Posts Tagged assessment

[BOOK Chapter] Long-Lasting Mental Fatigue After Traumatic Brain Injury – A Major Problem Most Often Neglected Diagnostic Criteria, Assessment, Relation to Emotional and Cognitive Problems, Cellular Background, and Aspects on Treatment

By Birgitta Johansson and Lars Rönnbäck

1. Introduction

Fatigue after traumatic brain injury (TBI) is common, but often overlooked. But for people fighting their fatigue after brain injury day after day, fatigue is a major problem. This post-injury mental fatigue is characterized by limited energy reserves to accomplish ordinary daily activities. Persons who have not experienced this extreme exhaustion which may appear suddenly, and without previous warning during mental activity, do not understand the problem. This is especially difficult to understand as the fatigue may appear even after seemingly trivial mental activities which, for uninjured persons, are regarded as relaxing and pleasant, as reading a book or having a conversation with friends. A normal, well-functioning, brain performs mental activities simultaneously throughout the day, but after a brain injury, it takes greater energy levels to deal with cognitive and emotional situations.

In this chapter, we highlight mental fatigue after TBI. In the case of long-lasting mental fatigue, it could be the only factor that keeps people from returning to the full range of activities that they pursued prior to their injury with work, studies and social activities. We describe mental fatigue and suggest diagnostic criteria and we also give a theoretical explanation for this. At the end of the chapter, we discuss treatment strategies and give some examples of possible therapeutic alternatives which may alleviate the mental fatigue.

Normally, the brain works in an energy-efficient manner and prominent energy reserves are present. This is due to well-functioning ion channel and amino acid transport systems and other effective physiological processes. After brain injury, some of these systems are down-regulated, and when mental energy requirements are high the physiological processes do not function to their full capacity; these cease to function efficiently with a resultant energy loss. This may be an explanation as to why the mental fatigue appears.

1.1. When does mental fatigue occur?

Annually, about 100-300/100 000 individuals sustain a TBI, and most of the injuries are mild in severity [1]. A majority of patients recover within one to three months following mild TBI [23].

Fatigue is one of the most important long-lasting symptoms following TBI, and is most severe immediately after head injury. However it is difficult to arrive at any clear figure as to how common fatigue or, in particular, mental fatigue is. The reason for this is that different results have been obtained, and these are attributable to differences in definitions and differences in the methodology in the various studies. In follow-up studies, the frequency of prolonged fatigue varies from 16 up to 73 % [46]. There is no correlation between persistent fatigue and severity of the primary injury, age of the person at injury or time since injury [78]. For those suffering from fatigue 3 months after the accident the fatigue remained relatively stable during longer periods [9]. In particular, for those subjects who were suffering from the syndrome one year after the accident improvement in the fatigue was limited [10].

In the above reports, fatigue is discussed in terms of a single construct, i.e. not differentiated between the physical or mental aspects. In this chapter, we consider mental fatigue as a separate construct and we discuss its relationship to cognitive and emotional symptoms.

1.2. Mental fatigue is not a separate diagnostic entity

Mental fatigue is not an illness, rather it represents a mental sequel, probably due to a disturbance of higher brain functions, either physical or psychological in origin. It is included in, and defined within the diagnoses Mild cognitive impairment (F06.7), Neurasthenia (F48.0) and Posttraumatic brain syndrome (F07.2) [11].

1.3. Typical characteristics of mental fatigue

A typical characteristic of pathological mental fatigue after TBI is that the mental exhaustion becomes pronounced during sensory stimulation or when cognitive tasks are performed for extended periods without breaks. There is a drain of mental energy upon mental activity in situations in which there is an invasion of the senses with an overload of impressions, and in noisy and hectic environments. The person feels that their brain is overloaded after a tiny load. Another typical feature is a disproportionally long recovery time needed to restore the mental energy levels after being mentally exhausted. The mental fatigue is also dependent on the total activity level as well as the nature of the demands of daily activities. Fatigue often fluctuates during the day depending on the activities carried out. Thus, this fatigue is a dynamic process with variations in the mental energy level. The fatigue can appear very rapidly and, when it does, it is not possible for the affected person to continue the ongoing activity. Common associated symptoms include: impaired memory and concentration capacity, slowness of thinking, irritability, tearfulness, sound and light sensitivity, sensitivity to stress, sleep problems, lack of initiative and headache [12].

For many persons, this mental fatigue is the dominating factor which limits the person’s ability to lead a normal life with work and social activities. For most people, fatigue subsides after a period of time while, for others, this pathological fatigue persists for several months or years even after the brain injury has healed. Interestingly, however is that as many as 30% of family or friends interpreted fatigue as laziness [9].

Theories as to the mechanisms accounting for mental fatigue including our own theory, suggest that cognitive activities require more resources and are more energy-demanding after brain injury than usual [1314]. Thus, more extensive neural circuits are used in TBI victims compared to controls during a given mental activity [15]. This indicates an increased cerebral effort after brain injury.

Figure 1.
Schematic representation of recovery of mental energy after TBI. The green line represents a full recovery while the blue and red lines represent impaired recovery in terms of the mental energy levels. Persons whose recovery follows the blue line recover partially. On their return to work and daily activities, they are not able to manage and they become exhausted. Persons whose recovery follows the red line do not recover and are not able to return to work and daily activities.


Therapist Luann Jacobs describes mild TBI and the lack of energy and lack of endurance that many can experience. As they are able to do what is normal and what appears normal, they run the risk that their symptoms will be misunderstood [16].

“Mild brain injury is a real misnomer, as it conveys the idea that nothing much is a problem when quite the opposite is more often true. It is called “mild” because, in fact, the mildly brain injured can walk, talk, eat and dress independently, often times drive a car, shop, cook, go to school, or even work.

What the term fails to account for is the inherent limits of how often, for how long (endurance), and the all-important, how consistently (e.g., every day, once a week) these activities can be performed. Even more elusive is the concept of how many of these daily activities can be done sequentially in a given day as is normal in the lives of people who are not brain injured.

