Quadriceps muscle activity during walking with a knee ankle foot orthosis is associated with improved gait ability in acute hemiplegic stroke patients with severe gait disturbance

IntroductionA knee-ankle-foot orthosis (KAFO) prevents knee buckling during walking and enables gait training for acute hemiplegic stroke patients with severe gait disturbances. Although the goal of gait training with a KAFO is to improve gait ability, that is, to acquire walking with an ankle-foot orthosis (AFO), it is not clear how gait training with a KAFO contributes to improving gait ability. Therefore, this study aimed to investigate the relationship between muscle activities during walking with a KAFO and the improvement of gait ability in hemiplegic stroke patients with severe gait disturbance.MethodsA prospective cohort study was conducted. Fifty acute hemiplegic stroke patients who could not walk with an AFO participated. Muscle activities of the paretic rectus femoris, biceps femoris, tibialis anterior, and soleus were assessed with surface electromyogram during walking with a KAFO. Electromyograms were assessed at the beginning of gait training and at the time the Ambulation Independence Measure score improved by 3 or higher, or discharge.ResultsEven in patients with complete hemiplegia, paretic rectus femoris, biceps femoris, and soleus showed periodic muscle activity during walking with a KAFO. Twenty-three patients improved to an Ambulation Independence Measure score of 3 or higher and were able to walk with an AFO (good recovery group). At the beginning of gait training, paretic rectus femoris muscle activity during the first double-limb support phase was significantly higher in the good recovery group than in the poor recovery group. The rectus femoris muscle activity significantly increased from before to after acute rehabilitation, which consisted mainly of gait training with a KAFO.DiscussionFor acute hemiplegic stroke patients with severe disturbance, the induction and enhancement of paretic quadriceps muscle activity during walking with a KAFO play an important role in acquiring walking with an AFO

Factor analysis for construct validity of a trunk impairment scale in Parkinson’s disease: a cross-sectional study

ObjectivesTo investigate the construct validity of the Trunk Impairment Scale (TIS), which was developed to assess trunk impairment in patients with stroke, in patients with Parkinson’s disease (PD).DesignThis retrospective, cross-sectional study enrolled consecutive PD inpatients. Correlation analysis was performed to clarify whether the TIS assessment was related to other balance functions, lower extremity muscle strength, or walking ability. Factor analysis was performed to see how the background factors of TIS differ from balance function, lower limb muscle strength, and walking ability.ResultsExamining the data of 471 patients with PD, there were relationships between TIS and the Mini-Balance Evaluation Systems Test (r = 0.67), Barthel Index (r = 0.57), general lower limb extension torque (r = 0.51), two-minute walk test (r = 0.54), Hoehn and Yahr stage (r = −0.61), and Movement Disorder Society Unified Parkinson’s Disease Rating Scale part III total points (r = −0.59). Factor analysis showed that TIS items were divided into three factors (an abdominal muscles and righting reflex component; a perception and verticality component; and a rotational component), differing from other scales that included clinical assessment items.ConclusionThe TIS can be useful for assessing the underlying trunk impairment as a basis for activities of daily living, gait function, and balance ability in patients with PD

