Chronic motor dysfunction after stroke: recovering wrist and finger extension by electromyography-triggered neuromuscular stimulation

Hybrid assistive systems for rehabilitation: lessons learned from functional electrical therapy in hemiplegics

This paper suggests that the optimal method for promoting of the recovery of upper extremity function in hemiplegic individuals is the use of hybrid assistive systems (HAS). The suggested HAS is a combination of stimulation of paralyzed distal segments (hand) in synchrony with robot controlled movements of proximal segments (upper arm and forearm). The use of HAS is envisioned as part of voluntary activation of preserved sensory-motor systems during task related exercise. This HAS design follows our results from functional electrical therapy, constraint induced movement therapy, intensive exercise therapy, and use of robots for rehabilitation. The suggestion is also based on strong evidences that cortical plasticity is best promoted by task related exercise and patterned electrical stimulation.

Improving selected hand functions using a noninvasive neuroprosthesis in persons with chronic stroke

BACKGROUND AND PURPOSE

Loss of upper extremity function following stroke remains a major rehabilitation challenge. The purpose of this investigation was to determine whether the Handmaster system (NESS Ltd., Ra'anana, Israel) could improve selected hand functions in persons with chronic upper extremity paresis following stroke.

METHODS

Twenty-nine poststroke subjects consented to participate in a home-based, 3-week, nonrandomized case series trial. Main outcome measures included 3 activities of daily living (ADL) tasks: (1) lifting a 2-handled pot, (2) holding a bag while standing with a cane, and (3) a subject-selected-ADL. Secondary outcomes included lifting a 600-g weight, grip strength, electrically induced finger motion, Fugl-Meyer spherical grasp, and perceived pain scale.

RESULTS

Comparing baseline to study end point with the neuroprosthesis, the percent of successful trials with lifting the pot, weight, and bag (0% v 93%, 14% v 100%, and 17% v 93%, respectively) increased significantly. All subjects performed successfully their selected ADL and improved their Fugl-Meyer scores using the neuroprosthesis. Grip strength (6.4 +/- 7.3N v 17.7 +/- 6.2N) and active finger motion (0.5 +/- 1.2 cm v 8.4 +/- 2.6 cm) also improved with the neuroprosthesis. Pain scores significantly decreased in subjects reporting pain at baseline. Responses to questionnaire were favorable regarding the utility and therapeutic benefits of the device.

CONCLUSIONS

We conclude that the Handmaster is a safe and effective noninvasive neuroprosthesis for improving the studied hand functions and impairments in selected persons with chronic hemiplegia secondary to stroke.

Effect of finger tracking combined with electrical stimulation on brain reorganization and hand function in subjects with stroke

Synergism of rehabilitative interventions could maximize recovery following stroke. We examined whether the combination of peripherally initiated electrical stimulation of finger extensors and centrally operating finger tracking training could accentuate brain reorganization and its relationship to recovery, beyond the effects of either treatment alone. Twenty subjects with stroke were randomly assigned to an electrical stimulation (ES), tracking training (TR) or combination (CM) group. Each group was trained for ten 1-h sessions over 2-3 weeks. Pretest and posttest measurements consisted of the Box and Block and Jebsen Taylor tests of manual dexterity and a finger tracking test that was performed during functional magnetic resonance imaging (fMRI). fMRI variables included laterality index and BOLD signal intensity of primary motor (M1), primary sensory (S1), sensorimotor (SMC) and premotor (PMC) cortices as well as, supplementary motor area (SMA). ES and CM groups improved on dexterity, whereas the TR group did not. Improvement in the CM group was not greater than the other two groups. Subjects who had an intact M1 showed greater functional improvement than those who had direct involvement of M1. fMRI analysis did not yield significant changes from pretest to posttest. In the CM group only, functional improvement was positively correlated with laterality index change in M1, S1, SMC and PMC, indicating greater ipsilesional control and was negatively correlated with BOLD Signal Intensity change in ipsilesional S1 and SMA, indicating neurophysiological trimming of irrelevant neurons. The correlational results suggest that the combined intervention may be more influential on brain reorganization than either treatment alone but a larger sample size, longer duration of training, or a restricted inclusion of stroke location and volume may be needed to demonstrate a difference in efficacy for producing behavioral changes.

Botulinum toxin a, evidence-based exercise therapy, and constraint-induced movement therapy for upper-limb hemiparesis attributable to stroke: a preliminary study

OBJECTIVE

To determine whether the combination of botulinum toxin A (BTX-A) treatment for the upper limb and a 4-wk course of exercise therapy could improve motor function sufficiently to allow those with poststroke hemiparesis and spasticity to achieve the minimal motor criteria (MMC) to be enrolled in constraint-induced movement therapy (CIMT), and to determine the feasibility of enrolling participants into CIMT if they meet MMC after treatment with a combination of BTX-A plus exercise therapy.

DESIGN

Twelve individuals received BTX-A and exercise therapy for 1 hr/day, three times per week, for 4 wks. Those who met MMC were enrolled in 2 wks of CIMT, and the rest received a home exercise program. Outcome measures included the Ashworth Scale, Wolf Motor Function Test (WMFT), the Motor Activity Log (MAL), the Box and Blocks Test (BBT), and the upper-extremity subtest of the Fugl-Meyer Assessment of Motor Function (FM-UE).

RESULTS

Ashworth Scale scores declined from a mean score of 2.0-1.2 (P = 0.01). Four of 12 subjects were able to achieve MMC (P = 0.026). CIMT participants improved in the BBT, the MAL, and the WMFT compared with their own baseline. Gains achieved during CIMT receded by week 24 as spasticity returned.

CONCLUSION

BTX-A plus exercise therapy shows potential to improve function for those with severe hand paresis and spasticity after stroke. Those who meet MMC may initially realize further modest gains through CIMT. However, gains are likely to recede as spasticity returns. Adding medications or modifying the therapy protocol to include activities such as functional neuromuscular stimulation or robotic training may yield a more potent effect.

The nature of hand motor impairment after stroke and its treatment

Hand motor impairments may be viewed as 1) a deficit in motor execution, resulting from weakness, spasticity, and abnormal muscle synergies, and/or 2) a deficit in higher-order processes, such as motor planning and motor learning, which lead to poorly formed sensorimotor associations that lead to impaired motor control. Although weakness and spasticity impede motor execution, strengthening and tone reduction represent simplistic solutions to the deficit in motor control after stroke. Deficits in hand motor control are better appreciated by examining the coordination of fingertip forces and movements during natural movements, and suggest that impairments in motor learning and planning are fundamental impediments to motor recovery following stroke. However, despite an explosion in the number of therapeutic protocols based on the principles of motor learning, little is known about the types of motor learning impairment that occur after stroke and how lesion location may influence motor relearning.

