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Electromyographic controlled neuromuscular electrical stimulation Scientific Articles and Abstracts.

Following is a selection of abstracts, articles and references, including double blind placebo controlled, on electromyographic controlled neuromuscular electrical stimulation (EMG triggered NMES). This information has been collected to show the benefits on the use of EMG triggered NMES. This technology is also referred to under many different names.

For further information see Frequently Asked Questions

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Does neuro-rehabilitation play a role in the recovery of walking in neurological populations?

This review demonstrates that neuro-rehabilitation approaches, based on recent neuroscience findings, can enhance locomotor recovery after a spinal cord injury or stroke. Findings are presented from more than 20 clinical studies conducted by numerous research groups on the effect of locomotor training using either body weight support (BWS), functional electrical stimulation (FES), pharmacological approaches or a combination of them. Among the approaches, only BWS-assisted locomotor training has been demonstrated to have a greater effect than conventional or locomotor training alone. However, when study results were combined and weighted for the number of subjects, the results indicated that there is a gradient of effects from small changes with the immediate application of FES or BWS to larger changes when locomotor training is combined with FES or BWS or pharmacological approaches. The findings of these studies suggest that these neuro-rehabilitation approaches do play a role in the recovery of walking in subjects with spinal cord injury or stroke. Several factors contribute to the potential for recovery including the site, etiology and chronicity of the injury, as well as the type, duration, and specificity of the intervention and whether interventions are combined. Furthermore, how these neuro-rehabilitation approaches may take advantage of the plasticity process following neurological lesion is also discussed.
Barbeau H. Physical and Occupational Therapy, McGill University, Montreal, Canada. Ann N Y Acad Sci.
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Electrical stimulation for swallowing disorders caused by stroke.

Background: An estimated 15 million adults in the United States are affected by dysphagia (difficulty swallowing). Severe dysphagia predisposes to medical complications such as aspiration pneumonia, bronchospasm, dehydration, malnutrition, and asphyxia. These can cause death or increased health care costs from increased severity of illness and prolonged length of stay. Existing modalities for treating dysphagia are generally ineffective, and at best it may take weeks to months to show improvement. One common conventional therapy, application of cold stimulus to the base of the anterior faucial arch, has been reported to be somewhat effective. We describe an alternative treatment consisting of transcutaneous electrical stimulation (ES) applied through electrodes placed on the neck. Objective: Compare the effectiveness of ES treatment to thermal-tactile stimulation (TS) treatment in patients with dysphagia caused by stroke and assess the safety of the technique. Methods: In this controlled study, stroke patients with swallowing disorder were alternately assigned to one of the two treatment groups (TS or ES). Entry criteria included a primary diagnosis of stroke and confirmation of swallowing disorder by modified barium swallow (MBS). TS consisted of touching the base of the anterior faucial arch with a metal probe chilled by immersion in ice. ES was administered with a modified hand-held battery-powered electrical stimulator connected to a pair of electrodes positioned on the neck. Daily treatments of TS or ES lasted 1 hour. Swallow function before and after the treatment regimen was scored from 0 (aspirates own saliva) to 6 (normal swallow) based on substances the patients could swallow during a modified barium swallow. Demographic data were compared with the test and Fisher exact test. Swallow scores were compared with the Mann-Whitney U test and Wilcoxon signed-rank test. Results: The treatment groups were of similar age and gender (p > 0.27), co-morbid conditions (p = 0.0044), and initial swallow score (p = 0.74). Both treatment groups showed improvement in swallow score, but the final swallow scores were higher in the ES group (p > 0.0001). In addition, 98% of ES patients showed some improvement, whereas 27% of TS patients remained at initial swallow score and 11% got worse. These results are based on similar numbers of treatments (average of 5.5 for ES and 6.0 for TS, p = 0.36). Conclusions: ES appears to be a safe and effective treatment for dysphagia due to stroke and results in better swallow function than conventional TS treatment.
Freed M.L. Respir. Care.
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Electrical stimulation of wrist extensors in poststroke hemiplegia.

