This study was funded by the Christian Doppler Research Foundation of the Austrian Council for Research and Technology Development and the Austrian Federal Ministry of Science, Research and Economy. We are grateful to Aron Cserveny for preparation of the illustrations included in the manuscript and to Frontiers in Neuroscience for permission of reproducing the data presented in the original article12.

<ol>
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The authors have nothing to disclose.

Biofeedback approaches have been widely used in the rehabilitation of several neuromuscular disorders, ranging from (hemi)-plegic conditions resulting from central pathologies such as brain hemorrhage and stroke18,19 to various musculoskeletal degeneration or injury and their surgical therapy20,21,22. Interestingly, the concept of structured biofeedback has not been implemented in clinical practice for peripheral nerve injuries. However, precisely in the rehabilitation of complex nerve injuries, practice, repetition, and structured training programs with appropriate biofeedback are necessary to establish correct motor patterns23.
Here, and in a previous study12, we presented a structured rehabilitation protocol using sEMG biofeedback for patients with lack of biological treatment alternatives eligible for prosthetic hand replacement, a concept today known as bionic reconstruction. The most apparent advantage of using a sEMG biofeedback set-up in the context of bionic reconstruction arises from the exact definition of sEMG hotspots, i.e., skin locations, where a relatively high amplitude of EMG activity can be measured transcutaneously. Various motor commands may be attempted alternately, as the sensors can easily be moved along the entire forearm, and - in case of missing detectable muscle function in the forearm - also in the upper arm and shoulder girdle. When a patient is asked to attempt to contract the muscles intended to perform a specific action (such as extending the wrist), an electrode can be placed, where (weak) muscle contraction is palpated by the examiner. Observing the EMG signal on the computer screen, one can easily determine whether the signal&#39;s amplitude consistently increases, when the patient attempts to contract this muscle. If the amplitude is not high enough or the signal is inconsistent, other motor commands with the same electrode position may be attempted. As oppose to needle EMG, this procedure is non-invasive, not painful and can be repeated for all muscles/muscle groups in the arm. Testing various motor commands at different muscle locations allows to identify the EMG hotspots, with the highest amplitude and reproducible activity associated with a specific motor action. After identification of the strongest EMG signals, these may be trained using sEMG biofeedback with regards to signal separation (co-activation of two or more EMG signals must not occur on the computer screen), signal strength (reflected by the EMG signal&#8217;s amplitude on the computer screen) and signal reproducibility (each attempt to contract the muscle must lead to an excursion of the respective EMG signal). At a later stage of training, EMG activity is directly translated into prosthetic function, first using a table top prosthesis (see Figure 3), which gives additional feedback to the patient allowing fine-tuning of grip strength, and then wearing the physical prosthesis.
In conventional amputees, a vast amount of literature has shown that targeted-muscle-reinnervation (TMR), i.e., the surgical transfer of residual arm nerves to alternative muscle sites in the chest and upper-arm, improves prosthetic function, since these re-innervated muscles serve as biological amplifiers of intuitive motor commands and provide physiologically appropriate EMG signals for prosthetic hand, wrist and elbow control24,25,26,27. Using pattern-recognition control systems, EMG data extracted from numerous sEMG signals placed over the skin of these re-innervated muscles can be decoded and translated to specific, reproducible motor outputs, which provides more reliable myoelectric prosthesis control28,29,30. Because the number of EMG signal sites and the myoelectric activity of the muscles in patients with brachial plexus avulsion injury are very limited, pattern recognition algorithms may not be used as is done for conventional amputees8. Still, with further research and improved technology, these systems may be able to extract more information on the existing faint muscle signals and therefore improve prosthetic function also in this peculiar patient group.
While the presented protocol is considered a guideline, details need to be adapted depending on the patient and the available equipment. Due to aberrant re-innervation occurring after such nerve injuries, motor commands do not necessarily result in the activation of anatomically &#8220;correct&#8221; muscles12. For example, the authors observed EMG activity at the forearm flexor compartment, while patients were attempting to open their hand. Therefore, various motor commands should be tested in order to identify EMG signals. Additionally, the residual muscular function (although in all cases too weak to generate useful hand movements) might largely vary across patients and cause variations in the required training time as shown in Table 2. Further, the choice of the prosthetic device and the number of electrodes used for control change the requirements for the precision of signal separation, the signal amplitude and the need of co-contraction. All of this needs to be taken into account during signal training, hybrid prosthesis training and actual prosthetic training, as it is also recommended in standard prosthetic training of amputees31. Regarding the devices used for sEMG biofeedback training, the authors consider devices suitable if they can simultaneously display the number of signals needed for prosthetic control, give real-time feedback, and can be either connected to a computer or display the signals on a screen themselves. Devices that allow adjusting the signal gain during training are preferred.
After rehabilitation, all patients were able to use their prosthesis during daily life activities and were satisfied with the decision to have their functionless hand replaced with a prosthetic device12. This functional improvement was reflected by significant increases in the mean ARAT scores from 2.83 &#177; 4.07 to 25.00 &#177; 10.94 (p = 0.028).
From our perspective, sEMG biofeedback set-ups present valuable tools to facilitate the cognitively demanding process of motor recovery associated with nerve injury and bionic reconstruction. The identification of optimal EMG electrode positioning and the testing of various motor commands with direct visualization of muscle activity is greatly simplified using sEMG biofeedback in a clinical set-up. Although sEMG biofeedback may also be used in the rehabilitation of biological upper limb function10,12, its application in the process of bionic reconstruction is considered particularly effective. Most importantly, the sEMG signals activated during training later reflect the electrode positions within the prosthetic socket, which is individually customized for each patient. Therefore, repetitive activation of these signals during training most likely increases future prosthetic handling and manual capacity. Direct visualization of this muscle activity also allows a patient to comprehend the concept of myoelectric hand control and he/she may follow the training progress more consciously.
In the future, our presented rehabilitation protocol might be extended with more advanced tools to enhance functional outcomes. This might include high density sEMG recordings to facilitate the process of electrode placement via activation heat maps32, further virtual solutions to evaluate EMG activity30,33, and serious games to enhance training motivation34. Additionally, novel technologies for prosthetic control, such as pattern recognition algorithms might also be used28,30,35. However, due to the reduced neuro-muscular interface, it is not clear whether currently commercially available systems designed for otherwise healthy amputees would significantly improve prosthetic function in this specific patient group. Future studies should evaluate the applicability and benefits of the listed novel technologies for the rehabilitation of patients with severe brachial plexus injuries. Additionally, controlled trials with higher patient numbers will also allow to demonstrate the positive effects of the current protocol using sEMG biofeedback with a higher level of evidence.

