Med Biol Eng Comput (2017) 55:1367–1378
DOI 10.1007/s11517-016-1597-3
ORIGINAL ARTICLE
A novel fuzzy approach for automatic Brunnstrom stage
classification using surface electromyography
Luca Liparulo1 · Zhe Zhang2 · Massimo Panella1 · Xudong Gu3 · Qiang Fang2
Received: 23 September 2015 / Accepted: 7 November 2016 / Published online: 1 December 2016
© International Federation for Medical and Biological Engineering 2016
Abstract  Clinical assessment plays a major role in post-
stroke rehabilitation programs for evaluating impairment
level and tracking recovery progress. Conventionally, this
process is manually performed by clinicians using chart-
based ordinal scales which can be both subjective and inef-
ficient. In this paper, a novel approach based on fuzzy logic
is proposed which automatically evaluates stroke patients’
impairment level using single-channel surface electromyo-
graphy (sEMG) signals and generates objective classifica-
tion results based on the widely used Brunnstrom stages
of recovery. The correlation between stroke-induced motor
impairment and sEMG features on both time and frequency
domain is investigated, and a specifically designed fuzzy
kernel classifier based on geometrically unconstrained
membership function is introduced in the study to tackle
the challenges in discriminating data classes with complex
* Qiang Fang
john.fang@rmit.edu.au
Luca Liparulo
luca.liparulo@uniroma1.it
Zhe Zhang
zhe.zhang@rmit.edu.au
Massimo Panella
massimo.panella@uniroma1.it
Xudong Gu
jxgxd@hotmail.com
1 quality of the stroke survivors. Although the tissue damage
Department of Information Engineering, Electronics
and Telecommunications, University of Rome “La Sapienza”,
Via Eudossiana 18, 00184 Rome, Italy
2
School of Electrical and Computer Engineering, RMIT
University, Melbourne, VIC 3000, Australia
3
Rehabilitation Medical Centre, Jiaxing 2nd Hospital,
Jiaxing 314000, Zhejiang, China
 