Background and purpose: It has been suggested that cyclic neuromuscular electrical stimulation (ES) may enhance motor recovery after stroke. We have investigated the effects of ES of the wrist extensors on impairment of wrist function and on upper-limb disability in patients being rehabilitated after acute stroke. Methods: We recruited 60 hemiparetic patients (mean age, 68 years) 2 to 4 weeks after stroke into a randomized, controlled, parallel-group study comparing standard rehabilitation treatment with standard treatment plus ES of wrist extensors (3 times 30 minutes daily for 8 weeks). Isometric strength of wrist extensors was measured using a device built for that purpose. Upper-limb disability was assessed with use of the Action Research Arm Test (ARAT). Observations were continued for 32 weeks (24 weeks after the finish of ES or the control intervention phase). Results: The change in isometric strength of wrist extensors (at an angle of 0 degrees extension) was significantly greater in the ES group than the control group at both 8 and 32 weeks (P=0.004, P=0.014 by Mann Whitney U test). At week 8 the grasp and grip subscores of the ARAT increased significantly in the ES group compared with that in the control group (P=0.013 and P=0.02, respectively); a similar trend was seen for the total ARAT score (P=0.11). In the subgroup of 33 patients with some residual wrist extensor strength at study entry (moment at 0 degrees extension >0), the ARAT total score had increased at week 8 by a mean of 21.1 (SD, 12.7) in the ES group compared with 10.3 (SD, 9.0) in the control group (P= 0.024, Mann Whitney U test); however, at 32 weeks the differences between these2 subgroupswere no longer statistically significant. Conclusions: ES of the wrist extensors enhances the recovery of isometric wrist extensor strength in hemiparetic stroke patients. Upper-limb disability was reduced after 8 weeks of ES therapy, with benefits most apparent in those with some residual motor function at the wrist...
Powell J. Dep. Bioengineering, University of Strathclyde, Glasgow, Scotland. Journal: Stroke.
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Functional electrostimulation in poststroke rehabilitation: a meta-analysis of the randomized controlled trials.

Objective: To assess the efficacy of functional electrical stimulation (FES) in the rehabilitation of hemiparesis in stroke. Design: A meta-analysis combined the reported randomized controlled trials of FES in stroke, using the effect size method of Glass, and the DerSimonian-Laird Random Effects Method for pooling studies. Setting: The included studies were published between 1978 and 1992. They were conducted In academic rehabilitation medicine settings. Patients: In all included studies, patients were in poststroke rehabilitation. The mean time after stroke varied from 1.5 to 29.2 months. Intervention: FES applied to a muscle or associated nerve in a hemiparetic extremity was compared to No FES. Main outcome measure: Change in paretic muscle force of contraction following FES was compared to change without FES. Results: For the four included studies, the mean effect size was .63 (95% CI: .29, .98). This result was statistically significant (p < .05). Conclusion: Pooling from randomized trials supports FES as promoting recovery of muscle strength after stroke. This effect is statistically significant. There is a reasonable likelihood of clinical significance as well.
Glanz M. Harvard School of Public Health, Boston, USA. Arch Phys Med Rehabilitation
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The effects of functional electrical stimulation on shoulder subluxation, arm function recovery, and shoulder pain in hemiplegic stroke patients.

The purpose of this study was to evaluate the effectiveness of a functional electrical stimulation (FES) treatment program designed to prevent glenohumeral joint stretching and subsequent subluxation and shoulder pain in stroke patients. Twenty-six recent hemiplegic stroke patients with shoulder muscle flaccidity were randomly assigned to either a control group (n = 13; 5 female, and 8 male) or experimental group (n = 13; 6 female, and 7 male). Both groups received conventional physical therapy. The experimental group received additional FES therapy where two flaccid/paralyzed shoulder muscles (supraspinatus and posterior deltoid) were induced to contract repetitively up to 6 hours a day for 6 weeks. Duration of both the FES session and muscle contraction/relaxation ratio were progressively increased as performance improved. The experimental group showed significant improvements in arm function, electromyographic activity of the posterior deltoid, range of motion, and reduction in subluxation (as indicated by x-ray) compared with the control group. We concluded that the FES program was effective in reducing the severity of shoulder subluxation and pain, and possibly facilitating recovery of arm function.
Faghri P.D. Rehabilitation Institute of Ohio, Dayton. Arch Phys Med Rehabilitation
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Electrical stimulation of wrist and fingers for hemiplegic patients.

Passive cyclical electrical stimulation was applied during a four-week treatment program to the wrist and finger extensors of 16 hemiplegic patients with flexor spasticity. The study noted the effects of this treatment on the patients' sensation; spasticity; passive range of motion of the wrist, metacarpophalangeal, and proximal interphalangeal joints; and strength in the wrist extensor muscles. Patients were divided into chronic and subacute groups. Both groups received electrical stimulation for three half-hour periods a day, seven days a week, as a substitute for all other range-of-motion techniques. Flexion contractures were prevented in the subacute group of patients at the wrist, metacarpophalangeal, and proximal interphalangeal joints. A statistically and clinically significant increase in wrist extension range occurred in the chronic group that had wrist flexion contractures before the electrical stimulation. Increased extension was noted at the metacarpophalangeal and proximal interphalangeal joints of patients in the chronic group. Those patients with some voluntary wrist extension before the treatment began were able to increase their extension strength during stimulation. No changes in skin sensation were noted and only a general trend in decreasing spasticity was apparent.
Baker L. Physical Therapy
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A pilot study to investigate the combined use of botulinum neurotoxin type a and functional electrical stimulation, with physiotherapy, in the treatment of spastic dropped foot in subacute stroke.

