Posts Tagged lower extremity

[WEB SITE] Stroke Rehabilitation from “Head to Toe”

By Devin Cooney, MOR, OTR/L; Brittany Merkh, PT, DPT; Kelly Tender, MS, CCC-SLP

According to the American Stroke Association, one in four people worldwide will have a stroke. It is the number five cause of death and a leading cause of long-term disability in the United States. More than 7 million stroke survivors are currently living in the United States.1

Many stroke survivors choose to go to an acute inpatient rehabilitation facility for their specific rehabilitation needs. In 2018, 1,494 individuals and their families selected Kessler Institute for Rehabilitation in Marlton, NJ, for their start of recovery. Thirty percent of those individuals were diagnosed with a stroke. Although their rehabilitation needs were different, they shared a common goal: to gain the skills, strengths, and strategies to rebuild their lives.

Recently, rehabilitation has shifted to include greater use of technology. The integration of technology-based rehabilitation within stroke recovery may empower an individual toward being more engaged in their own care in addition to forcing greater outcomes and providing objective data.2 Technology can be incorporated in stroke recovery from “head to toe,” including rehabilitation of cognitive-communication, recovery of swallow function, improvement of upper and lower extremity use, and restoration of the ability to walk.

 Communication and Swallow Function

Depending on the area of the brain in which a stroke occurs, a survivor may experience problems related to speech, reading, writing, and/or understanding words (aphasia). Technology is often incorporated into speech-language pathology treatment for individuals affected by aphasia at Kessler-Marlton. Technology such as smartphones, tablets, text-to-speech or word prediction software, augmentative-alternative communication devices, video telecommunication, and online support communities provide additional avenues for survivors affected by aphasia to communicate.3

Use of technology is also widely incorporated in the management of dysphagia. There are many causes of dysphagia, but a very common cause is stroke. Swallowing problems can lead to poor nutrition, pneumonia, and poorer quality of life. A specialized swallowing test (videofluoroscopic swallow study and/or fiber optic endoscopic evaluation of swallowing) is recommended to better assess the problems and determine a treatment plan. Swallowing exercises may be needed to improve strength and coordination of swallowing muscles. One example of technology utilized at Kessler-Marlton is surface electromyography (sEMG) biofeedback to provide visual monitoring of the sEMG signal to guide performance in swallowing therapy, increase active participation, provide objective data, and track outcomes.4,5 Use of sEMG in conjunction with swallow exercise has been shown to improve functional swallowing outcomes.6 Additional supportive interventions include neuromuscular stimulation, patterned electrical stimulation, pressure biofeedback to measure and target tongue strength, and dysphagia applications to offer education and personalized exercise programs to patients and their families.

Upper Extremity and Vision Restoration

Stroke survivors may have difficulty performing activities of daily living for various reasons. However, for the purpose of this article the focus will be on the recovery of upper extremity use and visual/visuo-spatial impairments. Occupational therapy (OT) is vital in stroke recovery, and the goal is to increase, improve, or restore independence within activities of daily living. While manual therapies are typically used with the majority of patients, therapists at Kessler Marlton incorporate supportive technology and equipment including an integrated therapy system with a touchscreen display that can be used for oculomotor therapy, motor control training, and cognitive learning; a computerized, task-oriented upper extremity workstation; and a hand rehabilitation system that uses a wireless orthosis to deliver electrical stimulation.

The integrated therapy systems is a large technological board with a touch screen. It can be used to target a wide range of impairments including vision-related activities. These activities focus on visuomotor coordination, reaction time, visual processing, and visuospatial perception. This technology engages patients and can be personalized to individual needs.

In addition to vision, OT focuses on the rehabilitation of the upper extremity when indicated. To facilitate this, the computerized upper extremity workstation is often utilized. It is a computerized training system with a full workstation as well as a computer program. It utilizes games and objective data to motivate and engage patients. This system offers the ability to complete both gross and fine motor activities including different grip and pinch patterns. Different planes of movement or positions can also be completed to downgrade or upgrade patient challenge.