Global brachial plexus injuries including the traumatic avulsion of nerve roots from the spinal cord represent one of the most severe nerve injuries in humans and usually affect young, otherwise healthy patients in the prime of life1,2. Depending on the number of nerve roots avulsed, complete upper limb paralysis may ensue since the nerval connection from the brain to the arm and hand is disrupted. Traditionally, the avulsion of nerve roots has been associated with poor outcomes3. With microsurgical nerve techniques gaining ground within the last decades, surgical results have been improved and useful motor function in the shoulder and elbow are usually restored4,5. The intrinsic musculature in the hand, which lies most distally, typically undergoes fatty degeneration resulting in irreversible atrophy before regenerating axons may reach it6. For such cases bionic reconstruction, which includes the elective amputation of the functionless &#34;plexus&#34;&#160;hand and its replacement with a mechatronic hand, has been described7,8. Residual muscle activity in a patient&#39;s forearm, which may be clinically insignificant (isometric contractions, M1 on the British Medical Research Council [BMRC] scale), is picked up from transcutaneous electrodes sensing electromyographic activity, which is then translated into various movements of a prosthetic hand9.
Enough surface electromyographic (sEMG) signals may be present upon initial consultation. In some cases, however, additional signals need to be established performing selective nerve and muscle transfers7. In either case, a structured rehabilitation protocol is needed to ensure sEMG signal consistency and subsequent optimal prosthetic function at the end of the process. A major challenge following nerve root avulsion and aberrant re-innervation as well as after nerve transfer surgery is the establishment of new motor patterns to allow volitional control over the target muscle. sEMG biofeedback methods have been widely used in the rehabilitation of stroke10. This method allows direct visualization of muscular activity that would otherwise be unnoticed due to muscular weakness and/or co-activation of antagonists. It thereby encourages patients to train their weak muscles, while providing precise feedback on the correct execution of motor tasks11.
In a recent publication we have shown for the first time that sEMG biofeedback may also be used in the rehabilitation of complex peripheral nerve injuries12. We believe that sEMG biofeedback is an extremely useful method to make a patient aware of the advancing re-innervation process after nerve transfer surgery. Also, faint muscle activity, which formerly was of no use to the patient, may be trained and strengthened for later prosthetic control using sEMG biofeedback, which allows concrete visualization of otherwise unnoticed muscle activity to both clinician and patient. The training progress may therefore be well comprehended and documented. Additionally, the use of direct feedback on muscle activity allows the clinician to correlate various motor commands with the associated signal amplitude and consistency, establishing the best motor strategies to allow robust prosthetic control in the future. In summary, the goal of this method is to facilitate the rehabilitation process by increasing a patient&#8217;s understanding, awareness and control of his/her sEMG signals, which will later drive a prosthetic hand.

