To enhance understanding of the relationship between upper limb and eye movements during reaching tasks in people with stroke.

METHODS

Eye movements were recorded from 10 control participants and 8 chronic stroke participants during a visual orienting task (Experiment 1) and a series of reaching tasks (Experiment 2). Stroke participants completed the reaching tasks using (i) their less impaired upper limb, (ii) their more impaired upper limb without support, and (iii) their more impaired upper limb, with support (SaeboMAS gravitational support and/or electrical stimulation). Participants were tested individually and completed both experiments in the same session.

RESULTS

Oculomotor control and the coordination between the upper limb and the oculomotor system were found to be intact in stroke participants when no limb movements were required, or when the less impaired upper limb was used. However, when the more impaired upper limb was used, success and accuracy in reaching decreased and patterns of eye movements changed, with an observed increase in eye movements to the limb itself. With upper limb support, patterns of hand-eye coordination were found to more closely resemble those of the control group.

CONCLUSION

Deficits in upper limb motor systems result in changes in patterns of eye movement behavior during reaching tasks. These changes in eye movement behavior can be modulated by providing upper limb support. Implications for Rehabilitation Deficits in upper limb motor systems can result in changes in patterns of eye movement behavior during reaching tasks. Upper limb support can reduce deficits in hand-eye coordination. Stroke rehabilitation outcomes should consider motor and oculomotor performance.

The Use of Functional Electrical Stimulation on the Upper Limb and Interscapular Muscles of Patients with Stroke for the Improvement of Reaching Movements: A Feasibility Study

Introduction

Reaching movements in stroke patients are characterized by decreased amplitudes at the shoulder and elbow joints and greater displacements of the trunk, compared to healthy subjects. The importance of an appropriate and specific contraction of the interscapular and upper limb (UL) muscles is crucial to achieving proper reaching movements. Functional electrical stimulation (FES) is used to activate the paretic muscles using short-duration electrical pulses.

Objective

To evaluate whether the application of FES in the UL and interscapular muscles of stroke patients with motor impairments of the UL modifies patients’ reaching patterns, measured using instrumental movement analysis systems.

Design

A cross-sectional study was carried out.

Setting

The VICON Motion System^® was used to conduct motion analysis.

Participants

Twenty-one patients with chronic stroke.

Intervention

The Compex^® electric stimulator was used to provide muscle stimulation during two conditions: a placebo condition and a FES condition.

Main outcome measures

We analyzed the joint kinematics (trunk, shoulder, and elbow) from the starting position until the affected hand reached the glass.

Results

Participants receiving FES carried out the movement with less trunk flexion, while shoulder flexion elbow extension was increased, compared to placebo conditions.

Conclusion

The application of FES to the UL and interscapular muscles of stroke patients with motor impairment of the UL has improved reaching movements.

Functional electrical stimulation for home-based upper-limb stroke rehabilitation

Functional electrical stimulation (FES) therapies have shown effectiveness in restoring movement post-stroke, especially when applied functionally to assist participants’ voluntary intention during repeated, motivating tasks. Recent development in non-contact sensors allows feedback to advanced controllers that precisely adjust FES via an electrode array to assist functional reach and grasp tasks. This has given rise to significant reduction in impairment, as measured in clinical trials. This paper describes the recent developments of a compact system suitable for transference to patients’ homes, with the intention of reducing upper-limb impairment following chronic stroke.

Electrogoniometer measurement and directional analysis of wrist angles and movements during the Sollerman hand function test

STUDY DESIGN

Clinical measurement.

INTRODUCTION

To investigate the characteristics of wrist motion (area, axis, and location) during activities of daily living (ADL) using electrogoniometry.

METHODS

A sample of 83 normal volunteers performed the Sollerman hand function test (SHFT) with a flexible biaxial electrogoniometer applied to their wrists. This technique is accurate and reliable and has been used before for assessment of wrist circumduction in normal volunteers. A software package was used to overlay an ellipse of best fit around the 2-dimensional trace of the electrogoniometer mathematically computing the area, location, and axis angle of the ellipse.

RESULTS

Most ADL could be completed within 20% of the total area of circumduction (3686°° ± 1575°°) of a normal wrist. An oblique plane in radial extension and ulnar flexion (dart-throwing motion plane) was used for rotation (-14° ± 32°) and power grip tasks (-29° ± 25°) during ADL; however, precision tasks (4° ± 28°), like writing, were performed more often in the flexion extension plane. In the dominant hand, only 2 power tasks were located in flexion region (cutting play dough [ulnar] and pouring carton [radial]), precision tasks were located centrally, and rotation and other power tasks were located in extension region.

