Upper Limb In Post-stroke Patients Research Articles

Literature review: User interface of system functional electrical stimulation (FES) and arm robotic rehabilitation

Interface technology development for human-robot interaction (HRI) in rehabilitation systems has increased in recent years. HRI can effectively achieve specific motor goals desired in rehabilitation, such as combining human intentions and actions with robotic devices to perform the desired stroke rehabilitation movements. Rehabilitation devices are starting to be directed towards using devices that integrate functional electrical stimulation (FES) with robotic arms because they have succeeded in providing promising interventions to restore arm function by intensively activating the muscles of post-stroke patients. However, FES requires a high level of accuracy to position the limbs for the functional tasks given because excessive electrical stimulation can cause fatigue in the patient, so it is necessary to provide electrical stimulation with an amplitude that suits the patient's needs. Unfortunately, most studies have a constant voltage amplitude and do not consider the voltage that matches the patient's muscle needs; this treatment can cause fatigue in the patient. Robotic devices as rehabilitation aids have the potential to support external power and adapt electrical stimulation needs to the voltage amplitude applied to the FES. Integrating FES with a robotic arm support system into one hybrid neuroprosthesis is attractive because the mechanical device can complement muscle action and increase rehabilitation's repeatability and accuracy rate. The integration of FES and robotic arms is a promising approach in the future. This article reviews the state of the art regarding motor rehabilitation using functional electrical stimulation (FES) devices and robotic arms for the upper limbs of post-stroke patients. A narrative review was done through a literature search using the IEEE-Xplore, Scopus, and PubMed databases. Nine different rehabilitation system articles were identified. The selected systems were compared critically by considering the design and actuators, components, technological aspects, and technological challenges that could be developed in the future. This article also examines the development of HRI and emerging research trends in HRI-based rehabilitation

The effectiveness of robotic rehabilitation for the functional recovery of the upper limb in post-stroke patients: a systematic review

Stroke is a significant contributor to global mortality and disability, and it is typically classified as a neurological disorder. A key component of stroke rehabilitation is improving upper limb function to reduce impairments and disabilities and their impact on activities of daily living. In the last few years, robot-assisted therapy (RT) arises as a novel and expanding approach in poststroke rehabilitation, which utilizes robotic devices to facilitate the recovery of motor function and task-oriented training. The aim of this systematic review, conducted through MEDLINE, CINAHL and EMBASE consultation, was to investigate the association between functional outcomes of the upper limb in patients with stroke after-effects and the use of robotic rehabilitation.The results of the included studies have highlighted the impact of robot-assisted rehabilitation, whether integrated with traditional physiotherapy, on several clinical outcomes such as pain, spasticity, motor function, hand and finger function and cognitive abilities. The introduction of the robot-assisted intervention, coupled with traditional treatment, maybe a valuable approach to improving quality of life and enhance not only motor function but also the cognitive ability of stroke patients, especially whether focusing on the early phase of stroke recovery with a high potential impact on clinical practice. Keywords: Stroke; Upper limb; Robotic rehabilitation; Neurological disorders; robot-assisted therapy;

Biomechanical assessment of the ipsilesional upper limb in post-stroke patients during multi-joint reaching tasks: A quantitative study.

In hemiplegic patients with stroke, investigating the ipsilesional limb may shed light on the upper limb motor control, impairments and mechanisms of functional recovery. Usually investigation of motor impairment and rehabilitative interventions in patients are performed only based on the contralesional limb. Previous studies found that also the ipsilesional limb presents motor deficits, mostly evaluated with clinical scales which could lack of sensibility. To quantitatively evaluate the performance of the ipsilesional limb in patient with stroke, we conducted an observational study in which 49 hemiplegic patients were enrolled, divided in subgroups based on the severity of impairment of the contralesional limb, and assessed with a kinematic, dynamic and motor control evaluation protocol on their ipsilesional upper limb during reaching movements. Measurements were repeated in the acute and subacute phases and compared to healthy controls. Our results showed that the ipsilesional limb presented lower kinematic and dynamic performances with respect to the healthy controls. Patients performed the movements slower and with a reduced range of motion, indicating a difficulty in controlling the motion of the arm. The energy and the power outputs were lower in both shoulder and elbow joint with a high significance level, confirming the limitation found in kinematics. Moreover, we showed that motor deficits were higher in the acute phase with respect to the subacute one and we found higher significant differences in the group with a more severe contralesional limb impairment. Ipsilesional upper limb biomechanics adds significant and more sensible measures for assessments based on multi-joints dynamics, providing a better insight on the upper limb motor control after stroke. These results could have clinical implications while evaluating and treating ipsilesional and contralesional upper limb impairments and dysfunctions in patients with stroke.