The optimal controller delay for myoelectric prostheses

A tradeoff exists when considering the delay created by multifunctional prosthesis controllers. Large controller delays maximize the amount of time available for EMG signal collection and analysis (and thus maximize classification accuracy); however, large delays also degrade prosthesis performance by decreasing the responsiveness of the prosthesis. To elucidate an "optimal controller delay" twenty able-bodied subjects performed the Box and Block Test using a device called PHABS (prosthetic hand for able bodied subjects). Tests were conducted with seven different levels of controller delay ranging from nearly 0-300 ms and with two different artificial hand speeds. Based on repeted measures ANOVA analysis and a linear mixed effects model, the optimal controller delay was found to range between approximately 100 ms for fast prehensors and 125 ms for slower prehensors. Furthermore, the linear mixed effects model shows that there is a linear degradation in performance with increasing delay.

Improving hand function in stroke survivors: a pilot study of contralaterally controlled functional electric stimulation in chronic hemiplegia

OBJECTIVE

To assess the feasibility of a new stroke rehabilitation therapy for the hemiparetic hand.

DESIGN

Case series. Pre- and postintervention assessment with 1- and 3-month follow-ups.

SETTING

Clinical research laboratory of a large public hospital.

PARTICIPANTS

Three subjects with chronic (>6mo postcerebrovascular accident) upper-extremity hemiplegia.

INTERVENTION

Subjects used an electric stimulator to cause the paretic hand extensor muscles to contract and thereby open the hand. Subjects controlled the intensity of the stimulation, and thus the degree of hand opening, by volitionally opening the unimpaired contralateral hand, which was detected by an instrumented glove. For 6 weeks, subjects used the stimulator to perform active repetitive hand-opening exercises 2 hours daily at home and functional tasks 1.5 hours twice a week in the laboratory.

MAIN OUTCOME MEASURES

Maximum voluntary finger extension, maximum voluntary isometric finger-extension moment, finger-movement control, and box and block test (BBT) score at pre- and posttreatment and at 1 month and 3 months posttreatment.

RESULTS

Maximum voluntary finger extension increased from baseline to end of treatment and from the end of treatment to 1-month follow-up in 2 subjects. Maximum voluntary isometric finger-extension moment, finger-movement control, and BBT score increased from baseline to the end of treatment and from the end of treatment to 1-month follow-up in all 3 subjects. The improvements generally declined at 3 months.

CONCLUSIONS

The results suggest a positive effect on motor impairment, meriting further investigation of the intervention.

Functional Electrical Stimulation Enhancement of Upper Extremity Functional Recovery During Stroke Rehabilitation: A Pilot Study

Objective. To test if functional electrical stimulation (FES) can enhance the recovery of upper extremity function during early stroke rehabilitation. Methods. Open-label block-randomized trial, begun during inpatient rehabilitation and continued at the patients' home. Patients were assigned to either FES combined with task-specific upper extremity rehabilitation (n = 7) or a control group that received task-specific therapy alone (n = 8) over 12 weeks. Outcome measures . Hand function (Box & Blocks, B&B; Jebsen-Taylor light object lift, J-T) and motor control (modified Fugl-Meyer, mF-M) were video-recorded for both upper extremities at baseline, 4, 8, and 12 weeks. Results. B&B mean score at 12 weeks favored ( P = .049) the FES group (42.3 ± 16.6 blocks) over the control group (26.3 ± 11.0 blocks). The FES group J-T task was 6.7 ± 2.9 seconds and faster ( P = .049) than the 11.8 ± 5.4 seconds of the control group. Mean mF-M score of the FES group at 12 weeks was 49.3 ± 5.1 points out of 54, compared to the control group that scored 40.6 ± 8.2 points ( P = .042). All patients regained hand function. Conclusion. Upper extremity task-oriented training that begins soon after stroke that incorporates FES may improve upper extremity functional use in patients with mild/moderate paresis more than task-oriented training without FES.

Strengthening interventions increase strength and improve activity after stroke: a systematic review

QUESTION

Is strength training after stroke effective (ie, does it increase strength), is it harmful (ie, does it increase spasticity), and is it worthwhile (ie, does it improve activity)?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Stroke participants were categorised as (i) acute, very weak, (ii) acute, weak, (iii) chronic, very weak, or (iv) chronic, weak.

INTERVENTION

Strengthening interventions were defined as interventions that involved attempts at repetitive, effortful muscle contractions and included biofeedback, electrical stimulation, muscle re-education, progressive resistance exercise, and mental practice.

OUTCOME MEASURES

Strength was measured as continuous measures of force or torque or ordinal measures such as manual muscle tests. Spasticity was measured using the modified Ashworth Scale, a custom made scale, or the Pendulum Test. Activity was measured directly, eg, 10-m Walk Test, or the Box and Block Test, or with scales that measured dependence such as the Barthel Index.

RESULTS

21 trials were identified and 15 had data that could be included in a meta-analysis. Effect sizes were calculated as standardised mean differences since various muscles were studied and different outcome measures were used. Across all stroke participants, strengthening interventions had a small positive effect on both strength (SMD 0.33, 95% CI 0.13 to 0.54) and activity (SMD 0.32, 95% CI 0.11 to 0.53). There was very little effect on spasticity (SMD -0.13, 95% CI -0.75 to 0.50).

CONCLUSION

Strengthening interventions increase strength, improve activity, and do not increase spasticity. These findings suggest that strengthening programs should be part of rehabilitation after stroke.

Efficacy of electrical stimulation to increase muscle strength in people with neurological conditions: a systematic review

BACKGROUND AND PURPOSE

Weakness in partially paralysed muscles is a disabling impairment for people with neurological conditions. Strength training programmes are widely administered to address this impairment. There is a common belief that the effectiveness of strength training programmes can be enhanced by the addition of electrical stimulation. The purpose of this systematic review was to assess the efficacy of electrical stimulation for increasing voluntary strength in people with neurological conditions.

METHOD

Eligible randomized trials of electrical stimulation were identified by searches of computerized databases. The search yielded 11,267 abstracts, of which 60 were retrieved. Two assessors independently reviewed full text versions of these articles.

RESULTS

Eighteen studies satisfied the inclusion criteria. These studies involved participants with spina bifida (n = 1), cerebral palsy (n = 1), peripheral nerve lesion (n = 1), multiple sclerosis (n = 1), spinal cord injury (n = 3) and stroke (n = 11). The mean (SD) PEDro score for trial quality was 4.9 (1.0) out of 10. Meta-analyses of studies involving similar patients were not done because of insufficient data or lack of homogeneity. The results of all studies were analysed individually.

CONCLUSION

Several studies suggest a modest beneficial effect of electrical stimulation in patients with stroke. It is not clear whether patients with other types of neurological disabilities benefit from electrical stimulation in the same way.