<table><tbody><tr><td>dry EMG electrodes</td><td>Ottobock Healthcare, Duderstadt, Germany</td><td>13E202 = 50</td><td>The EMG electrodes used in this study were bipolar and included a ground. They can be used both for EMG training with the Myoboy and for the control of a prosthetic device.</td></tr><tr><td>Myoboy</td><td>Otto bock Healthcare, Duderstadt, Germany</td><td>Myoboy</td><td>This device that can be used as stand alone device or with a computer. It allows to display EMG activity while using the dry EMG electrodes that can also be impeded in the prosthetic socket.</td></tr><tr><td>SensorHand Speed</td><td>Ottobock Healthcare, Duderstadt, Germany</td><td></td><td>All patients used this commercially available myoelectrical prosthesis as their standard prosthetic device and during functional testing. Fitting of patients undergoing this procedure is, however, not restricted to this device.</td></tr><tr><td>Standard laptop with Microsoft operating system</td><td></td><td></td><td>Usually, devices for EMG biofeedback connected to a computer do not require much computing power and thus work on any regular laptop</td></tr><tr><td>TeleMyo 2400T G2</td><td>Noraxon, US</td><td></td><td>A surface EMG biofeedback set-up used in our protocol, connected to TeleMyo-Software, which displays the recorded EMG activity as color-coded graphs on the computer screen</td></tr><tr><td>wet EMG electrodes</td><td>Ambu</td><td>Ambu Blue Sensor VL Adhesive Electrodes</td><td>These adhesive electrodes can be used in combination with many different EMG biofeedback devices, including the TeleMyo 2400T. While they cannot be moved easily, the wet contacts usually allow to detect very faint EMG signals as well.</td></tr></tbody></table>

surface electromyographic biofeedback as a rehabilitation tool for patients with global brachial plexus injury receiving bionic reconstruction

In patients with global brachial plexus injury and lack of biological treatment alternatives, bionic reconstruction, including the elective amputation of the functionless hand and its replacement with a prosthesis, has recently been described. Optimal prosthetic function depends on a structured rehabilitation protocol, as residual muscle activity in a patient&#8217;s arm is later translated into prosthetic function. Surface electromyographic (sEMG) biofeedback has been used during rehabilitation after stroke, but has so far not been used in patients with complex peripheral nerve injuries. Here, we present our rehabilitation protocol implemented in patients with global brachial plexus injuries suitable for bionic reconstruction, starting from identification of sEMG signals to final prosthetic training. This structured rehabilitation program facilitates motor relearning, which may be a cognitively debilitating process after complex nerve root avulsion injuries, aberrant re-innervation and extra-anatomical reconstruction (as is the case with nerve transfer surgery). The rehabilitation protocol using sEMG biofeedback aids in the establishment of new motor patterns as patients are being made aware of the advancing re-innervation process of target muscles. Additionally, faint signals may also be trained and improved using sEMG biofeedback, rendering a clinically &#34;useless&#34;&#160;muscle (exhibiting muscle strength M1 on the British Medical Research Council [BMRC] scale) eligible for dexterous prosthetic hand control. Furthermore, functional outcome scores after successful bionic reconstruction are presented in this article.

