Strengthening interventions for people after stroke

Stroke is one of the leading causes of death and disability. Muscle weakness in the paretic arm and leg is one of the most common impairments after stroke. Muscle weakness has been identified as one of the main contributors to activity limitations (such as walking or reaching and manipulation) and participation restrictions. This thesis includes a systematic review with meta-analysis and two assessor-blinded, multi-centre randomised controlled trials. The systematic review investigated if interventions involving repetitive practice improve strength after stroke, and if any improvements in strength are accompanied by improvements in activity. The overall SMD of repetitive practice on strength was 0.25 SD (95% CI 0.16 to 0.34) in favour of repetitive practice. The first trial investigated the effects of Functional Electrical Stimulation cycling on mobility and strength after acquired brain injury caused by stroke or trauma. The mean between-group differences (95% CI) for mobility and strength of the knee extensors of the paretic lower limb were –0.3/21 points (–3.2 to 2.7) and 7.5 Nm (–5.1 to 20.2), respectively, where positive values favoured the experimental group. The second trial investigated the effects of intensive sit-to-stand training on sit-to-stand ability and gross lower limb extension strength in people who are unable to stand up independently after stroke. The mean between-group differences (95% CI) for clinicians’ impressions of sit-to-stand change and gross lower limb extension strength were 1.57/15 points (0.02 to 3.11) and 6.2 degrees (0.5 to 11.9), respectively. The results from this research program suggest that: 1. Interventions involving repetitive practice should be prioritised in stroke rehabilitation programs because these interventions can improve both strength and activity after stroke. 2. Functional Electrical Stimulation cycling in addition to usual care may provide more opportunities for people who are very weak and immobile after acquired brain injury caused by stroke or trauma to improve lower limb strength, but there are no accompanied improvements in mobility. 3. Intensive sit-to-stand training in addition to usual care improves sit-to-stand ability and gross lower limb extension strength in people who are unable to stand up independently after stroke

Adaptive Closed-Loop Neuromorphic Controller for Use in Respiratory Pacing

Respiratory pacing can treat ventilatory insufficiency through electrical stimulation of the respiratory muscles, or the respective innervating nerves, to induce ventilation. It avoids some of the adverse effects associated with mechanical ventilation such as risk of diaphragm atrophy and lung damage. However, current respiratory pacing systems provide stimulation in an open-loop manner. This often requires users to undergo frequent tuning sessions with trained clinicians if the specified stimulation parameters are unable to induce sufficient ventilation in the presence of time-varying changes in muscle properties, chest biomechanics, and metabolic demand. Lack of adaptation to these changes may lead to complications arising from hyperventilation or hypoventilation. A novel adaptive closed-loop neuromorphic controller for respiratory pacing has been developed to address the need for closed-loop control respiratory pacing capable of responding to changes in metabolic production of CO2, diaphragm muscle health, and biomechanics. A 3-stage processes was utilized to develop the controller. First, an adaptive controller that could follow a preset within-breath volume profile was developed in silico and evaluated in vivo in anesthetized rats with an intact spinal cord or with diaphragm hemiparesis induced by spinal cord hemisection. Second, a neuromorphic computational model was developed to generate a desired trajectory that reflects changes in breath volume and respiratory rate in response to arterial CO2 levels. An enhanced controller capable of generating and matching this model-based desired trajectory was evaluated in silico and in vivo on rats with depressed ventilation and diaphragm hemiparesis. Finally, the enhanced adaptive controller was modified for human-related biomechanics and CO2 dynamics and evaluated in silico under changes of metabolic demand, presence of muscle fatigue, and after randomization of model parameters to reproduce expected between-subject differences. Results showed that the adaptive controller could adapt and modulate stimulation parameters and respiratory rate to follow a desired model-generated breath volume trajectory in response to dynamic arterial CO2 levels. In silico studies aimed at assessing potential for clinical translation showed that an enhanced controller modified for human use could successfully control ventilation to achieve and maintain normocapnic arterial CO2 levels. Overall, these results suggest that use of an adaptive closed-loop controller could lead to improved ventilatory outcomes and quality of life for users of adaptive respiratory pacing

