Hybrid Assistive Neuromuscular Dynamic Stimulation Therapy: A New Strategy for Improving Upper Extremity Function in Patients with Hemiparesis following Stroke

Abstract

Hybrid Assistive Neuromuscular Dynamic Stimulation (HANDS) therapy is one of the neurorehabilitation therapeutic approaches that facilitates the use of the paretic upper extremity (UE) in daily life by combining closed-loop electromyography- (EMG-) controlled neuromuscular electrical stimulation (NMES) with a wrist-hand splint. This closed-loop EMG-controlled NMES can change its stimulation intensity in direct proportion to the changes in voluntary generated EMG amplitudes recorded with surface electrodes placed on the target muscle. The stimulation was applied to the paretic finger extensors. Patients wore a wrist-hand splint and carried a portable stimulator in an arm holder for 8 hours during the daytime. The system was active for 8 hours, and patients were instructed to use their paretic hand as much as possible. HANDS therapy was conducted for 3 weeks. The patients were also instructed to practice bimanual activities in their daily lives. Paretic upper extremity motor function improved after 3 weeks of HANDS therapy. Functional improvement of upper extremity motor function and spasticity with HANDS therapy is based on the disinhibition of the affected hemisphere and modulation of reciprocal inhibition. HANDS therapy may offer a promising option for the management of the paretic UE in patients with stroke.

Biological effects of dosing aerobic exercise and neuromuscular electrical stimulation in rats

“…NMES also has high face validity for translation and affords a direct comparison of the biological effects of muscle stimulation in the absence of aerobic activity. NMES is an important intervention to reduce spasticity following a stroke 41 and to enhance recovery of muscle strength and function in the case of severe functional impairments, such as paresis, that cannot sufficiently support gait to walk or run 5 , 42 , 43 . Contrasting the biological effects of these two interventions aimed at the same organ system (muscle, blood, brain) is therefore possible.…”

Neuromuscular electrical stimulation-enhanced rehabilitation is associated with not only motor but also somatosensory cortical plasticity in chronic stroke patients: an interventional study

“…Participants were instructed, encouraged, and monitored to use their paretic limbs during tasks associated with real-life ADLs by rehabilitation nurses in the rehabilitation ward. 27,33 In brief, several practical tasks including lifting and grasping water bottles, opening and shutting drawers, drawing curtains, table cleaning, grasping and releasing towels, pinching clothes pegs, holding a hairdryer, opening a pack of seasonings, and locking doors were individually and subjectively enumerated by each participant through discussions with nurses and physiatrists referring to bilateral or unilateral ADL training studies. 38,39 The frequency of each task execution was monitored with a self-assessment information sheet, and the items were modified as necessary.…”

“…Hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy is a comprehensive neuro-rehabilitative treatment that utilizes integrated volitional control electrical stimulation (IVES), 26 which is a form of closed-loop electromyography (EMG)-controlled NMES. 27,28 NMES-based neurorehabilitation is recommended for severe upper extremity hemiparesis exerting minimal volitional muscle activation as class IIa therapy, 29 and has attracted wide attention in the field of stroke. 5,30 In particular, researchers have reported the combination of IVES and task-specific training induces significant functional recovery even in chronic stroke patients.…”

“…HANDS therapy is indicated when patients present with severe impairments, a small amount of detectable EMG activity in the wrist or finger extensor, and a lack of substantial voluntary movement. Because constraint-induced movement therapy cannot be applied in extreme cases, 27,28 HANDS therapy should theoretically occur in conjunction with brain machine interface-based rehabilitation for patients with the most severe forms of upper extremity paresis and with constraint-induced movement therapy for those with moderate to severe paresis. 32 Significant, long-lasting functional recovery of hand and wrist function and increases in daily practical use of the paretic limb have been reported in patients with subacute and chronic stroke.…”

A Hybrid Robotic System for Arm Training of Stroke Survivors: Concept and First Evaluation

“…However, EMG-triggered FES might not be enough to guarantee a close association between the voluntary drive and the stimulated motor response throughout the task execution. To overcome this limitation, FES control strategies, which promote the subject's active involvement during the whole task and not just trigger it [24], [25], have been developed but an extensive clinical validation of their efficacy is still missing.…”