In six patients with severe brachial plexus injuries including multiple nerve root avulsions the presented rehabilitation protocol using sEMG biofeedback was successfully implemented. Detailed patient characteristics can be found in Table 1. Figure 2 demonstrates the various phases of the structured rehabilitation protocol and detailed explanations on its implementation.
To demonstrate improvements in hand function before and after bionic reconstruction, a standardized assessment evaluating global upper extremity function was performed at two time points: before elective amputation of the functionless &#34;plexus&#34;&#160;hand as well as after successful prosthetic reconstruction and rehabilitation. The Action Research Arm test (ARAT) was originally developed to assess global upper extremity motor function in patients with cognitive impairment of hand control16. The standardized approach of Yozbatiran et al.17 was used in our studies. The ARAT consists of four different sections, which include tasks close to daily living. The test is timed by the observer who also rates the task performance from 0&#8722;3, with 3 indicating normal function. A maximum of 57 points is attainable indicating unimpaired motor function16. The number of therapy sessions with sEMG biofeedback and detailed results for each patient can be found in Table 2.
Although patient satisfaction with the offered rehabilitation protocol using sEMG biofeedback was not directly measured, all six patients reported to find it extremely helpful in comprehending the re-innervation process following nerve transfer surgery and to train the contraction of muscles with very faint activity that formerly was of no clinical use to them.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Case number</td>
			<td>Sex, age (years)</td>
			<td>Type of accident</td>
			<td>Type of lesion</td>
			<td colspan="2">Surgeries to improve biotechnological interface after initial reconstructions have failed to improve hand function</td>
		</tr>
		<tr>
			<td>1</td>
			<td>m, 32</td>
			<td>Fall from height</td>
			<td>Avulsion of C7&#8722;T1; traction injury of the infraclavicular plexus</td>
			<td colspan="2">Elective amputation of the forearm</td>
		</tr>
		<tr>
			<td>2</td>
			<td>m, 32</td>
			<td>Motorcycle accident</td>
			<td>Rupture of all 3 trunci of the BP</td>
			<td colspan="2">Free gracilis muscle transferred to forearm extensor compartment &#38; neurotization of deep branch of radial nerve to obturator nerve; elective amputation of the forearm</td>
		</tr>
		<tr>
			<td>3</td>
			<td>m, 55</td>
			<td>Motorcycle accident</td>
			<td>Avulsion of C5&#8722;T1</td>
			<td colspan="2">Elective amputation of the upper arm</td>
		</tr>
		<tr>
			<td>4</td>
			<td>m, 38</td>
			<td>Motorcycle accident</td>
			<td>Extensive damage to roots&#160;C5&#8722;C8; avulsion of T1</td>
			<td colspan="2">Elective amputation of the forearm</td>
		</tr>
		<tr>
			<td>5</td>
			<td>m, 27</td>
			<td>Motorcycle accident</td>
			<td>Avulsion C8&#8722;T1</td>
			<td colspan="2">Elective amputation of the forearm</td>
		</tr>
		<tr>
			<td>6</td>
			<td>m, 43</td>
			<td>Motorcycle accident</td>
			<td>Avulsion of C6&#8722;T1</td>
			<td colspan="2">Transfer of triceps muscle to infraspinatous fossa and transfer of biceps muscle to supraclavicular fossa to improve prosthetic fitting; Elective amputation of the arm (shoulder exarticulation)</td>
		</tr>
	</tbody>
</table>
Table 1: Patient characteristics.&#160;In all patients, bionic reconstruction was initiated due to infeasibility of biological treatment alternatives. Surgeries to establish EMG signals in the fore- and upper arm may include selective nerve and muscle transfers, which will then drive a myoelectric prosthetic hand. Elective amputation is either performed at a transradial or transhumeral level, depending on the residual muscle activity. All selective nerve transfers performed in this patient group were successful. This table has been modified from Sturma et al.12&#160;and reproduced with permission from Frontiers in Neuroscience.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Case number</td>
			<td>ARAT at baseline</td>
			<td>ARAT at follow-up</td>
			<td colspan="2">Start of sEMG training</td>
			<td>Number of therapy sessions in total (30 min each)</td>
		</tr>
		<tr>
			<td>1</td>
			<td>7</td>
			<td>35</td>
			<td colspan="2">Immediately after first consultation</td>
			<td>24</td>
		</tr>
		<tr>
			<td>2</td>
			<td>0</td>
			<td>15</td>
			<td colspan="2">Training with one signal immediately after first consultation; second signal was available 9 months after free gracillis transfer + nerve transfer</td>
			<td>30</td>
		</tr>
		<tr>
			<td>3</td>
			<td>0</td>
			<td>19</td>
			<td colspan="2">Immediately after first consultation</td>
			<td>16</td>
		</tr>
		<tr>
			<td>4</td>
			<td>1</td>
			<td>22</td>
			<td colspan="2">Immediately after first consultation</td>
			<td>20</td>
		</tr>
		<tr>
			<td>5</td>
			<td>9</td>
			<td>42</td>
			<td colspan="2">Immediately after decision to aim for a bionic reconstruction as biologic reconstruction failed</td>
			<td>20</td>
		</tr>
		<tr>
			<td>6</td>
			<td>0</td>
			<td>17</td>
			<td colspan="2">Immediately after first consultation</td>
			<td>22</td>
		</tr>
		<tr>
			<td>Mean (&#177; SD)</td>
			<td>2.83 &#177; 4.07</td>
			<td>25.00 &#177; 10.94</td>
			<td colspan="2"></td>
			<td>22 &#177; 4.32</td>
		</tr>
	</tbody>
</table>
Table 2:&#160;ARAT scores and number of therapy sessions.&#160;In the Action Research Arm test (ARAT), patients initially showed negligible upper limb function (mean 2.83, of a maximum of 57 points attainable). Useful function was restored after bionic reconstruction (mean 25.00, of 57). This table has been modified from Sturma et al.12&#160;and reproduced with permission from Frontiers in Neuroscience.

