Vera Zivanovic

Rehabilitation of Reaching and Grasping Function in Severe Hemiplegic Patients Using Functional Electrical Stimulation Therapy

Objective. The aim of this study was to establish the efficacy of a therapeutic intervention based on functional electrical stimulation (FES) therapy to improve reaching and grasping function after severe hemiplegia due to stroke. Methods. A total of 21 subjects with acute stroke were randomized into 2 groups, FES plus conventional occupational and physiotherapy (FES group) or only conventional therapy (control group) 5 days a week for 12 to 16 weeks. A third group of 7 subjects with chronic hemiplegia (at least 5 months poststroke) received only FES therapy (chronic group) and pre—post training changes were compared. FES was applied to proximal and then distal muscle groups during specific motor tasks. At baseline and at the end of treatment, grasping function was assessed using the Rehabilitation Engineering Laboratory Hand Function Test, along with more standard measures of rehabilitation outcome. Results. The FES group improved significantly more than the control group in terms of object manipulation, palmar grip torque, pinch grip pulling force, Barthel Index, Upper Extremity Fugl—Meyer scores, and Upper Extremity Chedoke—McMaster Stages of Motor Recovery. The chronic stroke subjects demonstrated improvements in most categories, but the changes were not statistically significant. Conclusions. FES therapy with upper extremity training may be an efficacious intervention in the rehabilitation of reaching and grasping function during acute stroke rehabilitation.

Functional electrical therapy: retraining grasping in spinal cord injury

Objective:To determine the clinical efficacy of functional electrical therapy in the rehabilitation of grasping function for quadriplegics.Study design:Randomized intervention-versus-control trial.Setting:Rehabilitation hospital for spinal cord injury in Toronto, Canada.Methods:A total of 21 people with new spinal cord injuries ranging from C3 to C7 were randomly assigned to two groups: Control (N=9) and Intervention (N=12). The intervention was functional electrical therapy, which consisted of repetitive grasping exercises using a neuroprosthesis that applied surface electrical stimulation to the arm to generate and/or assist grasping movements. It was applied by registered Occupational Therapists in a clinical setting. Main outcome measures were: Functional Independence Measure (FIM), Spinal Cord Independence Measure (SCIM), and the Rehabilitation Engineering Laboratory Hand Function Test. Consumer perceptions of functional electrical therapy were assessed via qualitative interviews.Results:Differences between the Control and Intervention groups could be observed although they are not significant due to an insufficient number of participants. Consumer perceptions were positive, including improved Activities of Daily Living and self-satisfaction.Conclusion:Functional electrical therapy has the potential to be an effective treatment modality to restore grasping function in quadriplegia. It can be implemented by occupational therapists in a clinical setting. Further research is required to establish suitable indications for participant selection. In addition, a larger number of participants is needed to demonstrate statistical significance of the Functional Electrical Therapy.

Functional Electrical Stimulation Therapy of Voluntary Grasping Versus Only Conventional Rehabilitation for Patients With Subacute Incomplete Tetraplegia A Randomized Clinical Trial

Background. Functional electrical stimulation therapy (FET) has a potential to improve voluntary grasping among individuals with tetraplegia secondary to traumatic spinal cord injury (SCI). Objective. This single-site, randomized controlled trial examined the efficacy of 40 hours of FET with conventional occupational therapy (COT) compared with COT alone to improve grasping. Methods. Twenty-four subjects with subacute traumatic incomplete SCI (C4-C7, AIS B-D) consented to participate in 40 hours of therapy over 8 weeks, beyond the conventional rehabilitation program. Subjects were randomized to receive FET + COT (n = 9) or COT (n = 12). The key outcomes were changes in Functional Independence Measure (FIM) self-care subscores, Spinal Cord Independence Measure (SCIM) self-care subscores, and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) performed at baseline and follow-up. Results. At the end of the treatments, the change in mean FIM self-care subscore for the FET + COT group was 20.1 versus 10 (P = .015) for the COT group. Subjects randomized to FET + COT also had greater improvements in the SCIM and TRI-HFT. No longer term follow-up was feasible. Conclusion. FET significantly reduced disability and improved voluntary grasping beyond the effects of considerable conventional upper extremity therapy in individuals with tetraplegia.