The fatigue they feel defies description, going far beyond and far deeper than anything a non-brain-injured person would consider profound exhaustion.”

Continue —-> Long-Lasting Mental Fatigue After Traumatic Brain Injury – A Major Problem Most Often Neglected Diagnostic Criteria, Assessment, Relation to Emotional and Cognitive Problems, Cellular Background, and Aspects on Treatment | IntechOpen

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[WEB PAGE] Definition of a Disability – Great Plains ADA Center

ADA-AA Definition of a Disability

The Americans with Disabilities Act (ADA) defines disability as a“physical or mental impairment that substantially limits one or more major life activities.” This is a legal definition, rather than a medical definition. The ADA definition of disability does not apply to disability-related services such as Social Security.  The definition of disability was expanded and clarified by the ADA Amendments Act in 2008.

The ADA definition of disability does not include a list of required medical conditions or categories. There is no “national registry” or any other type of certification process that people must complete to qualify as a person with a disability under the ADA.

At first glance, determining whether a person has a condition that meets the ADA definition of a disability may seem complicated and confusing.  However, the determination is based on three fairly straight-forward questions.

1) Is there a condition/impairment that impacts major life activities or body system functions?

  • When active-does not have to be a daily 24/7 impact.

2) Is the impact on major life activities or body system functions substantial?

  • Based on the level of impact when not using medication, an assistive device, receiving treatment, etc. (mitigating measure).
  • Based on comparison with the general population and peers.

3) Is the condition/impairment permanent or long-term?
The purpose of this article is to clarify this process by explaining the definition’s terminology and providing several real-life examples.

Major Life Activities

Major life activities are basic activities that most people can perform with little or no difficulty. These activities may be physical such as walking, seeing, hearing, standing, use of hands, etc.  Cognitive and social/emotional activities such as memory, paying attention, processing information, and maintaining well being and moods are considered major life activities.

Major life activities also include the activities required for body system functioning. Conditions which affect the functioning of the digestive, neurological, immune, and circulatory systems, etc. would be considered conditions that affect major life activities.

The definition of a disability was specifically expanded to include conditions or impairments that affect body functions (such as diabetes or rheumatoid arthritis) to ensure people with all types of disabilities are included in the definition and receive protections under the ADA.

Episodic Conditions and Remission

Some conditions and/or impairments have symptoms that are not always present. These types of conditions are called episodic. Disability is assessed on the impact of these conditions on major life activities and body functions when the symptoms are active.

If a person’s active symptoms meet the definition of a disability, then the individual is always covered by the ADA, even when the symptoms are not present. This reasoning also applies to conditions that may go into remission such as cancer.


Marla has multiple sclerosis and uses a wheelchair. At work, there are times when she walks short distances with a cane. When her condition is in remission, she only uses a cane. Some of Marla’s co-workers think she shouldn’t receive accommodations because she doesn’t always use a wheelchair.

Marla is considered a person with a disability at all times.  She does not have to use a wheelchair daily to receive accommodations related to using a wheelchair.

Jamal has completed chemotherapy and, at his last follow-up appointment, was told his cancer is in remission, but will still require follow-up care. Jamal is concerned that he will no longer be able to use his flex schedule to make-up time for follow-up appointments and continued treatments.

Jamal condition is in remission, but without continued treatment, the cancer would have a substantial impact on major life activities.  Jamal’s condition is considered a disability under the ADA.

Linn has Seasonal Affective Disorder. His symptoms of depression only affect major life activities at certain times of the year. Because Linn’s condition is long-term and impacts major life activities when present, it is considered a disability under the ADA, even though the condition is not always present.

Invisible Disabilities

A condition does not have to be visible or “readily apparent” to be considered a disability.  Many conditions that are not readily apparent to the general population still affect major life activities.  Whether or not a condition is “visible” is not a consideration when determining whether a person is covered by the ADA.  It is the impact of the condition on major life activities that determines disability.


Maria has dyslexia. She uses assistive technology to get information and prepare reports. Because reading and writing are major life activities, Maria is a person with a disability.

Joshua has been diagnosed with PTSD and receives treatment.  Joshua is outgoing and physically fit and probably would not be perceived as a person as a disability. However, based on how his condition affects his major life functioning (anxiety), Joshua is a person with a disability covered by the ADA.

Substantially Limited

Once it is determined that a person has a condition or impairment that affects major life activities, the next step is to assess the impact of the condition/impairment. The impact of the condition/impairment on a major life activity must be substantial to be considered a person with a disability under the ADA. The criteria used to determine whether or not the impact of a condition is substantial is based on two factors:

  • The nature and severity of impact on major life activities.
  • How long the impact will last or is expected to last (permanent or long-term).

A common sense assessment should be used to determine the nature and severity of a condition based upon comparing the person’s ability to perform a specific major life activity with that of most people in the general population. The same criteria is used for assessing body system functions.


Tamra is in her thirties. She has poor vision without glasses and must wear them to see clearly and function. Since wearing glasses or contacts to correct vision impairments is common in the general adult population, Tamra would not be considered a person with a disability.

Jean, on the other hand, is also in her thirties and has low vision and difficulty seeing contrast. She wears glasses, but still cannot see clearly and requires assistive technology to use computer screens and her smart phone. Jean’s level of visual difficulty is not typical for her age group in the general population. She would be considered to have a disability under the ADA.


Two employees have the diagnosis of asthma:

  • One employee uses an inhaler occasionally, and his asthma is very mild.
  • The other employee uses an inhaler occasionally, but flare-ups are severe and could be life-threatening.

In this example, the frequency that the condition occurs is the same, but the severity of the condition is different. The severity of asthma is the basis of determining which employee has a disability under the ADA.


Two employees experience migraine headaches.

One employee has a severe migraine headache two to three times a year, causing her to miss up to three days of work annually.

Another employee has a severe migraine headache 3-4 times a month, causing him to miss up to four days of work each month.

In this scenario, the severity of the condition is similar, but the frequency and impact on major life activities is different. While experiencing a migraine headache is not uncommon in the general population, the severity and frequency of the second employee’s migraines result in a substantial impact on major life activities.

