Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study.

BACKGROUND: Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care. OBJECTIVES: To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation. METHODS: Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation. RESULTS: The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days. CONCLUSIONS: The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

Effect of neuromuscular electrical stimulation on the recovery of people with COVID-19 admitted to the intensive care unit: A narrative review.

The rehabilitation of patients with COVID-19 after prolonged treatment in the intensive care unit is often complex and challenging. Patients may develop a myriad of long-term multiorgan impairments, affecting the respiratory, cardiac, neurological, digestive and musculoskeletal systems. Skeletal muscle dysfunction of respiratory and limb muscles, commonly referred to as intensive care unit acquired weakness, occurs in approximately 40% of all patients admitted to intensive care. The impact on mobility and return to activities of daily living is severe. Furthermore, many patients experience ongoing symptoms of fatigue, weakness and shortness of breath, in what is being described as "long COVID". Neuromuscular electrical stimulation is a technique in which small electrical impulses are applied to skeletal muscle to cause contractions when voluntary muscle contraction is difficult or impossible. Neuromuscular electrical stimulation can prevent muscle atrophy, improve muscle strength and function, maintain blood flow and reduce oedema. This review examines the evidence, current guidelines, and proposed benefits of using neuromuscular electrical stimulation with patients admitted to the intensive care unit. Practical recommendations for using electrical muscle stimulation in patients with COVID-19 are provided, and suggestions for further research are proposed. Evidence suggests NMES may play a role in the weaning of patients from ventilators and can be continued in the post-acute and longer-term phases of recovery. As such, NMES may be a suitable treatment modality to implement within rehabilitation pathways for COVID-19, with consideration of the practical and safety issues highlighted within this review.

An Exploratory Electrical Stimulation Protocol in the Management of an Infant With Spina Bifida: A Case Report.

An infant with myelomeningocele and underdevelopment of the thoracic spinal cord was treated with 2 protocols of electrical stimulation: functional electrical stimulation and transcutaneous spinal cord electrical stimulation. The protocols were incorporated into the infant's outpatient early intervention home programs. Prior to initiation of electrical stimulation treatment at age 6 months, the infant exhibited complete loss of sensation below the level of T8 and muscular paralysis below the level of T10. The unexpected emergence of somatosensory responses and spontaneous movements in the trunk and lower extremities are described, focusing on the electrical stimulation protocols. Spinal cord electrical stimulation protocols were not previously described in the medical literature regarding the management of children with spina bifida. Both functional and spinal cord electrical stimulation protocols used with this infant proved safe and well tolerated. The experience gained over 12 months of treatment is the subject of this case report.

Wearable technologies for active living and rehabilitation: Current research challenges and future opportunities.

This paper presents some recent developments in the field of wearable sensors and systems that are relevant to rehabilitation and provides examples of systems with evidence supporting their effectiveness for rehabilitation. A discussion of current challenges and future developments for selected systems is followed by suggestions for future directions needed to advance towards wider deployment of wearable sensors and systems for rehabilitation.

Functional electrical stimulation improves quality of life by reducing intermittent claudication.

