Posts Tagged hemiparesis

[ARTICLE] Efficacy and Safety of AbobotulinumtoxinA (Dysport) for the Treatment of Hemiparesis in Adults With Upper Limb Spasticity Previously Treated With Botulinum Toxin: Subanalysis From a Phase 3 Randomized Controlled Trial – Full Text

Abstract

Objective

To assess the efficacy and safety of abobotulinumtoxinA in adults with upper limb spasticity previously treated with botulinum toxin A (BoNT-A).

Design

post hoc analysis from a Phase 3, prospective, double-blind, randomized, placebo-controlled study (NCT01313299).

Setting

A total of 34 neurology or rehabilitation clinics in 9 countries.

Participants

Adults aged 18-80 years with hemiparesis, ≥6 months after stroke or traumatic brain injury. This analysis focused on a subgroup of subjects with previous onabotulinumtoxinA or incobotulinumtoxinA treatment (n = 105 of 243 in the total trial population) in the affected limb. The mean age was 52 years, and 62% were male.

Intervention

Study subjects were randomized 1:1:1 to receive a single injection session with abobotulinumtoxinA 500 or 1000 U or with placebo in the most hypertonic muscle group among the elbow, wrist, or finger flexors (primary target muscle group [PTMG]), and ≥2 additional muscle groups from the upper limb.

Main Outcome Measurements

Efficacy and safety measures were assessed, including muscle tone (Modified Ashworth Scale [MAS] in the PTMG), Physician Global Assessment (PGA), perceived function, spasticity, active movement, and treatment-emergent adverse events.

Results

At week 4, more subjects had ≥1 grade improvement in MAS for the PTMG with abobotulinumtoxinA versus placebo (abobotulinumtoxinA 500 U, 81.1%; abobotulinumtoxinA 1000 U, 75.0%; placebo, 25.0%). PGA scores ≥1 were achieved by 75.7% and 87.5% of abobotulinumtoxinA 500 and 1000 U subjects versus 41.7% with placebo. Perceived function (Disability Assessment Scale), spasticity angle (Tardieu Scale), and active movement were also improved with abobotulinumtoxinA. There were no treatment-related deaths or serious adverse events.

Conclusions

The efficacy and safety of abobotulinumtoxinA in subjects previously treated with BoNT-A were consistent with those in the total trial population. Hence, abobotulinumtoxinA is a treatment option in these patients, and no difference in initial dosing appears to be required compared to that in individuals not treated previously.

 

Introduction

Upper limb spasticity (ULS) is common after stroke or traumatic brain injury (TBI). The impact can be highly significant, including abnormal hand and arm positions, impaired self-care, and limited passive/active range of motion, as well as additional burden to the caregiver [1-5].

The effectiveness of treatment with intramuscularly injected botulinum toxin A (BoNT-A) in reducing muscle tone in patients with ULS is well established [5-8]. Several guidelines now recommend BoNT-A injections as a first-line treatment option in these patients [6,7,9-11].

AbobotulinumtoxinA (Dysport; Ipsen Biopharm, Wrexham, UK) is a BoNT-A preparation approved in the United States and Europe for the treatment of ULS in adult patients [12,13]. A recent clinical trial examined the efficacy and safety of a single injection session of abobotulinumtoxinA (500 or 1000 U) in 243 adults with ULS who had hemiparesis at least 6 months after stroke or TBI [14]. The effects observed included improvements in muscle tone, perceived function, spasticity, and active range of motion. Furthermore, the treatment was well tolerated, and all treatment-related adverse events (AEs) were mild or moderate in severity.

