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