Archive for category Rehabilitation robotics

[ARTICLE] Effects of Exoskeleton Gait Training on Balance, Load Distribution, and Functional Status in Stroke: A Randomized Controlled Trial – Full Text

Background: As a result of stroke, patients have problems with locomotion and transfers, which lead to frequent falls. Recovery after stroke is a major goal of rehabilitation, but it is difficult to choose which treatment method is most beneficial for stroke survivors. Recently, powered robotic exoskeletons are used in treatment to maximize the neural recovery of patients after stroke, but there are no studies evaluating the changes in balance among patients rehabilitated with an exoskeleton.

Purpose: The aim of this study was to evaluate the effects of Ekso GT exoskeleton-assisted gait training on balance, load distribution, and functional status of patients after ischemic stroke.

Methods: The outcomes are based on 44 patients aged 55–85 years after ischemic stroke who were previously randomly assigned into two groups: experimental (with Ekso GT rehabilitation) and control (with classical rehabilitation). At baseline and after 4 weeks of treatment, the patients were evaluated on balance, load distribution, and functional status using, respectively a stabilometric platform, the Barthel Index, and the Rivermead Mobility Index.

Results: In the experimental group, balance improved regarding the variables describing sway area as ellipse major and minor axes. In the control group, improvement was noted in sway velocity. After the therapy, total load distribution on feet in both groups showed a small and insignificant tendency toward reduction in the amount of uninvolved limb loading. In the control group, significant load transfer from the backfoot to the forefoot was noted. Both forms of rehabilitation caused significant changes in functional status.

Conclusions: Both training with the use of the Ekso GT exoskeleton and classical physiotherapy lead to functional improvement of patients after ischemic stroke. However, in the experimental group, improvement was observed in a larger number of categories, which may suggest potentially greater impact of treatment with the exoskeleton on functional status. Also, both forms of rehabilitation caused significant changes in balance, but we have noted some trends indicating that treatment with exoskeleton may be more beneficial for some patients. The load transfer from the backfoot to the forefoot observed in the control group was an unfavorable phenomenon. We suggest that the Ekso GT exoskeleton may be a promising tool in the rehabilitation of patients after stroke.

Introduction

Stroke is the third leading cause of death worldwide and is the most common cause of disability among adults (12). As a result of stroke, patients have problems with locomotion and transfers, which lead to frequent falls. People with hemiparesis have uneven distribution of body mass between the sides of the body, causing balance and coordination disorders, deep and superficial sensation, increased muscle tone, and fear of falling (23). Patients have problems with lack of normal postural muscle tone, and proper reciprocal innervation as well as normal, automatic movement patterns and balance reactions (4). Some studies have reported that balance alterations significantly limit the physical activity of stroke patients, which may be the reason for deconditioning of patients in the chronic phase and reduction in their gait possibilities as well as other activities of daily living (5). That is why gait rehabilitation and also balance therapy are very important in improving the quality of everyday and social life of those patients (6).

Gait training may improve not only strength, endurance, and coordination of the lower limbs but also the entire body of the patient, influencing general fitness and endurance, balance, normalization of muscle tone, and functional improvement (7). The Barthel Index (BI) and Rivermead Mobility Index (RMI) tests are considered to be proper criteria for assessing a patient’s functional state after stroke and good indicators of the effectiveness of the applied therapy (89).

Recovery after stroke is a major goal of rehabilitation, but it is difficult to choose which treatment method is most beneficial for stroke survivors. Recently, powered robotic exoskeletons are used in treatment to maximize the neural recovery of patients after stroke (1011). However, in a review paper, Louie and Eng (12) have reported that only four different types of powered exoskeletons have been studied among a small number of stroke patients, and the published data were controversial. Moreover, in the available literature, there are no studies evaluating the changes in balance among patients rehabilitated with an exoskeleton. Most authors have reported various aspects of walking, and only a few papers have presented data concerning changes in balance. Additionally, most of the studies used subjective tools such as the Berg Balance Scale (1314). There is a lack of studies in which changes in balance and load distribution due to rehabilitation with the exoskeleton would be examined using an objective tool—stabilometric platform; therefore, this study undertakes this task for the first time.

