Archive for January, 2019

[ARTICLE] Effectiveness of Robot-Assisted Upper Limb Training on Spasticity, Function and Muscle Activity in Chronic Stroke Patients Treated With Botulinum Toxin: A Randomized Single-Blinded Controlled Trial – Full Text

Background: The combined use of Robot-assisted UL training and Botulinum toxin (BoNT) appear to be a promising therapeutic synergism to improve UL function in chronic stroke patients.

Objective: To evaluate the effects of Robot-assisted UL training on UL spasticity, function, muscle strength and the electromyographic UL muscles activity in chronic stroke patients treated with Botulinum toxin.

Methods: This single-blind, randomized, controlled trial involved 32 chronic stroke outpatients with UL spastic hemiparesis. The experimental group (n = 16) received robot-assisted UL training and BoNT treatment. The control group (n = 16) received conventional treatment combined with BoNT treatment. Training protocols lasted for 5 weeks (45 min/session, two sessions/week). Before and after rehabilitation, a blinded rater evaluated patients. The primary outcome was the Modified Ashworth Scale (MAS). Secondary outcomes were the Fugl-Meyer Assessment Scale (FMA) and the Medical Research Council Scale (MRC). The electromyographic activity of 5 UL muscles during the “hand-to-mouth” task was explored only in the experimental group and 14 healthy age-matched controls using a surface Electromyography (EMGs).

Results: No significant between-group differences on the MAS and FMA were measured. The experimental group reported significantly greater improvements on UL muscle strength (p = 0.004; Cohen’s d = 0.49), shoulder abduction (p = 0.039; Cohen’s d = 0.42), external rotation (p = 0.019; Cohen’s d = 0.72), and elbow flexion (p = 0.043; Cohen’s d = 1.15) than the control group. Preliminary observation of muscular activity showed a different enhancement of the biceps brachii activation after the robot-assisted training.

Conclusions: Robot-assisted training is as effective as conventional training on muscle tone reduction when combined with Botulinum toxin in chronic stroke patients with UL spasticity. However, only the robot-assisted UL training contributed to improving muscle strength. The single-group analysis and the qualitative inspection of sEMG data performed in the experimental group showed improvement in the agonist muscles activity during the hand-to-mouth task.

Introduction

Upper limb (UL) sensorimotor impairments are one of the major determinants of long-term disability in stroke survivors (1). Several disturbances are the manifestation of UL impairments after stroke (i.e., muscle weakness, changes in muscle tone, joint disturbances, impaired motor control). However, spasticity and weakness are the primary reason for rehabilitative intervention in the chronic stages (13). Historically, spasticity refers to a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks resulting from hyperexcitability of the stretch reflex (4) while weakness is the loss of the ability to generate the normal amount of force.

From 7 to 38% of post-stroke patients complain of UL spasticity in the first year (5). The pathophysiology of spasticity is complicated, and new knowledge has progressively challenged this definition. Processes involving central and peripheral mechanisms contribute to the spastic movement disorder resulting in abnormal regulation of tonic stretch reflex and increased muscle resistance of the passively stretched muscle and deficits in agonist and antagonist coactivation (67). The resulting immobilization of the muscle at a fixed length for a prolonged time induces secondary biomechanical and viscoelastic properties changes in muscles and soft tissues, and pain (811). These peripheral mechanisms, in turn, leads to further stiffness, and viscoelastic muscle changes (28). Whether the muscular properties changes may be adaptive and secondary to paresis are uncertain. However, the management of UL spasticity should combine treatment of both the neurogenic and peripheral components of spasticity (910).

UL weakness after stroke is prevalent in both acute and chronic phases of recovery (3). It is a determinant of UL function in ADLs and other negative consequences such as bone mineral content (3), atrophy and altered muscle pattern of activation. Literature supports UL strengthening training effectiveness for all levels of impairment and in all stages of recovery (3). However, a small number of trials have been performed in chronic subgroup patients, and there is still controversy in including this procedure in UL rehabilitation (3).

Botulinum toxin (BoNT) injection in carefully selected muscles is a valuable treatment for spastic muscles in stroke patients improving deficits in agonist and antagonist coactivation, facilitating agonist recruitment and increasing active range of motion (681214). However, improvements in UL activity or performance is modest (13). With a view of improving UL function after stroke, moderate to high-quality evidence support combining BoNT treatment with other rehabilitation procedures (1915). Specifically, the integration of robotics in the UL rehabilitation holds promise for developing high-intensity, repetitive, task-specific, interactive treatment of upper limb (15). The combined use of these procedures to compensate for their limitations has been studied in only one pilot RCT reporting positive results in UL function (Fugl-Meyer UL Assessment scale) and muscular activation pattern (16). With the limits of the small sample, the results support the value of combining high-intensity UL training by robotics and BoNT treatment in patients with UL spastic paresis.