Among the subjects enrolled in this study, 105 had previously undergone treatment in the upper limb with onabotulinumtoxinA or incobotulinumtoxinA. The aim of the present analysis was to assess the efficacy and safety of abobotulinumtoxinA in adults with ULS who had been previously treated with a BoNT-A, and to describe the doses of abobotulinumtoxinA administered to these subjects. […]

Continue —> Efficacy and Safety of AbobotulinumtoxinA (Dysport) for the Treatment of Hemiparesis in Adults With Upper Limb Spasticity Previously Treated With Botulinum Toxin: Subanalysis From a Phase 3 Randomized Controlled Trial – ScienceDirect

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[ARTICLE] Kinect-based individualized upper extremity rehabilitation is effective and feasible for individuals with stroke using a transition from clinic to home protocol – Full Text PDF

Purpose: To investigate the effectiveness and feasibility of Kinect-based upper
extremity rehabilitation on functional performance in chronic stroke survivors.
Methods: This was a single cohort pre-post test study. Participants (N=10; mean age =
62.5 ± 9.06) engaged in Kinect-based training three times a week for four to five weeks
in a university laboratory. To simulate a clinic to home transfer condition,
individualized guidance was given to participants at the initial three sessions followed
by independent usage. Outcomes included Fugl-Meyer assessment of upper extremity,
Wolf Motor Function Test, Stroke Impact Scale, Confidence of Arm and Hand
Movement and Active Range of Motion. Participant experience was assessed using a
structured questionnaire and a semi-structured interview.
Results. Improvement was found in Fugl-Meyer assessment scores (p=0.001), Wolf
Motor Function Test, (p=0.008), Active Range of Motion (p<0.05) and Stroke Impact
Scale-Hand function (p=0.016). Clinically important differences were found in FuglMeyer
assessment scores (Δ= 5.70 ± 3.47) and Wolf Motor Function Test (Δ Time= –
4.45 ± 6.02; ∆ Functional Ability Scores= 0.29 ± 0.31). All participants could use the
system independently and recognized the importance of exercise individualization by
the therapist.
Conclusions. The Kinect-based UE rehabilitation provided clinically important
functional improvements to our study participants.

Introduction

Stroke is the leading cause of long-term adult disability in the United States [1].
More than a half of survivors continue suffering from upper-limb hemiparesis poststroke with only 5% of people recovering their full arm function [2]. The persistent
upper-limb dysfunction significantly impairs motor performance, and results in a
serious decline in functional ability as well as quality of life [3]. Intensive and repeated
practice with the paretic arm appears necessary to enhance arm recovery and facilitate
neural reorganization [4-7]. Nevertheless, the healthcare system provides limited
amounts and duration of therapy, making it difficult for stroke survivors to achieve
maximal arm recovery before discharge from outpatient rehabilitation or home care
[8,9]. Therefore, identifying novel modalities that are accessible and affordable to the
general public while allowing continued practice of the arm is imperative for improving
long-term upper-limb outcomes after stroke.
One potential approach is the use of low-cost virtual reality (VR)-based systems,
for example, the Microsoft Kinect system. The Kinect is a vision-based motion
capturing system that can detect gesture and movements of the body through its RGA
camera and depth sensors. It allows users to interact with the VR-based system without
holding or wearing specialized equipment or markers for tracking. Users can play
games or practice exercises using natural movements while observing the performance of their virtual avatars shown in real-time on the computer screen. Through this interactive observation and feedback, stroke survivors can correct their movements towards more normal patterns. Furthermore, the Kinect is small and portable, thus enabling stroke survivors to practice exercises in a familiar and private environment. […]

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[ARTICLE] Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trial – Full Text

To assess the feasibility of a randomized controlled trial to evaluate music therapy as a home-based intervention for arm hemiparesis in stroke.

A pilot feasibility randomized controlled trial, with cross-over design. Randomization by statistician using computer-generated, random numbers concealed in opaque envelopes.

Participants’ homes across Cambridgeshire, UK.

Eleven people with stroke and arm hemiparesis, 3–60 months post stroke, following discharge from community rehabilitation.

Each participant engaged in therapeutic instrumental music performance in 12 individual clinical contacts, twice weekly for six weeks.

Feasibility was estimated by recruitment from three community stroke teams over a 12-month period, attrition rates, completion of treatment and successful data collection. Structured interviews were conducted pre and post intervention to establish participant tolerance and preference. Action Research Arm Test and Nine-hole Peg Test data were collected at weeks 1, 6, 9, 15 and 18, pre and post intervention by a blinded assessor.

A total of 11 of 14 invited participants were recruited (intervention n = 6, waitlist n = 5). In total, 10 completed treatment and data collection.

