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BACKGROUND: Technology-supported rehabilitation can help alleviate the increasing need for cost-effective rehabilitation of neurological conditions, but use in clinical practice remains limited. Agreement on a core set of reliable, valid and accessible outcome measures to assess rehabilitation outcomes is needed to generate strong evidence about effectiveness of rehabilitation approaches, including technologies. This paper collates and synthesizes a core set from multiple sources; combining existing evidence, clinical practice guidelines and expert consensus into European recommendations for Clinical Assessment of Upper Limb In Neurorehabilitation (CAULIN). METHODS: Data from systematic reviews, clinical practice guidelines and expert consensus (Delphi methodology) were systematically extracted and synthesized using strength of evidence rating criteria, in addition to recommendations on assessment procedures. Three sets were defined: a core set: strong evidence for validity, reliability, responsiveness and clinical utility AND recommended by at least two sources; an extended set: strong evidence OR recommended by at least two sources and a supplementary set: some evidence OR recommended by at least one of the sources. RESULTS: In total, 12 measures (with primary focus on stroke) were included, encompassing body function and activity level of the International Classification of Functioning and Health. The core set recommended for clinical practice and research: Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT); the extended set recommended for clinical practice and/or clinical research: kinematic measures, Box and Block Test (BBT), Chedoke Arm Hand Activity Inventory (CAHAI), Wolf Motor Function Test (WMFT), Nine Hole Peg Test (NHPT) and ABILHAND; the supplementary set recommended for research or specific occasions: Motricity Index (MI); Chedoke-McMaster Stroke Assessment (CMSA), Stroke Rehabilitation Assessment Movement (STREAM), Frenchay Arm Test (FAT), Motor Assessment Scale (MAS) and body-worn movement sensors. Assessments should be conducted at pre-defined regular intervals by trained personnel. Global measures should be applied within 24 h of hospital admission and upper limb specific measures within 1 week. CONCLUSIONS: The CAULIN recommendations for outcome measures and assessment procedures provide a clear, simple, evidence-based three-level structure for upper limb assessment in neurological rehabilitation. Widespread adoption and sustained use will improve quality of clinical practice and facilitate meta-analysis, critical for the advancement of technology-supported neurorehabilitation.
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Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular , Consenso , Mano , Humanos , Recuperación de la Función , Reproducibilidad de los Resultados , Rehabilitación de Accidente Cerebrovascular/métodos , Extremidad SuperiorRESUMEN
BACKGROUND AND PURPOSE: Stroke, predominantly a condition of older age, is a major cause of acquired disability in the global population and puts an increasing burden on health care resources. Clear evidence for the importance of intensity of therapy in optimizing functional outcomes is found in animal models, supported by neuroimaging and behavioral research, and strengthened by recent meta-analyses from multiple clinical trials. However, providing intensive therapy using conventional treatment paradigms is expensive and sometimes not feasible because of social and environmental factors. This article addresses the need for cost-effective increased intensity of practice and suggests potential benefits of telehealth (TH) as an innovative model of care in physical therapy. SUMMARY OF KEY POINTS: We provide an overview of TH and present evidence that a web-supported program, used in conjunction with constraint-induced therapy (CIT), can increase intensity and adherence to a rehabilitation regimen. The design and feasibility testing of this web-based program, "LifeCIT," is presented. We describe how wearable sensors can monitor activity and provide feedback to patients and therapists. The methodology for the development of a wearable device with embedded inertial and mechanomyographic sensors, algorithms to classify functional movement, and a graphical user interface to present meaningful data to patients to support a home exercise program is explained. RECOMMENDATIONS FOR CLINICAL PRACTICE: We propose that wearable sensor technologies and TH programs have the potential to provide most-effective, intensive, home-based stroke rehabilitation.
