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

The Current Update of Conventional and Innovative Treatment Strategies for Central Nervous System Injury

This review explores the complex challenges and advancements in the treatment of traumatic brain injury (TBI) and spinal cord injury (SCI). Traumatic injuries to the central nervous system (CNS) trigger intricate pathophysiological responses, frequently leading to profound and enduring disabilities. This article delves into the dual phases of injury-primary impacts and the subsequent secondary biochemical cascades-that worsen initial damage. Conventional treatments have traditionally prioritized immediate stabilization, surgical interventions, and supportive medical care to manage both the primary and secondary damage associated with central nervous system injuries. We explore current surgical and medical management strategies, emphasizing the crucial role of rehabilitation and the promising potential of stem cell therapies and immune modulation. Advances in stem cell therapy, gene editing, and neuroprosthetics are revolutionizing treatment approaches, providing opportunities not just for recovery but also for the regeneration of impaired neural tissues. This review aims to emphasize emerging therapeutic strategies that hold promise for enhancing outcomes and improving the quality of life for affected individuals worldwide.

Stroke rehabilitation: from diagnosis to therapy

Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.

Effects of virtual reality-based robot therapy combined with task-oriented therapy on upper limb function and cerebral cortex activation in patients with stroke

BACKGROUND

This study aimed to investigate the effects of virtual reality (VR)-based robot therapy combined with task-oriented therapy on cerebral cortex activation and upper limb function in patients with stroke.

METHODS

This study included 46 patients with hemiplegia within 1 year of stroke onset. Patients were divided into an experimental group (n = 23) and a control group (n = 23) using a computer randomization program. The experimental group received VR-based robot and task-oriented therapies, whereas the control group received only task-oriented therapy. All participants received interventions for 40 minutes per session, 5 times a week, for 8 weeks. For the pre- and post-evaluation of all participants, the Fugl-Meyer Assessment for the upper extremity, manual function test, motor activity log, and Jebsen-Taylor Hand Function Test were used to evaluate changes in upper limb function and motor-evoked potential amplitudes were measured to compare cerebral cortex activation.

RESULTS

In comparison to the control group, experimental group demonstrated an improvement in the function of the upper limb (P < .01) and activation of the cerebral cortex (P < .01).

CONCLUSION

The combined intervention of VR-based robot and task-oriented therapies is valuable for improving upper limb function and cerebral cortex activation in patients with stroke.

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

BACKGROUND

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

METHOD

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

RESULT

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

CONCLUSIONS

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

A novel functional electrical stimulation sleeve based on textile-embedded dry electrodes

BACKGROUND

Functional electrical stimulation (FES) is a rehabilitation technique that enables functional improvements in patients with motor control impairments. This study presents an original design and prototyping method for a smart sleeve for FES applications. The article explains how to integrate a carbon-based dry electrode into a textile structure and ensure an electrical connection between the electrodes and the stimulator for effective delivery of the FES. It also describes the materials and the step-by-step manufacturing processes.

RESULTS

The carbon-based dry electrode is integrated into the textile substrate by a thermal compression molding process on an embroidered conductive matrix. This matrix is composed of textile silver-plated conductive yarns and is linked to the stimulator. Besides ensuring the electrical connection, the matrix improves the fixation between the textile substrate and the electrode. The stimulation intensity, the perceived comfort and the muscle torque generated by the smart FES sleeve were compared to hydrogel electrodes. The results show a better average comfort and a higher average stimulation intensity with the smart FES sleeve, while there were no significant differences for the muscle torque generated.

CONCLUSIONS

The integration of the proposed dry electrodes into a textile is a viable solution. The wearable FES system does not negatively impact the electrodes' performance, and tends to improve it. Additionally, the proposed prototyping method is applicable to an entire garment in order to target all muscles. Moreover, the process is feasible for industrial production and commercialization since all materials and processes used are already available on the market.

Efficacy of Dashmool Vasti as an adjuvant therapy with the standard of care (modern + physiotherapy) in the rehabilitation of stroke as compared to standard of care - a clinical trial protocol

Background

Stroke is ischemia and neurological dysfunction caused by acute brain circulation loss. It causes acute localized neurological abnormalities such as weakness, sensory deficit, or language issues that require long-term treatment. These deficiencies harm the patient and their family psychologically, socially, and economically. Thus, combination treatment can rapidly rehabilitate such patients. Detoxification methods like Ayurvedic medicated enema help stroke pathophysiology. Physical modalities in physiotherapy have been shown to facilitate normal movement and function on the stroke patient's affected side, increasing independence with everyday duties. A stroke patient may benefit from Dashmoola Niruha Basti, Function Electrical Stimulation (FES), and Motor Relearning Programme (MRP).

Aim & Objectives

This study compares the adjuvant role of Dashmoola Basti with MRP and FES in stroke recovery. The main goals of this study are to assess and compare the adjuvant role of Dashmoola Basti with standard control over sensorimotor function of lower extremities, static and dynamic balance in stroke patients; gait parameters; resistance experienced during passive range of motion; quality of life of patients; Barthel Index; Modified Ashworth Scale; and Fuglmeyer assessment, Single Limb Stance Test, Functional Reach Test.

Methods

A total of 40 patients will be enrolled and divided randomly into two equal groups. In Group A (control), standard treatment (modern + physiotherapy) will be prescribed for one month. In Group B (interventional group), Dashmoola Basti will be added to the aforementioned standard treatment for one month.

Expected results

Improvement in Fuglmeyer assessment, Single Limb Stance Test, Functional Reach Test, quality of Life of Patients, Barthel Index, Modified Ashworth scale, and National Institute of Health (NIH) stroke-scale-score will be observed and recorded.

Conclusions

Results and conclusions will be derived according to the data collected in case record form and assessment sheets filled at baseline and follow-up visits.

Trial registration

CTRI/2021/10/037445 dated 21.10.2021.

Electrotherapy in stroke rehabilitation can improve lower limb muscle characteristics: a systematic review and meta-analysis

PURPOSE

This review assesses the effect of electrotherapy (e.g. functional electrical stimulation (FES), motor and sensor therapeutic electrical stimulation (TES)) on muscle strength and skeletal muscle characteristics in individuals post-stroke compared to conventional or sham therapy.

METHODS

A systematic literature search was conducted in MEDLINE, SCOPUS, and Web of Science, focusing on randomized controlled trials investigating the effect of electrotherapy. Data of interest was extracted from eligible studies, and risk of bias was assessed.

RESULTS

In total, 23 studies (933 people post-stroke) were included, of which 17, which mainly focus on patients in a chronic stage of stroke recovery and the implementation of FES, were incorporated in the meta-analysis. A significant increase in muscle strength was found favoring electrotherapy over conventional therapy (SMD 0.63, 95% CI 0.34-0.91, I2 = 37%, p = 0.07) and over sham therapy (SMD 0.44, 95% CI 0.20-0.68, I2 = 38%, p = 0.08). Three studies investigated the effect on muscle thickness and found a significant increase in favor of electrostimulation when compared to conventional therapy (MD 0.11 cm, 95% CI 0.06-0.16, I2 = 0%, p = 0.50).

CONCLUSION

Current evidence suggests electrotherapy in combination with physiotherapy has positive effects on lower limb muscle strength and skeletal muscle characteristics in patients recovering from stroke.

Contralaterally Controlled Functional Electrical Stimulation for Improving Motor Function After Acquired Brain Injury: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically evaluate the effect of contralaterally controlled functional electrical stimulation (CCFES) on motor function after acquired brain injury (ABI).

DATA SOURCES

We searched the PubMed, Embase, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), Web of Science, SinoMed, CNKI, VIP Database for Chinese Technical Periodicals and Wanfang Database, from inception to December 2023.

STUDY SELECTION

Studies were included if they were randomized controlled trials assessing the effect of CCFES on motor function compared with routine rehabilitation or routine electrical stimulation after ABI. Two independent reviewers screened 894 articles for inclusion.

DATA EXTRACTION

The extracted data included study information, sample size, study population, interventions, measurement evaluated, and the test interval.