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

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

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

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. Functional Recovery of Upper Extremity Motor Function following Stroke Stroke is a common health-care problem that causes physical impairment, disability, and problems in social participation. The most common impairment caused by stroke is motor impairment. Motor impairment affects the control of the unilateral upper and lower extremities. Recovery of function in the hemiparetic upper extremity is noted in fewer than 15% of patients after stroke Patients often compensate for their paretic upper extremity by using their intact upper extremity in the performance of everyday tasks Principles of motor rehabilitation following stroke have been described as being dose-dependent and task-specific The goal of upper extremity rehabilitation is to improve the capability of the paretic upper extremity for ADL. Constraint-induced movement therapy (CIMT) has been developed to enhance the forced use of the paretic hand in ADL with reduction of the compensatory overuse of the intact upper extremity. However, to participate in CIMT, the candidates must be able to voluntary extend their fingers and wrist at least 10 degrees, practice for 6 hours daily in a 2-week course, and spend waking hours with their nonparetic hand in a mitt To counter potential problems inherent in the intensive services needed for CIMT, we developed an alternative therapeutic approach that provides high-intensity training to facilitate the use of the paretic upper extremity in daily living by combining closed-loop electromyography-(EMG-) controlled neuromuscular electrical stimulation (NMES) with a wrist-hand splint for patients with moderate to severe hemiparesis. Fujiwara et al. called this hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy HANDS Therapy A PubMed literature search was conducted using the MeSH terms stroke, rehabilitation, upper extremity function, and neuromuscular electrical stimulation, and 71 articles were identified. A further search of PubMed with the terms stroke, rehabilitation, upper extremity function, neuromuscular electrical stimulation, and splint identified 4 articles, all regarding HANDS therapy. HANDS therapy facilitates the use of the paretic upper extremity in daily living by combining closed-loop EMGcontrolled NMES with a wrist-hand splint for patients with moderate to severe hemiparesis. This HANDS system is active for 8 hours, and patients are instructed to use their paretic hand as much as possible while wearing the HANDS system. Their nonparetic upper extremity is not restrained. The patients are also instructed to practice bimanual activities in their ADL. All participants in HANDS therapy are admitted, and the length of the intervention is 21 days. They receive 90 minutes of occupational therapy per day, 5 days a week. Each session of occupational therapy consists of gentle stretching exercise of the paretic upper extremity and active muscle reeducation exercise. All participants are instructed how to use their paretic hand in ADL with the HANDS system. Occupational therapists are directed toward participants' goals and focused on their particular impairments and disabilities; thus, the specific therapy that each patient receives varies Fujiwara et al. Previous reports showed that none of the patients experienced any discomfort or significant disability with the HANDS therapy. Closed-Loop Electromyography-(EMG-) Controlled Neuromuscular Electrical Stimulation (NMES). Twenty-nine articles were found in PubMed using the terms stroke, electromyography, neuromuscular electrical stimulation, and upper extremity. Thirteen of 29 articles were on EMGtriggered NMES. Six of 29 articles were on EMG-controlled NMES. Two involved contralaterally controlled electrical stimulation. EMG-triggered NMES applies preset electrical stimulation when EMG activity reaches a target threshold. The stimulus intensity and duration are determined and not changeable. EMG-controlled NMES applies electrical stimulation during voluntary contraction and changes the stimulation intensity in proportion to the changes in EMG amplitude. For assistive stimulation, HANDS therapy used closedloop EMG-controlled NMES, which was developed by Muraoka It is difficult for patients with severe to moderate hemiparesis to extend their paretic fingers. As for hand function to perform ADL, pinch and release, and grip and release, are key functions. It is necessary to restore finger extension to perform ADL with the paretic upper extremity in patients with severe to moderate hemiparesis. To restore finger extension, electrical stimulation is applied to finger extensors in HANDS therapy. A pair of electrodes for EMG detection and stimulation (10 mm diameter) placed 20 mm apart on the Neural Plasticity affected EDC and one electrode (10 mm) for stimulation are placed on the affected EI. The EMG data and amount of stimulation were recorded with an attached data-logger system of the MURO device while the participants wore the MURO device. The participant's compliance with wearing the device for 8 hours during the daytime can be monitored using this data-logger system in HANDS therapy. Splint. The patients wear a wrist-hand splint (Wrist Support, Pacific Supply Co.) and carry a portable closed-loop EMG-controlled NMES with arm holder for 8 hours during the daytime. The rationale for combining the stimulation system with a wrist-hand splint was derived from the work of Fujiwara et al. The wrist-hand splint also makes the hand shape functional. Hand shape is important for hand function. The hand has longitudinal and transverse arches. These arches are important for holding, and thumb opposition and the web space are important for pinching. A wrist-hand splint helps to form the longitudinal and transverse arches, thumb opposition, and the web space in the han

Improvement of predictive accuracies of functional outcomes after subacute stroke inpatient rehabilitation by machine learning models.

ObjectivesStepwise linear regression (SLR) is the most common approach to predicting activities of daily living at discharge with the Functional Independence Measure (FIM) in stroke patients, but noisy nonlinear clinical data decrease the predictive accuracies of SLR. Machine learning is gaining attention in the medical field for such nonlinear data. Previous studies reported that machine learning models, regression tree (RT), ensemble learning (EL), artificial neural networks (ANNs), support vector regression (SVR), and Gaussian process regression (GPR), are robust to such data and increase predictive accuracies. This study aimed to compare the predictive accuracies of SLR and these machine learning models for FIM scores in stroke patients.MethodsSubacute stroke patients (N = 1,046) who underwent inpatient rehabilitation participated in this study. Only patients' background characteristics and FIM scores at admission were used to build each predictive model of SLR, RT, EL, ANN, SVR, and GPR with 10-fold cross-validation. The coefficient of determination (R2) and root mean square error (RMSE) values were compared between the actual and predicted discharge FIM scores and FIM gain.ResultsMachine learning models (R2 of RT = 0.75, EL = 0.78, ANN = 0.81, SVR = 0.80, GPR = 0.81) outperformed SLR (0.70) to predict discharge FIM motor scores. The predictive accuracies of machine learning methods for FIM total gain (R2 of RT = 0.48, EL = 0.51, ANN = 0.50, SVR = 0.51, GPR = 0.54) were also better than of SLR (0.22).ConclusionsThis study suggested that the machine learning models outperformed SLR for predicting FIM prognosis. The machine learning models used only patients' background characteristics and FIM scores at admission and more accurately predicted FIM gain than previous studies. ANN, SVR, and GPR outperformed RT and EL. GPR could have the best predictive accuracy for FIM prognosis

