Arm rehabilitation in post stroke subjects: A randomized controlled trial on the efficacy of myoelectrically driven FES applied in a task-oriented approach

Electrophysiology Methods for Assessing of Neurodegenerative and Post-Traumatic Processes as Applied to Translational Research

Electrophysiological studies have long established themselves as reliable methods for assessing the functional state of the brain and spinal cord, the degree of neurodegeneration, and evaluating the effectiveness of therapy. In addition, they can be used to diagnose, predict functional outcomes, and test the effectiveness of therapeutic and rehabilitation programs not only in clinical settings, but also at the preclinical level. Considering the urgent need to develop potential stimulators of neuroregeneration, it seems relevant to obtain objective data when modeling neurological diseases in animals. Thus, in the context of the application of electrophysiological methods, not only the comparison of the basic characteristics of bioelectrical activity of the brain and spinal cord in humans and animals, but also their changes against the background of neurodegenerative and post-traumatic processes are of particular importance. In light of the above, this review will contribute to a better understanding of the results of electrophysiological assessment in neurodegenerative and post-traumatic processes as well as the possibility of translating these methods from model animals to humans.

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.

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.

ROBOCOP (ROBOtic Care of Poststroke Pain): Study Protocol for a Randomized Trial to Assess Robot-Assisted Functional and Motor Recovery and Impact on Poststroke Pain Development

Background

Stroke is one of the most frequent causes of death and disability worldwide. It is accompanied by the impaired motor function of the upper extremities in over 69% of patients up to hemiplegia in the following 5 years in 56% of cases. This condition often is characterized by chronic poststroke pain, difficult to manage, further worsening quality of life. Poststroke pain occurs within 3–6 months. Robot-assisted neurorehabilitation using the Automatic Recovery Arm Motility Integrated System (ARAMIS) has proven efficacy in motor function recovery exploiting the movements and the strength of the unaffected arm. The rationale of the ROBOCOP (ROBOtic Care of Poststroke pain) randomized trial is the assessment of the impact of robot-assisted functional and motor recovery on the prevention of poststroke pain.

Methods

A total of 118 patients with hemiplegic arms due to stroke will be enrolled and randomly allocated with a 1:1 ratio to ARAMIS or conventional neurorehabilitation group. After a baseline screening at hospital discharge, ARAMIS or conventional rehabilitation will be performed for 8 weeks. The primary endpoint is the prevention of the development of poststroke pain and the secondary endpoints are prevention of spasticity and efficacy in clinical motor rehabilitation. The primary outcome measures consist in the visual analog scale and the doleur neuropatique 4 and the secondary outcome measures include: the Modified Ashworth Scale, the Resistance to Passive movement Scale; the Upper Extremity Subscale of the Fugl–Meyer Motor Assessment; the Action Research Arm Test; the Barthel Index for activities of daily living; and the magnetic resonance imaging (MRI) recovery-related parameters. After baseline, both primary and secondary outcome measures will be performed in the following time points: 1 month after stroke (t₁, half of the rehabilitation); 2 months after stroke (t₂, after rehabilitation); and 3 months (t₃) and 6 months (t₄) after stroke, critical for poststroke pain development.

Discussion

This is the first clinical trial investigating the efficacy of robot-assisted neurorehabilitation using ARAMIS on poststroke pain prevention. This study could remarkably improve the quality of life of stroke survivors.

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.

Detailed characterization of physiological EMG activations and directional tuning of upper-limb and trunk muscles in point-to-point reaching movements

In recent years, several studies have investigated upper-limb motion in a variety of scenarios including motor control, physiology, rehabilitation and industry. Such applications assess people’s kinematics and muscular performances, focusing on typical movements that simulate daily-life tasks. However, often only a limited interpretation of the EMG patterns is provided. In fact, rarely the assessments separate phasic (movement-related) and tonic (postural) EMG components, as well as the EMG in the acceleration and deceleration phases. With this paper, we provide a comprehensive and detailed characterization of the activity of upper-limb and trunk muscles in healthy people point-to-point upper limb movements. Our analysis includes in-depth muscle activation magnitude assessment, separation of phasic (movement-related) and tonic (postural) EMG activations, directional tuning, distinction between activations in the acceleration and deceleration phases. Results from our study highlight a predominant postural activity with respect to movement related muscular activity. The analysis based on the acceleration phase sheds light on finer motor control strategies, highlighting the role of each muscle in the acceleration and deceleration phase. The results of this study are applicable to several research fields, including physiology, rehabilitation, design of robots and assistive solutions, exoskeletons.

