[Textbook] Orthopedic Rehabilitation – Principles and Practice

Editors: Tony K. George, S. Ali Mostoufi, Alfred J. Tria Jr.

• A concise, practical guide to the principles and practice of orthopedic rehabilitation for residents and fellows
• Utilizes a consistent chapter format, arranged anatomically and covering each joint
• Written and edited by experts in both the orthopedic and physical medicine field

Sections

• Table of contents
• About this book
• Keywords
• Editors and Affiliations
• About the editors
• Bibliographic Information

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Table of contents (11 chapters)

1. Rehabilitation Principles for Interventional Orthopedics and Orthobiologics
   • Walter I. Sussman, Marc P. Gruner, David R. Bakal, Kenneth R. Mautner
   Pages 1-40
2. Rehabilitation of Cervical Spine Disorders
   • Laurent Delaveaux, Matthew Thomas, Brielle Hansen, Tony K. George
   Pages 41-66
3. Rehabilitation of Thoracic Spine Disorders
   • Tony K. George, Sneha Varghese, Mindy Chu, Brittney Tout, Hemant Kalia
   Pages 67-118
4. Rehabilitation of Lumbar Spine Disorders
   • Tony K. George, Matthew Thomas, Sruthi Nanduri, Liya Thomas, Wayne Bonkowski, Bobby Oommen
   Pages 119-149
5. Rehabilitation of Shoulder Disorders
   • William Micheo, Anthony Lombardi, Claudia Jimenez
   Pages 151-193
6. Rehabilitation of Elbow Disorders
   • Robert Bowers, Joshua M. Romero, Robert Pagan-Rosado, Dennis A. Colón
   Pages 195-242
7. Rehabilitation of Hand Disorders
   • Remy V. Rabinovich, Robert M. Zbeda, Steven Beldner, Daniel B. Polatsch
   Pages 243-285
8. Rehabilitation of Wrist Disorders
   • Robert M. Zbeda, Remy V. Rabinovich, Steven Beldner, Daniel B. Polatsch
   Pages 287-313
9. Rehabilitation of Hip Disorders
   • David A. Harwood, Anna H. Green, John P. Stelmach, Alfred J. Tria Jr.
   Pages 315-340
10. Rehabilitation of Knee Disorders
    • Giles R. Scuderi, Matt H. Nasra, Jeremy Silver, Kara L. Sarrel, Alfred J. Tria Jr.
    Pages 341-378
11. Rehabilitation of Foot and Ankle Disorders
    • Seyed Behrooz Mostofi, Naveen Joseph Mathai
    Pages 379-406

About this book

This pocket-sized guide provides a practical and comprehensive resource for orthopedic, PM&R, and musculoskeletal specialists, as well as primary care physicians who work in the community outpatient clinic setting. Its consistent chapter format covers each area with anatomy, physical examination, preoperative management, and postoperative rehabilitation sections for the spine and extremities.

The book presents treatment protocols for various injuries, including physical therapy measures such as weight bearing status, PRE, closed or open chain exercises, and timing for returning to routine or sport activities. Its concise presentation of rehabilitation for the upper and lower extremities, the hip and pelvis, and the spine enables quick reference and clinical decision-making.

Furthermore, the book includes a chapter on rehabilitation following the use of orthobiologics, making it a valuable resource for healthcare professionals involved in orthopedic rehabilitation after regenerative intervention.

Source

[Abstract] AGREE: A compliant-controlled upper-limb exoskeleton for physical rehabilitation of neurological patients

Abstract

In this work, we introduce the Agree exoskeleton, a robotic device designed to assist in upper-limb physical rehabilitation for post-stroke survivors. We detail the exoskeleton design at the mechatronic, actuation, and control levels. The Agree exoskeleton features a lightweight and adaptable mechanical design, which can be used with both the right and left arm, supporting three active degrees-of-freedom at the shoulder and one at the elbow. The device embodies a spring-pulley anti-gravity system to minimize torque requirements and has torque sensors on each joint for safe and smooth interaction with the user. The Agree control system, which employs a loadcell-based impedance control method, offers various modes of human-robot interaction, such as passive-assisted, active-assisted, and active-resistive exercises. Results from our experimental characterization demonstrate that the exoskeleton is capable of both compliant and rigid behavior, providing a wide range of haptic impedance and transparent behavior to both user-generated and therapist-generated forces. Our findings indicate that the Agree exoskeleton may be a viable option for safely assisting patients with neurological conditions.