Neuromuscular electrical stimulation in neurorehabilitation

This review provides a comprehensive overview of the clinical uses of neuromuscular electrical stimulation (NMES) for functional and therapeutic applications in subjects with spinal cord injury or stroke. Functional applications refer to the use of NMES to activate paralyzed muscles in precise sequence and magnitude to directly accomplish functional tasks. In therapeutic applications, NMES may lead to a specific effect that enhances function, but does not directly provide function. The specific neuroprosthetic or "functional" applications reviewed in this article include upper- and lower-limb motor movement for self-care tasks and mobility, respectively, bladder function, and respiratory control. Specific therapeutic applications include motor relearning, reduction of hemiplegic shoulder pain, muscle strengthening, prevention of muscle atrophy, prophylaxis of deep venous thrombosis, improvement of tissue oxygenation and peripheral hemodynamic functioning, and cardiopulmonary conditioning. Perspectives on future developments and clinical applications of NMES are presented.

Hybrid Power-Assisted Functional Electrical Stimulation to Improve Hemiparetic Upper-Extremity Function

OBJECTIVE

The effect on spastic hemiparesis of a hybrid therapy consisting of functional electrical stimulation and block therapy was examined.

DESIGN

Sixteen consecutively enrolled stroke patients who had spastic upper-extremity impairments more than 1 yr after stroke were recruited for this nonblinded randomized controlled trial. Patients underwent hybrid functional electrical stimulation therapy on their extensor carpi radialis longus and brevis, extensor digitorum communis, and extensor indicis proprius muscles once or twice a week for 4 mos after motor point blocks at the spastic finger flexor muscles. Surface electrodes picked up the electromyography signal and stimulated those muscles in proportion to the integrated electromyography signal obtained by the functional electrical stimulation device. The root mean square of the extensor carpi radialis longus and extensor digitorum communis maximum voluntary electromyography, active range of motion of wrist extension, finger extension, Modified Ashworth Scale, and two clinical tests were examined before and after training.

RESULTS

Root mean square, active range of motion, Modified Ashworth Scale, and two clinical tests showed marked improvement in all patients as compared with the control subjects.

CONCLUSIONS

The hybrid therapy was effective for patients with chronic spastic hemiparesis. Proprioceptional sensory feedback may have an important role in power-assisted functional electrical stimulation therapy.

Neuromuscular Electrical Stimulation Improves Severe Hand Dysfunction for Individuals With Chronic Stroke

Restoring hand function is difficult post-stroke. We sought to determine if applying neuromuscular electrical stimulation (NMES) was beneficial for reducing severe hand impairments. Subjects with chronic stroke (N=8; 3 Fe, 5 M; 58.3 +/- 6.9 y/o) received 10 sessions of NMES using two different methods applied in a counterbalanced order. In one intervention, we applied NMES (active) in a novel fashion using multiple stimulators on the forearm flexors and extensors to assist subjects with grasping and releasing a tennis ball. In the other intervention, the NMES ('passive') stimulated repeated wrist extension and flexion. Motor performance was assessed prior to and immediately following the interventions and at retention. Upper extremity (UE) Fugl-Myer scores significantly improved (p < 0.002) immediately following either intervention. Significant improvement was also observed in the Modified Ashworth Spasticity Scale (MASS) (p < 0.03), immediately following intervention, primarily due to the NMESpassive treatment (p < 0.034). Subjects performed grasping tasks significantly faster (p < 0.0433) following interventions, with performance speeds on dexterous manipulation increasing approximately 10% for NMESactive immediately following intervention, compared to only 0.1% improvement following NMESpassive. Generally, improvements in motor speed remained 10 days following NMESactive intervention, although slightly diminished. In conclusion, severe hand impairment was reduced after a short duration of NMES therapy in this pilot data set for individuals with chronic stroke. NMES-assisted grasping trended towards greater functional benefit than traditional NMES-activation of wrist flexors/extensors.

Motor learning: its relevance to stroke recovery and neurorehabilitation

PURPOSE OF REVIEW

Much of neurorehabilitation rests on the assumption that patients can improve with practice. This review will focus on arm movements and address the following questions: (i) What is motor learning? (ii) Do patients with hemiparesis have a learning deficit? (iii) Is recovery after injury a form of motor learning? (iv) Are approaches based on motor learning principles useful for rehabilitation?

RECENT FINDINGS

Motor learning can be broken into kinematic and dynamic components. Studies in healthy subjects suggest that retention of motor learning is best accomplished with variable training schedules. Animal models and functional imaging in humans show that the mature brain can undergo plastic changes during both learning and recovery. Quantitative motor control approaches allow differentiation between compensation and true recovery, although both improve with practice. Several promising new rehabilitation approaches are based on theories of motor learning. These include impairment oriented-training (IOT), constraint-induced movement therapy (CIMT), electromyogram (EMG)-triggered neuromuscular stimulation, robotic interactive therapy and virtual reality (VR).

SUMMARY

Motor learning mechanisms are operative during spontaneous stroke recovery and interact with rehabilitative training. For optimal results, rehabilitation techniques should be geared towards patients' specific motor deficits and possibly combined, for example, CIMT with VR. Two critical questions that should always be asked of a rehabilitation technique are whether gains persist for a significant period after training and whether they generalize to untrained tasks.

Electrostimulation for promoting recovery of movement or functional ability after stroke

BACKGROUND

Electrostimulation might improve motor recovery after stroke by providing neuromuscular re-training.

OBJECTIVES

To find if electrostimulation improved functional motor ability, and the ability to undertake activities of daily living.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), CINAHL (1982 to January 2004), AMED - Allied and Complementary Medicine Database (1985 to January 2004), Physiotherapy Evidence Database (PEDro), REHABDATA and the ISI Science Citation Index (1981 to 2003). We placed a request on the PHYSIO e-mail discussion list and contacted authors of relevant studies to elicit any unpublished or ongoing studies, searched the reference lists of included trials and contacted trialists.

SELECTION CRITERIA

Randomised controlled trials of electrostimulation delivered to the peripheral neuromuscular system which was designed to improve voluntary movement control, functional motor ability and activities of daily living.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data.

MAIN RESULTS

Of the 2077 references identified, 24 trials were included in this review. For electrostimulation compared with no treatment this review found that electrostimulation improved some aspects of functional motor ability and some aspects of motor impairment and normality of movement. In addition, there was a significant difference in favour of no treatment compared with electrostimulation for an aspect of functional motor ability. For electrostimulation compared with placebo this review found that electrostimulation improved an aspect of functional motor ability. For electrostimulation compared with conventional physical therapy this review found that electrostimulation improved an aspect of motor impairment. There were no statistically significant differences between electrostimulation and control treatment for all other outcomes. However, these results need to be interpreted with reference to the following: (1) the majority of analyses only contained one trial; (2) variation was found between included trials in time after stroke, level of functional deficit, and dose of electrostimulation; and (3) the possibility of selection and detection bias in the majority of included trials.