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Motivación , Cooperación del Paciente , Modalidades de Fisioterapia , Rehabilitación de Accidente Cerebrovascular/métodos , Telemedicina , Dispositivos Electrónicos Vestibles , Humanos , Internet , Movimiento , Accidente Cerebrovascular/fisiopatología , Resultado del TratamientoRESUMEN
BACKGROUND: The need for cost-effective neurorehabilitation is driving investment into technologies for patient assessment and treatment. Translation of these technologies into clinical practice is limited by a paucity of evidence for cost-effectiveness. Methodological issues, including lack of agreement on assessment methods, limit the value of meta-analyses of trials. In this paper we report the consensus reached on assessment protocols and outcome measures for evaluation of the upper extremity in neurorehabilitation using technology. The outcomes of this research will be part of the development of European guidelines. METHODS: A rigorous, systematic and comprehensive modified Delphi study incorporated questions and statements generation, design and piloting of consensus questionnaire and five consensus experts groups consisting of clinicians, clinical researchers, non-clinical researchers, and engineers, all with working experience of neurological assessments or technologies. For data analysis, two major groups were created: i) clinicians (e.g., practicing therapists and medical doctors) and ii) researchers (clinical and non-clinical researchers (e.g. movement scientists, technology developers and engineers). RESULTS: Fifteen questions or statements were identified during an initial ideas generation round, following which the questionnaire was designed and piloted. Subsequently, questions and statements went through five consensus rounds over 20 months in four European countries. Two hundred eight participants: 60 clinicians (29 %), 35 clinical researchers (17 %), 77 non-clinical researchers (37 %) and 35 engineers (17 %) contributed. At each round questions and statements were added and others removed. Consensus (≥69 %) was obtained for 22 statements on i) the perceived importance of recommendations; ii) the purpose of measurement; iii) use of a minimum set of measures; iv) minimum number, timing and duration of assessments; v) use of technology-generated assessments and the restriction of clinical assessments to validated outcome measures except in certain circumstances for research. CONCLUSIONS: Consensus was reached by a large international multidisciplinary expert panel on measures and protocols for assessment of the upper limb in research and clinical practice. Our results will inform the development of best practice for upper extremity assessment using technologies, and the formulation of evidence-based guidelines for the evaluation of upper extremity neurorehabilitation.
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BACKGROUND: Functional electrical stimulation (FES) during repetitive practice of everyday tasks can facilitate recovery of upper limb function following stroke. Reduction in impairment is strongly associated with how closely FES assists performance, with advanced iterative learning control (ILC) technology providing precise upper-limb assistance. The aim of this study is to investigate the feasibility of extending ILC technology to control FES of three muscle groups in the upper limb to facilitate functional motor recovery post-stroke. METHODS: Five stroke participants with established hemiplegia undertook eighteen intervention sessions, each of one hour duration. During each session FES was applied to the anterior deltoid, triceps, and wrist/finger extensors to assist performance of functional tasks with real-objects, including closing a drawer and pressing a light switch. Advanced model-based ILC controllers used kinematic data from previous attempts at each task to update the FES applied to each muscle on the subsequent trial. This produced stimulation profiles that facilitated accurate completion of each task while encouraging voluntary effort by the participant. Kinematic data were collected using a Microsoft Kinect, and mechanical arm support was provided by a SaeboMAS. Participants completed Fugl-Meyer and Action Research Arm Test clinical assessments pre- and post-intervention, as well as FES-unassisted tasks during each intervention session. RESULTS: Fugl-Meyer and Action Research Arm Test scores both significantly improved from pre- to post-intervention by 4.4 points. Improvements were also found in FES-unassisted performance, and the amount of arm support required to successfully perform the tasks was reduced. CONCLUSIONS: This feasibility study indicates that technology comprising low-cost hardware fused with advanced FES controllers accurately assists upper limb movement and may reduce upper limb impairments following stroke.
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Terapia por Estimulación Eléctrica/métodos , Recuperación de la Función , Rehabilitación de Accidente Cerebrovascular , Extremidad Superior/fisiopatología , Adulto , Fenómenos Biomecánicos , Codo/fisiopatología , Estudios de Factibilidad , Femenino , Hemiplejía/etiología , Hemiplejía/fisiopatología , Hemiplejía/rehabilitación , Humanos , Masculino , Persona de Mediana Edad , Hombro/fisiopatología , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/fisiopatología , Muñeca/fisiopatologíaRESUMEN
OBJECTIVES: To test parameters needed for the design of a larger trial including the following: 1) identifying eligible participants, recruitment, and retention rates; 2) the feasibility and acceptability of delivering functional electrical stimulation (FES) to the gluteus maximus and quadriceps femoris for acute stroke patients in a hospital rehabilitation setting; 3) the outcome measures; 4) obtaining initial estimates of effect size; and 5) clarifying the relevant control group. MATERIALS AND METHODS: Twenty-one people with acute stroke-mean age = 68 (min to max: 33-87) years; weeks postonset = 4.6 (min to max: 1-14)-were randomized to three groups to receive two weeks of balance training with FES, balance training alone, or usual care. Symmetry in normal standing, weight transfer onto the affected limb, balance, mobility, and speed of walking were assessed before, shortly after the end of training, and two weeks later by a blinded assessor. RESULTS: 1) FES was successfully delivered but not with the planned eight sessions; 2) no trends in favor of FES were found; and 3) 4% of those screened took part but approaching 20% might be recruited in the future, no single outcome measure was suitable for all participants, and more routine physiotherapy was delivered to the control group. CONCLUSIONS: FES is feasible in this patient group but further feasibility and definitive trials are required.
