Neuromuscular Electrical Stimulation for Motor Restoration in Hemiplegia

Neuromodulation technologies improve functional recovery after brain injury: From bench to bedside

Spontaneous recovery frequently proves maladaptive or insufficient because the plasticity of the injured adult mammalian central nervous system is limited. This limited plasticity serves as a primary barrier to functional recovery after brain injury. Neuromodulation technologies represent one of the fastest-growing fields in medicine. These techniques utilize electricity, magnetism, sound, and light to restore or optimize brain functions by promoting reorganization or long-term changes that support functional recovery in patients with brain injury. Therefore, this review aims to provide a comprehensive overview of the effects and underlying mechanisms of neuromodulation technologies in supporting motor function recovery after brain injury. Many of these technologies are widely used in clinical practice and show significant improvements in motor function across various types of brain injury. However, studies report negative findings, potentially due to variations in stimulation protocols, differences in observation periods, and the severity of functional impairments among participants across different clinical trials. Additionally, we observed that different neuromodulation techniques share remarkably similar mechanisms, including promoting neuroplasticity, enhancing neurotrophic factor release, improving cerebral blood flow, suppressing neuroinflammation, and providing neuroprotection. Finally, considering the advantages and disadvantages of various neuromodulation techniques, we propose that future development should focus on closed-loop neural circuit stimulation, personalized treatment, interdisciplinary collaboration, and precision stimulation.

Efficacy of acupuncture on lower limb motor dysfunction following stroke: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Acupuncture is widely used for Lower Limb Motor Dysfunction Following Stroke (LLMD) in China, though its effectiveness remains unclear. This meta-analysis aims to evaluate the effectiveness of acupuncture for LLMD.

METHODS

We searched eight databases, including PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang, VIP, and CBM, up to December 2023. Randomized controlled trials on acupuncture therapy for LLMD after stroke were included in this study. Outcome measures included motor function, balance function, walking ability, and daily living activities. Two researchers conducted independent literature screening, data extraction, and quality assessment in accordance with Cochrane Collaboration network's standards. Review Manager 5.3 and Stata 17.0 were used in data analysis. Results were presented as mean difference (MD) or standardized mean difference (SMD) with 95% confidence interval (95% CI).

RESULTS

Twelve studies involving 1318 patients, most of which showed low or unclear risk of bias, were included in this review. Meta-analysis results indicate that compared with conventional treatment, acupuncture intervention can improve scores in Fugl-Meyer Assessment for lower scale (SMD = -0.48, 95% CI [-0.92, -0.04], Z = 2.16, P = .03), Berg Balance Scale (SMD = -0.86, 95%CI [-1.65, -0.07], Z = 2.14, P = .03), Functional Ambulation Category scale (SMD = -0.74, 95%CI [-2.33, 0.84], Z = 0.92, P = .36), and Modified Barthel Index Scale (SMD = 0.27, 95%CI [-0.30, 0.84], Z = 0.94, P = .35).

CONCLUSION

The results of this study suggest that acupuncture combined rehabilitation training may be more effective than conventional rehabilitation alone in improving LLMD, balance function, walking ability, and daily living activities after stroke. Despite limitations due to the low quality of the included studies and methodological constraints, acupuncture combined with rehabilitation training may serve as an effective approach for the treatment of LLMD poststroke.

Efficacy of neuromuscular electrical stimulation with modern rehabilitation techniques in the treatment of acute ischemic stroke patients with post-motor dysfunction

BackgroundAcute ischemic stroke (AIS) refers to a sudden loss of blood flow in a region of the brain, which leads to a loss of neurological function.PurposeTo unveil the efficacy of neuromuscular electrical stimulation (NMES) with modern rehabilitation techniques in AIS patients with post-motor dysfunction.Material and MethodsA total of 200 AIS patients with post-motor dysfunction were divided into groups A, B, C, and D (n = 50). Patients in the four groups were routinely treated with medicine, on this basis: group B received NMES treatment; group C received modern rehabilitation technology treatment; and group D was treated with NMES and modern rehabilitation technology. Rehabilitation effect, cerebral hemodynamic indices, neurological function recovery, Fugl-Meyer Assessment (FMA) and Motor Assessment Scale (MAS) scores, self-care, and quality of life were compared.ResultsAfter treatment, the total effective rate of group D was 96% higher than that of group A (64%), group B (82%), and group C (84%). Bilateral middle cerebral artery Vm and Vs and scores of FMA, MAS, functional independence measure, and modified Barthel index increased; RI and NHISS scores decreased; and all group D improved significantly versus groups A, B, and C, and both groups B and C improved significantly versus group A.ConclusionNMES with modern rehabilitation technologies synergistically treat motor dysfunction after AIS with ideal rehabilitation effect, improving cerebral hemodynamics, neurological and limb motor function recovery, and self-care ability and quality of life.

The Effect of Peripheral Magnetic Stimulation on Functional Mobility and Morphology in Cerebral Palsy with Spastic Diplegia: A Randomized Controlled Trial

Peripheral magnetic stimulation (PMS) is commonly used for neurological conditions, but its effectiveness in enhancing functional mobility and morphology in children with spastic diplegia remains underexplored. This study assessed the impact of PMS with physical therapy (PT) versus PT alone on mobility and morphology in spastic diplegia. Forty-five children with spastic diplegia (mean age 12.7 ± 3.8 years) were randomly assigned to one of three intervention groups: PMS + PT, PT, or control, with fifteen children in each group. The training was conducted thrice weekly for eight weeks, included muscle morphology assessments, the 30 s sit-to-stand test (30sSTS), functional reach test (FRT), 10 m walk test (10MWT), and 6 min walk test (6MWT). The study revealed increased left quadricep and calf muscle thickness following PMS + PT (d = 0.19, 0.39, respectively; all p < 0.05). Improvement in 30sSTS was observed after both PMS + PT (d = 0.56) and PT (d = 1.43). FRT demonstrated increases following both PMS + PT and PT interventions (d = 1.52, 0.93, respectively). Furthermore, improvements were observed in 10MWT following PMS + PT and PT interventions (d = 1.20, 0.78), while PT increased the 6MWT (d = 0.82). The control group showed declines in 10MWT and 6MWT. The treatment significantly impacted FRT, 10MWT, and 6MWT in spastic diplegia. While PMS may not enhance physical capacities beyond PT alone, it may improve FRT and 10MWT outcomes.

Peripheral Electrical Stimulation on Motor Function and Activities of Daily Living After Stroke: A Systematic Review and Network Meta-analysis

OBJECTIVE

To compare the effects of different peripheral electrical stimulation protocols and current frequencies for poststroke motor function and activities of daily living.

DATA SOURCES

Seven databases (PubMed, Embase, Cochrane Library, Chinese National Knowledge Infrastructure, VIP Database, Wan-Fang Database, and Chinese Biomedical Database) were searched from inception to August 2024.

STUDY SELECTION

Two reviewers independently performed the literature selection. The included studies were randomized controlled trials providing peripheral electrical stimulation for patients with stroke.

DATA EXTRACTION

Two reviewers independently extracted data following a predeveloped Excel data collection sheet, including trial characteristics, intervention and comparator details, and outcome data. The risk of bias was evaluated by RoB2 tool, and the PRISMA guidelines were followed for reporting.

DATA SYNTHESIS

A total of 106 trials with 7513 participants were included. Meta-analysis showed that neuromuscular electrical stimulation (NMES) could be the optimal electrical stimulation protocol for improving the Fugl-Meyer Assessment score (standardized mean difference=1.67; 95% confidence interval [1.14-2.21]) and the modified Barthel Index score (standardized mean difference=1.73; 95% confidence interval [1.10-2.37]). The results showed that different frequencies of electrical stimulation ranked the top 5 in descending order for improving: (1) the Fugl-Meyer Assessment scores as follows: 20-30 Hz_NMES (surface under the cumulative ranking curve [SUCRA]=87.5%)>100 Hz_NMES (SUCRA=75.4%)>100 Hz_functional electrical stimulation (SUCRA=70.9%)>20/35 Hz_transcutaneous electrical acupoint stimulation (SUCRA=69.8%)>1-4 Hz_electrical acupuncture (SUCRA=69.6%) and (2) the modified Barthel Index scores as follows: 100 Hz_transcutaneous electrical nerve stimulation (SUCRA=77.3%)>5/15 Hz_NMES (SUCRA=68.3%)>100 Hz_transcutaneous electrical acupoint stimulation (SUCRA=65.6%)>35-50 Hz_functional electrical stimulation (SUCRA=64.8%)>1-4 Hz_electrical acupuncture (SUCRA=60.0%).

CONCLUSIONS

Adding electrical stimulation based on routine rehabilitation training can improve the motor dysfunction and activities of daily living of patients with stroke. Specifically, NMES with 20-30 Hz improves motor function best, whereas 100 Hz_transcutaneous electrical nerve stimulation improves activities of daily living best.

Therapeutic Intervention for Trunk Control Impairments in Central Nervous System Disorders: A Comprehensive Review of Methods and Efficacy

Objectives

Trunk control involves multiple brain regions related to motor control systems. Therefore, patients with central nervous system (CNS) disorders frequently exhibit impaired trunk control, decreasing their activities of daily living (ADL). Although some therapeutic interventions for trunk impairments have been effective, their general effects on CNS disorders remain unclear. This review aimed to clarify this issue in patients with stroke, cerebellar ataxia, and Parkinson's disease (PD), representing trunk control impairment by lesions in the cortical and corticospinal systems, cerebellum, and basal ganglia, respectively.

