Experiencing Functional Electrical Stimulation Roots on Education, and Clinical Developments in Paraplegia and Tetraplegia With Technological Innovation.

Cybernetics-based concepts can allow for complete independence for paralyzed individuals, including sensory motor recovery. Spinal cord injuries are responsible for a huge stress on health and a financial burden to society. This article focuses on novel procedures such as functional diagnosis for paraplegics and tetraplegics, cybertherapies toward lessening comorbidities such as cardiovascular diseases, osteoporosis, etc., and the production of new technology for upper and lower limb control. Functional electrical stimulation reflects a unique opportunity for bipedal gait to be achieved by paraplegics and tetraplegics. Education and training of undergraduates and postgraduates in engineering and life sciences have also been a major aim of this work.

Design and fast-fabrication of a system for functional electrical stimulation in upper limb of people with tetraplegia.

STUDY DESIGN: Proof of concept. OBJECTIVES: Standard Functional Electrical Stimulation (FES) systems can enhance motor learning in people with tetraplegia and are widely delivered by self-adhesive electrodes. Their limitations are dexterity, specific knowledge to place the electrodes on muscles, need to fix electrodes when they lose the gel layer, and time. We designed a new FES system, using an existing protocol of drinking-like movements, to the upper limb of a person with tetraplegia C5 that fits in any anthropometry and can be easily produced. Furthermore, we tested the system to assess its effectiveness and users' perception during FES rehabilitation. SETTING: São Carlos, SP, Brazil. METHODS: A shell was designed with parametric design and fast-fabrication methods, and a stimulation unit and a smartphone application were developed. Questionnaires assessed the perceptions of a patient and a physiotherapist, about the usability of the new system in relation to standard FES. Kinematic data of drinking-like movements were collected from the patient wearing both systems and compared with data from an aged-matched control subject. RESULTS: The results are a personalized shell and an intuitive FES system, overcoming the limitations of standard FES. The new system suggested better wrist-flexion control shown by the mean angles (-18.93°), then the other system (-59.35°), and compared with the control (-10.97°). CONCLUSIONS: Fast-fabrication with parametric design offers a promising alternative for personalizing FES systems, with potential for home use. Further studies are required including randomized clinical trials.

A hybrid system for upper limb movement restoration in quadriplegics.

Generally, quadriplegic individuals have difficulties performing object manipulation. Toward satisfactory manipulation, reach and grasp movements must be performed with voluntary control, and for that, grasp force feedback is essential. A hybrid system aiming at partial upper limb sensory-motor restoration for quadriplegics was built. Such device is composed of an elbow dynamic orthosis that provides elbow flexion/extension (range was approximately from 20 degrees to 120 degrees , and average angular speed was approximately 15 degrees /s) with forearm support, a wrist static orthosis and neuromuscular electrical stimulation for grasping generation, and a glove with force sensors that allows grasping force feedback. The glove presents two user interface modes: visual by light emitting diodes or audio emitted by buzzer. Voice control of the entire system (elbow dynamic orthosis and electrical stimulator) is performed by the patient. The movements provided by the hybrid system, combined with the scapular and shoulder movements performed by the patient, can aid quadriplegic individuals in tasks that involve reach and grasp movements.

Clinical assessment of spasticity in individuals with spinal cord injury.

OBJECTIVE: To evaluate the effect of neuromuscular electrical stimulation on spasticity in patients with spinal cord injury. METHODS: The study included eleven subjects with spinal cord injuries (C4 to T5). The modified Ashworth scale and pendulum test, which is accomplished through the Pendular Test Device - PTD (equipment which has a quartz crystal transducer accelerometer and optic fiber flexible electrogoniometer measuring the tensions and angular displacements). Patients underwent neuromuscular electrical stimulation (NMES) to the quadriceps muscle from fibular nerve, and the tests were administered before and after therapy. RESULTS: The data show a decrease in spasticity after NMES, with features such as increased variation between maximum and minimum peaks, i.e. increased amplitude of the curves. Furthermore, data from the subjective scale, and modified Ashworth scale after neuromuscular electrical stimulation also showed a reduction in the values of spasticity. CONCLUSION: The data suggest that NMES is effective in reducing spasticity immediately after completion. Level of Evidence II, Therapeutic Studies-Investigating the Results of Treatment .