The objective was to inform sample size calculations for a full randomized controlled trial (RCT). The design included an RCT pilot trial with a 16 week study period, including a 4 week baseline phase. The subjects were adults within 1 year of first stroke, ambulant with a spastic dropped foot. Twenty-one participants were recruited from the stroke services of 4 centers. For intervention all participants received physiotherapy; the treatment group also received botulinum neurotoxin Type A (BoNTA) intramuscular injections to triceps surae (800 U Dysport) and functional electrical stimulation (FES) of the common peroneal nerve to assist walking. The main outcome measure was walking speed. The result was a significant upward trend in median walking speed for both the control (p = 0.02) and treatment groups (nonstimulated p = 0.004, stimulated p = 0.042). Trend lines were different in location (p = 0.04 and p = 0.009, respectively). In conclusion, there is evidence of an additional, beneficial effect of BoNTA and FES. Sufficient information has been gained on the variability of the primary outcome measure to inform sample size calculations for a full RCT to quantify the treatment effect with precision.
Johnson C. Dep. Medical Physics, Salisbury District Hospital, UK
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The effects of ipsilateral forearm movement and contralateral hand grasp on the spastic hand opened by electrical stimulation.

The purpose of this study was to investigate the effects of ipsilateral arm movement and contralateral hand grasp on the spastic hand opened by open-loop electrical stimulation. The major problem of applying proper electrical stimulation is variable spasticity, the intensity of which changes with posture and movements of other parts of the body. Electrical stimulation was applied to extensor digitorum communis and ulnar nerve to open the affected hand. Different procedures were then used to assess the effects of moving the ipsilateral forearm and contracting the contralateral normal hand. Electrical stimulation opened the spastic hand in more than 95% of trials in all subjects, whether stimulation was applied before or after the movement of the forearm. Moving the ipsilateral forearm did have an effect on opening the hand, and making adjustment of stimulation intensities was necessary in all subjects. The stimulation opened the spastic hand during the contraction of the contralateral normal hand. Electrical stimulation could open the spastic hands most of the time, in the resence of ipsilateral forearm movement and contralateral normal hand contraction. If electrical stimulation was applied before the ipsilateral forearm was moved toward the target, stimulation intensities needed to be adjusted.
Lin C. Dep. Neurology, National Cheng-Kung University Hospital, Taiwan Neurorehabilitation Neural Repair
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The effects of neuromuscular stimulation-induced muscle contraction versus elevation on hand edema in CVA patients.

The purpose of this study was to evaluate the efficacy of the use of neuromuscular stimulation (NMS)-induced contraction of the paralyzed muscles to produce an active muscle pump for removing excess fluid and compare its effect with elevation of the upper extremity. The effects of 30 minutes of NMS of the finger and wrist flexors and extensors were compared with the effects of 30 minutes of limb elevation alone. Each of eight cerebrovascular accident (CVA) patients with visible hand edema received both treatments, one on each of 2 consecutive days. Measures of hand and arm volume and upper and lower arm girth were taken before and after each treatment. Analyses comparing mean percentage change scores for both treatments showed large and significant treatment effects for all dependent measures. The finding suggests that NMS was more effective for reduction of hand edema than limb elevation alone for this sample of eight CVA patients.
Faghri PD. Uni. of Connecticut, USA. Journal Hand Therapy
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Treating chronic hemiparesis with modified biofeedback.

Eleven patients with chronic spastic hemiparesis were treated with biosignal processing (BSP), a modified biofeedback method in which the patient practices useful tasks, not isolated individual movements. A surface EMG measures sequential movements, and an acoustic signal monitors muscle exertion. The patient first learns how the signal develops by using the unaffected limb. Then the patient tries to reproduce the course of the signal in the paretic limb. Patients received 12 to 30 treatments for upper and/or lower extremities. We measured maximum strength as expressed through the EMG signal; ability to perform the trained action as measured by specific grading systems; and general increase in movement competence during a Bobath movement test. Ten patients showed improved strength; four made marked progress in the performance of specific tasks with the upper extremity, as did four with the lower extremity. Four patients in each group improved in general movement. We recommend the integration of useful tasks into movement exercises in EMG biofeedback therapy.
Wissel J. Hosp. Am Urban, Berlin, Germany. Arch Phys Med Rehabilitation
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The effects of neuromuscular stimulation-induced muscle contraction versus elevation on hand edema in CVA patients.

