Functional electrical stimulation therapy controlled by a P300-based brain–computer interface, as a therapeutic alternative for upper limb motor function recovery in chronic post-stroke patients. A non-randomized pilot study

BackgroundMost stroke survivors have sustained upper limb impairment in their distal joints. An electromyography (EMG)-driven wrist/hand exoneuromusculoskeleton (WH-ENMS) was developed previously. The present study investigated the feasibility of a home-based self-help telerehabilitation program assisted by the aforementioned EMG-driven WH-ENMS and its rehabilitation effects after stroke.MethodsPersons with chronic stroke (n = 11) were recruited in a single-group trial. The training progress, including the training frequency and duration, was telemonitored. The clinical outcomes were evaluated using the Fugl–Meyer Assessment (FMA), Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Functional Independence Measure (FIM), and Modified Ashworth Scale (MAS). Improvement in muscle coordination was investigated in terms of the EMG activation level and the Co-contraction Index (CI) of the target muscles, including the abductor pollicis brevis (APB), flexor carpi radialis-flexor digitorum (FCR-FD), extensor carpi ulnaris-extensor digitorum (ECU-ED), biceps brachii (BIC), and triceps brachii (TRI). The movement smoothness and compensatory trunk movement were evaluated in terms of the following two kinematic parameters: number of movement units (NMUs) and maximal trunk displacement (MTD). The above evaluations were conducted before and after the training.ResultsAll of the participants completed the home-based program with an intensity of 63.0 ± 1.90 (mean ± SD) min/session and 3.73 ± 0.75 (mean ± SD) sessions/week. After the training, motor improvements in the entire upper limb were found, as indicated by the significant improvements (P < 0.05) in the FMA, ARAT, WMFT, and MAS; significant decreases (P < 0.05) in the EMG activation levels of the APB and FCR-FD; significant decreases (P < 0.05) in the CI of the ECU–ED/FCR–FD, ECU–ED/BIC, FCR–FD/APB, FCR–FD/BIC, FCR–FD/TRI, APB/BIC and BIC/TRI muscle pairs; and significant reductions (P < 0.05) in the NMUs and MTD.ConclusionsThe results suggested that the home-based self-help telerehabilitation program assisted by EMG-driven WH-ENMS is feasible and effective for improving the motor function of the paretic upper limb after stroke.Trial registration ClinicalTrials.gov. NCT03752775; Date of registration: November 20, 2018.

Effects of Repetitive Facilitative Exercise on Spasticity in the Upper Paretic Limb After Subacute Stroke

Background. Functional electrical stimulation therapy (FET) has a potential to improve voluntary grasping among individuals with tetraplegia secondary to traumatic spinal cord injury (SCI). Objective. This single-site, randomized controlled trial examined the efficacy of 40 hours of FET with conventional occupational therapy (COT) compared with COT alone to improve grasping. Methods. Twenty-four subjects with subacute traumatic incomplete SCI (C4-C7, AIS B-D) consented to participate in 40 hours of therapy over 8 weeks, beyond the conventional rehabilitation program. Subjects were randomized to receive FET + COT (n = 9) or COT (n = 12). The key outcomes were changes in Functional Independence Measure (FIM) self-care subscores, Spinal Cord Independence Measure (SCIM) self-care subscores, and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) performed at baseline and follow-up. Results. At the end of the treatments, the change in mean FIM self-care subscore for the FET + COT group was 20.1 versus 10 (P = .015) for the COT group. Subjects randomized to FET + COT also had greater improvements in the SCIM and TRI-HFT. No longer term follow-up was feasible. Conclusion. FET significantly reduced disability and improved voluntary grasping beyond the effects of considerable conventional upper extremity therapy in individuals with tetraplegia.

