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DE GRUYTER Current Directions in Biomedical Engineering 2022;8(3): 25-28 Orcizo Francisco Silvestre, Cintia Kelly Bittar, Rodrigo Kenji Yaly Aoki, Bruna Valentina Zuchatti, Danielly Caroline de Souza Ramello, Sofia de Siervi Derycke, Carla Fakih Alves, Mariana Buratti Mascarenhas, Alberto Cliquet Junior. Clinical outcomes of neuromuscular electrical stimulation applied to different neurological levels of spinal cord injuries: a pilot study. https://doi.org/10.1515/cdbme-2022-2007 mold at the structural and functional level when exposed to an environmental modification . NMES has contributed to Abstract: Electrical stimulation is a tool that has been functional and neurological gains during rehabilitation. used in various ways in the rehabilitation of spinal cord Neuroplasticity is the ability to adapt and shape at a structural injuries. Surface i.e. electromyography is an effective and functional level when exposed to a modification of the method for assessing the many conditions in which the medium . NMES has been contributing to functional and patient is. Objective: To evaluate the benefits through neurological gains during rehabilitation. neuromuscular electrostimulation in patients with spinal Some methods have been used to assist in the diagnosis cord injury and possible neuroplasticity gain observed in and analysis of some functions and disorders in people with electromyography. Method: This is a pilot study on the spinal cord injury. A neurological examination that examines evolution of clinical cases of different neurological levels the level of injury through sensory and painful pathways and of spinal cord injury. Conclusion: It was observed that motor strength is an international standard protocol required the spinal cord injured patients analyzed in this by the American Spinal Injury Association . preliminary study showed possible gain in neuroplasticity. Another way to evaluate patients with spinal cord injury is through electromyography (EMG). It is a painless and non- Keywords: Electrical Stimulation; Electromyography; Spinal invasive examination that has electrodes capable of cord injury. monitoring the electrical activity of the muscle to be evaluated. Thus, the clinical evolution of patients with spinal cord injury can be evaluated after NMES. For Clancy et al , 1. Introduction electromyography is the record of muscle activity. According to Cacho , EMG is used to evaluate the action potential of It has been sought to improve the quality of life of muscle fiber. Electromyography produces a visual analysis of people with spinal cord injury suffering from physical and the pattern of neuromuscular activity. Thus, the main psychological difficulties, one of which is Neuromuscular questions of this study were: "What are the benefits and Electrical Stimulation (NMES). According to Varoto & efficacy generated by NMES in the rehabilitation of people Cliquet , the NMES is a device that projects electrical with spinal cord injury?" and "What are the changes in the impulses into the muscle, reproducing nerve impulses . Its variables caused by the use of NMES presented through function is a possible neural restoration; and it has been used EMG? as a therapeutic resource for the rehabilitation of spinal cord injuries, showing relevant clinical results of possible gains in 2. Objective walking ability . It is important to note that the nervous system has Evaluate the benefits through neuromuscular neuroplasticity. Neuroplasticity is the ability to adapt and electrostimulation in patients with spinal cord injury and possible neuroplasticity gain observed in EMG . *Corresponding author: (Orcizo)(Francisco Silvestre) State 3. Materials and Methods University of Campinas UNICAMP, Street Tessalia Vieira de Camargo, 126 Campinas SP BRASIL e-mail: firstname.lastname@example.org and email@example.com The sample consisted of four patients, named A, B, C (Cintia Kelly)(Bittar): Av Jhon Boyd Dunlop, Ipaussurama and D. The patients in the sample underwent stimulation Garden. (PUCC), Campinas- SP- Brazil. protocol in the quadriceps and fibular muscles in the pilot (Rodrigo)(Kenji Yaly Aoki): Av Worker São Carlense, 400, Arnaldo Schimitd Park, São Carlos-São SP- Brazil EESC. study of 6 months of NMES treatment. A sitting NMES (Bruna Valentina)(Zuchatti), (Danielly Caroline)(de Souza protocol was first performed with duration of 20 minutes in Ramello), (Sofia)(de Siervi Derycke), (Carla)(Fakhi Alves), the quadriceps and 10 minutes in the fibula, totaling 30 (Mariana)(Buratti Mascarenhas), (Alberto)(Cliquet Junior): minutes. Street Tessalia Vieira de Camargo, 126. Campinas- SP Brazil, State University of Campinas UNICAMP. Acesso aberto. © 2022 O Autor(s), publicado por De Gruyter. Este trabalho é licenciado sob a atribuição creative commons 4.0 Internacional Licença. 