Methods

Using online databases, we searched for randomized controlled trials that investigated the effects of therapeutic interventions for trunk impairments in patients with stroke, cerebellar ataxia, and PD, reported in English from 2013 to 2023.

Results

Overall, 50 articles were reviewed. Core-stability exercise (CSE), which activates the trunk muscles, specifically in the lumbar and pelvic areas, through postural adjustment tasks, is effective in patients with stroke, cerebellar ataxia, and PD. Weight-shifting exercise, unstable surface training, training with transcutaneous electrical stimulation, and noninvasive brain stimulation have been effective in patients following stroke. The combination of CSE with task-oriented training based on daily activities has been effective in patients with cerebellar ataxia. Perceptual training, repetitive trans-spinal magnetic stimulation, and aquatic training effectively improved alignment and balance function in patients with PD.

Conclusions

This review provides evidence-based strategies to improve trunk control, ADL, and quality of life for patients with trunk control impairments caused by CNS disorders.

Latest Advancements in Transcutaneous Electrical Nerve Stimulation (TENS) and Electronic Muscle Stimulation (EMS): Revisiting an Established Therapy with New Possibilities

Transcutaneous Electrical Nerve Stimulation (TENS) and Electronic Muscle Stimulation (EMS) are non-invasive therapies widely used for pain relief and neuromuscular adaptation. However, the clinical research supporting the efficacy of TENS in chronic pain management is limited by significant methodological flaws, including small sample sizes and inconsistent reporting of stimulation parameters. TENS modulates pain perception through various techniques, targeting specific nerve fibers and pain pathways. High-frequency TENS is effective for segmental pain control, while low-frequency TENS, reliant on endogenous opioid pathways, may be less effective in opioid-tolerant patients. Additionally, TENS may influence autonomic functions, such as micro-perfusion and sympathetic tone, further broadening its therapeutic potential. EMS, on the other hand, enhances muscle strength and neuromuscular function, particularly in rehabilitation settings, by recruiting additional muscle fibers and improving neuromuscular efficiency. To address the limitations in existing clinical applications, future advancements in TENS and EMS technologies should focus on real-time optimization of stimulation parameters, consistent therapy delivery, and improved accessibility. Integrating automated and personalized adjustments can help streamline treatment, enhance patient compliance, and overcome traditional barriers to the effective implementation of these modalities. Additionally, developing systems that enable remote monitoring and customization of therapy protocols will expand the usability of TENS and EMS in diverse care settings. Future research must focus on rigorous study designs, standardized protocols, and meaningful patient-centered outcomes to fully realize the therapeutic potential of these modalities. Innovations like NXTSTIM EcoAI™ represent a significant advancement in delivering tailored, effective, and patient-friendly pain management and rehabilitation strategies.

Conservative Treatment of Neonatal Brachial Plexus Palsy: A Narrative Review

Neonatal brachial plexus palsy (NBPP) is a flaccid paralysis of the upper limbs that occurs in about 0.4 percent of live births. This condition can produce permanent disabilities; to date, there is no consensus on protocols to be applied for the rehabilitation of children with this condition. The aim of this article is to provide a concise overview of conservative treatment beyond traditional physical therapy for the management of the child with NBPP and to offer a number of useful options for creating the most comprehensive and functional rehabilitation treatment possible. We conducted a narrative review after analyzing articles from the past 50 years on PubMed, Cochrane Library, Scopus, and Web of Science with the following search string [("neonatal brachial plexus palsy" OR "obstetric brachial plexus palsy" OR "birth brachial plexus palsy") AND ("rehabilitation" OR "physiotherapy" OR "conservative treatment")]. We identified a potential of 1275 articles, but only 11 were exclusively about conservative approaches. The most represented rehabilitation approaches in the literature were botulinum toxin, constraint-induced movement therapy (CIMT), virtual reality, neuromuscular electrical stimulation, and kinesiotaping. In conclusion, the various rehabilitation approaches for NBPP are promising, but none can be considered the best option when used alone. In light of the current evidence, a multimodal approach is needed.

Home-based functional electrical stimulation protocol for people with chronic stroke. Efficacy and usability of a single-center cohort

BACKGROUND

Stroke survivors often face challenges in recovery and reintegration after acute care. Home-based rehabilitation, incorporating advanced technologies like Functional Electrical Stimulation (FES), shows promise for improving long-term outcomes by providing more accessible, high-intensity, and task-oriented rehabilitation outside traditional clinical settings.

METHOD

This study assessed efficacy and usability of a 10-week home-based rehabilitation protocol for 52 individuals with chronic stroke. The intervention featured a cloud-based platform, a mobile application, and functional electrical stimulation devices. Participants were categorized into groups for tailored exercise training and received both synchronous and asynchronous sessions. Efficacy was measured through standardized motor function tests, while usability was evaluated based on adherence, patient satisfaction, and the frequency of technical support requests.

RESULTS

High adherence (74.03%) and a satisfaction of 73% were observed. On average, patients performed on average 414 min of unsupervised exercise per week. Significant improvement, including a median decrease of 6.08 s (22%) in Timed Up and Go (TUG) [z (24) = 4.17, p < 0.001], a median decrease of 4.04 s (17%) in Five Times Sit to Stand (5STS) [z (28) = 3.96, p < 0.001], Motor Assessment Scale (MAS) showed a mean increase of 3.2 ± 2.8 points, paired t-test [t (20) = -5.01 p < 0.001] and an increase of 0.095 m/s (28%) in 10-Meter Walk Test (10MWT) [z (24) = 3.71, p < 0.001]. Clinical relevance was observed in all outcome measures compared with the reported Minimum Detectable Change.

CONCLUSION

This evaluation of a home-based physiotherapy protocol indicates that integrating FES devices with virtual platforms and mobile applications can sustain high adherence while improving functional outcomes in chronic stroke rehabilitation. The prescription of high-intensity training, significant improvements in balance, gait, and overall functionality were observed, highlighting the viability of this approach for home-based programs.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

Physical Agent, Mechanical, and Instrument-Assisted Modalities in Occupational Therapy Practice

This AOTA Position Statement describes how physical agent, mechanical, and instrument-assisted modalities (PAMIMs) may be used by occupational therapy practitioners (i.e., occupational therapists and occupational therapy assistants) as part of a comprehensive plan of intervention designed to enhance engagement in occupation.

Evaluating neuromuscular electrical stimulation for preventing and managing intensive care unit-acquired weakness: Current evidence and future directions

Intensive care unit-acquired weakness (ICU-AW) is a prevalent issue in critical care, leading to significant muscle atrophy and functional impairment. Aiming to address this, Neuromuscular Electrical Stimulation (NMES) has been explored as a therapy. This systematic review assesses NMES's safety and effectiveness in enhancing functional capacity and mobility in pre- and post-cardiac surgery patients. NMES was generally safe and feasible, with intervention sessions varying in frequency and duration. Improvements in muscle strength and 6-minute walking test distances were observed, particularly in preoperative settings, but postoperative benefits were inconsistent. NMES showed promise in preventing muscle loss and improving strength, although its impact on overall functional capacity remained uncertain. Challenges such as short ICU stays and body composition affecting NMES efficacy were noted. NMES also holds potential for other conditions like cerebral palsy and stroke. Further research is needed to optimize NMES protocols and better understand its full benefits in preventing ICU-AW and improving patient outcomes.

Effects of Neuromuscular Electrical Stimulation for Quadriceps Muscle Thickness and Lower Extremity Motor Score in Individuals with Subacute Incomplete Cervical Spinal Cord Injury: A Randomized Controlled Trial

OBJECTIVE

In this study, we aimed to determine the effects of 2-week neuromuscular electrical stimulation (NMES) on quadriceps muscle atrophy and lower extremity motor score in individuals with subacute incomplete cervical spinal cord injury (SCI).

METHODS

This stratified randomized controlled trial, conducted in the advanced critical care center of a university hospital, comprised 49 individuals with American Spinal Injury Association (ASIA) impairment scale grade C and D incomplete cervical SCI. The participants were stratified based on the ASIA impairment scale grade and randomly assigned to the control (n = 25) or NMES (n = 24) group. The control group participants received only conventional rehabilitation; the NMES group participants received conventional rehabilitation plus NMES in the quadriceps muscles of both lower limbs. The primary endpoints were quadriceps muscle thickness and L3 ASIA lower extremity motor score (L3 motor score), measured at the study's initiation and after 2 weeks.

RESULTS

The quadriceps muscle thickness changes on the stronger and weaker sides were -14.2% ± 11.3% and -15.1% ± 13.8%, respectively, in the NMES group and -25.7% ± 16.8% and -26.0% ± 13.3%, respectively, in the control group, indicating significantly lesser reduction on both sides in the NMES group (p <0.05). The L3 motor scores on the stronger and weaker sides were 0.8 ± 1.2 and 1.3 ± 1.4 (NMES group) and 0.4 ± 0.8 and 0.4 ± 0.8 (control group), respectively, indicating significant improvement only on the weaker side (p <0.05).

CONCLUSIONS

For subacute incomplete cervical SCI, 2 weeks of NMES reduces quadriceps muscle atrophy and improves the L3 motor score values on the weaker side compared with standard treatment.

