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

Wearable Integrated Volitional Control Electrical Stimulation Device as Treatment for Paresis of the Upper Extremity in Early Subacute Stroke Patients: A Randomized Controlled Non-inferiority Trial

OBJECTIVE

To investigate the effect of a wearable integrated volitional control electrical stimulation (WIVES) device that has been developed as more compact and simpler to use in daily life compared with conventional integrated volitional control electrical stimulation (IVES) devices.

DESIGN

Randomized controlled non-inferiority trial.

SETTING

Convalescent rehabilitation ward.

PARTICIPANTS

Patients with paresis of the upper extremity (UE) after early subacute stroke (N=20).

INTERVENTIONS

Eligible patients were randomized to receive IVES treatment or WIVES treatment for 8 hours per day for 28 days in daily living, in addition to standard rehabilitation treatment. In both groups, the extensor digitorum communis on the affected side was the target muscle for stimulation.

MAIN OUTCOME MEASURE

Primary outcomes were assessed with Fugl-Meyer Assessment of the UE (FMA-UE) before and after treatment. Non-inferiority was determined with a specified margin of non-inferiority.

RESULTS

Twenty patients completed the trial (IVES group: n=10, WIVES group: n=10). FMA-UE improved in both groups. The mean change in FMA-UE was 4.7 for the IVES group and 6.0 for the WIVES group (P>.05, 95% confidence interval: -6.73 to 4.13). The mean difference between the groups was 1.3, and the upper 95% confidence interval did not exceed the non-inferiority margin.

CONCLUSION

The effectiveness of WIVES treatment is non-inferior to that of IVES treatment. As a portable device, IVES may facilitate the use of affected upper extremities in daily living and may help improve paresis of the UE.

Effect of 3-Dimensional Robotic Therapy Combined with Electromyography-Triggered Neuromuscular Electrical Stimulation on Upper Limb Function and Cerebral Cortex Activation in Stroke Patients: A Randomized Controlled Trial

(1) Background: This study investigated the effect of 3-dimensional robotic therapy (RT) combined with electromyography-triggered neuromuscular electrical stimulation (RT-ENMES) on stroke patients' upper-limb function and cerebral cortex activation. (2) Methods: Sixty-one stroke patients were assigned randomly to one of three groups. The stroke patients were in the subacute stage between 2 and 6 months after onset. The three groups received 20 min of RT and 20 min of electromyography-triggered neuromuscular electrical stimulation (ENMES) in the RT-ENMES group (n = 21), 40 min of RT in the RT group (n = 20), and 40 min of ENMES in the ENMES group (n = 20). The treatments were for 40 min, 5 days per week, and for 8 weeks. Upper-extremity function was evaluated using the Fugl-Meyer assessment for upper extremity (FMA-UE), Wolf motor function test, and action research arm test (ARAT); cerebral cortex activation and motor-evoked potential (MEP) amplitude were evaluated before and after the study. (3) Results: The analysis showed significant changes in all evaluation items for all three groups in the before-and-after comparisons. Significant changes were observed in the FMA-UE, ARAT, and MEP; in the posttest, the RT-ENMES group showed more significant changes in the FMA-UE, ARAT, and MEP than the other two groups. (4) Conclusions: The study analysis suggests that RT-ENMES effectively improves upper-limb function and cerebral cortex activation in patients with stroke.

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

Background

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

Objective

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

Methods

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

Results and discussion

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

Use of peripheral electrical stimulation on healthy individual and patients after stroke and its effects on the somatosensory evoked potentials. A systematic review

INTRODUCTION

To date, a few studies have used somatosensory evoked potentials (SEP) to demonstrate cortical sensory changes among healthy subjects or to estimate cortical plasticity and rehabilitation prognosis in stroke patients after peripheral electrical stimulation (PES) intervention. The primary aim was to systematically review whether PES has a role in changing latencies and amplitudes of SEPs in healthy subjects and stroke patients. Moreover, we searched for a correlation between sensory and motor function assessments and changes in SEP components of included studies.

METHODS

The following databases were searched: Pubmed/MEDLINE, Scopus/ScienceDirect, Web of Science/Clarivate, Cochrane Library, The Physiotherapy Evidence Database (PEDro), and ClinicalTrials.gov. Titles and abstracts, as well as full-text reports, were screened for eligibility by two independent reviewers according to a priori defined eligibility criteria. There were no study limitations concerning the treatment of the upper limb, lower limb, or torso with PES.

RESULTS

The final systematic search resulted in 11,344 records, however only 10 were evaluated. We could not find enough evidence to confirm use of SEP as a predictor to estimate the rehabilitation prognosis after stroke. However, we found a correlation between different sensory and motor function assessments and changes in SEP components. The stroke studies involving PES that initiate a voluntary contraction used for a specific movement or task indicate a positive relationship and correlation to assessments of motor function. It could be indicated that PES have a predictive impact of sensory reorganization, as mirrored by the change in SEP amplitude and latency. However, it is not possible to verify the degree of connectivity between SEP and cortical plasticity. To confirm this hypothesis, we propose the conduction of randomized controlled trials in healthy volunteers and stroke patients.

SYSTEMATIC REVIEW REGISTRATION

https://doi.org/10.17605/OSF.IO/U7PSY.

Effects of Electromyography Bridge on Upper Limb Motor Functions in Stroke Participants: An Exploratory Randomized Controlled Trial

The electromyography bridge (EMGB) plays an important role in promoting the recovery of wrist joint function in stroke patients. We investigated the effects of the EMGB on promoting the recovery of upper limb function in hemiplegia. Twenty-four stroke patients with wrist dorsal extension dysfunction were recruited. Participants were randomized to undergo EMGB treatment or neuromuscular electrical stimulation (NMES). Treatments to wrist extensors were conducted for 25 min, twice a day, 5 days per week, for 1 month. Outcome measures: active range of motion (AROM) of wrist dorsal extension; Fugl-Meyer assessment for upper extremity (FMA-UE); Barthel index (BI); and muscle strength of wrist extensors. After interventions, patients in the NMES group had significantly greater improvement in the AROM of wrist dorsal extension at the 4th week and 1st month follow-up (p < 0.05). However, patients in the EMGB group had a statistically significant increase in AROM only at the follow-up assessment. No significant differences were observed in the AROM between the EMGB group and the NMES group (p > 0.05). For secondary outcomes in the EMGB group, compared to baseline measurements, FMA-UE, BI, extensor carpi radialis and extensor carpi ulnaris muscle strength were significantly different as early as the 4th week (p < 0.05). The muscle strength of the extensor digitorum communis muscle showed significant differences at the follow-up (p < 0.05). There were no statistically significant differences between patients in the two groups in any of the parameters evaluated (p > 0.05). The combination of EMGB or NMES with conventional treatment had similar effects on the improvement of the hemiplegic upper limb as assessed by wrist dorsal extension, FMA-UE, and activities of daily living. The improvement in both groups was maintained until 1 month after the intervention.