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[Abstract] CURER: A Lightweight Cable-Driven Compliant Upper Limb Rehabilitation Exoskeleton Robot

Abstract

Upper limb exoskeletons show promise for improving functionalities required for stroke patients. Despite recent progress, most of current upper limb rehabilitation devices are still bulky, heavy, and less compliant to be applied. This article presents a cable-driven compliant upper limb rehabilitation exoskeleton robot (CURER) with a lightweight frame and comfortable human–robot interaction. A modular series elastic actuator (SEA) was designed to provide controlled torque for each active robotic joint, and Bowden cables were applied to transfer controlled torque to distal joints. A six-bar double parallelogram mechanism was designed to implement 3 active degrees of freedom (DOFs) of a shoulder. An actuated elbow with 1 DOF and a wrist with a passive DOF were also developed for CURER. The anthropomorphic shoulder, elbow, and wrist joints can minimize misalignment between human upper limbs and the robot. The length of anthropomorphic arm was adjustable for a wide range of users. It can apply up to a 33 N·m torque in shoulder flexion/extension, abduction/adduction, intra/extra rotation, and elbow flexion/extension, with a range of 7.6–8.0 Hz position bandwidth in each actuation. CURER has a large range of motion and can provide accurate torque control for stroke patients’ requirements. Besides, a comprehensive rehabilitation strategy including robot-in-charge mode and human-in-charge mode was developed for different recovery stages. Experiments carried out on CURER actuation units demonstrated good position and impedance control performance. Finally, a virtual reality training system was developed to assist the subjects to accomplish upper limb rehabilitation efficiently.

Source

[Abstract] A Home-based Tele-rehabilitation System with Enhanced Therapist-patient Remote Interaction: A Feasibility Study

Abstract:

As a promising alternative to hospital-based manual therapy, robot-assisted tele-rehabilitation therapy has shown significant benefits in reducing the therapist’s workload and accelerating the patient’s recovery process. However, existing telerobotic systems for rehabilitation face barriers to implementing appropriate therapy treatment due to the lack of effective therapist-patient interactive capabilities. In this paper, we develop a home-based tele-rehabilitation system that implements two alternative training methods, including a haptic-enabled guided training that allows the therapist to adjust the intensity of therapeutic movements provided by the rehabilitation device and a surface electromyography (sEMG)-based supervised training that explores remote assessment of the patient’s kinesthetic awareness. Preliminary experiments were conducted to demonstrate the feasibility of the proposed alternative training methods and evaluate the functionality of the developed tele-rehabilitation system. Results showed that the proposed tele-rehabilitation system enabled therapist-in-the-loop to dynamically adjust the rehabilitation intensity and provided more interactivity in therapist-patient remote interaction.

Source

[Abstract] Design and Control of a Reconfigurable Upper Limb Rehabilitation Exoskeleton with Soft Modular Joints – Full Text PDF

Abstract

Upper limb rehabilitation robot can effectively help patients recover motor ability. Existing rehabilitation robots are usually driven by rigid motors and the mechanical structures cannot adapt to the different patients with the different physical parameters and different rehabilitation needs. This paper designs a reconfigurable upper limb rehabilitation exoskeleton for elbow and wrist joints driven by pneumatic muscle actuators (PMAs). The exoskeleton can assist patients to achieve elbow flexion/extension, wrist flexion/ extension and adduction/abduction by integrating soft elbow and wrist joint modules which can work separately or together. The wrist joint can realize two degrees of freedom (2-DoF) movement via adjustable modules. To conquer the dynamic model errors and load disturbances when reconstructing the modular joints, a non-singular fast terminal sliding mode control method based on nonlinear disturbance observer (NFTSMC-NDO) is proposed, and a position/force hierarchical control method is formed to ensure the controllability of the soft modular robot. Experimental results show that the proposed method can achieve high-precision motion control of soft modular joints and provide reconfigurable assistance for patients, improving the adaptability and compliance of rehabilitation training.