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Upper-limb motion is assessed with kinematics and EMG in many scenarios: motor control, physiology, rehabilitation, industry

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Separation of phasic (movement-related) and tonic (postural) EMG, and of acceleration and deceleration phases

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Comprehensive and detailed characterization of the EMG of upper-limb and trunk muscles in point-to-point upper limb movements

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EMG magnitude assessment, phasic and tonic EMG activations, directional tuning, acceleration and deceleration phases

FITFES: A Wearable Myoelectrically Controlled Functional Electrical Stimulator Designed Using a User-Centered Approach

Myoelectrically Controlled Functional Electrical Stimulation (MeCFES) has proven to be a useful tool in the rehabilitation of the hemiplegic arm. This paper reports the steps involved in the development of a wearable MeCFES device (FITFES) through a user-centered design. We defined the minimal viable features and functionalities requirements for the device design from a questionnaire-based survey among physiotherapists with experience in functional electrical stimulation. The result was a necklace layout that poses minimal hindrance to task-oriented movement therapy, the context in which it is aimed to be used. FITFES is battery-powered and embeds a standard low power Bluetooth module, enabling wireless control by using PC/Mobile devices vendor specific built-in libraries. It is designed to deliver a biphasic, charge-balanced stimulation current pulses of up to 113 mA with a maximum differential voltage of 300 V. The power consumption for typical clinical usage is 320 mW at 20mA stimulation current and of less than [Formula: see text] in sleep mode, thus ensuring an estimated full day of FITFES therapy on a battery charge. We conclude that a multidisciplinary user-centered approach can be successfully applied to the design of a clinically and ergonomically viable prototype of a wearable myoelectrically controlled functional electrical stimulator to be used in rehabilitation.

BEAGLE-A Kinematic Sensory System for Objective Hand Function Assessment in Technology-Mediated Rehabilitation

We present a hand functions assessment system (BEAGLE) for kinematic tracking of hand and finger movements, envisioned as a technology-mediated rehabilitation tool. The system is custom-designed for fast and easy placement on an impaired hand (spastic or flaccid), featuring inertial sensors integrated into simple finger caps and a hand strap. An algorithm for a range of motion (ROM) estimation was implemented to provide an objective assessment of hand functions. The efficacy and feasibility of the BEAGLE system were examined in a pilot clinical study performed with ten stroke survivors in the subacute phase. Participants received therapy within two consecutive intensity-matched rehabilitation cycles. The first consisted of conventional therapy, while the second involved a combination of conventional therapy and advanced functional electrical stimulation. Assessments were performed before and after each phase. These included BEAGLE estimates of active voluntary ROM for wrist and various digits, as well as two referent clinical measures for hand functions assessment, Fugl-Meyer and Action Research Arm Test. The results indicate that the ROM assessments can detect change with sensitivity comparable to the standardized clinical scales. Statistically significant changes between the beginning and the end of the second cycle existed in all observed measures, whereas none of these measurements showed a statistically significant improvement in the first therapy cycle. The noted usability metrics indicate that the BEAGLE could be integrated into the rehabilitation workflow in a clinical environment.

Sequentially applied myoelectrically controlled FES in a task-oriented approach and robotic therapy for the recovery of upper limb in post-stroke patients: A randomized controlled pilot study

BACKGROUND

Functional recovery of the plegic upper limb in post-stroke patients may be enhanced by sequentially applying a myoelectrically controlled FES (MeCFES), which allows the patient to voluntarily control the muscle contraction during a functional movement, and robotic therapy which allows many repetitions of movements.