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

Background

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

Aim

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

Methods

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

Results

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

Conclusion

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

EMG-Triggered Pedaling Training on Muscle Activation, Gait, and Motor Function for Stroke Patients

This study aimed to determine the effects of electromyography (EMG)-triggered pedaling training to improve motor functions in the lower extremities, muscle activation, gait, postural balance, and activities of daily living in stroke patients. Subjects were randomly allocated to two groups: the EMG-triggered pedaling training group (EMG-PTG, n = 21) and the traditional pedaling training group (TPTG, n = 20). Both groups trained five times per week for four weeks, with 50 min per session. Lower extremity motor function was assessed using the Fugl–Meyer Assessment (FMA). Muscle activation of the four muscles of the lower extremities was assessed using eight-channel electromyography, while gait ability was assessed using GaitRite. Postural balance was assessed using the Berg balance scale (BBS), the timed up and go (TUG), and functional reach tests (FRT). Daily activities were assessed using the Modified Barthel Index (MBI). For lower extremity motor function, gait ability, balance ability, and activities of daily living, the EMG-PTG showed significant improvement compared to TPTG (p < 0.05). These results suggest that EMG-triggered pedaling training effectively improves lower extremity motor function, muscle activation, gait, postural balance, and activities of daily living in stroke patients.

Effect of electromyography-triggered peripheral magnetic stimulation on voluntary swallow in healthy humans

BACKGROUND

Electrical stimulation therapy is effective for patients with dysphagia. However, because of the pain, strong stimulation cannot be applied. Although magnetic stimulation induces less pain, there are no reports on magnetic stimulation being synchronised with a swallowing reflex.

OBJECTIVE

This study aimed to determine whether it is possible to induce magnetic stimulation during a voluntary swallowing using electromyography (EMG)-triggered peripheral magnetic stimulation and to evaluate its effect on healthy individuals.

METHODS

A total of 20 healthy adults in seated position were instructed to swallow saliva and 10 ml of barium under videofluoroscopy. For concomitant use of magnetic stimulation, a magnetic stimulus for suprahyoid muscles at 30 Hz frequency was applied for 2 s when the EMG level in the sternohyoid muscle exceeded the threshold. During the voluntary swallowing, the movement of the hyoid bone and opening width of the upper oesophageal sphincter (UES) were measured. Furthermore, pressure topography was evaluated in 6 subjects using high-resolution manometry.

RESULTS

The magnetic stimulation significantly extended the movement time of the hyoid bone (p < 0.001). During liquid deglutition, significant increases were observed in the anterior maximum movement distance of the hyoid bone (p < 0.05), opening width of the UES (p < 0.001) and anterior movement distance of the hyoid bone at the maximum UES opening (p < 0.01). In the pressure topography, the maximum pressure immediately after UES closure significantly decreased with magnetic stimulation (p < 0.05).

CONCLUSION

EMG-triggered peripheral magnetic stimulation made it possible to apply magnetic stimulation during a voluntary swallowing.

Effects of Mirror Therapy Combined with EMG-Triggered Functional Electrical Stimulation to Improve on Standing Balance and Gait Ability in Patient with Chronic Stroke

This study was performed to evaluate the effects of EMG-triggered functional electrical stimulation on balance and gait ability on patient with Chronic Stroke. A total of 60 chronic stroke patients were divided into mirror treatment and functional electrical (MT-EF) Group, MT group, CON group. Each group performed 60 min a day five times a week for eight weeks. MT-FE group was performed 30 min five times a week for eight weeks in mirror therapy process with EMG-FES. MT group performed 30 min five times a week for eight weeks in mirror therapy process. CON group was performed 30 min five times a week for eight weeks in conservative treatment. To measure the balance ability, Biorescue (COP, LOS), Berg balance scale (BBS) and FRT, and the gait ability test was performed by 10 m walk test. MT-FE group revealed significant differences in COP, LOS, BBS, FRT and 10 m walk test as compared to the MT and CON groups (p < 0.05). Our results showed that MT-FE was more effective on COP, LOS, BBS, FRT and 10 m walk test in patients with chronic stroke. Our results also showed that MT-EF group was more effective on balance and gait ability in patients with chronic stroke. We suggest that this study can be used for intervention data for recovering balance and gait ability in chronic stroke patients.

Active proportional electromyogram controlled functional electrical stimulation system

Neurophysiological theories and past studies suggest that intention driven functional electrical stimulation (FES) could be effective in motor neurorehabilitation. Proportional control of FES using voluntary EMG may be used for this purpose. Electrical artefact contamination of voluntary electromyogram (EMG) during FES application makes the technique difficult to implement. Previous attempts to date either poorly extract the voluntary EMG from the artefacts, require a special hardware or are unsuitable for online application. Here we show an implementation of an entirely software-based solution that resolves the current problems in real-time using an adaptive filtering technique with an optional comb filter to extract voluntary EMG from muscles under FES. We demonstrated that unlike the classic comb filter approach, the signal extracted with the present technique was coherent with its noise-free version. Active FES, the resulting EMG-FES system was validated in a typical use case among fifteen patients with tetraplegia. Results showed that FES intensity modulated by the Active FES system was proportional to intentional movement. The Active FES system may inspire further research in neurorehabilitation and assistive technology.