Patients with chronic high spinal cord injury can be safely treated with neuromuscular electrical stimulation: cardiovascular function is unaffected / Pacientes com lesão crônica alta da medula espinhal podem ser tratados de forma segura com estimulação elétrica neuromuscular: a função cardiovascular não é afetada

OBJECTIVE: To identify changes in blood pressure and heart rate in individuals with chronic paraplegia undergone neuromuscular electrical stimulation treatment. METHOD: Design: Observational prospective. Participants: Twenty individuals with chronic paraplegia (neurological level above T6) belonging to two different groups (G1 and G2) were submitted to an upper limb exercise test. G1 patients (n=13) had been treated with neuromuscular electrical stimulation (25Hz, pulses of 300µs, 100V) for 2 years or more, at least once a week; G2 patients (n=7) did not receive neuromuscular electrical stimulation treatment; G3 individuals (n=6) were healthy volunteers. Procedures: Arterial blood pressure and heart rate were measured during four phases of the exercise test: at initial rest, during warmup, during the exercise itself, and at rest after the exercise. RESULTS: Systolic and diastolic blood pressures showed no statistical difference between groups. In the comparison between exercise phases, regardless of the group, systolic pressure was significantly higher and diastolic pressure significantly lower at the end of the exercise itself, when compared to all other phases. Resting heart rate was significantly lower in healthy controls vs. G1 and G2, which were not significantly different between themselves. Exercise increased heart rate in all groups. CONCLUSION: This study showed that the groups are normotensive and homogeneous in their results; heart rate was higher in both paraplegic groups compared to healthy controls, but no difference was found between treated vs. untreated groups. Thus, neuromuscular electrical stimulation is a safe and effective way to treat individuals with chronic paraplegia.

OBJETIVO: Identificar mudanças na pressão arterial e frequência cardíaca em indivíduos com paraplegia crônica tratados com estimulação elétrica neuromuscular. MÉTODO: Estudo prospectivo observacional. Participantes: vinte indivíduos com paraplegia crônica (nível neurológico acima de T6) pertencentes a dois diferentes grupos (G1 e G2) foram submetidos a um teste de exercício de membros superiores. Os pacientes do G1 (n = 13) haviam sido tratados com estimulação elétrica neuromuscular (25 Hz, pulsos de 300 µs, 100 V) por 2 anos ou mais, pelo menos uma vez por semana; os pacientes do G2 (n = 7) não receberam o tratamento com estimulação elétrica neuromuscular; os indivíduos do G3 (n = 6) eram voluntários saudáveis. Procedimentos: A pressão sanguínea arterial e a frequência cardíaca foram medidas durante quatro fases do teste de exercício: no repouso inicial, durante o aquecimento, durante o exercício e no repouso após o exercício. RESULTADOS: As pressões arteriais sistólica e diastólica não apresentaram diferença estatística entre os grupos. Na comparação entre as fases do exercício, independentemente do grupo, a pressão sistólica foi significativamente maior e a pressão diastólica significativamente menor no final do exercício, em comparação com todas as outras fases. A frequência cardíaca em repouso foi significativamente menor em controles saudáveis ​​versus G1 e G2, que não foram significativamente diferentes entre eles mesmos. O exercício aumentou a frequência cardíaca em todos os grupos. CONCLUSÃO: Este estudo mostrou que os grupos são normotensos e homogêneos em seus resultados; a frequência cardíaca foi maior em ambos os grupos paraplégicos em comparação com controles saudáveis, mas nenhuma diferença foi encontrada entre os grupos tratados versus os não tratados. Assim, a estimulação elétrica neuromuscular é uma maneira segura e eficaz de tratar indivíduos com paraplegia crônica.

Upper limb assessment in tetraplegia: clinical, functional and kinematic correlations.

The aim of this study was to correlate clinical and functional evaluations with kinematic variables of upper limp reach-to-grasp movement in patients with tetraplegia. Twenty chronic patients were selected to perform reach-to-grasp kinematic assessment using a target placed at a distance equal to the arm's length. Kinematic variables (hand peak velocity, movement time, percent time-to-maximal velocity, index of curvature, number of peaks, and joint range of motion) were correlated to clinical (Standard Neurological Classification of Spinal Cord Injury-American Spinal Injury Association) and functional [Functional Independence Measure (FIM) and Spinal Cord Independence Measure II (SCIM II)] evaluation scores. Twenty control participants were also selected to obtain normal reference parameters. There was a positive correlation between total motor index and FIM (r=0.6089; P=0.0044) and SCIM II (r=0.5229; P=0.018). Both functional scores showed positive correlation with each other (r=0.8283; P<0.0001). A correlation was also observed between the right and left motor indices, the motor FIM, and the SCIM II in most of the reach-to-grasp kinematic variables studied (hand peak velocity, movement time, index of curvature, and number of peaks). In contrast, for the joint range of motion (shoulder, elbow, and wrist), only the wrist in the horizontal plane showed correlation with clinical variables. This study shows that muscle strength assessed by the American Spinal Injury Association motor index influences the reach-to-grasp kinematic variables of patients with tetraplegia. However, the functional assessments did not present the same influence.