Effects of Radial Extracorporeal Shock Wave Therapy On Flexor Spasticity of the Upper Limb in Post-Stroke Patients: A Randomized Controlled Trial

Effects of Radial Extracorporeal Shock Wave Therapy On Flexor Spasticity of the Upper Limb in Post-Stroke Patients: A Randomized Controlled Trial

Effects of Radial Extracorporeal Shock Wave Therapy on Flexor Spasticity of the Upper Limb in Post-stroke Patients: Study Protocol for a Randomized Controlled Trial.

Background: Flexor spasticity of the upper limb is common in poststroke patients and seriously affects the recovery of upper limb function. However, there are no standard management protocols for this condition. Radial extracorporeal shock wave therapy (rESWT) is widely used for various diseases, some studies reported the effects of ESWT on reducing spasticity, but the mechanism of ESWT to reduce spasticity by affecting the excitability of stretch reflex or non-neural rheological components in spastic muscles or both is not yet clear. A large randomized controlled trial with comprehensive evaluation indicators is still needed. The study is to observe the effect of rESWT on flexor spasticity of the upper limb after stroke and explore its mechanism.Methods: A prospective, randomized, double-blind controlled trial is to be performed. One hundred participants will be recruited from the Inpatient Department of Zhujiang Hospital. Eligible patients will be randomly allocated to either receive three sessions of active rESWT (group A) or sham-placebo rESWT (group B) with 3-day intervals between each session. Assessment will be performed at baseline and at 24 h after each rESWT (t1, t2, and t3). The primary assessment outcome will be the Modified Ashworth Scale, and other assessments include surface electromyography, MyotonPRO digital muscle function evaluation, and infrared thermal imaging. All data will be analyzed using intention-to-treat principles. Multiple imputation by chained equations will be used to address missing data caused by loss to follow-up and nonresponses. Per protocol, analyses will also be performed on the participants who complete other assessments. Statistical analysis will be performed using SPSS software (version 20.0) and the significance level set at p < 0.05.Discussion: This trial aims to analyze the application of rESWT for the management of spasticity after stroke via appropriate assessments. We hypothesized that after receiving active rESWT, patients would show greater improvement of upper limb muscles compared with patients within the sham-placebo group. The rESWT would be an alternative to traditional methods, and the results of this study may provide support for the further study of potential mechanisms.Clinical Trial Registration:www.chictr.org.cn, identifier: ChiCTR1800016144.

Effects of Gamification in BCI Functional Rehabilitation.

ObjectiveTo evaluate whether introducing gamification in BCI rehabilitation of the upper limbs of post-stroke patients has a positive impact on their experience without altering their efficacy in creating motor mental images (MI).DesignA game was designed purposely adapted to the pace and goals of an established BCI-rehabilitation protocol. Rehabilitation was based on a double feedback: functional electrostimulation and animation of a virtual avatar of the patient’s limbs. The game introduced a narrative on top of this visual feedback with an external goal to achieve (protecting bits of cheese from a rat character). A pilot study was performed with 10 patients and a control group of six volunteers. Two rehabilitation sessions were done, each made up of one stage of calibration and two training stages, some stages with the game and others without. The accuracy of the classification computed was taken as a measure to compare the efficacy of MI. Users’ opinions were gathered through a questionnaire. No potentially identifiable human images or data are presented in this study.ResultsThe gamified rehabilitation presented in the pilot study does not impact on the efficacy of MI, but it improves users experience making it more fun.ConclusionThese preliminary results are encouraging to continue investigating how game narratives can be introduced in BCI rehabilitation to make it more gratifying and engaging.