AUTHORS' CONCLUSIONS

At present, there are insufficient robust data to inform clinical use of electrostimulation for neuromuscular re-training. Research is needed to address specific questions about the type of electrostimulation that might be most effective, in what dose and at what time after stroke.

Stroke recovery and its imaging

Functional imaging of stroke recovery is a unique source of information that might be useful in the development of restorative treatments. Several features of brain function change spontaneously after stroke. Current studies define many of the most common events. Key challenges for the future are to develop standardized approaches to help address certain questions, determine the psychometric qualities of these measures, and define the clinical usefulness of these methods.

An electrode configuration technique using an electrode matrix arrangement for FES-based upper arm rehabilitation systems

An upper limb electrical stimulation technique has been developed which features a novel self-configuration approach, to obtain an ideal wrist response from the patient. The system uses an analogue de-multiplexer in conjunction with an electrode matrix so that different electrode sites can be tested using only one channel of stimulation. A twin axis goniometer is attached to the patient's wrist and flex sensors are attached to the patient's fingers so that the control algorithm can assess the wrist response. A data acquisition unit logs the data for further analysis. A clinical investigation on healthy subjects was conducted to test the proposed system. The results show a high variation in hand response across different subjects. In addition, for all subjects tested an ideal response was found which shows some justification for the use of the proposed technique.

Influence of Electric Somatosensory Stimulation on Paretic-Hand Function in Chronic Stroke

OBJECTIVE

To test the influence of electric somatosensory stimulation on performance of the Jebsen-Taylor Hand Function Test (JTHFT), a widely used assessment of functional hand motor skills, by the paretic arm in patients with chronic stroke.

DESIGN

Initially, patients trained for several sessions until reaching plateau performance on the JTHFT. Subsequently, they entered a crossover randomized study, designed to evaluate the influence of somatosensory stimulation on JTHFT performance.

SETTING

A research laboratory.

PARTICIPANTS

Nine patients with chronic stroke (>/=1.5 y) who acutely had marked weakness (paralysis of the upper extremity is evaluated as equal or below Medical Research Council [MRC] grade 2) followed by improvement to an MRC grade of 4.24+/-0.43 (range, 3.5-4.9) and Fugl-Meyer Assessment (FMA) score of 86.43%+/-2.02% at the time of testing.

INTERVENTIONS

Two hours of electric somatosensory stimulation was applied to the (1) paretic hand, (2) paretic leg, or (3) no stimulation in different sessions, in a randomized order.

MAIN OUTCOME MEASURE

The time required to complete the JTHFT was analyzed by using repeated-measures analysis of variance (ANOVA) with factors time (pre-, postintervention) and intervention (paretic hand, paretic leg, no stimulation) followed by post hoc testing.

RESULTS

Significant effects of intervention and intervention by time interaction (P<.01) on JTHFT time was revealed by repeated-measures ANOVA. Post hoc testing documented improvements in JTHFT time with paretic hand stimulation alone (P<.005), an effect that appeared more prominent in subjects with lower FMA scores.

CONCLUSIONS

Somatosensory stimulation applied to a paretic limb can benefit performance of a functional test in patients with chronic stroke. This result supports the proposal that electric sensory stimulation in combination with training protocols may enhance the benefit of customary neurorehabilitative treatments and possibly motor learning.

Home-based electromyography-triggered stimulation in chronic stroke

OBJECTIVES

(1) To determine the feasibility of a home-based electromyography-triggered neuromuscular stimulation (ETMS) programme; and (2) to determine ETMS efficacy in increasing affected wrist extension and reducing affected arm impairment.

DESIGN

Randomized, controlled, pre-post, cross-over design.

SETTING

Outpatient rehabilitation hospital.

PATIENTS

Twelve chronic stroke patients with palpable muscle contraction in their affected wrist extensors but no movement (7 males; mean age = 59.75 years, age range 44-75 years; mean time since stroke = 52.75 months, range 13-131 months).

INTERVENTION

Subjects were randomly assigned to receive either: (a) ETMS use twice every weekday in 35-min increments during an eight-week period followed by an eight-week home exercise programme (ETMS/home exercise programme) (n=8); or (b) an eight-week home exercise programme followed by use of ETMS twice every weekday in 35-min increments during an eight-week period (home exercise programme) (n=4).

MAIN OUTCOME MEASURES

The Fugl-Meyer, Action Research Arm Test and goniometry.

RESULTS

After home exercise programme participation, subjects showed nominal or no changes on any of the outcome measures. After ETMS, patients showed modest impairment reductions, as shown by the Fugl-Meyer, and no Action Research Arm Test changes. However, both groups showed a 21 degree increase in active affected wrist extension after ETMS use.

CONCLUSION

ETMS use is feasible in the home environment. Neither participation in a traditional home exercise programme nor ETMS use conveyed changes on the Fugl-Meyer or Action Research Arm Test. However, ETMS use increased active affected limb extension. This new movement may provide a potential pathway for subjects to participate in other interventions, such as modified constraint induced therapy.

Back From the Brink: Electromyography-Triggered Stimulation Combined With Modified Constraint-Induced Movement Therapy in Chronic Stroke

OBJECTIVE

To determine the efficacy of a regimen that combines electromyography-triggered neuromuscular stimulation (ETMS) with modified constraint-induced movement therapy (mCIMT) in patients with chronic stroke.

DESIGN

Pre-post, case series.

SETTING

Outpatient rehabilitation hospital.

PARTICIPANTS

Six subjects who had had a stroke more [corrected] than 1 year before the study and who had upper-limb hemiparesis. All subjects were only able to activate the affected wrist extensors.

INTERVENTION

Subjects underwent ETMS twice every weekday in 35-minute increments during an 8-week period. One week after they completed the ETMS regimen, and after the outcome measures were readministered, subjects participated in mCIMT, which consisted of structured therapy sessions that emphasized use of the more affected arm in valued activities. The sessions were held 3 times a week for 10 weeks. The less affected arms were also restrained 5 days a week for 5 hours.

MAIN OUTCOME MEASURES

The Fugl-Meyer Assessment (FMA) of motor recovery, Action Research Arm Test (ARAT), and goniometry.

RESULTS

Subjects had nominal changes on the ARAT (mean change, 0.3), and no functional changes after ETMS. However, they had a mean increase of 21.5 degrees in affected wrist extension and an improved ability to perform the wrist items of the FMA (reflected by a mean increase of 4.1 points on the FMA), which qualified them for mCIMT. After mCIMT, subjects had a 15.5-point change on the FMA, an 11.4-point change on the ARAT, and a new ability to perform valued activities.