Automated functional electrical stimulation training system for upper-limb function recovery in poststroke patients

BACKGROUND

This paper describes the design and test of an automated functional electrical stimulation (FES) system for poststroke rehabilitation training. The aim of automated FES is to synchronize electrically induced movements to assist residual movements of patients.

METHODS

In the design of the FES system, an accelerometry module detected movement initiation and movement performed by post-stroke patients. The desired movement was displayed in visual game module. Synergy-based FES patterns were formulated using a normal pattern of muscle synergies from a healthy subject. Experiment 1 evaluated how different levels of trigger threshold or timing affected the variability of compound movements for forward reaching (FR) and lateral reaching (LR). Experiment 2 explored the effect of FES duration on compound movements.

RESULTS

Synchronizing FES-assisted movements with residual voluntary movements produced more consistent compound movements. Matching the duration of synergy-based FES to that of patients could assist slower movements of patients with reduced RMS errors.

CONCLUSIONS

Evidence indicated that synchronization and matching duration with residual voluntary movements of patients could improve the consistency of FES assisted movements. Automated FES training can reduce the burden of therapists to monitor the training process, which may encourage patients to complete the training.

Synergistic Effect of Combined Mirror Therapy on Upper Extremity in Patients With Stroke: A Systematic Review and Meta-Analysis

Background: There is an increasing trend for researchers to combine mirror therapy with another rehabilitation therapy when treating the upper extremity of patients with stroke.

Objective: To evaluate the synergistic effect of combined mirror therapy (MT) on the upper extremity in patients with stroke and to judge efficacies of four combined mirror therapy subgroups [EMGBF group: electromyographic biofeedback (EMGBF) + MT; MG group: mesh glove (MG) + MT; AT group: acupuncture (AT) + MT; ES group: EMG-triggered electrical stimulation (ES) + MT].

Methods: CNKI, Wan Fang, VIP, Web of Science, ScienceDirect, PubMed, OVID LWW, and Cochrane were used. We searched these databases for randomized controlled trials published from January 2013 to August 2019, which presented results of combining mirror therapy with other rehabilitation therapies. Quality assessments were performed using the Cochrane Handbook criteria in order to accurately review interventions. The primary outcomes were measured by the Fugl–Meyer Assessment—upper extremity (FMA-UE).

Results: Ten trials, with a total of 444 patients whose upper limb functions were damaged after stroke, were included in the meta-analysis. Compared with the control group, a remarkable effect of combined mirror therapy [all: weight mean difference in random effects model (WMD): 8.07, 95% confidence interval (CI) 5.87, 10.26] on functional recovery of the upper limb was detected. However, a high value of heterogeneity (χ2 = 20.09, df = 9; I² = 55%) was found. The subgroup analysis (EMGBF group: WMD = 8.95, 95% CI 6.33, 11.58; ES group: WMD = 10.14, 95% CI: 5.67, 15.01) showed moderate improvement in functional recovery of the upper extremity in patients with stroke when mirror therapy was combined with conventional therapy. Furthermore, no difference in efficacy on upper extremity in patients with stroke was observed between the EMGBF group and the ES group.

Conclusion: Despite the heterogeneity, the results indicate that combining mirror therapy with another rehabilitation therapy on the upper extremity in patients with stroke is better than single rehabilitation therapy. However, more randomized controlled clinical trials and larger sample sizes are required for an in-depth meta-analysis.

Effect of different electrical stimulation protocols for pelvic floor rehabilitation of postpartum women with extremely weak muscle strength: Randomized control trial

BACKGROUND

Pregnancy is one of the main risk factor of pelvic floor muscle dysfunction. Postpartum women with extremely weak muscle strength have difficulty to do voluntary pelvic floor muscle training. This study aims to evaluate the effects of different protocols of electrical stimulation in the treatment of postpartum women with extremely weak muscle strength.

METHODS

A total of 67 women were randomized into 2 groups: group A received transvaginal electrical stimulation (TVES) for 5 times, and group B received TVES for 3 times with electromyogram (EMG)-triggered neuromuscular stimulation twice. Subjects were evaluated before and after treatment. Pelvic muscle strength was measured by both digital vaginal palpation and EMG variables, and quality of life was investigated by 4 kinds of pelvic floor disease-related questionnaires.

RESULTS

According to the intention-to-treat principle, compared with baseline, in group A, EMG of contractile amplitude of endurance phase was significantly elevated (P = .03), variation of contractile amplitude in tonic phase was more stable after treatment (P = .004), and EMG of mean value of final rest was significantly elevated after treatment (P = .047). After 5 times treatments, the incidence of correct pelvic floor muscle contraction in group A was significantly elevated (P = .045). No significant difference of muscle strength test by digital vaginal palpation was detected between the 2 groups, so did questionnaires.

CONCLUSION

For postpartum women with extremely weak muscle strength, TVES for 5 times might be more benefit for control ability of pelvic muscle contractions and elevating muscle strength even in short-time treatment.

A Myoelectric Control Interface for Upper-Limb Robotic Rehabilitation Following Spinal Cord Injury

Spinal cord injury (SCI) is a widespread, life-altering injury leading to impairment of sensorimotor function that, while once thought to be permanent, is now being treated with the hope of one day being able to restore function. Surface electromyography (EMG) presents an opportunity to examine and promote human engagement at the neuromuscular level, enabling new protocols for intervention that could be combined with robotic rehabilitation, particularly when robot motion or force sensing may be unusable due to the user's impairment. In this paper, a myoelectric control interface to an exoskeleton for the elbow and wrist was evaluated on a population of ten able-bodied participants and four individuals with cervical-level SCI. The ability of an EMG classifier to discern intended direction of motion in single-degree-of-freedom (DoF) and multi-DoF control modes was assessed for usability in a therapy-like setting. The classifier demonstrated high accuracy for able-bodied participants (averages over 99% for single-DoF and near 90% for multi-DoF), and performance in the SCI group was promising, warranting further study (averages ranging from 85% to 95% for single-DoF, and variable multi-DoF performance averaging around 60%). These results are encouraging for the future use of myoelectric interfaces in robotic rehabilitation for SCI.

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).