separating surfaces. Experiments using sEMG data col-
lected from stroke patients have been carried out to exam-
ine the validity and feasibility of the proposed method. In
order to ensure the generalization capability of the classi-
fier, a cross-validation test has been performed. The results,
verified using the evaluation decisions provided by an
expert panel, have reached a rate of success of the 92.47%.
The proposed fuzzy classifier is also compared with other
pattern recognition techniques to demonstrate its superior
performance in this application.
Keywords  Stroke rehabilitation · Brunnstrom approach ·
Surface electromyography · Pattern recognition · Fuzzy
logic
1 Introduction
Stroke is an acute cerebrovascular disease caused by cer-
ebral hemorrhage or infarction and is considered as the
leading cause of death and long-term disabilities in the
world [7, 17, 40]. During a stroke incident, the interrup-
tion of brain blood supply, increased intracranial pressure
and toxic effects of the released blood can induce severe
damage to the brain tissues. Depending on the location of
the lesion, various body-functioning impairments can be
resulted including muscle weakness, sensory loss and cog-
nitive deficits which can have great impacts on the living
is often irreversible, it has been proven that it is possible
to partially regain the body functions by utilizing brains
remodeling ability [36] and the post-stroke rehabilitation
programs can have significant contributions in maximiz-
ing the positive outcomes of the recovery process [39, 59].
However, the current rehabilitation programs can be greatly
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labor-intensive and costly. By 2007, there are 62 million
stroke survivors worldwide and 55–75% of them suffer
from various degrees of body-functioning impairment and
requires rehabilitation services [15, 57]. The large expendi-
ture associated with the ever-growing stroke population has
driven substantial amount of researches into finding auto-
matic solutions to improve the effectiveness and cost-effi-
ciency of post-stroke rehabilitation [22, 45, 46, 68–70, 72].
The clinical evaluation of motor function has been an
important part of post-stroke rehabilitation. The deteriora-
tion of motor function caused by stroke can greatly reduce
patients muscle strength and dexterity which have direct
impact on patients ability of independent living [53]. By
conducting motor function assessments throughout a reha-
bilitation program, clinicians are able to track the patients
recovery progress and customize the training prescriptions
for optimal rehabilitation outcome. Conventionally, the
assessments are performed manually by experienced reha-
bilitation experts using chart-based ordinal scales such as
Brunnstrom stage of recovery [5, 6], Fugl-Meyer Assess-
ment (FMA) [20], Barthel Index [32] and National Insti-
tutes of Health Stroke Scale (NIHSS) [31]. The labor-inten-
sive assessment methods are not only inefficient but also
lacking in consensus between assessors which makes the
comparison of patients data across different institutes and
regions very difficult. In order to improve the efficiency
and reliability of motor function assessment in post-stroke
rehabilitation, automatic and objective assessment methods
are required.
The study on motor impairments caused by stroke has
attracted substantial amount of research attentions to
improve rehabilitation outcome. One solution, proposed
in several researches, is to introduce an automatic man-
agement system which is capable of unsupervised motion
recording and classification during a rehabilitation training
program and thus the doctors will be able to track patients’
training performance without having to attend every train-
ing session [18]. Inertial Measurement Unit (IMU)-based
motion tracking system is commonly considered as most
suitable due to its advantages of being compact, cost-effec-
tive and relatively easy to operate compared to its counter-
parts such as visual-based tracking systems [19]. Therefore,
to achieve high accuracy and optimal efficiency, the selec-
tion of data processing methods and classification algo-
rithms is crucial.
Surface electromyography (sEMG) records the electri-
cal activities produced by skeletal muscle groups using
electrodes attached to the skin surface. sEMG signals
can provide rich information about muscle activation and
functioning from neuro-electrophysiology perspective
and thus to aid the analysis and assessment of neurologi-
cal diseases. It is commonly adopted in clinical settings
when repetitive assessment of general muscle activation is
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Med Biol Eng Comput (2017) 55:1367–1378
needed due to the relatively simple and noninvasive pro-
cedure compared to intramuscular EMG [14, 16]. Due to
the ability of reflecting critical neural activities such as
motor unit recruitment and synchronization, sEMG has
already been proven effective for detecting neuromuscular
abnormalities, fatigue and voluntary motion intention [3,
4, 8].
Implementation of sEMG analysis can also be found
in post-stroke rehabilitation applications [9, 71]. After
stroke incident, the upper motor neuron lesion can lead
to imbalanced excitatory and inhibitory input to alpha
motor neurons and cause abnormal muscle excitability or
spasticity which eventually results in significant limita-
tion on patients motion [41]. Therefore, by investigating
the abnormalities in sEMG signals, valuable information
about stroke patients motor function impairment can be
obtained. In [71], high-density sEMG with 89 channel
recordings has been used for classifying different training
motions performed by stroke patients. A Hidden Markov
Multivariate Autoregressive (HMM-mAR) network-based
approach for bisectional stroke impairment classification