It cannot be concluded whether a larger trial would be feasible due to unavailable data regarding a number of eligible patients screened. Adherence to treatment, retention and interview responses might suggest that the intervention was motivating for participants.

Continue —>  Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trialClinical Rehabilitation – Alexander J Street, Wendy L Magee, Andrew Bateman, Michael Parker, Helen Odell-Miller, Jorg Fachner, 2018

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[Abstract] Effect of postural insoles on gait pattern in individuals with hemiparesis: A randomized controlled clinical trial.

Abstract

Introduction

Recovering the ability to walk is an important goal of physical therapy for patients who have survived cerebrovascular accident (stroke). Orthotics can provide a reduction in plantar flexion of the ankle, leading to greater stability in the stance phase of the gait cycle. Postural insoles can be used to reorganize the tone of muscle chains, which exerts an influence on postural control through correction reflexes. The aim of the present study was to perform kinematic and spatiotemporal analyses of gait in stroke survivors with hemiparesis during postural insole usage.

Material and Methods

Twenty stroke victims were randomly divided into two groups: 12 in the experimental group, who used insoles with corrective elements specifically designed for equinovarus foot, and eight in the control group, who used placebo insoles with no corrective elements. Both groups were also submitted to conventional physical therapy. The subjects were analyzed immediately following insole placement and after three months of insole usage. The SMART-D 140® system (BTS Engineering) with eight cameras sensitive to infrared light and the 32-channel SMART-D INTEGRATED WORKSTATION® were used for the three-dimensional gait evaluation.

Results

Significant improvements were found in kinematic range of movement in the ankle and knee as well as gains in ankle dorsiflexion and knee flexion in the experimental group in comparison to the control group after three months of using the insoles.

Conclusion

Postural insoles offer significant benefits to stroke survivors regarding the kinematics of gait, as evidenced by gains in ankle dorsiflexion and knee flexion after three months of usage in combination with conventional physical therapy.

Keywords:

via Effect of postural insoles on gait pattern in individuals with hemiparesis: A randomized controlled clinical trial – Journal of Bodywork and Movement Therapies

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[ARTICLE] Active rehabilitation training system for upper limb based on virtual reality – Full Text

 

In this article, an active rehabilitation training system based on the virtual reality technology is designed for patients with the upper-limb hemiparesis. The six-axis inertial measurement unit sensors are used to acquire the range of motion of both shoulder and elbow joints. In order to enhance the effect of rehabilitation training, several virtual rehabilitation training games based on the Unity3D engine are designed to complete different tasks from simple level to complicated level. The purpose is to increase the patients’ interest during the rehabilitation training. The basic functions of the virtual rehabilitation task scenes are tested and verified through the single-joint training and the multi-joint compounding training experiments. The experimental results show that the ranges of motion of both shoulder and elbow joints can reach the required ranges of a normal human in the rehabilitation training games. Therefore, the system which is easy to wear, low cost, wireless communication, real-time data acquisition, and interesting virtual rehabilitation task games can provide an effective rehabilitation training process for the upper-limb hemiparesis at home.

