E-stim therapy to measure and improve signal to affected hand

At an early phase in my recovery, when I had only barely begun to gain movement with my arm, therapists at the Rehabilitation Institute of Chicago(RIC) introduced a therapy that involved attachment of electrodes to the muscles around my arm and hands to an e-stimulation device that could measure and supplement signal sent from my brain to muscles that moved my hand.

How this works: when you think about moving a muscle, the device detects that Electromyographic (EMG) signal in that muscle. EMG's are electrical activities originating in the brain and transported via nerve cells to the muscles. These signals cause the muscles to contract.Often EMG signals are disturbed after a brain attack leading to paralysis
of muscles. A device can be programmed to provide NeuroMuscular Electrical nerve Stimulation (NMES) by applying an electrical stimulus for muscle rehabilitation. During NMES an electrical impulse is passed from a device to electrodes placed on the skin over a targeted muscle or muscle group. The stimulation causes the muscles to contract. The therapy helps you train the healthy parts of the brain following a stroke to take over the EMG signals that once came from the areas of the brain now affected by stroke. Repetitive use may help achieve voluntary muscle contractions of the paralyzed muscles by causing the brain to assign new brain cells to obtain direct muscle movement, assisted by the device

Why this therapy works: 1.)Visual feedback and positive reinforcement is provided by the device in the form of a real-time graphic display of amount of signal detected (measured in mega volts) and displayed as a X-Y line graph that moves towards the target level represented by horizontal line on graph, so as you increase the intensity of your focus and effort to lift the hand or fingers, the graph provides feedback and positive re-inforcement as the x-y line approaches the target threshold. 2.) bio-feedback and positive re-inforcement is provided by the device in the form of NMES (NeuroMuscular Electrical Stimulation) that causes the target muscles to contract thus completing the motion and providing a sometimes gratifying and exciting sensation of having re-gained voluntary motor control.

NOTE: this therapy alone will not restore function to a hand left paralyzed by stroke but can be enormously helpful if used in conjunction with other therapies that involve strengthening and stretching the muscles in and around the arm and hand andin addition to therapy that establishes a strong foundation in the form of the ability to bear the weight of the body with the affected arm. This mode of therapy is also more appropriate/helpful when only minimal level of signal can be detected. Once a "functional level" of signal can be detected, techniques such as Constraint-Induced Movement Therapy (CIMT), also known as forced use movement therapy might be more effective. One of the newer developments in stroke rehabilitation is called Constraint-Induced Movement Therapy (CIMT), also known as forced use movement therapy. This is an intensive neurorehabilitation therapy that aims to retrain the brain by constraining the unaffected arm and forcing the use of the weakened arm. One of the most exciting aspects of CIMT is that the amount of time since the stroke occurred does not appear to make a difference in the results of the therapy. Participants have regained the use of an affected arm and hand many years after their stroke.

This approach's premise is that the non-use of the weakened side becomes "learned behavior" and the stroke survivor needs constraint induced therapies to re-learn to use and strengthen the weakened side.

regaining/retraining brain to execute coordinted hand &finger movements

Once we've confirmed that signal is getting from brain to fingers, the trick is re-learning "controlled" and "coordinated" movement. Bio-feedback training uses graphical projection to show amount of signal (measured in mega volts) brain is sending different muscles as I execute hand movements such as making a fist or signaling a stop sign. You'd be surprised how these seemingly simple operations involved "learned" movements that are stored in the "pre-motor" section of the brain.. Alas mine was fried by the stroke so I'm going to have to re-learn and store coordinated movements like tying my shoes, buttoning buttons, rolling up my sleeves etc. The experience is something like using remote control with only "go" and stop" buttons and having to learn how to steer and just how much juice to give the "go" button. Oh yeah and then there's the wrinkle of flexion(contraction) and extension (relaxing)."Go"= flexion , which with the fingers means closed. Extending the fingers uses a different set of muscles, so you have to send a "go" signal to muscles along the forearm and base of the palm to make a stop signal with your hand- sending the "go" signal to fingers themselves results in flexing the fingers like a fist to give someone knucks or a punch. At first thought, the stop sign looks like a finger movement doesn't it? Well, not so fast...

The bio feedback on the screen above shows a graph of the signal received from brain to muscles along my forearm vs signal received by muscles on the top or back of my hand. So simple even a two year old can do this- hey, just remember: it's never too late to enjoy your childhood;-)

Bridging: The foundation for recovering arm and hand use

This simple, sometimes painful,sometimes frightening, sometimes frustrating exercise was for me a "break-through" therapy that pushed me, pulled me, and marked the mile-posts of recovering the function of my affected arm and hand.

How this works: Although there are many variations, the core of the exercise involves moving from a seated position, to a position in which weight is supported--first by both arms-- then through a sequence of adjusting position of legs to increase the amount of weight on and support provided by the weaker affected arm until most or all of the weight is supported by only one arm - the weaker affected arm. The therapist provides a sequence of instructions and (when appropriate) physical assistance that will gradually and safely help you to shift an increasing amount of weight onto your weaker affected arm.The therapist might, for example, provide support at the shoulder, the elbow, or the wrist - to make sure those joints are in optimal position to support the increasing amounts of weight induced by each adjustment of position in the sequence. Over time, your therapist might propose increasingly complex instructions for positioning your feet: moving feet farther from the chair or platform on which you're seated or upward onto steps or other objects- chairs perhaps even the steps of a ladder!

Why this works:The technique involves Constraint-Induced Movement Therapy (CIMT), also known as forced use movement therapy-- a therapy that aims to retrain the brain by constraining the unaffected arm and forcing the use of the weakened arm. The exercise helps to overcome the body's "guarding instinct" that detects the weakness of the impaired arm. Arm-bridging also works by providing bio-feedback and positive re-enforcement in the form of the "little victories" achieved by successfully and safely mastering each increasingly difficult bridging position. The benefits acquired include the obvious strengthening of the muscles required to support the weight of the torso. More subtle benefits include the gradual recovery of "voluntary --as opposed to "reflexive" control of the arm and hand. As you learn and re-learn how to manage moving from one position to the next with less assistance from your therapist, you are engaging and becoming increasingly conscious of your capacity to invoke and control dozens of muscles in the torso, shoulder, arm, and handto shift and then hold each position in the sequence. Over time, this and other therapies that assert conscious or voluntary muscle control will allow you to progress to higher levels of learned or "seemingly reflexive" movements so that you can execute your daily activities without the extraordinary levels of concentration required to execute the movements involved in therapies such as arm-bridging exercises. For example, as you re-acquire movement and strength of your arm and hand, you will notice that it is the more subtle skills and nuanced control that enables or inhibits smooth or "effortless" shaping of your hand for tasks such dressing or food preparation. The term "shaping" describes the skill of correctly positioning the hands and fingers to optimize leverage and application of pressure to perform tasks such as turning a door knob, picking up and holding a coffee cup (with crushing the cup and burning the hand with hot cofee.) For me, arm-bridging was instrumental to the awakening and development of the muscular and neurological network that enabled higher-level functions such as shaping.

The strategies and benefits of bridging illustrates several core principals about the recovery process:

• motor function recovers in a sequence of proximal to distal (near to the spine, then outward to the extremities away from the spine)
• my personal recovery folowed the sequence of:
• ability to bear body's weight with limb,
• ability to bear limb's weight with base and surrounding muscle groups
• ability to gain isolated control of individual muscle or muscle groups at and along the limb,
• ability to re-acquire full range of motion of limb and extremity (involves strength and flexibility)
• ability to re-acquire coordinated movement--getting the right amount of signal to the right muscles in the right sequence to execute correctly.