CONCLUSIONS

ETMS alone does not result in functional changes. However, it may elicit sufficient active affected wrist and finger extension increases to permit possible participation in mCIMT, which can result in marked functional gains. This study is among the first to show improved function in stroke patients who initially had little hand motor control, and it is among the first to effectively combine 2 singularly efficacious regimens.

Customized interactive robotic treatment for stroke: EMG-triggered therapy

A system for electromyographic (EMG) triggering of robot-assisted therapy (dubbed the EMG game) for stroke patients is presented. The onset of a patient's attempt to move is detected by monitoring EMG in selected muscles, whereupon the robot assists her or him to perform point-to-point movements in a horizontal plane. Besides delivering customized robot-assisted therapy, the system can record signals that may be useful to better understand the process of recovery from stroke. Preliminary experiments aimed at testing the proposed system and gaining insight into the potential of EMG-triggered, robot-assisted therapy are reported.

Évolution des concepts en rééducation du patient hémiplégique

INTRODUCTION

The author attempts to show the evolution of the ideas guiding the rehabilitation treatment of motricity disorders after a vascular or traumatic brain lesion.

METHOD

Expert opinion based on an uncomprehensive review of the literature, from the databases Reedoc and Medline and from the Institut Lionnois library in Nancy and the Charcot library in Paris.

RESULTS AND DISCUSSION

Many theories and techniques have been proposed. The modern history of this rehabilitation treatment has been marked by a period that stressed control of the abnormal motricity characterizing central motor disorders, sometimes too exclusively. The development of evidence-based medicine in the 1980s undermined certain dogmas. At the same time, the advent of cerebral imaging technology confirmed clinical observations and hypotheses concerning cerebral plasticity. Today, the rehabilitation treatment of these motor disorders uses notions of learning; the diversity and complementarity of the exercises, which must be task-oriented; relative earliness and intensity of therapy; close interactions between sensitivity and motricity; and different concepts as mental imagery, the perception of verticality, or muscle strengthening.

CONCLUSION

To its well-known preventive and palliative roles, rehabilitation treatment has now added a curative role. All the concepts applied today are not new, but the spirit of their application is new. Because we are sure that neurological recovery can be improved, no idea can be rejected at the outset; its effect must be demonstrated. Among the numerous ideas presently proposed, future studies will define the best ones, for the most suitable patient, at the best time.

Therapy of paretic arm in hemiplegic subjects augmented with a neural prosthesis: a cross-over study

There are indications that both intensive exercise and electrical stimulation have a beneficial effect on arm function in post-stroke hemiplegic patients. We recommend the use of Functional Electrical Therapy (FET), which combines electrical stimulation of the paretic arm and intensive voluntary movement of the arm to exercise daily functions. FET was applied 30 min daily for 3 weeks. Forty-one acute hemiplegics volunteered in the 18-months single blinded cross-over study (CoS). Nineteen patients (Group A) participated in FET during their acute hemiplegia, and 22 patients (Group B) participated in FET during their chronic phase of hemiplegia. Group B patients were controls during FET in acute hemiplegia, and Group A patients were controls during the FET in chronic hemiplegia. Thirty-two patients completed the study. The outcomes of the Upper Extremity Function Test (UEFT) were used to assess the ability of patients to functionally use objects, as were the Drawing Test (DT) (used to assess the coordination of the arm), the Modified Ashworth Scale, the range of movement, and the questionnaire estimating the patients' satisfaction with the usage of the paretic arm. Patients who participated in the FET during the acute phase of hemiplegia (Group A) reached functionality of the paretic arm, on average, in less than 6 weeks, and maintained this near-normal use of the arm and hand throughout the follow-up. The gains in all outcome scores were significantly larger in Group A after FET and at all follow-ups compared with the scores before the treatment. The gains in patients who participated in the FET in the chronic phase of hemiplegia (Group B) were measurable, yet not significant. The speed of recovery was larger during the period of the FET compared with the follow-up period. The gains in Group A were significantly larger compared with the gains in Group B. The FET greatly promotes the recovery of the paretic arm if applied during the acute phase of post-stroke hemiplegia.

The impact of physical therapy on functional outcomes after stroke: what's the evidence?

OBJECTIVE

To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke.

METHODS

MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10 intervention categories, which were analysed separately. If statistical pooling (weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a best-research synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score).

RESULTS

In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs). Methodological quality of all RCTs had a median of 5 points on the 10-point PEDro scale (range 2-8 points). Based on high-quality RCTs strong evidence was found in favour of task-oriented exercise training to restore balance and gait, and for strengthening the lower paretic limb. Summary effect sizes (SES) for functional outcomes ranged from 0.13 (95% Cl 0.03-0.23) for effects of high intensity of exercise training to 0.92 (95% Cl 0.54-1.29) for improving symmetry when moving from sitting to standing. Strong evidence was also found for therapies that were focused on functional training of the upper limb such as constraint-induced movement therapy (SES 0.46; 95% Cl 0.07-0.91), treadmill training with or without body weight support, respectively 0.70 (95% Cl 0.29-1.10) and 1.09 (95% Cl 0.56-1.61), aerobics (SES 0.39; 95% Cl 0.05-0.74), external auditory rhythms during gait (SES 0.91; 95% Cl 0.40-1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% Cl 0.76-2.06). No or insufficient evidence in terms of functional outcome was found for: traditional neurological treatment approaches; exercises for the upper limb; biofeedback; functional and neuromuscular electrical stimulation aimed at improving dexterity or gait performance; orthotics and assistive devices; and physical therapy interventions for reducing hemiplegic shoulder pain and hand oedema.

CONCLUSIONS

This review showed small to large effect sizes for task-oriented exercise training, in particular when applied intensively and early after stroke onset. In almost all high-quality RCTs, effects were mainly restricted to tasks directly trained in the exercise programme.

Excitability of chronic hemiparetic muscles: determination of chronaxie values and strength-duration curves and its implication in functional electrical stimulation

Central nervous system disorders affect the anatomy and physiology of the lower motoneuron. This fact has an impact on the stimulation parameters, especially on the duration of the stimulating impulses, for functional electrical stimulation in chronic hemiparetic patients. The aim of this study was thus to test the excitability and to determine chronaxie values and strength-duration curves of weak wrist and finger extensor muscles and spastic finger and wrist flexor muscles in the hemiparetic arm. Twelve patients with chronic hemiplegia (>6 months after the onset of the cerebral lesion) participated in the study. A constant current stimulator was used. As to chronaxie values no significant differences were found between the extensor muscles (mean+/-SD: 0.44+/-0.16 ms) and flexor muscles (mean+/-SD: 0.36+/-0.22 ms). A moderate variability was seen for both extensor muscles (0.2-0.8 ms) and flexor muscles (0.1-0.9 ms). These values are well within the normal range determined for innervated muscles. All strength-duration curves were completely normal for each muscle. We conclude that in chronic hemiparetic muscles, impulses of the same duration can be used as in muscles of healthy subjects.