Clinical scales are currently used to assess the rehabilitation treatment effects, but these outcome measures may suffer from some drawbacks that can be overcome by instrumental assessment as subjectivity, limited sensitivity, and the lack of information on the underlying training effects on motor control (17). Instrumental assessment, such as surface electromyography (sEMG) during a functional task execution allows assessing abnormal activation of spastic muscles and deficits of voluntary movements in patients with stroke.

Moreover, the hand-to-mouth task is representative of Activities of Daily Life (ADL) such as eating and drinking. Kinematic analysis of the hand-to-mouth task has been widely used to assess UL functions in individuals affected by neurological diseases showing adequate to more than adequate test-retest reliability in healthy subjects (1819). The task involves flexing the elbow a slightly flexing the shoulder against gravity, and it is considered to be a paradigmatic functional task for the assessment of spasticity and strength deficits on the elbow muscles (1720). Although sEMG has been reported to be a useful assessment procedure to detect muscle activity improvement after rehabilitation, limited results have been reported (1621).

The primary aim of this study was to explore the therapeutic synergisms of combined robot-assisted upper limb training and BoNT treatment on upper limb spasticity. The secondary aim was to evaluate the treatment effects on UL function, muscle strength, and the electromyographic activity of UL muscles during a functional task.

The combined treatment would contribute to decrease UL spasticity and improve function through a combination of training effects between BoNT neurolysis and the robotic treatment. A reduction of muscle tone would parallel improvement in muscle strength ought to the high-intensity, repetitive and task-specific robotic training. Since spasticity is associated with abnormal activation of shortening muscles and deficits in voluntary movement of the UL, the sEMG assessment would target these impairments (281115).

Materials and Methods

Trial Design

A single-blind RCT with two parallel group is reported. The primary endpoint was the changes in UL spasticity while the secondary endpoints were changes in UL function, muscle strength and the electromyographic activity of UL muscles during a functional task. The study was conducted according to the tenets of the Declaration of Helsinki, the guidelines for Good Clinical Practice, and the Consolidated Standards of Reporting Trials (CONSORT), approved by the local Ethics Committee “Nucleo ricerca clinica–Research and Biostatistic Support Unit” (prog n.2366), and registered at clinical trial (NCT03590314).

Patients

Chronic post-stroke patients with upper-limb spasticity referred to the Neurorehabilitation Unit (AOUI Verona) and the Physical Medicine and Rehabilitation Section, “OORR” Hospital (University of Foggia) were assessed for eligibility.

Inclusion criteria were: age > 18 years, diagnosis of ischemic or hemorrhagic first-ever stroke as documented by a computerized tomography scan or magnetic resonance imaging, at least 6 months since stroke, Modified Ashworth Scale (MAS) score (shoulder and elbow) ≤ 3 and ≥1+ (22), BoNT injection within the previous 12 weeks of at least one of muscles of the affected upper limb, Mini-Mental State Examination (MMSE) score ≥24 (23) and Trunk Control Test score = 100/100 (24).

Exclusion criteria were: any rehabilitation intervention in the 3 months before recruitment, bilateral cerebrovascular lesion, severe neuropsychologic impairment (global aphasia, severe attention deficit or neglect), joint orthopedic disorders.

All participants were informed regarding the experimental nature of the study. Informed consent was obtained from all subjects. The local ethics committee approved the study.

Interventions

Each patient underwent a BoNT injection in the paretic limb. The dose of BoNT injected into the target muscle was based on the severity of spasticity in each case. Different commercial formulations of BoNT were used according to the pharmaceutical portfolio contracts of our Hospitals (Onabotulinumtoxin A, Abobotulinumtoxin A, and Incobotulinumtoxin A). The dose, volume and number of injection sites were set accordingly. A Logiq ® Book XP portable ultrasound system (GE Healthcare; Chalfont St. Giles, UK) was used to inject BoNT into the target muscle.

Before the start of the study authors designed the experimental (EG) and the control group (CG) protocols. Two physiotherapists, one for each group, carried out the rehabilitation procedures. Patients of both groups received ten individual sessions (45 min/session, two sessions/week, five consecutive weeks). Treatments were performed in the rehabilitative gym of the G. B. Rossi University Hospital Neurological Rehabilitation Unit, or “OORR” Hospital.

Robot-Assisted UL Training

The Robot-assisted UL Training group was treated using the electromechanical device Armotion (Reha Technology, Olten, Switzerland). It is an end-effector device that allows goal-directed arm movements in a bi-dimensional space with visual feedback. It offers different training modalities such as passive, active, passive-active, perturbative, and assistive modes. The robot can move, drive or oppose the patient’s movement and allows creating a personalized treatment, varying parameters such as some repetitions, execution speed, resistance degree of motion. The exercises available from the software are supported by games that facilitate the functional use of the paretic arm (25). The robot is equipped with a control system called “impedance control” that modulates the robot movements for adapting to the motor behavior of the patient’s upper limb. The joints involved in the exercises were the shoulder and the elbow, is the wrist fixed to the device.