DATA SYNTHESIS

This study included 24 trials with 28 intervention-control pairs and 1148 participants with stroke. Meta-analysis showed that the CCFES group demonstrated more significant improvement than the control group in the Fugl-Meyer Assessment Scale (FMA) (standardized mean difference [SMD]=0.66, 95% confidence interval [CI]=0.44-0.88, P<.001), active range of motion (AROM) (SMD=0.77, 95% CI=0.54-1.01, P<.001), modified Barthel Index (MBI) (SMD=0.55, 95% CI=0.29-0.81, P<.001), Motricity Index (MI) (SMD=0.60, 95% CI=0.26-0.94, P<.001) surface electromyography (sEMG) (SMD=0.81, 95% CI=0.56-1.06, P<.001), and Functional Ambulation Category (FAC) (SMD=0.53, 95% CI=0.24-0.83, P<.001). The CCFES group showed no significant improvement over the control group in the Action Research Arm Test (ARAT) (SMD=0.24, 95% CI=-0.10-0.58, P=.17).

CONCLUSIONS

Our synthesized evidence suggests that CCFES could improve motor function in patients with stroke. More RCTs with other patients with brain injury are required to provide future evidence on the therapy effect of CCFES and make a contribution to the uniform standard of CCFES.

Demographic, biochemical, clinical, and cognitive symptom differences between smokers and non-smokers in Chinese older male patients with chronic schizophrenia

BACKGROUND

Several studies have suggested that smoking may impair cognitive function and worsen psychiatric symptoms in people with schizophrenia, but the results have not been consistent. There have been few studies to date that have examined the effects of smoking in older men with chronic schizophrenia.

METHODS

The participants in our study consisted of 167 order Chinese males with chronic schizophrenia and 359 normal control subjects. We split them into smoking and non-smoking groups based on whether or not they smoked. Second, we compared their differences in terms of general demographic characteristics (such as age, education, body mass index, age of illness onset, and course of disease), disease information (such as hypertension, diabetes, and hyperlipidemia), lifestyle factors (such as physical exercise and lunch break), blood biochemical indicators (such as albumin, triglyceride, total cholesterol, high-density lipoprotein, low-density lipoprotein and fasting blood glucose), and medication usage (such as clozapine, olanzapine, risperidone, and chlorpromazine). Lastly, a neuropsychological test battery was used to assess their psychiatric and cognitive symptoms, for example, the Montreal Cognitive Assessment (MoCA) was used to assess their overall cognitive functioning. Their depressive symptoms were assessed by the geriatric depression scale (GDS). Activities of daily living (ADL) were used to assess their ability to lead a daily life, while the positive and negative syndrome scales (PANSS) were used to assess their psychiatric symptoms.

RESULTS

Smokers who develop schizophrenia at older ages had a higher body mass index than non-smokers. We also found that plasma albumin, triglycerides, low-density lipoprotein, and fasting blood glucose concentrations were significantly higher in smokers. In contrast, smokers with schizophrenia also had lower PANSS total scores, negative symptom scores, and general psychopathology scores. A forward stepwise binary logistics regression analysis demonstrated a significant association between negative symptom scores and smoking status (B = 0.112, p < 0.001, OR = 1.119, 95% confidence interval: 1.059-1.181). Correlation analysis was carried out and it was found that the amount of cigarette consumption per day had a negative correlation with plasma albumin level(r = - 0.290, p = 0.004). However, no such association was found in normal controls.

CONCLUSIONS

Elderly Chinese men with schizophrenia have a higher percentage of smokers, and although smoking can reduce their plasma albumin levels, it does contribute to the prevention of negative symptoms.

Cortical activity associated with focal muscle vibration applied directly to the affected forearm flexor muscle in post-stroke patients: an fNIRS study

Objective

The purpose of this study was to utilize functional near-infrared spectroscopy (fNIRS) to identify changes in cortical activity caused by focal muscle vibration (FMV), which was directly administered to the affected forearm flexor muscles of hemiplegic stroke patients. Additionally, the study aimed to investigate the correlation between these changes and the clinical characteristics of the patients, thereby expanding the understanding of potential neurophysiological mechanisms linked to these effects.

Methods

Twenty-two stroke patients with right hemiplegia who were admitted to our ward for rehabilitation were selected for this study. The fNIRS data were collected from subjects using a block-design paradigm. Subsequently, the collected data were analyzed using the NirSpark software to determine the mean Oxyhemoglobin (Hbo) concentrations for each cortical region of interest (ROI) in the task and rest states for every subject. The stimulation task was FMV (frequency 60 Hz, amplitude 6 mm) directly applied to belly of the flexor carpi radialis muscle (FCR) on the affected side. Hbo was measured in six regions of interest (ROIs) in the cerebral cortex, which included the bilateral prefrontal cortex (PFC), sensorimotor cortex (SMC), and occipital cortex (OC). The clinical characteristics of the patients were assessed concurrently, including Lovett's 6-level muscle strength assessment, clinical muscle tone assessment, the upper extremity function items of the Fugl-Meyer Assessment (FMA-UE), Bruunstrom staging scale (BRS), and Modified Barthel index (MBI). Statistical analyses were conducted to determine the activation in the ROIs and to comprehend its correlation with the clinical characteristics of the patients.

Results

Statistical analysis revealed that, except for right OC, there were statistically significant differences between the mean Hbo in the task state and rest state for bilateral SMC, PFC, and left OC. A positive correlation was observed between the muscle strength of the affected wrist flexor group and the change values of Hbo (Hbo-CV), as well as the beta values in the left SMC, PFC, and OC. However, no statistical correlation was found between muscle strength and Hbo-CV or beta values in the right SMC, PFC, and OC. The BRS of the affected upper limb exhibited a positive correlation with the Hbo-CV or beta values in the left SMC and PFC. In contrast, no statistical correlation was observed in the right SMC, PFC, and bilateral OC. No significant correlation was found between the muscle tone of the affected wrist flexor group, FMA-UE, MBI, and Hbo-CV or beta values of cortical ROIs.

Conclusion

FMV-evoked sensory stimulation applied directly to the FCR belly on the paralyzed side activated additional brain cortices, including bilateral PFC and ipsilesional OC, along with bilateral SMC in stroke patients. However, the clinical characteristics of the patients were only correlated with the intensity of ipsilesional SMC and PFC activation. The results of this study provide neurophysiological theoretical support for the expanded clinical application of FMV.

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.

From monkeys to humans: observation-basedEMGbrain-computer interface decoders for humans with paralysis

Objective. Intracortical brain-computer interfaces (iBCIs) aim to enable individuals with paralysis to control the movement of virtual limbs and robotic arms. Because patients' paralysis prevents training a direct neural activity to limb movement decoder, most iBCIs rely on 'observation-based' decoding in which the patient watches a moving cursor while mentally envisioning making the movement. However, this reliance on observed target motion for decoder development precludes its application to the prediction of unobservable motor output like muscle activity. Here, we ask whether recordings of muscle activity from a surrogate individual performing the same movement as the iBCI patient can be used as target for an iBCI decoder.Approach. We test two possible approaches, each using data from a human iBCI user and a monkey, both performing similar motor actions. In one approach, we trained a decoder to predict the electromyographic (EMG) activity of a monkey from neural signals recorded from a human. We then contrast this to a second approach, based on the hypothesis that the low-dimensional 'latent' neural representations of motor behavior, known to be preserved across time for a given behavior, might also be preserved across individuals. We 'transferred' an EMG decoder trained solely on monkey data to the human iBCI user after using Canonical Correlation Analysis to align the human latent signals to those of the monkey.Main results. We found that both direct and transfer decoding approaches allowed accurate EMG predictions between two monkeys and from a monkey to a human.Significance. Our findings suggest that these latent representations of behavior are consistent across animals and even primate species. These methods are an important initial step in the development of iBCI decoders that generate EMG predictions that could serve as signals for a biomimetic decoder controlling motion and impedance of a prosthetic arm, or even muscle force directly through functional electrical stimulation.