Assessment of Disability and Mitigating Measures

Actions taken to eliminate or reduce the impact of an impairment/condition are called mitigating measures. This includes, but is not limited to, medication, treatments, assistive devices, hearing aids, wheelchairs, and therapies. The extent that a condition impacts major life activities is based upon how the condition affects a person without using a mitigating measure.


Bill has Type II diabetes, and insulin is his “mitigating measure.”  Bill has no limitations on his major life activities when he monitors his blood sugar and uses insulin. However, he uses insulin because his endocrine system is substantially impaired. Without insulin, the impact on his major life activities and overall body functions would be severe. Bill is covered by the ADA as a person with a disability.

Takeaway: Whether or not a person has a disability is based upon the impact of the condition or impairment on major life activities and body functions without the use of a mitigating measure.  A person does not have to use a reasonable accommodation in the workplace or other modifications to be covered by the ADA.

Length of Time or Duration of a Disability

Conditions and/or impairments that are short-term do not meet the definition of a disability under the ADA, even if the condition meets the other criteria:  substantial impact on major life activities.


Evan injured his back and is required to limit most physical activities for at least a week. He is in pain and must take medication.  However, he is expected to fully recover in 2 weeks.

Even though the impact of Evan’s condition is substantial, the impact is short-term and would not be considered a disability under the ADA.


Shawna became very ill with a life-threatening infection. She spent two days in the hospital before returning to work 1/2 days for a week. She then returned to work full time. Her infection is gone and she requires no extended treatment.

Although the impact of the condition was life-threatening, the impact was short-term with a full recovery.  Shawna would not be considered a person with a disability under the ADA.


Glenda was in a car accident. Her injuries were severe and she will require rehabilitation. Although Glenda is expected to fully recover, she will use a wheelchair and then a cane for at least six months.

Glenda’s injuries will not have a permanent impact on major life activities. However, she is covered under the ADA because of the length of time that her condition impacts major life activities.

Other Factors Covered by the ADA

ADA protections are provided to people who don’t have a disability, but may experience disability related discrimination based upon:

  • Having a record of a disability that is no longer present.
  • Having a condition or appearance that is regarded as a disability, but actually has no impact on major life activities.

Example: Record of Disability

Tim has been cancer-free for five years and is considered to be in complete remission. His employer does not promote him as expected because the employer says the “cancer may come back”.

Under the ADA, Tim is protected from discrimination that is based solely on his history of having a disability.

Example: Regarded As

Jenna has noticeable burn scars on her face.  Her scars have no impact on major life activities and require no medical care. However Jenna is turned away from a job interview because of her facial scars. The employer believes her scars will “make her unable to work with customers.”

Under the ADA, Jenna would be protected from discrimination because her employer regarded her scars as a disabling condition.

Definition of a Disability and Employment

A person with a condition that meets the definition of a disability under the ADA is protected from employment discrimination, but they must also be:

  • Qualified for the position they seek.
  • Able to perform the essential functions of the job with or without reasonable accommodations.

In other words, Title I of the ADA protects qualified individuals with disabilities who can perform the essential functions of the job with or without reasonable accommodations.

A person with a disability may be asked to provide documentation from their medical professional if their disability is not “readily apparent.”

Summary: Key Concepts

  • The definition of a disability is a legal definition rather than a medical definition.  The definition does not apply to qualifying for disability-related services such as Social Security.
  • There is no list of required medical conditions or categories included in the law. There is also no “national registry” or any other type of certification process that people must complete to be considered to have a disability under the ADA.
  • The ADA applies to all ages.  Children with disabilities are covered by the ADA.
  • The ADA makes no distinction between types of disabilities.  Individuals who meet the definition of a disability all have have the same rights under the ADA.
  • The criteria used to determine disability is based on the impact of the condition/impairment on major life activities instead of just the presence of the condition.
  • The impact of a condition on major life activities is assessed by how the condition affects major life activities without the use of mitigating measures (actions taken to alleviate symptoms or improve functioning such as medication, therapy, or hearing aids.)
  • The ADA protects people who have a past record of disability from discrimination.  The ADA also protects people who do not have a disability, but are “regarded as” having a disability.
  • The ADA protects people with disabilities from discrimination in the workplace, but they must be qualified for the job they hold or are seeking.

via Definition of a Disability | Great Plains ADA Center

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[VIDEO] Assessment of Visual Fields Video: Diane Dirette – YouTube

Watch a demonstration of assessing visual fields.

Read FREE related article:…

Visual Deficits:Now You See It, Now You Don’t- A Clinical Pearl by Diane Powers Dirette, PhD, OTL

Visual deficits match many diagnoses and, if undetected, can be mistaken for other problems – e.g. sensory, motor, balance and cognitive deficits. It’s critical, therefore, that therapists know how to complete a basic visual screening and to interpret the results. For example, how can you tell homonymous hemianopia apart from unilateral inattention? The screening tools are virtually the same, but the screening results differ subtly.

via Assessment of Visual Fields Video: Diane Dirette | MedBridge – YouTube

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[ARTICLE] Effects of Hand Configuration on the Grasping, Holding, and Placement of an Instrumented Object in Patients With Hemiparesis – Full Text


Objective: Limitations with manual dexterity are an important problem for patients suffering from hemiparesis post stroke. Sensorimotor deficits, compensatory strategies and the use of alternative grasping configurations may influence the efficiency of prehensile motor behavior. The aim of the present study is to examine how different grasp configurations affect patient ability to regulate both grip forces and object orientation when lifting, holding and placing an object.

Methods: Twelve stroke patients with mild to moderate hemiparesis were recruited. Each was required to lift, hold and replace an instrumented object. Four different grasp configurations were tested on both the hemiparetic and less affected arms. Load cells from each of the 6 faces of the instrumented object and an integrated inertial measurement unit were used to extract data regarding the timing of unloading/loading phases, regulation of grip forces, and object orientation throughout the task.