OBJECTIVE: To determine if Functional Electrical Stimulation (FES) would improve ischemic pain, walking distance, and quality of life of patients with intermittent claudication. DESIGN: Single blind, randomized block, two factorial design. PATIENTS: Patients diagnosed with Peripheral Artery Disease (PAD) and intermittent claudication (IC). Ankle Brachial Index ranged 0.4-0.9 on at least one leg. Patients were randomly assigned to experimental (FES+Walk, N=13) or control (WALK, N=14) groups. INTERVENTION: Experimental group patients received FES to the dorsiflexor and plantarflexor muscles while walking for 1h/day, six days/week for eight weeks. Control group patients received similar intervention without FES. A Follow-up period of both groups lasted eight weeks. OUTCOME MEASURES: Outcome measures were taken at baseline (T0), after intervention (T1), and after follow-up (T2). Primary measures included Perceived Pain Intensity (PPI), Six minute walk (6MW), and Peripheral Arterial Disease Quality of Life (PADQOL). Secondary measures included Intermittent Claudication Questionnaire (ICQ) and Timed Up and Go (TUG). RESULTS: Group by time interactions in PPI were significant (P<0.001) with differences of 27.9 points at T1 and 36.9 points at T2 favoring the FES+Walk group. Groups difference in Symptoms and Limitations in Physical Function of the PADQOL reached significance (T1=8.9, and T2=8.3 improvements; P=0.007). ICQ was significant (T1=9.3 and T2=13.1 improvements; P=0.003). Improvement in 6MW and TUG tests were similar between groups. CONCLUSIONS AND RELEVANCE: Walking with FES markedly reduced ischemic pain and enhanced QOL compared to just walking. FES while walking may offer an effective treatment option for the elderly with PAD and Intermittent Claudication. TRIAL REGISTRATION: NIH-NIA 1R21AG048001 https://projectreporter.nih.gov/project_info_description.cfm?aid=8748641&icde=30695377&ddparam=&ddvalue=&ddsub=&cr=1&csb=default&cs=ASC. https://clinicaltrials.gov/ct2/show/NCT02384980?term=David+Embrey&rank=1.

Modulation of resting state functional connectivity of the motor network by transcranial pulsed current stimulation.

The effects of transcranial pulsed current stimulation (tPCS) on resting state functional connectivity (rs-FC) within the motor network were investigated. Eleven healthy participants received one magnetic resonance imaging (MRI) session with three resting state functional MRI (rs-fMRI) scans, one before stimulation (PRE-STIM) to collect baseline measures, one during stimulation (STIM), and one after 13 min of stimulation (POST-STIM). Rs-FC measures during the STIM and POST-STIM conditions were compared to the PRE-STIM baseline. Regions of interest for the rs-FC analysis were extracted from the significantly activated clusters obtained during a finger tapping motor paradigm and included the right primary motor cortex (R M1), left primary motor cortex (L M1), supplemental motor area (SMA), and cerebellum (Cer). The main findings were reduced rs-FC between the left M1 and surrounding motor cortex, and increased rs-FC between the left M1 and left thalamus during stimulation, but increased rs-FC between the Cer and right insula after stimulations. Bivariate measures of connectivity demonstrate reduced strength of connectivity for the whole network average (p=0.044) and reduced diversity of connectivity for the network average during stimulation (p=0.024). During the POST-STIM condition, the trend of reduced diversity for the network average was statistically weaker (p=0.071). In conclusion, while many of the findings are comparable to previous reports using simultaneous transcranial direct current stimulation (tDCS) and fMRI acquisition, we also demonstrate additional changes in connectivity patterns that are induced by tPCS.

Safety and immediate effect of noninvasive transcranial pulsed current stimulation on gait and balance in Parkinson disease.

BACKGROUND: Noninvasive electrical stimulation of the brain (ESB) is being investigated as a valued intervention to enhance motor performance. OBJECTIVE: To ascertain the safety and ability of transcranial pulsed current stimulation (tPCS) to modulate variables of protective stepping and gait of individuals with Parkinson's disease. METHOD: Ten patients participated in a pilot study. During the first session, a tPCS delivered current for 20 minutes via a positive electrode placed over the primary motor area (M1). In week 2, participants walked for 20 minutes on a treadmill. In week 3, tPCS and treadmill for 20 minutes were combined. Pre-testing and post-testing of gait and protective stepping were administered, comparing post-intervention (tPCS alone, treadmill alone, tPCS + treadmill) with pre-intervention data. The 3 interventions were compared by calculating the difference between post-intervention and pre-intervention data. A significance level of P < .05 was adopted. RESULTS: Stride length increased from 102.1 ± 24.4 to 111.2 ± 22.1 cm, and gait velocity increased from 0.90 ± 0.23 to 0.985 ± 0.19 m/s after tPCS. Treadmill or treadmill + tPCS did not result in changes in the studied gait parameters. The tPCS session increased gait velocity and stride length significantly compared with treadmill or tPCS + treadmill. Overall, the number of steps needed to recover balance decreased after tPCS and tPCS + treadmill. CONCLUSION: Noninvasive tPCS over the primary motor cortex had no adverse effects on those with long-standing Parkinson's disease and may lead to acute improvement of gait and balance recovery.