The aim of this study was to evaluate the effectiveness of rehabilitation with Ekso GT exoskeleton in patients after ischemic stroke and to compare this type of therapy with the classical model of rehabilitation. The novelty of this study was the verification of the robot-assisted gait training effects on balance, load distribution, and functional status of stroke patients.[…]

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[ARTICLE] tDCS and Robotics on Upper Limb Stroke Rehabilitation: Effect Modification by Stroke Duration and Type of Stroke – Full Text

Abstract

Objective. The aim of this exploratory pilot study is to test the effects of bilateral tDCS combined with upper extremity robot-assisted therapy (RAT) on stroke survivors. Methods. We enrolled 23 subjects who were allocated to 2 groups: RAT + real tDCS and RAT + sham-tDCS. Each patient underwent 10 sessions (5 sessions/week) over two weeks. Outcome measures were collected before and after treatment: (i) Fugl-Meyer Assessment-Upper Extremity (FMA-UE), (ii) Box and Block Test (BBT), and (iii) Motor Activity Log (MAL). Results. Both groups reported a significant improvement in FMA-UE score after treatment (). No significant between-groups differences were found in motor function. However, when the analysis was adjusted for stroke type and duration, a significant interaction effect () was detected, showing that stroke duration (acute versus chronic) and type (cortical versus subcortical) modify the effect of tDCS and robotics on motor function. Patients with chronic and subcortical stroke benefited more from the treatments than patients with acute and cortical stroke, who presented very small changes. Conclusion. The additional use of bilateral tDCS to RAT seems to have a significant beneficial effect depending on the duration and type of stroke. These results should be verified by additional confirmatory studies.

1. Introduction

Stroke is a common primary cause of motor impairments and disability. Only about 15% of those with initial complete upper limb paralysis after stroke recover a functional use of their affected arm in daily life [12]. Greater intensity of upper extremity training after stroke improves functional recovery [3] as well as repetitive task training [4]. Motor practice, in turn, favors motor cortical reorganization, which is correlated with the degree of functional recovery [5]. Robotic devices for upper extremity rehabilitation after stroke have been shown to improve arm function [69]. They may enhance conventional motor therapy, increasing repetitions of well-defined motor tasks (massed practice) with an improvement of motivation due to the feedback of the device; they can be programmed to perform in different functional modalities according to the subject level of motor impairment. Robotic assistance may increase sensory inputs and reduce muscle tone with an overall improved patients’ confidence in performing movements and tasks that, without assistance, might be frustrating or even impossible to achieve [10]. In the past decade, neuromodulation approaches have been proposed with the aim of optimizing stroke motor rehabilitation. Among these, transcranial direct current stimulation (tDCS) represents a noninvasive tool to modulate motor cortical excitability inducing a brain polarization through the application of weak direct electrical currents on the scalp via sponge electrodes [11]. Transient, bidirectional, polarity-dependent modifications in motor cortical excitability can be elicited: anodal stimulation increases it, whereas cathodal stimulation decreases it [1213]. Moreover, on a behavioral viewpoint, tDCS can promote skilled motor function in chronic stroke survivors [14].

After a stroke, changes in motor cortex excitability occur leading to an unbalanced interhemispheric inhibition [11], because the depression of the contralesional hemisphere on the affected one is not balanced by a similar level of inhibition of the lesional hemisphere onto the unaffected one. It has been hypothesized that this phenomenon represents a potential maladaptive process with detrimental effects on arm motor function [15]. On this basis, to increase paretic arm function, an “interhemispheric competition model” has been adopted in noninvasive brain stimulation stroke research [1116]. Specifically, researchers applied anodal tDCS over the affected primary motor cortex (M1) [14], cathodal stimulation over the unaffected M1 [17], or, more recently, a combination of the two stimulation paradigms through a bilateral tDCS montage [18]. How noninvasive brain stimulation effects are relevant when coupled with a peripheral stimulation as rehabilitative interventions is now well established [19]. So far, tDCS effects on motor learning and arm function in stroke population have been extensively addressed in recent systematic reviews and meta-analysis reporting mixed conclusions [2024]. Indeed, the effectiveness and timing of these new rehabilitative techniques need to be defined by further investigations. We can hypothesize that tDCS primes motor cortex circuits, increasing motor cortex excitability that is sustained after a robot-assisted training [25]. Furthermore, the combination of these techniques enhances synaptic plasticity and motor relearning through long-term potentiation- (LTP-) and long-term depression- (LTD-) like phenomena on M1 [26].