Hybrid Robotic and Electrical Stimulation Assistance Can Enhance Performance and Reduce Mental Demand

Combining functional electrical stimulation (FES) and robotics may enhance recovery after stroke, by providing neural feedback with the former while improving quality of motion and minimizing muscular fatigue with the latter. Here, we explored whether and how FES, robot assistance and their combination, affect users' performance, effort, fatigue and user experience. 15 healthy participants performed a wrist flexion/extension tracking task with FES and/or robotic assistance. Tracking performance improved during the hybrid FES-robot and the robot-only assistance conditions in comparison to no assistance, but no improvement is observed when only FES is used. Fatigue, muscular and voluntary effort are estimated from electromyographic recording. Total muscle contraction and volitional activity are lowest with robotic assistance, whereas fatigue level do not change between the conditions. The NASA-Task Load Index answers indicate that participants found the task less mentally demanding during the hybrid and robot conditions than the FES condition. The addition of robotic assistance to FES training might thus facilitate an increased user engagement compared to robot training and allow longer motor training session than with FES assistance.

Stroke Recovery Is a Journey: Prediction and Potentials of Motor Recovery after a Stroke from a Practical Perspective

Stroke recovery is a journey. Stroke survivors can face many consequences that may last the rest of their lives. Assessment of initial impairments allows reasonable prediction of biological spontaneous recovery at 3 to 6 months for a majority of survivors. In real-world clinical practice, stroke survivors continue to improve their motor function beyond the spontaneous recovery period, but management plans for maximal recovery are not well understood. A model within the international classification of functioning (ICF) theoretical framework is proposed to systematically identify opportunities and potential barriers to maximize and realize the potentials of functional recovery from the acute to chronic stages and to maintain their function in the chronic stages. Health conditions of individuals, medical and neurological complications can be optimized under the care of specialized physicians. This permits stroke survivors to participate in various therapeutic interventions. Sufficient doses of appropriate interventions at the right time is critical for stroke motor rehabilitation. It is important to highlight that combining interventions is likely to yield better clinical outcomes. Caregivers, including family members, can assist and facilitate targeted therapeutic exercises for these individuals and can help stroke survivors comply with medical plans (medications, visits), and provide emotional support. With health optimization, comprehensive rehabilitation, support from family and caregivers and a commitment to a healthy lifestyle, many stroke survivors can overcome barriers and achieve potentials of maximum recovery and maintain their motor function in chronic stages. This ICF recovery model is likely to provide a guidance through the journey to best achieve stroke recovery potentials.

Functional Electrical Stimulation in Conjunction With Proprioceptive Neuromuscular Facilitation (PNF) Technique to Improve Upper Limb Function in Traumatic Brachial Plexus Injury: A Case Report

Traumatic brachial plexus injuries (TBPIs) in the adult population are primarily a result of road traffic accidents or falls on a shoulder, which mainly affects the young population. Adult TBPI is a serious incapacitating injury that affects young adults. It decreases the function of upper extremity muscles, which affects social participation and quality of life. Physiotherapy intervention demonstrates its effectiveness in enhancing and maintaining the function of the upper extremity, eventually decreasing the participation restriction and improving quality of life. The proprioceptive neuromuscular facilitation (PNF) technique has been selected as a useful therapeutic option to enhance upper limb function after TBPI. The preceding case report proved the effectiveness of six weeks of functional electrical stimulation in addition to the PNF technique in improving upper limb function after TBPI.

Synergy-based functional electrical stimulation and robotic-assisted for retraining reach-to-grasp in stroke: a study protocol for a randomized controlled trial

BACKGROUND

Stroke survivors have long-term upper limb impairment, which impacts the quality of life (QOL) and social reintegration, but there is lack of effective therapeutic strategies and novel technologies. Customized multi-muscle functional electrical stimulation (FES) based on the muscle synergy of healthy adults and robotic-assisted therapy (RAT) have been proved efficacy respectively. Synergy-based FES combined with RAT can be a novel and more effective therapy for upper limb recovery of stroke survivors from the perspective of synergistic enhancement. However, few studies have examined the effectiveness of combined synergy-based FES and RAT, especially for motor control evaluated by reach-to-grasp (RTG) movements. The main objective of the following research protocol is to evaluate the effectiveness and efficacy, as well as adoptability, of FES-RAT and FES or RAT rehabilitation program for upper limb function improvement after stroke.

METHODS

This will be an assessor-blinded randomized controlled trial involving a 12-week intervention and a 6-month follow-up. Stratified randomization will be used to equally and randomly assign 162 stroke patients into the FES + conventional rehabilitation program (CRP) group, RAT + CRP group and FES-RAT + CRP group. Interventions will be provided in 5 sessions per week, with a total of 60 sessions. The primary outcome measurements will include the Fugl-Meyer Assessment and Biomechanical Assessment of RTG movements. The secondary outcome measurements will include quality of life and brain neuroplasticity assessments by MRI. Evaluations will be performed at five time points, including at baseline, 6 weeks and 12 weeks from the start of treatment, and 3 months and 6 months following the end of treatment. A two-way analysis of variance with repeated measures will be applied to examine the main effects of the group, the time factor and group-time interaction effects.

DISCUSSION

The results of the study protocol will provide high quality evidence for integrated synergy-based FES and RAT, and synergy-based FES alone and guide the design of more effective treatment methods for stroke rehabilitation.

TRIAL REGISTRATION

ChiCTR2300071588.

Functional electrical stimulation therapy controlled by a P300-based brain-computer interface, as a therapeutic alternative for upper limb motor function recovery in chronic post-stroke patients. A non-randomized pilot study

Introduction

Up to 80% of post-stroke patients present upper-limb motor impairment (ULMI), causing functional limitations in daily activities and loss of independence. UMLI is seldom fully recovered after stroke when using conventional therapeutic approaches. Functional Electrical Stimulation Therapy (FEST) controlled by Brain-Computer Interface (BCI) is an alternative that may induce neuroplastic changes, even in chronic post-stroke patients. The purpose of this work was to evaluate the effects of a P300-based BCI-controlled FEST intervention, for ULMI recovery of chronic post-stroke patients.

Methods

A non-randomized pilot study was conducted, including 14 patients divided into 2 groups: BCI-FEST, and Conventional Therapy. Assessments of Upper limb functionality with Action Research Arm Test (ARAT), performance impairment with Fugl-Meyer assessment (FMA), Functional Independence Measure (FIM) and spasticity through Modified Ashworth Scale (MAS) were performed at baseline and after carrying out 20 therapy sessions, and the obtained scores compared using Chi square and Mann-Whitney U statistical tests (𝛼 = 0.05).

Results

After training, we found statistically significant differences between groups for FMA (p = 0.012), ARAT (p < 0.001), and FIM (p = 0.025) scales.

Discussion

It has been shown that FEST controlled by a P300-based BCI, may be more effective than conventional therapy to improve ULMI after stroke, regardless of chronicity.

Conclusion

The results of the proposed BCI-FEST intervention are promising, even for the most chronic post-stroke patients often relegated from novel interventions, whose expected recovery with conventional therapy is very low. It is necessary to carry out a randomized controlled trial in the future with a larger sample of patients.

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

Introduction

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

Materials and methods

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

Results

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

Discussion

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

Clinical trial registration

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

Manipulating facial musculature with functional electrical stimulation as an intervention for major depressive disorder: a focused search of literature for a proposal

BACKGROUND

Major Depressive Disorder (MDD) is associated with interoceptive deficits expressed throughout the body, particularly the facial musculature. According to the facial feedback hypothesis, afferent feedback from the facial muscles suffices to alter the emotional experience. Thus, manipulating the facial muscles could provide a new "mind-body" intervention for MDD. This article provides a conceptual overview of functional electrical stimulation (FES), a novel neuromodulation-based treatment modality that can be potentially used in the treatment of disorders of disrupted brain connectivity, such as MDD.

METHODS

A focused literature search was performed for clinical studies of FES as a modulatory treatment for mood symptoms. The literature is reviewed in a narrative format, integrating theories of emotion, facial expression, and MDD.