The Robot-assisted UL Training consisted of passive mobilization and stretching exercises for affected UL (10 min) followed by robot-assisted exercises (35 min). Four types of exercises contained within the Armotion software and amount of repetitions were selected as follows: (i) “Collect the coins” (45–75 coins/10 min), (ii) “Drive the car” (15–25 laps/10 min), (iii) “Wash the dishes” (40–60 repetitions/10 min), and (iv) “Burst the balloons” (100–150 balloons/5 min) (Figure 1). All exercises were oriented to achieving several goals in various directions, emphasizing the elbow flexion-extension and reaching movement. The robot allows participants to execute the exercises through an “assisted as needed” control strategy. For increment the difficulty, we have varied the assisted and non-assisted modality, increasing the number of repetitions over the study period.[…]

 

Figure 1. The upper limb robot-assisted training setting.

Continue —> Frontiers | Effectiveness of Robot-Assisted Upper Limb Training on Spasticity, Function and Muscle Activity in Chronic Stroke Patients Treated With Botulinum Toxin: A Randomized Single-Blinded Controlled Trial | Neurology

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[WEB SITE] Nonpharmacologic Approaches to Spasticity Management

Drug therapies alone are not considered sufficient for the treatment of spasticity, and the general consensus supports a broader therapeutic strategy.

Drug therapies alone are not considered sufficient for the treatment of spasticity, and the general consensus supports a broader therapeutic strategy.

Spasticity, defined as a velocity-dependent increase in muscle tone caused by the increased excitability of the muscle stretch reflex, is a challenging symptom that frequently accompanies severe neurological conditions including stroke, multiple sclerosis (MS), cerebral palsy (CP), and spinal cord injury.1 The mechanisms of spasticity are complex, involving an inhibitory/excitatory disruption to the spinal network that heightens muscle activity and spinal reflex responses as a result of compensatory structural neuronal reorganization to central nervous system damage or injury.1,2 The original site of the disrupted signal depends on the cause of central nervous system damage; stroke spasticity originates from the cerebral cortex, whereas spasticity associated with MS and spinal cord injury originates in the spinal cord.

The Role of Nonpharmacologic Therapies

Pharmacologic interventions including oral and injected drugs are a mainstay of spasticity management; however, drug therapies alone are not considered sufficient, and the general consensus supports a broader therapeutic strategy.2 “Spasticity management usually requires a multimodal approach, using nonpharmacological and pharmacological treatment strategies,” Patricia Branco Mills, MHSc, MD, FRCPC, physical medicine and rehabilitation specialist at GF Strong Rehabilitation Centre in Vancouver, British Columbia, Canada, told Neurology Advisor. “The goals are generally to improve function, quality of life, and medical/health status through a transdisciplinary, holistic approach,” Dr Mills said.

In a 2017 review of new technologic advances in neurorehabilitative treatments for spasticity, Naro and colleagues2 emphasized that physical therapy and occupational therapy should be included in any rehabilitation program for focal or generalized spasticity, with other therapies added to achieve optimal results. In a review of spasticity management in stroke, Francois Bethoux, MD,3 reported that because of complications associated with drug and surgical treatment that may exacerbate functional performance through weakness and compensatory hypertonia in weakened limbs, treatment should rely on nonpharmacologic approaches used either before or adjunctively to these strategies.3 In addition to PT, he pointed to multiple other modalities, including ultrasound, thermotherapy, neuromuscular electrical stimulation and muscle strengthening exercises applied to an agonist muscle, and robotic devices for stretching and movement training, as important to a treatment plan.3

Noninvasive Neuromodulation Therapies

Noninvasive neuromodulation therapies designed to modify neuroplastic mechanisms for better adaptive muscle responses via the application of electromagnetic stimuli in conjunction with weak currents and or biochemical agents show potential for reducing spasticity across a number of conditions.

Repetitive transcranial magnetic stimulation (rTMS) involving the indirect application of magnetic pulses in a repeating pattern to induce cortical excitability, has demonstrated more consistent magnitude and duration of benefits in studies of spasticity. In patients with MS, this modality, applied at high frequency (5 Hz, 900 pulses per 15-minute session) to the primary motor region of the brain for 10 sessions over the course of 2 weeks, improved lower limb spasticity for a week to a month after application in patients with relapsing remitting MS.4

Leo et al4 reported that several studies demonstrated that low-frequency rTMS applied to the healthy brain hemisphere reduced chronic stroke-associated upper limb spasticity for up to 1 month posttreatment, whereas high-frequency rTMS showed only limited benefits. It has also demonstrated lasting inhibitory aftereffects on corticospinal motor output that make it especially effective in conjunction with physical conditioning or other therapies for MS spasticity.4