The aims of this exploratory pilot study were twofold. Firstly, we wanted to test the effects of a bilateral tDCS montage combined with upper extremity robot-assisted training (RAT) compared to RAT alone on motor recovery, gross motor function, and arm functional use in a heterogeneous sample of stroke survivors. Secondly, we explored whether additional factors such as stroke duration and type could modify and also be predictors of tDCS and RAT response.[…]

Continue —->  tDCS and Robotics on Upper Limb Stroke Rehabilitation: Effect Modification by Stroke Duration and Type of Stroke

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[ARTICLE] Literature Review on the Effects of tDCS Coupled with Robotic Therapy in Post Stroke Upper Limb Rehabilitation – Full Text

Today neurological diseases such as stroke represent one of the leading cause of long-term disability. Many research efforts have been focused on designing new and effective rehabilitation strategies. In particular, robotic treatment for upper limb stroke rehabilitation has received significant attention due to its ability to provide high-intensity and repetitive movement therapy with less effort than traditional methods. In addition, the development of non-invasive brain stimulation techniques such as transcranial Direct Current Stimulation (tDCS) has also demonstrated the capability of modulating brain excitability thus increasing motor performance. The combination of these two methods is expected to enhance functional and motor recovery after stroke; to this purpose, the current trends in this research field are presented and discussed through an in-depth analysis of the state-of-the-art. The heterogeneity and the restricted number of collected studies make difficult to perform a systematic review. However, the literature analysis of the published data seems to demonstrate that the association of tDCS with robotic training has the same clinical gain derived from robotic therapy alone. Future studies should investigate combined approach tailored to the individual patient’s characteristics, critically evaluating the brain areas to be targeted and the induced functional changes.

Introduction

Stroke is one of the leading factors of morbidity and mortality worldwide (Warlow et al., 2001).

In Italy, stroke annual incidence varies between 175/100.000 and 360/100.000 in men and between 130/100.000 and 273/100.000 in women (Sacco et al., 2011). Further, still in Italy, a total of 196.000 individuals are affected by stroke each year, 80% are new episodes and 20% are relapses (Gensini, 2005).

Activities of daily living (ADLs) and human quality of life strongly depend on upper limb functioning (Franceschini et al., 2010). Therefore, one of the goals of post-stroke upper limb rehabilitation is to recover arm and hand functions, and enable the patients to perform ADLs independently.

It is shown in the literature that intensive as well as task-specific training can be very effective in upper limb rehabilitation treatments after stroke (Feys et al., 2004Lo et al., 2010Klamroth-Marganska et al., 2014); this training should be repetitive, challenging and functional for the patients. To this purpose, robotics represents a key enabling technology for addressing these requirements for a well-stratified group of stroke patients (i.e., moderate-to-severe subjects). Clinical studies, varying in design and methods, have examined the effect of robotic devices on upper-limb and lower-limb rehabilitation in a clinical setting (Prange et al., 2006Brewer et al., 2007Mehrholz et al., 2015). Moreover, in a multicenter randomized controlled trial on moderate-to-severe chronic stroke patients, robotic therapy resulted superior to usual care and not inferior to intensive conventional rehabilitation treatment in terms of recovery of upper limb motor function (Lo et al., 2010). In addition, using robotic devices allows delivering new therapy constraints to maximize the required movement pattern (Kwakkel et al., 2007). Therefore, it is possible to control task learning phase more easily with robots than with traditional therapeutic techniques, since robots allows patients to perform guided movements on predefined pathways and avoid possible uncontrolled movements (Kwakkel et al., 2007).

Despite the interesting advancements in this area, the type of therapy leading to optimal results remains controversial and elusive and patients are often left with considerable disability (Bastani and Jaberzadeh, 2012).

Recently, the application of non-invasive neuro-modulation strategies to counteract inter-hemispheric imbalance has been acquiring a growing interest in post-stroke rehabilitation (Duque et al., 2005Hummel and Cohen, 2006Bolognini et al., 2009Kandel et al., 2012). The adjunct of non-invasive interventions, such as the electrical brain stimulation or magnetic brain stimulation (Di Lazzaro et al., 2016), might be used to speed-up and maximize the potential benefit of rehabilitation treatments. In particular, transcranial Direct Current Stimulation (tDCS) may play an important role in stroke recovery since its capability to modify cortical excitability and neural activity (Lefaucheur, 2016Lefaucheur et al., 2017).

In fact, modulating the excitability of a targeted brain region non-invasively, can favor a normal balance in the interhemispheric interaction and, hence, facilitate the recovery of motor functions of the paretic limb (Kandel et al., 2012).

tDCS consists of applying low-intensity current (1–2 mA) between two or multiple small electrodes on the scalp (Dmochowski et al., 2011). Depending on the electrode polarity, an opposite polarization of brain tissues can be induced with consequent modification of the resting membrane potential. Anodal stimulation will induce depolarization and increased cortical excitability; cathodal stimulation will induce hyperpolarization and decreased cortical excitability (Nitsche and Paulus, 2000Fregni et al., 2005).