Results: Grip forces were greatest when using a palmar-digital grasp and lowest when using a top grasp. The time delay between peak acceleration and maximum grip force was also greatest for palmar-digital grasp and lowest for the top grasp. Use of the hemiparetic arm was associated with increased duration of the unloading phase and greater difficulty with maintaining the vertical orientation of the object at the transitions to object lifting and object placement. The occurrence of touch and push errors at the onset of grasp varied according to both grasp configuration and use of the hemiparetic arm.

Conclusion: Stroke patients exhibit impairments in the scale and temporal precision of grip force adjustments and reduced ability to maintain object orientation with various grasp configurations using the hemiparetic arm. Nonetheless, the timing and magnitude of grip force adjustments may be facilitated using a top grasp configuration. Conversely, whole hand prehension strategies compound difficulties with grip force scaling and inhibit the synchrony of grasp onset and object release.



Cerebrovascular accidents (stroke) are a frequent cause of disability (1) and the recovery of upper-limb function in particular, is a key determinant of independence in activities of daily living (2). Broadly speaking, the physical impairment experienced by patients is characterized by loss of strength, abnormal movement patterns (pathological synergies), and changes in muscle tone to the side of the body contralateral to the stroke (34). This presentation is commonly referred to as hemiparesis and its severity tends to reflect the extent of the lesion to the corticospinal tract (5). Subtle changes in movement kinematics and hand function on the ipsilesional upper-limb have also been documented and may be the consequence of direct impairment of ipsilateral motor pathways (67), as well as reorganization of the non-lesioned hemisphere to support recovery of motor-function in the hemiparetic limb (810). Above all though, patients living with stroke find that limitations with manual dexterity of the hemiparetic arm have the most significant effect upon their ability to carry out activities involving hand use in daily life (11).

These impairments in patient hand function manifest in multiple different aspects of motor performance. This may include reduced strength (3), loss of individuated finger control (12), and abnormal force control at the level of the fingers (13). Increased muscle tone and spasticity though the flexors of the wrist and hand may further compound these difficulties and inhibit the ability to open the hand in preparation for grasping (14). Atypical reaching and grasping patterns are often seen to emerge both as a consequence of and as a response to the motor dysfunction (1516).

Unfortunately, rehabilitation of upper limb impairments proves to be challenging. Whilst numerous therapeutic modalities (e.g., bilateral training, constraint-induced therapy, electrical stimulation, task-oriented, high intensity programs) have been evaluated in clinical trials, none have demonstrated consistent effects upon hand function (1719). Indeed, previous research papers have described therapy outcomes in upper limb rehabilitation post stroke as “unacceptably poor” (20). Ideally, the design of neurorehabilitation programs should be grounded upon an understanding of basic mechanisms involved in neural plasticity and motor learning (2122). Part of this process implies coming to terms with the factors which characterize the disorganization in voluntary motor output (21). However, the majority of clinical tools currently used for evaluating hand function distinguish motor performance according to ordinal rating scales or task completion time (e.g., Frenchay Arm Test, Jebson-Taylor Hand Function Test) (2324). These kinds of assessments lack sensitivity and may prove insufficient for detecting the presence of mild motor deficits or subtle, yet clinically important changes in hand coordination (2526). Evidence based frameworks for hand rehabilitation have specifically called for the integration of new technology to support patient assessment and treatment planning (27). Despite this, the transposition of technology for upper limb rehabilitation from the research domain into clinical practice has been limited (2829). In the assessment of manual dexterity, the underlying challenge involves analyzing sensorimotor function of the hand with respect to its interaction with objects in the environment (30).

Successfully managing grasping and object handling tasks requires skilled control of prehensile finger forces. In healthy adults, grip forces are regulated to be marginally greater than the minimum required to prevent the object from slipping (31). This safety margin is calibrated according to the shape, surface friction and weight distribution of the object (3233). As the hand moves through space (lifting, transporting, object placement), grip force is continually modulated, proportional to the load forces associated with the mass and acceleration of that object (34). This temporal coupling between grip and load forces is considered a hallmark of anticipatory sensorimotor control (35). Disruption to motor planning, volitional motor control or somatosensory feedback may lead to a breakdown in the timing and magnitude of grip force adjustments.

Numerous studies have examined grip force regulation in neurological pathologies including cerebellar dysfunction (36), peripheral sensory neuropathy (3738), Parkinson’s disease (36373940) as well as congenital and acquired brain lesions (13364145). For patients suffering from hemiparesis post stroke, difficulty with coordinating the grasping and lifting action are frequently associated with temporal discrepancies between grip forces and load forces (46). The cerebral hemisphere implicated in the CVA (1347) and the extent of the resulting sensory deficits (4849) have also been observed to influence anticipatory grip force scaling. This body of work highlights the potential interest of using instrumented objects for the diagnosis and evaluation of the impairments associated with hemiparesis (4546485053).

As it stands, these objective studies of hand function post stroke have focused primarily upon either the lifting or the vertical movement components in object handling. To a certain extent, this limitation has been related to technical restrictions. Other than a handful of studies by Hermsdorfer et al. (849), research in this field has predominantly used manipulanda designed for the study of precision grip, where strain gauge force transducers are attached to a separate base unit [e.g., (232529333537)]. These devices cannot be freely handled by subjects, much less a person with an upper-limb movement disorder. Indeed, patients with hemiparesis often experience specific impairments with precision grip (53) and regularly use alternative grasping strategies such as whole hand grasping (151654). Previous researchers have hypothesized that these alternative grasp strategies may impact grip force scaling (55) and compromise patient ability to manage hand-object-environment relationships during object manipulation (56).

In a recent study with healthy adult subjects, (57) we demonstrated how an instrumented object with multiple load cells and an integrated inertial measurement unit (58) may be used to examine relationships between different grasp configurations, grip force regulation and object orientation. The purpose of the present investigation was to extend this work to the study of patients with hemiparesis post stroke. The first objective was to compare how four alternative grasp configurations commonly used in daily tasks affect grip force regulation in this population. The second objective was to explore the timing and coordination of the whole task sequence (grasping, lifting, holding, placement and object release). The third and final objective was to evaluate the stability of the hand-held object’s orientation across the different phases of the task.[…]


Continue —> Frontiers | Effects of Hand Configuration on the Grasping, Holding, and Placement of an Instrumented Object in Patients With Hemiparesis | Neurology

Figure 1. Illustration of the iBox device and the experimental setup. (A) The iBox instrumented object. (B)Setup for the experimental procedure. Initial positions of the iBox and hand start area are indicated by the dotted lines. The gray shaded rectangle indicates the deposit area for the top grasp task.