Transcranial direct current stimulation (tDCS) is a method of direct application of low-amplitude current to the brain via rubber electrodes (with saline-dampened sponges) adhered to the scalp to induce excitability. The treatment exerts a neuromodulating effect on neuronal firing rates and plasticity with potential to restore normal balance of the polarity of the neurons. A few sham-controlled studies showed improved Modified Ashworth Scale scores and decreased lower limb spasticity after tDCS administered 5 times per week for 20 minutes, at a setting of 1 mA, for 1 to 4 weeks for patients with stroke as well as MS and CP.4 There were no complications, and adverse effects were minimal.4 A second review by the same group reported only short-term benefits of tDCS in MS and CP and concluded that the evidence in support of tDCS for spasticity was unconvincing, particularly when compared with more significant results from rTMS.

Other Noninvasive Therapies

Lacey Bromley, PT, DPT, NCS, MSCS, a physical therapist from Susan Bennett PT and Associates and a consultant in MS therapeutic strategies, explained that several inhibitory techniques can also be employed to reduce spasticity for a short period. “These include prolonged stretching of the spastic muscle (30-60 seconds), prolonged cold of the spastic muscle, biofeedback techniques, and cutaneous electric stimulation on the opposing muscle. However, these strategies will only reduce the tone temporarily.”

“We have had success utilizing [functional electrical stimulation] on the common peroneal nerve, which innervates the anterior tibialis muscle,” she told Neurology Advisor, referring to the task-directed stimulation therapy that, similar to neuromuscular electrical stimulation, delivers small impulses directly to the affected nerves to force muscle contraction that produces functional movement. Both therapies have demonstrated reductions in spasticity in CP, spinal cord injury, and stroke.2

A wide range of nonpharmacologic therapies and devices are under investigation for spasticity. Their benefits, however, rely largely on the hemisphere of application and the underlying mechanisms, which will require further study for better results.4 Dr Mills observed that many modalities that show promise include targeted exercises, casting/splints, and electromagnetic devices. “Given that pharmacological options can have side effects that patients want to avoid or minimize, there should be a high priority on investigating nonpharmacological treatment strategies that can be used on their own or to improve the effects of pharmacological strategies when given in combination,” Dr Mills said.

References

  1. Mukherjee A, Chakravarty A. Spasticity mechanisms – for the clinicianFront Neurol.2010;1:149.
  2. Naro A, Leo A, Russo M, et al. Breakthroughs in the spasticity management: Are non-pharmacological treatments the future?J Clin Neurosci. 2017;39:16-27.
  3. Bethoux F. Spasticity management after strokePhys Med Rehab Clin N Am. 2015;26:625-639.
  4. Leo A, Naro A, Molonia F, et al. Spasticity management: the current state of transcranial neuromodulationPM R. 2017;9(10):1020-1029.

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[NEWS] Struggling to focus? This new brain training app may help

In a world in which our brains are almost constantly overstimulated, many of us may find it challenging to stay focused for extended periods. Researchers from the University of Cambridge in the United Kingdom have now developed an app that trains the mind to maintain concentration.

This newly developed brain-training app could effectively improve your concentration and other cognitive skills.

Research suggests that a newly developed brain training app may improve our concentration and other cognitive skills.

Many, if not most, of us spend our days rapidly switching between competing tasks. We call this “multitasking,” and take pride in how efficient we are in dealing with multiple problems at the same time.

However, multitasking requires that we quickly redirect our focus from one activity to another and then back again, which, in time, can have a detrimental effect on our ability to concentrate.

“We’ve all experienced coming home from work feeling that we’ve been busy all day but unsure what we actually did,” says Prof. Barbara Sahakian from the Department of Psychiatry at the University of Cambridge.

“Most of us spend our time answering emails, looking at text messages, searching social media, trying to multitask. But, instead of getting a lot done, we sometimes struggle to complete even a single task and fail to achieve our goal for the day,” she adds, noting that we may even find it difficult to stay focused on pleasant, relaxing activities, such as watching TV.

Yet, she continues, “For complex tasks, we need to get in the ‘flow’ and stay focused.” So, how can we re-teach our minds to stay focused?

Prof. Sahakian and colleagues believe that they may have found an effective and uncomplicated solution to this problem.

The research team has developed a brain training app called “Decoder,” which can help users improve their concentration, memory, and numerical skills.

The scientists have recently conducted a study to test the effectiveness of their new app, and they now report their results in the journal Frontiers in Behavioral Neuroscience.

An app that improves concentration

In the study, Prof. Sahakian and team worked with a cohort of 75 young and healthy adult participants. The trial spanned 4 weeks, and all the participants took a special test measuring their concentration skills at both the beginning and the end of the study.