Background:Upper limb motor impairment is a common complication following stroke. Although few treatments are used to enhance motor function, still approximately 60% of survivors are left with upper limb motor impairment. Several studies have investigated vagus nerve stimulation (VNS) as a potential technique for upper limb function. However, the efficacy and safety of VNS on upper limb motor function after ischemic stroke have not been systematically evaluated. Therefore, a meta-analysis based on randomized controlled trial will be conducted to determine the efficacy and safety of VNS on upper limb motor function after ischemic stroke.Method:We searched PUBMED, MEDLINE, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure Library (CNKI), and Wan Fang Database until April 1, 2021.Results:Six studies consisting of 234 patients were included in the analysis. Compared with control group, VNS improved upper limb function via Fugl-Meyer Assessment-Upper Extremity (mean difference = 3.26, 95% confidence interval [CI] [2.79, 3.74], P < .00001) and Functional Independence Measurement (mean difference = 6.59, 95%CI [5.77, 7.41], P < .00001), but showed no significant change on Wolf motor function test (standardized mean difference = 0.31, 95%CI [–0.15, 0.77], P = .19). The number of adverse events were not significantly different between the studied groups (risk ratio = 1.05, 95%CI [0.85, 1.31], P = .64).Conclusion:VNS resulted in improvement of motor function in patients after ischemic stroke, especially in the sub-chronic stage. Moreover, compared with implanted VNS, transcutaneous VNS exhibited greater efficacy in poststroke patients. Based on this meta-analysis, VNS could be a feasible and safe therapy for upper limb motor impairment.

BackgroundStroke frequently causes upper limb dysfunction, impairing daily activities and quality of life. This study evaluates seven repetitive transcranial magnetic stimulation and transcranial direct current stimulation protocols for improving upper limb motor function, muscle tone, and daily living in stroke patients, providing evidence for optimizing non-invasive brain stimulation therapy.MethodsComputerized searches were conducted in the VIP database (VIP), Wan-fang database, China National Knowledge Infrastructure (CNKI), PubMed, SinoMed Database (CBM), Cochrane Library, and Web of Science databases to identify publicly published randomized controlled trials on different non-invasive brain stimulation techniques for upper limb motor dysfunction after stroke. The search period was up to November 2024. The Cochrane Risk of Bias tool (version 5.4.0) was used to assess the quality of the included studies. R software (version 4.1.1) was used to perform Bayesian network meta-analysis for data comparison and ranking.ResultsA total of 28 studies were included, with a total sample size of 1,340 patients, encompassing 7 non-invasive brain stimulation techniques. Probability ranking results indicated the following: for Fugl-Meyer Assessment for Upper Extremity (FMA-UE), the top three rankings were high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) (29%), continuous theta burst stimulation (cTBS) (27%), and anodal transcranial direct current stimulation (aDCS) (17.5%); for Barthel Index (BI), the top three were aDCS (71.5%), low-frequency repetitive transcranial magnetic stimulation(LF-rTMS) (20.9%), and HF-rTMS (4.4%); for Wolf Motor Function Test (WMFT), the top three were aDCS (63.6%), cTBS (13%), and HF-rTMS (9.1%); for Modified Ashworth Scale (MAS), the top three were intermittent theta burst stimulation (iTBS) (42%), LF-rTMS (24%), and cTBS (16%); for Action Research Arm Test (ARAT), the top three were iTBS (72.6%), aDCS (22.3%), and LF-rTMS (2.8%).ConclusionBased on the network meta-analysis results and probability ranking evidence, HF-rTMS is most likely to be the most effective intervention for restoring motor function (FMA-UE); aDCS may rank first for both activities of daily living (BI) and motor task performance (WMFT); iTBS appears beneficial for improving muscle tone regulation (MAS) and fine motor ability (ARAT). However, the results for ARAT (6 studies) and MAS (9 studies), based on a smaller number of studies, should be interpreted with caution due to limited evidence.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/, identifier CRD420251019764.