Murine model of neuromuscular electrical stimulation on squamous cell carcinoma: potential implications for dysphagia therapy.

BACKGROUND: Dysphagia is a potential consequence of treatment for head and neck cancer. Neuromuscular electrical stimulation (NMES) has evolved as a treatment option, with the goal of improved swallow function in patients with chronic dysphagia. However, the effects of NMES on tumorigenicity are unknown and often confound the initiation of this therapy, potentially limiting its efficacy in treating patients with head and neck cancer. METHODS: Squamous cell carcinoma was grown in the flank of athymic, nude mice. Mice were randomized into treatment and control groups; the experimental group received daily NMES directly to the flank for 8 days. RESULTS: Tumor volumes, recorded on days 0, 3, 7, and 10, demonstrated no significant differences between groups on each day of measurement. Immunohistochemical analysis of apoptosis, proliferation, and vascularization also failed to demonstrate statistically significant differences between treated and untreated groups. CONCLUSIONS: NMES does not promote the growth of underlying tumor in our model. These data may provide preliminary evidence that applying electrical stimulation over the muscles of the anterior neck does not increase the risk of tumorigenicity. Early initiation of NMES in this challenging population may be feasible from an oncologic standpoint.

Intensive training of subjects with chronic hemiparesis on a motorized cycle combined with functional electrical stimulation (FES): a feasibility and safety study.

BACKGROUND AND PURPOSE: This study tested the safety and ability of subjects with chronic hemiplegia to tolerate intensive training using a motorized cycle combined with functional electrical stimulation (FES) system. METHODS: A case series of 10 subjects with chronic stroke participated in 30-minute three times per week cycling on a stationary motorized cycling system combined with FES (RT300(TM) ). The stimulation activated the dorsal and plantar flexors, the quadriceps and the hamstrings using four channels and a stimulation pattern that assisted cycling motion of the paretic lower limb. Patients were instructed to cycle as close as possible to 60 rpm and the resistance to cycling was gradually increased using a computer-based algorithm. The training lasted eight weeks. RESULTS: All 10 participants completed the training without adverse reactions to the training or the FES. The kcal utilized during the training increased significantly (p = 0.0003) between session 1 (2.2 ± 0.47), session 12 (4.3 ± 1.2) and session 24 (7.5 ± 1.8). Peak pedaling power increased from 6.5 ± 0.5 W pre-training to 18.0 ± 5.4 W post-training. Locomotion variables that improved significantly were time to complete the get up and go test (45.4 ± 54.9 seconds vs. 34.0 ± 31.8 seconds) a 24.6% improvement (p = 0.03) and gait velocity, which increased 25.0% from 0.4 ± 0.3 m/sec to 0.5 ± 0.4 m/sec (p = 0.01). CONCLUSION: Using a motorized cycle combined with FES intensive training appears safe and can be tolerated by patients with chronic stroke of wide age range, diverse severity of cardio-pulmonary deconditioning, motor loss and locomotor deficits.

Utilization of physical therapy in home health care under the prospective payment system.