When appropriate, the hand rehabilitation system with wireless orthosis may be utilized to target the upper extremity. While neuromuscular electrical stimulation (NMES) can be used on different body parts and muscle groups, this device specifically targets the muscles of the hand. This system’s program settings such as pinching, grasping, and releasing can be utilized individually or while completing functional activities.

Restoration of the Lower Extremity

Many people who are affected by stroke lose function of their lower extremity to some capacity. The goal of the physical therapist (PT) is to facilitate improved functional independence and maximize safety with overall mobility while primarily focusing on lower extremity recovery. Recently, with the use of technology, rehabilitation and mobility can be initiated sooner, which translates into improved overall outcomes.

Within the inpatient rehabilitation setting at Kessler-Marlton, PTs have access to a multitude of technology options, including an adaptive cycling machine. The cycling device is multimodal and allows patients to participate passively, motor-supported, or actively. The passive mode allows for early mobilization of patients diagnosed with stroke, as it is able to assist with reducing muscle tone in those patients with hypertonicity. With patients who are not ready to perform ambulation itself, the passive mode also allows for repetitive motions that mimic the back-and-forth motion of walking. These repetitive, rhythmic movements help to stimulate the brain to reorganize and relearn motor tasks.

As patients improve and regain motor control and neuromuscular strength, the adaptive cycling machine can be used in the motor-supported mode, which allows the motor to assist to stimulate both strength and endurance until the patient is able to participate in active mode. In active mode, the patient is using her or his own strength to pedal.

Partial Weight-Bearing

As early mobilization is an important factor in recovery, another technological device that assists the user with partial weight-bearing is of great importance. This technology is a body weight-supported gait training device in which the patient is supported by an overhead suspension system and harness. This system allows the patient, who might not necessarily be able to stand on his or her own, the opportunity to force weight-bearing through the affected lower extremity to force motor recovery. In the upright position, it not only affords the patient the opportunity to weight-bear, but it also promotes proper upright posturing and provides the patient a safe, fall-free environment in which to practice initiating mobility. This system allows the therapist to provide hands-on assistance at the lower extremity or at the pelvis to achieve proper gait pattern. The device can be used for over-ground training or for training over the treadmill, which challenges a patient’s coordination and timing of the different phases of the gait cycle. As a patient improves, the overhead system can be adjusted to allow increased weight-bearing and increased degrees of freedom.

As the patient moves into a more ambulatory level, he or she still may demonstrate impairments in the amount or quality of movement in their lower extremity. The use of functional electrical stimulation (FES) may be used as a recovery tool. The FES device this facility uses is a wireless foot drop system that helps to stimulate the nerves and muscles of the affected lower extremity, most often at the ankle and in the thigh, to re-educate the brain and restore muscle function during walking. This system comes with a lower leg cuff to stimulate the ankle muscles in patients with difficulty clearing their toes or patients with foot drop. The system also comes with a thigh cuff to stimulate muscles in the upper leg to provide stability while in stance phase.

Although speech, occupational, and/or physical therapy itself has been shown to improve patient outcomes, the integration of technology in therapeutic intervention following stroke can maximize patient motivation and progress. For example, the inclusion of technology in physical therapy has been able to allow patients the opportunity to participate in therapy at earlier phases. This early mobilization is crucial to jump-start a patient’s recovery. The use of technology throughout the patient’s recovery process has been an integral part in demonstrating improved outcomes which allows physical therapists to facilitate recovery by working on the often stated patient-centered goal of returning to walking. RM

Devin Cooney, MOR, OTR/L, has worked at Kessler Institute for Rehabilitation—Marlton for the past 3 years. The majority of her career has been spent in the acute rehabilitation setting focusing on ADLs and IADLs to encourage safe return to home.