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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


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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[ARTICLE] Quantification of upper limb position sense using an exoskeleton and a virtual reality display – Full Text



Proprioceptive sense plays a significant role in the generation and correction of skilled movements and, consequently, in most activities of daily living. We developed a new proprioception assessment protocol that enables the quantification of elbow position sense without using the opposite arm, involving active movement of the evaluated limb or relying on working memory. The aims of this descriptive study were to validate this assessment protocol by quantifying the elbow position sense of healthy adults, before using it in individuals who sustained a stroke, and to investigate its test-retest reliability.


Elbow joint position sense was quantified using a robotic device and a virtual reality system. Two assessments were performed, by the same evaluator, with a one-week interval. While the participant’s arms and hands were occluded from vision, the exoskeleton passively moved the dominant arm from an initial to a target position. Then, a virtual arm representation was projected on a screen placed over the participant’s arm. This virtual representation and the real arm were not perfectly superimposed, however. Participants had to indicate verbally the relative position of their arm (more flexed or more extended; two-alternative forced choice paradigm) compared to the virtual representation. Each participant completed a total of 136 trials, distributed in three phases. The angular differences between the participant’s arm and the virtual representation ranged from 1° to 27° and changed pseudo-randomly across trials. No feedback about results was provided to the participants during the task. A discrimination threshold was statistically extracted from a sigmoid curve fit representing the relationship between the angular difference and the percentage of successful trials. Test-retest reliability was evaluated with 3 different complementary approaches, i.e. a Bland-Altman analysis, an intraclass correlation coefficient (ICC) and a standard error of measurement (SEm).


Thirty participants (24.6 years old; 17 males, 25 right-handed) completed both assessments. The mean discrimination thresholds were 7.0 ± 2.4 (mean ± standard deviation) and 5.9 ± 2.1 degrees for the first and the second assessment session, respectively. This small difference between assessments was significant (− 1.1 ± 2.2 degrees), however. The assessment protocol was characterized by a fair to good test-retest reliability (ICC = 0.47).


This study demonstrated the potential of this assessment protocol to objectively quantify elbow position sense in healthy individuals. Futures studies will validate this protocol in older adults and in individuals who sustained a stroke.



Proprioception is defined as the ability to perceive body segment positions and movements in space [1]. Sensory receptors involved in proprioception are mostly located in muscle [234], joint [56] and skin [37]. Proprioceptive sense is known to play a significant role in motor control [891011] and learning [812], particularly in the absence of vision. The importance of proprioceptive inputs has been demonstrated while studying individuals who presented lack of proprioception due to large-fiber sensory neuropathy [1112]. Despite an intact motor system, somatosensory deafferentation may lead to limitations in several activities involving motor skills, such as eating or dressing [12]. These disabilities may also be observed in individuals with proprioceptive impairments due to a stroke. Indeed, approximately half of the individuals who sustained a stroke present proprioceptive impairments in contralesional upper limb [13]. After a stroke, proprioception is known to be related to recovery of functional mobility and independence in activities of daily living (ADL; [14]). Fewer individuals with significant proprioceptive and motor losses (25%) were independent in ADL than individuals with motor deficits alone (78%). Moreover, fewer individuals with proprioceptive deficits (60%) after a stroke are discharged from the hospital directly to home compared to those without proprioceptive deficits (92%) [15].

Although the negative impact of proprioceptive impairments on motor and functional recovery is known, a large proportion of clinicians (70%) report not using standardised assessment to evaluate somatosensory deficits in patients with a stroke [16]. In clinical and research settings, proprioception is most frequently assessed with limb-matching tasks. Two types of matching tasks have commonly been used: the ipsilateral remembered matching task and the contralateral concurrent matching task [17]. In an ipsilateral remembered matching task, the evaluator or robotic device brings the patient’s limb to a target joint position, when the patient’s eyes are closed, keeps the limb in this position for several seconds, and then moves back the limb to the initial position. The patient needs to memorize the reference position and replicate it with the same (ipsilateral) limb. This task cannot, however, be used to evaluate proprioception in individuals with working memory issues, which represent around 25% of individuals who sustained a stroke [18]. In such cases, the matching error observed could reflect memory deficits, rather than proprioceptive impairments. Moreover, upper limb paresis affects 76% of individuals who sustained a stroke [19], making the task’s execution difficult or impossible. Assessing proprioception with the less affected arm as the indicator arm is therefore frequently considered in patients with hemiparesis. Indeed, in a contralateral concurrent matching task, the patient has to reproduce a mirror image of the evaluated limb position with the opposite (contralateral) limb [17]. However, considering that 20% of individuals who sustained a stroke also presents proprioceptive impairment on the ipsilateral side of the lesion [13], it would be difficult to ascertain whether the error is due to deficits in the evaluated arm, the opposite arm or both. In addition, interhemispheric communication is required in a contralateral concurrent matching task. Individuals with asymmetric stroke or with transcallosal degeneration would therefore be particularly disadvantaged while being assessed with a contralateral concurrent matching task [17].

In order to study proprioception in individuals who sustained a stroke, we developed an assessment protocol, that combines the use of an exoskeleton and a virtual reality system, enabling the quantification of position sense without using the opposite arm, involving active movement of the evaluated limb or relying on working memory. The primary objective of the present study was to validate the assessment protocol by quantifying the elbow joint position sense of healthy adults, before using this protocol with individuals who sustained a stroke. As a secondary objective, test-retest reliability of the assessment protocol was investigated.[…]


Continue —> Quantification of upper limb position sense using an exoskeleton and a virtual reality display | Journal of NeuroEngineering and Rehabilitation | Full Text


Fig. 1KINARM Exoskeleton Lab. a Modified wheelchair with each arm supported against gravity by exoskeletons; (b) Virtual reality display; (c) Virtual arm and real arm positions (blue line; non-visible for the participant) where ∆Θ represents the angular difference between the real and the virtual arm. The white circle corresponds to the center of rotation, i.e. the elbow joint

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[ARTICLE] SITAR: a system for independent task-oriented assessment and rehabilitation

Over recent years, task-oriented training has emerged as a dominant approach in neurorehabilitation. This article presents a novel, sensor-based system for independent task-oriented assessment and rehabilitation (SITAR) of the upper limb.