Application of neuromuscular electrical stimulation during immobilization of extremities for musculoskeletal conditions: A scoping review

BACKGROUND

Neuromuscular electrical stimulation (NMES) is effective at improving recovery after periods of disuse. It is unclear if NMES can be applied during periods of immobilization for musculoskeletal conditions to mitigate resulting impairments from disuse. The aim of this scoping review is to describe the state of the literature applying NMES during immobilization to treat upper and lower extremity musculoskeletal conditions.

METHODS

A literature search was conducted in October 2023 combining keywords related to "neuromuscular electrical stimulation", "musculoskeletal", and "immobilization" in Pubmed, Scopus, CINAHL, and Proquest Dissertations and Thesis with an English filter. Articles were included if an upper or lower extremity was immobilized during the NMES application and NMES was applied with surface electrodes. Articles were excluded if NMES was applied outside of the immobilization period, participants had a neurological condition that could impair neuromotor pathways, and/or electrical stimulation was applied invasively. Data extracted included study design, sample characteristics, immobilization protocol, intervention, stimulation parameters, outcome measures, and results. The Joanna Briggs Institute (JBI) Critical Appraisal Tools for Cohort Studies was used to assess quality for all included studies.

RESULTS

Six studies with 127 participants were included. The musculoskeletal conditions addressed were anterior cruciate ligament repair and tibia fracture. Immobilization procedures maintain knee flexion between 10 and 45° for four to six weeks. NMES was applied through holes cut in the casts. NMES duration ranged from 40 minutes to 8 hours a day with an alternating current ramping up over 0.4 to 4 seconds (s), the contraction duration between two and 20 s, and rest times between five and 50 s. NMES application improved quadriceps atrophy and strength outcomes in four studies.

DISCUSSION

The body of literature is limited to two patient populations, only a small sample of cohort studies, physiological outcomes, and all studies were published before 1989. The models used in these studies are outdated, so new models (i.e. distal radius fracture) are proposed to investigate NMES application during immobilization in musculoskeletal populations. This study highlights a substantial gap in the literature and that further investigation into NMES application during immobilization for musculoskeletal conditions is warranted.

Efficacy of electrical stimulation for post-stroke motor dysfunction: A protocol for systematic review and network meta-analysis

OBJECTIVE

This study aims to analyze the efficacy and safety of different electrical stimulation treatments for post-stroke motor dysfunction, and to quantitatively analyze the advantages between them and their possible benefits for patients.

METHODS

We will systematically search seven databases. All of them will be retrieved from inception to 15, April 2024. Two reviewers will evaluation the risk of bias in all included studies with the version 2 of the Cochrane risk-of-bias assessment tool. Data synthesis will be performed using a random-effects model of network meta-analysis to compare the efficacy and safety of different electrical stimulation therapies. The surface under the cumulative ranking curve was used to indicate the possibility of the pros and cons of the intervention. The strength of evidence will be assessed by the Grading of Recommendations, Assessment, Development, and Evaluation framework.

DISCUSSION

This study will provide evidence that electrical stimulation therapy can effectively improve motor function in stroke patients and will also provide some valuable references for clinical decision-making and treatment guidelines.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023459102.

Physiotherapy Approach to an Internal Capsule Infarct With Upper Motor Neuron Facial Nerve Palsy: A Case Report

The internal capsule (IC) is a vital brain structure housing descending and ascending fiber tracts, with traditional assumptions about the corticobulbar and corticospinal tracts descending through the genu and anterior third of the posterior limb of internal capsule (PLIC), respectively. However, observations of IC infarctions reveal that symptoms often deviate from the expected fiber pattern, prompting a deeper exploration of these complexities. The posterior limb of the IC receives its blood supply from the lenticulostriate branches of the middle cerebral artery and the anterior choroidal artery (AChA). AChA infarctions present a diverse array of symptoms beyond the classic triad, reflecting the intricate vascular supply and lesion patterns within this region. We present a case of a 74-year-old male farmer with right-hand dominance, who experienced a fall resulting in head and right lower limb injuries. Subsequently, he developed weakness in his left upper and lower limbs, facial deviation, slurred speech, and swelling in the right lower limb. Following these symptoms, his family promptly brought him to the hospital on November 30, 2023. Extensive investigations, including magnetic resonance imaging (MRI), revealed a hyper-acute infarct in the posterior limb of the left IC. The patient was admitted to the intensive care unit (ICU) for three days and later shifted to the neurology ward where medical management was commenced, including physiotherapy protocol that was started on December 2, 2023. Physiotherapy interventions were designed to address the patient's weakness, altered sensation, and diminished reflexes. Therapeutic goals focused on preventing complications, improving posture, enhancing range of motion (ROM), and mitigating breathing difficulties and mobility issues. The physiotherapy aimed to enhance the patient's overall physical and mental well-being, emphasizing independence and improved quality of life. Regular assessments and adjustments to the therapeutic interventions were made based on the patient's progress. This case underscores the importance of tailored physiotherapy interventions in addressing the diverse manifestations of IC infarctions, contributing to a comprehensive understanding of rehabilitation strategies in neurologically compromised individuals.

Functional electrical stimulation to enhance reactive balance among people with hemiparetic stroke

BACKGROUND

Individuals with stroke demonstrate a twofold higher fall incidence compared to healthy counterparts, potentially associated with deficits in reactive balance control, which is crucial for regaining balance from unpredictable perturbations to the body. Moreover, people with higher stroke-related motor impairment exhibit greater falls and cannot recover balance during higher perturbation intensities. Thus, they might need supplemental agents for fall prevention or even to be included in a perturbation-based protocol. Functional electrical stimulation is a widely used clinical modality for improving gait performance; however, it remains unknown whether it can enhance or interfere with reactive balance control.

METHODS

We recruited twelve ambulatory participants with hemiparetic stroke (61.48 ± 6.77 years) and moderate-to-high motor impairment (Chedoke-McMaster Stroke Leg Assessment ≤ 4/7). Each participant experienced 4 unpredicted paretic gait-slips, with and without functional electrical stimulation (provided 50-500 ms after perturbation) in random order. The paretic quadriceps muscle group was chosen to receive electrical stimulation, considering the role of support limb knee extensors for preventing limb-collapse. Outcomes including primary (laboratory falls), secondary (reactive stability, vertical limb support) and tertiary (compensatory step length, step initiation, execution time) measures were compared between the two conditions.

RESULTS

Participants demonstrated fewer falls, higher reactive stability, and higher vertical limb support (p < 0.05) following gait-slips with functional electrical stimulation compared to those without. This was accompanied by reduced step initiation time and a longer compensatory step (p < 0.05).

CONCLUSION

The application of functional electrical stimulation to paretic quadriceps following gait-slips reduced laboratory fall incidence with enhanced reactive balance outcomes among people with higher stroke-related motor impairment. Our results lay the preliminary groundwork for understanding the instantaneous neuromodulatory effect of functional electrical stimulation in preventing gait-slip falls, future studies could test its therapeutic effect on reactive balance. Clinical registry number: NCT04957355.

The efficacy of contralaterally controlled functional electrical stimulation compared to conventional neuromuscular electrical stimulation for recovery of limb function following a stroke: a systematic review and meta-analysis

Introduction

Limb paresis following a stroke is a common sequela that can impact patients' quality of life. Many rehabilitation strategies targeting the restoration of motor function exist. This systematic review and meta-analysis aim to evaluate the effects of contralaterally controlled functional electrical stimulation (CCFES) as a modality for limb rehabilitation. Unlike conventional neuromuscular electrical simulation (NMES), the contra-laterality in CCFES is achieved by two methods a bend angle sensor or an electromyographic bridge (EMGB) method, both of which targets signals from the unaffected limb.

Method

This review study was performed following the preferred reporting item for systematic review and meta-analysis (PRISMA) guidelines. Records that met the inclusion criteria were extracted from the following databases: Medline, Embase, and Cochrane Register of Controlled Trials (CENTRAL). Additional articles were also retrieved from clinicaltrials.gov and China/Asia on Demand (CAOD). Only randomized controlled studies (RCTs) were included.

Results

Sixteen RCTs met the inclusion criteria, and 14 of which were included in the quantitative analysis (meta-analysis). The results of the analysis show that when compared to conventional NMES, CCFES displayed a better improvement in the upper extremity Fugl-Meyer assessment (UEFMA) (SMD = 0.41, 95% CI: 0.21, 0.62, p-value <0.0001, I2 = 15%, GRADE: moderate), box and blocks test (BBT) (SMD = 0.48, 95% CI: 0.10, 0.86, p-value = 0.01, I2 = 0%, GRADE: very low), modified Barthel index (mBI) (SMD = 0.44, 95% CI: 0.16, 0.71, p-value = 0.002, I2 = 0%, GRADE: moderate), active range of motion (AROM) (SMD = 0.61, 95% CI: 0.29, 0.94, p-value = 0.0002, I2 = 23%, GRADE: moderate), and surface electromyography (sEMG) scores (SMD = 0.52, 95% CI: 0.14, 0.90, p-value = 0.008, I2 = 0%, GRADE: low). The results of the subgroup analysis for the type of sensor used in CCFES shows that an EMGB (SMD = 0.58, 95% CI: 0.33, 0.84, p-value <0.00001, I2 = 7%) is more effective than a bend angle sensor (SMD = 0.17, 95% CI: -0.12, 0.45, p-value = 0.25, I2 = 0%).