Development of a hybrid robotic system based on an adaptive and associative assistance for rehabilitation of reaching movement after stroke

Stroke causes irreversible neurological damage. Depending on the location and the size of this brain injury, different body functions could result affected. One of the most common consequences is motor impairments. The level of motor impairment affectation varies between post-stroke subjects, but often, it hampers the execution of most activities of daily living. Consequently, the quality of life of the stroke population is severely decreased. The rehabilitation of the upper-limb motor functions has gained special attention in the scientific community due the poor reported prognosis of post-stroke patients for recovering normal upper-extremity function after standard rehabilitation therapy. Driven by the advance of technology and the design of new rehabilitation methods, the use of robot devices, functional electrical stimulation and brain-computer interfaces as a neuromodulation system is proposed as a novel and promising rehabilitation tools. Although the uses of these technologies present potential benefits with respect to standard rehabilitation methods, there still are some milestones to be addressed for the consolidation of these methods and techniques in clinical settings. Mentioned evidences reflect the motivation for this dissertation. This thesis presents the development and validation of a hybrid robotic system based on an adaptive and associative assistance for rehabilitation of reaching movements in post-stroke subjects. The hybrid concept refers the combined use of robotic devices with functional electrical stimulation. Adaptive feature states a tailored assistance according to the users’ motor residual capabilities, while the associative term denotes a precise pairing between the users’ motor intent and the peripheral hybrid assistance. The development of the hybrid platform comprised the following tasks: 1. The identification of the current challenges for hybrid robotic system, considering twofold perspectives: technological and clinical. The hybrid systems submitted in literature were critically reviewed for such purpose. These identified features will lead the subsequent development and method framed in this work. 2. The development and validation of a hybrid robotic system, combining a mechanical exoskeleton with functional electrical stimulation to assist the execution of functional reaching movements. Several subsystems are integrated within the hybrid platform, which interact each other to cooperatively complement the rehabilitation task. Complementary, the implementation of a controller based on functional electrical stimulation to dynamically adjust the level of assistance is addressed. The controller is conceived to tackle one of the main limitations when using electrical stimulation, i.e. the highly nonlinear and time-varying muscle response. An experimental procedure was conducted with healthy and post-stroke patients to corroborate the technical feasibility and the usability evaluation of the system. 3. The implementation of an associative strategy within the hybrid platform. Three different strategies based on electroencephalography and electromyography signals were analytically compared. The main idea is to provide a precise temporal association between the hybrid assistance delivered at the periphery (arm muscles) and the users’ own intention to move and to configure a feasible clinical setup to be use in real rehabilitation scenarios. 4. Carry out a comprehensive pilot clinical intervention considering a small cohort of patient with post-stroke patients to evaluate the different proposed concepts and assess the feasibility of using the hybrid system in rehabilitation settings. In summary, the works here presented prove the feasibility of using the hybrid robotic system as a rehabilitative tool with post-stroke subjects. Moreover, it is demonstrated the adaptive controller is able to adjust the level of assistance to achieve successful tracking movement with the affected arm. Remarkably, the accurate association in time between motor cortex activation, represented through the motor-related cortical potential measured with electroencephalography, and the supplied hybrid assistance during the execution of functional (multidegree of freedom) reaching movement facilitate distributed cortical plasticity. These results encourage the validation of the overall hybrid concept in a large clinical trial including an increased number of patients with a control group, in order to achieve more robust clinical results and confirm the presented herein.Programa Oficial de Doctorado en Ingeniería Eléctrica, Electrónica y AutomáticaPresidente: Ramón Ceres Ruiz.- Secretario: Luis Enrique Moreno Lorente.- Vocal: Antonio Olivier

Effectiveness of intensive physiotherapy for gait improvement in stroke: systematic review