The SITAR is an ecosystem of interactive devices including a touch and force–sensitive tabletop and a set of intelligent objects enabling functional interaction. In contrast to most existing sensor-based systems, SITAR provides natural training of visuomotor coordination through collocated visual and haptic workspaces alongside multimodal feedback, facilitating learning and its transfer to real tasks. We illustrate the possibilities offered by the SITAR for sensorimotor assessment and therapy through pilot assessment and usability studies.

The pilot data from the assessment study demonstrates how the system can be used to assess different aspects of upper limb reaching, pick-and-place and sensory tactile resolution tasks. The pilot usability study indicates that patients are able to train arm-reaching movements independently using the SITAR with minimal involvement of the therapist and that they were motivated to pursue the SITAR-based therapy.

SITAR is a versatile, non-robotic tool that can be used to implement a range of therapeutic exercises and assessments for different types of patients, which is particularly well-suited for task-oriented training.

The increasing demand for intense, task-specific neurorehabilitation following neurological conditions such as stroke and spinal cord injury has stimulated extensive research into rehabilitation technology over the last two decades.1,2 In particular, robotic devices have been developed to deliver a high dose of engaging repetitive therapy in a controlled manner, decrease the therapist’s workload and facilitate learning. Current evidence from clinical interventions using these rehabilitation robots generally show results comparable to intensity-matched, conventional, one-to-one training with a therapist.35 Assuming the correct movements are being trained, the primary factor driving this recovery appears to be the intensity of voluntary practice during robotic therapy rather than any other factor such as physical assistance required.6,7 Moreover, most existing robotic devices to train the upper limb (UL) tend to be bulky and expensive, raising further questions on the use of complex, motorised systems for neurorehabilitation.

Recently, simpler, non-actuated devices, equipped with sensors to measure patients’ movement or interaction, have been designed to provide performance feedback, motivation and coaching during training.812 Research in haptics13,14 and human motor control15,16 has shown how visual, auditory and haptic feedback can be used to induce learning of a skill in a virtual or real dynamic environment. For example, simple force sensors (or even electromyography) can be used to infer motion control17and provide feedback on the required and actual performances, which can allow subjects to learn a desired task. Therefore, an appropriate therapy regime using passive devices that provide essential and engaging feedback can enhance learning of improved arm and hand use.

Such passive sensor-based systems can be used for both impairment-based training (e.g. gripAble18) and task-oriented training (ToT) (e.g. AutoCITE8,9, ReJoyce11). ToT views the patient as an active problem-solver, focusing rehabilitation on the acquisition of skills for performance of meaningful and relevant tasks rather than on isolated remediation of impairments.19,20 ToT has proven to be beneficial for participants and is currently considered as a dominant and effective approach for training.20,21

Sensor-based systems are ideal for delivering task-oriented therapy in an automated and engaging fashion. For instance, the AutoCITE system is a workstation containing various instrumented devices for training some of the tasks used in constraint-induced movement therapy.8 The ReJoyce uses a passive manipulandum with a composite instrumented object having various functionally shaped components to allow sensing and training of gross and fine hand functions.11 Timmermans et al.22reported how stroke survivors can carry out ToT by using objects on a tabletop with inertial measurement units (IMU) to record their movement. However, this system does not include force sensors, critical in assessing motor function.

In all these systems, subjects perform tasks such as reach or object manipulation at the tabletop level, while receiving visual feedback from a monitor placed in front of them. This dislocation of the visual and haptic workspaces may affect the transfer of skills learned in this virtual environment to real-world tasks. Furthermore, there is little work on using these systems for the quantitative task-oriented assessment of functional tasks. One exception to this is the ReJoyce arm and hand function test (RAHFT)23 to quantitatively assess arm and hand function. However, the RAHFT primarily focuses on range-of-movement in different arm and hand functions and does not assess the movement quality, which is essential for skilled action.2428

To address these limitations, this article introduces a novel, sensor-based System for Independent Task-Oriented Assessment and Rehabilitation (SITAR). The SITAR consists of an ecosystem of different modular devices capable of interacting with each other to provide an engaging interface with appropriate real-world context for both training and assessment of UL. The current realisation of the SITAR is an interactive tabletop with visual display as well as touch and force sensing capabilities and a set of intelligent objects. This system provides direct interaction with collocation of visual and haptic workspaces and a rich multisensory feedback through a mixed reality environment for neurorehabilitation.

The primary aim of this study is to present the SITAR concept, the current realisation of the system, together with preliminary data demonstrating the SITAR’s capabilities for UL assessment and training. The following section introduces the SITAR concept, providing the motivation and rationale for its design and specifications. Subsequently, we describe the current realisation of the SITAR, its different components and their capabilities. Finally, preliminary data from two pilot clinical studies are presented, which demonstrate the SITAR’s functionalities for ToT and assessment of the UL. […]

Continue —> SITAR: a system for independent task-oriented assessment and rehabilitation Journal of Rehabilitation and Assistive Technologies Engineering – Asif Hussain, Sivakumar Balasubramanian, Nick Roach, Julius Klein, Nathanael Jarrassé, Michael Mace, Ann David, Sarah Guy, Etienne Burdet, 2017

Figure 1. The SITAR concept with (a) the interactive table-top alongside some examples of intelligent objects developed including (b) iJar to train bimanual control, (c) iPen for drawing, and (d) iBox for manipulation and pick-and-place.