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Peso Corporal , Terapia por Estimulación Eléctrica/métodos , Terapia por Ejercicio/métodos , Equilibrio Postural/fisiología , Rehabilitación de Accidente Cerebrovascular , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Trastornos Neurológicos de la Marcha/etiología , Trastornos Neurológicos de la Marcha/rehabilitación , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Modalidades de Fisioterapia , Recuperación de la Función , Trastornos de la Sensación/etiología , Trastornos de la Sensación/terapia , Accidente Cerebrovascular/complicacionesRESUMEN
Functional Electrical Stimulation (FES) has been used to support mobility for people with upper motor neuron conditions such as stroke and multiple sclerosis for over 25 years. Recent development and publication of clinical practice guidelines (CPGs) provide evidence to guide clinical decision making for application of FES to improve mobility. Understanding key barriers to the implementation of these CPGs is a critical initial step necessary to create tailored knowledge translation strategies. A public involvement and engagement consultation was conducted with international stakeholders including researchers, clinicians and engineers working with FES to inform implementation strategies for CPG use internationally. Reflexive thematic analysis of the consultation transcripts revealed themes including inconsistent use of CPGs, barriers to implementation such as limited access to FES and low clinician confidence, and the need for a tiered education approach with ongoing support. Insights derived from this consultation will inform the development of knowledge translation strategies to support the next steps to implementing FES use for mobility.
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BACKGROUND: Novel stroke rehabilitation techniques that employ electrical stimulation (ES) and robotic technologies are effective in reducing upper limb impairments. ES is most effective when it is applied to support the patients' voluntary effort; however, current systems fail to fully exploit this connection. This study builds on previous work using advanced ES controllers, and aims to investigate the feasibility of Stimulation Assistance through Iterative Learning (SAIL), a novel upper limb stroke rehabilitation system which utilises robotic support, ES, and voluntary effort. METHODS: Five hemiparetic, chronic stroke participants with impaired upper limb function attended 18, 1 hour intervention sessions. Participants completed virtual reality tracking tasks whereby they moved their impaired arm to follow a slowly moving sphere along a specified trajectory. To do this, the participants' arm was supported by a robot. ES, mediated by advanced iterative learning control (ILC) algorithms, was applied to the triceps and anterior deltoid muscles. Each movement was repeated 6 times and ILC adjusted the amount of stimulation applied on each trial to improve accuracy and maximise voluntary effort. Participants completed clinical assessments (Fugl-Meyer, Action Research Arm Test) at baseline and post-intervention, as well as unassisted tracking tasks at the beginning and end of each intervention session. Data were analysed using t-tests and linear regression. RESULTS: From baseline to post-intervention, Fugl-Meyer scores improved, assisted and unassisted tracking performance improved, and the amount of ES required to assist tracking reduced. CONCLUSIONS: The concept of minimising support from ES using ILC algorithms was demonstrated. The positive results are promising with respect to reducing upper limb impairments following stroke, however, a larger study is required to confirm this.