The purpose of this study was to evaluate the efficacy of the use of neuromuscular stimulation (NMS)-induced contraction of the paralyzed muscles to produce an active muscle pump for removing excess fluid and compare its effect with elevation of the upper extremity. The effects of 30 minutes of NMS of the finger and wrist flexors and extensors were compared with the effects of 30 minutes of limb elevation alone. Each of eight cerebrovascular accident (CVA) patients with visible hand edema received both treatments, one on each of 2 consecutive days. Measures of hand and arm volume and upper and lower arm girth were taken before and after each treatment. Analyses comparing mean percentage change scores for both treatments showed large and significant treatment effects for all dependent measures. The finding suggests that NMS was more effective for reduction of hand edema than limb elevation alone for this sample of eight CVA patients.
Faghri PD. University of Connecticut, USA. Journal Hand Therapy
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Two Coupled Motor Recovery Protocols Are Better Than One Electromyogram Triggered Neuromuscular Stimulation and Bilateral Movements

Background and Purpose: Overcoming chronic hemiparesis from a cerebrovascular accident (CVA) can be challenging for many patiens, especially after the first 12 months after the CVA. With the use of established motor control theories, the present study investigated electromyogram (EMG)-triggered neuromuscular stimulation and bilateral coordination training. Methods: Twenty-five CVA subjects volunteered to participate in this motor recovery protocol study. Subjects were randomly assigned to 1 of 3 groups: (1) coupled protocol of EMG-triggered stimulation and bilateral movement (n=10); (2) EMG-triggered stimulation and unilateral movement (n=10); or (3) control (n=5). all participants completed 6 hours of rehabilitation during a 2-week period according to group assignments. Motor capabilities of the wrist and fingers were evaluated on the basis of 3 categories of motor tasks in a pretest - posttest control group design. Results: Significant findings for the (1) number of blocks moved in a functional task, (2) chronometric reaction times to initiate movements, and (3) sustained muscle contraction capability all favored the coupled bilateral movement training and EMG-triggered neuromuscular stimulation protocol group. In addition, the unilateral movement/stimulation group exceeded the control group in the number of blocks moved and rapid onset of muscle contractions. Conclusions: This new evidence is convincing in that subjects in the coupled protocol group were able to demonstrate enhanced voluntary motor control across 3 categories of tasks. Chronic hemiparesis decreased considerably in the wrist and fingers as CVA patients expanded their motor repertoire.
Cauraugh J.H. Journal: Stroke
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Electrostimulation for Stroke rehabilitation: Mechanisms and effect.

Purpose: The aims of this project are to assess the efficacy of EMG-controlled neuromuscular stimulation in enhancing the upper-extremity motor recovery of chronic stroke survivors, and to determine whether EMG-controlled neuromuscular stimulation mediates its effect on motor recovery via central mechanisms. Methodology: Phase I of the study will identify neurophysiologic measures of brain function that correlate with objective measures of motor impairment. Chronic stroke survivors will be evaluated with objective measures of motor impairment (active range of motion, joint torques, Fugl-Meyer Motor Assessment, and EMG initiation and termination characteristics) and neurophysiologic measures of central motor function (Single Photon Emission Computed Tomography, Transcortical Magnetic Stimulation and Somatosensory Evoked Potentials). Phase II will consist of a single-blinded, randomized clinical trial to assess the effects of EMG-controlled neuromuscular stimulation on objective measures of motor impairment and measures of central motor function identified in phase I. Progress: A total of 20 chronic stroke survivors will be enrolled in phase I over a 2-year period, and 34 chronic stroke survivors in phase II over a 3-year period. Implications: This study will demonstrate that EMG-controlled neuromuscular stimulation enhances the motor recovery of chronic stroke survivors, and that the motor recovery is mediated by central mechanisms. The proposed intervention may be effective for acute stroke survivors and persons with other forms of cerebral motor dysfunction such as traumatic brain injury, cerebral palsy and multiple sclerosis. EMG-controlled neuromuscular stimulation may also be effective for lower limb motor recovery. Finally, techniques developed for assessing central motor function may be useful for evaluating other interventions directed at stroke rehabilitation.
John Chae MD Center for Physical Medicine and Rehabilitation University of Cleveland, USA
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EMG-Controlled stimulator for stroke rehabilitation.