Watch this Scientific Journal Video about Surface Electromyographic Biofeedback as a Rehabilitation Tool for Patients with Global Brachial Plexus Injury Receiving Bionic Reconstruction at JoVE.com

Surface Electromyographic Biofeedback as a Rehabilitation Tool for Patients with Global Brachial Plexus Injury Receiving Bionic Reconstruction

Optimal functional outcomes after bionic reconstruction in patients with global brachial plexus injury depend on a structured rehabilitation protocol. Surface electromyographic guided training may improve the amplitude, separation and consistency of EMG signals, which - after elective amputation of a functionless hand - control and drive a prosthetic hand.

In patients with global brachial plexus injury and lack of biological treatment alternatives, bionic reconstruction, including the elective amputation of ...

surface-electromyographic-biofeedback-as-rehabilitation-tool-for

Nanyang Technological University

Research

JoVE Journal

Neuroscience

11.4K Views.  Medical University of Vienna. Oppervlakte elektromyografische biofeedback vereenvoudigt de identificatie en training van oppervlakte-EMG-signalen bij patiënten met brachial plexusletsels waarvan de spieractiviteit in de klepelarm extreem zwak is. Met het gebruik van het oppervlak EMG biofeedback, verschillende motor commando's en elektrode posities kunnen worden getest en herhaaldelijk getraind als de techniek is niet invasief, gemakkelijk toepasbaar, en goedkoop. Als u een systeem voor emg-biofeedback van het oppervlak ...

Video: Surface Electromyographic Biofeedback as a Rehabilitation Tool for Patients with Global Brachial Plexus Injury Receiving Bionic Reconstruction

A Structured Rehabilitation Protocol for Improved Multifunctional Prosthetic Control: A Case Study

Advances in robotic systems have resulted in prostheses for the upper limb that can produce multifunctional movements. However, these sophisticated systems require upper limb amputees to learn complex control schemes. Humans have the ability to learn new movements through imitation and other learning strategies. This protocol describes a structured rehabilitation method, which includes imitation, repetition, and reinforcement learning, and aims to assess if this method can improve multifunctional prosthetic control. A left below elbow amputee, with 4 years of experience in prosthetic use, took part in this case study. The prosthesis used was a Michelangelo hand with wrist rotation, and the added features of wrist flexion and extension, which allowed more combinations of hand movements. The participant&#8217;s Southampton Hand Assessment Procedure score improved from 58 to 71 following structured training. This suggests that a structured training protocol of imitation, repetition and reinforcement may have a role in learning to control a new prosthetic hand. A larger clinical study is however required to support these findings.

As prosthetic development moves towards the goal of natural control, harnessing amputees&#8217; inherent ability to learn new motor skills may enable proficiency. This manuscript describes a structured rehabilitation protocol, which includes imitation, repetition, and reinforcement learning strategies, for improved multifunctional prosthetic control.

Advances in robotic systems have resulted in prostheses for the upper limb that can produce multifunctional movements. However, these sophisticated ...