Introduction: Stroke is one of the leading causes of functional disability worldwide. Approximately 80% of post-stroke subjects have motor changes. Improvement of gait pattern is one of the main objectives of physiotherapists intervention in these cases. The real challenge in the recovery of gait after stroke is to understand how the remaining neural networks can be modified, to be able to provide response strategies that compensate for the function of the affected structures. There is evidence that intensive training, including physiotherapy, positively influences neuroplasticity, improving mobility, pattern and gait velocity in post-stroke recovery. Objectives: Review and analyze in a systematic way the experimental studies (RCT) that evaluate the effects of Intensive Physiotherapy on gait improvement in poststroke subjects. Methodology: Were only included all RCT performed in humans, without any specific age, that had a clinical diagnosis of stroke at any stage of evolution, with sensorimotor deficits and functional gait changes. The databases used were: Pubmed, PEDro (Physiotherapy Evidence Database) and CENTRAL (Cochrane Center Register of Controlled Trials). Results: After the application of the criteria, there were 4 final studies that were included in the systematic review. 3 of the studies obtained a score of 8 on the PEDro scale and 1 obtained a score of 4. The fact that there is clinical and methodological heterogeneity in the studies evaluated, supports the realization of the current systematic narrative review, without meta-analysis. Discussion: Although the results obtained in the 4 studies are promising, it is important to note that the significant improvements that have been found, should be carefully considered since pilot studies with small samples, such as these, are not designed to test differences between groups, in terms of the effectiveness of the intervention applied. Conclusion: Intensive Physiotherapy seems to be safe and applicable in post-stroke subjects and there are indications that it is effective in improving gait, namely speed, travelled distance and spatiotemporal parameters. However, there is a need to develop more RCTs with larger samples and that evaluate the longterm resultsN/

Feedback control of cycling in spinal cord injury using functional electrical stimulation

This thesis is concerned with the realisation of leg cycling by means of FES in SCI individuals with complete paraplegia. FES lower-limb cycling can be safely performed by paraplegics on static ergometers or recumbent tricycles. In this work, different FES cycling systems were developed for clinical and home use. Two design approaches have been followed. The first is based on the adaptation of commercially available recumbent tricycles. This results in devices which can be used as static trainers or for mobile cycling. The second design approach utilises a commercially available motorised ergometer which can be operated while sitting in a wheelchair. The developed FES cycling systems can be operated in isotonic (constant cycling resistance) or isokinetic mode (constant cadence) when used as static trainers. This represents a novelty compared to existing FES cycling systems. In order to realise isokinetic cycling, an electric motor is needed to assist or resist the cycling movement to maintain a constant cadence. Repetitive control technology is applied to the motor in this context to virtually eliminate disturbance caused by the FES activated musculature which are periodic with respect to the cadence. Furthermore, new methods for feedback control of the patient’s work rate have been introduced. A one year pilot study on FES cycling with paraplegic subjects has been carried out. Effective indoor cycling on a trainer setup could be achieved for long periods up to an hour, and mobile outdoor cycling was performed over useful distances. Power output of FES cycling was in the range of 15 to 20 W for two of the three subjects at the end of the pilot study. A muscle strengthening programme was carried out prior and concurrent to the FES cycling. Feedback control of FES assisted weight lifting exercises by quadriceps stimulation has been studied in this context

Muscular activation and corticospinal excitability adaptations to split crank cycling

Foot drop is a common motor impairment of the lower limb caused by Acquired Brain Injury (ABI) that can limit mobility and increase risk of falls. Split Crank (SC) cycling is proposed here as a novel paradigm to evoke functional neural plasticity and beneficial muscular adaptations to treat foot drop. Healthy participants were randomly assigned to SC or FC conditions for a 5 day intervention. Transcranial magnetic stimulation (TMS) evoked stimulus-response curves (SRCs) for tibialis anterior (TA) and muscle kinematic activation patterns for TA, soleus (SOL), biceps femoris (BF) and vastus lateralis (VL) during cycling were recorded before and after the first and last training sessions. SRCs revealed no beneficial TA corticospinal excitability adaptations to training but significant increases in duration of TA and BF activity were reported for TA and BF during SC cycling (p < .05). This occurred as an immediate response on initial exposure to the task. The strength of evidence for implementing SC cycling with ABI patients in the treatment of foot drop was weaker than hoped. However, increased duration of TA activation shows promise as beneficial for foot drop sufferers. Completion of the study provided new information on an unexplored exercise therapy and useful observations for facilitating clinical translation in the future