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A better understanding of the neural substrates that underlie motor recovery after stroke has led to the development of innovative rehabilitation strategies and tools that incorporate key elements of motor skill re-learning, i.e. intensive motor training involving goal-oriented repeated movements. Robotic devices for the upper limb are increasingly used in rehabilitation. Studies have demonstrated the effectiveness of these devices in reducing motor impairments, but less so for the improvement of upper limb function. Other studies have begun to investigate the benefits of combined approaches that target muscle function (functional electrical stimulation and Botulinum Toxin injections), modulate neural activity (Noninvasive Brain stimulation) and enhance motivation (Virtual Reality) in an attempt to potentialize the benefits of robot-mediated training. The aim of this paper is to overview the current status of such combined-treatments and to analyze the rationale behind them.

1. Introduction
Significant advances have been made in the management of stroke (including prevention, acute management and rehabilitation), however cerebrovascular diseases remain the third most common cause of death and the first cause of disability worldwide[1–6]. Stroke causes brain damage, leading to loss of motor function. Upper limb (UL) function is particularly reduced, resulting in disability. Many rehabilitation techniques have been developed over the last decades to facilitate motor recovery of the UL in order to improve functional ability and quality of life [7–10]. They are commonly based on principles of motor skill learning to promote plasticity of motor neural networks. These principles include intensive, repetitive, task-oriented movement-based training [11–19]. A better understanding of the neural substrates of motor re-learning has led to the development of innovative strategies and tools to deliver exercise that meets these requirements. Treatments mostly target the neurological impairment (paresis, spasticity etc.) through the activation of neural circuits or by acting on peripheral effectors. Robotic devices provide exercises that incorporate key elements of motor learning. Advanced robotic systems can offer highly repetitive, reproducible, interactive forms of training for the paretic limb, which are quantifiable. Robotic devices also enable easy and objective assessment of motor performance in standardized conditions by the recording of biomechanical data (i.e., speed, forces, etc.) [20–22]. This data can be used to analyze and assess motor recovery in stroke patients [23–26]. Since the 1990’s, many other technology-based approaches and innovative pharmaceutical treatments have also been developed for rehabilitation, including virtual reality (VR)-based systems, Botulinum neurotoxin (BoNT) injections and Non Invasive Brain stimulation (NIBS) (Direct Current Stimulation (tDCS) and repetitive Transcranial Magnetic Stimulation (rTMS)). There is currently no high-quality evidence to support any of these innovative interventions, despite the fact that some are used in routine practice [27]. By their respective mechanisms of action, each of these treatments could potentiate the effects of robotic therapy, leading to greater improvements in motor capacity. The aim of this paper is to review studies of combined treatments based on robotic rehabilitation, and to analyze the rationale behind such approaches. […]

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[WEB SITE] Technology-Enhanced Stroke Treatment

SaeboFlex from Saebo Inc, Charlotte, NC, is a mechanical wrist and hand orthosis that assists digit extension to allow for object release and improved hand function and use.

In the United States, someone has a stroke every 40 seconds.1 With stroke mortality decreasing, and more people surviving the acute stroke event, stroke is a leading cause of long-term disability in this country.1,2 The resultant immobility and loss of independent functioning in daily activities speaks to the need for comprehensive and intensive stroke rehabilitation that address the often lasting effects of the stroke.

According to the American Heart Association/American Stroke Association, stroke is not just an acute event, but a chronic condition, with rehabilitation requiring “a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others.”3 These stroke rehabilitation guidelines call for programs to include individually designed plans, retraining to improve abilities to perform daily tasks and improve mobility, balance training to improve balance and decrease the risk of falls, and other key components that address impairments in speech, vision, and cognition, among others.3

In order to maximize the potential for recovery, stroke rehabilitation programs should include intensive, repetitive, meaningful, and task-specific therapies.3 These therapies address the devastating effects of stroke—loss of mobility, decreased ambulation, loss of upper extremity function—all of which impact overall and long-term health and quality of life. At Burke Rehabilitation Hospital, White Plains, NY, more than 500 patients who have suffered a stroke are admitted annually for comprehensive, acute inpatient rehabilitation. The large multidisciplinary team is focused on improving functional independence in preparation for discharge and return home. Individual care plans are developed and often utilize the latest technologies to ensure patient access to the most advanced equipment and evidence-based interventions. Investments in rehabilitation technologies have assisted in providing optimal, state-of-the-art rehab care for patients.

Product ResourcesThe following companies provide technologies for functional measurement and assessment:





GAITRite/CIR Systems Inc

Gorbel Medical/SafeGait


Mobility Research


Saebo Inc



Vista Medical

Woodway USA

Mobility Retraining

Gait retraining is one of the primary goals of stroke rehabilitation. Patients often state their goal in rehab is “to walk again.” Many technologies are utilized to support the task-specific and impairment-focused interventions that facilitate pre-gait and ambulation tasks. Each offers unique features and benefits that assist patients and therapists with carrying out each individual’s treatment plan.

The ZeroG Lite from Aretech, Ashburn, Va, is a body-weight support treadmill system that allows patients to safely practice gait training tasks over a treadmill by altering the amount of body-weight support. The difficulty and challenge of the task can be adjusted for the patient’s ability to practice intensive gait and balance activities, and parameters can be changed to change the intensity and duration of the tasks. The treadmill can be inclined and the belt speed can be reversed to facilitate walking up and down slopes.

The Guldmann Active Trainer with Ceiling Mounted Track from Guldmann Inc, Tampa, Fla, is a ceiling track-mounted system that provides adjustable body weight support that is used to provide balance and gait training. Patients with lateropulsion (turning of gait to one side) can safety be brought to a supported upright position to assist with regaining midline orientation and improving posture and weight bearing. Patients who are ambulatory are able to use the trainer in therapy to decrease gait deviations and improve gait quality and speed. Other types of ceiling-mounted body weight support systems that can provide utility for rehabbing individuals affected by stroke include the ZeroG Gait and Balance Training System, also from Aretech. This system can help protect users from falls as well as facilitate functional activities such as walking, sit-to-stand, postural tasks, balance activities, and more. It is also built to accommodate users who weigh up to 400 pounds.