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Inteligencia Artificial , Estimulación Eléctrica/métodos , Trastornos del Movimiento/etiología , Trastornos del Movimiento/rehabilitación , Robótica/métodos , Dispositivos de Autoayuda , Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular/complicaciones , Adulto , Anciano , Algoritmos , Brazo/fisiología , Diseño de Equipo , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Movimiento/fisiología , Músculo Esquelético/fisiología , Paresia/rehabilitación , Desempeño Psicomotor/fisiología , Recuperación de la Función , Resultado del Tratamiento , Extremidad Superior/fisiología , Interfaz Usuario-ComputadorRESUMEN
BACKGROUND AND PURPOSE: Trunk control is thought to contribute to upper extremity function. It is unclear whether recovery of trunk control has an impact on the recovery of the upper extremity in people with stroke. This longitudinal study monitored the recovery of trunk control and upper extremity in the first 6 months following stroke. METHODS: Forty-five participants with stroke were assessed monthly for 6 months following stroke. Trunk control was assessed using the Trunk Impairment Scale (TIS); upper extremity impairment and function were assessed with the Fugl-Meyer (FMA) and Streamlined Wolf Motor Function Test (SWMFT) respectively. The SWMFT included the performance time (SWMFT-Time) and functional ability scale (SWMFT-FAS). The individual growth curve modeling was used to analyze the longitudinal data. RESULTS: The recovery curve of TIS, FMA, SWMFT-Time and SWMFT-FAS followed a quadratic trend, with the rate of recovery decreasing from the first to sixth month. As TIS score improved over time, FMA, SWMFT-Time and SWMFT-FAS improved in parallel with the TIS score. TIS at each time point was found to be a significant predictor of FMA, SWMFT-Time and SWMFT-FAS at 6 months post stroke. CONCLUSION: Our work has provided, for the first time, substantial evidence that the pattern of recovery of trunk control is similar to that of the recovery of upper extremity following stroke. In addition, this study provides evidence on which to design a prospective study to evaluate whether improvement in trunk control early post-stroke results in better long-term upper extremity function.
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Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular , Humanos , Estudios Longitudinales , Estudios Prospectivos , Recuperación de la Función , Accidente Cerebrovascular/complicaciones , Rehabilitación de Accidente Cerebrovascular/métodos , Extremidad SuperiorRESUMEN
OBJECTIVES: For rehabilitation of the poststroke upper limb in seven subjects, an external sensor-based system controls the timing of five to seven microstimulators implanted near radial nerve branches or their motor points to sequentially extend the elbow, wrist, and fingers with thumb extension and abduction, enabled at the subject's own pace. We hypothesize this system will support sequential activation of affected upper limb muscles intended to improve functional recovery. MATERIALS AND METHODS: Presented here is a personalized sensor-controlled stimulation system, including its architecture, sensor design, and testing of equipment specific to this study, including coils and sensors. RESULTS: All electrical and magnetic tests, and safety tests per International Electrotechnical Commission 60601-1 passed. One sensor type displayed a vulnerability to drop. CONCLUSIONS: The new control system tested safe, met requirements, and allowed each subject to activate the system at their own pace, making the rehabilitation process more acceptable and efficient.
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Brazo/fisiopatología , Terapia por Estimulación Eléctrica/instrumentación , Microelectrodos , Prótesis e Implantes , Rehabilitación de Accidente Cerebrovascular , Brazo/fisiología , Terapia por Estimulación Eléctrica/métodos , Humanos , Recuperación de la Función , Accidente Cerebrovascular/fisiopatologíaRESUMEN
OBJECTIVE: To examine the effect of home-based electrical stimulation using closed-loop control of implanted microstimulators on upper limb function and impairment, and subjects' perception of the system. MATERIALS AND METHODS: Six subjects with poststroke hemiparesis, and reduced upper limb function, who had taken part in Phase 1 of the study, were fitted with a personalized closed-loop control system (Phase 2) and used it at home during performance of functional tasks for 12 weeks (Phase 3). Main outcome measures were: Action Research Arm Test (ARAT), Fugl-Meyer upper limb assessment (FMA), and motor control (Tracking Index). Subjects' perception of the system was assessed in a structured interview. RESULTS: Improvement in ARAT (p=0.05), FMA (p=0.02), and Tracking Index (p=0.03) during Phase 3. Five subjects said using the system had changed their lives and improved their function, all performed functional tasks with the system, but external components were inconvenient. CONCLUSIONS: Closed-loop control improved in function. Subjective assessment identified that the external sensors were effective.