The upper limb has many degrees of freedom, and it is also a complex part of the human body by which people can accomplish fine movements during their activities in daily life. With the intensification of the aging problem in the world, the amount of stroke hemiparesis has shown a growing trend, especially in China, which has an enormous population.1 Approximately 30%–50% of these stroke survivors will suffer from chronic hemiparesis, especially involving their hands. In addition, spinal cord injury (SCI) and traffic accident survivors may also find limb movements’ disorder. Injury within the cervical region of the cord leads to tetraplegia, which leads to impairment of all four limbs. An estimated result shows that 55% of new cases will result in tetraplegia, while the other 45% will experience paraplegia due to injury below the cervical level.2Limb hemiparesis which is caused by stroke, SCI, or traffic accidents not only gives the patient’s daily life a great deal of inconvenience and even more makes the patient suffer from great mental pain but also brings a heavy stress and medical burden for the patient’s family and society. Technology has been developed in an effort to facilitate rehabilitation for the patient. Upper-limb rehabilitation is one of the fastest growing areas in modern neurorehabilitation. Quality of life can be improved with efficient therapy.3 At present, rehabilitation therapy of upper limb with traditional rehabilitation therapy is commonly used, that is, rehabilitation therapists perform rehabilitation trainings on individuals. Now with the development of robot technology, the rehabilitation of robot-assisted training is also rising up. The MIT-Manus4 is an example of end-effector-based and arm-rehabilitation robotic device, while the ARMin device5 is an example of arm-rehabilitation exoskeletons which also allows pronation/supination of the lower arm and wrist flexion/extension. It could be operated in three modes: passive mobilization, active game-supported arm therapy, and active training of activities of daily living (ADLs). The end-effector-based robots have practical advantages (usability, simplicity, and cost-effectiveness), and exoskeleton robots have biomechanical advantages (better guidance). Currently, the automatic rehabilitation devices on market as mentioned above are mostly complex and expensive, which are often used in the hospitals and clinics are not affordable to ordinary patients. Therefore, one of the research objectives aims to develop the upper-limb rehabilitation training system with minimal structure and low cost and can be used in patient’s home. But in China, it can be seen that patients with upper-limb orthosis in home is only for fixing the arm and just move autonomously according to the setting angle. The researches on intelligent domestic rehabilitation device just begins, most of which are in the experimental stage and not yet market oriented.6,7

Another problem is that the patients are treated with low initiative and dull training process which does not motivate them, while the treatment effect is not obvious.8,9 Computer games based on virtual reality (VR) are a good way to mobilize the patients’ initiative in the training, so the rehabilitation effect on a particular movement task will be greatly improved.10 VR environments provide an excellent method to manipulate task conditions in training. The effects and the intensity of training can be enhanced and designed more challenging, since the implementation of VR can build a channel both visual and haptic communication can be involved in. The research on VR system which is applied to rehabilitation training was initiated a few years ago. Mazzone et al.11 made a study on the effect of rehabilitation training for patients with shoulder joints training using VR technology. This study aimed to determine whether performance of shoulder exercises in virtual reality gaming (VRG) results in similar muscle activation as non-VRG exercise. The conclusion was drawn that exercise with VRG should be effective to reduce shoulder pain caused by spinal injury. Fischer et al.12 conducted a preliminary study claim that stroke patients could assist themselves in training their hands in the virtual environment. The purpose of this pilot study was to investigate the impact of assisted motor training in a virtual environment on hand function for the stroke survivors. Participants had 6 weeks of training in reach-to-grasp of both virtual and actual objects. After the training period, participants in all three groups demonstrated a decrease in time to perform some of the functional tasks. These designs based on VR have achieved some success and then the second research objective is to add the VR technology to the intelligent domestic rehabilitation device. These studies are mainly designed for the single joint of the upper-limb rehabilitation training. Therefore, it is necessary to carry out the research on multi-joint combined training device for patients who can just stay home by training with VR tasks of adjustable game levels.

Another important element which needs to be considered as an ultimate success using at home is its ease of use. Therefore, simple active rehabilitation device should be developed. The setup time of such device should be fast, besides measurement, treatment approaches, and incorporating gaming, and should provide intuitive interfaces that can be directly utilized by the individuals. This study will introduce an active rehabilitation training system for upper limb based on VR technology, which has some advantages such as simple structure, easy to manipulate, and portable for household. It also mobilizes patients’ initiative with adjustable difficulty level of VR tasks so that the individuals’ rehabilitation effect of the upper limb is obviously improved.

The active rehabilitation training system for upper limb based on VR is designed for the pronation/supination and flexion movement trainings of the elbow joint and the extension/flexion and abduction exercises of the shoulder joint. By adding the games in training processes, the patients may actively participate in rehabilitation trainings, while the efficiency will be greatly improved. The portable and easy-to-use design of this system can effectively reduce the problem of the medical resources shortage in the rehabilitation field.

Overall scheme of the system

The system is composed of two parts: the upper-limb posture detection system and the virtual rehabilitation training task scene, as shown in Figure 1.

figure

Figure 1. Schematic diagram of an active rehabilitation training system for upper limb based on VR.