Conclusion

The results of this study provide strong evidence that shows CCFES being a better electrical stimulation modality compared to conventional NMES. This could be explained by the fact that CCFES is bilateral in nature which offers a platform for better neuroplasticity following a stroke. There is still a need for high-quality studies with a standardized approach comparing CCFES to other treatment modalities.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=342670, identifier CRD42022342670.

Peripheral electrical stimulation on neuroplasticity and motor function in stroke patients: a systematic review and meta-analysis

INTRODUCTION

The use of electrotherapy has been presented as a great resource for the professional physiotherapist in the most diverse pathologies. Stroke is a neurological condition responsible for sequelae such as hemiplegia that directly impair the quality of life of patients.

OBJECTIVE

This study aimed to review the literature on the effects of electrotherapeutic resources on motor function and neuroplasticity in individuals with post-stroke sequelae.

MATERIALS AND METHODS

2427 articles were found in databases according to search criteria for each base according to the included descriptors (EndNote Web). After exclusion of duplicate articles, automatically and manually, Phase 1 was performed - reading of titles and abstracts of 1626 articles according to eligibility criteria by two blinded reviewers using the programme Rayyan QCRI (Qatar Computing Research Institute), conflicts were resolved in consensus between the two reviewers. Thus, 13 articles were selected for Phase 2-13 articles were selected for reading in full, leaving 8 articles in this review. To assess the quality of bias of the selected studies, the PEDro Scale was used.

RESULTS

In the assessment of neuroplasticity, statistically significant results were found in two studies (p < 0.05). However, the effects of electrostimulation stood out significantly in the motor function of these individuals (p < 0.05). It can be considered with neuroplasticity, since improved functionality can be related to electrostimulation-induced neuroplasticity. Conclusions Electrostimulation is able to promote neuroplasticity and increase motor function, generating positive effects in the treatment of individuals with post-stroke sequelae.

Virtual Reality Intervention and Its Impact on Upper Extremity Function in the Stroke Population: A Scoping Review

The aim of this scoping review was to examine virtual reality (VR) interventions used within rehabilitation and their effect on the functional outcomes of individuals with stroke. Specifically, this study sought to determine the impact of VR on the upper extremity (UE) use of participants as it relates to body function, occupational participation, and overall UE function (UEfxn). Twenty-six articles were selected for inclusion and results were extracted to determine common themes of outcomes among the effects of VR intervention (VRI). Thematic analysis included details about the VRIs used, as well as the change in UE outcomes post-VRI. Overall, positive change in UEfxn was found across many of the studies, indicating that VR technologies may be an effective intervention technique for individuals, poststroke. Findings of this review encourage clinicians to conduct further research regarding VR technology for UE rehabilitation poststroke.

A comprehensive guide to BCI-based stroke neurorehabilitation interventions

Brain-Computer Interfaces (BCIs) offer the potential to facilitate neurorehabilitation in stroke patients by decoding user intentions from the central nervous system, thereby enabling control over external devices. Despite their promise, the diverse range of intervention parameters and technical challenges in clinical settings have hindered the accumulation of substantial evidence supporting the efficacy and effectiveness of BCIs in stroke rehabilitation. This article introduces a practical guide designed to navigate through these challenges in conducting BCI interventions for stroke rehabilitation. Applicable regardless of infrastructure and study design limitations, this guide acts as a comprehensive reference for executing BCI-based stroke interventions. Furthermore, it encapsulates insights gleaned from administering hundreds of BCI rehabilitation sessions to stroke patients.•Presents a comprehensive methodology for implementing BCI-based upper extremity therapy in stroke patients.•Provides detailed guidance on the number of sessions, trials, as well as the necessary hardware and software for effective intervention.

Prefrontal cortex activity of active motion, cyclic electrical muscle stimulation, assisted motion, and imagery of wrist extension in stroke using fNIRS

OBJECTIVES

This study aimed to determine whether the prefrontal cortex (PFC) was activated during four training approaches for wrist extension in patients with stroke, including active motion, cyclic electrical muscle stimulation (EMS), assisted motion, and motor imagery (MI).

MATERIALS AND METHODS

We conducted a cross-sectional study involving 16 patients with stroke, and adopted functional near-infrared spectroscopy (fNIRS) to observe PFC activity during four treatment paradigms. The beta value of 53 channels in fNIRS under each paradigm, compared to the baseline, was evaluated using single sample t-test. The one-way analysis of variance with post hoc analysis was employed to compare the difference of significantly activated channels among four treatment paradigms.

RESULTS

This study revealed that the active motion (t values ranging from 2.399 to 4.368, p values <0.05), as well as MI of wrist extension (t values ranging from 2.161 to 4.378, p values <0.05), significantly increased HBO concentration across the entire PFC. The cyclic EMS enhanced the activation of Broca's area and frontal pole (FP) (t values ranging from -2.540 to 2.303, p values <0.05). The assisted motion induced significant activation in Broca's area, dorsolateral prefrontal cortex, and FP (t values ranging from -2.226 to 3.056, p values <0.05). The difference in ΔHBO among the four tasks was seen in Broca's area, FP, and frontal eye field.

CONCLUSIONS

Active wrist extension and MI activate most PFC areas, whereas assisted motion and single-use of cyclic EMS have limited effectiveness for PFC activation in stroke patients.

Mirror therapy combined with neuromuscular electrical stimulation for poststroke lower extremity motor function recovery: a systematic review and meta-analysis

The combination of mirror therapy (MT) and neuromuscular electrical stimulation (NMES) has been devised as an intervention method in stroke rehabilitation; however, few studies have investigated its efficacy in lower extremity motor function recovery. In this systematic review and meta-analysis, we examined the effectiveness of combined MT and NMES therapy in improving poststroke walking speed, spasticity, balance and other gait parameters. Randomized controlled trials (RCTs) were selected from PubMed, Cochrane Library, EMBASE, and Scopus databases. In total, six RCTs which involving 181 participants were included. Our findings indicate that MT combined with NMES elicits greater improvement relative to control group in walking speed (SMD = 0.67, 95% confidence interval [CI] 0.26-1.07, P = 0.001), Berg Balance Scale (SMD = 0.72; 95% CI 0.31-1.13; P = 0.0007), cadence (SMD = 0.59, 95% CI 0.02-1.16, P = 0.04), step length (SMD = 0.94, 95% CI 0.35-1.53, P = 0.002), and stride length (SMD = 0.95, 95% CI 0.36-1.54, P = 0.002) but not in modified Ashworth scale (SMD =  - 0.40, 95% CI - 1.05 to 0.26, P = 0.23). Our findings suggest that MT combined with NMES may be a suitable supplemental intervention to conventional therapy in stroke survivors.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

ChiCTR2300071588.

A Flexible Conductive Electrode Using Boronic-Acid Modified Carbon Dots

Flexible electrodes are becoming a topic of interest for a range of applications including implantation. They can be used for neural signal recording and for electrical stimulation of atrophying muscles. Unlike the traditionally used metal electrodes that are harsh to the body's tissues, flexible electrodes conduct electricity while preserving the delicate tissues. Polydimethylsiloxane (PDMS), a non-conductive synthetic polymer characterized by its flexibility, low cost, biocompatibility, and durability during implantation, has been explored as a matrix for flexible electrodes. This study reports the synthesis of composite boronic acid-modified carbon dots (BA-CDs)/PDMS electrode materials. The performance of the composite electrode is evaluated electrochemically (for its conductivity and charge storage capacity) and mechanically (Young's modulus). Furthermore, the effect of increasing the PDMS crosslinking density on the electrode's performance is studied based on the hypothesis that a higher crosslinking will bring the BA-CDs closer together, thereby facilitating the movement of electrons. Results of this study showed that incorporating 10% BA-CDs dispersed with 16% glycerol in 74% PDMS with a higher crosslinking density resulted in a bulk impedance of 47.7 Ω and a conductivity of 2.68×10-3 S/cm, both of which surpassed that of the same composition with lower crosslinking. The synthesized flexible electrode material was capable of charge storage although the charge storage capacity (0.00365 mC/cm2) was lower than the safe limit for some tissue activation. Furthermore, the electrode maintained a modulus of elasticity (0.2322 MPa) that is compatible with biological soft tissues.Clinical Relevance- This study reports a conductive electrode that has a flexibility compatible with that of biological tissues for future purposes such as neural signal recording and tissue electrical stimulation (e.g. atrophying muscles). The reported BA-CD/PDMS electrode overcomes the limitations of the harsh metals previously used as implantable electrodes that harm the biological tissues due to their high rigidity.

New Artificial Intelligence-Integrated Electromyography-Driven Robot Hand for Upper Extremity Rehabilitation of Patients With Stroke: A Randomized, Controlled Trial

BACKGROUND

An artificial intelligence (AI)-integrated electromyography (EMG)-driven robot hand was devised for upper extremity (UE) rehabilitation. This robot detects patients' intentions to perform finger extension and flexion based on the EMG activities of 3 forearm muscles.

OBJECTIVE

This study aimed to assess the effect of this robot in patients with chronic stroke.

METHODS

This was a single-blinded, randomized, controlled trial with a 4-week follow-up period. Twenty patients were assigned to the active (n = 11) and control (n = 9) groups. Patients in the active group received 40 minutes of active finger training with this robot twice a week for 4 weeks. Patients in the control group received passive finger training with the same robot. The Fugl-Meyer assessment of UE motor function (FMA), motor activity log-14 amount of use score (MAL-14 AOU), modified Ashworth scale (MAS), H reflex, and reciprocal inhibition were assessed before, post, and post-4 weeks (post-4w) of intervention.

