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<\/figure><\/div>\n\n\n\nFES fosters a collaborative effort to find solutions via a consortium of five nationally recognized institutions: the Louis Stokes Cleveland VA Medical Center, Case Western Reserve University, MetroHealth Medical Center, University Hospitals and the Cleveland Clinic Neurological Institute. By using neurostimulation and neuromodulation research and applications, the Cleveland FES vigorously seeks solutions as it fosters a culture of collaboration and support.
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In the Gait program, Buckwald spends 15 minutes on a treadmill wearing devices on his head. Because this is a randomized control trial, the device may or may not be sending mild impulses into his brain. As he walks the treadmill, virtual reality presents him a wooded pathway on a large video screen in front of him, with his footsteps appearing on the path.
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Objects are placed on the right side of the path, forcing Buckwald to lift his right leg and even \u201chold\u201d it over the object. That action prompts him to rely on his stroke-affected left leg, which allows his nerves to regain function, perhaps in a manner different from the way they functioned before the stroke.
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\u201cThe overall hope is that the research will lead to a better understanding of how people recover after stroke, and to develop better ways of helping people recover,\u201d says Pundik, a stroke Neurologist, the Medical Director of the Stroke Program at the Louis Stokes Cleveland VA Medical Center, Director of the Brain Plasticity and NeuroRecovery Lab at FES Center and an Associate Professor of Neurology at CWRU School of Medicine..
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The treadmill, which is just one part of Buckwald\u2019s therapy regime, includes 34 \u201cobstacles\u201d and can move at varying speeds and inclines (Buckwald\u2019s reference to \u201cfaster and higher). Fourteen cameras measure precise details of the use of the impaired foot. Among the measurements are ones for motion and force, including the torque on the affected foot and ankle \u2013 how much power it can generate and absorb. Participants can go through the \u201ccourse\u201d six times.
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\u201cSomething is helping,\u201d says Buckwald, who stays as active as he can, including cutting his lawn. \u201cI know a lot of stuff is helping. The physical therapy is helping. The exercises are helping.\u201d
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Pundik\u2019s research involves not only tDCS but also Transcranial Magnetic Stimulation (TMS) which uses a magnetic field to generate electrical currents in the brain. The technology already is being used to treat depression and Parkinson\u2019s, though with Parkinson\u2019s the treatment is via deep brain stimulation.
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Pundik concedes the challenges in helping stroke survivors are significant. As FES investigator Ahlam Salameh, PhD says, \u201cStroke is sudden and life-changing (and) not a lot of people handle it well.\u201d Pundik evaluates the neuroplastic brain changes through the use of functional MRIs (FMRI) and diffusion tensor imaging (DTI).
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\u201cWe\u2019re definitely on the cutting edge of where the (electrical stimulation) field is right now,\u201d she says. \u201cThere are so many different options of how stimulation is applied, and different options for what the stimulation is paired with. Literally thousands of different options.\u201d
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![\"\"](\"https:\/\/fescenter.org\/wp-content\/uploads\/2021\/11\/vGait064-1024x576.jpg\")
<\/figure><\/div>\n\n\n\nThe work takes time, and demands patience, which Pundik sometimes lacks because her desire to help her patients is strong. While Parkinson\u2019s and depression have a very consistent brain pathology, stroke injury is unique to each individual.
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\u201cSo, it\u2019s hard to find one treatment that fits everybody,\u201d she says, \u201cthough we\u2019re certainly trying to figure that out.\u201d
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A Hand in Daily Life<\/h3>\n\n\n\n
Jayme Knutson, PhD, another FES investigator focused on brain plasticity, uses CCFES \u2013 contralaterally controlled functional electrical stimulation \u2013 in his work at Cleveland\u2019s MetroHealth Medical Center. He is an Associate Professor of Physical Medicine and Rehabilitation (PM&R) at CWRU and the Director of Research at the MetroHealth Center for Rehabilitation Research, and a Biomedical Engineer at the Louis Stokes Cleveland VA Medical Center. His focus is developing new therapies for stroke survivors who have lost hand function on one side of the body.
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Knutson and his team put a glove on the good hand. The glove has sensors that can detect when the hand opens. That glove is connected to a stimulator on the affected arm. The team asks the research participant to open both hands.
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\u201cWhen they open the gloved hand, electrical stimulation opens the affected hand, and they can then practice using the affected hand to do tasks.\u201d Knutson says.
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![\"\"](\"https:\/\/fescenter.org\/wp-content\/uploads\/2021\/11\/DSC_1270-1024x684.jpg\")
<\/figure><\/div>\n\n\n\n\u201cWe still have a lot to learn about what\u2019s happening in the brain, but it seems to respond to that,\u201d Knutson says. \u201cCCFES therapy seems to be sending signals back to the brain that are rewarding its attempt to open the hand.\u201d
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Neuroplasticity at work \u2013 over time and with therapy and repetition the work coaxes the brain to change the way it sends signals to the impaired hand that lead to better hand movement and function.