RESULTS

A rich body of literature on FES supports the notion that peripheral muscle manipulation in patients with stroke or spinal cord injury may enhance central neuroplasticity, restoring lost sensorimotor function. These neuroplastic effects suggest that FES may be a promising innovative intervention for psychiatric disorders of disrupted brain connectivity, such as MDD. Recent pilot data on repetitive FES applied to the facial muscles in healthy participants and patients with MDD show early promise, suggesting that FES may attenuate the negative interoceptive bias associated with MDD by enhancing positive facial feedback. Neurobiologically, the amygdala and nodes of the emotion-to-motor transformation loop may serve as potential neural targets for facial FES in MDD, as they integrate proprioceptive and interoceptive inputs from muscles of facial expression and fine-tune their motor output in line with socio-emotional context.

CONCLUSIONS

Manipulating facial muscles may represent a mechanistically novel treatment strategy for MDD and other disorders of disrupted brain connectivity that is worthy of investigation in phase II/III trials.

The Effect of Diagonal Exercise Training for Neurorehabilitation on Functional Activity in Stroke Patients: A Pilot Study

Functional movements of the human body occur multifacetedly. This pilot study investigated the effects of neurorehabilitation training, including diagonal movements, balance, gait, fall efficacy, and activities of daily living in stroke patients. Twenty-eight patients diagnosed with stroke by a specialist were divided into experimental groups applying diagonal exercise training and control groups applying sagittal exercise training. The five times sit-to-stand test (FTSST), timed up and go (TUG) test, and Berg balance scale (BBS) were used to evaluate balance ability, the falls efficacy scale (FES) was used to evaluate fall efficacy, and the modified Barthel index (MBI) was used to evaluate activities of daily living. All evaluations were conducted once prior to intervention implementation and again six weeks after the final intervention. In the study results, the experimental group to which the diagonal exercise training was applied had statistically significant changes in FTSST, BBS, and FES compared to the control group. In conclusion, the rehabilitation program, including diagonal exercise training, increased the patient's balance and reduced the fear of falling.

BCI-activated electrical stimulation in children with perinatal stroke and hemiparesis: A pilot study

Background

Perinatal stroke (PS) causes most hemiparetic cerebral palsy (CP) and results in lifelong disability. Children with severe hemiparesis have limited rehabilitation options. Brain computer interface- activated functional electrical stimulation (BCI-FES) of target muscles may enhance upper extremity function in hemiparetic adults. We conducted a pilot clinical trial to assess the safety and feasibility of BCI-FES in children with hemiparetic CP.

Methods

Thirteen participants (mean age = 12.2 years, 31% female) were recruited from a population-based cohort. Inclusion criteria were: (1) MRI-confirmed PS, (2) disabling hemiparetic CP, (3) age 6–18 years, (4) informed consent/assent. Those with neurological comorbidities or unstable epilepsy were excluded. Participants attended two BCI sessions: training and rehabilitation. They wore an EEG-BCI headset and two forearm extensor stimulation electrodes. Participants’ imagination of wrist extension was classified on EEG, after which muscle stimulation and visual feedback were provided when the correct visualization was detected.

Results

No serious adverse events or dropouts occurred. The most common complaints were mild headache, headset discomfort and muscle fatigue. Children ranked the experience as comparable to a long car ride and none reported as unpleasant. Sessions lasted a mean of 87 min with 33 min of stimulation delivered. Mean classification accuracies were (M = 78.78%, SD = 9.97) for training and (M = 73.48, SD = 12.41) for rehabilitation. Mean Cohen’s Kappa across rehabilitation trials was M = 0.43, SD = 0.29, range = 0.019–1.00, suggesting BCI competency.

Conclusion

Brain computer interface-FES was well -tolerated and feasible in children with hemiparesis. This paves the way for clinical trials to optimize approaches and test efficacy.

A Cross-Sectional Study: Determining Factors of Functional Independence and Quality of Life of Patients One Month after Having Suffered a Stroke

(1) Background: loss of quality of life (QoL) and functional independence are two of the most common consequences of suffering a stroke. The main objective of this research is to study which factors are the greatest determinants of functional capacity and QoL a month after suffering a stroke so that they can be considered in early interventions. (2) Methods: a cross-sectional study was conducted which sample consisted of 81 people who had previously suffered a stroke. The study population was recruited at the time of discharge from the Neurology Service and Stroke Unit of the hospitals of Burgos and Córdoba, Spain, through a consecutive sampling. Data were collected one month after participants experienced a stroke, and the main study variables were quality of life, measured with the Stroke-Specific Quality of Life Measure (NEWSQOL), and functional independence, measured with the Functional Independence Measure-Functional Assessment Measure (FIM-FAM). (3) Results: the factors associated with a worse QoL and functional capacity one month after having suffered a stroke were living in a different dwelling than the usual flat or house (p < 0.05), a worse cognitive capacity (p < 0.001) and a worse functional capacity of the affected upper limb (p < 0.001). A higher age was related to a worse functional capacity one month after suffering a stroke (p = 0.048). (4) Conclusions: the type of dwelling, age, cognitive ability and functional capacity of the affected upper limb are determining aspects in functional independence and QoL during the first weeks after a stroke.

Synergic effect of the combination of mirror therapy and electrical stimulation for lower extremity motor function recovery in stroke survivors: a meta-analysis of randomized controlled trials

OBJECTIVES

To explore the synergic effect of the combination of mirror therapy and electrical stimulation on lower limb motor function recovery in stroke survivors.

MATERIALS AND METHODS

PubMed, Web of Science, Embase, Cochrane Library, CINAHL, CNKI, Wan Fang, CBM were searched from inception to December 2020. Randomized controlled trials that compared the combined therapy with another single therapy were included. A pre-determined data collection form was used to extract data. Two authors independently extracted data and used the Cochrane Handbook criteria to assess the quality of included studies.

RESULTS

Six studies, with a total of 437 patients were included. There was an overall positive effect on lower limb motor function recovery, according to Fugl-Meyer Assessment for the Lower Extremity [all: WMD in fixed effects model: 5.63, 95% CI 4.86, 6.39] and Brunnstrom stage [all: WMD in fixed effects model: 0.49, 95% CI 0.32, 0.66].

CONCLUSIONS

The results indicate that the combination of mirror therapy and electrical stimulation for lower extremity motor function recovery in stroke survivors may have a positive effect.

Effect of Transcranial Direct Current Stimulation Augmented with Motor Imagery and Upper-Limb Functional Training for Upper-Limb Stroke Rehabilitation: A Prospective Randomized Controlled Trial

BACKGROUND

Combining transcranial direct current stimulation (tDCS) with other therapies is reported to produce promising results in patients with stroke. The purpose of the study was to determine the effect of combining tDCS with motor imagery (MI) and upper-limb functional training for upper-limb rehabilitation among patients with chronic stroke.

METHODS

A single-center, prospective, randomized controlled trial was conducted among 64 patients with chronic stroke. The control group received sham tDCS with MI, while the experimental group received real tDCS with MI. Both groups performed five different upper-limb functional training exercises coupled with tDCS for 30 min, five times per week for two weeks. Fugl-Meyer's scale (FMA) and the Action Research Arm Test (ARAT) were used to measure the outcome measures at baseline and after the completion of the 10th session.

RESULTS

Analysis of covariance showed significant improvements in the post-test mean scores for FMA (F (414.4) = 35.79, p < 0.001; η² = 0.37) and ARAT (F (440.09) = 37.46, p < 0.001; η² = 0.38) in the experimental group compared to the control group while controlling for baseline scores.

CONCLUSIONS

Anodal tDCS stimulation over the affected primary motor cortex coupled with MI and upper-limb functional training reduces impairment and disability of the upper limbs among patients with chronic stroke.