Sensorimotor Connectivity after Motor Exercise with Neurofeedback in Post-Stroke Patients with Hemiplegia

Impaired finger motor function in post-stroke hemiplegia is a debilitating condition with no evidence-based or accessible treatments. Here, we evaluated the neurophysiological effectiveness of direct brain control of robotic exoskeleton that provides movement support contingent with brain activity. To elucidate the mechanisms underlying the neurofeedback intervention, we assessed resting-state functional connectivity with functional magnetic resonance imaging (rsfcMRI) between the ipsilesional sensory and motor cortices before and after a single 1-h intervention. Eighteen stroke patients were randomly assigned to crossover interventions in a double-blind and sham-controlled design. One patient dropped out midway through the study, and 17 patients were included in this analysis. Interventions involved motor imagery, robotic assistance, and neuromuscular electrical stimulation administered to a paretic finger. The neurofeedback intervention delivered stimulations contingent on desynchronized ipsilesional electroencephalographic (EEG) oscillations during imagined movement, and the control intervention delivered sensorimotor stimulations that were independent of EEG oscillations. There was a significant time × intervention interaction in rsfcMRI in the ipsilesional sensorimotor cortex. Post-hoc analysis showed a larger gain in increased functional connectivity during the neurofeedback intervention. Although the neurofeedback intervention delivered fewer total sensorimotor stimulations compared to the sham-control, rsfcMRI in the ipsilesional sensorimotor cortices was increased during the neurofeedback intervention compared to the sham-control. Higher coactivation of the sensory and motor cortices during neurofeedback intervention enhanced rsfcMRI in the ipsilesional sensorimotor cortices. This study showed neurophysiological evidence that EEG-contingent neurofeedback is a promising strategy to induce intrinsic ipsilesional sensorimotor reorganization, supporting the importance of integrating closed-loop sensorimotor processing at a neurophysiological level.

Multi-Sensorimotor Training Improves Proprioception and Balance in Subacute Stroke Patients: A Randomized Controlled Pilot Trial

Introduction: The objective was to determine whether advanced rehabilitation therapy combined with conventional rehabilitation therapy consisting of sensorimotor exercises would be superior to usual treadmill training for proprioception variation and balance ability in subacute stroke patients.

Methods: Thirty subjects (post-stroke time period: 3.96 ± 1.19 months) were randomly assigned to either a multi-sensorimotor training group (n = 19) or a treadmill training group (n = 18). Both groups first performed conventional physical therapy for 30 min, after which the multi-sensorimotor training group performed multi-sensorimotor training for 30 min, and the treadmill training group performed treadmill gait training for 30 min. Both groups performed the therapeutic interventions 5 days per week for 8 weeks. The primary outcome (proprioception variation) was evaluated using an acryl panel and electrogoniometer. The secondary outcome (balance ability) was measured using the Biodex Balance system before intervention and after 8 weeks.

Results: The multi-sensorimotor training and treadmill training groups showed significant improvement in proprioception variation and balance (overall, A-P and M-L) (all P < 0.05). In particular, the multi-sensorimotor training group showed more significant differences in proprioception variation (P = 0.002) and anterior-posterior (A-P) balance ability (P = 0.033) than the treadmill training group.

Conclusions: The multi-sensorimotor training program performed on multiple types of sensory input had a beneficial effect on proprioception sense in the paretic lower limb and A-P balance. A large-scale randomized controlled study is needed to prove the effect of this training.

Clinical Trial Registration:https://cris.nih.go.kr/cris/, identifier KCT0003097.

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.

A Novel EMG-driven Functional Electrical Stimulator for Post- Stroke Individuals to Practice Activities of Daily Living

Prior research has demonstrated that hand function can be recovered in individuals with mild stroke through an intervention that is both 'intense' and 'functional'. However, in individuals with moderate to severe post stroke hand paresis, current evidence for an effective intervention to regain hand function is almost absent. A possible contributor to such poor recovery in these individuals may be the inability to intensively practice with the paretic hand during activities of daily living (ADLs). Many ADLs require use of the paretic arm and hand. Due to post-stroke abnormal muscle synergies, functional arm movements, such as lifting or reaching, often result in unwanted activity in the wrist/finger flexors. This makes voluntary hand opening more difficult. A possible solution to enable these individuals to practice with their paretic hand in a functional context is using devices to assist hand opening. Unfortunately, most of currently available hand rehabilitation devices do not sufficiently address hand opening with the appearance of abnormal muscle synergies. We, therefore, developed a synergy resistant, electromyographic (EMG)-driven electrical stimulation device that allows for $\mathbf {Re}$liable and $\mathbf {In}$tuitive control of the hand (ReIn-Hand) opening while using the paretic arm during lifting and reaching.

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

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

Interventions to Improve Movement and Functional Outcomes in Adult Stroke Rehabilitation: Review and Evidence Summary

Background

Patients who have had a stroke may not be familiar with the terminology nor have the resources to efficiently search for evidence-based rehabilitation therapies to restore movement and functional outcomes. Recognizing that a thorough systematic review on this topic is beyond the scope of this article, we conducted a rapid review evidence summary to determine the level of evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Objective

The objective of this study was to find evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Methods

Medline Complete, PubMed, CINAHL Complete, Cochrane Database, Rehabilitation and Sports Medicine Source, Dissertation Abstracts International, and National Guideline Clearinghouse, from 1996 to April of 2016, were searched. From 348 articles, 173 met the following inclusion criteria: (1) published systematic reviews or meta-analyses, (2) outcomes target functional movement or motor skills of the upper and lower limbs, (3) non-pharmacological interventions that are commonly delivered to post-stroke population (acute and chronic), (4) human studies, and (5) English. Evidence tables were created to analyze the findings of systematic reviews and meta-analyses by category of interventions and outcomes.

Results

This rapid review found that the following interventions possess credible evidence to improve functional movement of persons with stroke: cardiorespiratory training, therapeutic exercise (ie, strengthening), task-oriented training (task-specific training), constraint-induced movement therapy (CIMT), mental practice, and mirror therapy. Neuromuscular electrical stimulation (NMES) (ie, functional electrical stimulation) shows promise as an intervention for stroke survivors.