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

Functional recovery of the plegic upper limb in post-stroke patients may be enhanced by sequentially applying a myoelectrically controlled FES (MeCFES), which allows the patient to voluntarily control the muscle contraction during a functional movement, and robotic therapy which allows many repetitions of movements. Evaluate the efficacy of MeCFES followed by robotic therapy compared to standard care arm rehabilitation for post-stroke patients. Eighteen stroke subjects (onset ⩾ 3 months, age 60.1 ± 15.5) were recruited and randomized to receive an experimental combination of MeCFES during task-oriented reaching followed by robot therapy (MRG) or same intensity conventional rehabilitation care (CG) aimed at the recovery of the upper limb (20 sessions/45 minutes). Change was evaluated through Fugl-Meyer upper extremity (FMA-UE), Reaching Performance Scale and Box and Block Test. The experimental treatment resulted in higher improvement on the FMA-UE compared with CG (P= 0.04), with a 10-point increase following intervention. Effect sizes were moderate in favor of the MRG group on FMA-UE, FMA-UE proximal and RPS (0.37-0.56). Preliminary findings indicate that a combination of MeCFES and robotic treatment may be more effective than standard care for recovery of the plegic arm in persons > 3 months after stroke. The mix of motor learning techniques may be important for successful rehabilitation of arm function.

Influence of positional changes on spasticity of the upper extremity in poststroke hemiplegic patients

BackgroundSpasticity commonly occurs in hemiplegic patients with stroke, and clinical experience indicates that upper limb spasticity is more apparent when patients are standing than when they are lying down. Few reports have investigated how positional changes impact the spasticity of the upper limb and trigger a combined movement called the “hemiplegic posture”. ObjectiveThe objective of this study was to explore the influence of different body positions on the spasticity of the upper extremity. MethodsEighty-four poststroke patients with upper limb spasticity were recruited for this study. We measured the spasticity of hemiplegic upper limbs involving elbow flexors, wrist flexors and digitorum flexors using the Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS) and Triple Spasticity Scale (TSS) in three positions, i.e., supine, sitting and standing. The results were obtained by comparing one position with another for each muscle. ResultsAll the MAS, MTS and TSS scores of all the muscles of the upper limb were significantly lower in the supine position than in the other positions (all P < 0.05), and the MTS and TSS scores were statistically higher while standing than while sitting (P < 0.05). ConclusionHigh modulation of spasticity in the upper limbs measured using the MAS, MTS and TSS when transitioning to the standing position from either the supine or sitting position demonstrated that posture plays a role in modulating the spasticity of the hemiplegic upper limb in poststroke patients.

Intrathecal baclofen therapy versus conventional medical management in post-stroke spasticity: Assessment of patient-reported outcome: Quality of life, pain and satisfaction (SISTERS)

SISTERS is the first multicenter randomized trial demonstrating superiority of intrathecal baclofen (ITB) therapy versus conventional medical management (CMM) with oral antispastic in decreasing muscle hypertonia in lower and upper limbs of post-stroke patients with severe spasticity. Here we report Numeric Pain Rating Scale (NPRS), Quality of Life (QoL) assessed by EQ-5D and Stroke Specific QoL (SS-QoL), satisfaction and safety. Sixty stroke patients with spasticity in ≥ 2 extremities and an Ashworth Scale score ≥ 3 in ≥ 2 affected muscle groups in the lower limbs were randomized to ITB or CMM group and both arms received physiotherapy. Mean changes (SD) from baseline to month 6 in ITB patients versus CMM group were −1.17 (3.17) vs. 0.00 (3.29) for NPRS actual pain, −1.61 (2.29) vs. 0.24 (3.07) for NPRS least pain and 0.09 (0.26) vs. 0.01 (0.16) for EQ-5D utility score. These between-group differences were statistically significant ( P < 0.05, Wilcoxon test). ITB patients showed greater improvements in NPRS worst pain [−1.35 (2.42) vs. −0.04 (3.69)], EQ-5D health status [9.68 (20.42) vs. 4.40 (21.75)] and SS-QoL [0.26 (0.58) vs. 0.05 (0.58)], although between-group differences were not statistically significant. Extreme problems of individual EQ-5D dimensions at baseline were reported by 30%, 26%, 17% and 13% of ITB patients in self-care, usual activities, pain/discomfort and mobility, respectively. At 6 months there was a decrease in the percentage of patients reporting extreme problems for all domains except mobility. More ITB than CMM patients (73% vs. 48%) were satisfied with the spasticity reduction at month 6. In total 17 (68%) ITB implanted patients reported at least one treatment-related adverse events versus 7 (20%) in CMM group. No treatment-related adverse event led to discontinuation of ITB therapy. Reduction of muscle tone with ITB therapy is associated with improvements in pain and QoL in post-stroke patients with severe spasticity.