In the past, several studies have demonstrated a tDCS effect in terms of increased primary motor cortex activation assessed with fMRI (Hummel et al., 2005Lindenberg et al., 2010).

The inter-hemispheric inhibitory competition model (Duque et al., 2005) implies that, to restore the interhemispheric balance altered after a stroke, one can either increase the excitability of the affected hemisphere with the anodal tDCS, or decrease the activity of the healthy hemisphere with cathodal tDCS (Hummel and Cohen, 2006).

The use of bilateral tDCS (applying simultaneously anodal electrode on the affected hemisphere and cathodal electrode on the unaffected hemisphere, Tazoe et al., 2014) could also be an effective strategy to produce interhemispheric rebalancing effects. Notwithstanding the promising achievements, the debate on tDCS efficacy in neurorehabilitation is still active and not entirely examined (Stagg and Johansen-Berg, 2013).

The application of tDCS might also have an impact on shoulder abduction (SABD) loading effects in individuals with moderate to severe chronic stroke; however, it is insufficient to make significant changes at higher SABD loads (Yao et al., 2015).

Furthermore, several neuromodulatory protocols have been applied together with robotic gait training to induce cortical plasticity and promote motor recovery after stroke. Motor excitability induced by paired associative stimulation, i.e., repetitive transcranial magnetic stimulation (rTMS) and tDCS has shown to be a potential neuromodulatory adjuvant of walking rehabilitation in patients with chronic stroke (Jayaram and Stinear, 2009) although there was no evidence regarding the efficacy of these protocols with respect to the others.

On the other hand, robot-assisted repetition with electromechanical gait trainer (Hesse et al., 1997Hesse and Uhlenbrock, 2000) improved gait performance and maintained functional recovery at follow-up even during the chronic phase of stroke (Peurala et al., 2005Dias et al., 2007). This could be likely due to the gait-like movement that allowed patients to practice a complete gait cycle, achieving better symmetric and physiological walking (Dias et al., 2007).

In this context, the adjunct of tDCS (delivered over the lower extremity motor cortex) to robotic locomotor exercises showed the capability to enhance the effectiveness of robotic gait training in chronic stroke patients (Danzl et al., 2013).

Conversely, while administering tDCS did not produce any reverse effects on chronic stroke patients, on the other hand it seemed to have no additional effect on robot-assisted gait training (Geroin et al., 2011). This could be due to the peculiar neural organization of locomotion, which involves both cortical (motor cortex) and spinal (central pattern generators) control (Dietz, 2002Geroin et al., 2011).

Recently, another study has supported the hypothesis that anodal tDCS combined with cathodal transcutaneous spinal direct current stimulation (tsDCS) may be useful to improve the effects of robotic gait training in chronic stroke (Picelli et al., 2015).

Finally, combination of tDCS and robotic training has shown a promising strategy for improving arm, hand and lower extremity motor functions in persons with incomplete spinal cord injury (Raithatha et al., 2016Yozbatiran et al., 2016).

All these approaches justify the growing interest of the scientific community in the evaluation of the effects of upper limb robot-aided motor training coupled with tDCS in stroke, relying on the adjunct of tDCS to further enhance primary effects of motor recovery (Triccas et al., 2016).

This paper intends to carry out an in-depth study of the literature regarding the effects of the combined use of tDCS and RT on motor and functional recovery in post stroke subjects. Moreover, the expected added value provided by this work is to complete the current knowledge in the neurorehabilitation field, by critically evaluating and comparing (when possible) the available results as well as discussing inconsistencies and possible issues. As a final goal, indications for the development of future and more specific rehabilitation protocols tailored to subject’s needs are provided.

The paper is structured as follows. In Section “Overview of the Main Studies on tDCS Coupled with Upper-Limb Robotic Treatment” an overview of clinical studies that analyze effects of tDCS combined with upper limb robotic therapy (RT) is reported.

Section “Discussion” presents a critical discussion of the presented studies aimed to assess the efficacy of this novel combined approach. Finally, Section “Conclusions and future perspectives” reports final considerations and future suggestions.

Overview of the Main Studies on tDCS Coupled with Upper-Limb Robotic Treatment

The study of the effects deriving from the coupled use of tDCS and RT represents a relatively young field of interest. In fact, the number of studies that have tried to investigate and prove the successful combination of these two techniques is limited.