Evaluating the validity of a functional electrical stimulation clinical decision making tool: A qualitative study

INTRODUCTION

Following central nervous system damage, the recovery of motor function is a priority. For some neurological populations, functional electrical stimulation (FES) is recommended in best practice guidelines for neurorehabilitation. However, limited resources exist to guide FES application, despite clinicians reporting that a lack of FES knowledge prevents use in clinical practice. The FES Clinical Decision Making Tool was developed to assist clinicians with FES application and translation into clinical practice. The purpose of this study was to evaluate the content validity of the Tool from the perspectives of Canadian physical and occupational therapists using FES in neurorehabilitation.

METHODS

Thirteen participants (twelve women, one man), aged 40.5 ± 10.3 years, participated in individual semi-structured interviews to explore their clinical decision making experiences when applying FES and to evaluate the content validity (i.e., appropriateness, comprehensibility, and comprehensiveness) of the Tool. Interviews were analyzed using a qualitative conventional content analysis following the DEPICT model.

RESULTS

Three themes were identified. 1) Clinician context influences FES usage. Participants' experiences with FES use varied and application was influenced by treatment goals. 2) Parameter selection in clinical practice. Participants identified decision-making strategies and the challenges of parameter selection. 3) With modifications, the Tool is a valid resource to inform FES applications. Participants discussed its strengths, limitations, and suggested changes. While the Tool is useful, a more extensive resource (e.g., appendix) for the Tool is warranted.

DISCUSSION

A revised Tool was created to improve its comprehensiveness and comprehensibility. Thus, the Tool is a valid resource for applying FES in neurorehabilitation.

Effects of repetitive transcranial magnetic stimulation combined with functional electrical stimulation on hand function of stroke: A randomized controlled trial

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation technique that has been widely used for hand function recovery in patients with subacute and chronic stroke. OBJECTIVE: To observe the effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with functional electrical stimulation (FES) on hand function recovery during convalescence of stroke. METHODS: Patients were divided into3 groups of 20 patients in each. All patients received routine training. rTMS group was treated with low-frequency repetitive transcranial magnetic stimulation (rTMS). FES group received functional electrical stimulation (FES) therapy. Observation group was treated with low-frequency rTMS and FES. The changes of TMS-MEP in the 3 groups were observed at the time of enrollment and after 2 courses of treatment, respectively, and the total active activity of fingers (TAM) and Fugl-Meyer assessment (FMA) rating scale were evaluated in wrist and hand parts. RESULTS: The amplitude of TMS-MEP was significantly higher than that of FES group. FMA score and TAM score in the observation group were significantly better than that of rTMS group and FES group. CONCLUSION: Low-frequency rTMS combined with FES treatment can effectively improve the range of motion of fingers, and significantly improve the grasp, pinching and other functions of hands.

Application of a Brain-Computer Interface System with Visual and Motor Feedback in Limb and Brain Functional Rehabilitation after Stroke: Case Report

(1) Objective: To investigate the feasibility, safety, and effectiveness of a brain-computer interface (BCI) system with visual and motor feedback in limb and brain function rehabilitation after stroke. (2) Methods: First, we recruited three hemiplegic stroke patients to perform rehabilitation training using a BCI system with visual and motor feedback for two consecutive days (four sessions) to verify the feasibility and safety of the system. Then, we recruited five other hemiplegic stroke patients for rehabilitation training (6 days a week, lasting for 12-14 days) using the same BCI system to verify the effectiveness. The mean and Cohen's w were used to compare the changes in limb motor and brain functions before and after training. (3) Results: In the feasibility verification, the continuous motor state switching time (CMSST) of the three patients was 17.8 ± 21.0s, and the motor state percentages (MSPs) in the upper and lower limb training were 52.6 ± 25.7% and 72.4 ± 24.0%, respectively. The effective training revolutions (ETRs) per minute were 25.8 ± 13.0 for upper limb and 24.8 ± 6.4 for lower limb. There were no adverse events during the training process. Compared with the baseline, the motor function indices of the five patients were improved, including sitting balance ability, upper limb Fugel-Meyer assessment (FMA), lower limb FMA, 6 min walking distance, modified Barthel index, and root mean square (RMS) value of triceps surae, which increased by 0.4, 8.0, 5.4, 11.4, 7.0, and 0.9, respectively, and all had large effect sizes (Cohen's w ≥ 0.5). The brain function indices of the five patients, including the amplitudes of the motor evoked potentials (MEP) on the non-lesion side and lesion side, increased by 3.6 and 3.7, respectively; the latency of MEP on the non-lesion side was shortened by 2.6 ms, and all had large effect sizes (Cohen's w ≥ 0.5). (4) Conclusions: The BCI system with visual and motor feedback is applicable in active rehabilitation training of stroke patients with hemiplegia, and the pilot results show potential multidimensional benefits after a short course of treatment.

Ultrasound-Guided Median Nerve Electrical Stimulation to Promote Upper Limb Function Recovery after Stroke

Peripheral electrical nerve stimulation enhances hand function during stroke rehabilitation. Here, we proposed a percutaneous direct median nerve stimulation guided by ultrasound (ultrasound‐guided median nerve electrical stimulation, UG-MNES) and evaluated its feasibility and effectiveness in the treatment of stroke patients with upper limb extremity impairments. Sixty-three stroke patients (2-3 months of onset) were randomly divided into control and UG-MNES groups. Both groups received routine rehabilitation and the UG-MNES group received an additional ultrasound-guided electrical stimulation of the median nerve at 2 Hz, 0.2 ms pulse-width for 20 minutes with gradual intensity enhancement. The Fugl-Meyer Assessment for upper extremity motor function (FMA-UE) was used as the primary outcome. The secondary outcomes were the Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK), Hand Function Rating Scale, Brunnstrom Stages, and Barthel Index scores for motor and daily functions. All the participants completed the trial without any side effects or adverse events during the intervention. After 4 weeks of intervention, the functions of the upper limbs on the hemiplegic side in both groups achieved significant recovery. Compared to the control group, all evaluation indices used in this trial were improved significantly in the UG-MNES group after 2 and 4 weeks of intervention; particularly, the first intervention of UG-MNES immediately improved all the assessment items significantly. In conclusion, the UG-MNES is a safe and feasible treatment for stroke patients with upper limb extremity impairments and could significantly improve the motor function of the affected upper limb, especially in the first intervention. The UG-MNES could be an effective alternative intervention for stroke with upper limb extremity impairments.

Time to reconcile research findings and clinical practice on upper limb neurorehabilitation

The problem

In the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs.

Proposed solutions

The objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions.

Conclusions

It's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery.

A Novel Patient-Tailored, Cumulative Neurotechnology-Based Therapy for Upper-Limb Rehabilitation in Severely Impaired Chronic Stroke Patients: The AVANCER Study Protocol

Effective, patient-tailored rehabilitation to restore upper-limb motor function in severely impaired stroke patients is still missing. If suitably combined and administered in a personalized fashion, neurotechnologies offer a large potential to assist rehabilitative therapies to enhance individual treatment effects. AVANCER (clinicaltrials.gov NCT04448483) is a two-center proof-of-concept trial with an individual based cumulative longitudinal intervention design aiming at reducing upper-limb motor impairment in severely affected stroke patients with the help of multiple neurotechnologies. AVANCER will determine feasibility, safety, and effectivity of this innovative intervention. Thirty chronic stroke patients with a Fugl-Meyer assessment of the upper limb (FM-UE) <20 will be recruited at two centers. All patients will undergo the cumulative personalized intervention within two phases: the first uses an EEG-based brain-computer interface to trigger a variety of patient-tailored movements supported by multi-channel functional electrical stimulation in combination with a hand exoskeleton. This phase will be continued until patients do not improve anymore according to a quantitative threshold based on the FM-UE. The second interventional phase will add non-invasive brain stimulation by means of anodal transcranial direct current stimulation to the motor cortex to the initial approach. Each phase will last for a minimum of 11 sessions. Clinical and multimodal assessments are longitudinally acquired, before the first interventional phase, at the switch to the second interventional phase and at the end of the second interventional phase. The primary outcome measure is the 66-point FM-UE, a significant improvement of at least four points is hypothesized and considered clinically relevant. Several clinical and system neuroscience secondary outcome measures are additionally evaluated. AVANCER aims to provide evidence for a safe, effective, personalized, adjuvant treatment for patients with severe upper-extremity impairment for whom to date there is no efficient treatment available.