RESULTS

FMA was significantly improved at both post (P = .011) and post-4w (P = .021) in the active group. The control group did not show significant improvement in FMA at the post. MAL-14 AOU was improved at the post in the active group (P = .03). In the active group, there were significant improvements in wrist MAS at post (P = .024) and post-4w (P = .026).

CONCLUSIONS

The AI-integrated EMG-driven robot improved UE motor function and spasticity, which persisted for 4 weeks. This robot hand might be useful for UE rehabilitation of patients with stroke.Clinical Trial Registry Name: The effect of robotic rehabilitation using XMM-HR2 for the paretic upper extremity among hemiparetic patients with stroke.Clinical Trial Registration-URL: https://jrct.niph.go.jp/Unique Identifier: jRCTs032200045.

Attentional State-Dependent Peripheral Electrical Stimulation During Action Observation Enhances Cortical Activations in Stroke Patients

Brain-computer interface (BCI) is a promising technique that enables patients' interaction with computers or machines by analyzing specific brain signal patterns and provides patients with brain state-dependent feedback to assist in their rehabilitation. Action observation (AO) and peripheral electrical stimulation (PES) are conventional methods used to enhance rehabilitation outcomes by promoting neural plasticity. In this study, we assessed the effects of attentional state-dependent feedback in the combined application of BCI-AO with PES on sensorimotor cortical activation in patients after stroke. Our approach involved showing the participants a video with repetitive grasping actions under four different tasks. A mu band suppression (8-13 Hz) corresponding to each task was computed. A topographical representation showed that mu suppression of the dominant (healthy) and affected hemispheres (stroke) gradually became prominent during the tasks. There were significant differences in mu suppression in the affected motor and frontal cortices of the stroke patients. The involvement of both frontal and motor cortices became prominent in the BCI-AO+triggered PES task, in which feedback was given to the patients according to their attentive watching. Our findings suggest that synchronous stimulation according to patient attention is important for neurorehabilitation of stroke patients, which can be achieved with the combination of BCI-AO feedback with PES. BCI-AO feedback combined with PES could be effective in facilitating sensorimotor cortical activation in the affected hemispheres of stroke patients.

Balance Training with Weight Shift-Triggered Electrical Stimulation for Stroke Patients: A Randomized Controlled Trial

This study aimed to determine the effects of balance training with weight shift-triggered electrical stimulation to improve balance, lower-extremity motor function, and activities of daily living in patients with stroke. The participants were randomly allocated to the balance training with electrical stimulation group (BT-ESG, n = 29) or the balance training group (BTG, n = 30). Both groups were trained 5 times per week for 6 weeks for 50 min per session. To evaluate static balance, postural sway was assessed and dynamic balance was assessed using the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and functional reach test (FRT). Lower-extremity motor function was assessed using the Fugl-Meyer assessment. Daily activities were assessed using the Modified Barthel Index. As for static balance, BT-ESG showed a significant improvement compared to BTG in postural swat in both the eyes-open (velocity moment; effect size, 0.88; 95% confidence interval, -1.16 to -1.30), or eyes-closed state (velocity moment; effect size, 0.81; 95% confidence interval, -1.22 to -0.27). Dynamic balance, which includes TUG (effect size, 0.90; 95% confidence interval, -4.67 to -1.25), BBS (effect size, 1.26; 95% confidence interval, -2.84 to 6.83), and FRT (effect size, 1.45; 95% confidence interval, 1.92 to 4.08), in addition to lower-extremity motor function (effect size, 1.38; 95% confidence interval, 2.25 to 4.97), and activities of daily living (effect size, 2.04; 95% confidence interval, 2.04 to 937), showed significant improvement in BT-ESG compared to BTG. These results suggest that balance training with weight shift-triggered electrical stimulation effectively improves balance, lower-extremity motor function, and activities of daily living in patients with stroke.

Combined neuromuscular electrical stimulation and transcutaneous spinal direct current stimulation increases motor cortical plasticity in healthy humans

Introduction

Neuromuscular electrical stimulation (NMES) induces neural plasticity of the central nervous system (CNS) and improves motor function in patients with CNS lesions. However, the extended stimulus duration of NMES reduces its clinical applicability. Transcutaneous spinal direct current stimulation (tsDCS), which increases afferent input, may enhance the effects and reduce the stimulus duration of NMES. This study investigated the excitability of the motor cortex, somatosensory cortex, and spinal motor neurons after the combined stimulation of NMES and tsDCS.

Methods

Among the 55 participants in this study, 24 were allocated to experiment 1, 15 to experiment 2, and 16 to experiment 3. They received intervention for 20 min on different days: (1) NMES combined with tsDCS (NMES + tsDCS), (2) NMES combined with sham tsDCS (NMES + sham tsDCS), and (3) sham NMES combined with tsDCS (sham NMES + tsDCS). NMES was delivered to the right common peroneal nerve at 25 Hz with the intensity at 120% of the motor threshold. For tsDCS, the cathodal electrode was positioned on the thoracic 10th–12th vertebral levels, and the anodal electrode was located on the right shoulder. The stimulus intensity was 2.5 mA. In experiment 1, motor evoked potentials (MEPs) and short-latency intracortical inhibition (SICI) were measured by transcranial magnetic stimulation up to 60 min after stimulation. The spinal motor neurons’ excitability was assessed by recording the posterior root muscle reflex (PRMR) induced via transcutaneous spinal cord stimulation in experiment 2, and the primary somatosensory cortex excitability was evaluated by recording the somatosensory evoked potentials (SEPs) in experiment 3 up to 15 min after stimulation.

Results

Compared to before the stimulation, NMES + tsDCS significantly increased MEP for 60 min or more, and significantly decreased SICI immediately after. Conversely contrast, the PRMR significantly decreased immediately after, and SEPs were unchanged.

Discussion

These results suggest that simultaneous afferent inputs from different stimulus positions critically induce primary motor cortex plasticity. The combined stimulation of NMES with tsDCS may facilitate the development of a new neurorehabilitation technique.

Cortical processing during robot and functional electrical stimulation

Introduction

Like alpha rhythm, the somatosensory mu rhythm is suppressed in the presence of somatosensory inputs by implying cortical excitation. Sensorimotor rhythm (SMR) can be classified into two oscillatory frequency components: mu rhythm (8-13 Hz) and beta rhythm (14-25 Hz). The suppressed/enhanced SMR is a neural correlate of cortical activation related to efferent and afferent movement information. Therefore, it would be necessary to understand cortical information processing in diverse movement situations for clinical applications.

Methods

In this work, the EEG of 10 healthy volunteers was recorded while fingers were moved passively under different kinetic and kinematic conditions for proprioceptive stimulation. For the kinetics aspect, afferent brain activity (no simultaneous volition) was compared under two conditions of finger extension: (1) generated by an orthosis and (2) generated by the orthosis simultaneously combined and assisted with functional electrical stimulation (FES) applied at the forearm muscles related to finger extension. For the kinematic aspect, the finger extension was divided into two phases: (1) dynamic extension and (2) static extension (holding the extended position).

Results

In the kinematic aspect, both mu and beta rhythms were more suppressed during a dynamic than a static condition. However, only the mu rhythm showed a significant difference between kinetic conditions (with and without FES) affected by attention to proprioception after transitioning from dynamic to static state, but the beta rhythm was not.

Discussion

Our results indicate that mu rhythm was influenced considerably by muscle kinetics during finger movement produced by external devices, which has relevant implications for the design of neuromodulation and neurorehabilitation interventions.

Low-level voluntary input enhances corticospinal excitability during ankle dorsiflexion neuromuscular electrical stimulation in healthy young adults

Previous evidence indicated that interventions with combined neuromuscular electrical stimulation (NMES) and voluntary muscle contractions could have superior effects on corticospinal excitability when the produced total force is larger than each single intervention. However, it is unclear whether the superior effects exist when the produced force is matched between the interventions. Ten able-bodied individuals performed three intervention sessions on separate days: (i) NMES-tibialis anterior (TA) stimulation; (ii) NMES+VOL-TA stimulation combined with voluntary ankle dorsiflexion; (iii) VOL-voluntary ankle dorsiflexion. Each intervention was exerted at the same total output of 20% of maximal force and applied intermittently (5 s ON / 19 s OFF) for 16 min. Motor evoked potentials (MEP) of the right TA and soleus muscles and maximum motor response (Mmax) of the common peroneal nerve were assessed: before, during, and for 30 min after each intervention. Additionally, the ankle dorsiflexion force-matching task was evaluated before and after each intervention. Consequently, the TA MEP/Mmax during NMES+VOL and VOL sessions were significantly facilitated immediately after the interventions started until the interventions were over. Compared to NMES, larger facilitation was observed during NMES+VOL and VOL sessions, but no difference was found between them. Motor control was not affected by any interventions. Although superior combined effects were not shown compared to voluntary contractions alone, low-level voluntary contractions combined with NMES resulted in facilitated corticospinal excitability compared to NMES alone. This suggests that the voluntary drive could improve the effects of NMES even during low-level contractions, even if motor control is not affected.

Effectiveness of physical therapy interventions on post-stroke spasticity: An umbrella review

BACKGROUND

Post-stroke spasticity is often one of the primary impairments addressed in rehabilitation. However, limited guidance exists on the effectiveness of physical therapy (PT) interventions for post-stroke spasticity.