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\u201cWe\u2019ve done a number of studies in many of stroke survivors, and we\u2019ve seen positive outcomes from those studies,\u201d Knutson says. \u201cIt doesn\u2019t mean that everybody in the study recovered normal hand function.
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\u201cBut a majority of the people in the studies got an improvement in hand function that was significant, that made a difference for them, that helped them open their hand and use it more in their daily life.\u201d
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![\"\"](\"https:\/\/fescenter.org\/wp-content\/uploads\/2021\/11\/DSC_1213-1024x684.jpg\")
<\/figure><\/div>\n\n\n\nKnutson now is lead researcher on a multi-site study that is taking place in Atlanta (Emory University), New Jersey (The Kessler Foundation), Baltimore (Johns Hopkins) and Cleveland (MetroHealth) to see if other sites will see the same results. He also has developed a study with colleague and FES Investigator Michael Fu, PhD, that combines CCFES with custom-designed video games, which challenges patients to achieve better control of finger opening during their therapy. An Oberlin, Ohio, company is working on making CCFES commercially available for clinical use.
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\u201cWhen therapists see the CCFES device on a video or at a presentation, they immediately want it,\u201d Knutson says. \u201cAnd I think they want it because they recognize a tool that has potential.\u201d
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Time to Remember<\/h3>\n\n\n\n
Salameh\u2019s work is with a NIRS — Near Infrared Spectroscopy and Imagining — device that can measure brain oxygenation during activity or rest. The NIRS is a cap, commercially available, with infrared lights that can project a detailed picture of the brain\u2019s neural activity. The cap fits tightly over the scalp, and resembles the caps worn by participants who appear in video games or in front of other green screens.
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Salameh works in the Brain Plasticity and NeuroRehabilitation Laboratory at the VA and is part of the StrokeNet research project. She explains that activities require energy, and energy means bringing blood to the active tissue. Seeing that blood activity in the brain through the infrared sensors gives researchers a good picture of working pathways.
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Her thinking relates to infancy and childhood, when the brain is in a developing state. As children learn to walk or interact, they become more adept at an action the more they do it. After stroke, the brain reverts to a similar state, she says. Repeated activity can re-teach the brain to sharpen.
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![\"\"](\"https:\/\/fescenter.org\/wp-content\/uploads\/2021\/11\/TMS047-1024x683.jpg\")
<\/figure><\/div>\n\n\n\nThe NIRS image combined with an EEG that measures deeper electrical brain activity provides a complete picture. In simple terms, NIRS shows blood flow, the EEG how the blood flow is being used.
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\u201cIt\u2019s not building new neurons, just re-directing how the neurons connect with each other,\u201d she says. \u201cMaking new networks, and new communications between neurons.\u201d
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In her work with research participants who have lost hand or arm function, Salameh places a myoelectrically controlled device over the mid-arm, with slots for fingers. The device has a sensor that moves the fingers when it detects even the slightest electrical activity in the arm. Over time, the brain is taught how to move the hand and fingers again.
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\u201cWhat this is doing is actually reminding her that this is how it feels to use this muscle,\u201d Salameh says. \u201cShe has the connection, it\u2019s just that she\u2019s forgotten how to use it.\u201d
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Therapy involves 18 sessions over a six-week period, 90 minutes per session. Salameh admits that\u2019s a lot, but it\u2019s important to take advantage of the time because research shows the most impactful recovery takes place between two days and six months after the stroke.
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\u201cYou really have to repeat, repeat, repeat,\u201d she says, which makes sense when it\u2019s compared to the repetitive activities of the child.
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Salameh relayed a story of a research participant who when she started had trouble opening her hand and bending her elbow. After a few weeks, she was able to open her hand, close it around an object, move it, put it on a different table and pick it up and put it on another table.
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Salameh\u2019s reaction?
\u201cOh, I screamed,\u201d she says.
<\/p>\n\n\n\n
In further describing her feelings, she sums up the attitude of all the FES investigators.
<\/p>\n\n\n\n
\u201cIt\u2019s really nice because you see the individual as excited as when they took their first steps as a child all over again.\u201d
<\/p>\n","protected":false},"excerpt":{"rendered":"
Robert Buckwald strides with purpose and determination into a therapy room at the FES Center\u2019s Brain Plasticity and NeuroRehabilitation Lab in Cleveland. He drags his left leg slightly, the lingering effects of a stroke. A brace wraps his left ankle and calf. He strides toward a chair, sits down assertively and without a hello or […]<\/p>\n","protected":false},"author":3,"featured_media":29089,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-26856","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-news-news"],"acf":[],"_links":{"self":[{"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/posts\/26856","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/comments?post=26856"}],"version-history":[{"count":1,"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/posts\/26856\/revisions"}],"predecessor-version":[{"id":27838,"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/posts\/26856\/revisions\/27838"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/media\/29089"}],"wp:attachment":[{"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/media?parent=26856"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/categories?post=26856"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/fescenter.org\/test\/wp-json\/wp\/v2\/tags?post=26856"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}