EMG based FES for post-stroke rehabilitation

Purpose: The purpose of this study was to evaluate the effects of a virtual upper extremity training program using the RAPAEL Smart Glove on upper extremity function in stroke survivors with chronic hemiparesis and to focus the training program development using the Smart Glove as a feasibility study. Methods: This study was conducted using a single group and pre-post test research design in the outpatient departments of local rehabilitation units. Ten chronic hemiparetic stroke survivors with a diagnosis of first stroke received therapeutic rehabilitation at the rehabilitation units. All the participants used a virtual reality program with the RAPAEL Smart Glove for 30 minutes per session 3 days a week over 8 weeks. They also received conventional occupational therapy with functional electrical stimulation for 40 minutes per session 3 days a week for 8 weeks as an additional therapy. To analyze the effects of this therapeutic intervention, four clinical measures, including the box-block test (BBT), the Wolf motor function test (WMFT), the trail-making score, the Jebsen Taylor hand function test (JTHFT), and grip strength, were used. Results: Upon completion of the intervention in week 8, all the participants demonstrated significant WMFT, JTT, BBT, grip strength, and trail-making score gains compared to the respective baselines at week 0. Conclusion: This study suggests that virtual upper extremity training using the RAPAEL Smart Glove has a reasonable and beneficial effects on upper extremity function in chronic hemiparetic stroke survivors.

Background: Stroke is a leading contributor to disability globally, emphasizing the need for effective rehabilitation techniques. Circuit class training (CCT) and individual, task-specific training (ITST) have emerged as potential approaches for enhancing upper extremity function in stroke survivors. Comparative analyses of their efficacy, especially among chronic stroke patients, are scant. Objective: This study aimed to evaluate and compare the impacts of CCT and ITST on upper extremity spasticity, motor function, and quality of life in individuals with chronic stroke. Methods: In a randomized controlled trial, 36 chronic stroke patients were allocated to either CCT or ITST groups. Participants were aged 45-70 years, had experienced a single stroke episode, and were at least 6 months post-stroke, with specific inclusion criteria regarding spasticity and motor function levels. The interventions were delivered for 1.5 hours daily, five days a week, over eight weeks. Outcomes were measured using the Modified Ashworth Scale (MAS) for spasticity, Functional Independence Measure for Upper Extremity (FMA-UE) for motor function, and Stroke-Specific Quality of Life (SS-QOL) scale for quality of life, analyzed using SPSS version 25. Results: Post-intervention, both CCT and ITST participants exhibited significant improvements in their outcomes. MAS scores showed a reduction in spasticity, with average improvements not significantly differing between the groups. FMA-UE scores increased by an average of 10 points in both groups, indicating enhanced motor function without a significant difference between the groups (p > 0.05). SS-QOL scores improved by an average of 20 points in each group, reflecting better quality of life, with no significant intergroup difference observed. Conclusion: The study concludes that CCT and ITST are equally effective in ameliorating upper extremity spasticity, motor function, and quality of life among chronic stroke patients. The selection between CCT and ITST can thus be personalized based on patient preferences, available resources, and logistical considerations, maintaining rehabilitation efficacy.

Loss of arm function occurs in up to 85% of stroke survivors. Home-based telerehabilitation is a viable approach for upper limb training post-stroke when rehabilitation services are not available. Method: A costing analysis of a telerehabilitation program was conducted under several scenarios, alongside a single-blind two-arm randomized controlled trial with participants randomly allocated to control (N=25) or intervention group (N=26). Detailed analysis of the cost for two different scenarios for providing telerehabilitation were conducted. The fixed costs of the telerehabilitation are an important determinant of the total costs of the program. The detailed breakdown of the costs allows for costs of future proposed telerehabilitation programs to be easily estimated. The costs analysis found that a program supplying all required technology costs between CAD$475 per patient and CAD$482 per patient, while a program supplying only a camera would have total costs between CAD$242 per patient and $245 per patient. The findings of this study support the potential implementation of telerehabilitation for stroke survivors for improving accessibility to rehabilitation services. This cost-analysis study will facilitate the implementation and future research on cost-effectiveness of such interventions.