Conclusions

Most commonly delivered therapeutic interventions to improve motor recovery after a stroke possess moderate quality evidence and are effective. Future research recommendations, such as optimal timing and dosage, would help rehabilitation professionals tailor interventions to achieve the best outcomes for stroke survivors.

The effects of electromyography-triggered electrical stimulation on shoulder subluxation, muscle activation, pain, and function in persons with stroke: A pilot study

OBJECTIVES

The purpose of this study was to examine the effects of task-oriented electromyography-triggered stimulation for shoulder subluxation, muscle activation, pain and upper extremity function in hemiparetic stroke patients.

METHODS

Twenty participants with subacute hemiparetic stroke were recruited for this study and were randomly divided into two groups: experimental group (n = 10) and control group (n = 10). Subjects in the experimental group participated in task-oriented electromyography triggered stimulation for 30 minutes, five times a week for four weeks, whereas the control group received cyclic functional electrical stimulation for 30 minutes, five times a week for four weeks. Subjects in both groups received conventional physical therapy for four weeks (30 min/day, five times/week). Data collected included the degree of shoulder subluxation which had been confirmed by X-ray, muscle activation of the supraspinatus and posterior deltoid muscles by electromyography, pain by the Visual Analogue Scale (VAS), and hand function by the Fugl-Meyer Assessment (FMA) before and after the four week exercise period.

RESULTS

The results showed significant improvement in shoulder subluxation, muscle activation, and VAS results in the experimental group, compared with the control group(p < 0.05). FMA scores showed no significant differences between the two groups.

CONCLUSIONS

In conclusion, task-oriented electromyography-triggered stimulation improved shoulder subluxation, muscle activation, pain and upper extremity function. These results suggest that task-oriented electromyography-triggered stimulation is effective and beneficial for individuals with subacute stroke, and that further studies should be conducted on multivarious anatomical regions.

Effectiveness of upper limb functional electrical stimulation after stroke for the improvement of activities of daily living and motor function: a systematic review and meta-analysis

BACKGROUND

Stroke can lead to significant impairment of upper limb function which affects performance of activities of daily living (ADL). Functional electrical stimulation (FES) involves electrical stimulation of motor neurons such that muscle groups contract and create or augment a moment about a joint. Whilst lower limb FES was established in post-stroke rehabilitation, there is a lack of clarity on the effectiveness of upper limb FES. This systematic review aims to evaluate the effectiveness of post-stroke upper limb FES on ADL and motor outcomes.

METHODS

Systematic review of randomised controlled trials from MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, ICTRP and ClinicalTrials.gov. Citation checking of included studies and systematic reviews. Eligibility criteria: participants > 18 years with haemorrhagic/ischaemic stroke, intervention group received upper limb FES plus standard care, control group received standard care. Outcomes were ADL (primary), functional motor ability (secondary) and other motor outcomes (tertiary). Quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

RESULTS

Twenty studies were included. No significant benefit of FES was found for objective ADL measures reported in six studies (standardised mean difference (SMD) 0.64; 95% Confidence Interval (CI) [-0.02, 1.30]; total participants in FES group (n) = 67); combination of all ADL measures was not possible. Analysis of three studies where FES was initiated on average within 2 months post-stroke showed a significant benefit of FES on ADL (SMD 1.24; CI [0.46, 2.03]; n = 32). In three studies where FES was initiated more than 1 year after stroke, no significant ADL improvements were seen (SMD -0.10; CI [-0.59, 0.38], n = 35). Quality assessment using GRADE found very low quality evidence in all analyses due to heterogeneity, low participant numbers and lack of blinding.

CONCLUSIONS

FES is a promising therapy which could play a part in future stroke rehabilitation. This review found a statistically significant benefit from FES applied within 2 months of stroke on the primary outcome of ADL. However, due to the very low (GRADE) quality evidence of these analyses, firm conclusions cannot be drawn about the effectiveness of FES or its optimum therapeutic window. Hence, there is a need for high quality large-scale randomised controlled trials of upper limb FES after stroke.

TRIAL REGISTRATION

PROSPERO: CRD42015025162 , Date:11/08/2015.

Plastic Changes in Human Motor Cortical Output Induced by Random but not Closed-Loop Peripheral Stimulation: the Curse of Causality

Previous work showed that repetitive peripheral nerve stimulation can induce plastic changes in motor cortical output. Triggering electrical stimulation of central structures from natural activity can also generate plasticity. In this study, we tested whether triggering peripheral nerve stimulation from muscle activity would likewise induce changes in motor output. We developed a wearable electronic device capable of recording electromyogram (EMG) and delivering electrical stimulation under closed-loop control. This allowed paired stimuli to be delivered over longer periods than standard laboratory-based protocols. We tested this device in healthy human volunteers. Motor cortical output in relaxed thenar muscles was first assessed via the recruitment curve of responses to contralateral transcranial magnetic stimulation. The wearable device was then configured to record thenar EMG and stimulate the median nerve at the wrist (intensity around motor threshold, rate ~0.66 Hz). Subjects carried out normal daily activities for 4-7 h, before returning to the laboratory for repeated recruitment curve assessment. Four stimulation protocols were tested (9-14 subjects each): No Stim, no stimuli delivered; Activity, stimuli triggered by EMG activity above threshold; Saved, stimuli timed according to a previous Activity session in the same subject; Rest, stimuli given when EMG was silent. As expected, No Stim did not modify the recruitment curve. Activity and Rest conditions produced no significant effects across subjects, although there were changes in some individuals. Saved produced a significant and substantial increase, with average responses 2.14 times larger at 30% stimulator intensity above threshold. We argue that unavoidable delays in the closed loop feedback, due mainly to central and peripheral conduction times, mean that stimuli in the Activity paradigm arrived too late after cortical activation to generate consistent plastic changes. By contrast, stimuli delivered essentially at random during the Saved paradigm may have caused a generalized increase in cortical excitability akin to stochastic resonance, leading to plastic changes in corticospinal output. Our study demonstrates that non-invasive closed loop stimulation may be critically limited by conduction delays and the unavoidable constraint of causality.