Brazilian practice guidelines for stroke rehabilitation: Part II

The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

Parents' perceptions of functional electrical stimulation as an upper limb intervention for young children with hemiparesis: qualitative interviews with mothers

Background/objective

To explore parents’ perceptions of an upper extremity (UE) intervention using functional electrical stimulation (FES) for young children with hemiparesis.

Methods

Parents of children aged 3–6 years with a history of perinatal stroke, impaired UE function, and participation in a 12-week FES intervention delivered at a hospital were included in this exploratory qualitative study. Nine mothers participated in a semi-structured interview < 1 week after their child completed the FES intervention (MyndMove®, MyndTec Inc.) targeting the hemiparetic UE. Open-ended questions queried parents’ goals, perceived benefits, and challenges of the FES intervention. Interviews were audio recorded and transcribed verbatim. Qualitative conventional content analysis was used to analyze the transcripts.

Results

Five themes were identified. 1) Parents’ expectations for the FES intervention. Mothers described setting functional, exploratory, and realistic goals, yet feeling initial apprehension towards FES. 2) Perceived improvement. Physical, functional, and psychological improvements were observed with FES; however, there was still room for improvement. 3) Factors influencing the FES intervention. Program structure, therapist factors, and child factors influenced perceived success. 4) Lack of access to intensive therapy. Mothers noted that FES is not provided in mainstream therapy; however, they wanted access to FES outside of the study. They also highlighted socioeconomic challenges to accessing FES. 5) Strategies to facilitate participation. The mothers provided suggestions for program structure and delivery, and session delivery.

Conclusions

Mothers perceived the FES intervention to have physical, functional and psychological benefits for their children. Interest in continuing with FES highlights a need to improve access to this therapy for young children.

Upper Limb Stroke Rehabilitation Using Surface Electromyography: A Systematic Review and Meta-Analysis

Background

Upper limb impairment is common after stroke, and many will not regain full upper limb function. Different technologies based on surface electromyography (sEMG) have been used in stroke rehabilitation, but there is no collated evidence on the different sEMG-driven interventions and their effect on upper limb function in people with stroke.

Aim

Synthesize existing evidence and perform a meta-analysis on the effect of different types of sEMG-driven interventions on upper limb function in people with stroke.

Methods

PubMed, SCOPUS, and PEDro databases were systematically searched for eligible randomized clinical trials that utilize sEMG-driven interventions to improve upper limb function assessed by Fugl-Meyer Assessment (FMA-UE) in stroke. The PEDro scale was used to evaluate the methodological quality and the risk of bias of the included studies. In addition, a meta-analysis utilizing a random effect model was performed for studies comparing sEMG interventions to non-sEMG interventions and for studies comparing different sEMG interventions protocols.

Results

Twenty-four studies comprising 808 participants were included in this review. The methodological quality was good to fair. The meta-analysis showed no differences in the total effect, assessed by total FMA-UE score, comparing sEMG interventions to non-sEMG interventions (14 studies, 509 participants, SMD 0.14, P 0.37, 95% CI –0.18 to 0.46, I² 55%). Similarly, no difference in the overall effect was found for the meta-analysis comparing different types of sEMG interventions (7 studies, 213 participants, SMD 0.42, P 0.23, 95% CI –0.34 to 1.18, I² 73%). Twenty out of the twenty-four studies, including participants with varying impairment levels at all stages of stroke recovery, reported statistically significant improvements in upper limb function at post-sEMG intervention compared to baseline.

Conclusion

This review and meta-analysis could not discern the effect of sEMG in comparison to a non-sEMG intervention or the most effective type of sEMG intervention for improving upper limb function in stroke populations. Current evidence suggests that sEMG is a promising tool to further improve functional recovery, but randomized clinical trials with larger sample sizes are needed to verify whether the effect on upper extremity function of a specific sEMG intervention is superior compared to other non-sEMG or other type of sEMG interventions.

Adaptations in Muscular Strength for Individuals With Multiple Sclerosis Following Robotic Rehabilitation: A Scoping Review

Muscular weakness and loss of motor function are common symptoms of multiple sclerosis. Robotic rehabilitation can improve sensorimotor function and motor control in this population. However, many studies using robotics for rehabilitation have overlooked changes in muscular strength, despite research demonstrating its utility in combating functional impairments. The purpose of this scoping review was to critically examine changes in muscular strength following robotic rehabilitation interventions for individuals with multiple sclerosis. A literature search of five databases was conducted and search terms included a combination of three primary terms: robotic rehabilitation/training, muscular strength, and multiple sclerosis. Thirty one articles were found, and following inclusion criteria, 5 remained for further investigation. Although muscular strength was not the primary targeted outcome of the training for any of the included articles, increases in muscular strength were present in most of the studies suggesting that robotic therapy with a resistive load can be an effective alternative to resistance training for increasing muscular strength. Outcome measures of isometric knee-extensor force (kg) (right: p < 0.05, left: p < 0.05), isometric knee flexion and extension torque (Nm) (p < 0.05), ankle dorsiflexion and plantarflexion torque (Nm) (all p < 0.05) and handgrip force (kg) (p < 0.05) all improved following a robotic training intervention. These adaptations occurred with sustained low resistive loads of hand grip or during gait training. This scoping review concludes that, despite a lack of studies focusing on strength, there is evidence robotics is a useful modality to improve muscular strength in combination with motor control and neuromotor improvements. A call for more studies to document changes in strength during robotic rehabilitation protocols is warranted.

Postural control during turn on the light task assisted by functional electrical stimulation in post stroke subjects

Postural control mechanisms have a determinant role in reaching tasks and are typically impaired in post-stroke patients. Functional electrical stimulation (FES) has been demonstrated to be a promising therapy for improving upper limb (UL) function. However, according to our knowledge, no study has evaluated FES influence on postural control. This study aims to evaluate the influence of FES UL assistance, during turning on the light task, in the related postural control mechanisms. An observational study involving ten post-stroke subjects with UL dysfunction was performed. Early and anticipatory postural adjustments (EPAs and APAs, respectively), the weight shift, the center of pressure and the center of mass (CoM) displacement were analyzed during the turning on the light task with and without the FES assistance. FES parameters were adjusted to improve UL function according to a consensus between physiotherapists' and patients' perspectives. The ANOVA repeated measures, Paired sample t and McNemar tests were used to compare postural control between the assisted and non-assisted conditions. When the task was assisted by FES, the number of participants that presented APAs increased (p = 0.031). UL FES assistance during turning on the light task can improve postural control in neurological patients with UL impairments.

Efficacy of Four-Channel Functional Electrical Stimulation on Moderate Arm Paresis in Subacute Stroke Patients—Results from a Randomized Controlled Trial

This preliminary randomized clinical trial explores the efficacy of task-oriented electromyography (EMG)-triggered multichannel functional electrical stimulation (EMG-MES) compared to single-channel cyclic neuromuscular electrical stimulation (cNMES) on regaining control of voluntary movements (CVM) and the ability to execute arm-hand-activities in subacute stroke patients with moderate arm paresis. Twelve ischemic stroke patients (Fugl-Meyer Assessment Arm Section (FMA-AS) score: 19–47) with comparable demographics were block-randomized to receive 15 sessions of cNMES or EMG-MES over three weeks additionally to a conventional neurorehabilitation program including task-oriented arm training. FMA-AS, Box-and-Block Test (BBT), and Stroke-Impact-Scale (SIS) were recorded at baseline and follow-up. All participants demonstrated significant improvement in FMA-AS and BBT. Participants treated with EMG-MES had a higher mean gain in FMA-AS than those treated with cNMES. In the SIS daily activities domain, both groups improved non-significantly; participants in the EMG-MES group had higher improvement in arm-hand use and stroke recovery. EMG-MES treatment demonstrated a higher gain of CVM and self-reported daily activities, arm-hand use, and stroke recovery compared to cNMES treatment of the wrist only. The protocol of this proof-of-concept study seems robust enough to be used in a larger trial to confirm these preliminary findings.