As part of the trial, the researchers divided the participants into three groups. They asked one group to play the new Decoder training game, while the second group had to play Bingo, and the third group received no game to play.

Those in the first two groups played their respective games during eight 1-hour sessions over the 4 weeks, and they did so under the researchers’ supervision.

At the end of the trial period, the researchers found that the participants who had played Decoder demonstrated better attention skills than both the participants who had played Bingo and those who had played no game at all.

The researchers state that these improvements were “significant” and comparable to the effects of medication that doctors prescribe for the treatment of attention-impairing conditions, such as attention deficit hyperactivity disorder (ADHD).

App could help with ADHD

In the next step of the trial, Prof. Sahakian and team wanted to test whether Decoder could boost concentration without negatively affecting a person’s ability to shift their attention effectively from one task to another.

To do so, they asked participants who had used Decoder and Bingo to take the Trail Making Test (TMT), which assesses individuals’ attention-shifting capacity. The researchers found that Decoder players performed better on the TMT than Bingo players.

Finally, participants who played Decoder reported higher rates of enjoyment while participating in this activity, as well as stronger motivation and better alertness throughout all their sessions.

“Many people tell me that they have trouble focusing their attention. Decoder should help them improve their ability to do this,” says Prof. Sahakian.

“In addition to healthy people, we hope that the game will be beneficial for patients who have impairments in attention, including those with ADHD or traumatic brain injury. We plan to start a study with traumatic brain injury patients this year,” the researcher also notes.

An ‘evidence-based game’

Cambridge Enterprise recently licensed the new game to app developer Peak, who specialize in the release of brain training apps. Peak have adapted Decoder for the iPad platform, and the game is now available from the App Store as part of the Peak Brain Training package.

George Savulich, another of the current study’s authors, notes that, unlike other apps that claim to train the brain but do not necessarily deliver on their promise, he and his colleagues based the development of Decoder on hard scientific evidence.

Many brain training apps on the market are not supported by rigorous scientific evidence. Our evidence-based game is developed interactively […]. The level of difficulty is matched to the individual player, and participants enjoy the challenge of the cognitive training.”

George Savulich

“Peak’s version of Decoder is even more challenging than our original test game, so it will allow players to continue to gain even larger benefits in performance over time,” Prof. Sahakian adds.

“By licensing our game, we hope it can reach a wide audience who are able to benefit by improving their attention,” she says.

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[NEWS] MbientLab Launches its MIOTherapy Physical Therapy Wearable Technology

Unique technology platform uses smart sensors, therapeutic exercises and games to improve rehabilitation and recovery for patients undergoing physical therapy

MIO is a complete, wearable sensor solution that automatically measures, analyzes, and stores a patient's physical therapy data. (Graphic: Business Wire)

MIO is a complete, wearable sensor solution that automatically measures, analyzes, and stores a patient’s physical therapy data. (Graphic: Business Wire)

January 28, 2019 09:00 AM Eastern Standard Time

 

SAN FRANCISCO–(BUSINESS WIRE)–MbientLab, a company building the next generation of sensors and tools for the healthcare industry, has announced the availability of its MIOTherapy (MIO) wearable technology for physical and occupational therapists. MIO is the first wearable technology platform that integrates the effectiveness of traditional physical therapy with smart sensors, therapeutic exercises, games, and 3D visualization technology to personalize and improve outpatient rehabilitation and accelerate recovery.

.@mbientLab announces the launch of its @MioTherapy wearable technology for physical and occupational therapists to improve rehabilitation and recovery for patients undergoing #physicaltherapy.

Research shows that most physical therapy patients do not fully adhere to their plans for care because of factors that include lack of social support, self-doubt and perceived barriers to exercise.1 This results in millions of Americans living with preventable mobility issues and pain that reduce their quality of life. This lack of compliance also increases the cost of healthcare for these patients due to a higher number of urgent care and emergency room visits related to their injuries, and in some cases, inpatient post-acute care stays.

Using a unique combination of technology software and sensors, MIO helps physical and occupational therapists improve the experience and outcomes of therapy for their patients. MIO provides consistently accurate measurements that can be used to monitor and personalize treatment, increase patient compliance, reduce recovery time, and reduce healthcare costs.

“I’ve found the MIO based technology to be an invaluable tool in improving post-operative care for my patients where position is critical. It’s clear to me that MIO will be a great platform for doctors and physical therapists to analyze, adjust and customize patient treatment plans using precise measurements captured in real time,” said Frank Brodie, M.D., clinical faculty, University of California San Francisco. “This technology provides data that enables me to have an accurate understanding of my patients’ ongoing progress and adjust accordingly. I look forward to integrating MIO even more into my practice.”