25 After 30 days of treatment of sitting NMES, an orthostatism protocol was initiated for each minute standing, at the same time of pause for sitting rest. 3.2 Electromyography (EMG) Subsequently, a gait protocol was performed, in which the following method was used, the five-minute gait test in Electromyography is a technique for monitoring the the hospital corridor and rest pauses until completing the total electrical activity of excitable membranes of muscle cells and 30 minutes of NMES. The quadriceps and fibular nerves patients were analyzed following the recommendations of were stimulated in the gait with NMES and assist of the SENIAM . The device used in this study to perform the walker. It is emphasized that no physical activity was surface EMG examination was the Electromyography- performed during NMES, only knee extension and back NORAXON . Surface EMG was measured in anterior fascia flexion when the patient performed the NMES seated , due to late, rectus femoris pre and pos NMES. The signals were the reaction of electrical impulses in the stimulated nerves. filtered by smoothing with an RMS algorithm. During the Patient A underwent treatment with NMES at home EMG examination, it was requested by verbal command that every day, because of the RISE project and once a week all patients perform hip flexion and knee extension performed gait treatment at the Unicamp clinical hospital in movements, which was performed within one minute of each an orthostatic position. Patient D performed a sitting NMES requested movement. protocol, and only performed knee extension due to electrical impulse generated in the quadriceps. 3.3 Scale ASIA - (AIS) It is important to highlight that the NMES protocol was established once a week following a protocol established by A neurological examination that examines the level of the outpatient clinic. injury through sensory and painful pathways and motor Electromyography (EMG) was performed separately strength is an international standard protocol mandated by the from NMES. Another point, EMG was performed in the pre- American Spinal Injury Association (AIS) . and post-treatment period of NMES. During the evaluation of EMG, it was requested by means of a verbal command for Table 1. Characteristics of the subjects and the Control the patient s to perform the movements of the hip and flexion Individual of the hip and knee extension, with signs of muscle Patient Gender Age Injury Injury AIS activation during EMG. Time (years) A Male 28 Flaccid 4 Level Paraplegia A, T12 3.1 Neuromuscular electrical stimulation B Male 43 Spastic 2 Level (NMES) paraplegia C, T11 C Male 40 Spastic 16 Level paraplegia C, T 6 A four-channel electric stimulator was used, generating a D female 62 Spastic 20 Level 25Hzpulse train with rectangular pulses of 300μ duration, with paraplegia D, T 8 intensity of 70-150 V and another stimulator that has a pulse Individual Male 20-29 - - - control 1 train with 10 and 2 milliseconds; 1 kΩ of charge, is the Individual Male 40-49 - - - impedance of skin fat, measuring not the stimulator of treatment Control 2 or oscilloscope for resorption, i.e. it is not safe to measure in the Individual female 60-69 - - - Control 3 patient. 4. Results Figure 1. 4-channel electric stimulator, and another 2-channel stimulator with 2 milliseconds. Patients A, B, C and D were evaluated by EMG source: photos of the devices used in the outpatient clinic. examination, the results are described in table 2 and 3. 26 Table 2. Hip Flexion-Electromyography results. Table 3. Knee Extension-Electromyography results. Patient Phases Muscle Average Minimum Maximum Standard Deviation A Pre treatment Tensor fl. Lt 22,8 12 33,6 15,27 Tensor fl. Rt 64,25 35,9 92,6 40,09 Rectus fem. Rt 154,75* 54,5* 255* 141,77* Rectus fem. Lt 5,9 4,8 7 1,55 After treatment Tensor fl. Lt 110,6 47,2 174 89,66 Tensor fl. Rt 106,45 52,9 160 75,73 Rectus fem. Rt 15,1 8,9 21,3 8,76 Rectus fem. Lt 12,95 7,2 18,7 8,13 Control 1 Tensor fl. Lt 325,9 98,8 553 321,16 Tensor fl. Rt 168 62 274 149,9 Rectus fem. Rt 68,55 22,1 115 65,69 Rectus fem. Lt 61,75 16,5 107 63,99 B Pre treatment Tensor fl. Lt 23,95 13,5 34,4 14,77 Tensor fl. Rt 31,3 16,4 46,2 21,07 Rectus fem. Rt 111,7 95,4 128 23,05 Rectus fem. Lt 69,05 37,1 101 45,18 After treatment Tensor fl. Lt 127,6 48,2 207 112,28 Tensor fl. Rt 17,95 6,3 29,6 16,47 Rectus fem. Rt 22,2 6,5 37,9 22,2 Rectus fem. Lt 55,5 23,8 87,2 44,83 Control 2 Tensor fl. Lt 88 38 138 70,71 Tensor fl. Rt 159,75 71,5 248 124,8 Rectus fem. Rt 21,3 11,3 31,3 14,14 Rectus fem. Lt 18 10,3 25,7 10,88 C Pre treatment Tensor fl. Lt 3,7 3,1 4,3 0,84 Tensor fl. Rt 55,55* 22,6* 88,5* 46,59* Rectus fem. Rt 1,67 1,4 1,95 0,38 Rectus fem. Lt 8,4 5,2 11,6 4,52 After treatment Tensor fl. Lt 20,15 4,6 35,7 21,99 Tensor fl. Rt 7,7 2,5 12,9 7,35 Rectus fem. Rt 5,25 1,8 8,7 4,87 Rectus fem. Lt 8,85 2,6 15,1 8,83 Control 2 Tensor fl. Lt 88 38 138 70,71 Tensor fl. Rt 159,75 71,5 248 124,8 Rectus fem. Rt 21,3 11,3 31,3 14,14 Rectus fem. Lt 18 10,3 25,7 10,88 D Pre treatment Tensor fl. Lt 9,4 6,6 12,2 3,95 Tensor fl. Rt 27,65 17,8 37,5 13,93 Rectus fem. Rt 30,85 18,2 43,5 17,88 Rectus fem. Lt 7,45 5,4 9,5 2,89 After treatment Tensor fl. Lt 