The Effects of the Biceps Brachii and Brachioradialis on Elbow Flexor Muscle Strength and Spasticity in Stroke Patients

Objective

Muscle weakness and spasticity are common consequences of stroke, leading to a decrease in physical activity. The effective implementation of precision rehabilitation requires detailed rehabilitation evaluation. We aimed to analyze the surface electromyography (sEMG) signal features of elbow flexor muscle (biceps brachii and brachioradialis) spasticity in maximum voluntary isometric contraction (MVIC) and fast passive extension (FPE) in stroke patients and to explore the main muscle groups that affect the active movement and spasticity of the elbow flexor muscles to provide an objective reference for optimizing stroke rehabilitation.

Methods

Fifteen patients with elbow flexor spasticity after stroke were enrolled in this study. sEMG signals of the paretic and nonparetic elbow flexor muscles (biceps and brachioradialis) were detected during MVIC and FPE, and root mean square (RMS) values were calculated. The RMS values (mean and peak) of the biceps and brachioradialis were compared between the paretic and nonparetic sides. Additionally, the correlation between the manual muscle test (MMT) score and the RMS values (mean and peak) of the paretic elbow flexors during MVIC was analyzed, and the correlation between the modified Ashworth scale (MAS) score and the RMS values (mean and peak) of the paretic elbow flexors during FPE was analyzed.

Results

During MVIC exercise, the RMS values (mean and peak) of the biceps and brachioradialis on the paretic side were significantly lower than those on the nonparetic side (p < 0.01), and the RMS values (mean and peak) of the bilateral biceps were significantly higher than those of the brachioradialis (p < 0.01). The MMT score was positively correlated with the mean and peak RMS values of the paretic biceps and brachioradialis (r = 0.89, r = 0.91, r = 0.82, r = 0.85; p < 0.001). During FPE exercise, the RMS values (mean and peak) of the biceps and brachioradialis on the paretic side were significantly higher than those on the nonparetic side (p < 0.01), and the RMS values (mean and peak) of the brachioradialis on the paretic side were significantly higher than those of the biceps (p < 0.01). TheMAS score was positively correlated with the mean RMS of the paretic biceps and brachioradialis (r = 0.62, p = 0.021; r = 0.74, p = 0.004), and the MAS score was positively correlated with the peak RMS of the paretic brachioradialis (r = 0.59, p = 0.029) but had no significant correlation with the peak RMS of the paretic biceps (r = 0.49, p > 0.05).

Conclusions

The results confirm that the biceps is a vital muscle in active elbow flexion and that the brachioradialis plays an important role in elbow flexor spasticity, suggesting that the biceps should be the focus of muscle strength training of the elbow flexors and that the role of the brachioradialis should not be ignored in the treatment of elbow flexor spasticity. This study also confirmed the application value of sEMG in the objective assessment of individual muscle strength and spasticity in stroke patients.

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.

Application of Logistic Regression and Decision Tree Models in the Prediction of Activities of Daily Living in Patients with Stroke

An improvement in the activities of daily living (ADLs) is significantly related to the quality of life and prognoses of patients with stroke. However, the factors predicting significant improvement in ADL (SI-ADL) have not yet been clarified. Therefore, we sought to identify the key factors affecting SI-ADL in patients with stroke after rehabilitation therapy using both logistic regression modeling and decision tree modeling. We retrospectively collected and analyzed the clinical data of 190 patients with stroke who underwent rehabilitation therapy at our hospital between January 2020 and July 2020. General and rehabilitation therapy data were extracted, and the Barthel index (BI) score was used for outcome assessment. We defined SI-ADL as an improvement in the BI score by 15 points or more during hospitalization. Logistic regression and decision tree models were established to explore the SI-ADL predictors. We then used receiver operating characteristic (ROC) curves to compare the logistic regression and decision tree models. Univariate analysis revealed that compared with the non-SI-ADL group, the SI-ADL group showed a significantly shorter course of stroke, longer hospital stay, and higher rate of receiving occupational and speech therapies (all $P<0.05$ ). Binary logistic regression analysis revealed the course of stroke at admission ( $\text{odds}\text{ratio}\left(\text{OR}\right)=0.986$ , $95\%\text{confidence}\text{interval}\left(\text{CI}\right)=0.979$ –0.993; $P<0.001$ ) and the length of hospital stay ( $\text{OR}=1.030$ , $95\%\text{CI}=1.013$ –1.047; P =0.001) as the independent predictors of SI-ADL. ROC comparisons revealed no significant differences in the areas under the curves for the logistic regression and decision tree models (0.808 vs. 0.831; $z=0.977$ , $P=0.329$ ). Both models identified the course of disease at admission and the length of hospital stay as key factors affecting SI-ADL. Early initiation of rehabilitation therapy is of immense importance for improving the ADLs in patients with stroke.

A Flexible Pulse Generator Based on a Field Programmable Gate Array Architecture for Functional Electrical Stimulation

Non-invasive Functional Electrical Stimulation (FES) is a technique applied for motor rehabilitation of patients with central nervous system injury. This technique requires programmable multichannel systems to configure the stimulation parameters (amplitude, frequency, and pulse width). Most FES systems are based on microcontrollers with fixed architecture; this limits the control of the parameters and the scaling to multiple channels. Although field programmable gate arrays (FPGA) have been used in FES systems as alternative to microcontrollers, most of them focus on signal acquisition, processing, or communication functions, or are for invasive stimulation. A few FES systems report using FPGAs for parameter configuration and pulse generation in non-invasive FES. However, generally they limit the value of the frequency or amplitude parameters to enable multichannel operation. This restricts free selection of parameters and implementation of modulation patterns, previously reported to delay FES-induced muscle fatigue. To overcome those limitations, this paper presents a proof-of-concept (technology readiness level three-TRL 3) regarding the technical feasibility and potential use of an FPGA-based pulse generator for non-invasive FES applications (PG-nFES). The main aims were: (1) the development of a flexible pulse generator for FES applications and (2) to perform a proof-of-concept of the system, comprising: electrical characterization of the stimulation parameters, and verification of its potential for upper limb FES applications. Biphasic stimulation pulses with high linearity (r² > 0.9998) and repeatability (>0.81) were achieved by combining the PG-nFES with a current-controlled output stage. Average percentage error in the characterizations was under 3% for amplitude (1–48 mA) and pulse width (20–400 μs), and 0% for frequency (10–150 Hz). A six-channel version of the PG-nFES was implemented to demonstrate the scalability feature. The independence of parameters was tested with three patterns of co-modulation of two parameters. Moreover, two complete FES channels were implemented and the claimed features of the PG-nFES were verified by performing upper limb functional movements involving the hand and the arm. Finally, the system enabled implementation of a stimulation pattern with co-modulation of frequency and pulse width, applied successfully for efficient elbow during repetitions of a functional movement.

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.

Post-Stroke Treatment with Neuromuscular Functional Electrostimulation of Antagonistic Muscles and Kinesiotherapy Evaluated with Electromyography and Clinical Studies in a Two-Month Follow-Up

The aim of this study was to determine the sustained influence of personalized neuromuscular functional electrical stimulation (NMFES) combined with kinesiotherapy (mainly, proprioceptive neuromuscular facilitation (PNF)) on the activity of muscle motor units acting antagonistically at the wrist and the ankle in a large population of post-stroke patients. Clinical evaluations of spasticity (Ashworth scale), manual muscle testing (Lovett scale), and surface electromyography recordings at rest (rEMG) and during attempts of maximal muscle contraction (mcEMG) were performed three times in 120 post-stroke patients (T0: up to 7 days after the incidence; T1: after 21 days of treatment; T2: after 60 days of treatment). Patients (N = 120) were divided into two subgroups-60 patients received personalized NMFES and PNF treatment (NMFES+K), and the other 60 received only PNF (K). The NMFES+K therapy resulted in a decrease in spasticity and an increase in muscle strength of mainly flexor muscles, in comparison with the K group. A positive correlation between the increase of rEMG amplitudes and high Ashworth scale scores and a positive correlation between low amplitudes of mcEMG and low Lovett scale scores were found in the wrist flexors and calf muscles on the paretic side. Negative correlations were found between the rEMG and mcEMG amplitudes in the recordings. The five-grade alternate activity score of the antagonists' actions improved in the NMFES+K group. These improvements in the results of controlled NMFES treatment combined with PNF in patients having experienced an ischemic stroke, in comparison to the use of kinesiotherapy alone, might justify the application of conjoined rehabilitation procedures based on neurophysiological approaches. Considering the results of clinical and neurophysiological studies, we suppose that NMFES of the antagonistic muscle groups acting at the wrist and the ankle may evoke its positive effects in post-stroke patients by the modulation of the activity more in the spinal motor centers, including the level of Ia inhibitory neurons, than only at the muscular level.