Brain-computer interfaces (BCIs) have emerged as transformative tools for translating users’ neural signals into commands for external devices. The urgent need for innovative treatments to enhance upper limb motor function in stroke survivors is underscored by the limitations of traditional rehabilitation methods. The development of communication and control technology for individuals with severe neuromuscular diseases, particularly stroke patients, is centered on utilizing electroencephalographic (EEG) signals to accurately decode users’ intentions and operate external devices. Two healthy subjects and a stroke patient were enrolled to acquire EEG signals using the EMOTIV EPOC+ sensor. The experimental procedure involved recording five actions for both motor imagery and facial expression signals to control the 3D-printed upper limb exoskeleton. EEGLAB and BCILAB software were used for preprocessing and classification. The results showed successful EEG-based control of the exoskeleton, representing a significant advancement in assistive technology for individuals with motor impairments. The support vector machine (SVM) classifier achieved higher accuracy in both offline and online modes for both motor imaginary and facial expression tasks. The conclusion highlights the appropriateness of using EEGLAB for offline EEG data analysis and BCILAB for both offline and online analysis and classification. The integration of servo motors in the exoskeleton, allowing movements in five Degrees of Freedom (DOF), positions it as an effective rehabilitation solution for individuals with upper limb impairments.

Cognitive impairment was a common sequela among stroke survivors, and exercise intervention was a promising non-pharmacological treatment modality for it. To explore the effects of exercise intervention programs on cognitive and motor function in patients with cognitive impairment after stroke. Systematic review and meta-analysis. Seven online databases (PubMed, Embase, Cochrane Library, Web of Science, Scopus, PsycInfo, and SPORTDiscus) were searched from their inception to 10 February 2022. Randomised controlled trials (RCTs) comparing the effects of exercise with non-exercise rehabilitation, using the Montreal Cognitive Assessment, Addenbrooke's Cognitive Examination, Mini-Mental State Examination, Trial Making Test, Upper and Lower Extremity Fugl-Meyer Assessment, Berg Balance Scale, and Barthel Index, were selected. Calculations for each assessment were performed for the overall effect and the therapy of interest, taking into account the effect of stroke severity or stimulus parameters. Twelve RCTs involving 975 participants and investigating nine different types of exercise interventions were included. The results were not affected by participant characteristics or reactive balance outcomes. Our results emphasise the importance of lightweight and operable aerobic exercises. Exercise itself had a high potential to improve cognitive impairment and motor function after stroke. Exercise had significant positive effects on alleviating cognitive and motor impairments after stroke.

Background: Stroke often affect sexual health in a negative way. The common sexual dysfunction amongst stroke survivors are decreased libido, impaired erectile and ejaculatory functions, decreased vaginal lubrications, impaired ego, self-esteem, and depression. Objective: To find the effectiveness of Functional electrical stimulation on improving erectile function in Post-stroke patients. Methods: It is a single - blinded randomized controlled trail, 486 hemiplegic patients from a 1st stroke admitted into the Hospital were screened for the study of whom 180 patients full filled the inclusion criteria and were randomly divided into two groups. 120 patients completed the study. Functional electrical stimulation group was given functional electrical stimulation, for a period of 4 weeks with 4 sessions per week with 15 min each session. After the intervention, the patients were trained for pelvic floor and home exercises. Conventional Physiotherapy group was given pelvic floor and home exercises. The erectile dysfunction was measured by International Index of Erectile Function and erectile function was measured by erectile hardness. Results: The mean of differences between Preintervention and postintervention IIEF in FES group is 8.85 SD +/-3.16 and that of Conventional Physio. group is 5.13 SD +/- 3.92. With‘t’ value 4.53, the test is significant at p<0.05, which indicates the results are statistically significant. The mean of differences between Preintervention and postintervention EHS in FES group is 1.63 SD +/-1.28 and that of Conventional Physio. group is 0.77 SD +/- 0.87. With‘t’ value 4.34, the test is significant at p<0.05, which indicates the results are statistically significant. The magnitude of the experiment effect revealed large effect (Cohen’s d >0.7). Conclusion: We conclude from this study that Functional electrical stimulation improves erectile function in stroke survivors and is a treatment of choice for erectile dysfunction in post-stroke patients.