PURPOSE: Aging adults who are homebound while recovering from illness or surgery are often referred to physical therapy for home-based rehabilitation care. The efficacy of such home-based interventions has not been thoroughly studied. The purpose of this study was to analyze the utilization of physical therapy services in one home health care agency under the prospective payment system. A review was conducted to determine the interaction between the number of physical therapy visits, duration of care, comorbidities, and the functional outcomes of toileting, transferring, and ambulation/ locomotion at discharge. METHODS: The study design was a retrospective chart review of 99 patients with orthopedic diagnoses from one home health care agency in York, Pennsylvania who were admitted and discharged in the 2005 calendar year. RESULTS: For all subjects (N = 99), the mean number of physical therapy visits was 5.7 (3.2), and the average duration of an episode of care was 20.5 (10.6) days. There was a significant improvement (P = .000) in all 3 functional activities, as scored by the Outcome and Assessment Information Set (OASIS) functional scale following the episode of physical therapy intervention. CONCLUSIONS: Physical therapy may be beneficial to the study's homebound patients in improving their functional abilities.

Functional electrical stimulation to dorsiflexors and plantar flexors during gait to improve walking in adults with chronic hemiplegia.

OBJECTIVE: To determine whether functional electrical stimulation (FES) timed to activate the dorsiflexors and plantar flexors during gait improves the walking of adults with hemiplegia. DESIGN: Randomized crossover trial. SETTING: Outpatient rehabilitation clinic. PARTICIPANTS: Adults with hemiplegia (N=28) with a mean age +/- SD of 60+/-10.9 years and 4.9+/-3.8 years postincident. INTERVENTIONS: Intervention "A" included 3 months of wearing the FES system, which activated automatically during walking for 6 to 8h/d, 7d/wk, plus walking 1h/d, 6d/wk. Intervention "B" included 3 months of walking 1h/d, 6d/wk without FES. Of the 28 patients who completed the study, 15 were randomly assigned to group A-B, 13 to group B-A. Crossover occurred at 3 months. MAIN OUTCOME MEASURES: Variables were measured at pretreatment, 3 months, and 6 months. Three primary outcomes were selected a priori and included 2 functional variables, the 6-minute walk test and the Emory Functional Ambulatory Profile, and 1 participation variable, the Stroke Impact Scale. Secondary impairment measures included muscle strength and spasticity. Assessments were done without electrical stimulation. RESULTS: In phase 1, patients who received treatment A (A-B group) showed improvement compared with patients who received treatment B (B-A group) on the 6-minute walk test (P=.02), Emory Functional Ambulatory Profile (P=.08), and Stroke Impact Scale (P=.03). In phase 2, the A-B group maintained improvement in all 3 primary outcomes even without FES. Both groups improved significantly on all primary outcome measures, comparing 6-month to initial measures (P

Defining and measuring residual deficits of the upper extremity following stroke: a new perspective.

PURPOSE: To propose and test a new measure to quantify residual deficits (Rd) following stroke and provide preliminary evidence supporting its usefulness. METHODS: Patients (N = 46) were stratified based on projected rate of upper extremity recovery and were randomly assigned to task-oriented (control) or task-oriented plus functional electrical stimulation (FES) training groups. All performed the Box & Blocks and the Jebsen-Taylor light object lift tests with the nonparetic and paretic upper extremities. A modified Fugl-Meyer test was performed on the paretic upper extremity. The calculation Rd = 100 - (paretic/nonparetic x 100) was made for each subgroup: task-specific training alone (control subgroup) or task-specific training plus functional electrical stimulation (FES subgroup). Data from each of these two groups were analyzed separately. RESULTS: Intrasession and between-sessions tests of the nonparetic or paretic extremity yielded interclass correlation (ICC) values between 0.77 and 0.99. After training for 12 weeks, the Rd of the paretic upper extremity of patients who used the FES was significantly less compared to the control group (p < .05). The deficits of patients with slow recovery profile were as expected much greater. CONCLUSIONS: Rd is a valid, highly reproducible, and dimensionless outcome measure. It should permit objective comparison of effectiveness between and within various rehabilitative intervention options regardless of the outcome measure(s) used.

Functional electrical stimulation (FES) may modify the poor prognosis of stroke survivors with severe motor loss of the upper extremity: a preliminary study.