Análise clinica da espasticidade em indivíduos com lesão medular / Clinical assessment of spasticity in individuals with spinal cord injury

OBJETIVO: Avaliar o efeito da estimulação elétrica neuromuscular na espasticidade nos pacientes com lesão medular.MÉTODOS: Participaram do estudo onze sujeitos lesados medulares (C4 a T5). Foram utilizados para esta avaliação a escala modificada de Ashworth e o teste pendular, que foi realizado através do Dispositivo de Teste Pendular - DTP (o equipamento possui um acelerômetro de transdutores de cristais de quartzo e eletrogoniômetro de fibra óptica flexível que mede as tensões e os deslocamentos angulares). Os pacientes realizaram estimulação elétrica neuromuscular (EENM) nos músculos quadríceps e nervo fibular, sendo que os testes foram aplicados antes e após o procedimento.RESULTADOS: Os dados mostram uma diminuição da espasticidade após a EENM, com características tais como um aumento na variação entre o pico máximo e o mínimo, ou seja, aumento da amplitude das curvas. Além disso, os dados da escala subjetiva, e escala modificada de Ashworth, após a estimulação elétrica neuromuscular também apresentaram uma redução nos valores da espasticidade.CONCLUSÃO: Os dados sugerem que a EENM é eficaz para reduzir a espasticidade imediatamente após a sua realização. Nível de Evidência II, Estudos Terapêuticos -Investigação dos Resultados do Tratamento.

OBJECTIVE: To evaluate the effect of neuromuscular electrical stimulation on spasticity in patients with spinal cord injury.METHODS: The study included eleven subjects with spinal cord injuries (C4 to T5). The modified Ashworth scale and pendulum test, which is accomplished through the Pendular Test Device - PTD (equipment which has a quartz crystal transducer accelerometer and optic fiber flexible electrogoniometer measuring the tensions and angular displacements). Patients underwent neuromuscular electrical stimulation (NMES) to the quadriceps muscle from fibular nerve, and the tests were administered before and after therapy.RESULTS: The data show a decrease in spasticity after NMES, with features such as increased variation between maximum and minimum peaks, i.e. increased amplitude of the curves. Furthermore, data from the subjective scale, and modified Ashworth scale after neuromuscular electrical stimulation also showed a reduction in the values of spasticity.CONCLUSION: The data suggest that NMES is effective in reducing spasticity immediately after completion. Level of Evidence II, Therapeutic Studies-Investigating the Results of Treatment.

Avaliação cinemática da transferência de paraplégicos da cadeira de rodas / Kinematic assessment of transfer of paraplegic subjects from the wheelchair

OBJETIVO: Avaliar a estratégia das transferências de paraplégicos da cadeira de rodas. MÉTODOS: Participaram do estudo doze sujeitos lesados medulares (T2 a T12), aptos a realizar independentemente a transferência da cadeira de rodas para um tablado com um metro quadrado (m²) de área por meio metro de altura. As imagens de marcadores reflexivos nos pontos anatômicos foram capturadas por seis câmeras de infravermelho ProReflex e processadas através de um software específico (QTrac). Parâmetros cinemáticos do tronco, cabeça, ombros e cotovelos foram avaliados. RESULTADOS: Os dados analisados comparam o lado preferencial do sujeito para realizar a transferência com o lado não preferencial, de acordo com as funções desempenhadas de cada segmento corporal. O deslocamento angular da cabeça no plano sagital (y-z) e ombros no plano transversal (x-y) mostraram significâncias estatísticas (p<0,05). Conclusão: Os dados obtidos neste estudo mostraram que há diferenças na estratégia da transferência dos paraplégicos do lado preferencial em comparação com o lado não preferencial. Nível de Evidência II, Desenvolvimento de critérios diagnósticos em pacientes consecutivos (com padrão de evidência "ouro" aplicado).

OBJECTIVE: To evaluate the transfer strategy of paraplegic subjects from their wheelchairs. METHODS: Twelve thoracic spinal cord injured subjects participated in this study (T2 to T12). The subjects were able to independently transfer from a wheelchair to a one square meter (m2) table, half a meter in height. Images of reflexive anatomic markers were captured by six ProReflex infrared cameras and processed using a QTRac Capture software. Kinematic parameters of the trunk, head, shoulders and elbows were evaluated. RESULTS: The data analyzed compared the subjects' preferential side for performing transfers, according to the functions performed by each body segment. Angular displacement of the head on sagittal plan (y-z), and the shoulders on the transversal plan (x-y), showed statistical differences (p<0.05). Conclusion: the data obtained on this study showed that there are differences in transfer strategies of paraplegic subjects to their preferential side, in comparison with the non-preferential side. Level of Evidence II, Development of diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).