Improving Hand Function in Stroke Survivors: A Pilot Study of Contralaterally Controlled Functional Electric Stimulation in Chronic Hemiplegia

Control of limb movements may be impaired after stroke due to the loss of connectivity between the cerebral cortex and spinal cord. A notion to improve motor function in stroke survivors is to use alternate motor fibers, such as the reticulospinal tract (RST), which originate from the brainstem and terminate at different levels of spinal cord. One way of targeting the RST is to use a "StartReact" protocol to foster premature release of a preplanned movement in response to a startling stimulus. Our aim was to find support for the preservation of such StartReact effect in stroke survivors. We conducted a systematic review with meta-analysis of literature published in English up to September 2020, to explore differences in motor responses to startling stimuli in StartReact effects. Protocol of the study was registered (PROSPERO Registration No. CRD42020191581). PubMed, Google Scholar, Web of Science, PsycINFO, and Science Direct were searched for relevant literature. The meta-analysis contained six studies involving a total of 151 stroke and healthy participants. Muscle onset latency data were extracted from the qualifying studies and compared using RevMan. StartReact effect was present in both stroke and healthy groups, represented by shortened muscle onset latency when startling stimulus was present. There was considerable heterogeneity of the outcome measures, which was attributed to the range of motor impairments among stroke survivors and methodologies used. Our findings support the notion of preservation of preprogramming ability and suitability of RST and StartReact effect for motor rehabilitation following stroke.

Baroreceptor reflex sensitivity index (BRSI) derived from phase IV of the Valsalva manoeuvre is used to evaluate heart functioning in stroke survivors. Ten subjects (five normal controls and five stroke survivors) are analyzed and compared. The comparison shows that stroke patients have a lower BRSI value than normal subjects and the values fall into the range characterized as clinically depressed.< <ETX xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">&gt;</ETX>

BackgroundStroke is associated with an increased risk of dementia; however, the impact of stroke on cognition has been found to be variable, such that stroke survivors can show decline, remain stable, or revert to baseline cognitive functioning. Knowing the natural history of cognitive impairment after stroke is important for intervention. The aim of this systematic review is to investigate the longitudinal course of cognitive function in stroke survivors.Methods and ResultsThree electronic databases (Medline, Embase, PsycINFO) were searched using OvidSP from inception to July 15, 2016. Longitudinal studies with ≥2 time points of cognitive assessment after stroke were included. In total, 5952 articles were retrieved and 14 were included. There was a trend toward significant deterioration in cognitive test scores in stroke survivors (8 studies). Cognitive stability (3 studies) and improvement (3 studies) were also demonstrated, although follow‐up time tended to be shorter in these studies. Variables associated with impairment included age, ethnicity, premorbid cognitive performance, depression, stroke location, and history of previous stroke. Associations with APOE*E4 (apolipoprotein E with the E4 allele) allele status and sex were mixed.ConclusionsStroke is associated with an increased risk of cognitive decline, but cognitive decline is not a consequence. Factors associated with decline, such as sociodemographic status, health‐related comorbidity, stroke history, and clinical features could be used in models to predict future risk of dementia after stroke. A risk model approach could identify patients at greatest risk for timely intervention to reduce the frequency or delay the onset of poststroke cognitive impairment and dementia.