OBJECTIVES: This nonblinded, block-randomized clinical trial tested the hypothesis that task-oriented functional electrical stimulation (FES) can enhance the recovery of upper-extremity volitional motor control and functional ability in patients with poor prognosis. DESIGN: Ischemic stroke survivors (FES + exercise group, n = 13, 17.4 +/- 7.6 days after stroke, and exercise-only group n = 13, 23.8 +/- 10.9 days after stroke) trained with task-specific exercises, 30 min, twice each day. The FES group practiced the exercises combined with FES that enabled opening and closing of the paretic hand and continued with FES without exercises for up to 90 mins of additional time twice a day. Both groups trained for 12 wks. Volitional motor control (modified Fugl-Meyer [mF-M]), hand function (Box & Blocks [B&B], and Jebsen-Taylor light object lift [J-T]) were video recorded for both upper extremities at baseline and at 4, 8, and 12 wks. RESULTS: Mean mF-M score of the FES group (24 +/- 13.7) was significantly better (P = 0.05) at 12 wks compared with the control group that scored 14.2 +/- 10.6 points. The B&B mean score did not reach statistical significance (P = 0.058) in favor of the FES group (10.5 +/- 2.4 blocks) over the control group (2.5 +/- 4.9 blocks). The J-T task time did not differ between groups. Eight (FES) compared with three (control) patients regained the ability to transfer five or more blocks (P = 0.051), and six (FES) compared with two (control) completed the J-T task in 30 sec or less after 12 wks of training (P = 0.09). CONCLUSIONS: FES + exercise as used in this preliminary study is likely to minimize motor loss, but it may not significantly enhance the ability to use the upper extremity after ischemic stroke. Anecdotally, more patients may regain some functional ability after training with FES compared with training without FES. Patients with severe motor loss may require prolonged task-specific FES training.

Functional electrical stimulation enhancement of upper extremity functional recovery during stroke rehabilitation: a pilot study.

OBJECTIVE: To test if functional electrical stimulation (FES) can enhance the recovery of upper extremity function during early stroke rehabilitation. METHODS: Open-label block-randomized trial, begun during inpatient rehabilitation and continued at the patients' home. Patients were assigned to either FES combined with task-specific upper extremity rehabilitation (n = 7) or a control group that received task-specific therapy alone (n = 8) over 12 weeks. Outcome measures . Hand function (Box & Blocks, B & B; Jebsen-Taylor light object lift, J-T) and motor control (modified Fugl-Meyer, mF-M) were video-recorded for both upper extremities at baseline, 4, 8, and 12 weeks. RESULTS: B&B mean score at 12 weeks favored (P = .049) the FES group (42.3 +/- 16.6 blocks) over the control group (26.3 +/- 11.0 blocks). The FES group J-T task was 6.7 +/- 2.9 seconds and faster (P = .049) than the 11.8 +/- 5.4 seconds of the control group. Mean mF-M score of the FES group at 12 weeks was 49.3 +/- 5.1 points out of 54, compared to the control group that scored 40.6 +/- 8.2 points (P = .042). All patients regained hand function. CONCLUSION: Upper extremity task-oriented training that begins soon after stroke that incorporates FES may improve upper extremity functional use in patients with mild/moderate paresis more than task-oriented training without FES.

Reliability estimation of grouped functional imaging data using penalized maximum likelihood.

We analyzed grouped fMRI data and developed a reliability analysis for such data using the method of penalized maximum likelihood (ML). Specifically, this technique was applied to a somatosensory paradigm that used a mechanical probe to provide noxious stimuli to the foot, and a paradigm consisting of four levels of graded peripheral neuromuscular electrical stimulation (NMES). In each case, reliability maps of activation were generated. Receiver operating characteristic (ROC) curves were constructed in the case of the graded NMES paradigm for each level of stimulation, which revealed an increase in the specificity of activation with increasing stimulation levels. In addition, penalized ML was used to determine whether the grouped reliability maps obtained from one stimulus level were significantly different from those obtained at other levels. The results show a significant difference (P < 0.01) in the reliability of activation from one stimulation level to the next. These results are in agreement with those obtained using generalized linear modeling (GLM). While the reliability maps generated are not directly comparable, they are qualitatively similar to those obtained by controlling the expected false discovery rate (FDR). The proposed methodology can be used to objectively compare activation maps between groups, as well as to perform reliability assessments. Furthermore, this method potentially can be used to assess the longitudinal effect of treatment therapies within a group.

