Implanted neuroprosthesis for assisting arm and hand function after stroke: a case study

Neurostimulation After Stroke

Neural stimulation technology aids stroke survivors in regaining lost motor functions. This article explores its applications in upper and lower limb stroke rehabilitation. The authors review various methods to target the corticomotor system, including transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and vagus nerve stimulation. In addition, the authors review the use of peripheral neuromuscular electrical stimulation for therapeutic and assistive purposes, including transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, and functional electrical stimulation. For each, the authors examine the potential benefits, limitations, safety considerations, and FDA status.

Neural Interface-Based Motor Neuroprosthesis in Poststroke Upper Limb Neurorehabilitation: An Individual Patient Data Meta-analysis

OBJECTIVE

To determine the efficacy of neural interface-based neurorehabilitation, including brain-computer interface, through conventional and individual patient data (IPD) meta-analysis and to assess clinical parameters associated with positive response to neural interface-based neurorehabilitation.

DATA SOURCES

PubMed, EMBASE, and Cochrane Library databases up to February 2022 were reviewed.

STUDY SELECTION

Studies using neural interface-controlled physical effectors (functional electrical stimulation and/or powered exoskeletons) and reported Fugl-Meyer Assessment-upper-extremity (FMA-UE) scores were identified. This meta-analysis was prospectively registered on PROSPERO (#CRD42022312428). PRISMA guidelines were followed.

DATA EXTRACTION

Changes in FMA-UE scores were pooled to estimate the mean effect size. Subgroup analyses were performed on clinical parameters and neural interface parameters with both study-level variables and IPD.

DATA SYNTHESIS

Forty-six studies containing 617 patients were included. Twenty-nine studies involving 214 patients reported IPD. FMA-UE scores increased by a mean of 5.23 (95% confidence interval [CI]: 3.85-6.61). Systems that used motor attempt resulted in greater FMA-UE gain than motor imagery, as did training lasting >4 vs ≤4 weeks. On IPD analysis, the mean time-to-improvement above minimal clinically important difference (MCID) was 12 weeks (95% CI: 7 to not reached). At 6 months, 58% improved above MCID (95% CI: 41%-70%). Patients with severe impairment (P=.042) and age >50 years (P=.0022) correlated with the failure to improve above the MCID on univariate log-rank tests. However, these factors were only borderline significant on multivariate Cox analysis (hazard ratio [HR] 0.15, P=.08 and HR 0.47, P=.06, respectively).

CONCLUSION

Neural interface-based motor rehabilitation resulted in significant, although modest, reductions in poststroke impairment and should be considered for wider applications in stroke neurorehabilitation.

Peripheral nerve blocks of wrist and finger flexors can increase hand opening in chronic hemiparetic stroke

Introduction

Hand opening is reduced by abnormal wrist and finger flexor activity in many individuals with stroke. This flexor activity also limits hand opening produced by functional electrical stimulation (FES) of finger and wrist extensor muscles. Recent advances in electrical nerve block technologies have the potential to mitigate this abnormal flexor behavior, but the actual impact of nerve block on hand opening in stroke has not yet been investigated.

Methods

In this study, we applied the local anesthetic ropivacaine to the median and ulnar nerve to induce a complete motor block in 9 individuals with stroke and observed the impact of this block on hand opening as measured by hand pentagonal area. Volitional hand opening and FES-driven hand opening were measured, both while the arm was fully supported on a haptic table (Unloaded) and while lifting against gravity (Loaded). Linear mixed effect regression (LMER) modeling was used to determine the effect of Block.

Results

The ropivacaine block allowed increased hand opening, both volitional and FES-driven, and for both unloaded and loaded conditions. Notably, only the FES-driven and Loaded condition's improvement in hand opening with the block was statistically significant. Hand opening in the FES and Loaded condition improved following nerve block by nearly 20%.

Conclusion

Our results suggest that many individuals with stroke would see improved hand-opening with wrist and finger flexor activity curtailed by nerve block, especially when FES is used to drive the typically paretic finger and wrist extensor muscles. Such a nerve block (potentially produced by aforementioned emerging electrical nerve block technologies) could thus significantly address prior observed shortcomings of FES interventions for individuals with stroke.

A mirror therapy system using virtual reality and an actuated exoskeleton for the recovery of hand motor impairments: a study of acceptability, usability, and embodiment

Hand motor impairments are one of the main causes of disabilities worldwide. Rehabilitation procedures like mirror therapy are given crucial importance. In the traditional setup, the patient moves the healthy hand in front of a mirror; the view of the mirrored motion tricks the brain into thinking that the impaired hand is moving as well, stimulating the recovery of the lost hand functionalities. We propose an innovative mirror therapy system that leverages and couples cutting-edge technologies. Virtual reality recreates an immersive and effective mirroring effect; a soft hand exoskeleton accompanies the virtual visual perception by physically inducing the mirrored motion to the real hand. Three working modes of our system have been tested with 21 healthy users. The system is ranked as acceptable by the system usability scale; it does not provoke adverse events or sickness in the users, according to the simulator sickness questionnaire; the three execution modes are also compared w.r.t. the sense of embodiment, evaluated through another customized questionnaire. The achieved results show the potential of our system as a clinical tool and reveal its social and economic impact.