BackgroundFunctional recovery of arm movement typically plateaus following a stroke, leaving chronic motor deficits. Brain-computer interfaces (BCI) may be a potential treatment for post-stroke deficitsMethodsIn this n-of-1 trial (NCT03913286), a person with chronic subcortical stroke with upper-limb motor impairment used a powered elbow-wrist-hand orthosis that opened and closed the affected hand using cortical activity, recorded from a percutaneous BCI comprised of four microelectrode arrays implanted in the ipsilesional precentral gyrus, based on decoding of spiking patterns and high frequency field potentials generated by imagined hand movements. The system was evaluated in a home setting for 12 weeksResultsRobust single unit activity, modulating with attempted or imagined movement, was present throughout the precentral gyrus. The participant acquired voluntary control over a hand-orthosis, achieving 10 points on the Action Research Arm Test using the BCI, compared to 0 without any device, and 5 using myoelectric control. Strength, spasticity, the Fugl-Meyer scores improved.ConclusionsWe demonstrate in a human being that ensembles of individual neurons in the cortex overlying a chronic supratentorial, subcortical stroke remain active and engaged in motor representation and planning and can be used to electrically bypass the stroke and promote limb function. The participant’s ability to rapidly acquire control over otherwise paralyzed hand opening, more than 18 months after a stroke, may justify development of a fully implanted movement restoration system to expand the utility of fully implantable BCI to a clinical population that numbers in the tens of millions worldwide.

BackgroundPost-stroke aphasia concurrent with upper limb (UL) motor dysfunction is very common and difficult to rehabilitate. Although mirror therapy (MT) has demonstrated efficacy in treating aphasia and UL motor dysfunction separately, it has not been utilized to address both conditions simultaneously. Our study introduces a novel Synchronous Mirror Therapy (SMT) system that integrates speech-language therapy with UL motor training to evaluate its clinical feasibility, preliminary efficacy, and potential cortical mechanisms.MethodFifteen patients and five therapists participated in this study. The patients had aphasia and UL motor dysfunction and underwent the SMT intervention ten times. They were evaluated through functional assessment scales (Aphasia Quotient of Western Aphasia Battery (WAB-AQ); Assessment of Fugl-Meyer Upper Limb scale (FMA-UL); Action Research Arm Test (ARAT)) and three questionnaires, and functional near-infrared (fNIRS) test. We analyzed the questionnaire results, functional changes before and after SMT, and differences between the SMT intervention and rest periods.ResultsNine patients underwent all SMT treatment sessions. Patients and therapists gave high ratings for SMT. Compared with before SMT interventions, significant improvements were observed in language function (WAB-AQ: p = 0.008) and UL motor function (FMA-UL: p = 0.007; ARAT: p = 0.016) after all SMT interventions, along with significant changes in three fNIRS channels (channel 9, p < 0.001; channel 20, p = 0.005; channel 30, p = 0.046) during the SMT intervention.ConclusionThe SMT intervention demonstrated feasibility and received positive feedback from both patients and therapists. The results indicate potential benefits of SMT in improving language and UL motor function for post-stroke patients. fNIRS findings suggest possible enhanced cortical activation during SMT, which may be associated with neural recovery processes. While encouraging, this still necessitates validation through larger sample sizes and rigorous randomized controlled designs.

Maximizing stroke recovery with advanced technologies: A comprehensive assessment of robot-assisted, EMG-Controlled robotics, virtual reality, and mirror therapy interventions