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Brazo/fisiopatología , Terapia por Estimulación Eléctrica/instrumentación , Microelectrodos , Prótesis e Implantes , Rehabilitación de Accidente Cerebrovascular , Adulto , Anciano , Brazo/fisiología , Terapia por Estimulación Eléctrica/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Desempeño Psicomotor , Recuperación de la Función , Accidente Cerebrovascular/fisiopatología , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: Cost-effective neurorehabilitation is essential owing to financial constraints on healthcare resources. Technologies have the potential to contribute but without strong clinical evidence are unlikely to be widely reimbursed. This review presents evidence of new technologies since 2008 and identifies barriers to translation of technologies into clinical practice. RECENT FINDINGS: Technology has not been shown to be superior to intensively matched existing therapies. Research has been undertaken into the development and preliminary clinical testing of novel technologies including robotics, electrical stimulation, constraint-induced movement therapy, assistive orthoses, noninvasive brain stimulation, virtual reality and gaming devices. Translation of the research into clinical practice has been impeded by a lack of robust evidence of clinical effectiveness and usability. Underlying mechanisms associated with recovery are beginning to be explored, which may lead to more targeted interventions. Improvements in function have been demonstrated beyond the normal recovery period, but few trials demonstrate lasting effects. SUMMARY: Technologies, alone or combined, may offer a cost-effective way to deliver intensive neurorehabilitation therapy in clinical and community environments, and have the potential to empower patients to take more responsibility for their rehabilitation and continue with long-term exercise.
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Enfermedades del Sistema Nervioso Central/rehabilitación , Técnicas de Laboratorio Clínico/instrumentación , Técnicas de Laboratorio Clínico/tendencias , Modalidades de Fisioterapia/instrumentación , Modalidades de Fisioterapia/tendencias , Actividades Cotidianas , Enfermedades del Sistema Nervioso Central/economía , Técnicas de Laboratorio Clínico/economía , Análisis Costo-Beneficio/economía , Terapia por Estimulación Eléctrica/economía , Terapia por Estimulación Eléctrica/instrumentación , Terapia por Estimulación Eléctrica/métodos , Costos de la Atención en Salud/tendencias , Humanos , Evaluación de Resultado en la Atención de Salud/economía , Evaluación de Resultado en la Atención de Salud/métodos , Modalidades de Fisioterapia/economía , Mecanismo de Reembolso/economía , Mecanismo de Reembolso/tendencias , Robótica/economía , Robótica/instrumentación , Robótica/tendenciasRESUMEN
PURPOSE: To investigate the relationship between upper limb impairments and activity limitation. METHOD: A cross sectional, single assessment observational study in which people with hemiplegia as a result of a stroke underwent a testing procedure in an instrumented wrist rig in which the following measures of impairment were recorded: Spasticity; motor control (ability to track a moving target); muscle activation patterns during tracking; stiffness; range of active movement and isometric muscle strength. Participants also performed clinical tests of upper limb activity (Action Research Arm Test) and hyper-tonicity (Modified Ashworth Scale). RESULTS: Seventeen people with hemiplegia whose mean age was 57 (SD 13.4) took part. Their mean upper limb activity, measured by the Action Research Arm Test, was 19.3 (SD 11.2). Statistically significant positive relationships between level of activity and the negative features of the upper motor neuron syndrome such as motor control r = 0.710 (p = 0.003), active range of movement r = 0.540 (p = 0.025) and strength into flexion r = 0.515 (p = 0.034) and extension r = 0.575 (p = 0.016) were identified, but not with the positive features, such as spasticity or the secondary features such as stiffness. CONCLUSIONS: The negative features of the upper motor neuron syndrome appear more likely to affect upper limb activity than the positive or secondary features, but findings need confirming in different study populations, preferably with larger samples.
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Brazo/fisiopatología , Hemiplejía/fisiopatología , Espasticidad Muscular/fisiopatología , Accidente Cerebrovascular/complicaciones , Adulto , Anciano , Estudios Transversales , Femenino , Hemiplejía/etiología , Humanos , Masculino , Persona de Mediana Edad , Actividad Motora , Fuerza Muscular/fisiología , Rango del Movimiento Articular , Recuperación de la Función , Análisis de RegresiónRESUMEN
The Stroke Recovery and Rehabilitation Roundtable (SRRR) meetings bring together an international group of preclinical and clinical researchers along with statisticians, methodologists, funders and consumers, working to accelerate the development of effective treatments for stroke recovery and to support best-evidence uptake in rehabilitation practice. The first meeting (2016) focused on four recommendation areas: translation of preclinical evidence into human discovery trials; recovery biomarkers to provide knowledge of therapeutic targets and prognosis in human stroke; intervention development, monitoring, and reporting standards; and standardized measurement in motor recovery trials. The impact of SRRR is growing, with uptake of recommendations emerging, and funders exploring ways to incorporate research targets and recommendations. At our second meeting (SRRR2, 2018), we worked on new priority areas: (1) cognitive impairment, (2) standardizing metrics for measuring quality of movement, (3) improving development of recovery trials, and (4) moving evidence-based treatments into practice. To accelerate progress towards breakthrough treatments, formation of an International Stroke Recovery and Rehabilitation Alliance is our next step, where working groups will take recommendations and build partnerships needed to achieve our goals.