has been introduced in [9], and the result suggests that
it is possible to identify post-stroke impairments using
sEMG. Finally, in [61] the authors have hypothesized that
two electromyographic (EMG) channel recordings could
provide useful information for evaluating the outcome of
rehabilitation determining the spatial characteristics of
motor activity. The analysis has been carried out defining
14 different movements and using support vector machines
(SVMs) with the implementation of radial basis function
(RBF) kernels. However, in order to replace the current
human experience based on motor function assessment,
multi-level stroke impairment classification needs to be
investigated.
In this paper, a novel fuzzy kernel-based approach is pro-
posed to automatically classify stroke patients motor func-
tion impairment based on Brunnstrom scale using sEMG.
As for other similar applications [33, 43], the system is
designed to be efficient and practical for implementation in
rehabilitation programs, especially where human supervi-
sion is reduced such as home- or community-based training
environment. Therefore, single-channel sEMG data sam-
pled during dynamic training movements are adopted in
this research. The validity of the proposed method is tested
with 93 sEMG samples collected from 9 stroke patients.
The participating patients motor function impairment lev-
els are classified based on Brunnstrom stage of recovery by
an expert panel prior to the experiment, and the automatic
classification results generated by the proposed system are
compared with the experts judgment. Both 10-fold and
leave one out (LOO) cross-validation methods have been
taken to ensure repeatable results and to estimate the gener-
alization capability of the trained classifier.
Med Biol Eng Comput (2017) 55:1367–1378 1369
Fig. 1  Flowchart of the proposed sEMG-based automatic
Brunnstrom stage classification system
The rest of the paper will be arranged as follows: the
experiment setup and the proposed algorithm will be intro-
duced in Sect. 2; the results will be presented in Sect. 3 and
discussed in Sect. 4. In Sect. 5, we will draw our conclu-
sions and we will explain the future works.
2 Methods
The overview of the proposed motion classifier system is
shown in Fig. 1. The sEMG data are first sampled from
stroke patients during a repetitive rehabilitation training
movement. The raw signal is then preprocessed before
features are extracted. A normalization step is also per-
formed before classifier training in order to accommodate
every feature of the data space in the range between 0 and
1. During the cross-validation test, the data are segregated
into three groups: the training, validation and testing data-
set. The classifier is first trained and validated using the
training and validation set in order to optimize the internal
parameter, and then the performance of the system is exam-
ined using the testing data. Both 10-fold and LOO cross-
validation methods have been adopted to ensure the gener-
alizability of the proposed system.
2.1 Brunnstrom stages of recovery
Brunnstrom approach is a classification method which
models the motor recovery process following stroke-
induced hemiplegia with a six-stage ordinal scale [5, 6].
It is commonly adopted in post-stroke rehabilitation and
research programs as an assessment tool for evaluating
stroke patients body function impairment due to its reli-
ability, simplicity and clinically proven validity [27, 38, 52,
55, 62]. The Brunnstrom stages of recovery cover the com-
plete motor recovery progression from the initial stage of
complete flaccidity and no voluntary movement to the final
stage when spasticity disappears and near normal isolated
joint movements become possible. Brunnstrom approach
emphasizes on the unique patterns associated with stroke
recovery including the development of motor spasticity,
synergies patterns and voluntary motions. The simple six-
stage assessment system not only makes the Brunnstrom
approach easy to be implemented as a repetitive follow-
up test but also improves the communication efficiency
with patients by allowing them to easily understand their
own recovery progress [55]. This advantage can be further
extended by introducing the automatic assessment methods
introduced in this study.
2.2 Fuzzy classification
Pattern recognition is considered as an efficient approach
for analyzing either small or large amounts of data. It can
be described as a method of grouping and dividing objects
using a variety of measures of similarity or dissimilarity
based on a suitable number of features that can represent a
dataset [60]. The applications of pattern recognition can be
found in almost every field in science and technology. Early
in the twentieth-century, a large number of algorithms
and related variants have been proposed in the literature,
and many of them were designed to suit specific applica-
tions. When the a priori knowledge of the data permits the
label assignment within a number of categories or classes,
the process is known as supervised classification [21, 25].
This type of classification algorithms learn in a data-driven
fashion based on predetermined input and output pairs, and
produce models that are capable of labeling new input pat-
terns autonomously.
An important component of a classification process is
the selection of a suitable number of features to represent
the data [48]. Various methods using suited pattern recog-
nition approaches are illustrated in [42], in order to estab-
lish feature ranking, selection and extraction, including the
dimensionality reduction that is often a critical procedure
for the computational cost management. Once a set of fea-
tures has been selected and extracted from the available
dataset, a classification model from the input space of the
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1370 Med Biol Eng Comput (2017) 55:1367–1378

