Early Stroke Rehabilitation of the Upper Limb Assisted with an Electromyography-Driven Neuromuscular Electrical Stimulation-Robotic Arm

Abstract

BackgroundEffective poststroke motor rehabilitation depends on repeated limb practice with voluntary efforts. An electromyography (EMG)-driven neuromuscular electrical stimulation (NMES)-robot arm was designed for the multi-joint physical training on the elbow, the wrist, and the fingers.ObjectivesTo investigate the training effects of the device-assisted approach on subacute stroke patients and to compare the effects with those achieved by the traditional physical treatments.MethodThis study was a pilot randomized controlled trial with a 3-month follow-up. Subacute stroke participants were randomly assigned into two groups, and then received 20-session upper limb training with the EMG-driven NMES-robotic arm (NMES-robot group, n = 14) or the time-matched traditional therapy (the control, n = 10). For the evaluation of the training effects, clinical assessments including Fugl-Meyer Assessment (FMA), Modified Ashworth Score (MAS), Action Research Arm Test (ARAT), and Function Independence Measurement (FIM) were conducted before, after the rehabilitation training, and 3 months later. Session-by-session EMG parameters in the NMES-robot group, including normalized co-contraction Indexes (CI) and EMG activation level of target muscles, were used to monitor the progress in muscular coordination patterns.ResultsSignificant improvements were obtained in FMA (full score and shoulder/elbow), ARAT, and FIM [P < 0.001, effect sizes (EFs) > 0.279] for both groups. Significant improvement in FMA wrist/hand was only observed in the NMES-robot group (P < 0.001, EFs = 0.435) after the treatments. Significant reduction in MAS wrist was observed in the NMES-robot group after the training (P < 0.05, EFs = 0.145) and the effects were maintained for 3 months. MAS scores in the control group were elevated following training (P < 0.05, EFs > 0.24), and remained at an elevated level when assessed 3 months later. The EMG parameters indicated a release of muscle co-contraction in the muscle pairs of biceps brachii and flexor carpi radialis and biceps brachii and triceps brachii, as well as a reduction of muscle activation level in the wrist flexor in the NMES-robot group.ConclusionThe NMES-robot-assisted training was effective for early stroke upper limb rehabilitation and promoted independence in the daily living comparable to the traditional physical therapy. It could achieve higher motor outcomes at the distal joints and more effective release in muscle tones than the traditional therapy.Clinical Trial Registration, identifier NCT02117089; date of registration: April 10, 2014.

Effects of Neuromuscular Electrical Stimulation on Hemiplegic Upper Limb of Stroke Survivors: A Meta-Analysis of Randomized Controlled Trials

“…RCTs data were all Mean ± SD and two were 95%CI 17,18 . The Chi-squared and I-square (I 2 ) tests were used to analyse trial statistical heterogeneity.…”

“…Amongst all, these selected trials were different in study quality: besides 12 17,18,26,[28][29][30][31][32][33][34][35][36] blind trials were at low risk of bias, one study 27 was assessed as high risk of bias out of not blind. 2 35, 36 trials adopted concealed allocation, which were regarded as low risk of bias.…”

“…One study 34 was at high risk of bias due to incomplete outcome data. Moreover, 6 studies 17,18,28,31,33,35 were at low risk of bias due to random sequence generation by computer or pseudorandom number sequence. One study 36 was at high risk of bias for free of other sources of bias.…”

“…Additionally, NMES treatment did not display a positive effect on the wrist MAS SMD=-0.12, 95%CI -0.43 to 0.19, P=0.434). The meta-analysis of 5 17,26,33,35,36 studies implied a distinct benefit in the intervention group (n = 114) in improving ARAT, which had inconspicuous heterogeneity compared with the control group (n = 113) (SMD = 0.31, 95% CI 0.05 to 0.58, P = 0.019, I 2 = 0%). Moreover, NMES therapy was effective when measured by MAL-AOU score (SMD=0.59,95%CI 0.15 to 1.04, P=0.009), which contrasts with BI score (SMD=0.51,95%CI -0.65 to 1.66, P=0.392) that exhibited no benefit in upper limb rehabilitation (Fig 2A-E).…”

Upper-Limb Exoskeletons for Stroke Rehabilitation

“…When FES is combined with the patient's residual voluntary effort [1], cortical plasticity seems to be enhanced, having therefore the potential to improve the therapeutic effects of FES [6]. The combined action of robotassisted therapy supporting elbow and wrist motion and EMG-triggered FES has shown positive effects on muscle coordination in subacute [24] and chronic stroke survivors [25]. FES has been combined also with passive anti-gravity exoskeletons, e.g.…”