A wide literature search updated to January 2017 has been conducted resorting to the main databases, such as Pubmed Central (PMC), Cochrane, Scopus, Google Scholar. The following keywords have been employed: tDCS AND stroke* OR ictus OR hemiplegia* AND robot* OR robotic therapy*, upper-limb rehabilitation, brain stimulation techniques, neurorehabilitation, rehabilitation robotics. Studies have been included only when focused on the novel therapeutic approach based on tDCS combined with robotic upper limb therapy.

The following inclusion criteria have been utilized:

1. Be a single session clinical trial (i.e., compare pre-treatment and post-treatment performance) or controlled trial (i.e., clinical trial with a control group, either randomized or not).

2. Involve stroke patients.

3. Concern movement therapy with a robotic device.

4. Include transcranial Direct Current Stimulation (tDCS) as Non-Invasive Brain Stimulation Technique.

5. Focus on upper-limb motor control (and possibly functional abilities).

6. Use relevant motor control and functional ability outcome measures.

7. Be a full-length publication in a peer-reviewed journal.

To enable the most complete overview of the current literature, the search has not been limited by patient subgroups (i.e., acute, subacute, or chronic) or by language.

A flowchart of the search and inclusion process is shown in Figure 1. A total of 830 papers has been gathered by using the aforementioned search method. The abstracts matching the inclusion criteria have been selected. When appropriate, the full paper has been read. Therefore, from the initial 830 papers, 820 have been excluded since they did not meet the inclusion criteria. The remaining 10 papers have been carefully read. Eight studies are journal papers while 2 are conference papers.

Figure 1. Flowchart of the search and inclusion process.

[…]

 

Continue —->  Frontiers | Literature Review on the Effects of tDCS Coupled with Robotic Therapy in Post Stroke Upper Limb Rehabilitation | Human Neuroscience

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[Study] Design a Smart Exoskeleton Robotic Arm for Elbow Rehabilitation – Full Text PDF

Abstract

This study presents a smart arm exoskeleton roboticdevice that designed to perform the physical therapy for disabled patients in order to rehabilitate the affected limb. The basic principle of this exoskeleton is its dependence on electromyography signal; MyoWare sensor was used to measure surface electromyography signal. Surface electrodes were used between skin and MyoWare to pick up the signal from biceps brachii muscle. The microcontroller processes the signal of muscle activity and outputs a voltage to control the direction of a motor. The motor moves the actuator arm through Bowden cable. The exoskeleton robot is one degree of freedom performs the flexion and extension of the elbow joint. After the design was completed, it was tested according to some parameters to check its efficiency. The resultsindicated the feasibility of this exoskeleton to move according to muscle’s signal and to tolerate the human arm’s weight whatever the human weight.

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Source: D Suárez-Iglesias, C Ayán Perez, N Mendoza-Laiz… – Frontiers in Psychology, 2020

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[Abstract] State-of-the-art robotic gait rehabilitation orthoses: Design and control aspects

Abstract

Background: Robot assisted gait training is a rapidly evolving rehabilitation practice. Various robotic orthoses have been developed during the past two decades for the gait training of patients suffering from neurologic injuries. These robotic orthoses can provide systematic gait training and reduce the work load of physical therapists. Biomechanical gait parameters can also be recorded and analysed more precisely as compared to manual physical therapy.
Objectives: A review of robotic orthoses developed for providing gait training of neurologically impaired patients is provided in this paper. Methods: Recent developments in the mechanism design and actuation methods of these robotic gait training orthoses are presented. Control strategies developed for these robotic gait training orthoses in the recent years are also discussed in detail. These control strategies have the capability to provide customised gait training according to the disability level and stage of rehabilitation of neurologically impaired subjects.
Results: A detailed discussion regarding the mechanism design, actuation and control strategies with potential developments and improvements is provided at the end of the paper.
Conclusions: A number of robotic orthoses and novel control strategies have been developed to provide gait training according to the disability level of patients and have shown encouraging results. There is a need to develop improved robotic mechanisms, actuation methods and control strategies that can provide naturalistic gait patterns, safe human-robot interaction and customized gait training, respectively. Extensive clinical trials need to be carried out to ascertain the efficacy of these robotic rehabilitation orthoses.

 

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[Abstract] Exploration of barriers and enablers for evidence-based interventions for upper limb rehabilitation following a stroke: Use of Constraint Induced Movement Therapy and Robot Assisted Therapy in NHS Scotland

The routine use of evidence-based upper limb rehabilitation interventions after stroke has the potential to improve function and increase independence. Two such interventions are Constraint Induced Movement Therapy and Robot Assisted Therapy. Despite evidence to support both interventions, their use within the National Health Service appears, anecdotally, to be low. We sought to understand user perceptions in order to explain low uptake in clinical practice.