OBJECTIVE

To evaluate the quality of evidence of PT interventions for post-stroke spasticity.

METHODS

Ovid (Medline), Cochrane Library, CINAHL, Scopus, PEDro, and PROSPERO were searched to identify reviews based on the following criteria: 1) published between 2012 and 2021, 2) participants older than 18 years old, 3) post-stroke spasticity, 4) PT interventions, 5) clinical or neurophysiological measures of spasticity as primary outcomes. Assessment of Multiple Systematic Reviews 2 and the Grades of Recommendations Assessment, Development, and Evaluation assessed methodological quality.

RESULTS

Eight articles were included in the analysis. No high-quality evidence was found. Moderate quality evidence exists for transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, resistance training, and lower extremity ergometer training with or without functional electrical stimulation. Low quality evidence exists for dynamic stretching, botulinum toxin with constraint-induced movement therapy, and static stretching using positional orthoses.

CONCLUSION

Findings suggest that PT should prioritize a combination of active strategies over passive interventions, but further studies are needed prioritizing analyses of the movement system in managing post-stroke spasticity in conjunction with medical therapies.

The Effect of Neuromuscular Electrical Nerve Stimulation in the Management of Post-stroke Spasticity: A Scoping Review

Stroke is a cerebrovascular disorder characterized by the sudden onset of symptoms and clinical signs caused by either vascular infraction or hemorrhage. One of the main symptoms in the majority of post-stroke patients is spasticity. The main therapeutic options of spasticity in post-stroke patients include pharmacological interventions, rehabilitation techniques, and surgery. This review aims to explore the effectiveness of Neuromuscular Electrical Stimulation (NMES) for post-stroke spastic hemiparetic limb (upper and lower). Thorough research of the PubMed Medline database was performed. Records were limited to clinical studies published between 01/01/2010 and 01/01/2022. The results were screened by the authors in pairs. The search identified 26 records. After screening, nine records met the inclusion-exclusion criteria and were assessed. There were seven studies for spastic upper limbs and two for spastic lower limbs. The approaches investigated the effectiveness of electrical stimulation on post-stroke spastic upper or lower limb. Spasticity was measured through the modified Ashworth scale (MAS) and electromyographic recordings (EMG). In most cases, spasticity was decreased for at least two weeks post-intervention. In conclusion, NMES can be used either solo or in combination with different physical therapy modalities in order to produce optimal results, taking into consideration the specific needs and limitations of each individual patient. Based on the existing literature, as well as the limitations of the included studies, the authors believe that future studies on the subject of NMES in the management of post-stroke spasticity should focus on carefully examining each electrical parameter.

Contralaterally controlled neuromuscular electrical stimulation-induced changes in functional connectivity in patients with stroke assessed using functional near-infrared spectroscopy

Contralaterally controlled neuromuscular electrical stimulation (CCNMES) is an innovative therapy in stroke rehabilitation which has been verified in clinical studies. However, the underlying mechanism of CCNMES are yet to be comprehensively revealed. The main purpose of this study was to apply functional near-infrared spectroscopy (fNIRS) to compare CCNMES-related changes in functional connectivity (FC) within a cortical network after stroke with those induced by neuromuscular electrical stimulation (NMES) when performing wrist extension with hemiplegic upper extremity. Thirty-one stroke patients with right hemisphere lesion were randomly assigned to CCNMES (n = 16) or NMES (n = 15) groups. Patients in both groups received two tasks: 10-min rest and 10-min electrical stimulation task. In each task, the cerebral oxygenation signals in the prefrontal cortex (PFC), bilateral primary motor cortex (M1), and primary sensory cortex (S1) were measured by a 35-channel fNIRS. Compared with NMES, FC between ipsilesional M1 and contralesional M1/S1 were significantly strengthened during CCNMES. Additionally, significantly higher coupling strengths between ipsilesional PFC and contralesional M1/S1 were observed in the CCNMES group. Our findings suggest that CCNMES promotes the regulatory functions of ipsilesional prefrontal and motor areas as well as contralesional sensorimotor areas within the functional network in patients with stroke.

After 55 Years of Neurorehabilitation, What Is the Plan?

Neurological disorders often cause severe long-term disabilities with substantial activity limitations and participation restrictions such as community integration, family functioning, employment, social interaction and participation. Increasing understanding of brain functioning has opened new perspectives for more integrative interventions, boosting the intrinsic central nervous system neuroplastic capabilities in order to achieve efficient behavioral restitution. Neurorehabilitation must take into account the many aspects of the individual through a comprehensive analysis of actual and potential cognitive, behavioral, emotional and physical skills, while increasing awareness and understanding of the new self of the person being dealt with. The exclusive adoption by the rehabilitator of objective functional measures often overlooks the values and goals of the disabled person. Indeed, each individual has their own rhythm, unique life history and personality construct. In this challenging context, it is essential to deepen the assessment through subjective measures, which more adequately reflect the patient’s perspective in order to shape genuinely tailored instead of standardized neurorehabilitation approaches. In this overly complex panorama, where confounding and prognostic factors also strongly influence potential functional recovery, the healthcare community needs to rethink neurorehabilitation formats.

Hip and Knee Joint Angles Determine Fatigue Onset during Quadriceps Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation (NMES) has been used to increase muscle strength and physical function. However, NMES induces rapid fatigue, limiting its application. To date, the effect of quadriceps femoris (QF) muscle length by knee and hip joint manipulation on NMES-induced contraction fatigability is not clear. We aimed to quantify the effects of different muscle lengths on NMES-induced contraction fatigability, fatigue index, and electromyographic (EMG) activity for QF muscle. QF maximum evoked contraction (QMEC) was applied in a 26 min protocol (10 s on; 120 s off; 12 contractions) in 20 healthy participants (24.0 ± 4.6 years old), over 4 sessions on different days to test different conditions. The tested conditions were as follows: supine with knee flexion of 60° (SUP60), seated with knee flexion of 60° (SIT60), supine with knee flexion of 20° (SUP20), and seated with knee flexion of 20° (SIT20). Contraction fatigability (torque decline assessed by maximal voluntary contraction [MVC] and during NMES), fatigue index (percentage reduction in MVC), and EMG activity (root mean square [RMS] and median frequency) of the superficial QF' constituents were assessed. After NMES, all positions except SUP20 had an absolute reduction in MVC (p < .001). Fatigue index was greater in SIT20 than in SIT60 (p < .001) and SUP20 (p = .01). There was significant torque reduction across the 12 QMEC in SUP60 and SIT60, up to 10.5% (p < .001–.005) and 9.49% (p < .001–.033), respectively. There was no torque reduction during NMES in SUP20 and SIT20. Fatigue was accompanied by an increase in RMS (p = .032) and a decrease in median frequency for SUP60 (p < .001). Median frequency increased only in the SUP20 condition (p = .021). We concluded that QF NMES-induced contraction fatigability is greater when the knee is flexed at 60° compared to 20°. In addition, a supine position promotes earlier fatigue for a 60° knee flexion, but it delays fatigue onset for a 20° knee flexion compared to the seated position. These results provide a rationale for lower limb positioning during NMES, which depends on training objectives, e.g., strengthening or task-specific functionality training.

Upper Extremity Contralaterally Controlled Functional Electrical Stimulation Versus Neuromuscular Electrical Stimulation in Post-Stroke Individuals: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Electrical stimulation has been employed as a safe and effective therapy for improving arm function after stroke. Contralaterally controlled functional electrical stimulation (CCFES) is a unique method that has progressed from application in small feasibility studies to implementation in several randomized controlled trials. However, no meta-analysis has been conducted to summarize its efficacy.

OBJECTIVE

To summarize the effect size of CCFES through measures of upper extremity motor recovery compared with that of neuromuscular electrical stimulation (NMES).

METHODS

The PubMed, Cochrane Library, EMBASE, Scopus, and Google Scholar databases were searched. Randomized controlled trials (RCTs) were selected and subjected to meta-analysis and risk of bias assessment.

RESULTS

6 RCTs were selected and 267 participants were included. The Upper Extremity Fugl-Meyer assessment (UEFMA) was included in all studies, the Box and Blocks test (BBT) and active range of motion (AROM) were included in 3 and 4 studies, respectively. The modified Barthel Index (mBI) and Arm Motor Abilities Test (AMAT) were included in 2 and 3 studies, respectively. The CCFES group demonstrated greater improvement than the NMES did in UEFMA (SMD = .42, 95% CI = .07-.76), BBT (SMD = .48, 95% CI = .10-.86), AROM (SMD = .54, 95% CI = .23-.86), and mBI (SMD = .54, 95% CI = .12-.97). However, the results for AMAT did not differ significantly (SMD = .34, 95% CI = -.03-.72).

CONCLUSION

Contralaterally controlled functional electrical stimulation produced greater improvements in upper extremity hemiplegia in people with stroke than NMES did. PROSPERO registration number: CRD42021245831.

Efficacy of contralaterally controlled functional electrical stimulation compared to cyclic neuromuscular electrical stimulation and task-oriented training for recovery of hand function after stroke: study protocol for a multi-site randomized controlled trial

BACKGROUND

Multi-site studies in stroke rehabilitation are important for determining whether a technology and/or treatment can be successfully administered by sites other than the originating site and with similar positive outcomes. This study is the first multi-site clinical trial of a novel intervention for post-stroke upper limb rehabilitation called contralaterally controlled functional electrical stimulation (CCFES). Previous pilot and single-site studies showed positive effects of CCFES on upper limb impairment and hand dexterity in stroke survivors. The main purpose of this study is to confirm and demonstrate the efficacy of CCFES in a larger group of most likely responders across multiple clinical sites.