Purpose: The general purpose of this project is to develop a device for facilitating motor relearning for stroke survivors. The device will detect weak electromyographic (EMG) signals generated by a paretic muscle and consequently deliver stimulation currents to the same muscle to result in its strong contraction. The device will consist of a set of electrodes for sensing and stimulation and electronic circuitry for signal processing and stimulus generation. Methodology: During Phase I, we shall pursue the following objectives to produce and assess a pre-prototype device: first, we shall develop a tripolar intramuscular electrode that is suitable for both EMG sensing and muscle stimulation. The electrode should have a diameter small enough to be loaded into a 19-gauge hypodermic needle for percutaneous implantation. It should be durable enough to withstand muscle contraction without breakage for at least 4 weeks, and sufficiently flexible and include an anchoring mechanism capable of maintaining the intended position for the same period. Then we shall develop electronic circuits that, when connected to the tripolar intramuscular electrode, can reliably detect EMG signals and deliver stimulation pulses to the target muscle. The detecting circuitry should be able to detect very weak EMG signals, in the order of 1 ÁV in a paretic muscle, while having high immunity to the very strong stimulation artifact generated by the stimulus current. The stimulation circuitry should be able to generate charge-balanced, current-regulated, biphasic pulses for safe and effective intramuscular stimulation.  Finally, we shall evaluate the performance of the sensing-stimulation system in three stroke survivors. The implantation of the intramuscular electrode should be simple for the physician and well tolerated by the patients. The patient should be able to control the stimulation reliably after a short period of training and adjustment. The desirable exercise modes should be obtained in the paretic limbs without accompanying pain or discomfort. The use of the device should result in improved range of motion and flexion-extension torque at the involved joints. Progress: Electrodes have been designed and developed for the purpose of sensing EMG signals and stimulating the muscle from which those EMG signals were detected. A laboratory version of the EMG-controlled stimulator has been developed. The device is capable of processing two EMG signals and using them to control the onset and termination of stimulation pulses from four stimulation channels. Future plans: The tripolar electrodes and the EMG-controlled stimulator will be tested on a number of persons with hemiplegia. After the system has been miniaturized, subjects will use the device for exercise at home, and the effectiveness of the intervention will be assessed.
Zi-Ping Fang, PhD Cleveland FES Center, USA
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Biofeedback and functional electric stimulation in stroke rehabilitation.

The study examined the efficacy of functional electric stimulation (FES) and biofeedback (BFB) treatment of gait dysfunction in patients with hemiplegia after stroke. These two therapeutic modalities were tested alone and in combination in a prospective, controlled, randomized trial. The authors hypothesized that in concurrent use, these two modalities would complement one another. Thirty-six hemiplegic patients undergoing rehabilitation after stroke were accepted for study and randomized into four groups to receive either control, FES, BFB, or combined therapies. Each patient received 30 minutes of treatment three times per week for six weeks, in addition to their general rehabilitation program. Quantitative gait analysis was performed biweekly on each subject during the experimental therapy and for four weeks afterward. Thirty-two subjects completed the study. Combined therapy with BFB and FES resulted in improvements in both knee and ankle minimum flexion angles during swing phase that were statistically significant with p = 0.05 and p = 0.02, respectively. Velocity of gait, cycle time, and symmetry of stance phases also improved. The length of time elapsed since the stroke did not prove to be a significant factor.
Cozean C.D. Ohio State University. Arch Phys Med Rehabilitation
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Electrical stimulation in early stroke rehabilitation of the upper limb with inattention.

Use of electrical stimulation early in stroke rehabilitation may benefit recovery of function. This case report describes the clinical outcomes following electrical stimulation for the supraspinatus of a 25-year-old patient four weeks after a right-sided stroke. In this patient, use of electrical stimulation for a total of four hours in 4.5 weeks, appeared to have a number of benefits: subluxation was reduced and patient attention to the arm was increased. There was also a notable improvement in functional use of the arm when task-specific upper limb training was incorporated. Whilst not conclusive, the results of this case study reinforce the value of electrical stimulation in the early management of the upper limb in a stroke patient who clearly demonstrated inattention to his upper limb. The results also   highlight the need for well controlled studies to investigate the benefits of electrical stimulation and to establish the optimal timing and parameters for this intervention. Therapists can then more effectively optimise effective upper limb rehabilitation following stroke.
Mackenzie-Knapp M. School of Physiotherapy, La Trobe University, Bundoora, Australia. Aust J. Physiother.
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Percutaneous, intramuscular neuromuscular electrical stimulation for the treatment of shoulder subluxation and pain in chronic hemiplegia: a case report.