Background Many stroke survivors do not regain full function of their upper limb, which can have a devastating effect for participation in daily activities. Objectives This research aimed to systematically review stroke survivors’ lived experiences of upper limb recovery. Our objectives explored stroke survivors’ barriers and facilitators to recovery and the clinical implications for health professionals. Methods We searched the databases of MEDLINE, EMCARE, CINAHL, Scopus, and Web of Science using keywords and synonyms of ‘stroke survivors’, ‘upper limb’, ‘recovery’, and ‘perspectives’. Studies were appraised using the Critical Appraisal Skills Programme (CASP) Qualitative checklist. Data were analyzed descriptively and analytically using a thematic synthesis approach. We graded the emerging descriptive themes using the Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual). A protocol was registered apriori in PROSPERO (ID:181379). Results Eleven studies were included for review. Nine descriptive themes and three analytical themes emerged from the data that influenced upper limb recovery: 1) psychological wellbeing, 2) rehabilitation, and 3) relationships. Conclusions Barriers to upper limb recovery included health professionals’ attitudes particularly towards a lack of inclusivity in goal setting. In addition, stroke survivors perceived therapists focused on upper limb compensation rather than functional recovery, which was disempowering. Facilitators that enhanced recovery included the stroke survivors’ personal attitudes (psychological well-being) and external supports from family, friends, health professionals, and stroke survivor peers. Such supports enhanced the stroke survivors’ journey towards acceptance and adapting to their ‘new normal’ thus building confidence and self-efficacy to re-establish identity.

This pilot study examined whether ischemic conditioning (IC), a noninvasive, cost-effective, and easy-to-administer intervention, could improve gait speed and paretic leg muscle function in stroke survivors. We hypothesized that 2 wk of IC training would increase self-selected walking speed, increase paretic muscle strength, and reduce neuromuscular fatigability in chronic stroke survivors. Twenty-two chronic stroke survivors received either IC or IC Sham on their paretic leg every other day for 2 wk (7 total sessions). IC involved 5-min bouts of ischemia, repeated five times, using a cuff inflated to 225 mmHg on the paretic thigh. For IC Sham, the cuff inflation pressure was 10 mmHg. Self-selected walking speed was assessed using the 10-m walk test, and paretic leg knee extensor strength and fatigability were assessed using a Biodex dynamometer. Self-selected walking speed increased in the IC group (0.86 ± 0.21 m/s pretest vs. 1.04 ± 0.22 m/s posttest, means ± SD; P < 0.001) but not in the IC Sham group (0.92 ± 0.47 m/s pretest vs. 0.96 ± 0.46 m/s posttest; P = 0.25). Paretic leg maximum voluntary contractions were unchanged in both groups (103 ± 57 N·m pre-IC vs. 109 ± 65 N·m post-IC; 103 ± 59 N·m pre-IC Sham vs. 108 ± 67 N·m post-IC Sham; P = 0.81); however, participants in the IC group maintained a submaximal isometric contraction longer than participants in the IC Sham group (278 ± 163 s pre-IC vs. 496 ± 313 s post-IC, P = 0.004; 397 ± 203 s pre-IC Sham vs. 355 ± 195 s post-IC Sham; P = 0.46). The results from this pilot study thus indicate that IC training has the potential to improve walking speed and paretic muscle fatigue resistance poststroke. NEW & NOTEWORTHY This pilot study is the first to demonstrate that ischemic conditioning can improve self-selected walking speed and reduce paretic muscle fatigue in stroke survivors. Ischemic conditioning has been shown to be safe in numerous patient populations, can be accomplished at home or at the bedside in only 45 min, and requires no specialized training. Future larger studies are warranted to determine the efficacy of ischemic conditioning as a neurorehabilitation therapy poststroke.

This study investigated the effects of comprehensive core body resistance exercise on lower extremity motor function in stroke survivors. This resistance exercise was developed to aid stroke patients with various severity to perform this exercise, aimed to improve their core strength, stability, and control. Thirty-four stroke patients aged 47.7±13.16 years old were selected from the Rehabilitation Department, Queen Elizabeth I Hospital in Sabah, Malaysia. All patients underwent supervised training either assistive, active or active resistance exercise, biweekly for 12 weeks. Motor function was evaluated using Fugl-Meyer Assessment Lower Extremity (FMA-LE). The data were collected at baseline and at four weeks training interval. Repeated measures ANOVA and paired t test were employed to analyse the effects of the resistance exercise on lower extremity motor function. The twelve-week resistance exercise showed statistically significant effects on lower extremity motor function, lower extremity, coordination/speed, passive joint motion, and joint pain. However, sensation was found insignificant. Paired t test showed statistically significant improvement in lower extremity motor function, lower extremity, coordination/speed, passive joint motion, joint pain, and sensation. This study suggested that the obtained results indicate that the core body resistance exercise was applicable without any induced negative effect such as spasticity or joint pain.