Neurobiology of rehabilitation

Rehabilitation aims to lessen the physical and cognitive impairments and disabilities of patients with stroke, multiple sclerosis, spinal cord or brain injury, and other neurologic diseases. Conventional approaches beyond compensatory adjustments to disability may be augmented by applying some of the myriad experimental results about mechanisms of intrinsic biological changes after injury and the effects of extrinsic manipulations on spared neuronal assemblies. The organization and inherent adaptability of the anatomical nodes within distributed pathways of the central nervous system offer a flexible substrate for treatment strategies that drive activity-dependent plasticity. Opportunities for a new generation of approaches are manifested by rodent and non-human primate studies that reveal morphologic and physiologic adaptations induced by injury, by learning-associated practice, by the effects of pharmacologic neuromodulators, by the behavioral and molecular bases for enhancing activity-dependent synaptic plasticity, and by cell replacement, gene therapy, and regenerative biologic strategies. Techniques such as functional magnetic resonance imaging and transcranial magnetic stimulation will help determine the most optimal physiologic effects of interventions in patients as the cortical representations for skilled movements and cognitive processes are modified by the combination of conventional and biologic therapies. As clinicians digest the finer details of the neurobiology of rehabilitation, they will translate laboratory data into controlled clinical trials. By determining how much they can influence neural reorganization, clinicians will extend the opportunities for neurorestoration.

Strategies for stroke rehabilitation

Rehabilitation after hemiplegic stroke has typically relied on the training of patients in compensatory strategies. The translation of neuroscientific research into care has led to new approaches and renewed promise for better outcomes. Improved motor control can progress with task-specific training incorporating increased use of proximal and distal movements during intensive practice of real-world activities. Functional gains are incorrectly said to plateau by 3-6 months. Many patients retain latent sensorimotor function that can be realised any time after stroke with a pulse of goal-directed therapy. The amount of practice probably best determines gains for a given level of residual movement ability. Clinicians should encourage patients to build greater strength, speed, endurance, and precision of multijoint movements on tasks that increase independence and enrich daily activity. Imaging tools may help clinicians determine the capacity of residual networks to respond to a therapeutic approach and help establish optimal dose-response curves for training. Promising adjunct approaches include practice with robotic devices or in a virtual environment, electrical stimulation to increase cortical excitability during training, and drugs to optimise molecular mechanisms for learning. Biological strategies for neural repair may augment rehabilitation in the next decade.

Electrical stimulation of the upper limb in stroke: stimulation of the extensors of the hand vs. alternate stimulation of flexors and extensors

OBJECTIVE

To investigate whether there is a difference in functional improvement in the affected arm of chronic stroke patients when comparing two methods of electrical stimulation.

DESIGN

Explanatory trial in which 30 chronic stroke patients with impaired arm function were randomly allocated to either alternating electrical stimulation of the extensor and flexor muscles of the hand (group A) or electrical stimulation of the extensors only (group B). Primary outcome measure was the Action Research Arm test to assess arm function. Grip strength, Motricity Index, Ashworth Scale, and range of motion of the wrist were secondary outcome measures.

RESULTS

Improvement on the Action Research Arm test was 1.0 point in group A and 3.3 points in group B; the difference in functional gain was 2.3 points (95% confidence interval, -1.06 to 5.60). The success rate (i.e., percentage of patients with a clinically relevant improvement of >5.7 points on the Action Research Arm test) was 27% in group B (four patients) and 8% in group A (one patient). The differences in functional gain and success rate were not statistically significant, neither were the differences between the two groups on the secondary outcome measures.

CONCLUSION

The difference between the two stimulation strategies was not statistically significant.

Electromyogram-triggered neuromuscular stimulation and stroke motor recovery of arm/hand functions: a meta-analysis

Debate persists about the effectiveness of poststroke behavioral interventions for progress toward motor recovery. The current meta-analysis assessed the effect of electromyogram (EMG)-triggered neuromuscular stimulation on arm and hand functions. Computer searches of PubMed and Cochran databases, as well as hand searches of reference lists identified seven EMG-triggered neuromuscular stimulation studies. Outcome measures focused on arm and hand motor capability functions. In addition, the quality of each study was rated on three guidelines: randomization, double blind, and dropouts. After adjusting data for consistency in the arm/hand outcome measures and to avoid bias, five active stimulation studies were included in the analysis. Rehabilitation treatment in each study focused on wrist extension. The total number of individuals in the treatment groups was 47 whereas the control groups had 39 subjects. The meta-analysis revealed a significant overall mean effect size (delta=0.82, S.D.=0.59). A homogeneity test indicated that the pooled standardized effect sizes estimated the same treatment effect. A fail-safe test for null effect findings revealed that 15 studies were required to reduce the large effect (0.82) to a small effect (0.20). These improved wrist extension motor capabilities findings support EMG-triggered neuromuscular stimulation as an effective poststroke protocol.

Poststroke motor dysfunction and spasticity: novel pharmacological and physical treatment strategies

Following stroke, approximately 90% of patients experience persistent neurological motor deficits that lead to disability and handicap. Both pharmacological and physical treatment strategies for motor rehabilitation may be considered. In terms of pharmacological treatment, drugs that may potentially promote motor recovery when added to a regimen of physical therapy include the stimulants amphetamine and methylphenidate, as well as levodopa and fluoxetine. Botulinum toxin A has proven effective and well tolerated in several placebo-controlled trials for the treatment of focal upper and lower limb spasticity, although it has not been shown to improve motor function. The focal injection of botulinum toxin A inhibits the release of acetylcholine into the synaptic cleft, resulting in a reversible paresis of the muscles relevant for the spastic deformity. Other drugs, such as benzodiazepines, antiepileptic drugs and antipsychotics, may have detrimental effects on motor function and should be avoided, if possible. With respect to physical strategies, modern concepts of motor learning favour a task-specific repetitive approach that induces skill-acquisition relevant to the patient's daily life. Constrained-induced movement therapy based on the concept of learned non-use, electromyography-triggered electrical stimulation of the wrist muscles, robot-assisted motor rehabilitation to increase therapy intensity and bilateral practice to facilitate the movement of the paretic extremity are examples in upper limb rehabilitation. Lower limb rehabilitation has been enriched by treadmill training with partial bodyweight support, enabling the practice of up to 1000 steps per session; automated gait rehabilitation to relieve the strenuous effort required of the therapist; and rhythmic auditory stimulation, applying individually adjusted music to improve walking speed and symmetry.

