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Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke.

ABSTRACT: Brain-computer interfaces (BCI) are used in stroke rehabilitation to translate brain signals into intended movements of the paralyzed limb. However, the efficacy and mechanisms of BCI-based therapies remain unclear. Here we show that BCI coupled to functional electrical stimulation (FES) elicits significant, clinically relevant, and lasting motor recovery in chronic stroke survivors more effectively than sham FES. Such recovery is associated to quantitative signatures of functional neuroplasticity. BCI patients exhibit a significant functional recovery after the intervention, which remains 6-12 months after the end of therapy. Electroencephalography analysis pinpoints significant differences in favor of the BCI group, mainly consisting in an increase in functional connectivity between motor areas in the affected hemisphere. This increase is significantly correlated with functional improvement. Results illustrate how a BCI-FES therapy can drive significant functional recovery and purposeful plasticity thanks to contingent activation of body natural efferent and afferent pathways.

SUBMITTER: Biasiucci A

PROVIDER: S-EPMC6010454 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke.

Biasiucci A A Leeb R R Iturrate I I Perdikis S S Al-Khodairy A A Corbet T T Schnider A A Schmidlin T T Zhang H H Bassolino M M Viceic D D Vuadens P P Guggisberg A G AG Millán J D R JDR

Nature communications 20180620 1

Brain-computer interfaces (BCI) are used in stroke rehabilitation to translate brain signals into intended movements of the paralyzed limb. However, the efficacy and mechanisms of BCI-based therapies remain unclear. Here we show that BCI coupled to functional electrical stimulation (FES) elicits significant, clinically relevant, and lasting motor recovery in chronic stroke survivors more effectively than sham FES. Such recovery is associated to quantitative signatures of functional neuroplastici ...[more]

PMID: 29925890

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Project description:ObjectiveMotor recovery after stroke depends on the integrity of ipsilesional motor circuits and interactions between the ipsilesional and contralesional hemispheres. In this sham-controlled randomized trial, we investigated whether noninvasive modulation of regional excitability of bilateral motor cortices in combination with physical and occupational therapy improves motor outcome after stroke.MethodsTwenty chronic stroke patients were randomly assigned to receive 5 consecutive sessions of either 1) bihemispheric transcranial direct current stimulation (tDCS) (anodal tDCS to upregulate excitability of ipsilesional motor cortex and cathodal tDCS to downregulate excitability of contralesional motor cortex) with simultaneous physical/occupational therapy or 2) sham stimulation with simultaneous physical/occupational therapy. Changes in motor impairment (Upper Extremity Fugl-Meyer) and motor activity (Wolf Motor Function Test) assessments were outcome measures while functional imaging parameters were used to identify neural correlates of motor improvement.ResultsThe improvement of motor function was significantly greater in the real stimulation group (20.7% in Fugl-Meyer and 19.1% in Wolf Motor Function Test scores) when compared to the sham group (3.2% in Fugl-Meyer and 6.0% in Wolf Motor Function Test scores). The effects outlasted the stimulation by at least 1 week. In the real-stimulation group, stronger activation of intact ipsilesional motor regions during paced movements of the affected limb were found postintervention whereas no significant activation changes were seen in the control group.ConclusionsThe combination of bihemispheric tDCS and peripheral sensorimotor activities improved motor functions in chronic stroke patients that outlasted the intervention period. This novel approach may potentiate cerebral adaptive processes that facilitate motor recovery after stroke.Classification of evidenceThis study provides Class I evidence that for adult patients with ischemic stroke treated at least 5 months after their first and only stroke, bihemispheric tDCS and simultaneous physical/occupational therapy given over 5 consecutive sessions significantly improves motor function as measured by the Upper Extremity Fugl-Meyer assessment (raw change treated 6.1 ± 3.4, sham 1.2 ± 1.0).

Project description:IntroductionMany patients with stroke have moderate to severe long-term sensorimotor impairments, often including inability to execute movements of the affected arm or hand. Limited recovery from stroke may be partly caused by imbalanced interaction between the cerebral hemispheres, with reduced excitability of the ipsilesional motor cortex while excitability of the contralesional motor cortex is increased. Non-invasive brain stimulation with inhibitory repetitive transcranial magnetic stimulation (rTMS) of the contralesional hemisphere may aid in relieving a post-stroke interhemispheric excitability imbalance, which could improve functional recovery. There are encouraging effects of theta burst stimulation (TBS), a form of TMS, in patients with chronic stroke, but evidence on efficacy and long-term effects on arm function of contralesional TBS in patients with subacute hemiparetic stroke is lacking.Methods and analysisIn a randomised clinical trial, we will assign 60 patients with a first-ever ischaemic stroke in the previous 7-14 days and a persistent paresis of one arm to 10 sessions of real stimulation with TBS of the contralesional primary motor cortex or to sham stimulation over a period of 2 weeks. Both types of stimulation will be followed by upper limb training. A subset of patients will undergo five MRI sessions to assess post-stroke brain reorganisation. The primary outcome measure will be the upper limb function score, assessed from grasp, grip, pinch and gross movements in the action research arm test, measured at 3 months after stroke. Patients will be blinded to treatment allocation. The primary outcome at 3 months will also be assessed in a blinded fashion.Ethics and disseminationThe study has been approved by the Medical Research Ethics Committee of the University Medical Center Utrecht, The Netherlands. The results will be disseminated through (open access) peer-reviewed publications, networks of scientists, professionals and the public, and presented at conferences.Trial registration numberNTR6133.