Effect of mirror therapy on upper extremity motor function in stroke patients: a randomized controlled trial

[Purpose] This study aimed to evaluate the effectiveness of mirror therapy combined with a conventional rehabilitation program on upper extremity motor and functional recovery in stroke patients. [Subjects and Methods] Thirty-one hemiplegic patients were included. The patients were randomly assigned to a mirror (n=16) or conventional group (n=15). The patients in both groups underwent conventional therapy for 4 weeks (60-120 minutes/day, 5 days/week). The mirror group received mirror therapy, consisting of periodic flexion and extension movements of the wrist and fingers on the non-paralyzed side. The patients in the conventional group performed the same exercises against the non-reflecting face of the mirror. The patients were evaluated at the beginning and end of the treatment by a blinded assessor using the Brunnstrom stage, Fugl-Meyer Assessment (FMA) upper extremity score, and the Functional Independence Measure (FIM) self-care score. [Results] There was an improvement in Brunnstrom stage and the FIM self-care score in both groups, but the post-treatment FMA score was significantly higher in the mirror therapy group than in the conventional treatment group. [Conclusion] Mirror therapy in addition to a conventional rehabilitation program was found to provide additional benefit in motor recovery of the upper extremity in stroke patients.

Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery

Stroke is one of the leading causes for disability worldwide. Motor function deficits due to stroke affect the patients' mobility, their limitation in daily life activities, their participation in society and their odds of returning to professional activities. All of these factors contribute to a low overall quality of life. Rehabilitation training is the most effective way to reduce motor impairments in stroke patients. This multiple systematic review focuses both on standard treatment methods and on innovating rehabilitation techniques used to promote upper extremity motor function in stroke patients. A total number of 5712 publications on stroke rehabilitation was systematically reviewed for relevance and quality with regards to upper extremity motor outcome. This procedure yielded 270 publications corresponding to the inclusion criteria of the systematic review. Recent technology-based interventions in stroke rehabilitation including non-invasive brain stimulation, robot-assisted training, and virtual reality immersion are addressed. Finally, a decisional tree based on evidence from the literature and characteristics of stroke patients is proposed. At present, the stroke rehabilitation field faces the challenge to tailor evidence-based treatment strategies to the needs of the individual stroke patient. Interventions can be combined in order to achieve the maximal motor function recovery for each patient. Though the efficacy of some interventions may be under debate, motor skill learning, and some new technological approaches give promising outcome prognosis in stroke motor rehabilitation.

Effects of Unilateral Upper Limb Training in Two Distinct Prognostic Groups Early After Stroke

Background and Objective. Favorable prognosis of the upper limb depends on preservation or return of voluntary finger extension (FE) early after stroke. The present study aimed to determine the effects of modified constraint-induced movement therapy (mCIMT) and electromyography-triggered neuromuscular stimulation (EMG-NMS) on upper limb capacity early poststroke. Methods. A total of 159 ischemic stroke patients were included: 58 patients with a favorable prognosis (>10° of FE) were randomly allocated to 3 weeks of mCIMT or usual care only; 101 patients with an unfavorable prognosis were allocated to 3-week EMG-NMS or usual care only. Both interventions started within 14 days poststroke, lasted up until 5 weeks, focused at preservation or return of FE. Results. Upper limb capacity was measured with the Action Research Arm Test (ARAT), assessed weekly within the first 5 weeks poststroke and at postassessments at 8, 12, and 26 weeks. Clinically relevant differences in ARAT in favor of mCIMT were found after 5, 8, and 12 weeks poststroke (respectively, 6, 7, and 7 points; P < .05), but not after 26 weeks. We did not find statistically significant differences between mCIMT and usual care on impairment measures, such as the Fugl-Meyer assessment of the arm (FMA-UE). EMG-NMS did not result in significant differences. Conclusions. Three weeks of early mCIMT is superior to usual care in terms of regaining upper limb capacity in patients with a favorable prognosis; 3 weeks of EMG-NMS in patients with an unfavorable prognosis is not beneficial. Despite meaningful improvements in upper limb capacity, no evidence was found that the time-dependent neurological improvements early poststroke are significantly influenced by either mCIMT or EMG-NMS.

Development of network-based multichannel neuromuscular electrical stimulation system for stroke rehabilitation

Neuromuscular electrical stimulation (NMES) is a promising assistive technology for stroke rehabilitation. Here we present the design and development of a multimuscle stimulation system as an emerging therapy for people with paretic stroke. A network-based multichannel NMES system was integrated based on dual bus architecture of communication and an H-bridge current regulator with a power booster. The structure of the system was a body area network embedded with multiple stimulators and a communication protocol of controlled area network to transmit muscle stimulation parameter information to individual stimulators. A graphical user interface was designed to allow clinicians to specify temporal patterns and muscle stimulation parameters. We completed and tested a prototype of the hardware and communication software modules of the multichannel NMES system. The prototype system was first verified in nondisabled subjects for safety, and then tested in subjects with stroke for feasibility with assisting multijoint movements. Results showed that synergistic stimulation of multiple muscles in subjects with stroke improved performance of multijoint movements with more natural velocity profiles at elbow and shoulder and reduced acromion excursion due to compensatory trunk rotation. The network-based NMES system may provide an innovative solution that allows more physiological activation of multiple muscles in multijoint task training for patients with stroke.

Specifications of an electromyogram-driven neuromuscular stimulator for upper limb functional recovery

An electromyogram (EMG)-driven neuromuscular stimulator for upper limb functional recovery (Muraoka et al., 1998) can stimulate target muscles in proportion to the amount of voluntary EMG of the identical target muscles. Furthermore, it can facilitate the contraction of paralyzed muscles by electrical stimulation at subthreshold intensity level. Although it has been suggested that to use the stimulator for as long a time as possible might be needed for more effective treatment, the utilization time was limited by the size of the stimulator, which involved a laptop personal computer. To use in daily life, the device was improved to be a smaller size of 95×65×40 mm (including batteries) which was equivalent to a mobile phone (in 2002). The stimulator was called the Integrated Volitional-control Electrical Stimulator (IVES). IVES has already been manufactured and its use has spread in Japan since 2008. Nowadays, therapy using IVES is an effective therapy to improve the motor function of the upper limb in post-stroke patients with hemiparesis. However, the signal processing and internal structure of IVES has not yet been reported. In this study the device specification of IVES is described, especially its electrical circuits and signal processing that detect voluntary EMG and stimulate from the same electrodes. IVES uses two DIACs for detecting voluntary EMG from stimulating electrodes. The DIACs switch passively between the stimulation circuit and the EMG amplifier circuit. Furthermore, the signal processing of the time-shifted difference of the 2-cycle EMG signal following identical stimulation pulses eliminates stimulation artifacts and evoked potentials, and extracts voluntary EMG.