Neuromotor prosthetic to treat stroke-related paresis: N-of-1 trial

Background

Functional recovery of arm movement typically plateaus following a stroke, leaving chronic motor deficits. Brain-computer interfaces (BCI) may be a potential treatment for post-stroke deficits

Methods

In this n-of-1 trial (NCT03913286), a person with chronic subcortical stroke with upper-limb motor impairment used a powered elbow-wrist-hand orthosis that opened and closed the affected hand using cortical activity, recorded from a percutaneous BCI comprised of four microelectrode arrays implanted in the ipsilesional precentral gyrus, based on decoding of spiking patterns and high frequency field potentials generated by imagined hand movements. The system was evaluated in a home setting for 12 weeks

Results

Robust single unit activity, modulating with attempted or imagined movement, was present throughout the precentral gyrus. The participant acquired voluntary control over a hand-orthosis, achieving 10 points on the Action Research Arm Test using the BCI, compared to 0 without any device, and 5 using myoelectric control. Strength, spasticity, the Fugl-Meyer scores improved.

Conclusions

We demonstrate in a human being that ensembles of individual neurons in the cortex overlying a chronic supratentorial, subcortical stroke remain active and engaged in motor representation and planning and can be used to electrically bypass the stroke and promote limb function. The participant’s ability to rapidly acquire control over otherwise paralyzed hand opening, more than 18 months after a stroke, may justify development of a fully implanted movement restoration system to expand the utility of fully implantable BCI to a clinical population that numbers in the tens of millions worldwide.

Stroke is a restriction of blood flow to part of the brain and can lead to chronic issues with a person’s ability to control the limbs. The aim of this study was to see if a new type of device could restore movement in a person with arm weakness due to a stroke that occurred a year earlier. In our trial, a sensor was implanted into the surface of the brain, near the site of the stroke, and was connected to a computer that generated a command to open and close the hand with a motorized brace worn on the hand. This person was able to use their own brain activity to trigger the brace and pick up and move objects. This research could support the development of similar medical devices to restore movement in people who have had strokes.

Serruya et al. test in an N-of-1 trial whether a wearable, powered exoskeletal orthosis, driven by a percutaneous, implanted brain–computer interface can restore voluntary upper extremity function following chronic hemiparesis subsequent to a cerebral subcortical stroke. Using this approach, voluntary opening of the paralyzed hand is restored.

User-Centered Virtual Environment for Post-Stroke Motor Rehabilitation

The use of Virtual Reality in the rehabilitation of lost or diminished functions after a stroke has been shown to be an innovative means in motor recovery. However, there are still several design challenges to increment the efficiency of these systems. This paper presents the development and evaluation of a non-immersive 3D virtual environment for post-stroke rehabilitation of elbow flexion-extension movements, which considers the therapist as a direct user and the patient as a secondary user. The development of virtual environment was supported by the criteria of a team of specialists in physical and occupational therapy, following the philosophy of User-Centered Design through three iterations, and incorporating tasks based on the Activities of Daily Living of the Barthel scale. Tests were carried out with healthy users and a patient with a diagnosis of stroke, using the SUS test and a flow status questionnaire respectively. Average satisfaction of user group without diagnosis was 79.6 out of 100 points. On the other hand, according to mean values observed with the patient, dimensions of control sense (6.33) and positive emotional experience (6.66) reflect an "optimal" experience, which indicates an enjoyment of virtual tasks de-spite the effort made to fulfill them.

Design and Testing of Stimulation and Myoelectric Recording Modules in an Implanted Distributed Neuroprosthetic System

Implantable motor neuroprostheses can restore functionality to individuals with neurological disabilities by electrically activating paralyzed muscles in coordinated patterns. The typical design of neuroprosthetic systems relies on a single multi-use device, but this limits the number of stimulus and sensor channels that can be practically implemented. To address this limitation, a modular neuroprosthesis, the "Networked Neuroprosthesis" (NNP), was developed. The NNP system is the first fully implanted modular neuroprosthesis that includes implantation of all power, signal processing, biopotential signal recording, and stimulating components. This paper describes the design of stimulation and recording modules, bench testing to verify stimulus outputs and appropriate filtering and recording, and validation that the components function properly while implemented in persons with spinal cord injury. The results of system testing demonstrated that the NNP was functional and capable of generating stimulus pulses and recording myoelectric, temperature, and accelerometer signals. Based on the successful design, manufacturing, and testing of the NNP System, multiple clinical applications are anticipated.