OBJECTIVE

Evaluate the efficacy of MeCFES followed by robotic therapy compared to standard care arm rehabilitation for post-stroke patients.

METHODS

Eighteen stroke subjects (onset ⩾ 3 months, age 60.1 ± 15.5) were recruited and randomized to receive an experimental combination of MeCFES during task-oriented reaching followed by robot therapy (MRG) or same intensity conventional rehabilitation care (CG) aimed at the recovery of the upper limb (20 sessions/45 minutes). Change was evaluated through Fugl-Meyer upper extremity (FMA-UE), Reaching Performance Scale and Box and Block Test.

RESULTS

The experimental treatment resulted in higher improvement on the FMA-UE compared with CG (P= 0.04), with a 10-point increase following intervention. Effect sizes were moderate in favor of the MRG group on FMA-UE, FMA-UE proximal and RPS (0.37-0.56).

CONCLUSIONS

Preliminary findings indicate that a combination of MeCFES and robotic treatment may be more effective than standard care for recovery of the plegic arm in persons > 3 months after stroke. The mix of motor learning techniques may be important for successful rehabilitation of arm function.

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

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

Effect of an EMG-FES Interface on Ankle Joint Training Combined with Real-Time Feedback on Balance and Gait in Patients with Stroke Hemiparesis

This study evaluated the effects of an electromyography-functional electrical stimulation interface (EMG-FES interface) combined with real-time balance and gait feedback on ankle joint training in patients with stroke hemiplegia. Twenty-six stroke patients participated in this study. All subjects were randomly assigned to either the EMG-FES interface combined with real-time feedback on ankle joint training (RFEF) group (n = 13) or the EMG-FES interface on ankle joint training (EF) group (n = 13). Subjects in both groups were trained for 20 min a day, 5 times a week, for 4 weeks. Similarly, all participants underwent a standard rehabilitation physical therapy for 60 min a day, 5 times a week, for 4 weeks. The RFEF group showed significant increases in weight-bearing lunge test (WBLT), Tardieu Scale (TS), Timed Up and Go Test (TUG), Berg Balance Scale (BBS), velocity, cadence, step length, stride length, stance per, and swing per (p < 0.05). Likewise, the EF group showed significant increases in WBLT, TUG, BBS, velocity, and cadence (p < 0.05). Moreover, the RFEF group showed significantly greater improvements than the EF group in terms of WBLT, Tardieu Scale, TUG, BBS, velocity, step length, stride length, stance per, and swing per (p < 0.05). Ankle joint training using an EMG-FES interface combined with real-time feedback improved ankle range of motion (ROM), muscle tone, balance, and gait in stroke patients. These results suggest that an EMG-FES interface combined with real-time feedback is feasible and suitable for ankle joint training in individuals with stroke.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Myoelectrically Controlled FES to Enhance Tenodesis Grip in People With Cervical Spinal Cord Lesion: A Usability Study

People with tetraplegia are often lacking grip strength, causing impairment in activities of daily living. For them, improving hand function is a priority because it is important for autonomy and participation in daily life. A tendon transfer surgery may be an option to improve the tenodesis grip, but it is an invasive procedure. Alternatively a similar effect can be produced, using a non-invasive method. We have previously described how myoelectrically controlled functional electrical stimulation (MeCFES) can be efficient for enhancing grip strength, using a one channel research prototype with wired connections to surface electrodes. In this paper we focus on the usability for activities of daily living and how it can fulfill an actual need. We recruited 27 participants with a cervical spinal cord lesion (C5-C7) for this trial. They tested the device in 12 sessions of 2 h each, in which the participants performed self selected activities involving the tenodesis grip. User centered outcomes were validated questionnaires: the Individually Prioritized Problem Assessment (IPPA) and the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST). Furthermore, they were asked if they found the device useful for continued use in daily life. The device facilitated prioritized activities for all participants. The IPPA change score was 4.6 on average (STD:3.5, effect size:1.3), meaning that the system greatly facilitated problematic tasks and the large effect size evinces that this was a meaningful improvement of hand function. It compares to the impact that a mobility device like a wheelchair has on daily living. Fourteen subjects found the system useful, expressing the need for such a neuroprosthesis. Examples of acquiring new abilities while using the device, indicate that the method could have a therapeutic use as well. Furthermore, results from the IPPA questionnaire are indicating what issues people with tetraplegia may hope to solve with a neuroprosthesis for the hand. The satisfaction of the device (QUEST) indicates that further effort in development should address wearability, eliminate wires, and improve the fitting procedure.