Tolerance and conditioning to neuro-muscular electrical stimulation within and between sessions and gender.

THIS STUDY WAS CONDUCTED TO DETERMINE: 1) If healthy subjects can be conditioned to tolerate clinically useful electrically induced muscle contraction; and 2) If there is a gender difference in response to such conditioning. Healthy volunteers (10 males, 11 females, mean age of 27.6 ± 5.8 yrs) were tested during each of 6 testing sessions. Maximal voluntary isometric contractions (MVIC) of the right quadriceps femoris (RQF) recorded by a computerized dynamometer. Electrical stimulation delivered through two surface electrodes and stimulation amplitude increased until the subject indicated to stop. After a 1 min rest the amplitude increased again to the same phase charge level, and the electrically induced contraction (EIC) was recorded by the dynamometer. Measurements of stimulation amplitude were repeated in each of 10 stimulation bouts per session. Measurements of EIC were repeated in session six. Statistical analyses included Multivariate ANOVAs, and Newman-Kuel's post-hoc tests (p < 0.01). Mean values of phase charge increased from session 1 to 6 for all subjects. Males tolerated significantly higher phase charge. The mean %MVIC torque generated by female subjects was initially only 11.2 ± 21.6% but reached 42.9 ± 25.4% at the end of the 6th session. Males' %MVIC torque values were significantly higher reaching 49.0 ± 41.6% and 73.5 ± 18.7% in the first and last trials respectively. Using the criterion that electrically induced contractions must be at least 25% of MVIC to be considered clinically useful, 36% of females were below this threshold at the end of the last session. In contrast, all males exceeded the 25% MVIC threshold at the end of the study. Most healthy subjects can be conditioned to electrical stimulation of the quadriceps, but depending on the criteria of therapeutic value and gender, some males and even more females may not reach the desired stimulation goal in 6 sessions. Females may require more conditioning sessions to reach contraction levels of therapeutic benefits. The reason(s) for the confounding factor of gender remains unknown. Key PointsNeuromuscular electrical stimulation (NMES) can strengthen skeletal musclesTolerance to NMES improves within 6 sessionsConditioning is a key to eliciting stronger contraction and to increasing the number of subjects that can benefit from NMESHealthy males can tolerate higher stimulusintensity and higher electrically induced quadriceps femoris contraction.

A home-based, self-administered stimulation program to improve selected hand functions of chronic stroke.

OBJECTIVES: To test if a combined stimulation-training program can improve selected hand functions and impairments of chronic stroke survivors. DESIGN: Pretest-Posttest, multi-site 5-week training program. Stroke survivors (N = 77) with chronic upper limb paresis completed a home-based stimulation program combining activation of the wrist-fingers flexors and extensors with functional grasp, hold and release training. Subjects trained 2-3 times each day, 7 days a week. Outcome measures included: the Jebsen-Taylor simulated feeding (S-feed); light object lift (J-T light); heavy object lift (J-T heavy); Box and Blocks test (B+B); Nine-Hole Peg (9-HP); Ashworth scale (Spasticity); Visual analog scale-VAS (Pain). Paired t-tests (alpha < 0.01) were performed on each study outcome. RESULTS: Simulated feeding time decreased from 39.1 +/- 30.9 sec to 25.5 +/- 23.3 sec (34.8% improvement). The task time of the J-T light decreased by 13.3 sec and the J-T heavy by 11.5 sec (44.9% and 40.9% improvement respectively). The number of blocks moved increased from 19.4 +/- 11.6 to 24.5 +/- 12.5 (26.3% improvement) and the time to complete the 9-HP decreased from 178.8 +/- 170.8 to 105.0 +/- 117.1 sec (58.7% improvement). Mean reduction of spasticity was 0.87 and 0.78 points at the elbow and wrist respectively. Patients with persistent pain (N = 33) reported mean reduction from 3.5 +/- 2.5 to 1.9 +/- 1.8. CONCLUSIONS: Five weeks of daily home training with a task-specific stimulation program improved selected hand functions and upper limb impairments associated with chronic post-stroke paresis.