Standing with electrical stimulation and splinting is no better than standing alone for management of ankle plantarflexion contractures in people with traumatic brain injury: a randomised trial

QUESTION

Is a combination of standing, electrical stimulation and splinting more effective than standing alone for the management of ankle contractures after severe brain injury?

DESIGN

A multi-centre randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

Thirty-six adults with severe traumatic brain injury and ankle plantarflexion contractures.

INTERVENTION

All participants underwent a 6-week program. The experimental group received tilt table standing, electrical stimulation and ankle splinting. The control group received tilt table standing alone.

OUTCOME MEASURES

The primary outcome was passive ankle dorsiflexion with a 12Nm torque. Secondary outcomes included: passive dorsiflexion with lower torques (3, 5, 7 and 9Nm); spasticity; the walking item of the Functional Independence Measure; walking speed; global perceived effect of treatment; and perceived treatment credibility. OUTCOME MEASURES were taken at baseline (Week 0), end of intervention (Week 6), and follow-up (Week 10).

RESULTS

The mean between-group differences (95% CI) for passive ankle dorsiflexion at Week 6 and Week 10 were -3 degrees (-8 to 2) and -1 degrees (-6 to 4), respectively, in favour of the control group. There was a small mean reduction of 1 point in spasticity at Week 6 (95% CI 0.1 to 1.8) in favour of the experimental group, but this effect disappeared at Week 10. There were no differences for other secondary outcome measures except the physiotherapists' perceived treatment credibility.

CONCLUSION

Tilt table standing with electrical stimulation and splinting is not better than tilt table standing alone for the management of ankle contractures after severe brain injury.

TRIAL REGISTRATION

ACTRN12608000637347. [Leung J, Harvey LA, Moseley AM, Whiteside B, Simpson M, Stroud K (2014) Standing with electrical stimulation and splinting is no better than standing alone for management of ankle plantarflexion contractures in people with traumatic brain injury: a randomised trial.Journal of Physiotherapy60: 201-208].

Interventions for improving upper limb function after stroke

BACKGROUND

Improving upper limb function is a core element of stroke rehabilitation needed to maximise patient outcomes and reduce disability. Evidence about effects of individual treatment techniques and modalities is synthesised within many reviews. For selection of effective rehabilitation treatment, the relative effectiveness of interventions must be known. However, a comprehensive overview of systematic reviews in this area is currently lacking.

OBJECTIVES

To carry out a Cochrane overview by synthesising systematic reviews of interventions provided to improve upper limb function after stroke.

METHODS

SEARCH METHODS

We comprehensively searched the Cochrane Database of Systematic Reviews; the Database of Reviews of Effects; and PROSPERO (an international prospective register of systematic reviews) (June 2013). We also contacted review authors in an effort to identify further relevant reviews.

SELECTION CRITERIA

We included Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs) of patients with stroke comparing upper limb interventions with no treatment, usual care or alternative treatments. Our primary outcome of interest was upper limb function; secondary outcomes included motor impairment and performance of activities of daily living. When we identified overlapping reviews, we systematically identified the most up-to-date and comprehensive review and excluded reviews that overlapped with this.

DATA COLLECTION AND ANALYSIS

Two overview authors independently applied the selection criteria, excluding reviews that were superseded by more up-to-date reviews including the same (or similar) studies. Two overview authors independently assessed the methodological quality of reviews (using a modified version of the AMSTAR tool) and extracted data. Quality of evidence within each comparison in each review was determined using objective criteria (based on numbers of participants, risk of bias, heterogeneity and review quality) to apply GRADE (Grades of Recommendation, Assessment, Development and Evaluation) levels of evidence. We resolved disagreements through discussion. We systematically tabulated the effects of interventions and used quality of evidence to determine implications for clinical practice and to make recommendations for future research.

MAIN RESULTS

Our searches identified 1840 records, from which we included 40 completed reviews (19 Cochrane; 21 non-Cochrane), covering 18 individual interventions and dose and setting of interventions. The 40 reviews contain 503 studies (18,078 participants). We extracted pooled data from 31 reviews related to 127 comparisons. We judged the quality of evidence to be high for 1/127 comparisons (transcranial direct current stimulation (tDCS) demonstrating no benefit for outcomes of activities of daily living (ADLs)); moderate for 49/127 comparisons (covering seven individual interventions) and low or very low for 77/127 comparisons.Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, virtual reality and a relatively high dose of repetitive task practice, suggesting that these may be effective interventions; moderate-quality evidence also indicated that unilateral arm training may be more effective than bilateral arm training. Information was insufficient to reveal the relative effectiveness of different interventions.Moderate-quality evidence from subgroup analyses comparing greater and lesser doses of mental practice, repetitive task training and virtual reality demonstrates a beneficial effect for the group given the greater dose, although not for the group given the smaller dose; however tests for subgroup differences do not suggest a statistically significant difference between these groups. Future research related to dose is essential.Specific recommendations for future research are derived from current evidence. These recommendations include but are not limited to adequately powered, high-quality RCTs to confirm the benefit of CIMT, mental practice, mirror therapy, virtual reality and a relatively high dose of repetitive task practice; high-quality RCTs to explore the effects of repetitive transcranial magnetic stimulation (rTMS), tDCS, hands-on therapy, music therapy, pharmacological interventions and interventions for sensory impairment; and up-to-date reviews related to biofeedback, Bobath therapy, electrical stimulation, reach-to-grasp exercise, repetitive task training, strength training and stretching and positioning.