The Bioness Vector from Valencia, Calif-based Bioness is also a ceiling-mounted body-weight support system that can provide a safe environment for over-ground training. The system has an adjustable fall limit setting, and the overhead track designs can be built to a clinic’s specifications. The SafeGait 360° Balance and Mobility Trainer from Gorbel Inc-Medical Division, Fishers, NY, is another overhead track system built to provide dynamic body-weight support and fall protection for early rehab post-stroke.

Other technologies that provide body-weight support for rehab training include LiteGait from Mobility Research, Tempe, Ariz, a gait training device that controls weight bearing, posture, and balance over a treadmill or over ground. It allows individuals to comfortably walk in a secure environment free of falls, altering weight bearing capacity via a sling support. LiteGait provides proper posture, reduces weight bearing, eliminates concerns for balance, and facilitates the training of coordinated lower extremity movement. The device can retrain postural stability and upright posture.

The Lokomat is a robotic device from Hocoma USA, Norwell, Mass, designed to provide highly repetitive physiological gait training that can be useful to therapists treating patients affected by neurological impairment. The user is supported by a harness suspended overhead while using an individually adjustable exoskeleton. Speed, loading, and robotic support all can be adjusted.

The WalkAide System from Innovative Neurotronics, Reno, Nev, is a myo-orthotic device, which combines electrical stimulation with orthotic technology in the treatment of foot drop. It is used to improve independence, functional mobility, and safety.

Also utilized is the NESS L300 Plus Foot Drop System available from Bioness, a neuro-orthotic and rehabilitation system that provides electrical currents to stimulate nerves and muscles to assist with a more natural walking pattern, reduce muscle spasms, reduce muscle loss, maintain or improve range of motion, and increase local blood circulation. It, too, is used to improve independence, functional mobility, and safety in the treatment of foot drop.

The Up n’ Go, offered by Easy Walking, Maple Glen, Pa, is a support device with a suspension system that allows for gait training through partial weight bearing and assists with sit to stand transitions. The device is lightweight and adjustable, allowing use with individuals with a range of balance and strength capabilities…

More —> Technology-Enhanced Stroke Treatment – Physical Therapy Products

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[ARTICLE] Development and assessment of a hand assist device: GRIPIT – Full Text



Although various hand assist devices have been commercialized for people with paralysis, they are somewhat limited in terms of tool fixation and device attachment method. Hand exoskeleton robots allow users to grasp a wider range of tools but are heavy, complicated, and bulky owing to the presence of numerous actuators and controllers. The GRIPIT hand assist device overcomes the limitations of both conventional devices and exoskeleton robots by providing improved tool fixation and device attachment in a lightweight and compact device. GRIPIT has been designed to assist tripod grasp for people with spinal cord injury because this grasp posture is frequently used in school and offices for such activities as writing and grasping small objects.


The main development objective of GRIPIT is to assist users to grasp tools with their own hand using a lightweight, compact assistive device that is manually operated via a single wire. GRIPIT consists of only a glove, a wire, and a small structure that maintains tendon tension to permit a stable grasp. The tendon routing points are designed to apply force to the thumb, index finger, and middle finger to form a tripod grasp. A tension-maintenance structure sustains the grasp posture with appropriate tension. Following device development, four people with spinal cord injury were recruited to verify the writing performance of GRIPIT compared to the performance of a conventional penholder and handwriting. Writing was chosen as the assessment task because it requires a tripod grasp, which is one of the main performance objectives of GRIPIT.


New assessment, which includes six different writing tasks, was devised to measure writing ability from various viewpoints including both qualitative and quantitative methods, while most conventional assessments include only qualitative methods or simple time measuring assessments. Appearance, portability, difficulty of wearing, difficulty of grasping the subject, writing sensation, fatigability, and legibility were measured to assess qualitative performance while writing various words and sentences. Results showed that GRIPIT is relatively complicated to wear and use compared to a conventional assist device but has advantages for writing sensation, fatigability, and legibility because it affords sufficient grasp force during writing. Two quantitative performance factors were assessed, accuracy of writing and solidity of writing. To assess accuracy of writing, we asked subjects to draw various figures under given conditions. To assess solidity of writing, pen tip force and the angle variation of the pen were measured. Quantitative evaluation results showed that GRIPIT helps users to write accurately without pen shakes even high force is applied on the pen.


Qualitative and quantitative results were better when subjects used GRIPIT than when they used the conventional penholder, mainly because GRIPIT allowed them to exert a higher grasp force. Grasp force is important because disabled people cannot control their fingers and thus need to move their entire arm to write, while non-disabled people only need to move their fingers to write. The tension-maintenance structure developed for GRIPIT provides appropriate grasp force and moment balance on the user’s hand, but the other writing method only fixes the pen using friction force or requires the user’s arm to generate a grasp force.


The hand is one of the most essential body parts for independent living because so many tasks of daily life, such as writing, eating, and grasping, require a functional hand. People who suffer from permanent paralysis of the hand owing to cerebral palsy, spinal cord injury (SCI), stroke, and other neurological disorders require assistive or rehabilitation devices in order to regain independence and return to work [1, 2].

A selection of commercialized hand assist devices is shown in Fig. 1. These devices are attached to the user’s arm or hand with Velcro® or elastic bands, and hand tools such as pens, forks, and paintbrushes are clamped into a hole in the devices. One drawback of these devices is that they can only grasp one type of tool because the receiving hole is a constant size. Users also must sometimes sustain an awkward posture to use a tool because it is mounted into the device in an unfamiliar position. Additionally, the Velcro or elastic band used to fix the device can apply high pressure to the skin if the strapping is too tight, and tools can be too shaky to use if the strapping becomes too loose. These problems reduce the usability of these devices and require users to put in a certain of amount of training time to become familiar with their use.

Fig. 1 Various types of hand assist devices for people with hand paralysis. a Writing aid. b Eating aid. c Grasping aid. d Cooking aid

Continue —> Development and assessment of a hand assist device: GRIPIT | Journal of NeuroEngineering and Rehabilitation | Full Text

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