data can be learnt. The performance of the model is meas-

ured by assessing its ability to correctly label new obser-
vations. In order to obtain an unbiased examination of the
generalization error, 10-fold cross-validation and LOO are
adopted in the study [37].
Conventional (crisp) classification algorithms allow a
binary decision only, which assigns each input pattern a
single class [35]. Conversely, fuzzy algorithms are able to Fig. 2  MF computation for a simple 2-D case using (2): a cone-
shaped kernel is placed at each point within the class
tolerate the overlapping of classes and to deal with uncer-
tainty within data, as the estimated classification models
yield fuzzy labels using a degree of membership of any
input pattern to each class with a range between 0 and 1
[49, 63–65]. Non-exclusive classification based on fuzzy
models is therefore able to produce an extended interpreta-
tion of data structures [47, 66], where overlapping classes
may exist, and makes more robust the successive decision-
making process, when a single class must be necessar-
ily determined, for example, by using a Winner-Takes-All
(WTA) strategy.
The feature vectors extracted by complex signals
obtained from the sEMG data, collected from post-stroke
patients characterized by different Brunnstrom stages, are
Fig. 3  The structure of the proposed fuzzy kernel classifier
associated with overlapping data structures. In fact, some
patients might be likely assigned to several Brunnstrom
stages with a certain degree of uncertainty. This means that In our approach, each linear kernel is associated with a
input patterns related to those patients should be character- MF represented by a number L of points corresponding to
ized by a partial membership to different classes, each class the patterns belonging to that class; this is inversely related
representing a particular Brunnstrom stage. to the distance of a pattern from the cluster boundaries.
The underlying idea of this paper is to prove that the This method exploits the superposition of an appropriate
combined use of fuzzy logic with a more flexible geometry number of functions for building the MF of each cluster.
of the classification model, which will be based on a suited Let L × N be a matrix V, where N is the number of data
prototype of fuzzy membership function (MF) [28–30], can features:
solve the problem of the sEMG-based classification of the    
Brunnstrom stage by assigning each pattern a fuzzy label v1 v11 · · · v1N
with a typical decision-making procedure based on WTA V =  ...  =  ... .. 
(1)
  
. 
strategy in order to determine the most appropriate stage. vL vL1 · · · vLN
In addition, an innovative and extended type of information
will be provided to Clinicians. Let x be the pattern whose MF to the class must be com-
puted, the MF for that point is represented by:
2.3 Unconstrained MF
L
  γ 
A flexible and computationally affordable MF is adopted in
µ(x) = max 0, 1 − d2 (x, vi ) , (2)
δ
i=1
the proposed study to cope with the complex shaped data
clusters and improve the classification performance. A MF where d2 (x, vi ), i = 1 . . . L, is the pattern-to-ith-point
is constructed by combining cone-shaped linear kernels Euclidean distance and δ is the maximum distance that can
evaluated for each pattern based on point-to-boundary dis- occur between two patterns. This value can be determined
tance. As a result, it does not have the constraints derived simply based on the total number of features using the fol-
from specific geometrical structures (such as hypercubes, lowing expression:
hyperspheres, regular polytopes) and can adapt to various √
shapes depending on the structure of data clusters. This δ = N. (3)
approach was originally introduced in [29, 30], where the An example of cone-based MF is illustrated in Fig. 2. It is
results have proven that the unconstrained MF is effective based on a toy example with a single class composed by 12
and feasible when dealing with complex clustering tasks. randomly generated patterns. The graphical representation