This case report describes the first survivor with chronic stroke who was treated with percutaneous, intramuscular neuromuscular electrical stimulation (NMES) for shoulder subluxation and pain. The patient developed shoulder subluxation and pain within 2 mo of his stroke. After discharge from acute inpatient rehabilitation, he developed shoulder and hand pain, which was treated with subacromial bursa steroid injection and ibuprofen with eventual resolution. The patient remained clinically stable until approximately 15 months after his stroke-when he developed severe shoulder pain associated with shoulder abduction, external rotation, and downward traction. The patient could not tolerate transcutaneous NMES because of the pain of stimulation. At approximately 17 mo post-stroke, the patient's posterior deltoid, middle deltoid, and supraspinatus muscles were percutaneously implanted with intramuscular electrodes. After 6 wk of percutaneous, intramuscular NMES treatment, marked improvements in shoulder subluxation and pain, and modest improvements in activities of daily living and motor function were noted. One year after the onset of treatment, the patient remained pain free, but subluxation had recurred. However, the patient was able to volitionally reduce the subluxation by abducting his shoulder. The patient remained pain free for up to 40 months after the initiation of percutaneous, intramuscular NMES treatment. This case report demonstrates the feasibility of using percutaneous, intramuscular NMES for treating shoulder subluxation and pain in hemiplegia.
Chae J. Dep.of Physical Medicine and Rehabilitation, Cleveland, USA. Am J Phys Med Rehabilitation

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Techniques to Improve Function of the Arm and Hand in Chronic Hemiplegia.

Summary: We evaluated functional improvement in the upper limb of chronic (more than six months' duration) stroke patients who received one of two electrical stimulation treatments, conventional treatment, or no treatment. Twenty-two right-handed patients were assigned to one of four groups studied for 12 months post treatment. Subjects received (1) EMG-initiated electrical stimulation of wrist extensors (EMG-stimulation), (2) low-intensity electrical stimulation of wrist extensors combined with voluntary contractions (B/B), (3) proprioceptive neuromuscular facilitation (PNF) exercises, or (4) no treatment. Subjects were treated for three months. Before treatment, upon completion of treatment, and three and nine months after treatment, subjects were evaluated by the Fugl-Meyer (FM) post-stroke motor recovery test and by grip strength. Subjects also attempted three Jebsen-Taylor hand function tests and a finger tapping test at the same evaluation sessions, but many were unable to complete these tests. During the course of treatment, FM scores of subjects receiving PNF improved 18%, B/B improved 25%, and EMG-stimulation improved 42%. The aggregate FM improvement of the treated groups was significant from pre-treatment to post-treatment, and the improvement was maintained at three-months and nine-months follow-ups (all p<.005).the treated subjects' improvement in grip strength was also maintained at both follow-ups (p, .10). In contrast, the control group showed no significant change in FM scores or grip strength. The four treated subjects who were able to perform the hand function tests and finger tapping at all four evaluations also improved on these tests.  We conclude that chronic stroke patients can achieve and maintain functional improvements, especially by combining electrical stimulation techniques with voluntary effort.
George H. Kraft MD Arch Phys Med Rehabilitation
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Electromyographically triggered electric muscle stimulation for chronic hemiplegia.

Electromyographically triggered electric muscle stimulation (EMS) was evaluated in combination with conventional treatment in 69 consecutive post-cerebrovascular accident outpatients whose onset of hemiplegia was four months to 14 years earlier. Six subjects initially exhibited no residual volitional activity in targeted muscles, and all patients had undergone conventional therapy with little or no functional recovery. Prescribed treatment (patient compliance was frequently substandard) involved several months of four to five sessions per week, focusing on wrist extension and/or ankle dorsiflexion initially and often other movements later. During 30 to 300 movement attempts per session, EMG's that exceeded a preset threshold triggered immediate stimulation to force movement completion. Over sessions, patients commonly realized substantially improved increases in voluntary EMG capabilities generally proportionate to the frequency of treatment sessions. Parallel improvements were also found for subjectively scaled functional measures of range-of-motion and ambulation. Motivation was important to success, but side and nature of stroke, age, and post-stroke interval were not. Progress often far exceeded that of previous conventional therapy. Regarding mechanisms, impaired proprioceptive feedback is considered central to stroke-disrupted sensorimotor control. EMG-triggered EMS is intended to improve brain relearning by reinstating proprioceptive feedback time-locked to each attempted movement. Clinical results were consistent with this theory.
R.W. Fields, Arch. Phys. Med. Rehabilitation
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Chronic Motor Dysfunction After Stroke.