Brittany Merkh, PT, DPT, is Co-Chair of the Stroke Program at Kessler Institute for Rehabilitation in Marlton, New Jersey. Most of her career has been spent in acute rehabilitation, treating patients with a variety of diagnoses.

Kelly Tender, MS, CCC-SLP, is senior speech-language pathologist and leader within the SLP department. Her certifications and training include MDTP, VitalStim, PENS, and sEMG. She is a member of the hospital’s stroke committee. For more information, contact


1. About Stroke. www.stroke.org Published 2019. Accessed November 21, 2019.

2. Des Roches C, Kiran S. Technology-based rehabilitation to improve communication after acquired brain injury. Front Neurosci. 2017;11. doi:10.3389/fnins.2017.00382. Accessed November 21, 2019.

3. Technology for People with Aphasia. www.stroke.org Published 2019. Accessed October 12, 2019.

4. Steele C. Treating dysphagia with sEMG biofeedback. The ASHA Leader. 2004;9(13):2-23. doi:

5. Crary M, Carnaby (Mann) G, Groher M, Helseth E. Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback. Dysphagia. 2004;19(3). doi:

6. Bogaardt H, Grolman W, Fokkens W. The use of biofeedback in the treatment of chronic dysphagia in stroke patients. Folia Phoniatrica et Logopaedica. 2009;61(4):200-205. doi:

via Stroke Rehabilitation from “Head to Toe” – Rehab Managment

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[Abstract] A Method for Self-Service Rehabilitation Training of Human Lower Limbs – IEEE Conference Publication


Recently, rehabilitation robot technologies have been paid more attention by the researchers in the fields of rehabilitation medicine engineering and robotics. To assist active rehabilitation of patients with unilateral lower extremity injury, we propose a new self-service rehabilitation training method in which the injured lower limbs are controlled by using the contralateral healthy upper ones. First, the movement data of upper and lower limbs of a healthy person in normal walk are acquired by gait measurement experiments. Second, the eigenvectors of upper and lower limb movements in a cycle are extracted in turn. Third, the linear relationship between the movement of upper and lower limbs is identified using the least squares method. Finally, the results of simulation experiments show that the established linear mapping can achieve good accuracy and adaptability, and the self-service rehabilitation training method is effective.

via A Method for Self-Service Rehabilitation Training of Human Lower Limbs – IEEE Conference Publication

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[ARTICLE] Experiences of treadmill walking with non-immersive virtual reality after stroke or acquired brain injury : A qualitative study – Full Text



It is well known that physical activity levels for persons after stroke or acquired brain injuries do not reach existing recommendations. Walking training is highly important since the ability to walk is considered to be a meaningful occupation for most people, and is often reduced after a brain injury. This suggests a need to innovate stroke rehabilitation, so that forms of walking training that are user-friendly and enjoyable can be provided.


An interview study was carried out with persons after stroke (n = 8), or acquired brain injury (n = 2) at a rehabilitation unit at Sahlgrenska University Hospital. We used a semi-structured interview guide to investigate experiences and thoughts about walking on a treadmill with non-immersive virtual reality feedback. The contents were analyzed through an inductive approach, using qualitative content analysis.


The virtual reality experience was perceived as enjoyable, exciting, and challenging. Participants stressed that the visual and auditory feedback increased their motivation to walk on a treadmill. However, for some participants, the virtual reality experience was too challenging, and extreme tiredness or fatigue were reported after the walking session.


Participants’ thoughts and experiences indicated that the Virtual Reality walking system could serve as a complement to more traditional forms of walking training. Early after a brain injury, virtual reality could be a way to train the ability to handle individually adapted multisensory input while walking. Obvious benefits were that participants perceived it as engaging and exciting.


In general, physical activity levels in rehabilitation units are low [] and do not reach the recommendations for persons with stroke or acquired brain injury (ABI) []. There are also indications that the intensity of physiotherapy sessions after stroke is mostly at low levels []. Several barriers may contribute to inactivity, such as neurological deficits, cognitive impairment, environmental factors, and lack of motivation [].