Stroke is a leading cause of long-term disability, with most survivors showing upper limb motor impairment. Spasticity is a common outcome, marked by excessive muscle tone during quick joint extension. This can reduce range of motion, limit functional arm use, and cause pain. Despite the prominence of spasticity, its relationship to motor recovery and underlying neural mechanisms remains unclear. In this longitudinal study, we examine how post-stroke spasticity relates to upper limb motor recovery and investigate associated patterns of neuroanatomical injury (both lesions and networks). Methods: We recruited 59 acute stroke patients in the first week after stroke, all of whom underwent MR neuroimaging. Patients returned at 3 months to have upper limb spasticity measured with the Modified Ashworth Scale (MAS). Both times, upper limb motor impairment was measured with the Fugl-Meyer scale (FMA). We used (a) Voxel Lesion Symptom Mapping (VLSM) to link lesion location to presence of spasticity (MAS≥1) with and without FMA as a covariate and (b) Lesion Network Mapping (LNM) to quantify patients’ lesion connectivity in order to estimate spasticity-related disruptions of functional brain networks. Results: Patients showed recovery of motor impairment from acute (FMA: 31.1±3.1, mean±SEM) to subacute phase (FMA: 43.9±2.9). More severe impairment (lower FMA) in first week after stroke predicted development of spasticity (MAS≥1) at 3 months (Spearman’s ρ=-0.6, p=4.3×10 -7 , Fig.1a). Patients with spasticity at 3 months showed markedly less recovery of FMA (Fig.1b). Voxels associated with both spasticity and motor impairment centered on the corticospinal tract (CST); voxels uniquely associated with spasticity centered in basal ganglia (Fig.2). Lesions in patients with spasticity (vs. without) were connected to ext. capsule, operculum, and orbitofrontal cortex (OFC) (Fig.3). Discussion: In the first 3 months after stroke, the development of upper limb spasticity is associated with worse motor impairment and reduced recovery. The effect of CST damage on spasticity is compounded by lesions to basal ganglia. LNM associated spasticity with networks including OFC. Developing spasticity after acute stroke is thus associated with direct damage to CST but also damage to and connectivity with broader neuromodulatory networks including basal ganglia and OFC. Findings open the door to targeted neurorehabilitation, e.g. neuromodulation, to improve specific components of hemiparesis.

Stroke leads to long term disability and spasticity is one of them. Neurodynamic is a movement which aimed to restore the electrical signal directed to the nerve and the spinal cord. The neural mobilization is used to restore the movement and improve elasticity of nervous system to improve the arm function and regain the motor ability in patients with stroke. Objective: To assess the effects of neurodynamics on spasticity in upper extremities of stroke patients. Methods: It is a Randomized controlled trial. Data was collected from 46 stroke Patients. Simple Random Sampling was done and data was collected from District headquarters hospital (DHQ) Jhelum. Patients with chronic stroke, age 40-60 years, Modified Ashworth Scale (MAS) ≥1 to 3 and both male and female were included in this study. For 6 weeks, the experimental group received conventional therapy with neurodynamics (10 reps/ set, 1 set/ day, 3 days/week), whereas the control group received conventional treatment (12 reps/ set, 1 set/ day, 3 days/week). The MAS, Fugl Meyer Upper Extremity Scale (FMUE), goniometry and Action Research Arm Test were used to examine the participants at zero, three, and six weeks (ARAT). The Shapiro-Wilk test was used to ensure that the data was normal, and statistical analysis was performed using SPSS 21. Results: Statistically significant improvement was found in between group analyses in MAS, FM-UE motor score and AROM as the p-value was &lt;0.05. There was no significant difference in ARAT, FM-UE sensation, joint pain, passive joint motion, coordination and PROM as p-value was &gt;0.05. Statistically significant improvement was found in within group analyses in MAS, FM-UE motor score, sensation, joint pain, AROM and PROM as the p-value was &lt;0.05 except in ARAT and FM-UE coordination. Conclusion: The result shows that neurodynamic combined with conventional treatment was more effective than conventional treatment alone to reduce spasticity, improve upper extremity function and AROM. The result also shows that there was significant improvement in upper extremity joint pain, sensation and PROM and no improvement occurred in coordination and fine task performance within groups. The study concludes that neurodynamic is effective for spasticity and has additional benefit in improving UE functional performance and active range of motion but the effects of neurodynamic combined with conventional treatment are no different than conventional treatment alone on passive range of motion, joint pain, coordination, fine task performance and sensation.