Sleep during low-frequency repetitive transcranial magnetic stimulation is associated with functional improvement in upper limb hemiparesis after stroke

Many studies have reported that repetitive transcranial magnetic stimulation (rTMS) is beneficial for post-stroke patients with upper limb hemiparesis. It was reported that application of rTMS during sleep could possibly strengthen neural plasticity. The purpose of this study was to investigate the relationship between sleep during low-frequency rTMS session and improvement of motor function in affected upper limb in post-stroke patients after inpatient rehabilitation combined with rTMS using the bispectral index (BIS) monitor. During 15-day hospitalization, each patient received rTMS and intensive occupational therapy. Low-frequency rTMS with 1Hz was applied over the contralesional motor cortex. During rTMS session, adhesive sensor was put on each patient's forehead and connected to the BIS monitor. The mean score for the maximum change of BIS values during each rTMS session (ΔBIS) was calculated. We regarded the patients with and over 10 of mean ΔBIS as Asleep group and under 10 as Awake group. Fugl-Meyer assessment (FMA) and Action Research Arm Test (ARAT) were evaluated on admission and discharge. Awake group included six patients and Asleep group included seven patients. There was no significant difference in clinical characteristics and in increase of FMA between two groups. Asleep group was significantly superior to Awake group in the increase of ARAT (p < 0.05). There was a significant correlation between the mean of ΔBIS and increase of ARAT (ρ = 0.78, p = 0.002). Sleep during low-frequency rTMS may contribute to improvement of motor function in the affected upper limb.

Effects of repetitive transcranial magnetic stimulation and intensive occupational therapy on motor neuron excitability in poststroke hemiparetic patients: A neurophysiological investigation using F-wave parameters

Background: The combination protocol of repetitive transcranial magnetic stimulation (RTMS) and intensive occupational therapy (OT) improves motor function of the paretic upper limb in poststroke patients. However, the effect of RTMS/OT on motor neuron excitability remains to be investigated. The purpose of this study was to determine the effect of 15-day application of RTMS/OT on motor neuron excitability in such patients using neurophysiological studies including F-wave parameter measurements. Subjects and Methods: Ten poststroke patients with spastic upper limb hemiparesis were studied (mean age: 57.4 ± 8.1 years, ±SD). Patients were hospitalized for 15 days to receive RTMS/OT. One session of 40-min low-frequency RTMS and two sessions of 120-min intensive OT were provided daily. Neurophysiological studies including F-wave parameters measurements were performed on the days of admission/discharge. Motor function and spasticity of the affected upper limb were evaluated on the same time points. Results: RTMS/OT significantly improved motor function of the affected upper limb. RTMS/OT decreased the modified Ashworth scale (MAS) in the affected upper limb (p < 0.05), but did not change F-wave frequency in either upper limb. However, both F-mean/M ratio and F-max/M ratio significantly decreased in the affected upper limb (all p < 0.05). Conclusions: The 15-day protocol of LF-RTMS/OT produced significant reduction of motor neuron excitability. RTMS/OT can potentially produce significant reduction in upper limb spasticity in the affected upper limb, although this finding should be confirmed in a larger number of patients.