METHODS

Up to 129 stroke survivors with moderate to severe upper extremity hemiparesis at 4 clinical trial sites will be randomized to CCFES, cyclic neuromuscular electrical stimulation (cNMES), or task-oriented-training (TOT). Participants will receive 12 weeks of group-specific therapy. Blinded assessments of upper limb impairment and activity limitation, quality of life, and neurophysiology will be used to compare outcomes at baseline, after treatment, and up to 6 months post-treatment. The primary endpoint is change in dexterity from baseline to 6 months post-treatment.

DISCUSSION

Loss of hand function following stroke is a major rehabilitation problem affecting millions of people per year globally. More effective rehabilitation therapies are needed to restore hand function in these individuals. This study will determine whether CCFES therapy produces greater improvements in upper extremity function than cNMES or TOT, and will begin to elucidate the different mechanisms underlying each of the three treatments. This multi-site study is a critical step in advancing a novel method of rehabilitation toward clinical translation and widespread dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03574623 . Registered prior to first enrollment; July 2, 2018.

Effect of neuromuscular electrical stimulation combined with swallowing rehabilitation training on the treatment efficacy and life quality of stroke patients with dysphagia

PURPOSE

To explore the therapeutic efficacy of neuromuscular electrical stimulation (NMES) combined with swallowing rehabilitation training on the healing effect and quality of life of stroke patients with dysphagia.

METHODS

The clinical data of 63 stroke patients admitted to the First Affiliated Hospital of Zhengzhou University from October 2019 to September 2020 were retrospectively analyzed. The included patients were divided into two groups according to different treatment plans: an observation group (n=33) treated with NMES combined with swallowing rehabilitation training, and a control group (n=30) treated by swallowing rehabilitation training alone. Before and after 2 courses of treatment, the Water swallow test, Functional Oral Intake Scale (FOIS), and MD Anderson Dysphagia Inventory (MDADI) were used to assess the swallowing function of patients in the two groups, and the National Institutes of Health Stroke Scale (NIHSS) was used to evaluate patients' neurological deficit; the SA7550 surface electromyogram (EMG) analysis system was applied to collect surface EMG, and the F113-5 medical X-ray TV system was used to detect the mobility of the hyoid-throat complex; the negative emotions of patients were assessed using the Hamilton Rating Scale for Depression (HAMD) before and after treatment, and the quality of life was evaluated by the Swallowing Quality of Life (SWAL-QOL) questionnaire; and the occurrence of adverse reactions during treatment was recorded and compared between the two groups.

RESULTS

There was no significant difference in swallowing function, duration of swallowing, maximum amplitude value, and hyoid-throat complex mobility between the two groups before treatment (P>0.05), nor were there any differences in the scores of FOIS, MDADI, NIHSS, HAMD, and SWAL-QOL before treatment (P>0.05). After treatment, however, the above indicators of both groups were significantly improved (P<0.05), and the improvements were more significant in the observation group compared with the control group (P<0.05). Moreover, the incidence of adverse reactions in both groups were relatively low without significant difference between groups (P>0.05).

CONCLUSION

NMES combined with swallowing rehabilitation training is effective in the treatment of swallowing dysfunction following stroke. It can effectively improve patients' swallowing function and quality of life, and relieve their negative emotions, with a high safety profile, which is worthy of clinical promotion.

Rehabilitation of Upper Limb Motor Impairment in Stroke: A Narrative Review on the Prevalence, Risk Factors, and Economic Statistics of Stroke and State of the Art Therapies

Stroke has been one of the leading causes of disability worldwide and is still a social health issue. Keeping in view the importance of physical rehabilitation of stroke patients, an analytical review has been compiled in which different therapies have been reviewed for their effectiveness, such as functional electric stimulation (FES), noninvasive brain stimulation (NIBS) including transcranial direct current stimulation (t-DCS) and transcranial magnetic stimulation (t-MS), invasive epidural cortical stimulation, virtual reality (VR) rehabilitation, task-oriented therapy, robot-assisted training, tele rehabilitation, and cerebral plasticity for the rehabilitation of upper extremity motor impairment. New therapeutic rehabilitation techniques are also being investigated, such as VR. This literature review mainly focuses on the randomized controlled studies, reviews, and statistical meta-analyses associated with motor rehabilitation after stroke. Moreover, with the increasing prevalence rate and the adverse socio-economic consequences of stroke, a statistical analysis covering its economic factors such as treatment, medication and post-stroke care services, and risk factors (modifiable and non-modifiable) have also been discussed. This review suggests that if the prevalence rate of the disease remains persistent, a considerable increase in the stroke population is expected by 2025, causing a substantial economic burden on society, as the survival rate of stroke is high compared to other diseases. Compared to all the other therapies, VR has now emerged as the modern approach towards rehabilitation motor activity of impaired limbs. A range of randomized controlled studies and experimental trials were reviewed to analyse the effectiveness of VR as a rehabilitative treatment with considerable satisfactory results. However, more clinical controlled trials are required to establish a strong evidence base for VR to be widely accepted as a preferred rehabilitation therapy for stroke.

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

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

Effectiveness of a Novel Contralaterally Controlled Neuromuscular Electrical Stimulation for Restoring Lower Limb Motor Performance and Activities of Daily Living in Stroke Survivors: A Randomized Controlled Trial

Background

Contralaterally controlled neuromuscular electrical stimulation (CCNMES) is a novel electrical stimulation treatment for stroke; however, reports on the efficacy of CCNMES on lower extremity function after stroke are scarce.

Objective

To compare the effects of CCNMES versus NMES on lower extremity function and activities of daily living (ADL) in subacute stroke patients.

Methods

Forty-four patients with a history of subacute stroke were randomly assigned to a CCNMES group and a NMES group (n = 22 per group). Twenty-one patients in each group completed the study per protocol, with one subject lost in follow-up in each group. The CCNMES group received CCNMES to the tibialis anterior (TA) and the peroneus longus and brevis muscles to induce ankle dorsiflexion motion, whereas the NMES group received NMES. The stimulus current was a biphasic waveform with a pulse duration of 200 μs and a frequency of 60 Hz. Patients in both groups underwent five 15 min sessions of electrical stimulation per week for three weeks. Indicators of motor function and ADL were measured pre- and posttreatment, including the Fugl–Meyer assessment of the lower extremity (FMA-LE) and modified Barthel index (MBI). Surface electromyography (sEMG) assessments included average electromyography (aEMG), integrated electromyography (iEMG), and root mean square (RMS) of the paretic TA muscle.

Results

Values for the FMA-LE, MBI, aEMG, iEMG, and RMS of the affected TA muscle were significantly increased in both groups after treatment (p < 0.01). Patients in the CCNMES group showed significant improvements in all the measurements compared with the NMES group after treatment. Within-group differences in all post- and pretreatment indicators were significantly greater in the CCNMES group than in the NMES group (p < 0.05).

Conclusion

CCNMES improved motor function and ADL ability to a greater extent than the conventional NMES in subacute stroke patients.

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

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

Effectiveness of Contralaterally Controlled Functional Electrical Stimulation versus Neuromuscular Electrical Stimulation on Upper Limb Motor Functional Recovery in Subacute Stroke Patients: A Randomized Controlled Trial

Purpose

To compare the effectiveness of contralaterally controlled functional electrical stimulation (CCFES) versus neuromuscular electrical stimulation (NMES) on motor recovery of the upper limb in subacute stroke patients.

Materials and Methods

Fifty patients within six months poststroke were randomly assigned to the CCFES group (n = 25) and the NMES group (n = 25). Both groups underwent routine rehabilitation plus 20-minute stimulation on wrist extensors per day, five days a week, for 3 weeks. Fugl-Meyer Assessment of upper extremity (FMA-UE), action research arm test (ARAT), Barthel Index (BI), and surface electromyography (sEMG) were assessed at baseline and end of intervention.

Results

After a 3-week intervention, FMA-UE and BI increased in both groups (p < 0.05). ARAT increased significantly only in the CCFES group (p < 0.05). The changes of FMA-UE, ARAT, and BI in the CCFES group were not greater than those in the NMES group. The improvement in sEMG response of extensor carpi radialis by CCFES was greater than that by NMES (p = 0.026). The cocontraction ratio (CCR) of flexor carpi radialis did not decrease in both groups.

Conclusions

CCFES improved upper limb motor function, but did not show better treatment effect than NMES. CCFES significantly enhanced the sEMG response of paretic extensor carpi radialis compared with NMES, but did not decrease the cocontraction of antagonist.

Neuromuscular electrical stimulation for motor recovery in pediatric neurological conditions: a scoping review

AIM

To explore the breadth of pediatric neurological conditions for which neuromuscular electrical stimulation (NMES) has been studied.

METHOD

Databases (PubMed, Google Scholar, Scopus, and Embase) were searched from 2000 to 2020, using the search terms 'neuromuscular electrical stimulation' OR 'functional electrical stimulation' with at least one of the words 'pediatric OR child OR children OR adolescent', and without the words 'dysphagia OR implanted OR enuresis OR constipation'. Articles focused on adults or individuals with cerebral palsy (CP) were excluded.