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.

Electroneurographic Evaluation of Neural Impulse Transmission in Patients after Ischemic Stroke Following Functional Electrical Stimulation of Antagonistic Muscles at Wrist and Ankle in Two-Month Follow-Up

The available data from electroneurography (ENG) studies on the transmission of neural impulses in the motor fibers of upper and lower extremity nerves following neuromuscular functional electrical stimulation (NMFES) combined with kinesiotherapy in post-stroke patients during sixty-day observation do not provide convincing results. This study aims to compare the effectiveness of an NMFES of antagonistic muscle groups at the wrist and ankle and kinesiotherapy based mainly on proprioceptive neuromuscular facilitation (PNF). An ENG was performed once in a group of 60 healthy volunteers and three times in 120 patients after stroke (T0, up to 7 days after the incident; T1, after 21 days of treatment; and T2, after 60 days of treatment); 60 subjects received personalized NMFES and PNF treatment (NMFES+K), while the other 60 received only PNF (K). An ENG studied peripheral (M-wave recordings), C8 and L5 ventral root (F-wave recordings) neural impulse transmission in the peroneal and the ulnar nerves on the hemiparetic side. Both groups statistically differed in their amplitudes of M-wave recording parameters after peroneal nerve stimulation performed at T0 and T2 compared with the control group. After 60 days of treatment, only the patients from the NMFES+K group showed significant improvement in M-wave recordings. The application of the proposed NMFES electrostimulation algorithm combined with PNF improved the peripheral neural transmission in peroneal but not ulnar motor nerve fibers in patients after ischemic stroke. Combined kinesiotherapy and safe, personalized, controlled electrotherapy after stroke give better results than kinesiotherapy alone.

Personalized protocol and scoring scale for functional electrical stimulation of the hand: A pilot feasibility study

BACKGROUND

Complex personalized Functional Electrical Stimulation (FES) protocols for calibrating parameters and electrode positioning have been proposed, most being time-consuming or technically cumbersome for clinical settings. Therefore, there is a need for new personalized FES protocols that generate comfortable, functional hand movements, while being feasible for clinical translation.

OBJECTIVE

To develop a personalized FES protocol, comprising electrode placement and parameter selection, to generate hand opening (HO), power grasp (PW) and precision grip (PG) movements, and compare in a pilot feasibility study its performance to a non-personalized protocol based on standard FES guidelines.

METHODS

Two FES protocols, one personalized (P1) and one non-personalized (P2), were used to produce hand movements in twenty-three healthy participants. FES-induced movements were assessed with a new scoring scale which comprises items for selectivity, functionality, and comfort.

RESULTS

Higher FES-HSS scores were obtained with P1 for all movements: HO (p= 0.00013), PW (p= 0.00007), PG (p= 0.00460). Electrode placement time was significantly shorter for P2 (p= 0.00003). Comfort scores were similar for both protocols.

CONCLUSIONS

The personalized protocol for electrode placement and parameter selection enabled functional FES-induced hand movements and presented advantages over a non-personalized protocol. This protocol warrants further investigation to confirm its suitability for developing upper-limb rehabilitation interventions with clinical translational potential.

Virtual motor training to improve the activities of daily living, hand grip, and gross motor function among children with cerebral palsy: Meta-regression analysis

BACKGROUND

Given that cerebral palsy is a lifelong condition, continuous motor training is necessary to correct abnormal posture and patterns to improve functional performance.

OBJECTIVE

To explore the essential features of virtual motor training and identify its effects on the activities of daily living, hand grip function, and gross motor function among children with cerebral palsy.

METHODS

Ten databases were systematically searched for randomized controlled trials from inception until October 15, 2019. Studies with a randomized controlled trials design, children with cerebral palsy, comparisons of virtual motor training with other interventions, and activities of daily living, hand grip, and gross motor function outcomes were included. Subgroup analyses and meta-regression were performed. The effect size was assessed using random-effects meta-analysis and evaluated by using Hedges' g. Random effects univariate meta-regression model was used to examine the association of covariates with intervention effectiveness.

RESULTS

Seventeen randomized controlled trials with 853 participants were included. Meta-analysis indicated that the virtual motor training had significant positive effects on activities of daily living (g = 0.31, 95% confidence interval, CI = 0.10, 0.51), grip (g = 0.40, 95% CI = 0.08, 0.71), and gross motor (g = 0.71, 95% CI = 0.43, 0.99) function. Univariate random-effects meta-regression analysis indicated an increase in activities of daily living scores for motion capture systems that used depth imaging compared with those that used digital imaging.

SIGNIFICANCE

Our systematic review indicated that virtual motor function may significantly improve ADLs, hand grip, and gross motor functions among children with cerebral palsy.

Combining Action Observation Treatment with a Brain-Computer Interface System: Perspectives on Neurorehabilitation

Action observation treatment (AOT) exploits a neurophysiological mechanism, matching an observed action on the neural substrates where that action is motorically represented. This mechanism is also known as mirror mechanism. In a typical AOT session, one can distinguish an observation phase and an execution phase. During the observation phase, the patient observes a daily action and soon after, during the execution phase, he/she is asked to perform the observed action at the best of his/her ability. Indeed, the execution phase may sometimes be difficult for those patients where motor impairment is severe. Although, in the current practice, the physiotherapist does not intervene on the quality of the execution phase, here, we propose a stimulation system based on neurophysiological parameters. This perspective article focuses on the possibility to combine AOT with a brain–computer interface system (BCI) that stimulates upper limb muscles, thus facilitating the execution of actions during a rehabilitation session. Combining a rehabilitation tool that is well-grounded in neurophysiology with a stimulation system, such as the one proposed, may improve the efficacy of AOT in the treatment of severe neurological patients, including stroke patients, Parkinson’s disease patients, and children with cerebral palsy.

Emergence of flexible technology in developing advanced systems for post-stroke rehabilitation: a comprehensive review

OBJECTIVE

Stroke is one of the most common neural disorders, which causes physical disabilities and motor impairments among its survivors. Several technologies have been developed for providing stroke rehabilitation and to assist the survivors in performing their daily life activities. Currently, the use of flexible technology (FT) for stroke rehabilitation systems is on a rise that allows the development of more compact and lightweight wearable systems, which stroke survivors can easily use for long-term activities.

APPROACH

For stroke applications, FT mainly includes the "flexible/stretchable electronics", "e-textile (electronic textile)" and "soft robotics". Thus, a thorough literature review has been performed to report the practical implementation of FT for post-stroke application.

MAIN RESULTS

In this review, the highlights of the advancement of FT in stroke rehabilitation systems are dealt with. Such systems mainly involve the "biosignal acquisition unit", "rehabilitation devices" and "assistive systems". In terms of biosignals acquisition, electroencephalography (EEG) and electromyography (EMG) are comprehensively described. For rehabilitation/assistive systems, the application of functional electrical stimulation (FES) and robotics units (exoskeleton, orthosis, etc.) have been explained.

SIGNIFICANCE

This is the first review article that compiles the different studies regarding flexible technology based post-stroke systems. Furthermore, the technological advantages, limitations, and possible future implications are also discussed to help improve and advance the flexible systems for the betterment of the stroke community.