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Congresos como Asunto , Investigación en Rehabilitación/normas , Rehabilitación de Accidente Cerebrovascular/normas , Accidente Cerebrovascular/diagnóstico , Disfunción Cognitiva/complicaciones , Disfunción Cognitiva/diagnóstico , Humanos , Accidente Cerebrovascular/complicacionesRESUMEN
BACKGROUND: Objective assessment of impairments after stroke is vital for evidence-based therapy and progress monitoring. OBJECTIVE: This study determines the utility of outcome measures obtained from an instrumented wrist rig for future rehabilitation trials. The tests undertaken were evaluated in terms of sensitivity to detect differences between normal and impaired participants, test-retest repeatability (repeatability coefficient and intraclass correlation coefficient [ICC]), and interrater agreement (Bland and Altman limits of agreement). METHODS: Twelve participants with chronic poststroke hemiparesis (mean 5.6 years); and 12 unimpaired volunteers performed a series of tasks in the rig. The hemiparetic arm (impaired group) and dominant arm (unimpaired group) were tested in 3 sessions on the same day by 2 assessors. Signals were analyzed to derive a tracking index (motor control), stretch index (spasticity), flexor modulation index (FMI) (muscle activation), force angle index (FAI) (stiffness), range of movement, and isometric force. RESULTS AND CONCLUSIONS: The means of all tests differed between impaired and unimpaired participants except for range of movement into flexion, the FAI, and the FMI. Repeatability coefficients for each test are presented as benchmark values for use in future trials in which the wrist rig tests may be used to detect change. Test-retest reliability was excellent in the impaired group (ICC = 0.88-0.98) and poor to excellent in the unimpaired group (ICC = 0.06-0.89). The Bland-Altman ranges showed no bias between assessors, and that the interassessor variability was similar to that between repeats by the same assessor for most tests.
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Hemiplejía/rehabilitación , Espasticidad Muscular/rehabilitación , Desempeño Psicomotor/fisiología , Muñeca/inervación , Adulto , Anciano , Análisis de Varianza , Evaluación de la Discapacidad , Femenino , Hemiplejía/etiología , Humanos , Masculino , Persona de Mediana Edad , Movimiento , Contracción Muscular/fisiología , Espasticidad Muscular/etiología , Evaluación de Resultado en la Atención de Salud , Propiocepción , Rango del Movimiento Articular/fisiología , Reflejo de Estiramiento/fisiología , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Accidente Cerebrovascular/complicaciones , Rehabilitación de Accidente CerebrovascularRESUMEN
A kinematic model is presented based on surface marker placement generating wrist, metacarpal arch, fingers and thumb movements. Standard calculations are used throughout the model and then applied to the specified marker placement. A static trial involving eight unimpaired participants was carried out to assess inter-rater reliability. The standard deviations across the data were comparable to manual goniometers. In addition, a test-retest trial of ten unimpaired participants is also reported to illustrate the variability of movement at the wrist joint, metacarpal arch, and index finger as an example of model output when repeating the same task many times. Light and heavyweight versions of the tasks are assessed and characteristics of individual movement strategies presented. The participant trial showed moderate correlation in radial/ulnar deviation of the wrist (r = 0.65), and strong correlation in both metacarpal arch joints (r = 0.75 and r = 0.85), the MCP (r = 0.79), and PIP (r = 0.87) joints of the index finger. The results indicate that individuals use repeated strategies of movement when lifting light and heavyweight versions of the same object, but showed no obvious repeated pattern of movement across the population.