27,85 12,5 43,2 21,7 27 Legend: In table 2 and 3 the values with asterisks* indicate noises that may have been caused by absence from treatment for two months. It is important to external interference such as electronic devices or spasticity, depending on the patient. Source: highlight that, although EMG has relevant results in patient Software Excel® of Microsoft version 2019. "A, B and D". The AIS does not change or, however, a functional gain of voluntary movements was observed in all It is important to highlight that patient D, when she patients, as shown in tab. 2 and 3. These results corroborate entered the treatment in the outpatient clinic, was classified some studies, which show that NMES is a rehabilitation as AIS A, however, when she entered this pilot study , her method that generates several benefits and leads to a possible classification was AIS D and remained so; Patient D presents gain of movements, generating nervous system adaptations 9,10 voluntary movements and walks with the help of a walking. and that this is possible to be observed through EMG . The Therefore, it was observed that the clinical results of EMG, limitation of this study was a small number of cases due to a which were extremely significant, showing the efficacy of pilot study and future studies will be conducted with a larger NMES treatment. sample to confirm this data. Patient A has a lower motor neuron lesion. After treatment with NMES, it was expected that there would be 6. Conclusion greater recruitment of the hip flexion muscles with a possible innervation of the muscles, resulting in the presence of It was observed in this study that there was according to voluntary movement. the parameters of EMG, a possible improvement in The figures below represent a sample of the EMG results neuroplasticity and gains of voluntary movements in patients. of post-treatment patient B patients compared with individual control 2. References Patient B Control 2  Varoto, R., & Cliquet Jr, A. (2015). Experiencing roots of functional electrical stimulation in education, and clinical developments in paraplegia and tetraplegia with technological innovation. Artificial Organs, 39(10), E187-E201.  Ck Bittar, Cliquet A Jr. Effects of electrical stimulation of the quadriceps and previous tibial muscles on the feet and ankles of patients with spinal cord injury. Spinal Cord. 2010; 48 (12): 881‐885. doi: 10.1038 / sc.2010.50.  Araújo TS, Brandão A, Didier T, Bracco B, Gamboa HF, Cliquet A. Analysis of descriptive electrophysiological parameters in contralateral interlimb reflexes on tetraplegic patients. Spinal Cord. Figure 2. Images of the electromyography chart result for patient 2 and control individual. 2014 Dec;52(12):894-900. doi: 10.1038/sc.2014.169. Epub 2014 ®. Source: Electromyography-NORAXON Oct 7. PMID: 25288037.  ASIA American Spinal Injury Association - AIS, http://asia- spinalinjury.org. The figure above is a result of the EMG examination that  Clancy, E.A., Morin, E. L., & Merletti, R. (2002). Sample shows signs of action potential in knee extension movement problems, noise reduction and amplitude estimation in superficial after six months of NMES treatment and compared to one electromyography. Journal of Electromyography and Kinesiology, control individual. 12(1), 1-16.  Cacho, E. W. A., de Oliveira, R., Ortolan, R. L., Varoto, R., & Cliquet, A. (2011). Evaluation of the upper limb in tetraplegia: clinical, functional and kinematic correlations. International Journal 5. Discussion of Rehabilitation Research, 34(1), 65-72.  Carraro, U., Edmunds, K. J., & Gargiulo, P. (2015). 3D false color computed tomography for diagnosis and follow-up of permanent denervated human muscles submitted to home-based Functional The data presented in the tables above show EMG signs Electrical Stimulation. European Journal of Translational after the application of NMES protocols for patients with spinal Myology, 25(2). cord injury at different neurological levels of injury. When  SENIAM, www.seniam.org. comparing patients with control subjects, he showed significant  Jo, H. J., & Perez, M. A. (2020). Corticospinal-motor neuronal results in the EMG examination, showing that the action plasticity promotes exercise-mediated recovery in humans with potential showed that the signals evolved in the amount of spinal cord injury. Brain, 143(5), 1368-1382. frequency of muscle activation. During this preliminary pilot  Castro de Medeiros, R., Jaccard, A. P.B., & Cliquet, A. (2010). study, there was also a considerable approximation of the results Sagittarius alignment of the spine in paraplegics: a new paradigm for rehabilitation under neuromuscular electrical stimulation. Balm of patients "A, B and D" in relation to their control subjects. C, 48(3), 251-25. Patient "C" did not present significant results due to his
Current Directions in Biomedical Engineering – de Gruyter
Published: Sep 1, 2022
Keywords: Electrical Stimulation; Electromyography; Spinal cord injury
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