Distal versus proximal - an investigation on different supportive strategies by robots for upper limb rehabilitation after stroke: a randomized controlled trial

Abstract

Background Different 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. Methods Thirty 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. Results Significant 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). Conclusions Robotic 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 registration ClinicalTrials.gov , identifier NCT02117089; date of registration: April 10, 2014. https://clinicaltrials.gov/ct2/show/NCT02117089

Effects of priming intermittent theta burst stimulation on upper limb motor recovery after stroke: study protocol for a proof-of-concept randomised controlled trial

“…We decide to adopt a more flexible training schedule, because most community stroke survivors are unable to visit our laboratory on a daily basis. Similar schedule for motor training has been used in previous studies for patients with chronic stroke 44 45…”

An Exoneuromusculoskeleton for Self-Help Upper Limb Rehabilitation After Stroke

“…The NMES compartment provided electrical stimulation (square pulse with adjustable pulse width of 0-300 ls, 70 V, 40 Hz) 39 to the muscle of the biceps brachii (BIC) during elbow flexion, muscle of the triceps brachii (lateral head, TRI) during elbow extension, muscle union of the flexor carpi radialis (FCR) and the flexor digitorum (FD) during wrist flexion with the hand closed, and muscle union of the extensor carpi ulnaris (ECU) and the extensor digitorum (ED) during wrist extension with the hand open. 40 The activation of the musculoskeletons and NMES were controlled by the…”

“…EMG electrodes (2 • 3 cm 2 , Blue Sensor N; Ambu, Inc.) were attached to the skin surface of the aforementioned target muscle unions and muscles (the configuration specified in a previous study 40,69 was used).The collected EMG signals were amplified with a gain of 1000 (amplifier: INA 333; Texas Instruments, Inc.), band-pass filtered from 10 to 500 Hz, and then sampled with 1000 Hz for digitization for offline processing. 69,70 Two EMG parameters were calculated for quantitative session-by-session monitoring of the evolution of the muscle activation and coordination patterns: (1) the normalized EMG activation level of each target muscle and (2) the normalized EMG cocontraction index (CI) between muscle pairs.…”

“…This finding was consistent with those of clinical trials on NMES-assisted poststroke rehabilitation. 39,40,93 Limb practice with close-to-normal muscular coordination and minimized compensatory motions was achieved through the combined assistance of NMES and mechanical torque in the joint extension phases. 39,45 Such limb practice led to a reduction in excessive muscle activities and superior muscle coordination, as revealed by the decrease in the EMG activation levels at the flexors, cocontractions between the antagonist muscle pairs related to the wrist/hand and elbow, and cocontractions between the elbow flexor and the distal joints.…”

Characterization and wearability evaluation of a fully portable wrist exoskeleton for unsupervised training after stroke

“…the wrist) are closely linked with the acute state of proximal functions (shoulder or elbow) [15]. In the same vein, distal training can lead to positive effects at the shoulder and elbow [16][17][18]. While the hand has received a lot of attention from the research community, there remains a need to provide wrist function training.…”