Quality of the stroke rehabilitation research

The Stroke Rehabilitation Evidence-Based Review revealed a wide range of quality scores across primary studies. The aim of this section is to determine what differences there are across studies and to provide a detailed examination of methodological issues in the stroke rehabilitation literature. Methodology of each article was assessed using the Physiotherapy Evidence Database (PEDro) quality scale. Mean PEDro scores and percentage of studies meeting individual PEDro criteria were determined for all studies, for therapy-based studies only, and for drug-based studies only. It was noted that the stroke rehabilitation literature lacked rigor in the area of concealed allocation, blinding of the assessor, and intention-to-treat analysis. Investigation of the methodological quality of stroke rehabilitation literature emphasizes the need for improved treatment protocols, taking into account previous deficits, during research.

Electrical stimulation driving functional improvements and cortical changes in subjects with stroke

It has been proposed that somatosensory stimulation in the form of electromyographically triggered neuromuscular electrical stimulation (NMES) to the peripheral nerve can influence functional measures of motor performance in subjects with stroke and can additionally produce changes in cortical excitability. Using a controlled, double-blind design, we studied the effects of intensive (60 h/3 weeks) treatment at home with NMES compared with a sham treatment, applied to the extensor muscles of the hemiplegic forearm to facilitate hand opening in 16 chronic stroke subjects. We investigated improvement in functional use of the hand and change in cortical activation as measured by functional magnetic resonance imaging (fMRI). Following treatment, subjects improved on measures of grasp and release of objects (Box and Block Test and Jebsen Taylor Hand Function Test [JTHFT]: small objects, stacking, heavy cans), isometric finger extension strength, and self-rated Motor Activity Log (MAL): Amount of Use and How Well score. The sham subjects did not improve on any grasp and release measure or self-rated scale, but did improve on isometric finger extension strength. Importantly, however, following crossover, these subjects improved further in the measure of strength, grasp and release (Box and Block [JTHFT]: page turning), and self-rated MAL: Amount of Use score and How Well score. Using fMRI and a finger-tracking task, an index of cortical intensity in the ipsilateral somatosensory cortex increased significantly from pre-test to post-test following treatment. Cortical activation, as measured by voxel count, did not change. These findings suggest that NMES may have an important role in stimulating cortical sensory areas allowing for improved motor function.

Stroke motor recovery: active neuromuscular stimulation and repetitive practice schedules

OBJECTIVE

To investigate progress toward motor recovery in patients with chronic hemiparesis (mean time since stroke 3.2 years), comparing different types of practice schedules.

DESIGN

To increase voluntary control of the upper extremity, active neuromuscular stimulation was administered during blocked and random practice schedules as patients performed three specific movements: wrist/finger extension, elbow joint extension, and shoulder joint abduction.

METHODS

34 stroke subjects volunteered to participate and were randomly assigned to one of three treatment groups: blocked practice (the same movement was repetitively performed on successive trials) combined with active neuromuscular stimulation; random practice (different movements on successive trials) along with active stimulation; or no active stimulation assistance control group. Subjects completed two days of 90 minute training for each of two weeks with at least 24 hours of rest between sessions. A session was three sets of 30 successful active neuromuscular stimulation trials with the three movements executed 10 times/set.

RESULTS

Mixed design analyses on three categories of behavioural measures indicated motor improvements for the blocked and random practice/stimulation groups in comparison with the control group during the post-test period, with a larger number of blocks moved, faster premotor and motor reaction times, and less variability in the sustained muscular contraction task.

CONCLUSIONS

Upper extremity rehabilitation intervention of active stimulation and blocked practice performed as well as stimulation/random practice. Moreover, these purposeful voluntary movement findings support and extend sensorimotor integration theory to both practice schedules.

Electromyographic Biofeedback in the Treatment of the Hemiplegic Hand

OBJECTIVE

To evaluate the efficacy of electromyographic (EMG) biofeedback treatment in the functional recovery of the hemiplegic hand.

DESIGN

A total of 27 patients were randomly assigned to EMG biofeedback or placebo EMG biofeedback groups. Both treatments were applied five times a week for a period of 20 days. In addition, the patients in both groups received an exercise program according to the Brunnstrom's neurophysiologic approach. Goniometric measurements for wrist extension, scale for judging the performance of drinking from a glass, Brunnstrom's stages of recovery for hand, and surface EMG potentials were used for the clinical assessments. All patients were assessed before treatment and after 20 treatment sessions.

RESULTS

The results showed that there were statistically significant improvements in all variables in both groups, but the improvements in active range of motion and surface EMG potentials were significantly greater in the EMG biofeedback group at the end of the treatment.

CONCLUSION

Our study demonstrates the potential benefits of EMG biofeedback in conjunction with neurophysiologic rehabilitation technique to maximize the hand function in hemiplegic patients.

Gait and hand function enhancement following training with a multi-segment hybrid-orthosis stimulation system in stroke patients

The majority of stroke survivors continue to suffer residual functional deficits due to weakness and inadequate motor control of their paretic muscles. Non-invasive functional electrical stimulation has been limited to stimulation of only 1-2 muscle groups. The purpose of this study was to test if the use of a multi-segment hybrid orthosis-stimulation system combined with electrically augmented functional training would promote improvement in gait and hand functions of patients with chronic hemiparesis. A control group (n = 9) received individual instructions for specific functional training and self-exercised up to 60 minutes twice daily. The stimulated group (n = 10) received self-administered electrical stimulation training using the NESS system. Training time increased to 60 minutes twice daily and comprised of specific functional exercise. Each group trained for 3 months. Upper limb outcome measures included the Box & Block (B & B) and 3 sub-tests of the Jebsen-Taylor (J & T) battery. Gait outcomes included 10-meter walk time, speed, cadence, and number of steps. Post-test-pretest data were analyzed by unpaired t-tests (P = 0.05). The stimulated group improved significantly compared to the control group in B & B (7.9 +/- 4.5 vs 0.2 +/- 2.2 more blocks); J & T simulated feeding (12.6 +/- 14.8 vs 1.2 +/- 2.09 sec); J & T light object lift (8.2 +/- 9.7 vs. -0.3 +/- 2.8 sec); J & T heavy object lift (7.6 +/- 11.0 vs -0.8 +/- 1.6 sec); walk time (3.3 +/- 1.1 sec vs -0.3 +/- 1.8 sec); walking speed (0.33 +/- 0.12 vs. -0.01 +/- 0.1 m/sec); cadence (0.30 +/- 0.18 vs. -0.02 +/- 0.14 steps/sec). The number of steps over 10 m decreased 2.7 +/- 1.4 vs -0.2 +/- 1.98 steps. We concluded that electrically-dependent functional training with multi-segment hybrid orthosis-stimulation system can improve the studied functional outcomes of chronic stroke survivors.