Functional MRI determination of a dose-response relationship to lower extremity neuromuscular electrical stimulation in healthy subjects.

Although empirical evidence supports the use of neuromuscular electrical stimulation (NMES) to treat physical impairments associated with stroke, the mechanisms underlying the efficacy of this modality are poorly understood. Recent studies have employed functional imaging to investigations of brain responses to median nerve stimulation. These studies suggest a dose-response relationship may exist between selected stimulation parameters and hemodynamic responses in sensorimotor regions. However, substantial gaps exist in this literature. The present study was designed to address these deficiencies. Ten healthy subjects participated. In phase one, four stimulus intensity levels were established: (1). sensory threshold [Th], (2). (MM-Th)x0.333+Th [low-intermediate level, LI], (3). (MM-Th)x0.666+Th [high-intermediate level, HI], and (4). maximal motor (MM). In phase two, subjects were scanned using a spiral-echoplanar imaging technique at each stimulus level. Image sets were analyzed to determine hemodynamic responses at the highest Pearson correlation level ( r) ascertained for each of five areas of interest (AOI): (1). primary sensory, (2). primary motor, (3). cingulate gyrus, (4). thalamus, and (5). cerebellum. ANOVA demonstrated significant main effects for BOLD signal amplitude ( p<0.05) changes in all AOI. Similarly, ANOVA showed significant differences in the volume of activation ( p<0.05) with increasing stimulus intensity in four AOI. Secondary analyses of pooled data showed increasing probabilities of activation at higher stimulus intensities within each AOI. Collectively, these data indicate a dose-response relationship exists between lower extremity NMES and brain activation in specific neural regions. The current results, while limited in their generalizability, are foundational for future studies of interventions using NMES.

Persons with C5 or C6 tetraplegia achieve selected functional gains using a neuroprosthesis.

OBJECTIVE: To test the efficacy and safety of the NESS Handmaster neuroprosthesis with subjects with C5 or C6 tetraplegia. DESIGN: Interventional, nonrandomized case series. SETTING: Subjects' residence and university research laboratory. PARTICIPANTS: Men, 3 to 17 years after C5 (n=5) and C6 (n=2) spinal cord injury (SCI). INTERVENTION: Subjects practiced with the neuroprosthesis daily to regain grasp, hold, and release ability and to restore selected functions of 1 of the 2 paralyzed hands. Subjects were observed 2 to 3 times weekly for 3 weeks. MAIN OUTCOME MEASURES: Three activities of daily living (ADL) tasks: (1) pick up a telephone, (2) eat food with a fork, and (3) perform 1 individually selected ADL task and 2 grasp, hold, and release tasks (lift a videocassette, lift a 150-g weight). Secondary outcomes were grip strength, electrically induced finger motion, and Fugl-Meyer spherical grasp. Nonparametric data were analyzed with the Wilcoxon signed-rank test, and parametric data (grip strength and finger motion) were analyzed by analysis of variance. All tests were considered significant at P equal to.01. RESULTS: At study completion, all 7 subjects were 100% successful at using the Handmaster in the studied ADL and grasp, hold, and release tasks. Significant improvements occurred in grip strength (from.57+/-.98N at baseline to 16.5+/-4.4N), finger linear motion (from 0.0cm at baseline to 8.4+/-3.2cm), and Fugl-Meyer scores. No safety issues were encountered. Six of 7 subjects rated their overall performance as "excellent." CONCLUSIONS: The Handmaster is a safe, noninvasive neuroprosthesis that improves hand function of selected subjects with C5 or C6 SCI.