A combination of a cross-sectional online survey with therapists and semi-structured interviews with stroke patients was used to explore uptake and user opinions on the benefits, enablers and barriers to each intervention.

The therapists surveyed reported low use of Constraint Induced Movement Therapy and Robot Assisted Therapy in clinical practice within the Scottish National Health Service. Barriers identified by therapists were inadequate staffing, and a lack of training and resources. Interviews with stroke patients identified themes that may help us to understand the acceptability of each intervention, such as the impact of motivation.

Barriers to the uptake of Constraint Induced Movement Therapy and Robot Assisted Therapy within the clinical setting were found to be similar. Further qualitative research should be completed in order to help us understand the role patient motivation plays in uptake.

via Exploration of barriers and enablers for evidence-based interventions for upper limb rehabilitation following a stroke: Use of Constraint Induced Movement Therapy and Robot Assisted Therapy in NHS Scotland – Gillian Sweeney, Mark Barber, Andrew Kerr,

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[ARTICLE] Design and Analysis of a Wearable Upper Limb Rehabilitation Robot with Characteristics of Tension Mechanism – Full Text HTML

Abstract

Nowadays, patients with mild and moderate upper limb paralysis caused by cerebral apoplexy are uncomfortable with autonomous rehabilitation. In this paper, according to the “rope + toothed belt” generalized rope drive design scheme, we design a utility model for a wearable upper limb rehabilitation robot with a tension mechanism. Owing to study of the human upper extremity anatomy, movement mechanisms, and the ranges of motion, it can determine the range of motion angles of the human arm joints, and design the shoulder joint, elbow joint, and wrist joint separately under the principle of ensuring the minimum driving torque. Then, the kinematics, workspace and dynamics analysis of each structure are performed. Finally, the control system of the rehabilitation robot is designed. The experimental results show that the structure is convenient to wear on the human body, and the robot’s freedom of movement matches well with the freedom of movement of the human body. It can effectively support and traction the front and rear arms of the affected limb, and accurately transmit the applied traction force to the upper limb of the joints. The rationality of the wearable upper limb rehabilitation robot design is verified, which can help patients achieve rehabilitation training and provide an effective rehabilitation equipment for patients with hemiplegia caused by stroke.

1. Introduction

The number of young patients with functional impairment of the upper limbs caused by stroke has increased rapidly, as influenced by accelerated pace of life, poor lifestyles and environmental factors [1,2]. Limb movement disorder, which is caused by hemiplegia after stroke, not only reduces the quality of life of patients, but also brings great pain to their physiology and psychology. Effective rehabilitation training can improve the defect of patients’ nerve function and maintain the degree of joint activity; it also prevents joint spasms and enhances the final rehabilitation degree of patients’ motor functions significantly [3]. The traditional rehabilitation training is one-to-one auxiliary exercise for patients by therapists. This method is difficult to develop an effective treatment plan, and it is tough to control accurately [4]. With the development of rehabilitation robot technology and rehabilitation medicine, the rehabilitation robot has become a novel motor nerve rehabilitation treatment technology. It is of great significance to take advantage of rehabilitation robot technology for rehabilitation training to the recovery of limb function of stroke patients [5]. The traditional methods of treatment, which are based on the therapist’s clinical experience, have the problems of large staff consumption, long rehabilitation cycles, limited rehabilitation effects, and so on. The research and application of rehabilitation robot system is expected to alleviate the contradiction between supply and demand of rehabilitation medical resources effectively, and improve the quality of life of stroke patients [6,7].[…]

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Figure 1. Shoulder joint freedom of motion. (a) Flexion/extension; (b) abduction/adduction; (c) internal rotation/external rotation.

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[Abstract+ References] Upper Limb Rehabilitation Electromechanical System for Stroke Patients – Conference paper

Abstract

The mechanical and electrical system of upper limb rehabilitation is a kind of medical equipment which relies on the aid of machine to help stroke patients to carry out upper limb activity training. Many stroke patients can not move independently, which greatly limits their lives. In this paper, we have learned the etiology and symptoms of stroke patients, scientifically formulated their training methods and movements, and fully considered the safety and practicability of the equipment, and used relatively light materials as far as possible. For stroke patients to provide a safe, comfortable, effective upper limb wearable exoskeleton machine, can be anytime and anywhere rehabilitation training, simple appearance, low cost, suitable for stroke patients to use, to help them recover. Realize the independence of movement.