Full Text PDF

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[ARTICLE] An Exoneuromusculoskeleton for Self-Help Upper Limb Rehabilitation After Stroke – Full Text

Abstract

This article presents a novel electromyography (EMG)-driven exoneuromusculoskeleton that integrates the neuromuscular electrical stimulation (NMES), soft pneumatic muscle, and exoskeleton techniques, for self-help upper limb training after stroke. The developed system can assist the elbow, wrist, and fingers to perform sequential arm reaching and withdrawing tasks under voluntary effort control through EMG, with a lightweight, compact, and low-power requirement design. The pressure/torque transmission properties of the designed musculoskeletons were quantified, and the assistive capability of the developed system was evaluated on patients with chronic stroke (n = 10). The designed musculoskeletons exerted sufficient mechanical torque to support joint extension for stroke survivors. Compared with the limb performance when no assistance was provided, the limb performance (measured as the range of motion in joint extension) significantly improved when mechanical torque and NMES were provided (p < 0.05). A pilot trial was conducted on patients with chronic stroke (n = 15) to investigate the feasibility of using the developed system in self-help training and the rehabilitation effects of the system. All the participants completed the self-help device-assisted training with minimal professional assistance. After a 20-session training, significant improvements were noted in the voluntary motor function and release of muscle spasticity at the elbow, wrist, and fingers, as indicated by the clinical scores (p < 0.05). The EMG parameters (p < 0.05) indicated that the muscular coordination of the entire upper limb improved significantly after training. The results suggested that the developed system can effectively support self-help upper limb rehabilitation after stroke. ClinicalTrials.gov Register Number NCT03752775.

Introduction

Upper limb motor deficits are noted in >80% of stroke survivors,^1,2 who require continuous long-term physical rehabilitation to reduce upper limb impairments.^3,4 Restoration of poststroke limb function requires intensive repeated training of the paralyzed limb^5,6 with maximized voluntary motor effort^7,8 and minimized compensatory motions in close-to-normal muscular coordination.^8,9 However, long-term poststroke rehabilitation is challenging because of the expanding stroke population and insufficiency of professional staff worldwide.^10,11 Effective rehabilitation methods with potential for self-help training by stroke survivors are urgently required to improve the independency of stroke survivors and decrease the burden on the health care system. Suitable technologies for these methods are currently lacking.^11,12

Various rehabilitation robots have been developed to assist the labor-intensive process of physical poststroke training, with main advantages of higher dosage and lower cost compared with traditional “one-to-one” manual physical therapy.¹³ However, these robots are large equipment powered by alternating current (AC) that require professional operation in a clinical environment with limited access to outpatients. Mobile exoskeletons are an emerging technology with wearable application. These exoskeletons are powered by portable batteries and have potential for user-independent self-help rehabilitation that can be accessed anytime, even in unconventional environments (e.g., at home).^12,14,15 However, currently available upper limb exoskeletons, which are composed of rigid materials and actuated by electrical motors, are constrained by their heavy weight and low torque-to-weight ratio, which limit their user-independent applications. These exoskeletons require high-power consumption because their actuations must generate sufficient torque to support paralyzed limbs as well as the weight of the system worn on the body. Thus, most exoskeletons require AC supply,^11,15,16 which triggers electrical safety concerns for user-independent usage.

Furthermore, the body/device integration is neither stable nor comfortable in current rigid exoskeletons, with misalignment or migration occurring during repeated practice mainly because of the non-negligible weights mounted onto the paretic limb.^11,14 Misalignments with additional loads deteriorate abnormal muscular coordination in the paralyzed upper limb, which undermines the rehabilitative potential of the aforementioned systems.^17,18 Therefore, most rigid exoskeletons for poststroke upper limb rehabilitation are still used under the close assistance of professionals in clinical environments, and their rehabilitation effects in user-independent operations are unclear.