DISCUSSION

This study has identified that wrist motion during the ADL requires varying degrees of movement in oblique planes. Using electrogoniometry, we could visualize the area, location, and plane of motion during ADL. This could assist future researchers to compare procedures leading to loss of motion in specific quadrants of wrist motion and its impact on patient's ability in performing particular ADL. It could guide hand therapists to specifically focus on retraining the ADL that may be affected when wrist range of motion is lost after injury.

LEVEL OF EVIDENCE

Diagnostic level III.

Iterative learning control with applications in energy generation, lasers and health care

Many physical systems make repeated executions of the same finite time duration task. One example is a robot in a factory or warehouse whose task is to collect an object in sequence from a location, transfer it over a finite duration, place it at a specified location or on a moving conveyor and then return for the next one and so on. Iterative learning control was especially developed for systems with this mode of operation and this paper gives an overview of this control design method using relatively recent relevant applications in wind turbines, free-electron lasers and health care, as exemplars to demonstrate its applicability.

Hybrid robotic systems for upper limb rehabilitation after stroke: A review

In recent years the combined use of functional electrical stimulation (FES) and robotic devices, called hybrid robotic rehabilitation systems, has emerged as a promising approach for rehabilitation of lower and upper limb motor functions. This paper presents a review of the state of the art of current hybrid robotic solutions for upper limb rehabilitation after stroke. For this aim, studies have been selected through a search using web databases: IEEE-Xplore, Scopus and PubMed. A total of 10 different hybrid robotic systems were identified, and they are presented in this paper. Selected systems are critically compared considering their technological components and aspects that form part of the hybrid robotic solution, the proposed control strategies that have been implemented, as well as the current technological challenges in this topic. Additionally, we will present and discuss the corresponding evidences on the effectiveness of these hybrid robotic therapies. The review also discusses the future trends in this field.

Hybrid Neuroprosthesis for the Upper Limb: Combining Brain-Controlled Neuromuscular Stimulation with a Multi-Joint Arm Exoskeleton

Brain-machine interface-controlled (BMI) neurofeedback training aims to modulate cortical physiology and is applied during neurorehabilitation to increase the responsiveness of the brain to subsequent physiotherapy. In a parallel line of research, robotic exoskeletons are used in goal-oriented rehabilitation exercises for patients with severe motor impairment to extend their range of motion (ROM) and the intensity of training. Furthermore, neuromuscular electrical stimulation (NMES) is applied in neurologically impaired patients to restore muscle strength by closing the sensorimotor loop. In this proof-of-principle study, we explored an integrated approach for providing assistance as needed to amplify the task-related ROM and the movement-related brain modulation during rehabilitation exercises of severely impaired patients. For this purpose, we combined these three approaches (BMI, NMES, and exoskeleton) in an integrated neuroprosthesis and studied the feasibility of this device in seven severely affected chronic stroke patients who performed wrist flexion and extension exercises while receiving feedback via a virtual environment. They were assisted by a gravity-compensating, seven degree-of-freedom exoskeleton which was attached to the paretic arm. NMES was applied to the wrist extensor and flexor muscles during the exercises and was controlled by a hybrid BMI based on both sensorimotor cortical desynchronization (ERD) and electromyography (EMG) activity. The stimulation intensity was individualized for each targeted muscle and remained subthreshold, i.e., induced no overt support. The hybrid BMI controlled the stimulation significantly better than the offline analyzed ERD (p = 0.028) or EMG (p = 0.021) modality alone. Neuromuscular stimulation could be well integrated into the exoskeleton-based training and amplified both the task-related ROM (p = 0.009) and the movement-related brain modulation (p = 0.019). Combining a hybrid BMI with neuromuscular stimulation and antigravity assistance augments upper limb function and brain activity during rehabilitation exercises and may thus provide a novel restorative framework for severely affected stroke patients.

Closed-Loop Neuroprosthesis for Reach-to-Grasp Assistance: Combining Adaptive Multi-channel Neuromuscular Stimulation with a Multi-joint Arm Exoskeleton

Stroke patients with severe motor deficits cannot execute task-oriented rehabilitation exercises with their affected upper extremity. Advanced rehabilitation technology may support them in performing such reach-to-grasp movements. The challenge is, however, to provide assistance as needed, while maintaining the participants' commitment during the exercises. In this feasibility study, we introduced a closed-loop neuroprosthesis for reach-to-grasp assistance which combines adaptive multi-channel neuromuscular stimulation with a multi-joint arm exoskeleton. Eighteen severely affected chronic stroke patients were assisted by a gravity-compensating, seven-degree-of-freedom exoskeleton which was attached to the paretic arm for performing reach-to-grasp exercises resembling activities of daily living in a virtual environment. During the exercises, adaptive electrical stimulation was applied to seven different muscles of the upper extremity in a performance-dependent way to enhance the task-oriented movement trajectory. The stimulation intensity was individualized for each targeted muscle and remained subthreshold, i.e., induced no overt support. Closed-loop neuromuscular stimulation could be well integrated into the exoskeleton-based training, and increased the task-related range of motion (p = 0.0004) and movement velocity (p = 0.015), while preserving accuracy. The highest relative stimulation intensity was required to facilitate the grasping function. The facilitated range of motion correlated with the upper extremity Fugl-Meyer Assessment score of the patients (p = 0.028). Combining adaptive multi-channel neuromuscular stimulation with antigravity assistance amplifies the residual motor capabilities of severely affected stroke patients during rehabilitation exercises and may thus provide a customized training environment for patient-tailored support while preserving the participants' engagement.