 

Continue —> Active rehabilitation training system for upper limb based on virtual realityAdvances in Mechanical Engineering – Jianhai Han, Shujun Lian, Bingjing Guo, Xiangpan Li, Aimin You, 2017

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[ARTICLE] The spasticity in the motor and functional disability in adults with post-stroke hemiparetic

Abstract

Introduction: Spasticity acts as a limiting factor in motor and functional recovery after Stroke, impairing the performance of daily living activities.

Objective: To analyze the influence of spasticity on main muscle groups and to associate it with motor impairment and functional level of chronic hemiparetic patients after stroke.

Methods: Twenty-seven chronic hemiparetic patients of both sexes were selected at the Physical Therapy and Occupational Therapy Service of the Unicamp Clinics Hospital. Assessments were carried out in two sessions, in the first one the motor impairment (Fugl-Meyer Assessment – FM) and functional impairment (Barthel Index – BI) were evaluated, and in the second, the degree of spasticity of the main muscle groups (Modified Ashworth Scale – MAS).

Results: A negative correlation was detected between upper limb spasticity and motor and functional impairment. No muscle group evaluated in the lower limbs showed correlation between muscle tone and the level of impairment of the lower extremity on FM and the functional level measured by BI.

Conclusion: Spasticity has been shown to be a negative influence factor in the level of motor and functional impairment of the upper limbs of chronic hemiparetic patients after stroke.

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via The spasticity in the motor and functional disability in adults with post-stroke hemiparetic | de Oliveira Cacho | Fisioterapia em Movimento

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[Abstract] Neurotech: Robotic Assist Devices Show Gains in Walking for Crouch Gait in Cerebral Palsy and Post-Stroke Hemiparesis

via Neurotech: Robotic Assist Devices Show Gains in Walking for… : Neurology Today

ARTICLE IN BRIEF

Figure

Developers of robotic devices discuss advances in the technologies to help people improve walking post-stroke and improve couch gait in cerebral palsy. Independent experts in neurorehabilitation review the potential and possible caveats of these devices.

Three novel robotic assistance devices, one for hemiparetic gait following stroke, and two for crouch gait in children with cerebral palsy, have each demonstrated improved walking in preliminary clinical trials.

For stroke patients, a robotic exosuit made of a soft, clothing-like anchor attached to motorized cables was shown to increase the paretic limb’s forward propulsion and the paretic ankle’s swing phase dorsiflexion in both treadmill and over-ground walking.

For children with crouch gait due to cerebral palsy, one trial used a cable-driven robot called a Tethered Pelvic Assist Device, or TPAD. The laboratory-based device is designed to strengthen the extensor muscles, especially the soleus in the calves, by putting downward pressure on them during training. After six weeks of practice with the device, the children’s posture was more upright, with greater step length and toe clearance, when walking without it.

Also for children with crouch gait, the third study examined the use of a wearable exoskeleton that provides a burst of knee extension assistance at just the right moment when a child or adolescent is walking. None of the seven participants, age 5 to 17, fell while using it, and six of the seven showed postural improvements equivalent to those previously reported from surgery.

While promising, the devices will require far more testing in randomized trials before their true value can be known, said a leading specialist in neurological rehabilitation.

“These are foundational studies; they’re just beginning to get started,” said Bruce H. Dobkin, MD, FRCP, distinguished professor of clinical neurology and director of the Neurological Rehabilitation and Research Program at the Geffen School of Medicine at the University of California, Los Angeles. “The cost, safety, user-friendliness, and ability to use at differing levels of disability severity — all those are major challenges.”

Even so, each of the three devices employs a new kind of robotic assistance unlike any existing on the market.

“Most robotics for neurological injuries are heavy, power-hungry exosuits for people with spinal cord injuries who can’t walk at all,” said a coauthor of the study for stroke patients, Terry D. Ellis, PT, PhD, NCS, director of the Center for Neurorehabilitation at Boston University. “But there’s a whole bunch of people who have disabilities, who can walk, but don’t walk well. They need facilitation or augmentation to restore some of the normal components of walking.”

A ROBOT POST-STROKE

Published in the July 26 edition of Science Translational Medicine, the study of a robotic exosuit tested in nine post-stroke patients used what it called “garment-like, functional textile anchors” rather than a hard, metallic exterior. Worn on only the paretic limb, the suit was designed to be as unobtrusive as possible.