Behavior

Robotic Mirror Therapy System for Functional Recovery of Hemiplegic Arms

Mirror therapy has been performed as effective occupational therapy in a clinical setting for functional recovery of a hemiplegic arm after stroke. It is conducted by eliciting an illusion through use of a mirror as if the hemiplegic arm is moving in real-time while moving the healthy arm. It can facilitate brain neuroplasticity through activation of the sensorimotor cortex. However, conventional mirror therapy has a critical limitation in that the hemiplegic arm is not actually moving. Thus, we developed a real-time 2-axis mirror robot system as a simple add-on module for conventional mirror therapy using a closed feedback mechanism, which enables real-time movement of the hemiplegic arm. We used 3 Attitude and Heading Reference System sensors, 2 brushless DC motors for elbow and wrist joints, and exoskeletal frames. In a feasibility study on 6 healthy subjects, robotic mirror therapy was safe and feasible. We further selected tasks useful for activities of daily living training through feedback from rehabilitation doctors. A chronic stroke patient showed improvement in the Fugl-Meyer assessment scale and elbow flexor spasticity after a 2-week application of the mirror robot system. Robotic mirror therapy may enhance proprioceptive input to the sensory cortex, which is considered to be important in neuroplasticity and functional recovery of hemiplegic arms. The mirror robot system presented herein can be easily developed and utilized effectively to advance occupational therapy.

We developed a real-time mirror robot system for functional recovery of hemiplegic arms using automatic control technology, conducted a clinical study on healthy subjects, and determined tasks through feedback from rehabilitation doctors. This simple mirror robot can be applied effectively to occupational therapy in stroke patients with a hemiplegic arm.

Mirror therapy has been performed as effective occupational therapy in a clinical setting for functional recovery of a hemiplegic arm after stroke. It is ...

Bioengineering

The Muscle Cuff Regenerative Peripheral Nerve Interface for the Amplification of Intact Peripheral Nerve Signals

Robotic exoskeletons have gained recent acclaim within the field of rehabilitative medicine as a promising modality for functional restoration for those individuals with extremity weakness. However, their use remains largely confined to research institutions, frequently operating as a means of static extremity support as motor detection methods remain unreliable. Peripheral nerve interfaces have arisen as a potential solution to this shortcoming; however, due to their inherently small amplitudes, these signals can be difficult to differentiate from background noise, lowering their overall motor detection accuracy. As current interfaces rely on abiotic materials, inherent material breakdown can occur alongside foreign body tissue reaction over time, further impacting their accuracy. The Muscle Cuff Regenerative Peripheral Nerve Interface (MC-RPNI) was designed to overcome these noted complications. Consisting of a segment of free muscle graft secured circumferentially to an intact peripheral nerve, the construct regenerates and becomes reinnervated by the contained nerve over time. In rats, this construct has demonstrated the ability to amplify a peripheral nerve's motor efferent action potentials up to 100 times the normal value through the generation of compound muscle action potentials (CMAPs). This signal amplification facilitates high accuracy detection of motor intent, potentially enabling reliable utilization of exoskeleton devices.

This manuscript provides an innovative method for developing a biologic peripheral nerve interface termed the Muscle Cuff Regenerative Peripheral Nerve Interface (MC-RPNI). This surgical construct can amplify its associated peripheral nerve's motor efferent signals to facilitate accurate detection of motor intent and the potential control of exoskeleton devices.

Robotic exoskeletons have gained recent acclaim within the field of rehabilitative medicine as a promising modality for functional restoration for those ...

Structured Motor Rehabilitation After Selective Nerve Transfers

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning.
Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation.

Here, we present a protocol for the motor rehabilitation of patients with severe nerve injuries and selective nerve transfer surgery. It aims at restoring the motor function proposing several stages in patient education, early-stage therapy after surgery and interventions for rehabilitation after successful re-innervation of the nerve&#8217;s target.

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on ...

Medicine

Development of a Novel Task-oriented Rehabilitation Program using a Bimanual Exoskeleton Robotic Hand

A robot-assisted hand is used for the rehabilitation of patients with impaired upper limb function, particularly for stroke patients with a loss of motor control. However, it is unclear how conventional occupational training strategies can be applied to the use of rehabilitation robots. Novel robotic technologies and occupational therapy concepts are used to develop a protocol that allows patients with impaired upper limb function to grasp objects using their affected hand through a variety of pinching and grasping functions. To conduct this appropriately, we used five types of objects: a peg, a rectangular cube, a cube, a ball, and a cylindrical bar. We also equipped the patients with a robotic hand, the Mirror Hand, an exoskeleton&#160;hand that is fitted to the subject&#8217;s affected hand and follows the movement of the sensor glove fitted to their unaffected hand (bimanual movement training (BMT)). This study had two stages. Three healthy subjects were first recruited to test the feasibility and acceptability of the training program. Three patients with hand dysfunction caused by stroke were then recruited to confirm the feasibility and acceptability of the training program, which was conducted on 3 consecutive days. On each day, the patient was monitored during 5 min of movement in a passive range of motion, 5 min of robot-assisted bimanual movement, and task-oriented training using the five objects. The results showed that both healthy subjects and subjects who had suffered a stroke in conjunction with the robotic hand could successfully grasp the objects. Both healthy subjects and those who had suffered a stroke performed well with the robot-assisted task-oriented training program in terms of feasibility and acceptability.