Virtual reality (VR) therapy has gained attention as a promising intervention in stroke rehabilitation, particularly for its potential to enhance motor function and promote neuroplasticity. However, its specific effects on balance, mobility, and gait remain underexplored. This review aims to provide a comprehensive evaluation of the effectiveness of VR therapy on the recovery of lower limb function in stroke survivors. Randomized controlled trials comparing VR therapy with conventional therapy were eligible for inclusion. All studies were identified through databases, such as MEDLINE, Embase, PubMed, Cochrane Library, Web of Science, and PsycINFO (up to July 2024). The primary outcomes included balance, assessed using the Berg Balance Scale (BBS), and mobility, measured with the Timed Up and Go Test (TUG) and 10-Meter Walk Test (10-MWT). Secondary outcomes included gait parameters (stride length and step length), the Functional Reach Test (FRT), the Dynamic Gait Index (DGI), and the Falls Efficacy Scale-International (FES-I). RevMan version 5.4 (The Cochrane Collaboration) software was used for the meta-analysis. A total of 2145 studies were screened, and 24 randomized controlled trials that met the inclusion criteria were included, involving 768 participants. Meta-analysis results showed that VR therapy, compared to conventional therapy, significantly improved BBS (mean difference [MD] 3.29, 95% CI 0.52-6.06; P=.02), TUG (MD -1.67, 95% CI -2.89 to -0.46; P=.007), and step length (MD 3.59, 95% CI 0.50-6.69; P=.02). However, no significant difference was observed between the 2 groups in 10-MWT (MD -0.91, 95% CI -3.33 to 1.50; P=.46), stride length (MD 5.63, 95% CI -0.73 to 11.99; P=.08), FRT (MD 2.68, 95% CI -0.30 to 5.67; P=.08), DGI (MD 1.08, 95% CI -0.41 to 2.58; P=.16), and FES-I (MD 0.16, 95% CI -2.92 to 3.24; P=.92). In the subgroup analyses, significant improvements in balance and mobility were observed in patients receiving greater than or equal to 20 sessions, with BBS improved by 5.14 points (95% CI 0.43-9.85; P=.03) and TUG reduced by 1.98 seconds (95% CI -3.33 to -0.63; P=.004). In addition, patients who received VR therapy more than 6 months after stroke showed greater improvements in BBS (MD 1.64, 95% CI 0.14-3.14; P=.03), compared to those who received VR therapy between 7 days and 6 months after stroke. Long-term VR-based therapies are more effective in improving functional ability after stroke. VR therapy has demonstrated significant potential for enhancing lower limb recovery, especially when applied with frequencies of ≥20 sessions.

Stroke significantly impacts an individual’s ability to perform instrumental activities of daily living (IADLs). Intraindividual variability (IIV) is characterized by heightened fluctuations across multiple attempts at a task. IIV is a behavioral indicator of central nervous system instability that may contribute directly to compromised capacity to perform IADLs following stroke. This study aimed to investigate the relationship between IIV and IADL performance in stroke survivors and determine whether executive control and/or motor capacity serve as mediating pathways. In this cross-sectional observational study, 84 stroke survivors and 35 healthy older adults participated. We derived latent factor scores for IIV from reaction time and goal directed tasks, IADL performance from the Observed Task of Daily Living and Functional Activities Questionnaire, executive control from tests of divided attention, selective attention, cognitive flexibility, and processing speed, and motor capacity from grip and ankle strength. We examined the association between IIV and IADL performance and conducted a parallel mediation analysis to determine whether executive control and motor capacity mediated this relationship. Higher IIV was associated with compromised IADL performance. Mediation analyses showed that the relationship between IIV and IADL performance was significantly mediated by executive control but not motor capacity while controlling for the covariate of age. Behavioral variability after stroke impacts everyday function primarily through a cognitive pathway. These findings highlight executive control as a key therapeutic target in stroke rehabilitation to mitigate the functional consequences of neural instability on instrumental activities of daily living.