“It’s much more compatible with the real world than a rigid device would be,” said the first author of the paper, Louis N. Awad, PT, DPT, PhD, an assistant professor of physical therapy at Boston University, and a research faculty member at Spaulding Rehabilitation Hospital. “Ordinary clothes are made of soft material. We don’t don a metallic pair of pants and walk out the door. That’s our goal — robotic clothing that helps people with difficulty walking.”

Attached to cables tethered to a belt worn around the hips, the exosuit functioned in synchrony with a wearer’s paretic limb to facilitate an immediate increase in the paretic ankle’s swing phase dorsiflexion and forward propulsion (p< 0.05), according to the paper.

The improved movements resulted in a 20 percent reduction in forward propulsion interlimb asymmetry and a 10 percent reduction in the energy cost of walking, which together were equivalent to a nearly one-third lower metabolic burden — a 32 percent reduction — while walking.

Although the study did include some over-ground walking, it was not designed to test whether the exosuit had any therapeutic effects that might carry over to when patients are not wearing it.

“This is a proof of concept paper,” said Dr. Ellis. “Down the road we need to conduct trials in more ecologically valid environments, and to see if it has therapeutic value. For now we wanted to demonstrate that the device can facilitate more normal walking.”

While applauding the study as “clever,” Dr. Dobkin said it remained to be seen whether the robotic exosuit would prove to have significant therapeutic effects that would stand up in randomized trials in natural environments. He pointed to randomized trials published in recent years showing that peroneal nerve functional electrical stimulators have no greater therapeutic effect than do standard ankle-foot orthoses.

“It’s similar to all the work that was done using the electrical stimulation of the ankle,” Dr. Dobkin said. “The real question is whether it will lead to improved function when you walk over-ground. Walking on a treadmill is not terribly natural.”

He also pointed out that the nine patients in the study were able to walk on average at about two miles per hour. “That’s already pretty fast,” he said. In addition, he said, the 20 percent reduction in interlimb asymmetry is relatively modest.

But, said Dr. Dobkin, people can improve their gait by 20 percent just by sustained practice. “When you see modest changes like this with the device, you wonder if the same changes couldn’t have been achieved without it,” he said.

Steven L. Wolf, PhD, PT, FAPTA, FAHA, professor in the department of rehabilitation medicine at Emory University School of Medicine, pointed out that existing robotic devices to help people who are completely unable to walk can cost patients up to $250,000. Perhaps the exosuit might become an improvement over what presently exists both in terms of function and cost, he said.

“Most existing devices are beautiful but incredibly expensive,” Dr. Wolf said. “Is the bang in the buck? Not as yet, in my opinion. The evidence for persistent benefit from these device is just not there.”

IMPROVING CROUCH GAIT IN CP

The first of the two studies using robotic devices to improve crouch gait in children with cerebral palsy was published on July 26 in Science Robotics, led by senior author Sunil K. Agrawal, PhD, professor of mechanical engineering and rehabilitation medicine at Columbia University.

Rather than directly straighten the children’s posture, Dr. Agrawal’s seemingly contradictory approach was to increase the downward force on their pelvis as they attempted to walk on a treadmill. The tension in each wire, attached to a belt on the pelvis, is modulated in real time by a motor placed around the treadmill in response to motion capture data from cameras. Unlike other robotic devices that have been tested for treating crouch gait, the TPAD has no rigid links to the body, permitting free movement of the legs.

After training in the device for 15 sessions of 16 minutes each over the course of six weeks, the six participants showed enhanced upright posture, improved muscle coordination, increased step length, range of motion of the lower limb angles, toe clearance, and heel-to-toe pattern.

“You can see a marked difference before and after,” Dr. Agrawal said. “We heard from families and the children themselves that they were walking faster, with better posture. Now we have to see if we should use a higher magnitude of downward pull, how long each training session should be, and for how many sessions.”

Commenting on the TPAD study, Dr. Dobkin said, “The kids who were selected for inclusion were not necessarily the kind who get surgery. They had less of a crouch, a little bit more of a push-off. The question is whether training like this will lead to good over-ground walking. They got a hint of that.”