This study reports the development of a novel robot-assisted task-oriented program for hand rehabilitation. The developmental process consists of experiments using both healthy subjects and subjects who have had a stroke and suffered from subsequent motor control dysfunction.

A robot-assisted hand is used for the rehabilitation of patients with impaired upper limb function, particularly for stroke patients with a loss of motor ...

Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective activation of muscle units is made possible by surgically re-routing nerves, yielding a high number of independent myoelectric control signals. However, this intervention requires careful patient selection and specific rehabilitation therapy. Here a rehabilitation protocol is presented for high-level upper limb amputees undergoing TMR, based on an expert Delphi study. Interventions before surgery include detailed patient assessment and general measures for pain control, muscle endurance and strength, balance, and range of motion of the remaining joints. After surgery, additional therapeutic interventions focus on edema control and scar treatment and the selective activation of cortical areas responsible for upper limb control. Following successful&#160;reinnervation of target muscles, surface electromyographic (sEMG) biofeedback is used to train the activation of the novel muscular units. Later on, a table-top prosthesis may provide the first experience of prosthetic control. After fitting the actual prosthesis, training includes repetitive drills without objects, object manipulation, and finally, activities of daily living. Ultimately, regular patient appointments and functional assessments allow tracking prosthetic function and enabling early interventions if malfunctioning.

This work presents a protocol to enhance prosthetic function after selective nerve transfer surgery. Rehabilitation interventions include patient information and selection, support of wound healing, cortical re-activation of sensory-motor areas of the upper limb, training of selective muscle activation, prosthetic handling in daily life, and regular follow-up assessments.

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective ...

Restoring Post-Stroke Motor Function by Motor Imagery Brain-Computer Interface

Motor Imagery Brain-Computer Interface in Rehabilitation of Upper Limb Motor Dysfunction After Stroke

The rehabilitation effect of patients with moderate or severe upper limb motor dysfunction after stroke is poor, which has been the focus of research owing to the difficulties encountered. Brain-computer interface (BCI) represents a hot frontier technology in brain neuroscience research. It refers to the direct conversion of the sensory perception, imagery, cognition, and thinking of users or subjects into actions, without reliance on peripheral nerves or muscles, to establish direct communication and control channels between the brain and external devices. Motor imagery brain-computer interface (MI-BCI) is the most common clinical application of rehabilitation as a non-invasive means of rehabilitation. Previous clinical studies have confirmed that MI-BCI positively improves motor dysfunction in patients after stroke. However, there is a lack of clinical operation demonstration. To that end, this study describes in detail the treatment of MI-BCI for patients with moderate and severe upper limb dysfunction after stroke and shows the intervention effect of MI-BCI through clinical function evaluation and brain function evaluation results, thereby providing ideas and references for clinical rehabilitation application and mechanism research.

Author Spotlight: Using Motor Imagery Brain-Computer Interface to Improve Motor and Cognitive Function in Stroke Patients

The purpose of this study is to provide an important reference for the standard clinical operation of motor imagery brain-computer interface (MI-BCI) for upper limb motor dysfunction after stroke.

The rehabilitation effect of patients with moderate or severe upper limb motor dysfunction after stroke is poor, which has been the focus of research ...

Brain-Computer Interface-controlled Upper Limb Robotic System for Enhancing Daily Activities in Stroke Patients

This study introduces a Brain-Computer Interface (BCI)-controlled upper limb assistive robot for post-stroke rehabilitation. The system utilizes electroencephalogram (EEG) and electrooculogram (EOG) signals to help users assist upper limb function in everyday tasks while interacting with a robotic hand. We evaluated the effectiveness of this BCI-robot system using the Berlin Bimanual Test for Stroke (BeBiTS), a set of 10 daily living tasks involving both hands. Eight stroke patients participated in this study, but only four participants could adapt to the BCI robot system training and perform the postBeBiTS. Notably, when the preBeBiTS score for each item was four or less, the BCI robot system showed greater assistive effectiveness in the postBeBiTS assessment. Furthermore, our current robotic hand does not assist with arm and wrist functions, limiting its use in tasks requiring complex hand movements. More participants are required to confirm the training effectiveness of the BCI-robot system, and future research should consider using robots that can assist with a broader range of upper limb functions. This study aimed to determine the BCI-robot system's ability to assist patients in performing daily living activities.