RESULTS

Thirty-five studies met the inclusion criteria, with a total of 353 pediatric participants (293 unique participants; mean age 7y 4mo, range 1wk-38y). NMES was applied in a range of pediatric conditions other than CP, including stroke, spinal cord injury, myelomeningocele, scoliosis, congenital clubfoot, obstetric brachial plexus injury, genetic neuromuscular diseases, and other neuromuscular conditions causing weakness.

INTERPRETATION

All 35 studies concluded that NMES was well-tolerated and most studies suggested that NMES could augment traditional therapy methods to improve strength. Outcome measurements were heterogeneous. Further research on NMES with larger, randomized studies will help clarify its potential to improve physiology and mobility in pediatric patients with neuromuscular conditions. What this paper adds Neuromuscular electrical stimulation (NMES) appears to be tolerated by pediatric patients. NMES shows potential for augmenting recovery in pediatric patients with a range of rehabilitation needs.

Neuromuscular Electrical Stimulation Improves Activities of Daily Living Post Stroke: A Systematic Review and Meta-analysis

Objectives

(1) To elucidate the effectiveness of neuromuscular electrical stimulation (NMES) toward improving activities of daily living (ADL) and functional motor ability post stroke and (2) to investigate the influence of paresis severity and the timing of treatment initiation for the effectiveness of NMES.

Data Sources

PubMed, MEDLINE, Embase, Physiotherapy Evidence Database (PEDro) and Cochrane Library searched for relevant articles from database inception to May 2020.

Study Selection

The inclusion criteria were randomized controlled trials exploring the effect of NMES toward improving ADL or functional motor ability in survivors of stroke. The search identified 6064 potential articles with 20 being included.

Data Extraction

Two independent reviewers conducted the data extraction. Methodological quality was assessed using the PEDro scale and the Cochrane Risk of Bias Tool.

Data Synthesis

Data from 428 and 659 participants (mean age, 62.4 years; 54% male) for outcomes of ADL and functional motor ability, respectively, were pooled in a random-effect meta-analysis. The analysis revealed a significant positive effect of NMES toward ADL (standardized mean difference [SMD], 0.41; 95% CI, 0.14-0.67; P=.003), whereas no effect on functional motor ability was evident. Subgroup analyses showed that application of NMES in the subacute stage (SMD, 0.44; 95% CI, 0.09-0.78; P=.01) and in the upper extremity (SMD, 0.34; 95% CI, 0.04-0.64; P=.02) improved ADL, whereas a beneficial effect was observed for functional motor abilities in patients with severe paresis (SMD, 0.41; 95% CI, 0.12-0.70; P=.005).

Conclusions

The results of the present meta-analysis are indicative of potential beneficial effects of NMES toward improving ADL post stroke, whereas the potential for improving functional motor ability appears less clear. Furthermore, subgroup analyses indicated that NMES application in the subacute stage and targeted at the upper extremity is efficacious for ADL rehabilitation and that functional motor abilities can be positively affected in patients with severe paresis.

Combined Use of EMG and EEG Techniques for Neuromotor Assessment in Rehabilitative Applications: A Systematic Review

Electroencephalography (EEG) and electromyography (EMG) are widespread and well-known quantitative techniques used for gathering biological signals at cortical and muscular levels, respectively. Indeed, they provide relevant insights for increasing knowledge in different domains, such as physical and cognitive, and research fields, including neuromotor rehabilitation. So far, EEG and EMG techniques have been independently exploited to guide or assess the outcome of the rehabilitation, preferring one technique over the other according to the aim of the investigation. More recently, the combination of EEG and EMG started to be considered as a potential breakthrough approach to improve rehabilitation effectiveness. However, since it is a relatively recent research field, we observed that no comprehensive reviews available nor standard procedures and setups for simultaneous acquisitions and processing have been identified. Consequently, this paper presents a systematic review of EEG and EMG applications specifically aimed at evaluating and assessing neuromotor performance, focusing on cortico-muscular interactions in the rehabilitation field. A total of 213 articles were identified from scientific databases, and, following rigorous scrutiny, 55 were analyzed in detail in this review. Most of the applications are focused on the study of stroke patients, and the rehabilitation target is usually on the upper or lower limbs. Regarding the methodological approaches used to acquire and process data, our results show that a simultaneous EEG and EMG acquisition is quite common in the field, but it is mostly performed with EMG as a support technique for more specific EEG approaches. Non-specific processing methods such as EEG-EMG coherence are used to provide combined EEG/EMG signal analysis, but rarely both signals are analyzed using state-of-the-art techniques that are gold-standard in each of the two domains. Future directions may be oriented toward multi-domain approaches able to exploit the full potential of combined EEG and EMG, for example targeting a wider range of pathologies and implementing more structured clinical trials to confirm the results of the current pilot studies.

Reactive Exercises with Interactive Objects: Interim Analysis of a Randomized Trial on Task-Driven NMES Grasp Rehabilitation for Subacute and Early Chronic Stroke Patients

Enriched environments and tools are believed to promote grasp rehabilitation after stroke. We designed S2, an interactive grasp rehabilitation system consisting of smart objects, custom orthoses for selective grasp constraining, and an electrode array system for forearm NMES. Motor improvements and perceived usability of a new enriched upper limb training system for sub-acute stroke patients was assessed in this interim analysis. Inclusion criteria: sub-acute stroke patients with MMSE>20, ipsilesional MI>80%, and contralesional MI<80%. Effects of 30-min therapy supplements, conventional vs. S2 prototype, are compared through a parallel two-arms dose-matched open-label trial, lasting 27 sessions. Clinical centres: Asklepios Neurologische Klinik Falkenstein, Königstein im Taunus, Germany, and Clinica Villa Beretta, Costa Masnaga, Italy. Assessment scales: ARAT, System Usability, and Technology Acceptance. Methodology: 26 participants were block randomized, allocated to the study (control N=12, experimental N=14) and underwent the training protocol. Among them, 11 participants with ARAT score at inclusion below 35, n = 6 in the experimental group, and n = 5 in the control group were analysed. Results: participants in the enriched treatment group displayed a larger improvement in the ARAT scale (+14.9 pts, pval=0.0494). Perceived usability differed between clinics. No adverse effect was observed in relation to the treatments. Trial status: closed. Conclusions: The S2 system, developed according to shared clinical directives, was tested in a clinical proof of concept. Variations of ARAT scores confirm the feasibility of clinical investigation for hand rehabilitation after stroke.

Application of neuromuscular electrical stimulation on the support limb during reactive balance control in persons with stroke: a pilot study

The aim of the present study was to investigate the effect of the application of neuromuscular electrical stimulation to the quadriceps muscle of the paretic limb during externally induced stance perturbations on reactive balance control and on fall outcomes in people with chronic stroke. Ten participants experienced 12 stance treadmill perturbation trails, 6 forward balance perturbation trials and 6 backward balance perturbation trials. For each perturbation condition, three perturbation trials were delivered synchronized with neuromuscular electrical stimulation applied to the quadriceps of the paretic limb and three perturbation trials were delivered without stimulation. Behavioral outcome measures, such as incidence of laboratory falls and number of compensatory steps, kinematic outcome measures, such as margin of stability and minimum hip high values after the perturbation, step initiation time, step execution time and step length of the stepping leg were analyzed. The application of neuromuscular electrical stimulation on the paretic quadriceps between the range of 50 and 500 ms after stance forward and backward perturbations reduced the laboratory falls incidence (p < 0.05), improved stability values (p < 0.05) and reduced the hip height descent (p < 0.05) compared to the experimental condition in which participants were exposed to stance perturbations without neuromuscular electrical stimulation. Additionally, step initiation time of the recovery step was lower in neuromuscular electrical stimulation condition during the forward balance perturbation protocol. Our results showed that the application of neuromuscular electrical stimulation on the knee extensor muscles of the paretic limb reduces the incidence of laboratory falls, enhances reactive stability control and reduces vertical limb collapse after stance forward and backward perturbations in people with chronic stroke.

Cortico-muscular interaction to monitor the effects of neuromuscular electrical stimulation pedaling training in chronic stroke

Neuromuscular electrical stimulation (NMES) has been widely utilized in post-stroke motor restoration. However, its impact on the closed-loop sensorimotor control process remains largely unclear. This is the first study to investigate the directional changes in cortico-muscular interactions after repetitive rehabilitation training by measuring the noninvasive electroencephalogram (EEG) and electromyography (EMG) signals. In this study, 10 subjects with chronic stroke received 20 sessions of NMES-pedaling interventions, and each training session included three 10-min NMES-driven pedaling trials. In addition, pre- and post-intervention assessments of lower limb isometric contraction were conducted before and after the whole NMES-pedaling interventions. The EEG (128 channels) and EMG (3 bilateral lower limb sensors) signals were collected during the isometric contraction tasks for the paretic and non-paretic lower limbs. Both the cortico-muscular coherence (CMC) and generalized partial directed coherence (GPDC) values were analyzed between eight selected EEG channels in the central primary motor cortex and EMG channels. The results revealed significant clinical improvements. Additionally, rehabilitation training facilitated cortico-muscular interaction of the ipsilesional brain and paretic lower limbs (p = 0.004). Moreover, both the descending and ascending cortico-muscular pathways were altered after NMES-training (p = 0.001, p < 0.001). Therefore, the results implied potential applications of EEG-EMG in understanding neuromuscular changes during the post-stroke motor rehabilitation process.