With the introduction of soft materials in mechanical actuation, soft robotic equipment has been designed using easily deformable materials with light and flexible actuators that conform to human body contours^19–22 so as to achieve superior body/device integration to that provided by rigid robotic equipment. Three main types of actuation systems, namely cable, hydraulic, and pneumatic systems, are used in current wearable soft robots.²¹ Cable systems used cables with desired tension attached to a target limb for flexion/extension.^11,23 The cable-driven upper limb exoskeletons usually have a lightweight design with low inertia in the wearable part accommodating possible joint misalignment between the paretic limb and the exoskeleton.²³ However, the cable is driven by electric motors with gears/pulleys, leading to an increment of complexity and overall weight of the whole assembly.²³ Hydraulic systems are powered by hydraulic pressure, and able to produce greater torque compared with the actuators in cable and pneumatic systems.^11,23,24 However, few hydraulic systems have been developed for upper limb, because they are relatively heavy and complex in the design, requiring additional space to accommodate the fluid and to prevent leakages under pressure.^11,16,23

In contrast, pneumatic systems (pneumatic muscles) are the most commonly adopted actuation for the upper limb.^21,23 Pneumatic exoskeletons have high torque-to-weight ratios because of the low weight of the wearable part actuated by air.^21,25–29 However, pneumatic systems are usually bulky and slow in power transmission from pressure to torque during air inflation by compressors for needed air volume and pressure compared with electrical motor actuation in rigid exoskeleton to achieve equivalent mechanical outputs (e.g., joint torque).^23,30 Large and high-power compressors connected to the pneumatic muscles constrain these devices for user-independent applications.²¹ Thus, a novel lightweight mechanical design is required to achieve optimized body/device integration with fast power transmission, high torque-to-weight ratios, and low-power consumption for user-independent self-help rehabilitation.

Neuromuscular electrical stimulation (NMES), proposed for upper limb rehabilitation,^31,32 can activate the contraction of impaired muscles to generate limb movement^31,32 and effectively enhance the muscle force and sensory feedback for motor relearning after stroke.³³ However, controlling motion kinematics, such as the range of motion (ROM) and trajectory, by using NMES alone is difficult because of the limited stimulating precision in fine motor control.³⁴ Recently, NMES has been combined with mechanical robots in poststroke training.³⁵ The combined NMES-robot treatment is more effective than treatment involving the use of only NMES or only a robot in upper limb rehabilitation, particularly in improving muscular coordination by reducing muscular compensation.³⁶ The integration of NMES into a robot can trigger the biological actuation of target muscles to reduce the demand of mechanical support from the robot part.¹¹ However, little has been done on the integration of NMES with mobile exoskeletons or soft robots.

In this study, we designed a multi-integrated robotic system that combines the NMES, soft pneumatic muscle, and exoskeleton techniques, namely exoneuromusculoskeleton, for upper limb rehabilitation after stroke. Mechanical integration between rigid exoskeleton and pneumatic muscle (i.e., exomusculoskeleton) can enable high torque-to-weight ratios with a compact size and fast power transmission. By combining NMES with the exomusculoskeleton (i.e., exoneuromusculoskeleton), the mechanical scale and power requirement of the entire system can be reduced due to the evoked muscular effort. In addition, NMES and mechanical assistance enable the achievement of close-to-normal muscular coordination with minimized compensatory motions. To optimize therapeutic outcomes, electromyography (EMG) of the paralyzed limb has been used to indicate voluntary intentions³⁷ to maximize voluntary motor effort during practice for better improvements in voluntary motor functions with longer sustainability compared with those with passive limb motions.³⁸

In this study, we designed an EMG-driven exoneuromusculoskeleton to assist the upper limb physical practice at the elbow, wrist, and fingers. The assistive capability of the designed system was evaluated on patients with chronic stroke. The designed system’s feasibility of self-help operation and rehabilitation effects were also investigated through a pilot single-group trial.

Methods

The designed exoneuromusculoskeleton (Fig. 1) could be worn on the paretic upper limb of a stroke survivor. The designed system comprised two wearable parts: the elbow (158 g) and wrist/hand (50 g). Both parts were connected to a pump box (80 g) mounted on the upper limb. Moreover, a control box (358 g) that included system control circuits and a rechargeable 12-V battery could be carried on the waist. The developed system can assist a stroke survivor to perform sequential arm reaching and withdrawing tasks, namely (1) elbow extension, (2) wrist extension with the hand open, (3) wrist flexion with the hand closed, and (4) elbow flexion. Real-time control and wireless communication between the control box and a mobile application (app) were achieved on a smartphone through a microprocessor and Bluetooth module.