Effects of robot therapy on upper body kinematics and arm function in persons post stroke: a pilot randomized controlled trial

BACKGROUND

Robot-based rehabilitation for persons post-stroke may improve arm function and daily-life activities as measured by clinical scales, but its effects on motor strategies during functional tasks are still poorly investigated. This study aimed at assessing the effects of robot-therapy versus arm-specific physiotherapy in persons post-stroke on motor strategies derived from upper body instrumented kinematic analysis, and on arm function measured by clinical scales.

METHODS

Forty persons in the sub-acute and chronic stage post-stroke were recruited. This sample included all those subjects, enrolled in a larger bi-center study, who underwent instrumented kinematic analysis and who were randomized in Center 2 into Robot (R_Group) and Control Group (C_Group). R_Group received robot-assisted training. C_Group received arm-specific treatment delivered by a physiotherapist. Pre- and post-training assessment included clinical scales and instrumented kinematic analysis of arm and trunk during a virtual untrained task simulating the transport of an object onto a shelf. Instrumented outcomes included shoulder/elbow coordination, elbow extension and trunk sagittal compensation. Clinical outcomes included Fugl-Meyer Motor Assessment of Upper Extremity (FM-UE), modified Ashworth Scale (MAS) and Functional Independence Measure (FIM).

RESULTS

R_Group showed larger post-training improvements of shoulder/elbow coordination (Cohen's d = - 0.81, p = 0.019), elbow extension (Cohen's d = - 0.71, p = 0.038), and trunk movement (Cohen's d = - 1.12, p = 0.002). Both groups showed comparable improvements in clinical scales, except proximal muscles MAS that decreased more in R_Group (Cohen's d = - 0.83, p = 0.018). Ancillary analyses on chronic subjects confirmed these results and revealed larger improvements after robot-therapy in the proximal portion of FM-UE (Cohen's d = 1.16, p = 0.019).

CONCLUSIONS

Robot-assisted rehabilitation was as effective as arm-specific physiotherapy in reducing arm impairment (FM-UE) in persons post-stroke, but it was more effective in improving motor control strategies adopted during an untrained task involving vertical movements not practiced during training. Specifically, robot therapy induced larger improvements of shoulder/elbow coordination and greater reduction of abnormal trunk sagittal movements. The beneficial effects of robot therapy seemed more pronounced in chronic subjects. Future studies on a larger sample should be performed to corroborate present findings.

TRIAL REGISTRATION

www.ClinicalTrials.gov NCT03530358. Registered 21 May 2018. Retrospectively registered.

Motor neuroprosthesis for promoting recovery of function after stroke

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effects of a Robot-Assisted Arm Training Plus Hand Functional Electrical Stimulation on Recovery After Stroke: A Randomized Clinical Trial

OBJECTIVE

To compare the effects of unilateral, proximal arm robot-assisted therapy combined with hand functional electrical stimulation with intensive conventional therapy for restoring arm function in survivors of subacute stroke.

DESIGN

This was a single-blinded, randomized controlled trial.

SETTING

Inpatient rehabilitation university hospital.

PARTICIPANTS

Patients (N=40) diagnosed as having ischemic stroke (time since stroke <8wk) and upper limb impairment were enrolled.