Advances in selective activation of muscles for non-invasive motor neuroprostheses

Non-invasive neuroprosthetic (NP) technologies for movement compensation and rehabilitation remain with challenges for their clinical application. Two of those major challenges are selective activation of muscles and fatigue management. This review discusses how electrode arrays improve the efficiency and selectivity of functional electrical stimulation (FES) applied via transcutaneous electrodes. In this paper we review the principles and achievements during the last decade on techniques for artificial motor unit recruitment to improve the selective activation of muscles. We review the key factors affecting the outcome of muscle force production via multi-pad transcutaneous electrical stimulation and discuss how stimulation parameters can be set to optimize external activation of body segments. A detailed review of existing electrode array systems proposed by different research teams is also provided. Furthermore, a review of the targeted applications of existing electrode arrays for control of upper and lower limb NPs is provided. Eventually, last section demonstrates the potential of electrode arrays to overcome the major challenges of NPs for compensation and rehabilitation of patient-specific impairments.

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.

An Exploratory Investigation on the Use of Closed-Loop Electrical Stimulation to Assist Individuals with Stroke to Perform Fine Movements with Their Hemiparetic Arm

Stroke is the leading cause of upper limb impairments resulting in disability. Modern rehabilitation includes training with robotic exoskeletons and functional electrical stimulation (FES). However, there is a gap in knowledge to define the detailed use of FES in stroke rehabilitation. In this paper, we explore applying closed-loop FES to the upper extremities of healthy volunteers and individuals with a hemiparetic arm resulting from stroke. We used a set of gyroscopes to monitor arm movements and used a non-linear controller, namely, the robust integral of the sign of the error (RISE), to assess the viability of controlling FES in closed loop. Further, we explored the application of closed-loop FES in improving functional tasks performed by individuals with stroke. Four healthy individuals of ages 27–32 years old and five individuals with stroke of ages 61–83 years old participated in this study. We used the Rehastim FES unit (Hasomed Ltd.) with real-time modulation of pulse width and amplitude. Both healthy and stroke individuals were tested in RISE-controlled single and multi-joint upper limb motions following first a sinusoidal trajectory. Individuals with stroke were also asked to perform the following functional tasks: picking up a basket, picking and placing an object on a table, cutting a pizza, pulling back a chair, eating with a spoon, as well as using a stapler and grasping a pen. Healthy individuals were instructed to keep their arm relaxed during the experiment. Most individuals with stroke were able to follow the sinusoid trajectories with their arm joints under the sole excitation of the closed-loop-controlled FES. One individual with stroke, who was unable to perform any of the functional tasks independently, succeeded in completing all the tasks when FES was used. Three other individuals with stroke, who were unable to complete a few tasks independently, completed some of them when FES was used. The remaining stroke participant was able to complete all tasks with and without FES. Our results suggest that individuals with a low Fugl–Meyer score or a higher level of disability may benefit the most with the use of closed-loop-controlled FES.

Computational models of upper-limb motion during functional reaching tasks for application in FES-based stroke rehabilitation

Functional electrical stimulation (FES) has been shown to be an effective approach to upper-limb stroke rehabilitation, where it is used to assist arm and shoulder motion. Model-based FES controllers have recently confirmed significant potential to improve accuracy of functional reaching tasks, but they typically require a reference trajectory to track. Few upper-limb FES control schemes embed a computational model of the task; however, this is critical to ensure the controller reinforces the intended movement with high accuracy. This paper derives computational motor control models of functional tasks that can be directly embedded in real-time FES control schemes, removing the need for a predefined reference trajectory. Dynamic models of the electrically stimulated arm are first derived, and constrained optimisation problems are formulated to encapsulate common activities of daily living. These are solved using iterative algorithms, and results are compared with kinematic data from 12 subjects and found to fit closely (mean fitting between 63.2% and 84.0%). The optimisation is performed iteratively using kinematic variables and hence can be transformed into an iterative learning control algorithm by replacing simulation signals with experimental data. The approach is therefore capable of controlling FES in real time to assist tasks in a manner corresponding to unimpaired natural movement. By ensuring that assistance is aligned with voluntary intention, the controller hence maximises the potential effectiveness of future stroke rehabilitation trials.