The second crouch-gait study, published on August 23 in Science Translational Medicine, involved a wearable exoskeleton designed for over-land use, and was described by the authors as the first robotic device designed specifically to treat a gait disorder in children and adolescents. Rather than force the lower limb to move in a particular way, “the exoskeleton dynamically changed the posture by introducing bursts of knee extension assistance during discrete portions of the walking cycle, a perturbation that resulted in maintained or increase knee extensor muscle activity during exoskeleton use,” the paper stated.

“In the last decade, there’s been a groundswell of work on exoskeletons, but a majority of them are designed to permit mobility after spinal injury in adults who have lost the ability to walk,” said senior author Thomas Bulea, PhD, a staff scientist in the functional and applied biomechanics section of the rehabilitation medicine department at the National Institutes of Health Clinical Center in Bethesda, MD. “There hasn’t been much done for the pediatric population who just need to improve their walking.”

A coauthor of the paper, Diane L. Damiano, PT, PhD, chief of the section in which Dr. Bulea works, said the purpose of the wearable exoskeleton is different than that of the TPAD device developed by Dr. Agrawal.

“His device is designed to strengthen the calf muscles by increasing the resistance on them,” she said. “His results were good, but this is very different from what we are doing. We have a wearable device. It’s not meant to be used in a lab for training. We’re not necessarily trying to strengthen them, although that would be a desired outcome; we are instead trying to assist their abilities to help them practice being more upright while they walk. This is something that they would wear throughout the day for several months with the goal that their posture will ultimately be improved without the device.”

A surprising observation, she added, was that some children saw it as something cool to wear.

LINK UP FOR MORE INFORMATION:

•. Awad LN, Bae J, O’Donnell K, et al A soft robotic exosuit improves walking in patients after stroke http://stm.sciencemag.org/content/9/400/eaai9084. Sci Transl Med 2017; 9 (400). pii: eaai9084.

•. Video of the soft robotic exosuit for stroke patients: http://www.sciencetranslationalmedicine.org/cgi/content/full/9/400/eaai9084/DC1

•. Kang J, Martelli D, Vashista V, et al Robot-driven downward pelvic pull to improve crouch gait in children with cerebral palsy http://robotics.sciencemag.org/content/2/8/eaan2634. Sci Robot 2017;2(8): eaan2634.

•. Video of the robot-driven downward pelvic pull device can be seen at http://engineering.columbia.edu/news/sunil-agrawal-cerebral-palsy-crouch-gait

•. Lerner ZF, Damiano DL, Bulea TC. A lower-extremity exoskeleton improves knee extension in children with crouch gait from cerebral palsy http://stm.sciencemag.org/content/9/404/eaam9145. Sci Transl Med 2017; 9 (404). pii: eaam9145.

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[Abstract] Proposition of a classification of adult patients with hemiparesis in chronic phase

Objective

Patients who have developed hemiparesis after central nervous system lesion often experience reduced walking capacity. Related gaitabnormalities at hip, knee, and ankle joints during swing induce decreased foot clearance and increased risk of falls, and thus need a meticulous management. This study aimed to (1) propose a classification focusing on these abnormalities for adult patients with hemiparesis, (2) evaluate its discriminatory capacity using clinical gait analysis (CGA).

Material/patients and methods

Twenty-six patients (10 women, 16 men) with hemiparesis (13 left, 13 right) in chronic phase (i.e. hemiparesis more than 6 months old) were included in this study. Clinical examination (i.e. passive range of motion, muscle weakness, and spasticity) and video records were conducted on each patient. The following classification was then applied: group I (GI) was mainly characterized by a decreased ankle dorsiflexion during swing, group II (GII) and group III (GIII) by a decreased knee flexion during swing, completed by a reduced range of hip motion and a hip flexors weakness in GIII. Subdivisions were also applied on each group to describe (a) absence or (b) presence of genu recurvatum during stance. The discriminatory capacity of the classification was then evaluated. For that, all patients were instrumented with cutaneous reflective markers and at least 5 gait cycles were recorded using optoelectronic cameras (OQUS, Qualisys, Sweden). A statistical analysis (ANOVA) was then performed between each group and subgroup on 24 kinematic parameters and walking speed.