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Mano/fisiología , Interpretación de Imagen Asistida por Computador/métodos , Modelos Biológicos , Movimiento/fisiología , Fotograbar/métodos , Análisis y Desempeño de Tareas , Muñeca/fisiología , Adulto , Fenómenos Biomecánicos/métodos , Simulación por Computador , Femenino , Mano/anatomía & histología , Humanos , Interpretación de Imagen Asistida por Computador/instrumentación , Masculino , Fotograbar/instrumentación , Muñeca/anatomía & histologíaRESUMEN
OBJECTIVE: To investigate the feasibility of implanting microstimulators to deliver programmed nerve stimulation for sequenced muscle activation to recover arm-hand functions. DESIGN: By using a minimally invasive procedure and local anesthesia, 5 to 7 microstimulators can be safely and comfortably implanted adjacent to targeted radial nerve branches in the arm and forearm of 7 subjects with poststroke paresis. The microstimulators' position should remain stable with no tissue infection and can be programmed to produce effective personalized functional muscle activity with no discomfort for a preliminary 12-week study. Clinical testing, before and after the study, is reported in the accompanying study. SETTING: Microstimulator implantations in a sterile operating room. PARTICIPANTS: Seven adults, with poststroke hemiparesis of 12 months or more. INTERVENTION: Under local anesthesia, a stimulating probe was inserted to identify radial nerve branches. Microstimulators were inserted by using an introducer and were retrievable for 6 days by attached suture. Each device was powered via a radiofrequency link from 2 external cuff coils connected to a control unit. MAIN OUTCOME MEASURES: To achieve low threshold values at the target sites with minimal implant discomfort. Microstimulators and external equipment were monitored over 12 weeks of exercise. RESULTS: Seven subjects were implanted with 41 microstimulators, 5 to 7 per subject, taking 3.5 to 6 hours. Implantation pain levels were 20% more than anticipated. No infections or microstimulator failures occurred. Mean nerve thresholds ranged between 4.0 to 7.7 microcoulomb/cm(2)/phase over 90 days, indicating that cathodes were within 2 to 4 mm of target sites. In 1 subject, 2 additional microstimulators were inserted. CONCLUSIONS: Microstimulators were safely implanted with no infection or failure. The system was reliable and programmed effectively to perform exercises at home for functional restoration.
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Brazo/fisiopatología , Terapia por Estimulación Eléctrica/instrumentación , Hemiplejía/rehabilitación , Rehabilitación de Accidente Cerebrovascular , Adulto , Anciano , Electrodos Implantados , Diseño de Equipo , Estudios de Factibilidad , Femenino , Hemiplejía/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Nervio Radial/fisiología , Recuperación de la Función , Seguridad , Accidente Cerebrovascular/fisiopatología , Resultado del TratamientoRESUMEN
OBJECTIVE: To investigate the therapeutic effect of functional exercise augmented by programmable implanted microstimulators on arm and hand function. DESIGN: Before and after study. SETTING: Implantation was performed in a neurosurgery unit, systems were programmed, and tests were conducted in a university laboratory and subjects exercised at home. PARTICIPANTS: Hemiparetic subjects (N=7) with reduced upper-limb function who were at least 12 months poststroke were recruited from the community. No subjects withdrew. INTERVENTION: Microstimulators were implanted into the arms and forearms to activate elbow, wrist, and finger extension, and thumb abduction. After training and programming of the system, subjects underwent 12 weeks of functional home-based exercise with stimulation. MAIN OUTCOME MEASURES: The primary functional measure was the Action Research Arm Test (ARAT). Impairment measures included upper-limb Fugl-Meyer Assessment (FMA) and tests of motor control (tracking index), spasticity (electromyography stretch index) strength, and active range of motion (AROM). The assessor was not blinded, but scores were validated by an independent blinded observer. RESULTS: All subjects were able to perform functional activities at home by using the system. Compliance was excellent, and there were no serious adverse events. Statistically significant improvements were measured (P<.05) in the tracking index (57.3 degrees(2)+/-48.65 degrees(2)), FMA score (6.3+/-3.59), wrist-extensor strength (5.5+/-4.37 N), and wrist AROM (19.3 degrees +/-18.96 degrees). The mean improvement in ARAT score +/- SD of 4.9+/-7.89 was not statistically significant. CONCLUSIONS: This study has shown the feasibility of a programmable implanted microstimulator system used at home to perform functional exercises and a reduction in impairment after 12 weeks.