INTERVENTIONS

Participants randomized to the experimental group received 30 sessions (5 sessions/wk) of robot-assisted arm therapy and hand functional electrical stimulation (RAT+FES). Participants randomized to the control group received a time-matched intensive conventional therapy.

MAIN OUTCOME MEASURES

The primary outcome was arm motor recovery measured with the Fugl-Meyer Motor Assessment. Secondary outcomes included motor function, arm spasticity, and activities of daily living. Measurements were performed at baseline, after 3 weeks, at the end of treatment, and at 6-month follow-up. Presence of motor evoked potentials (MEPs) was also measured at baseline.

RESULTS

Both groups significantly improved all outcome measures except for spasticity without differences between groups. Patients with moderate impairment and presence of MEPs who underwent early rehabilitation (<30d post stroke) demonstrated the greatest clinical improvements.

CONCLUSIONS

RAT+FES was no more effective than intensive conventional arm training. However, at the same level of arm impairment and corticospinal tract integrity, it induced a higher level of arm recovery.

Comparing EMG-Based Human-Machine Interfaces for Estimating Continuous, Coordinated Movements

Electromyography (EMG)-based interfaces are trending toward continuous, simultaneous control with multiple degrees of freedom. Emerging methods range from data-driven approaches to biomechanical model-based methods. However, there has been no direct comparison between these two types of continuous EMG-based interfaces. The aim of this study was to compare a musculoskeletal model (MM) with two data-driven approaches, linear regression (LR) and artificial neural network (ANN), for predicting continuous wrist and hand motions for EMG-based interfaces. Six able-bodied subjects and one transradial amputee subject performed (missing) metacarpophalangeal (MCP) and wrist flexion/extension, simultaneously or independently, while four EMG signals were recorded from forearm muscles. To add variation to the EMG signals, the subjects repeated the MCP and wrist motions at various upper extremity postures. For each subject, the EMG signals collected from the neutral posture were used to build the EMG interfaces; the EMG signals collected from all postures were used to evaluate the interfaces. The performance of the interface was quantified by Pearson's correlation coefficient (r) and the normalized root mean square error (NRMSE) between measured and estimated joint angles. The results demonstrated that the MM predicted movements more accurately, with higher r values and lower NRMSE, than either LR or ANN. Similar results were observed in the transradial amputee. Additionally, the variation in r across postures, an indicator of reliability against posture changes, was significantly lower (better) for the MM than for either LR or ANN. Our findings suggest that incorporating musculoskeletal knowledge into EMG-based human-machine interfaces could improve the estimation of continuous, coordinated motion.

Effectiveness of electrical stimulation therapy in improving arm function after stroke: a systematic review and a meta-analysis of randomised controlled trials

OBJECTIVE

The aim of this study is to investigate the effectiveness of electrical stimulation in arm function recovery after stroke.

METHODS

Data were obtained from the PubMed, Cochrane Library, Embase, and Scopus databases from their inception until 12 January 2019. Only randomized controlled trials (RCTs) reporting the effects of electrical stimulation on the recovery of arm function after stroke were selected.

RESULTS

Forty-eight RCTs with a total of 1712 patients were included in the analysis. The body function assessment, Upper-Extremity Fugl-Meyer Assessment, indicated more favorable outcomes in the electrical stimulation group than in the placebo group immediately after treatment (23 RCTs (n = 794): standard mean difference (SMD) = 0.67, 95% confidence interval (CI) = 0.51-0.84) and at follow-up (12 RCTs (n = 391): SMD = 0.66, 95% CI = 0.35-0.97). The activity assessment, Action Research Arm Test, revealed superior outcomes in the electrical stimulation group than those in the placebo group immediately after treatment (10 RCTs (n = 411): SMD = 0.70, 95% CI = 0.39-1.02) and at follow-up (8 RCTs (n = 289): SMD = 0.93, 95% CI = 0.34-1.52). Other activity assessments, including Wolf Motor Function Test, Box and Block Test, and Motor Activity Log, also revealed superior outcomes in the electrical stimulation group than those in the placebo group. Comparisons between three types of electrical stimulation (sensory, cyclic, and electromyography-triggered electrical stimulation) groups revealed no significant differences in the body function and activity.