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Med Biol Eng Comput (2017) 55:1367–1378 1371
of the MF is obtained by taking the summation of the 12
overlapped kernel functions constructed over each pattern
within the class. The MF is normalized within a range from
0 to 1.
2.4 Proposed fuzzy classifier
The design of the proposed fuzzy classifier is presented in
Fig. 3. After acquiring the normalized input dataset a label
vector L vector for any pattern x is evaluated:
L = µ(1) (x) µ(2) (x) . . . µ(K) (x) , (4)
where the kth element of L represents the fuzzy MF of the
pattern to the kth class. The fuzzified input is then directly
passed to a Winner-Takes-All (WTA) process for decision
making and the corresponding crisp label of the largest
value in the L vector will be chosen as the most suitable
class for pattern x.
The original data pool is first divided into training and
validation sets for determining the optimal parameters
for the model learning. By applying the aforementioned
method (2), the proposed classifier can then establish a set
of fuzzy MFs to classify input patterns to the corresponding
Brunnstrom stages.
The γ value is the only parameter to be optimized in the
training phase. It defines the slope of the MF: the greater
the value of γ , the faster the function falls to zero as the
distance increases and vice versa as revealed in Fig. 4. The
optimization process is critical for achieving the best esti-
mation of the clusters. An excessively small value might
result in unwanted class overlapping, while a large value
may cause indeterminable clusters as the area covered by
MFs will be insufficient and the degree of membership to
all the known classes could be very close to zero.
2.5 Experimental setup
In order to examine the performance of the proposed sys-
tem, an experiment with data sampled from actual stroke
patients has been conducted. The detail of the dataset,
experimental setup and processing procedure will be
presented.
2.5.1 Experiment protocol
The sEMG data samples are collected from the stroke
patients in the Jiaxing 2nd hospital rehabilitation centre,
Zhejiang, China. The data access and experiments have
been approved by the ethic committees of RMIT University
and Jiaxing 2nd hospital. Nine stroke patients (3 males, 6
females, mean age 67.2 ± 29.2) with various level of body
function impairment (Brunnstrom stages II– IV) have par-
ticipated in the experiment. The subjects were verified to be
Fig. 4  Fuzzy MF evaluation with various γ values
within the phase of stroke recovery using computer tomog-
raphy (CT) or magnetic resonance imaging (MRI). In order
to meet safety and ethics requirements, following inclusion
criteria were imposed:
1. no hemodynamic instability;
2. no severe cognitive impairments;
3. no dementia;
4. no major post-stroke complication;
5. able and willing to give consent.
Although sEMG-based approach can effectively detect
voluntary motion intention for stroke patients even at very
early stage of recovery, no stage I patients were involved
in the experiment due to unstable condition and high risk
of complications. All subjects were examined by an expert
panel for Brunnstrom stages prior to the sampling experi-
ment. Three panel members are selected from the rehabili-
tation doctors, who have:
1. extensive clinical experience with stroke patients and
stroke rehabilitation;
2. experience in conducting stroke rehabilitation related
medical research.
Ninety-three distinct sEMG time series have been collected
using a Noraxon TeleMyo DTS 2400 system sampled at
3 kHz with Ag/AgCl surface electrodes. An arm abduction
and adduction movement was used during the sampling
experiment, and the sEMG data were sampled from mid-
dle deltoid muscle. The movement starts with arms being
relaxed at side of the body with fingers pointing down nat-
urally. The patient then smoothly raises the arm which is
being sampled sideways to reach the maximum angle pos-
sible before slowly lowering it back to the starting position
and get ready for the next repetition. At the beginning of
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the data sampling process, the experiment procedure and

involved exercise movements are first explained to the par-
ticipating patients. Enough time has been given for prac-
tice and rest before the actual sEMG sampling. The surface
electrodes are placed on the muscle belly with an interval
of 2 cm. The reference electrode is located at where no
muscle activation can be detected during the movement.
The skin surface is prepared with gauze and alcohol to
remove dead skins and clean the excess of oil before elec-
trodes placement. During each recording, no more than 5
repetitions of the movement are done by each patient to
reduce the influence of muscle fatigue which may signifi-
cantly affect the sample quality for early recovery stage
or elderly patients. The sampling process is repeated 2–3
times for each individual with new electrodes and re-ini-
tialized setup which gives the patients enough time to rest
Fig. 5  The segmentation of a sEMG signal sampled from a stage-3
and also introduces variability such as the change in skin patient. The high-frequency blue waveform in the background is the
impedance. The sEMG data were collected from both the original filtered sEMG signal. The slow varying green thin line is the
impaired and healthy sides of the body for comparison. rectified signal obtained using a 2048 points Hamming window. The
horizontal dashed line indicates the amplitude threshold for activation
detection which is set to be 40% of the signal median. The red rec-
2.5.2 Feature extraction tangles are the windows for signal segmentation (color figure online)

The sEMG signals sampled at 3000 Hz are first fed through

a 10th order digital ellipse bandpass filter with a pass-band
from 20 to 500 Hz and 30 dB attenuation on stop-bands for
noise reduction. The filtered samples are also rectified for
activation detection using root-mean-square (RMS) method
with a sliding Hamming window as presented in the fol-
lowing. Let x be the filtered EMG input signal, the rectifi-
cation process can be written as:

1 n+L−1
s(n) = [x(k)w(k)]2 , 1 ≤ n ≤ N, (5)
L k=n
where N is the number of windowed segments, L is the
window length, and w(k) is the Hamming window function
defined as:
classification. The details of each feature are presented
below:
• Maximum amplitude The maximum amplitude reached
in the rectified signal.
• Mean amplitude The mean amplitude of the rectified
signal.
• Activation duration The length of data segment which
represents the duration of the muscle activation as illus-
trated in Fig. 5.
• Signal energy The energy estimated using Teager Kaiser
Energy Operator (TKEO) during muscle activation. The
TKEO in discrete form is given in [23, 24] as:

ψ[x(n)] = x(n)2 − x(n + 1)x(n − 1),

k (7)
w(k) = 0.54 − 0.46 cos 2π , 1 ≤ k < L. (6)
L−1
The muscle activations were then automatically localized
by setting a threshold in relation to signal magnitude. The
segmentation process of a sEMG signal sampled from a
stage-3 patient is illustrated in Fig. 5. It can be seen that
rectangular windows are applied over the detected move-
ment onsets. The window length is calculated to be 20%
larger than the activation period determined by an ampli-
tude threshold to cover the complete movement. The acti-
vation periods which are too close to the beginning or the
end of the sample are disposed to avoid the inclusion of
unintended or incomplete movements.
Ten features on both time and frequency domain are
extracted from the segmented sEMG samples before
where x(n) is the sEMG data sequence. The signal
energy can then be calculated as:
N

ENE = ψ[x(n)]. (8)
n−1
• Maximum changing rate the peak value in the first
derivative of the rectified sEMG signal.
• The 2nd and 3nd linear prediction coefficient (LPC)
The 2nd and 3nd LPC is computed by constructing a
2nd order forward linear predictor of the sEMG sam-
ple signal and minimizing the prediction error with
least-squares method using the ‘lpc’ function in MAT-
LAB.

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Med Biol Eng Comput (2017) 55:1367–1378 1373

• Average zero crossing (ZC) rate the ZC rate is calcu- Table 1  Results regarding the correlation between sEMG signal
lated by counting the zero crossing events of the origi- attributes and the progression of post-stroke recovery
nal sEMG signal within a window which is defined as: Feature InfoGain ReliefF Pearson Significance

n+L−1 Maximum amplitude 1.017 0.130 0.71 P < 0.001

1 
C(n) = sgn(x(k)x(k + 1)), (9) Mean amplitude 1.201 0.149 0.73 P < 0.001
L
k=n Activation duration 0.286 0.036 −0.36 P < 0.001
Signal energy 1.231 0.042 0.57 P < 0.001
where L is the window length and x is the original
sEMG signal. The average ZC rate is computed as: Maximum changing rate 0.677 0.117 0.73 P < 0.001
2nd LPC 0.548 0.076 0.32 P < 0.001
N
1  3rd LPC 0.228 0.086 −0.03 P = 0.388
AZC = C(n). (10) Average zero crossing 0.386 0.047 0.50 P < 0.001
N
n=1 rate
MPF 0.652 0.091 0.60 P < 0.001
• Mean power frequency (MPF) The MPF is the centroid
MF 0.641 0.091 0.64 P < 0.001
frequency of the signal power spectrum defined as:
N
n=1 P(n)f (n)
MPF = N , (11)
n=1 P(n)

where P is the power spectrum estimated using Welch’s

modified periodogram method and f is the normalized
frequency vector.
• Median frequency (MF) MF is the frequency which
divides the sEMG power spectrum into two equal por-
tions with same accumulated power. It can be defined as
the value such that:
MF N N
  1
P(n) = P(n) = P(n). (12)
2
n=1 n=MF n=1

3 Results

The dataset D used in the experiment is a M × N matrix, as
in the following:
   
d1 d11 · · · d1N
D =  ...  =  ... .. ,
(13)
  