Neuroprosthesis for Retraining Reaching and Grasping Functions in Severe Hemiplegic Patients

During the course of rehabilitation hemiplegic patients who have Chedoke McMaster Stages of Motor Recovery scores 4 and 5 measured three weeks after onset of stroke often improve their arm and hand function to the point that they can later use it in the activities of daily living (ADL) ( 1 ). These patients can be considered to have mild arm and hand paralysis since they can grasp objects and manipulate them with minor restrictions in the range of movement and force. On the other hand, hemiplegic patients who have Chedoke McMaster Stages of Motor Recovery scores 1 and 2 measured three weeks after onset of stroke, during the course of rehabilitation seldom improve their arm and hand function, and when they do, the improvements are not sufficient to allow these patients to use the arm and hand in ADL ( 1 ). These patients can be also described as patients who have severe arm and hand paralysis. Patients with severe arm and hand paralysis cannot move their arm and hand voluntarily at all or have very limited voluntary movements that cannot be used to carry out ADL. In recent years a variety of treatments such as constraint induced therapy, functional electrical therapy, biofeedback therapy, and robotics assisted therapies, were proposed which main objective is to improve reaching and grasping functions in subjects with unilateral arm paralysis. These therapies have shown encouraging results in patients with mild arm and hand paralysis. However, the efficacy of these therapies was limited when they were applied to patients with severe arm and hand paralysis. This article describes a new rehabilitation technique that can improve both reaching and grasping functions in hemiplegic patients with severe unilateral arm paralysis. A neuroprosthesis that applies surface electrical stimulation technology was used to retrain hemiplegic patients who had severe arm and hand paralysis to reach and grasp. The neuroprosthesis was applied both to acute and long‐term hemiplegic patients. Patients who were treated with the neuroprosthesis were compared to those patients who were administered only standard physiotherapy and occupational therapy appropriate for hemiplegic patients with unilateral upper extremity paralysis (controls). The treated and control patients had approximately the same time allocated for arm and hand therapy. After the treatment program was completed, the patients treated with the neuroprosthesis significantly improved their reaching and grasping functions and were able to use them in ADL. However, the majority of the control patients did not improve their arm and hand functions significantly and were not able to use them in ADL.

Feasibility and efficacy of upper limb robotic rehabilitation in a subacute cervical spinal cord injury population

Study design: Multi-center pilot study.Objectives:To investigate the use of an upper limb robotic rehabilitation device (Armeo Spring, Hocoma AG, Switzerland) in a subacute cervical spinal cord injury (SCI) population.Setting: Two Canadian inpatient rehabilitation centers.Methods:Twelve subjects (motor level C4–C6, ASIA Impairment Scale A–D) completed the training, which consisted of 16.1±4.6 sessions over 5.2±1.4 weeks. Two types of outcomes were recorded: (1) feasibility of incorporating the device into an inpatient rehabilitation program (compliance with training schedule, reduction in therapist time required and subject questionnaires) and (2) efficacy of the robotic rehabilitation for improving functional outcomes (Graded and Redefined Assessment of Strength, Sensibility and Prehension (GRASSP), action research arm test, grip dynamometry and range of motion).Results:By the end of the training period, the robot-assisted training was shown to require active therapist involvement for 25±11% (mean±s.d.) of the total session time. In the group of all subjects and in a subgroup composed of motor-incomplete subjects, no statistically significant differences were found between intervention and control limbs for any of the outcome measures. In a subgroup of subjects with partial hand function at baseline, the GRASSP-Sensibility component showed a statistically significant increase (6.0±1.6 (mean±s.e.m.) point increase between baseline and discharge for the intervention limbs versus 1.9±0.9 points for the control limbs).Conclusion:The pilot results suggest that individuals with some preserved hand function after SCI may be better candidates for rehabilitation training using the Armeo Spring device.

Relationship Between Clinical Assessments of Function and Measurements From an Upper-Limb Robotic Rehabilitation Device in Cervical Spinal Cord Injury

Upper limb robotic rehabilitation devices can collect quantitative data about the users movements. Identifying relationships between robotic sensor data and manual clinical assessment scores would enable more precise tracking of the time course of recovery after injury and reduce the need for time-consuming manual assessments by skilled personnel. This study used measurements from robotic rehabilitation sessions to predict clinical scores in a traumatic cervical spinal cord injury (SCI) population. A retrospective analysis was conducted on data collected from subjects using the Armeo Spring (Hocoma, AG) in three rehabilitation centers. Fourteen predictive variables were explored, relating to range-of-motion, movement smoothness, and grip ability. Regression models using up to four predictors were developed to describe the following clinical scores: the GRASSP (consisting of four sub-scores), the ARAT, and the SCIM. The resulting adjusted R^2 value was highest for the GRASSP “Quantitative Prehension” component (0.78), and lowest for the GRASSP “Sensibility” component (0.54). In contrast to comparable studies in stroke survivors, movement smoothness was least beneficial for predicting clinical scores in SCI. Prediction of upper-limb clinical scores in SCI is feasible using measurements from a robotic rehabilitation device, without the need for dedicated assessment procedures.