Patients using MIO attach its sensors to any body part using stickers or flexible straps, so that physical therapists can measure, collect, and record all motion from a specific body area, delivering key insights about a patient’s range of motion and measurable progress through their exercise program. The extremely accurate sensors measure, analyze, and store a patient’s physical therapy data in the cloud for easy access and analysis via the MIO App. MIO also offers real-time 3D visualization, providing an exact picture of what the patient is doing at any moment, and can be used in-office or via a telehealth platform with clinical oversight.

“We are excited to offer physical and occupational therapists a wearable technology platform that improves patient and provider engagement, and ultimately supports better results and a quicker recovery time for patients,” said Laura Kassovic, co-founder and CEO of MbientLab. “Serving as their virtual assistant, MIO will help physical therapists rethink how they provide physical therapy and work to heal their patients so they can get back to doing the things they enjoy.”

MIO has undergone extensive sensor testing with more than a dozen third-party users, including physical therapists, researchers, clinics, and university labs. Since 2013, there have been more than 250 papers published on the use of the MbientLab sensors used in MIO. Physicians at the University of California, San Francisco have demonstrated that the MIO sensors can increase patient compliance by 20 percent to 80 percent in post-operative retinal surgery patients.2 Researchers at Duke University also found an average cost-savings of $2,745 per patient undergoing virtual physical therapy with MIO compared to traditional physical therapy.3

MIO is now commercially available in the United States and internationally and can be purchased by physical and occupational therapists, caregivers and researchers at www.miotherapy.com. MIO is available through monthly subscription plans that include the app, sensors, and access to the cloud, as well as unlimited and free customer support via email, and on-site services.

About MIOTherapy

MIOTherapy is the first wearable technology that integrates the effectiveness of traditional physical therapy with therapeutic exercises, games, and smart sensors to improve outpatient rehabilitation and speed up recovery. Visit www.miotherapy.com or follow @miotherapy on Twitter, @miotherapy on Facebook and @miotherapy on Instagram for more information.

About MbientLab

MbientLab is building the next generation of sensors and tools for the healthcare industry including motion capture and analytics, biometrics, kinematics, industrial control, research and product development. Visit www.mbientlab.com for more information.

Picha KJ, Howell DM. A model to increase rehabilitation adherence to home exercise programmes in patients with varying levels of self-efficacy. Musculoskeletal Care, 2018; 16:233-237.

Brodie et al., Novel positioning with real-time feedback for improved postoperative positioning: pilot study in control subjects; May 2017

Duke Clinical Research Institute, VERITAS research study, 2016

Contacts

for MbientLab
Hannah Boxerman
707-326-0870
hannah@healthandcommerce.com

 

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[Abstract + References] Cartesian Sliding Mode Control of an Upper Extremity Exoskeleton Robot for Rehabilitation

Abstract

Rehabilitation robots play an important role in rehabilitation treatment. Unlike conventional rehabilitation approach, the rehabilitation robotics provides an intensive rehabilitation motion with different modes (passive, active and active-assisted) based on the ability of the exoskeleton robot to perform assistive motion for a long period. However, this technology is still an emerging field. In this chapter, we present a Cartesian adaptive control based on a robust proportional sliding mode combined with time delay estimation for controlling a redundant exoskeleton robot called ETS-MARSE subject to uncertain nonlinear dynamics and external forces. The main objective of this research is to allow the exoskeleton robot to perform both rehabilitation modes, passive and active assistive motions with real subjects. The stability of the closed loop system is solved systematically, ensuring asymptotic convergence of the output tracking errors. Experimental results confirm the efficiency of the proposed control to provide an excellent performance despite the presence of dynamic uncertainties and external disturbances.

References

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  19. Shieh, H.-J., & Hsu, C.-H. (2008). An adaptive approximator-based backstepping control approach for piezoactuator-driven stages. IEEE Transactions on Industrial Electronics, 55(4), 1729–1738.CrossRefGoogle Scholar
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[ARTICLE] Development of a Novel Home Based Multiscene Upper Limb Rehabilitation Training and Evaluation System for Post-stroke Patients – Full Text PDF

ABSTRACT

Upper limb rehabilitation requires long-term, repetitive rehabilitation training and assessment, and many patients cannot pay for expensive medical fees in the hospital for so long time. It is necessary to design an effective, low cost, and reasonable home rehabilitation and evaluation system. In this paper, we developed a novel home based multi-scene upper limb rehabilitation training and evaluation system (HomeRehabMaster) for post-stroke patients. Based on the Kinect sensor and posture sensor, multi-sensors fusion method was used to track the motion of the patients. Multiple virtual scenes were designed to encourage rehabilitation training of upper limbs and trunk. A rehabilitation evaluation method integrating Fugl-meyer assessment (FMA) scale and upper limb reachable workspace relative surface area (RSA) was
proposed, and a FMA-RSA assessment model was established to assess upper limb motor function.
Correlation based dynamic time warping (CBDTW) was used to solve the problem of inconsistent upper limb movement path in different patients. Two clinical trials were conducted. The experimental results show that the system is very friendly to the subjects, the rehabilitation assessment results by this system are highly correlated with the therapist’s (the highest forecast accuracy was 92.7% in the 13th item), and longterm rehabilitation training can improve the upper limb motor function of the patients statistically significant (p=0.02<0.05). The system has the potential to become an effective home rehabilitation training and evaluation system.[…]
Full Text PDF —>  IEEE Xplore Full-Text PDF:

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[Webthesis] DESIGN AND CONTROL OF A ROBOTIC EXOSKELETON FOR WRIST REHABILITATION – Full Text

Abstract

Control of a exoskeleton with different sensors using a microcontroller and Matlab: This project will be used the exoskeleton for wrist rehabilitation and evaluation designed in the RoboticsLab. This device is actuated with SMA (Shape Memory Alloys) wires and it has two DOF. The objectives of the work will be: to integrate position and pressure sensors into the exoskeleton; to use the information of these sensors to control in position and / or strength the exoskeleton in repetitive tasks for the flexion-extension movement of the wrist; collect data on the execution of the task that could be used by the doctor to evaluate the patient’s progression.

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[WEB SITE] Electrical stimulation in brain bypasses senses, instructs movement

Date:December 7, 2017
Source:University of Rochester Medical Center
Summary:The brain’s complex network of neurons enables us to interpret and effortlessly navigate and interact with the world around us. But when these links are damaged due to injury or stroke, critical tasks like perception and movement can be disrupted. New research is helping scientists figure out how to harness the brain’s plasticity to rewire these lost connections, an advance that could accelerate the development of neuro-prosthetics.
FULL STORY

The brain’s complex network of neurons enables us to interpret and effortlessly navigate and interact with the world around us. But when these links are damaged due to injury or stroke, critical tasks like perception and movement can be disrupted. New research is helping scientists figure out how to harness the brain’s plasticity to rewire these lost connections, an advance that could accelerate the development of neuro-prosthetics.

A new study authored by Marc Schieber, M.D., Ph.D., and Kevin Mazurek, Ph.D. with the University of Rochester Medical Center Department of Neurology and the Del Monte Institute for Neuroscience, which appears in the journal Neuron, shows that very low levels of electrical stimulation delivered directly to an area of the brain responsible for motor function can instruct an appropriate response or action, essentially replacing the signals we would normally receive from the parts of the brain that process what we hear, see, and feel.

“The analogy is what happens when we approach a red light,” said Schieber. “The light itself does not cause us to step on the brake, rather our brain has been trained to process this visual cue and send signals to another parts of the brain that control movement. In this study, what we describe is akin to replacing the red light with an electrical stimulation which the brain has learned to associate with the need to take an action that stops the car.”

The findings could have significant implications for the development of brain-computer interfaces and neuro-prosthetics, which would allow a person to control a prosthetic device by tapping into the electrical activity of their brain.

To be effective, these technologies must not only receive output from the brain but also deliver input. For example, can a mechanical arm tell the user that the object they are holding is hot or cold? However, delivering this information to the part of the brain responsible for processing sensory inputs does not work if this part of the brain is injured or the connections between it and the motor cortex are lost. In these instances, some form of input needs to be generated that replaces the signals that combine sensory perception with motor control and the brain needs to “learn” what these new signals mean.

“Researchers have been interested primarily in stimulating the primary sensory cortices to input information into the brain,” said Schieber. “What we have shown in this study is that you don’t have to be in a sensory-receiving area in order for the subject to have an experience they can identify.”

A similar approach is employed with cochlear implants for hearing loss which translate sounds into electrical stimulation of the inner ear and, over time, the brain learns to interpret these inputs as sound.

In the new study, the researchers detail a set of experiments in which monkeys were trained to perform a task when presented with a visual cue, either turning, pushing, or pulling specific objects when prompted by different lights. While this occurred, the animals simultaneously received a very mild electrical stimulus called a micro-stimulation in different areas of the premotor cortex — the part of the brain that initiates movement — depending upon the task and light combination.

The researchers then replicated the experiments, but this time omitted the visual cue of the lights and instead only delivered the micro-stimulation. The animals were able to successfully identify and perform the tasks they had learned to associate with the different electrical inputs. When the pairing of micro-stimulation with a particular action was reshuffled, the animals were able to adjust, indicating that the association between stimulation and a specific movement was learned and not fixed.

“Most work on the development of inputs to the brain for use with brain-computer interfaces has focused primarily on the sensory areas of the brain,” said Mazurek. “In this study, we show you can expand the neural real estate that can be targeted for therapies. This could be very important for people who have lost function in areas of their brain due to stroke, injury, or other diseases. We can potentially bypass the damaged part of the brain where connections have been lost and deliver information to an intact part of the brain.”

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Materials provided by University of Rochester Medical CenterNote: Content may be edited for style and length.