AUTHORS' CONCLUSIONS

Large numbers of overlapping reviews related to interventions to improve upper limb function following stroke have been identified, and this overview serves to signpost clinicians and policy makers toward relevant systematic reviews to support clinical decisions, providing one accessible, comprehensive document, which should support clinicians and policy makers in clinical decision making for stroke rehabilitation.Currently, no high-quality evidence can be found for any interventions that are currently used as part of routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions. Effective collaboration is urgently needed to support large, robust RCTs of interventions currently used routinely within clinical practice. Evidence related to dose of interventions is particularly needed, as this information has widespread clinical and research implications.

The modulatory effect of electrical stimulation on the excitability of the corticospinal tract varies according to the type of muscle contraction being performed

Afferent input caused by electrical stimulation of a peripheral nerve increases corticospinal excitability during voluntary contractions, indicating that proprioceptive sensory input arriving at the cortex plays a fundamental role in modulating corticospinal excitability. The purpose of this study was to investigate whether the effect of electrical stimulation on the corticospinal excitability varies according to the type of muscle contraction being performed. Motor-evoked potentials (MEPs) were elicited by transcranial magnetic stimulation (TMS) during a shortening contraction, an isometric contraction, or no contraction of the first dorsal interosseous (FDI) muscle. In some trials, electrical stimulation of the ulnar nerve was performed at 110% of the sensory threshold or 110% of the motor threshold prior to TMS. Electrical stimulation involved either a train of 50 pulses at 10 Hz or a single pulse. Shortening contraction with the train of electrical stimuli significantly increased MEP amplitudes, and the increase was dependent on the type of stimulation. Isometric contraction with the train of electrical stimuli and electrical stimulation without voluntary contraction did not affect MEP amplitudes. A single pulse of electrical stimulation did not affect MEP amplitudes in any condition. Thus, electrical-stimulation-induced modulation of corticospinal excitability varied according to the type of muscle contraction performed and the type of stimulation. These results show that the type of contraction should be considered when using electrical stimulation for rehabilitation in patients with central nervous system lesions.

Progress in sensorimotor rehabilitative physical therapy programs for stroke patients

Impaired motor and functional activity following stroke often has negative impacts on the patient, the family and society. The available rehabilitation programs for stroke patients are reviewed. Conventional rehabilitation strategies (Bobath, Brunnstrom, proprioception neuromuscular facilitation, motor relearning and function-based principles) are the mainstream tactics in clinical practices. Numerous advanced strategies for sensory-motor functional enhancement, including electrical stimulation, electromyographic biofeedback, constraint-induced movement therapy, robotics-aided systems, virtual reality, intermittent compression, partial body weight supported treadmill training and thermal stimulation, are being developed and incorporated into conventional rehabilitation programs. The concept of combining valuable rehabilitative procedures into “a training package”, based on the patient’s functional status during different recovery phases after stroke is proposed. Integrated sensorimotor rehabilitation programs with appropriate temporal arrangements might provide great functional benefits for stroke patients.

Electrical stimulation and splinting were not clearly more effective than splinting alone for contracture management after acquired brain injury: a randomised trial

QUESTION

Is electrical stimulation and splinting more effective than splinting alone for the management of wrist contracture following acquired brain injury?

DESIGN

A multi-centre randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Thirty-six adults with first stroke or traumatic brain injury and mild to moderate wrist flexion contractures.

INTERVENTION

The experimental group received electrical stimulation to the wrist and finger extensor muscles for 1 hour a day over 4 weeks while the control group did not. Both groups wore a splint for 12 hours a day during this 4-week period.

OUTCOME MEASURES

The primary outcome was passive wrist extension measured with a 3Nm torque and with the fingers in extension. Secondary outcomes included passive wrist extension, wrist and finger extensor strength, wrist flexor spasticity, motor control of the hand, and Global Perceived Effect of Treatment, and perception of treatment credibility. Outcome measures were taken at baseline, at the end of the intervention period (4 weeks), and after a 2-week follow-up period (6 weeks).

RESULTS

At 4 and 6 weeks, the mean between-group difference (95% CI) for passive wrist extension was 7 degrees (-2 to 15) and -3 degrees (-13 to 7), respectively. Secondary outcomes were statistically non-significant or were of borderline statistical significance.

CONCLUSION

It is not clear whether electrical stimulation and splinting is more effective than splinting alone for the management of wrist contracture after acquired brain injury. Therapists' confidence in the efficacy of electrical stimulation for contracture management is not yet justified.

Breathing-controlled Electrical Stimulation (BreEStim) for management of neuropathic pain and spasticity

Electrical stimulation (EStim) refers to the application of electrical current to muscles or nerves in order to achieve functional and therapeutic goals. It has been extensively used in various clinical settings. Based upon recent discoveries related to the systemic effects of voluntary breathing and intrinsic physiological interactions among systems during voluntary breathing, a new EStim protocol, Breathing-controlled Electrical Stimulation (BreEStim), has been developed to augment the effects of electrical stimulation. In BreEStim, a single-pulse electrical stimulus is triggered and delivered to the target area when the airflow rate of an isolated voluntary inspiration reaches the threshold. BreEStim integrates intrinsic physiological interactions that are activated during voluntary breathing and has demonstrated excellent clinical efficacy. Two representative applications of BreEStim are reported with detailed protocols: management of post-stroke finger flexor spasticity and neuropathic pain in spinal cord injury.

Noninvasive brain stimulation in neurorehabilitation

Stroke is the major cause of long-term disability worldwide, with impaired manual dexterity being a common feature. In the past few years, noninvasive brain stimulation (NIBS) techniques, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), have been investigated as adjuvant strategies to neurorehabilitative interventions. These NIBS techniques can be used to modulate cortical excitability during and for several minutes after the end of the stimulation period. Depending on the stimulation parameters, cortical excitability can be reduced (inhibition) or enhanced (facilitation). Differential modulation of cortical excitability in the affected and unaffected hemisphere of patients with stroke may induce plastic changes within neural networks active during functional recovery. The aims of this chapter are to describe results from these proof-of-principle trials and discuss possible putative mechanisms underlying such effects. Neurophysiological and neuroimaging changes induced by application of NIBS are reviewed briefly.