. 
dM dM1 · · · dMN
where M = 93 is the number of the motions performed by
9 patients with various level of body function impairment
(Brunnstrom stage II–IV) and N = 10 is the number of
data features.
The extracted features are first tested against Brunnstrom
stages of recovery to investigate the correlation between
sEMG signal attributes and the progression of post-stroke
recovery. Different evaluation methods including InfoGain,
ReliefF and Pearson correlation coefficient are adopted in
order to analyze the contribution, correlation strength and
statistical significance of the selected features. InfoGain
measures the contribution of each feature in terms of the
information gain with respect to the labels. It is evaluated
by subtracting joint entropy of the feature and class from
Fig. 6  Example of the classification output during the validation
phase. The γ ∗ corresponds to the best error rate and will be used in
the testing phase
the entropy of the feature. On the other hand, ReliefF [50]
can examine how relevant the features are to the classifi-
cation problem by implementing an instance-based nearest
neighbor search. The labels of randomly selected samples
are compared to the samples nearby and a large number of
neighbors with different labels on a single axis can indicate
an irrelevant feature. The Pearson correlation coefficients
[54] and the p values are also calculated to demonstrate the
strength and the significance of the correlation between the
features and the Brunnstrom stages. The complete result is
shown in Table 1. InfoGain and ReliefF are implemented
using WEKA data mining workbench, and the result listed
is the ranker output.
Figure  6 has demonstrated how the proposed fuzzy ker-
nel classifier is tuned with cross-validation to realize accu-
rate Brunnstrom stage classification. The learning phase has
been performed by evaluating the classification error while

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Table 2  10-fold and leave one out cross-validation—error rate Table 3  The confusion matrix computed using the proposed uncon-
strained fuzzy kernel-based classifier applied to the test data with a
Algorithm used Error rate (%) Error rate (%) 10-fold cross-validation
(10 fold) (LOO)
Classified outcome Accuracy (%)
Fuzzy kernel classifier 7.53 8.60
II III IV Healthy
FIS classifier (Sugeno) 9.68 11.83
FIS classifier (Mamdani) 9.68 11.83 Actual value
Neuro-fuzzy classifier 11.83 17.20  Stage II 17 0 1 0 94.44
LDA 30.11 31.18  Stage III 0 30 2 0 93.75
QDA 17.20 19.35  Stage IV 3 0 11 0 78.57
NaiveBayes 24.73 23.66  Healthy 0 0 1 28 96.55
SVM 24.73 22.58 At stage II, passive movement and spasticity occur. At stage III,
CART 16.13 15.05 active movement starts with increased spasticity. At stage IV, signifi-
PNN 45.16 46.24 cant motor control emerges and at healthy stage, coordination reap-
pears and normal function returns

changing the γ value in a computable range between 2 and

10 with a step of 0.1 as depicted in the graph. Therefore, the
γ ∗ chosen for the testing phase is the minimum value in cor-
respondence of the best error rate, calculated over a suited
validation set. Both 10-fold and LOO cross-validation meth-
ods have been performed on the above discussed data, and
the performance is evaluated based on the averaged accuracy
(number of correctly classified data divided by the total num-
ber of data, in percentage) calculated over each partition.
In order to demonstrate that the proposed method is able
to obtain the smaller error rate, different classification algo-
rithms, trained in the Matlab™ software (version R2013a),
have been also tested for comparison. All included methods
are tuned and optimized in the same cross-validation pro-
cess with the same dataset. The algorithms for comparison
are described as follows:
Fig. 7  Comparison of samples from paretic and non-paretic side
• A fuzzy inference system (FIS) both with Mamdani and
Sugeno type [34, 58], trained with the subtractive clus-
tering (SUBCL) method [12] and a neuro-fuzzy classi-
fier whose parameters are adapted by the scaled conju-
gate gradient method, is included as fuzzy approaches.
• Support vector machine (SVM) [13] and classification
and regression tree (CART) [51] are included as hard/
crisp approaches.
• Linear discriminant analysis (LDA) and quadratic dis-
criminant analysis (QDA) [26], Naive Bayes classifier
[2] and the feedforward probabilistic neural network
(PNN) [56] are included as probabilistic approaches.