Asunto(s)
Brazo/fisiopatología , Terapia por Estimulación Eléctrica/instrumentación , Paresia/rehabilitación , Rehabilitación de Accidente Cerebrovascular , Adulto , Anciano , Electrodos Implantados , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paresia/fisiopatología , Rango del Movimiento Articular/fisiología , Recuperación de la Función , Accidente Cerebrovascular/fisiopatologíaRESUMEN
PURPOSE: To enhance understanding of the relationship between upper limb and eye movements during reaching tasks in people with stroke. METHODS: Eye movements were recorded from 10 control participants and 8 chronic stroke participants during a visual orienting task (Experiment 1) and a series of reaching tasks (Experiment 2). Stroke participants completed the reaching tasks using (i) their less impaired upper limb, (ii) their more impaired upper limb without support, and (iii) their more impaired upper limb, with support (SaeboMAS gravitational support and/or electrical stimulation). Participants were tested individually and completed both experiments in the same session. RESULTS: Oculomotor control and the coordination between the upper limb and the oculomotor system were found to be intact in stroke participants when no limb movements were required, or when the less impaired upper limb was used. However, when the more impaired upper limb was used, success and accuracy in reaching decreased and patterns of eye movements changed, with an observed increase in eye movements to the limb itself. With upper limb support, patterns of hand-eye coordination were found to more closely resemble those of the control group. CONCLUSION: Deficits in upper limb motor systems result in changes in patterns of eye movement behavior during reaching tasks. These changes in eye movement behavior can be modulated by providing upper limb support. Implications for Rehabilitation Deficits in upper limb motor systems can result in changes in patterns of eye movement behavior during reaching tasks. Upper limb support can reduce deficits in hand-eye coordination. Stroke rehabilitation outcomes should consider motor and oculomotor performance.
Asunto(s)
Movimientos Oculares , Músculos Oculomotores/fisiopatología , Rehabilitación de Accidente Cerebrovascular/métodos , Accidente Cerebrovascular , Extremidad Superior/fisiopatología , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Análisis y Desempeño de Tareas , Resultado del TratamientoRESUMEN
PURPOSE: Reliability of motor-evoked potential threshold and amplitude measurement of upper limb muscles is important when detecting changes in cortical excitability. The objective of this study was to investigate intra-rater, test-retest reliability and minimal detectable change of resting motor threshold and amplitude of a proximal and distal upper limb muscles, anterior deltoid and distal extensor digitorum communis in healthy adults. METHOD: To measure motor-evoked potential responses, transcranial magnetic stimulation was interfaced with electromyography and neuronavigation equipment. Two measurements were conducted on day 1 and a third measurement three days later. Reliability was analysed using intraclass correlation coefficients. RESULTS: Twenty participants completed the study. Excellent intra-rater (intraclass correlation coefficient = 0.91 (extensor digitorum), 0.94 (anterior deltoid)) and good to excellent test-retest reliability (intraclass correlation coefficient = 0.69 (anterior deltoid), 0.84 (extensor digitorum)) was found for resting motor threshold. Minimal detectable change for resting motor threshold was found at 10.95% (extensor digitorum) and 16.35% (anterior deltoid) between first and third measurements. Motor-evoked potential amplitude of extensor digitorum communis had fair to good intra-rater (intraclass correlation coefficient = 0.50) and test-retest reliability (intraclass correlation coefficient = 0.65). CONCLUSIONS: Our results suggest that resting motor threshold is a reliable neurophysiological measure even for proximal shoulder muscles. Future research should further explore the reliability of motor-evoked potential amplitude before integration into neurological rehabilitation.
RESUMEN
OBJECTIVE: To evaluate a selective implantable drop foot stimulator (ActiGait) in terms of effect on walking and safety. DESIGN: A phase II trial in which a consecutive sample of participants acted as their own controls. SUBJECTS: People who had suffered a stroke at least 6 months prior to recruitment and had a drop-foot that affected walking were recruited from 3 rehabilitation centres in Denmark. METHODS: Stimulators were implanted into all participants. Outcome measures were range of ankle dorsiflexion with stimulation and maximum walking speed and distance walked in 4 minutes. Measurements were applied before implantation, at 90 days and at a long-term follow-up assessment. Changes over time and with and without stimulation are reported. Safety was evaluated by nerve conduction velocity and adverse events. RESULTS: Fifteen participants were implanted and 13 completed the trial. Long-term improvements were detected in walking speed and distance walked in 4 minutes when stimulated, and the orthotic effect of stimulation showed statistically significant improvement. The device did not compromise nerve conduction velocity and no serious device-related adverse events were reported. Technical problems were resolved by the long-term follow-up assessment at which further improvement in walking was observed. CONCLUSION: This trial has evaluated the safety and performance of the device, which was well accepted by patients and did not compromise safety.