Results

Only one patient could not be classified, 5 were classified in GI (1 GIa, 4 GIb), 15 in GII (7 GIIa, 8 GIIb), and 5 in GIII (1 GIIIa, 4 GIIIb). When subgroups (a) and (b) were combined, 16 of the 25 assessed parameters revealed a statistically significant difference (P-level < 0.05) between at least two groups. In particular, the maximum knee flexion in swing and the total amplitude of hip flexion-extension were significantly different between groups.

Discussion – conclusion

This classification can be performed in regular clinical practice (using clinical evaluation and video records). It should thus ease the development of clinical management algorithms and the efficiency assessment of related therapies.

Source: Proposition of a classification of adult patients with hemiparesis in chronic phase – ScienceDirect

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[Abstract] Robot-assisted mirroring exercise as a physical therapy for hemiparesis rehabilitation

Abstract:

The paper suggests a therapeutic device for hemiparesis that combines robot-assisted rehabilitation and mirror therapy. The robot, which consists of a motor, a position sensor, and a torque sensor, is provided not only to the paralyzed wrist, but also to the unaffected wrist to induce a symmetric movement between the joints. As a user rotates his healthy wrist to the direction of either flexion or extension, the motor on the damaged side rotates and reflects the motion of the normal side to the symmetric angular position. To verify performance of the device, five stroke patients joined a clinical experiment to practice a 10-minute mirroring exercise. Subjects on Brunnstrom stage 3 had shown relatively high repulsive torques due to severe spasticity toward their neutral wrist positions with a maximum magnitude of 0.300kgfm, which was reduced to 0.161kgfm after the exercise. Subjects on stage 5 practiced active bilateral exercises using both wrists with a small repulsive torque of 0.052kgfm only at the extreme extensional angle. The range of motion of affected wrist increased as a result of decrease in spasticity. The therapeutic device not only guided a voluntary exercise to loose spasticity and increase ROM of affected wrist, but also helped distinguish patients with different Brunnstrom stages according to the size of repulsive torque and phase difference between the torque and the wrist position.

Source: Robot-assisted mirroring exercise as a physical therapy for hemiparesis rehabilitation – IEEE Conference Publication

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[Abstract] Virtual reality and non-invasive brain stimulation in stroke: How effective is their combination for upper limb motor improvement?

Abstract:

Upper limb (UL) hemiparesis is frequently a disabling consequence of stroke. The ability to improve UL functioning is associated with motor relearning and experience dependent neuroplasticity. Interventions such as non-invasive brain stimulation (NIBS) and task-practice in virtual environments (VEs) can influence motor relearning as well as adaptive plasticity. However, the effectiveness of a combination of NIBS and task-practice in VEs on UL motor improvement has not been systematically examined. The objective of this review was to examine the evidence regarding the effectiveness of combining NIBS with task-practice in VEs on UL motor impairment and activity levels. A systematic review of the published literature was conducted using standard methodology. Study quality was assessed using the PEDro scale and Down’s and Black checklist. Four studies examining the effects of a combination of NIBS (involving transcranial direct current stimulation; tDCS and repetitive transcranial magnetic stimulation; rTMS) were retrieved. Of these, three studies were randomized controlled trials (RCTs) and one was a cross-sectional study. There was 1a level evidence that the combination of NIBS and task-practice in a VE was beneficial in the sub-acute stage. A combination of training in a VE with rTMS as well as tDCS was beneficial for motor improvements in the UL in sub-acute stage of stroke (1b level). The combination was not found to be superior compared to task practice in VEs alone in the chronic stage (1b level). The results suggest that people with stroke may be capable of improving levels of motor impairment and activity in the sub-acute stage if their rehabilitation program involves a combination on NIBS and VE training. Emergent questions regarding the use of more sensitive outcomes, different types of stimulation parameters, locations and training environments still need to be addressed.

Source: Virtual reality and non-invasive brain stimulation in stroke: How effective is their combination for upper limb motor improvement? – IEEE Xplore Document

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