In Table 2 the final results over the test set are shown. It
can be seen that all the tested fuzzy methods achieved bet-
ter performance compared to the others and the proposed
fuzzy classifier attained the minimum error rate and the
best performance in terms of accuracy. Fig. 8  Correlation between median frequency and Brunnstrom stages

13
Med Biol Eng Comput (2017) 55:1367–1378 1375
The detailed performance result of the proposed fuzzy
classifier using 10-fold cross-validation is presented in
Table 3 in the form of a confusion matrix.
4 Discussion
By comparing the sEMG signal attributes and the progres-
sion of post-stroke recovery, it can be seen that the most of
features are strongly correlated with the Brunnstrom stages
especially amplitude, changing rate and frequency domain
features. Some of the results are visualized in Figs. 7 and 8.
Mean amplitude and median frequency both exhibit strong
correlation with the recovery progress and contribute sig-
nificant information gain which can benefit classification
performance. As depicted in Fig. 7, the sEMG samples
from paretic and non-paretic group can almost be sepa-
rated using only the two features and the overlapping is
relatively mild. It can be observed that the signal sam-
pled from unaffected limb usually has higher median fre-
quency and stronger average amplitude. The correlation
between the median frequency and Brunnstrom stages is
demonstrated in Fig. 8 with the red-dotted line indicating
the strong Pearson correlation coefficient. As a result, the
classification of stroke-impaired and unaffected samples
as performed in [10, 11] can be achieved with sEMG fea-
tures without too much difficulty. However, the automatic
classification of stroke patients at different impairment
level or recovery stage has significantly greater value than
the binary classification of healthy and stroke-impaired
subjects which is obvious and unnecessary in most clini-
cal settings. Brunnstrom stage classification is compara-
tively more challenging, and it cannot be achieved with
individual features due to the noticeable class overlapping
presented within the recovering stages. Therefore, in order
to achieve class separation, multiple features must be com-
bined using more sophisticated classification.
Regarding the final results over the test set, shown
in Tables 2 and 3, high single class sensitivity can be
observed in stage II, III and healthy group. The classifi-
cation of impairment level based on clinical scales using
solely sEMG is still a difficult task. Features which tar-
geted in Brunnstrom classification such as synergy pat-
tern development can be hard to capture on single-channel
sEMG and the relatively small sample number for stage IV
group may also have hindered the performance. Neverthe-
less, the performance of the proposed approach is highly
competitive to many current state-of-art inertia or optical
measurement-based classification methods [1, 22, 44, 67]
and it proves that, alone with kinematic and physiologi-
cal inputs, single-channel sEMG sampled during dynamic
exercise can also be treated as a valid evidence for post-
stroke impairment level classification.
5 Conclusions
In this paper, a novel fuzzy approach for automatic
Brunnstrom classification using sEMG has been proposed.
After investigating the sEMG data on both time and fre-
quency domain, strong correlations between the extracted
features and stroke patients’ recovery progress have been
be observed. By implementing specifically designed fuzzy
kernel classifier, the system is capable of automatically per-
forming objective and reliable assessment of stroke patients
motor impairment and produces highly accurate classifica-
tion outcomes that agree with human expert’s decision as
demonstrated in the experiment results. The automatic clas-
sification system can be integrated into post-stroke rehabili-
tation training programs to reduce the human effort involved
in the repetitive clinical assessment, especially in a training
environment with reduced supervision such as committee-
or home-based rehabilitation programs. The objective pro-
cess can also serve as supplementary evidence for human
observation-based assessment and help to create unified
evaluation standards for more reliable data comparison
across different institutions. In the future, it is expected that
the application of the proposed approach will be expanded
to more clinical assessment scales to suit various clinical
situations. The classification system will also be integrated
into rehabilitation programs for long-term evaluation.
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Xudong Gu  is the chairman
of the Rehabilitation Centre at
Jiaxing 2nd Hospital, a profes-
sor at Jiaxing University, China,
and a standing committee mem-
ber of Chinese Medical Doctor
Association, Rehabilitation
Doctor Association.
13
Med Biol Eng Comput (2017) 55:1367–1378
Qiang Fang  is a Senior Lec-
turer of Biomedical Engineering
at RMIT University. His
research focuses on bioelectron-
ics and biomicroelectronics
especially in the areas of weara-
ble and implantable technolo-
gies applicable to rehabilitation
and neurology.
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