 

via Electrical stimulation in brain bypasses senses, instructs movement — ScienceDaily

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[BLOG POST] “Minimal Detectable Change For Gait Speed Is Dependent On Baseline Gait Speed In Individuals With Chronic Stroke” – Abstract

 

The following article has just been accepted for publication in Journal of Neurologic Physical Therapy:
“Minimal Detectable Change For Gait Speed Is Dependent On Baseline Gait Speed In Individuals With Chronic Stroke”
By
Michael D Lewek, PT, PhD; Robert Sykes III

Provisional Abstract:

Background and Purpose: Given the heterogeneity of mobility outcomes post-stroke, the purpose of this study was to examine how the minimal detectable change (MDC) for gait speed varies based on an individual’s baseline walking speed.

Methods: Seventy six participants with chronic stroke and able to walk without therapist assistance participated in two visits to record overground self-selected comfortable gait speed (CGS) and fast gait speed (FGS). Based on the CGS at visit one, participants were assigned to one of three speed groups: LOW (<0.4 m/s; N=32), MOD (0.4 m/s to 0.8 m/s; N=29), and HIGH functioning group (>0.8 m/s; N=15). Participants were then reclassified using updated gait speed cutoffs of 0.49 and 0.93 m/s. For each group, we determined test-retest reliability between visits, and the minimal detectable change for CGS and FGS.

Results: Gait speed significantly increased from visit one to visit two for each group (p<0.001). The reliability for CGS declined with increasing gait speed, and MDC95 values increased with increasing gait speed (LOW: 0.10 m/s; MED: 0.15 m/s; HIGH: 0.18 m/s). Similar findings were observed for FGS, and when participants were recoded using alternative thresholds.

Discussion and Conclusions: Slower walkers demonstrated greater consistency in walking speed from day to day, which contributed to a smaller MDC95 than faster walkers. These data will help researchers and clinicians adjust their expectations and goals when working with individuals with chronic stroke. Expectations for changing gait speed should be based on baseline gait speed, and will allow for more appropriate assessments of intervention outcomes.

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via JUST ACCEPTED: “Minimal Detectable Change For Gait Speed Is Dependent On Baseline Gait Speed In Individuals With Chronic Stroke”

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[WEB SITE] The New Seizure Terminology

Active Epilepsy in Primary Care

Epilepsy is a disorder of the brain characterized by an enduring predisposition to having seizures, defined as episodes of abnormally excessive or synchronous neuronal activity in the brain, resulting in transient signs or symptoms.[1,2] Approximately 1.2% of the US population, or about 3.4 million people, have active epilepsy. Active epilepsy refers to a patient who is currently on antiepileptic medications and/or has had one or more seizures in the past year.[3,4]

Although there are healthcare providers who specialize in epilepsy—namely neurologists and epileptologists—only 53%–67% of patients in the United States with active epilepsy reported recently (“in the past year”) seeing a neurologist or epileptologist.[5,6] Meanwhile, 86% reported recently seeing a general practitioner.[5]

Given that primary care providers are likely to see patients with seizures and epilepsy—some of whom may not be in the care of a neurologist or epileptologist—we would like to review the most current seizure terminology to help these clinicians better understand the different types of seizures and the importance of standardized terminology around seizures.

Accurate Seizure Classification

Accurately classifying different types of seizures using the latest standardized terminology is essential for several reasons. First, it allows healthcare providers and patients to accurately and effectively communicate with one another about seizure type using the same clear language. Second, some medications or therapies are more effective or only approved for specific seizure types and not others, so that errors in classifying seizure type may lead to ineffective treatment. Third, some types of drug-resistant seizures can effectively be treated by surgery, whereas others cannot. Fourth, current and future clinical research studies may have certain inclusion and exclusion criteria based on seizure type, so that knowledge of seizure type would be important prior to enrollment. Finally, accurate classification would lead to a better understanding of seizure type burden in the population, allowing various clinical, research, and public health resources to be allocated appropriately.

Historical Seizure Terminology

For centuries, seizures have been described using various terms. For instance, the terms “grand mal” (referring to seizures with bilateral tonic-clonic movements and loss of consciousness) and “petit mal” (seizures with behavioral arrest) have been used since the 1800s. With a better understanding of seizures and the advent of video electroencephalography (EEG), the International League Against Epilepsy (ILAE) published the first official classification of seizure types in 1981, introducing such terms as “partial vs generalized” and “simple vs complex.” However, many of these historical terms have been criticized as being imprecise or nonspecific (eg, petit mal may refer to many different types of seizures with behavioral arrest) or confusing and misleading (eg, the term “partial” might suggest that a seizure was not a “full” one). With increasing knowledge, several iterations of ILAE’s classification of seizure types have been published over the years to improve clarity, with the most recent being published in 2017.[17]

Continue —> The New Seizure Terminology

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