Project description:Promoting the recovery of motor function and optimizing rehabilitation strategies for stroke patients is closely associated with the challenge of individual prediction. To date, stroke research has identified critical pathophysiological neural underpinnings at the cellular level as well as with regard to network reorganization. However, in order to generate reliable readouts at the level of individual patients and thereby realize translation from bench to bedside, we are still in a need for innovative methods. The combined use of transcranial magnetic stimulation (TMS) and EEG has proven powerful to record both local and network responses at an individual's level. To elucidate the potential of TMS-EEG to assess motor recovery after stroke, we used neuronavigated TMS-EEG over ipsilesional primary motor cortex (M1) in 28 stroke patients in the first days after stroke. Twenty-five of these patients were reassessed after >3 months post-stroke. In the early post-stroke phase (6.7 ± 2.5 days), the TMS-evoked EEG responses featured two markedly different response morphologies upon TMS to ipsilesional M1. In the first group of patients, TMS elicited a differentiated and sustained EEG response with a series of deflections sequentially involving both hemispheres. This response type resembled the patterns of bilateral activation as observed in the healthy comparison group. By contrast, in a subgroup of severely affected patients, TMS evoked a slow and simplified local response. Quantifying the TMS-EEG responses in the time and time-frequency domain revealed that stroke patients exhibited slower and simple responses with higher amplitudes compared to healthy controls. Importantly, these patterns of activity changes after stroke were not only linked to the initial motor deficit, but also to motor recovery after >3 months post-stroke. Thus, the data revealed a substantial impairment of local effects as well as causal interactions within the motor network early after stroke. Additionally, for severely affected patients with absent motor evoked potentials and identical clinical phenotype, TMS-EEG provided differential response patterns indicative of the individual potential for recovery of function. Thereby, TMS-EEG extends the methodological repertoire in stroke research by allowing the assessment of individual response profiles.

Project description:BACKGROUND:Effective poststroke motor rehabilitation depends on repeated limb practice with voluntary efforts. An electromyography (EMG)-driven neuromuscular electrical stimulation (NMES)-robot arm was designed for the multi-joint physical training on the elbow, the wrist, and the fingers. OBJECTIVES:To investigate the training effects of the device-assisted approach on subacute stroke patients and to compare the effects with those achieved by the traditional physical treatments. METHOD:This study was a pilot randomized controlled trial with a 3-month follow-up. Subacute stroke participants were randomly assigned into two groups, and then received 20-session upper limb training with the EMG-driven NMES-robotic arm (NMES-robot group, n?=?14) or the time-matched traditional therapy (the control, n?=?10). For the evaluation of the training effects, clinical assessments including Fugl-Meyer Assessment (FMA), Modified Ashworth Score (MAS), Action Research Arm Test (ARAT), and Function Independence Measurement (FIM) were conducted before, after the rehabilitation training, and 3?months later. Session-by-session EMG parameters in the NMES-robot group, including normalized co-contraction Indexes (CI) and EMG activation level of target muscles, were used to monitor the progress in muscular coordination patterns. RESULTS:Significant improvements were obtained in FMA (full score and shoulder/elbow), ARAT, and FIM [P?<?0.001, effect sizes (EFs)?>?0.279] for both groups. Significant improvement in FMA wrist/hand was only observed in the NMES-robot group (P?<?0.001, EFs?=?0.435) after the treatments. Significant reduction in MAS wrist was observed in the NMES-robot group after the training (P?<?0.05, EFs?=?0.145) and the effects were maintained for 3?months. MAS scores in the control group were elevated following training (P?<?0.05, EFs?>?0.24), and remained at an elevated level when assessed 3?months later. The EMG parameters indicated a release of muscle co-contraction in the muscle pairs of biceps brachii and flexor carpi radialis and biceps brachii and triceps brachii, as well as a reduction of muscle activation level in the wrist flexor in the NMES-robot group. CONCLUSION:The NMES-robot-assisted training was effective for early stroke upper limb rehabilitation and promoted independence in the daily living comparable to the traditional physical therapy. It could achieve higher motor outcomes at the distal joints and more effective release in muscle tones than the traditional therapy. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, identifier NCT02117089; date of registration: April 10, 2014.

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Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke.

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Brain-actuated functional electrical stimulation elicits lasting arm motor recovery after stroke.

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