Summary: Recovering Wrist and Finger Extension by Electromyography Triggered Neuromuscular Stimulation. Background and Purpose: After stroke, many individuals have chronic unilateral motor dysfunction in the upper extremity that severely limits their functional movement control. The purpose of this study was to determine the effect of electromyography triggered neuromuscular electrical stimulation on the wrist and finger extension muscles in individuals who had a stroke >1 year earlier. Methods: Eleven individuals volunteered to participate and were randomly assigned to either the electromyography triggered neuromuscular stimulation experimental group (7subjects) or the control group (4 subjects). After completing a pre-test involving 5 motor capability tests, the post-stroke subjects completed 12 treatment sessions (30 minutes each) according to group assignments. Once the control subjects completed 12 sessions attempting wrist and finger extension without any external assistance and were post-tested, they were then given 12 sessions of the rehabilitation treatment. Result: The Box and Block test and the force-generation task (sustained muscular contraction) revealed significant findings (P<0.05). The experimental group moved significantly more blocks and displayed a higher isometric force impulse after the rehabilitation treatment. Conclusions: Two lines of evidence clearly support the use of the electromyography triggered neuromuscular electrical stimulation treatment to rehabilitate wrist and finger extension movements of hemiparetic individuals > year after stroke. The treatment program decreased motor dysfunction and improved the motor capabilities in this group of post-stroke individuals. J. Cauraugh, PhD. et. al. Journal Physiotherapy
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Electromyogram Triggered Neuromuscular Stimulation for Improving the Arm Function of Acute stroke Survivors: A Randomized Pilot Study.

Objective: To assess the efficacy of electromyogram (EMG)-triggered neuromuscular stimulation (EMG-stimulation) in enhancing upper extremity motor and functional recovery of acute stroke survivors. Design: A pilot randomized, single-blinded clinical trial. Setting: Freestanding in-patient rehabilitation facility. Patients: Nine subjects who were within 6 weeks of their first unifocal nonhemorrhagic stroke were randomly assigned to either the EMG-stimulation (n=4) or control (n=5) group. All subjects had a detectable EMG signal (>5ÁV) from the surface of the paretic extensor carpi radialis and voluntary wrist of the paretic extensor carpi radialis and voluntary wrist extension in synergy or in isolation with muscle grade of <3/5. Intervention: All subjects received two 30-minute sessions per say of wrist strengthening exercises with EMG-stimulation (experimental) or without (control) for the duration of their rehabilitation stay. Main Outcome Measures: Upper extremity Fugl-Meyer motor assessment and the feeding, grooming, and upper body dressing items of the Functional Independence Measure (FIM) were assessed at study entry and at discharge. Results: Subjects treated with EMG-stimulation exhibited significantly greater gains in Fugl-Meyer (27.0 vs 10.4; p=.05), and FIM (6.0 vs 3.4: p=.02) scores compared with controls. Conclusion: Data suggest that EMG-stimulation enhances the arm function of acute stroke survivors.
G. Francisco, MD OTR. Arch. Phys. Med. Rehabilitation
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Mental Practice of Motor Skills used in post-stroke Rehabilitation has Own Effects on Central Nervous Activation.

In the last years it has been shown that the use of the EMG triggered electrical myostimulation (ETEM) brings good results in post-stroke rehabilitation. It has been hypothesized that the relearning effects obtained by means of ETEM are due to the reinstatement of proprioceptive feedback. However, the technique is most powerful if imagination of motor acts (the so called mental practice) is used as an initial part of ETEM. Since mental practice in healthy people leads to central nervous activation processes as well as to an improvement of motor skills, we investigated the effects of mental practice alone on central nervous activity by means of EEG in stroke patients. Twelve left-sided hemiplegic patients who underwent a specific post-stroke rehabilitation treatment were requested to perform a simple arm movement sequence. In the following mental practice period the patients were requested to imagine the same sequence without any real movement. EEG background activity was recorded during baseline and imagination periods. After the calculation of z-transformed power values within the alpha and beta-1 band, differences between rest and imagination periods were evaluated for significance. Stroke patients showed significant decreases of alpha as well as beta-1 power during mental practice in comparison to the rest period. These changes are similar to those obtained in healthy subjects. Central alpha power diminished only during imagination of the contralateral arm. This phenomenon as well as the decrease of beta-1 power in central derivation were also obtained during real motor performance and might indicate an activation of the sensorimotor cortex. In accordance with the hypothesis of internal feedback mechanisms, this activation is a necessary prerequisite for motor learning during mental practice. We conclude that mental practice of motor skills might have own effects in post-stroke rehabilitation.
T. Weiss International J. Neuroscience
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Treatment of Hemiplegia by Means of Imagination-dependent EMG-triggered muscle stimulation.