Functional Electrical Stimulation Therapy for Grasping in Traumatic Incomplete Spinal Cord Injury: Randomized Control Trial

The purpose of this single-site randomized control trial was to assess the short-term and long-term efficacy of functional electrical stimulation (FES) therapy over conventional occupational therapy in improving voluntary hand function in incomplete C4-C7 spinal cord injury individuals. All 22 participants recruited in this randomized control trial received treatment for both the left and right upper extremities. Every participant, irrespective of group allocation, received one dose (60 min per day, 5 days per week for the duration of 8 weeks) of conventional occupational therapy for hand function. Of the 22 participants, 12 individuals received an additional dose of conventional occupational therapy, while the remaining 10 participants received a dose of FES hand therapy. The primary outcome measure was Functional Independence Measure (FIM) self-care subscore. The secondary outcome measures were Spinal Cord Independence Measure (SCIM) self-care subscore and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT). The participants who received FES therapy showed significantly greater improvements in hand function at discharge, and were able to maintain their gains at long-term follow-up as assessed using FIM self-care subscore, SCIM self-care subscore, and TRI-HFT. The FES therapy effectively increased independence and thereby improved quality of life of individuals with tetraplegia when compared with conventional occupational therapy.

Effect of intensive functional electrical stimulation therapy on upper-limb motor recovery after stroke: case study of a patient with chronic stroke.

PURPOSE Motivated by a prior successful randomized controlled trial showing that functional electrical stimulation (FES) therapy can restore voluntary arm and hand function in people with severe stroke, this study was designed to examine neuromuscular changes in the upper limb following intensive FES therapy, consisting of task-specific upper-limb movements with a combination of preprogrammed FES and manual assisted motion. METHODS The patient was a 22-year-old woman who had suffered a haemorrhagic stroke 2 years earlier. FES therapy was administered for 1 hour twice daily for 12 weeks, for a total of 108 treatment sessions. RESULTS While maximal voluntary contraction level of the upper-limb muscles did not show significant improvement, the ability to initiate and stop the muscle contraction voluntarily was regained in several upper-limb muscles (approx. 5%-15% of the maximum voluntary contraction of the same muscle in the less-affected arm). A reduction in arm spasticity was also observed, as indicated by the reduction of H-reflex in the wrist flexor muscle (82.1% to 45.0% in Hmax/Mmax) and decreased Modified Ashworth Scale scores (from 3 to 2 for the hand and 4 to 3 for the arm). Coordination between shoulder and elbow joints during the circle-drawing test improved considerably over the course of FES therapy: the patient was unable to draw a circle at all at baseline but was able to do so proficiently at discharge. CONCLUSION Improvements in upper-limb function observed in people with severe stroke following intensive FES therapy can be attributed to (a) regained ability to voluntarily contract muscles of the affected arm, (b) reduced spasticity and improved muscle tone in the same muscles, and (c) increased range of motion of all joints.

Functional Electrical Stimulation Therapy for Recovery of Reaching and Grasping in Severe Chronic Pediatric Stroke Patients

Stroke affects 2.7 children per 100,000 annually, leaving many of them with lifelong residual impairments despite intensive rehabilitation. In the present study the authors evaluated the effectiveness of 48 hours of transcutaneous functional electrical stimulation therapy for retraining voluntary reaching and grasping in 4 severe chronic pediatric stroke participants. Participants were assessed using the Rehabilitation Engineering Laboratory Hand Function Test, Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, and Assisting Hand Assessment. All participants improved on all measures. The average change scores on selected Rehabilitation Engineering Laboratory Hand Function Test components were 14.5 for object manipulation (P = .042), 0.78 Nm for instrumented cylinder (P = .068), and 14 for wooden blocks (P = .068) and on the grasp component of Quality of Upper Extremity Skills Test was 25.93 (P = .068). These results provide preliminary evidence that functional electrical stimulation therapy has the potential to improve upper limb function in severe chronic pediatric stroke patients.

Restoring Voluntary Grasping Function in Individuals with Incomplete Chronic Spinal Cord Injury: Pilot Study

BACKGROUND Functional electrical stimulation (FES) therapy has been shown to be one of the most promising approaches for improving voluntary grasping function in individuals with subacute cervical spinal cord injury (SCI). OBJECTIVE To determine the effectiveness of FES therapy, as compared to conventional occupational therapy (COT), in improving voluntary hand function in individuals with chronic (≥24 months post injury), incomplete (American Spinal Injury Association Impairment Scale [AIS] B-D), C4 to C7 SCI. METHODS Eight participants were randomized to the intervention group (FES therapy; n = 5) or the control group (COT; n = 3). Both groups received 39 hours of therapy over 13 to 16 weeks. The primary outcome measure was the Toronto Rehabilitation Institute-Hand Function Test (TRI-HFT), and the secondary outcome measures were Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP), Functional Independence Measure (FIM) self-care subscore, and Spinal Cord Independence Measure (SCIM) self-care subscore. Outcome assessments were performed at baseline, after 39 sessions of therapy, and at 6 months following the baseline assessment. RESULTS After 39 sessions of therapy, the intervention group improved by 5.8 points on the TRI-HFTs Object Manipulation Task, whereas the control group changed by only 1.17 points. Similarly, after 39 sessions of therapy, the intervention group improved by 4.6 points on the FIM self-care subscore, whereas the control group did not change at all. CONCLUSION The results of the pilot data justify a clinical trial to compare FES therapy and COT alone to improve voluntary hand function in individuals with chronic incomplete tetraplegia.