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    Cifuentes, C., Braidot, A., Rodriguez, L., et al.: Development of a wearable ZigBee sensor system for upper limb rehabilitation robotics. In: 2012 4th IEEE RAS & EMBS International Conference on Biomedical Robotics and Biomechatronics (BioRob). IEEE (2012)Google Scholar
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    Tang, B.: Application of piezoelectric patches for chatter suppression in machining processes. Measurement 138, 225–231 (2019)CrossRefGoogle Scholar
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    Zeiaee, A., Soltani-Zarrin, R., Langari, R., Tafreshi, R.: Design and kinematic analysis of a novel upper limb exoskeleton for rehabilitation of stroke patients. In: 2017 International Conference on Rehabilitation Robotics (ICORR) (2017)Google Scholar
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    Liu, H., Du, T., Wang, T., Fan, J., Qu, Y.: Design and trial operation of tele-rehabilitation gradient motor function self-evaluating system for stroke patients. Zhongguo yi liao qi xie za zhi = Chin. J. Med. Instrum. 42(2), 88–91 (2018)Google Scholar
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    Meng, F., Tong, K.Y., Chan, S.T., Wong, W.W., Lui, K.H., Tang, K.W., et al.: BCI-FES training system design and implementation for rehabilitation of stroke patients (2008)Google Scholar
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    Hesse, S., Kuhlmann, H., Wilk, J., Tomelleri, C., Kirker, S.G.B.: A new electromechanical trainer for sensorimotor rehabilitation of paralysed fingers: a case series in chronic and acute stroke patients. J. Neuroeng. Rehabil. 5(1), 21 (2008)CrossRefGoogle Scholar
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[Abstract] An Automated Game-Based Variable-Stiffness Exoskeleton for Hand Rehabilitation – Full Text PDF

Abstract

In this paper, we propose and demonstrate the functionality of a novel exoskeleton which provides variable resistance training for human hands. It is intended for people who suffer from diminished hand strength and low dexterity due to non-severe forms of neuropathy or other ailments. A new variable-stiffness mechanism is designed based on the concept of aligning three different sized springs to produce four different levels of stiffness, for variable kinesthetic feedback during an exercise. Moreover, the design incorporates an interactive computer game and a flexible sensor-based glove that motivates the patients to use the exoskeleton. The patients can exercise their hands by playing the game and see their progress recorded from the glove for further motivation. Thus the rehabilitation training will be consistent and the patients will re-learn proper hand function through neuroplasticity. The developed exoskeleton is intrinsically safe when compared with active exoskeleton systems since the applied compliance provides only passive resistance. The design is also comparatively lighter than literature designs and commercial platforms.

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via An Automated Game-Based Variable-Stiffness Exoskeleton for Hand Rehabilitation – Volume 9, No. 4, April 2020 – IJMERR

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[REVIEW ARTICLE ] Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach – Full Text

Robot-mediated therapy is an innovative form of rehabilitation that enables highly repetitive, intensive, adaptive, and quantifiable physical training. It has been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis. Multiple studies collated in a growing number of review articles showed the positive effects on motor impairment, less clearly on functional limitations. After describing the current status of robotic therapy after upper limb paresis due to stroke, this overview addresses basic principles related to robotic therapy applied to upper limb paresis. We demonstrate how this innovation is an evidence-based approach in that it meets both the improved clinical and more fundamental knowledge-base about regaining effective motor function after stroke and the need of more objective, flexible and controlled therapeutic paradigms.

Introduction

Robot-mediated rehabilitation is an innovative exercise-based therapy using robotic devices that enable the implementation of highly repetitive, intensive, adaptive, and quantifiable physical training. Since the first clinical studies with the MIT-Manus robot (1), robotic applications have been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis but also in cerebral palsy (2), multiple sclerosis (3), spinal cord injury (4), and other disease types. Thus, multiple studies suggested that robot-assisted training, integrated into a multidisciplinary program, resulted in an additional reduction of motor impairments in comparison to usual care alone in different stages of stroke recovery: namely, acute (57), subacute (18), and chronic phases after the stroke onset (911). Typically, patients engaged in the robotic therapy showed an impairment reduction of 5 points or more in the Fugl-Meyer assessment as compared to usual care. Of notice, rehabilitation studies conducted during the chronic stroke phase suggest that a 5-point differential represents the minimum clinically important difference (MCID), i.e., the magnitude of change that is necessary to produce real-world benefits for patients (12). These results were collated in multiple review articles and meta-analyses (1317). In contrast, the advantage of robotic training over usual care in terms of functional benefit is less clear, but there are recent results that suggest how best to organize training to achieve superior results in terms of both impairment and function (18). Indeed, the use of the robotic tool has allowed us the parse and study the ingredients that should form an efficacious and efficient rehabilitation program. The aim of this paper is to provide a general overview of the current state of robotic training in upper limb rehabilitation after stroke, to analyze the rationale behind its use, and to discuss our working model on how to more effectively employ robotics to promote motor recovery after stroke.