Progress toward motor recovery with active neuromuscular stimulation: muscle activation pattern evidence after a stroke

Chronic cerebrovascular accident individuals with partial paralysis in an upper extremity typically demonstrate difficulty in voluntarily controlling movement initiation. This study investigated patterns of electromyogram (EMG) activation levels while stroke subjects voluntarily initiated their impaired wrist and finger extensor muscles. Twenty subjects were randomly assigned to either a unilateral movement/stimulation group or a bilateral movement/stimulation group. Participants completed 4 days (6 h over 2 weeks) of active neuromuscular stimulation (i.e., 5 s/trial, 90 trials/day, biphasic waveform) on the wrist and finger extensors according to group assignments. The EMG activation levels were analyzed with a three-factor mixed design Motor recovery protocol x Session block x Trial block (2 x 2 x 3) ANOVA with repeated measures on the second and third factors. This robust analysis revealed higher EMG activation levels for the coupled bilateral movement/stimulation group than the unilateral movement/stimulation group. In addition, higher muscle activation levels were found for the second session block as well as trial blocks 2 and 3. Overall, these findings indicated improved motor capabilities of the impaired muscles as evidenced by the higher voluntary EMG activation levels.

Neuromuscular electrical stimulation for motor relearning in hemiparesis

Neuromuscular electrical stimulation may have an important role in improving the motor function of stroke survivors. Active, repetitive movement training mediated by transcutaneous cyclic and EMG-triggered NMES may facilitate the motor recovery of stroke survivors. Multicenter, double-blinded, randomized clinical trials should be pursued to confirm the motor-relearning effects of transcutaneous NMES and to define appropriate prescriptive specifications. Intramuscular EMG-controlled NMES may be superior to transcutaneous systems and is presently undergoing preliminary randomized clinical trials. Neuroprostheses systems may provided the highest level of goal-oriented activity and cognitive investments, which may lead to significant motor relearning. Implementation of clinically viable neuroprosthesis systems, however, will probably require additional technical developments including more reliable control paradigms and methods for blocking undesirable muscle contractions. In view of the dynamic nature of the present health care environment, the future of NMES technology is difficult to predict. By necessity, scientists and clinicians must continue to explore new ideas and to improve on the present systems. Components will be smaller, more durable, and more reliable. Control issues will remain critical for both motor relearning and neuroprosthetic applications, and the implementation of cortical control is likely to dictate the nature of future generations of NMES systems. Finally, consumers will direct future developments. In the present health care environment, where cost has become an overwhelming factor in the development and implementation of new technology, the consumer will become one of technology's greatest advocates. The usual drive toward greater complexity will be tempered by the practical issues of clinical implementation, where patient acceptance is often a function of a tenuous balance between the burden or cost associated with using a system and the system's impact on the user's life.

Upper limb motor function in hemiparesis: concurrent validity of the Arm Motor Ability test

OBJECTIVE

To evaluate the concurrent validity of the Arm Motor Ability Test (AMAT) using the Fugl-Meyer Assessment (FMA) as the criterion measure of poststroke upper limb motor impairment.

DESIGN

Upper limb motor impairment and arm ability of 30 chronic stroke survivors were assessed with the FMA and AMAT, respectively. Spearman's correlation coefficients were generated relating the components of FMA and AMAT. Scatterplots were generated to provide qualitative assessments of the relationship between FMA and AMAT. Bar graphs of FMA and AMAT normalized to their maximum scores were generated to compare the levels of motor status measured by each instrument.

RESULTS

All components of AMAT correlated highly with FMA total (r = 0.92-0.94; P < 0.001). AMAT functional ability and AMAT quality of movement were linearly related with FMA total. However, AMAT time of performance exhibited significant ceiling and floor effects with respect to FMA. Normalized AMAT scores were generally lower than normalized FMA scores (P < 0.001), with the greatest difference in scores observed in subjects with more severe motor impairments.

CONCLUSION

This study demonstrates a high degree of concurrent criterion validity of the AMAT. However, AMAT tends to underestimate the arm motor status of those with more severe motor impairments.

Therapeutic electrical stimulation to improve motor control and functional abilities of the upper extremity after stroke: a systematic review

BACKGROUND

Therapeutic electrical stimulation (TES) is a therapeutic strategy aimed at improving impairments of the upper extremity in stroke.

OBJECTIVE

Assessment of the available evidence on the effect of TES of the affected upper extremity in improving motor control and functional abilities after stroke.

METHODS

A systematic literature search was performed to identify randomized controlled trials (RCTs) that have studied the effect of TES on motor control and functional abilities. The methodological quality of the studies was assessed systematically by two raters. The reported outcomes were examined to evaluate the effect of TES and to identify a possible relationship with patient characteristics, method of stimulation and methodological quality. When possible, effect sizes were calculated (Hedges' g).

RESULTS

Six RCTs were included. The methodological scores ranged from 7 to 16 (maximum 19). All studies assessed the effect on motor control, and four reported a positive effect. Effect sizes calculated in three studies ranged from 0.55 to 1.46. Only two studies assessed the effect on functional ability, one reported a positive effect. Subgroup analyses in two studies suggest a better response to stimulation in less severely affected patients. Apart from this, no relationship between effect and patient characteristics, method of stimulation or methodological quality could be detected.

CONCLUSIONS

The present review suggests a positive effect of electrical stimulation on motor control. No conclusions can be drawn with regard to the effect on functional abilities.

Restitution of reaching and grasping promoted by functional electrical therapy

Functional electrical therapy (FET) is a new term describing a combination of functional electrical stimulation that generates life-like movement and intensive exercise in humans with central nervous system lesions. We hypothesized that FET can promote a significant recovery of functioning if applied in subacute stroke subjects. The study included 16 stroke subjects divided into a low functioning group (LFG) and a high functioning group (HFG) based on their ability to control wrist and fingers and randomly associated into FET and controls. The FET consisted of 30 min daily sessions during 3 weeks. The exercise comprised functional use of daily necessary activities (e.g., writing, using a telephone receiver, and drinking from a can). The outcome presented in this article is the upper-extremity function test performed before and after the therapy. The change in performance of the HFG group was significant. The number of successful repetitive movements in 2 min was doubled and 1.6 times increased for controls, and the time to perform the movement was decreased by 71% percent and by 36% in controls. In the LFG FET group, the difference in performance was the following. First, the number of tasks was increased from 0 to 6 (total of 11 tasks). Second, the averaged number of successful repetitive movements was increased from 0 to 3. The functional improvement in the FET LFG is probably not sufficient to make the more affected arm/hand effective for daily necessities; thus, the FET effects could deteriorate over a longer time. The subjects from the control LFG made only a marginal improvement. The follow-up for each subject will continue for 12 months after the beginning of the treatment.