Feasibility of task-specific brain-machine interface training for upper-extremity paralysis in patients with chronic hemiparetic stroke

Objective: Brain-machine interface training was developed for upper-extremity rehabilitation for patients with severe hemiparesis. Its clinical application, however, has been limited because of its lack of feasibility in real-world rehabilitation settings. We developed a new compact task-specific brain-machine interface system that enables task-specific training, including reach-and-grasp tasks, and studied its clinical feasibility and effectiveness for upper-extremity motor paralysis in patients with stroke. Design: Prospective before–after study. Subjects: Twenty-six patients with severe chronic hemiparetic stroke. Methods: Participants were trained with the brain-machine interface system to pick up and release pegs during 40-min sessions and 40 min of standard occupational therapy per day for 10 days. Fugl-Meyer upper-extremity motor (FMA) and Motor Activity Log-14 amount of use (MAL-AOU) scores were assessed before and after the intervention. To test its feasibility, 4 occupational therapists who operated the system for the first time assessed it with the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) 2.0. Results: FMA and MAL-AOU scores improved significantly after brain-machine interface training, with the effect sizes being medium and large, respectively (p<0.01, d=0.55; p<0.01, d=0.88). QUEST effectiveness and safety scores showed feasibility and satisfaction in the clinical setting. Conclusion: Our newly developed compact brain-machine interface system is feasible for use in real-world clinical settings

Comparing the contribution of each clinical indicator in predictive models trained on 980 subacute stroke patients: a retrospective study

Abstract Post-stroke disability affects patients’ lifestyles after discharge, and it is essential to predict functional recovery early in hospitalization to allow time for appropriate decisions. Previous studies reported important clinical indicators, but only a few clinical indicators were analyzed due to insufficient numbers of cases. Although review articles can exhaustively identify many prognostic factors, it remains impossible to compare the contribution of each predictor. This study aimed to determine which clinical indicators contribute more to predicting the functional independence measure (FIM) at discharge by comparing standardized coefficients. In this study, 980 participants were enrolled to build predictive models with 32 clinical indicators, including the stroke impairment assessment set (SIAS). Trunk function had the most significant standardized coefficient of 0.221. The predictive models also identified easy FIM sub-items, SIAS, and grip strength on the unaffected side as having positive standardized coefficients. As for the predictive accuracy of this model, R2 was 0.741. This is the first report that included FIM sub-items separately in post-stroke predictive models with other clinical indicators. Trunk function and easy FIM sub-items were included in the predictive model with larger positive standardized coefficients. This predictive model may predict prognosis with high accuracy, fewer clinical indicators, and less effort to predict

Investigation of the Effect of Nutritional Supplementation with Whey Protein and Vitamin D on Muscle Mass and Muscle Quality in Subacute Post-Stroke Rehabilitation Patients: A Randomized, Single-Blinded, Placebo-Controlled Trial

In post-stroke hemiparesis patients, the skeletal muscle mass decrease rapidly with the histological degradation. We investigated the effect of nutritional supplementation with whey protein and vitamin D on the muscle mass and muscle quality, in post-stroke convalescent rehabilitation patients in a randomized, single-blinded, placebo-controlled trial. Fifty patients were randomly assigned to two groups; HP group received supplemental jelly (100 kcal; whey protein 10 g; vitamin D 20 &mu;g) twice a day throughout up to 16-week period, the control group received placebo jelly. Cross-sectional area (CSA) of thigh muscle, skeletal muscle index (SMI), muscle strength, activity of daily living (ADL), and some nutritional indicators in blood were measured. Although no significant difference was observed in CSA and SMI between the groups, fat infiltration into the thighs muscle was singnificantly lower in the HP group. There were no significant difference in muscle strength and ADL between the groups. Blood urea nitrogen and serum 25(OH)D at endpoint were significantly higher in the HP group but physiological normal ranges. Supplementation with whey protein and vitamin D in post-stroke patients led to suppression of fat infiltration into the muscle. Long-term follow-up studies are needed to verify whether this nutritional intervention provides substantial benefits for the prognosis of stroke survivors