TetraGrip - a four channel upper limb FES device for people with C5/C6 tetraplegia: device design and clinical outcome

The TetraGrip is an inertial measurement unit-controlled surface upper limb FES device developed for improving hand functions of people with tetraplegia. The reliability of the control system and the repeatability and reproducibility of the device were assessed by analysing the results obtained when 14 able-bodied volunteers used the device. These volunteers were able to generate the control signals effectively once they had sufficient training. The two tetraplegic volunteers participated in a 12-week long clinical study (exercise, 4 weeks; functional tasks, 8 weeks), where they used the device to perform functional tasks. Outcome measures used were the grasp release test, the grip strength test, and the box and block test. Both tetraplegic volunteers showed improvement in performing the tasks specified in all outcome measures. The TetraGrip performed as intended when the able-bodied volunteers used it, and it improved the hand functions of both volunteers with tetraplegia. However, a larger clinical study is necessary to assess the performance of the device with a wider range of people with tetraplegia such as those with C5 complete/incomplete.

Electrode placement on the forearm for selective stimulation of finger extension/flexion

It is still challenging to achieve a complex grasp or fine finger control by using surface functional electrical stimulation (FES), which usually requires a precise electrode configuration under laboratory or clinical settings. The goals of this study are as follows: 1) to study the possibility of selectively activating individual fingers; 2) to investigate whether the current activation threshold and selective range of individual fingers are affected by two factors: changes in the electrode position and forearm rotation (pronation, neutral and supination); and 3) to explore a theoretical model for guidance of the electrode placement used for selective activation of individual fingers. A coordinate system with more than 400 grid points was established over the forearm skin surface. A searching procedure was used to traverse all grid points to identify the stimulation points for finger extension/flexion by applying monophasic stimulation pulses. Some of the stimulation points for finger extension and flexion were selected and tested in their respective two different forearm postures according to the number and the type of the activated fingers and the strength of finger action response to the electrical stimulation at the stimulation point. The activation thresholds and current ranges of the selectively activated finger at each stimulation point were determined by visual analysis. The stimulation points were divided into three groups (“Low”, “Medium” and “High”) according to the thresholds of the 1^st activated fingers. The angles produced by the selectively activated finger within selective current ranges were measured and analyzed. Selective stimulation of extension/flexion is possible for most fingers. Small changes in electrode position and forearm rotation have no significant effect on the threshold amplitude and the current range for the selective activation of most fingers (p > 0.05). The current range is the largest (more than 2 mA) for selective activation of the thumb, followed by those for the index, ring, middle and little fingers. The stimulation points in the “Low” group for all five fingers lead to noticeable finger angles at low current intensity, especially for the index, middle, and ring fingers. The slopes of the finger angle variation in the “Low” group for digits 2~4 are inversely proportional to the current intensity, whereas the slopes of the finger angle variation in other groups and in all groups for the thumb and little finger are proportional to the current intensity. It is possible to selectively activate the extension/flexion of most fingers by stimulating the forearm muscles. The physiological characteristics of each finger should be considered when placing the negative electrode for selective stimulation of individual fingers. The electrode placement used for the selective activation of individual fingers should not be confined to the location with the lowest activation threshold.

Neurophysiology and neural engineering: a review

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

Upper limb functional electrical stimulation devices and their man-machine interfaces

Functional Electrical Stimulation (FES) is a technique that uses electricity to activate the nerves of a muscle that is paralysed due to hemiplegia, multiple sclerosis, Parkinson's disease or spinal cord injury (SCI). FES has been widely used to restore upper limb functions in people with hemiplegia and C5-C7 tetraplegia and has improved their ability to perform their activities of daily living (ADL). At the time of writing, a detailed literature review of the existing upper limb FES devices and their man-machine interfaces (MMI) showed that only the NESS H200 was commercially available. However, the rigid arm splint doesn't fit everyone and prevents the use of a tenodesis grip. Hence, a robust and versatile upper limb FES device that can be used by a wider group of people is required.

Neuromuscular Electrical Stimulation for Motor Restoration in Hemiplegia

This article reviews the most common therapeutic and neuroprosthetic applications of neuromuscular electrical stimulation (NMES) for upper and lower extremity stroke rehabilitation. Fundamental NMES principles and purposes in stroke rehabilitation are explained. NMES modalities used for upper and lower limb rehabilitation are described, and efficacy studies are summarized. The evidence for peripheral and central mechanisms of action is also summarized.

Hand-in-hand advances in biomedical engineering and sensorimotor restoration

BACKGROUND

Living in a multisensory world entails the continuous sensory processing of environmental information in order to enact appropriate motor routines. The interaction between our body and our brain is the crucial factor for achieving such sensorimotor integration ability. Several clinical conditions dramatically affect the constant body-brain exchange, but the latest developments in biomedical engineering provide promising solutions for overcoming this communication breakdown.