FIG. 1. (a) Overview of the exoneuromusculoskeleton, with the inner structures of a pump box and the control box. (b) Attachment of the musculoskeletons, and structures with dimensions of the elbow musculoskeleton and the hand musculoskeleton (all the dimensions are in millimeters). EMG, electromyography; NMES, neuromuscular electrical stimulation.

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[Abstract] A Home-based Bilateral Rehabilitation System with sEMG-based Real-time Variable Stiffness

Abstract

Bilateral rehabilitation allows patients with hemiparesis to exploit the cooperative capabilities of both arms to promote the recovery process. Although various approaches have been proposed to facilitate synchronized robot-assisted bilateral movements, few studies have focused on addressing the varying joint stiffness resulting from dynamic motions. This paper presents a novel bilateral rehabilitation system that implements a surface electromyography (sEMG)-based stiffness control to achieve real-time stiffness adjustment based on the user’s dynamic motion. An sEMG-driven musculoskeletal model that incorporates muscle activation and muscular contraction dynamics is developed to provide reference signals for the robot’s real-time stiffness control. Preliminary experiments were conducted to evaluate the system performance in tracking accuracy and comfortability, which showed the proposed rehabilitation system with sEMG-based real-time stiffness variation achieved fast adaption to the patient’s dynamic movement as well as improving the comfort in robot-assisted bilateral training.

Source

[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.

 Full Text PDF

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

[Abstract] An interactive and innovative application for hand rehabilitation through virtual reality

Abstract

Physiotherapy has been very monotonous for patients and they tend to lose interest and motivation in exercising. Introducing games with short term goals in the field of rehabilitation is the best alternative, to maintain patients’ motivation. Our research focuses on gamification of hand rehabilitation exercises to engage patients’ wholly in rehab and to maintain their compliance to repeated exercising, for a speedy recovery from hand injuries (wrist, elbow and fingers). This is achieved by integrating leap motion sensor with unity game development engine. Exercises (as gestures) are recognised and validated by leap motion sensor. Game application for exercises is developed using unity. Gamification alternative has been implemented by very few in the globe and it has been taken as a challenge in our research. We could successfully design and build an engine which would be interactive and real-time, providing platform for rehabilitation. We have tested the same with patients and received positive feedbacks. We have enabled the user to know the score through GUI.

 

via An interactive and innovative application for hand rehabilitation through virtual reality: International Journal of Advanced Intelligence Paradigms: Vol 15, No 3

[Abstract] A 5-Degrees-of-Freedom Lightweight Elbow-Wrist Exoskeleton for Forearm Fine-Motion Rehabilitation

Abstract

Exoskeleton robots have been demonstrated to effectively assist the rehabilitation of patients with upper or lower limb disabilities. To make exoskeletons more accessible to patients, they need to be lightweight and compact without major performance tradeoffs. Existing upper-limb exoskeletons focus on assistance with coarse-motion of the upper arm while forearm fine-motion rehabilitation is often ignored. This paper presents an elbow-wrist exoskeleton with five degrees-of-freedom (DoFs). Using geared bearings, slider crank mechanisms, and a spherical mechanism for the wrist and elbow modules, this exoskeleton can provide 5-DoF rotary motion forearm assistance. The optimized exoskeleton dimensions allow sufficient rotation output while the motors are placed parallel to the forearm and elbow joint. Thus compactness and less inertia loading can be achieved. Linear and rotary series elastic actuators (SEAs) with high torque-to-weight ratios are proposed to accurately measure and control interaction force and impedance between exoskeleton and forearm. The resulting 3-kg exoskeleton can be used alone or easily in combination with other exoskeleton robots to provide various robot-aided upper limb rehabilitation.

via A 5-Degrees-of-Freedom Lightweight Elbow-Wrist Exoskeleton for Forearm Fine-Motion Rehabilitation – IEEE Journals & Magazine