Upper Extremity Robotic Therapy: Current Status

Robotic systems used in the field of neurorehabilitation can be organized under two basic categories: exoskeleton and end-effector type robots. Exoskeleton robotic systems allow us to accurately determine the kinematic configuration of human joints, while end-effector type robots exert forces only in the most distal part of the affected limb. A growing number of commercial robotic devices have been developed employing either configuration. Examples of exoskeleton type include the Armeo®Spring, Armeo®Power, and Myomo® and of end-effector type include the InMotion™, Burt®, Kinarm™ and REAplan®. Both categories enable the implementation of intensive training and there are many other devices in different stages of development or commercialization (1920).

The last decade has seen an exponential growth in both the number of devices as well as clinical trials. The results coalesced in a set of systematic reviews, meta-analyses (1317) and guidelines such as those published by the American Heart Association and the Veterans Administration (AHA and VA) (21). There is a clear consensus that upper limb therapy using robotic devices over 30–60-min sessions, is safe despite the larger number of movement repetitions (14).

This technic is feasible and showed a high rate of eligibility; in the VA ROBOTICS (911) study, nearly two thirds of interviewed stroke survivors were enrolled in the study. As a comparison the EXCITE cohort of constraint-induced movement therapy enrolled only 6% of the screened patients participated (22). On that issue, it is relevant to notice the admission criteria of both chronic stroke studies. ROBOTICS enrolled subjects with Fugl-Meyer assessment (FMA) of 38 or lower (out of 66) while EXCITE typically enrolled subjects with an FMA of 42 or higher. Duret and colleagues demonstrated that the target population, based on motor impairments, seems to be broader in the robotic intervention which includes patients with severe motor impairments, a group that typically has not seen much benefit from usual care (23). Indeed, Duret found that more severely impaired patients benefited more from robot-assisted training and that co-factors such as age, aphasia, and neglect had no impact on the amount of repetitive movements performed and were not contraindicated. Furthermore, all patients enrolled in robotic training were satisfied with the intervention. This result is consistent with the literature (24).

The main outcome result is that robotic therapy led to significantly more improvement in impairment as compared to conventional usual care, but only slightly more on motor function of the limb segments targeted by the robotic device (16). For example, Bertani et al. (15) and Zhang et al. (17) found that robotic training was more effective in reducing motor impairment than conventional usual care therapy in patients with chronic stroke, and further meta-analyses suggested that using robotic therapy as an adjunct to conventional usual care treatment is more effective than robotic training alone (1317). Other examples of disproven beliefs: many rehabilitation professionals mistakenly expected significant increase of muscle hyperactivity and shoulder pain due to the intensive training. Most studies showed just the opposite, i.e., that intensive robotic training was associated with tone reduction as compared to the usual care groups (92526). These results are shattering the resistance to the widespread adoption of robotic therapy as a therapeutic modality post-stroke.

That said, not all is rosy. Superior changes in functional outcomes were more controversial until the very last years as most studies and reviews concluded that robotic therapy did not improve activities of daily living beyond traditional care. One first step was reached in 2015 with Mehrholz et al. (14), who found that robotic therapy can provide more functional benefits when compared to other interventions however with a quality of evidence low to very low. 2018 may have seen a decisive step in favor of robotic as the latest meta-analysis conducted by Mehrholz et al. (27) concluded that robot-assisted arm training may improve activities of daily living in the acute phase after stroke with a high quality of evidence However, the results must be interpreted with caution because of the high variability in trial designs as evidenced by the multicenter study (28) in which robotic rehabilitation using the Armeo®Spring, a non-motorized device, was compared to self-management with negative results on motor impairments and potential functional benefits in the robotic group.

The Robot Assisted Training for the Upper Limb after Stroke (RATULS) study (29) might clarify things and put everyone in agreement on the topic. Of notice, RATULS goes beyond the Veterans Administration ROBOTICS with chronic stroke or the French REM_AVC study with subacute stroke. RATULS included 770 stroke patients and covered all stroke phases, from acute to chronic, and it included a positive meaningful control in addition to usual care.[…]

 

Continue —-> Frontiers | Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach | Neurology

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