NEW METHOD

The ultimate technological developments succeeded in transforming neuronal electrical activity into computational input for robotic devices, giving birth to the era of the so-called brain-machine interfaces. Combining rehabilitation robotics and experimental neuroscience the rise of brain-machine interfaces into clinical protocols provided the technological solution for bypassing the neural disconnection and restore sensorimotor function.

RESULTS

Based on these advances, the recovery of sensorimotor functionality is progressively becoming a concrete reality. However, despite the success of several recent techniques, some open issues still need to be addressed.

COMPARISON WITH EXISTING METHOD(S)

Typical interventions for sensorimotor deficits include pharmaceutical treatments and manual/robotic assistance in passive movements. These procedures achieve symptoms relief but their applicability to more severe disconnection pathologies is limited (e.g. spinal cord injury or amputation).

CONCLUSIONS

Here we review how state-of-the-art solutions in biomedical engineering are continuously increasing expectances in sensorimotor rehabilitation, as well as the current challenges especially with regards to the translation of the signals from brain-machine interfaces into sensory feedback and the incorporation of brain-machine interfaces into daily activities.

Control of robotic assistance using poststroke residual voluntary effort

Poststroke hemiparesis limits the ability to reach, in part due to involuntary muscle co-activation (synergies). Robotic approaches are being developed for both therapeutic benefit and continuous assistance during activities of daily living. Robotic assistance may enable participants to exert less effort, thereby reducing expression of the abnormal co-activation patterns, which could allow participants to reach further. This study evaluated how well participants could perform a reaching task with robotic assistance that was either provided independent of effort in the vertical direction or in the sagittal plane in proportion to voluntary effort estimated from electromyograms (EMG) on the affected side. Participants who could not reach targets without assistance were enabled to reach further with assistance. Constant anti-gravity force assistance that was independent of voluntary effort did not reduce the quality of reach and enabled participants to exert less effort while maintaining different target locations. Force assistance that was proportional to voluntary effort on the affected side enabled participants to exert less effort and could be controlled to successfully reach targets, but participants had increased difficulty maintaining a stable position. These results suggest that residual effort on the affected side can produce an effective command signal for poststroke assistive devices.

The influence of functional electrical stimulation on hand motor recovery in stroke patients: a review

Neuromuscular stimulation has been used as one potential rehabilitative treatment option to restore motor function and improve recovery in patients with paresis. Especially stroke patients who often regain only limited hand function would greatly benefit from a therapy that enhances recovery and restores movement. Multiple studies investigated the effect of functional electrical stimulation on hand paresis, the results however are inconsistent. Here we review the current literature on functional electrical stimulation on hand motor recovery in stroke patients. We discuss the impact of different parameters such as stage after stoke, degree of impairment, spasticity and treatment protocols on the functional outcome. Importantly, we outline the results from recent studies investigating the cortical effects elicited by functional electrical stimulation giving insights into the underlying mechanisms responsible for long-term treatment effects. Bringing together the findings from present research it becomes clear that both, treatment outcomes as well as the neurophysiologic mechanisms causing functional recovery, vary depending on patient characteristics. In order to develop unified treatment guidelines it is essential to conduct homogenous studies assessing the impact of different parameters on rehabilitative success.

Functional electrical stimulation to augment poststroke reach and hand opening in the presence of voluntary effort: a pilot study

BACKGROUND

Hemiparesis after stroke can severely limit an individual's ability to perform activities of daily living. Functional electrical stimulation (FES) has the potential to generate functional arm and hand movements. We have observed that FES can produce functional hand opening when a stroke patient is relaxed, but the FES-produced hand opening is often overpowered by finger flexor coactivation in response to patient attempts to reach and open the hand.

OBJECTIVE

To determine if stimulating both reaching muscles and hand opening muscles makes it possible to achieve useful amounts of simultaneous reach and hand opening even in the presence of submaximal reaching effort.

METHODS

We measured reach and hand opening during a reach-then-open the hand task under different combinations of voluntary effort and FES for both reach and hand opening.

RESULTS

As effort was reduced and stimulation generated more movement, a greater amount of reach and hand opening was achieved. For the first time, this study quantified the effect of voluntary effort for reach and hand opening on stimulated hand opening. It also showed variability in the interaction of voluntary effort and stimulation between participants. Additionally, when participants were instructed to reach with partial effort during simultaneous FES, they achieved greater reach and hand opening.

CONCLUSIONS

Simultaneous reaching and FES hand opening is improved by including FES for reach and reducing voluntary effort. In the future, an upper extremity neuroprosthesis that uses a combination of voluntary effort and FES assistance may enable users to perform activities of daily living.