CONCLUSION

Electrical stimulation therapy can effectively improve the arm function in stroke patients.

Translation and Initial Validation of the Chinese Version of the Action Research Arm Test in People with Stroke

Purpose

This study aimed to translate the English version of the Action Research Arm Test (ARAT) into Chinese and to evaluate the initial validation of the Chinese version (C-ARAT) in patients with a first stroke.

Methods

An expert group translated the original ARAT from English into Chinese using a forward-backward procedure. Forty-four patients (36 men and 8 women) aged 22–80 years with a first stroke were enrolled in this study. The participants were evaluated using 3 stroke-specific outcome measures: C-ARAT, the upper extremity section of the Fugl–Meyer assessment (UE-FMA), and the Wolf Motor Function Test (WMFT). Internal consistency was analysed using Cronbach's α coefficients and item-scale correlations. Concurrent validity was determined using Spearman's rank correlation coefficients. Floor and ceiling effects were considered to be present when more than 20% of patients fell outside the preliminarily set lower or upper boundary, respectively.

Results

The C-ARAT items yielded excellent internal consistency, with a Cronbach's α of 0.98 (p < 0.001) and item-total correlations ranging from 0.727 to 0.948 (p < 0.001). The C-ARAT exhibited good-to-excellent correlations with the UE-FMA and WMFT functional ability (WMFT-FA) scores, with respective ρ values of 0.824 and 0.852 (p < 0.001), and an excellent negative correlation with the WMFT performance time (WMFT-time), with a ρ value of -0.940 (p < 0.001). The C-ARAT subscales generally exhibited good-to-excellent correlations with stroke-specific assessments, with ρ values ranging from 0.773 to 0.927 (p < 0.001). However, the gross subscale exhibited moderate-to-good correlations with the UE-FMA and WMFT-FA scores, with respective ρ values of 0.665 and 0.720 (p < 0.001). No significant floor effect was observed, and a significant ceiling effect was observed only on the WMFT-time.

Conclusions

The C-ARAT demonstrated excellent internal consistency and good-to-excellent concurrent validity. This test could be used to evaluate upper extremity function in stroke patients without cognitive impairment.

Electromyogram-Related Neuromuscular Electrical Stimulation for Restoring Wrist and Hand Movement in Poststroke Hemiplegia: A Systematic Review and Meta-Analysis

Background. Clinical trials have demonstrated some benefits of electromyogram-triggered/controlled neuromuscular electrical stimulation (EMG-NMES) on motor recovery of upper limb (UL) function in patients with stroke. However, EMG-NMES use in clinical practice is limited due to a lack of evidence supporting its effectiveness. Objective. To perform a systematic review and meta-analysis to determine the effects of EMG-NMES on stroke UL recovery based on each of the International Classification of Functioning, Disability, and Health (ICF) domains. Methods. Database searches identified clinical trials comparing the effect of EMG-NMES versus no treatment or another treatment on stroke upper extremity motor recovery. A meta-analysis was done for outcomes at each ICF domain (Body Structure and Function, Activity and Participation) at posttest (short-term) and follow-up periods. Subgroup analyses were conducted based on stroke chronicity (acute/subacute, chronic phases). Sensitivity analysis was done by removing studies rated as poor or fair quality (PEDro score <6). Results. Twenty-six studies (782 patients) met the inclusion criteria. Fifty percent of them were considered to be of high quality. The meta-analysis showed that EMG-NMES has a robust short-term effect on improving UL motor impairment in the Body Structure and Function domain. No evidence was found in favor of EMG-NMES for the Activity and Participation domain. EMG-NMES had a stronger effect for each ICF domain in chronic (≥3 months) compared to acute/subacute phases. Conclusion. EMG-NMES is effective in the short term in improving UL impairment in individuals with chronic stroke.