Summary: The imagination of a movement elevates the electrical activity of paralyzed muscles. By means of a device this changed activity is used to generate low-frequency pulses which in turn are applied to induce a contraction of the spastic antagonist muscles. In this way the imagination-dependent muscle stimulation - triggered by EMG - circumvents the spastic movement patterns. The patient becomes able to regain forgotten movements by means of the method described. During the acute phase after a stroke it was applicable in only one third of our patients (n=40). Another group consisted of out-patients (n=20). In 18 of these a functional improvement of the paralyzed arm was attained after treatment for six months.
J. Danz Physikalische Medizin
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Rehabilitation of walking with electromyographic biofeedback in foot-drop after stroke. Randomized controlled Trial.

Background and purpose: Alterations of gait cycle and foot-drop on the paretic limb are characteristic of stroke patients. Electromyographic biofeedback treatment has been used in rehabilitation of walking, but results are controversial. We performed gait analysis to evaluate the efficacy of electromyographic biofeedback compared with physical therapy. Methods: Sixteen patients with ischemic stroke were enrolled in the study. The experimental group (4 men, 4 women) received electromyographic biofeedback treatment together with physical therapy. The control group (5 men, 3 women) was treated with physical therapy only. Clinical and functional evaluations before and after treatment were performed using Canadian Neurological, Adams, Ashworth, Basmajian and Barthel Index scales. Computerized gait analysis was performed in all patients. Results: Electromyographic biofeedback patients showed significantly increased scores on the Adams scale (P < .05) and Basmajian scale (P < .01). Gait analysis in this group showed a recovery of foot-drop in the swing phase (P < .02) after training. Conclusions: Our data confirm that the electromyographic biofeedback technique increases muscle strength and improves recovery of functional locomotion in patients with hemiparesis and foot-drop after cerebral ischemia.
Intiso D. Rehabilitation Center, IRCCS, Rome, Italy. Journal: Stroke
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Feedback of ankle joint angle and soleus electromyography in the rehabilitation of hemiplegic gait.

A computer-assisted feedback system was developed to present to walking subjects instantaneous feedback of their muscle activity or joint angular excursions during gait. Targets for muscle activity or joint motion were displayed on the feedback screen along with timing cues that prompted muscle activity or joint flexion/extension at specific times during the gait cycle. The purpose was to compare the effectiveness of joint angle and electromyographic (EMG) feedback to a focused program of physical therapy for gait. Eight hemiplegic stroke patients were treated with ankle joint angle feedback, EMG biofeedback from the soleus muscle, and conventional physical therapy for gait in a three-period crossover design. PT was given either first or last in the sequence of treatments. Gait analysis prior to and following each type of treatment revealed that the feedback treatments resulted in significant increases in stride length and walking velocity and in positive changes in push-off impulse, gait symmetry, and standing weight-bearing symmetry, as evaluated in a general linear model and paired t-tests. Overall, physical therapy produced no significant changes. However, when physical therapy was the first treatment of the sequence, significant increases in stride length and velocity were observed. When physical therapy was last, there were significant negative changes in gait symmetry and standing weight-bearing symmetry, and negative trends in stride length, walking velocity, and push-off impulse. It is concluded that computer-assisted feedback is an effective tool for retraining gait in stroke patients.
Colborne G.R. Queen's University, Kingston, Canada Arch Phys Med Rehabilitation
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Myobiofeedback in motor re-education of wrist and fingers after hemispherial stroke.

32 patients with different grade of hemiparesis, were in the first weeks after a cerebral vascular accident treated by means of EMG-feedback in respect to volar and dorsal flexion of the wrist, flexion and extension of the fingers, and opposition of thumb to the second ev. other fingers. EMG was registered from suitable muscles of the paretic limb. The attempt of volitional movement at the paretic side was conditioned with a reinforced mirror synergia of the same type from the healthy to the damaged side. The patient observed the effect on the EMG screen. After 3-6 conditionings the patient performed the volitional movement alone. In 25 of patients (e.g. 78.1%) improvement was obtained, at least in EMG. A good correlation was found between effect of the procedures and severity of paresis (p less than 0.05; chi 2 = 7.35).
Rathkolb O. Research Center, Vienna, Austria. Electromyogr. Clin. Neurophysiology
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