BackgroundDifferent mechanical supporting strategies to the joints in the upper extremity (UE) may lead to varied rehabilitative effects after stroke. This study compared the rehabilitation effectiveness achieved by electromyography (EMG)-driven neuromuscular electrical stimulation (NMES)-robotic systems when supporting to the distal fingers and to the proximal (wrist-elbow) joints.MethodsThirty subjects with chronic stroke were randomly assigned to receive motor trainings with NMES-robotic support to the finger joints (hand group, n = 15) and with support to the wrist-elbow joints (sleeve group, n = 15). The training effects were evaluated by the clinical scores of Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Modified Ashworth Scale (MAS) before and after the trainings, as well as 3 months later. The cross-session EMG monitoring of EMG activation level and co-contraction index (CI) were also applied to investigate the recovery progress of muscle activations and muscle coordination patterns through the training sessions.ResultsSignificant improvements (P < 0.05) in FMA full score, FMA shoulder/elbow (FMA-SE) and ARAT scores were found in both groups, whereas significant improvements (P < 0.05) in FMA wrist/hand (FMA-WH) and MAS scores were only observed in the hand group. Significant decrease of EMG activation levels (P < 0.05) of UE flexors was observed in both groups. Significant decrease in CI values (P < 0.05) was observed in both groups in the muscle pairs of biceps brachii and triceps brachii (BIC&TRI) and the wrist-finger flexors (flexor carpi radialis-flexor digitorum) and TRI (FCR-FD&TRI). The EMG activation levels and CIs of the hand group exhibited faster reductions across the training sessions than the sleeve group (P < 0.05).ConclusionsRobotic supports to either the distal fingers or the proximal elbow-wrist could achieve motor improvements in UE. The robotic support directly to the distal fingers was more effective than to the proximal parts in improving finger motor functions and in releasing muscle spasticity in the whole UE.Clinical trial registrationClinicalTrials.gov, identifier NCT02117089; date of registration: April 10, 2014. https://clinicaltrials.gov/ct2/show/NCT02117089

To characterize individuals with stroke who responded or did not respond to upper limb motor treatment by analyzing muscle synergy patterns (similarity, merging, and fractionation). This study is a secondary analysis of a multicenter randomized controlled trial. Inpatients of 2 specialized neurorehabilitation hospitals. We enrolled individuals (N=62) with a unilateral first-event ischemic or hemorrhagic stroke and severe-to-mild upper limb motor impairment (Fugl-Meyer Assessment-Upper Extremity score of 5-61, of 66). We excluded people with untreated seizure, severe cognitive, or verbal comprehension impairment. After randomization, individuals were allocated to conventional, virtual reality, or robot-assisted treatment groups (20 sessions, 1 h/d, 5 d/wk, 4wk). A blinded assessor performed assessments both before and after the intervention. Surface electromyography recordings from 16 muscles during reaching tasks were collected pre- and post-treatment. We extracted muscle synergy patterns (similarity, merging, and fractionation) of the stroke-affected and unaffected upper limb of each subject. Overall, individuals improved upper limb motor function (Fugl-Meyer Assessment-Upper Extremity change score=7.14±7.46; P<.001). We identified 34 responders to treatment showing clinically significant improvement (over the Minimal Clinically Important Difference of 5 points on the Fugl-Meyer Assessment-Upper Extremity). The responders showed decreased merging of synergies (P=.016) as compared with the non-responders (P=.025), who conversely showed improved similarity of synergies (P=.006). In individuals with stroke undergoing upper limb motor rehabilitation, changes in the synergy merging pattern may serve as a potential marker to distinguish responders from non-responders.