Bihemispheric repetitive transcranial magnetic stimulation combined with intensive occupational therapy for upper limb hemiparesis after stroke

We investigated the safety, feasibility, and efficacy of the combination of bihemispheric repetitive transcranial magnetic stimulation (rTMS) and intensive occupational therapy (OT) for upper limb hemiparesis in poststroke patients. The study participants were eight poststroke patients with upper limb hemiparesis (age at intervention: 62.8±4.9 years, time after stroke: 84.3±87.2 months, mean±SD). During 15 days of hospitalization, each patient received 10 sessions of 40-min bihemispheric rTMS and 240-min intensive OT (120-min one-to-one training and 120-min self-training). One session of bihemispheric rTMS comprised the application of both 1 and 10 Hz rTMS (2000 stimuli for each hemisphere). The Fugl-Meyer Assessment, Wolf Motor Function Test, and the Modified Ashworth Scale were administered on the day of admission and at discharge. All patients completed the treatment without any adverse effects. Motor function of the affected upper limb improved significantly, on the basis of changes in Fugl-Meyer Assessment and Wolf Motor Function Test (P<0.05, each). A significant decrease in the Modified Ashworth Scale score was noted in the elbow, wrist, and finger flexors of the affected upper limb (P<0.05, each). The combination of bihemispheric rTMS and intensive OT was safe and feasible therapy for poststroke hemiparetic patients, and improved motor function of the hemiparetic upper limb in poststroke patients. The findings provide a new avenue for the treatment of patients with poststroke hemiparesis.

Effect of low-frequency rTMS on motor neuron excitability after stroke

The purpose of this study was to test the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) over the non-lesional hemisphere on motor neuron excitability of the paretic upper limb in post-stroke patients by electrophysiological examination. Thirteen post-stroke patients with spastic upper limb hemiparesis were studied (age, 57.5 ± 11.1 years; time after stroke, 55.2 ± 51.4 months). Low-frequency rTMS of 1 Hz was applied for 20 min to the motor cortex of the non-lesional hemisphere. The M-response amplitude and F-wave parameters were recorded in the abductor pollicis brevis muscle following stimulation of the median nerve in both the affected and unaffected upper limbs. The F-wave frequency, F-max/M ratio (ratio of maximum F-wave amplitude to M-response amplitude), and F-mean/M ratio (the ratio of mean F-wave amplitude to the M-response amplitude) were measured before and after the 20-min rTMS, analyzed for both limbs. Application of low-frequency rTMS did not result in significant changes in the frequency of F-wave and F-max/M ratio in both upper limbs, but significantly decreased F-mean/M ratio in the affected upper limb (P < 0.005), but not in the unaffected limb. Low-frequency rTMS applied to the non-lesional hemisphere might be potentially useful therapeutically for post-stroke patients with spastic upper limb hemiparesis.

Anti-spastic effects of the direct application of vibratory stimuli to the spastic muscles of hemiplegic limbs in post-stroke patients: A proof-of-principle study

To investigate whether the direct application of vibratory stimuli inhibits spasticity in the hemiplegic upper limbs of post-stroke patients. A randomized controlled study. Thirty-six post-stroke patients. Patients were randomly allocated to the "Rest group", "Stretch group", or "Direct application of vibratory stimuli group". After relaxing in a supine posture for 30 min, subjects received the interventions for 5 min. The Modified Ashworth Scale scores and F-wave parameters were recorded before, immediately after and 30 min after each intervention. The Rest group showed no significant changes in F-wave parameters and Modified Ashworth Scale scores. The Stretch group showed a tendency to decrease in F-wave amplitude and F/M ratio immediately after the intervention, but not 30 min later. The Direct application of vibratory stimuli group showed significant improvements in F-wave parameters and Modified Ashworth Scale scores immediately after the intervention, which remained 30 minutes later. The changes in F-wave parameters and Modified Ashworth Scale scores observed in the Direct application of vibratory stimuli group significantly differed from those in the Rest group and the Stretch group. The direct application of vibratory stimuli has anti-spastic effects in the hemiplegic upper limbs of post-stroke patients.