This study introduces a brain-computer interface (BCI) system for stroke patients, which combines electroencephalography and electrooculography signals to control an upper limb robotic hand, enhancing daily activities. The evaluation used the Berlin Bimanual Test for Stroke (BeBiTS).

This study introduces a Brain-Computer Interface (BCI)-controlled upper limb assistive robot for post-stroke rehabilitation. The system utilizes ...

Functional OT and Near-IR Spectroscopy to Study Brain Function Remodeling

Investigating the Effect of Different Types of Exercise on Upper Limb Functional Recovery in Patients with Right Hemisphere Damage Based on fNIRS

To investigate the effects of functional occupational therapy (FOT) combined with different types of exercise on upper limb motor function recovery and brain function remodeling in patients with right hemisphere damage (RHD) by analyzing functional near-infrared spectroscopy (fNIRS). Patients (n = 32) with RHD at Beijing Bo'ai Hospital were recruited and randomly allocated to receive either FOT combined with passive motion (N=16) or FOT combined with assisted active movement (N=16). The passive motion group (FOT-PM) received functional occupational therapy for 20 min and passive exercise for 10 min in each session, while the assisted active movement group (FOT-AAM) received functional occupational therapy for 20 min and assisted active exercise for 10 min. Both groups received conventional drug therapy and other rehabilitation therapy. Treatment was performed once a day, 5 times a week for 4 weeks. The recovery of motor function and activities of daily living (ADL) was assessed using Fugl-Meyer Assessment upper extremity (FMA-UE) and modified Barthel index (MBI) before and after treatment, and brain activation of the bilateral motor area was analyzed with fNIRS. The findings suggested that FOT combined with AAM was more effective than FOT combined with PM in improving the motor function of RHD patients' upper limbs and fingers, improving their ability to perform activities of daily living, and facilitating brain function remodeling of the motor area.

Author Spotlight: Advancing Upper Limb Rehabilitation in Patients with Right Hemisphere Damage Using Assisted Active Exercise

Here, we investigate the effect of functional occupational therapy combined with assisted active or passive motion on the upper limb function of patients with right hemisphere damage and explore the effect of functional near-infrared spectroscopy on brain function remodeling.

To investigate the effects of functional occupational therapy (FOT) combined with different types of exercise on upper limb motor function recovery and ...

Integrated Robotic and Conventional Therapy for Post-Stroke Upper Limb Recovery

Enhancing Upper Limb Function and Motor Skills Post-Stroke Through an Upper Limb Rehabilitation Robot

Cerebrovascular accidents, commonly known as strokes, represent a prevalent neurological event leading to significant upper limb disabilities, thereby profoundly affecting individuals' activities of daily living and diminishing their quality of life. Traditional rehabilitation methods for upper limb recovery post-stroke are often hindered by limitations, including therapist and patient fatigue, reliance on singular training methodologies, and lack of sustained motivation. Addressing these challenges, this study introduces an upper limb rehabilitation robot, which uses intelligent feedback motion control to improve therapeutic outcomes. The system is distinguished by its capability to adjust the direction and magnitude of force feedback dynamically, based on the detection of spastic movements during exercises, thereby offering a tailored therapeutic experience. This system is equipped with four distinct training modes, intelligent assessment of joint range of motion, and the ability to personalize training programs. Moreover, it provides an immersive interactive gaming experience coupled with comprehensive safety measures. This multifaceted approach not only elevates the engagement and interest of participants beyond traditional rehabilitation protocols but also demonstrates significant improvements in upper limb functionality and the activities of daily living among hemiplegic patients. The system exemplifies an advanced tool in upper limb rehabilitation, offering a synergistic blend of precision, personalization, and interactive engagement, thereby broadening the therapeutic options available to stroke survivors.

Author Spotlight: Enhancing Post-Stroke Upper Limb Rehabilitation with Robotic Technologies for Improved Motor Recovery and Functional Outcomes

This protocol describes an upper limb rehabilitation robot that provides intelligent feedback through four modes. These modes enhance upper limb function and flexibility, thereby improving patients' quality of life.

Cerebrovascular accidents, commonly known as strokes, represent a prevalent neurological event leading to significant upper limb disabilities, thereby ...

Surface Electromyographic Biofeedback as a Rehabilitation Tool for Patients with Global Brachial Plexus Injury Receiving Bionic Reconstruction

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