Background: Action Observation Therapy (AOT) is a top-down approach that has been recently introduced in the rehabilitation of neurological disorders mainly after stroke. The main goal of this study was to investigate the effects and feasibility of a new technique in AOT procedure (called self-AOT) following periods of no treatment and routine AOT intervention on upper limb motor function, occupational performance and neurophysiological changes in a stroke patient. Methods: A single-subject A-B-A-C design was used and a 58-year-old woman with a 3-year history of left hemiplegia poststroke participated in this study. In the baseline (A1, A2) phases, the patient received no treatment. In the first intervention (B phase), she received a 4-week AOT, and in the second intervention (C phase), a 4 week of Self-AOT was practiced. In all phases, upper limb motor recovery as a target outcome was evaluated on 4 occasions using the Fugl-Meyer assessment. Upper limb function, dexterity and spasticity were assessed using Action Research Arm Test, Box-Block Test and Modified Modified Ashworth Scale respectively. Occupational Performance/Satisfaction was assessed with Canadian Occupational Performance Measure and to assess neuroplasticity, Motor Evoked Potential was recorded by Transcranial Magnetic Stimulation. Visual analysis, slope, and percentage of non-overlapping data were used for assessing the changes between phases. Results: Percentage of non-overlapping data and slopes indicated that motor recovery had clinically relevant improvements after both interventions compared to baselines. Other outcomes also showed improvements except for spasticity of wrist/elbow flexors and Motor Evoked Potential of opponens indicis. Conclusion: Self-AOT may be as effective as other procedures of AOT for improving upper limb motor function, occupational performance/satisfaction, and cortical excitability post-stroke.

ABSTRACTBackground: The Action Research Arm Test (ARAT) has been extensively used for patients with stroke in many countries. However, the ARAT has been reported to have ceiling effects. Employing a time evaluation system could be expected to improve the ceiling effects in the ARAT.Objective: To investigate (1) the psychometric properties of the Japanese version of the ARAT in patients with stroke; (2) the psychometric properties of the performance timescale of the ARAT in patients with stroke.Methods: A prospective, cross-sectional, single-center study involving 30 patients with mild-to-severe hemiparesis was conducted. All patients were recruited from the college hospital in Japan from June 2016 to March 2017. The ARAT and the Fugl-Meyer Assessment, the Box-and-Block Test, and the Motor Activity Log were employed. The simultaneous/non-simultaneous inter-rater reliability/agreement, the internal consistency, the validity, and the floor/ceiling effects were assessed.Results: Regarding the ARAT score, intraclass correlation coefficient (ICC) ranged from 0.974 to 0.990 (P < 0.001) for non-simultaneous evaluation; and from 0.994 to 0.998 (P < 0.001) for simultaneous evaluation. Regarding the ARAT time, ICC was 0.992 (P < 0.001) for non-simultaneous evaluation; and 1.000 (P < 0.001) for simultaneous evaluation.Conclusions: The Japanese version of the ARAT is highly reliable and valid for measuring upper-extremity function in patients with stroke. Adding the performance timescale on the ARAT score scale can partially solve the “ceiling effect problem”.

Longitudinal observations of upper limb motor recovery after stroke have suggested that certain subgroups may exhibit distinct recovery patterns. Here we sought to examine whether the predictive ability for post-stroke upper limb motor outcomes could be enhanced by applying conventional stratification strategies. For 60 individuals who suffered the first stroke, upper limb motor impairment was assessed with the upper extremity Fugl-Meyer assessment (UE-FMA) at 2 weeks as a baseline and then 3 months post-stroke. Brain structural damage at baseline was assessed by MRI data-derived markers ranging from traditional lesion size to the lesion load and to the disconnectome. Linear regression models for predicting upper limb motor outcomes (UE-FMA score at 3 months post-stroke) based on baseline upper limb motor impairment (UE-FMA score at 2 weeks post-stroke), brain structural damage, and their combinations were generated, and those with the best predictive performance were determined for individual subgroups stratified according to initial impairment (severe and non-severe), lesion location (cortical and non-cortical), and neurophysiological status (motor evoked potential-positive and motor evoked potential-negative). The best predictions were made by baseline upper limb motor impairment alone for subgroups with less functional impairment (non-severe) or less structural involvement (non-cortical), but by the combination of baseline upper limb motor impairment and brain structural damage for the other subgroups. The predictive models tailored for subgroups determined according to initial impairment and neurophysiological status yielded a smaller overall error than that for the whole group in upper limb motor outcome predictions. The predictive ability for upper limb motor outcomes could be enhanced beyond the one-size-fits-all model for all individuals with stroke by applying specific stratification strategies, with stratification according to initial impairment being the most promising. We expect that predictive models tailored for individual subgroups could lead closer to the personalized prognosis of upper limb motor outcomes after stroke.