A dose-response effect on exercise outcome after stroke has been shown, and training should be highly repetitive and task oriented []. Walking training is important and considered to be a meaningful occupation for most people. To increase walking exercise intensity, treadmill walking has been proposed as a means of task-oriented training that gives the opportunity for many repetitions, and has shown to promote a more normal walking pattern []. Walking on a moving surface like a treadmill is more demanding than walking on the ground in terms of sensory processing, postural control and movement coordination. From a motivational perspective, treadmill walking may be perceived as boring the long run.

Training of goal-specific activities with a high number of repetitions may be offered using virtual reality (VR) applications, which have been introduced in neurological rehabilitation []. Training using VR has also been suggested to enhance neuroplasticity after stroke [] by means of offering multisensory stimulation at a high intensity. VR comprises computer-based real-time simulation of an environment with user interaction [] visually displayed on a screen or through head-mounted devices. Differences in technology and visual presentations in 2D or 3D enable varying types of feedback, levels of immersion and sense of presence in the virtual environment []. VR feedback can be mediated through vision, hearing, touch, movement, or smell. The technique provides performance feedback–both directly experienced and objectively quantified, and may thereby increase exercise motivation, and improve motor performance [].

Following stroke, VR training has been mostly described for the upper limb but also for the lower limb; balance and walking as well as for perceptual/cognitive skills []. VR has shown a potential for positive effects on walking and balance abilities, although the number of studies are low and the evidence for its superiority to other methods is low [].

Although few adverse events from VR training have been described, some participants have reported headache or dizziness [] and knowledge is lacking regarding how persons affected by brain injuries perceive the exposure of multisensory input, during a complex activity such as treadmill walking with VR. The potential effects on motivation and participant experience of VR are scarcely investigated [] and mostly focused on upper limb activities and games []. Based on this, we wanted to investigate patients’ overall experiences of a VR concept in walking training.

The aim of the present study was to explore the experiences of VR in addition to walking on a treadmill in persons with stroke or acquired brain injuries. Participants’ overall experiences and suggestions for development of the exercise method were areas of interest.[…]


Continue —>  Experiences of treadmill walking with non-immersive virtual reality after stroke or acquired brain injury – A qualitative study

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[Abstract] Use of Kinesio taping in lower-extremity rehabilitation of post-stroke patients: A systematic review and meta-analysis.



and purpose: The benefits of Kinesio taping (KT) in post-stroke rehabilitation have not been determined. This study aimed to evaluate its effects on lower-extremity rehabilitation in patients after a stroke.


A literature search was performed using EBSCOhost, Embase, Physiotherapy Evidence Database (PEDro), PubMed, Cochrane, Web of Science, China National Knowledge Infrastructure (CNKI), SinoMed, and Wanfang Data through June 2018. Randomized controlled trials (RCTs) on the use of KT during lower-extremity, post-stroke rehabilitation were selected. Meta-analysis was conducted.


A total of 14 RCTs of low to moderate quality were reviewed and included 783 participants. Results indicated that KT significantly improved patients’ lower extremity spasticity, motor function, balance, ambulation, gait parameters, and daily activities, with few adverse effects.


KT may have positive effects on lower-extremity, post-stroke rehabilitation. Due to the limited number and quality of the research, additional studies are needed to identify KT benefits.

via Use of Kinesio taping in lower-extremity rehabilitation of post-stroke patients: A systematic review and meta-analysis. – PubMed – NCBI

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[Abstract] The Efficacy of Lower Extremity Mirror Therapy for Improving Balance, Gait, and Motor Function Poststroke: A Systematic Review and Meta-Analysis



Mirror therapy is less commonly used to target the lower extremity after stroke to improve outcomes but is simple to perform. This review and meta-analysis aimed to evaluate the efficacy of lower extremity mirror therapy in improving balance, gait, and motor function for individuals with stroke.


PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, and PsychINFO were searched from inception to May 2018 for randomized controlled trials (RCTs) comparing lower extremity mirror therapy to a control intervention for people with stroke. Pooled effects were determined by separate meta-analyses of gait speed, mobility, balance, and motor recovery.


Seventeen RCTs involving 633 participants were included. Thirteen studies reported a significant between-group difference favoring mirror therapy in at least one lower extremity outcome. In a meta-analysis of 6 trials that reported change in gait speed, a large beneficial effect was observed following mirror therapy training (standardized mean differences [SMD] = 1.04 [95% confidence interval [CI] = .43, 1.66], I2 = 73%, and P < .001). Lower extremity mirror therapy also had a positive effect on mobility (5 studies, SMD = .46 [95% CI = .01, .90], I2 = 43%, and P = .05) and motor recovery (7 studies, SMD = .47 [95% CI = .21, .74], I2 = 0%, and P < .001). A significant pooled effect was not found for balance capacity.


Mirror therapy for the lower extremity has a large effect for gait speed improvement. This review also found a small positive effect of mirror therapy for mobility and lower extremity motor recovery after stroke.


via The Efficacy of Lower Extremity Mirror Therapy for Improving Balance, Gait, and Motor Function Poststroke: A Systematic Review and Meta-Analysis – Journal of Stroke and Cerebrovascular Diseases

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[Abstract] Effects of robot-(Morning Walk®) assisted gait training for patients after stroke: a randomized controlled trial

To investigate the effects of Morning Walk®–assisted gait training for patients with stroke.

Prospective randomized controlled trial.

Three hospital rehabilitation departments (two tertiary and one secondary).

We enrolled 58 patients with hemiparesis following a first-time stroke within the preceding year and with Functional Ambulation Category scores ⩾2.

The patients were randomly assigned to one of two treatment groups: 30 minutes of training with Morning Walk®, a lower limb rehabilitation robot, plus 1 hour of conventional physiotherapy (Morning Walk® group; n = 28); or 1.5 hour of conventional physiotherapy (control group; n = 30). All received treatment five times per week for three weeks.

The primary outcomes were walking ability, assessed using the Functional Ambulation Category scale, and lower limb function, assessed using the Motricity Index-Lower. Secondary outcomes included the 10 Meter Walk Test, Modified Barthel Index, Rivermead Mobility Index, and Berg Balance Scale scores.

A total of 10 patients were lost to follow-up, leaving a cohort of 48 for the final analyses. After training, all outcome measures significantly improved in both groups. In Motricity Index-Lower of the affected limb, the Morning Walk® group (∆mean ± SD; 19.68 ± 14.06) showed greater improvement (p = .034) than the control group (∆mean ± SD; 11.70 ± 10.65). And Berg Balance Scale scores improved more (p = .047) in the Morning Walk®group (∆mean ± SD; 14.36 ± 9.01) than the control group (∆mean ± SD; 9.65 ± 8.14).

Compared with conventional physiotherapy alone, our results suggest that voluntary strength and balance of stroke patients with hemiparesis might be improved with Morning Walk®–assisted gait training combined with conventional physiotherapy.


via Effects of robot-(Morning Walk®) assisted gait training for patients after stroke: a randomized controlled trial – JaYoung Kim, Dae Yul Kim, Min Ho Chun, Seong Woo Kim, Ha Ra Jeon, Chang Ho Hwang, Jong Kyoung Choi, Suhwan Bae, 2018

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[Abstract] Simultaneous stimulation in bilateral leg motor areas with intermittent theta burst stimulation to improve functional performance after stroke: a feasibility pilot study



BACKGROUND: Intermittent theta burst stimulation (iTBS) was widely used in stroke rehabilitation and was more efficient than repetitive transcranial magnetic stimulation in terms of inducing larger motor evoked potential and producing longer effects. To our knowledge, the outcomes are not available combining rehabilitation and iTBS for improving motor function of lower extremities in patients with stroke.
AIM: To evaluate the feasibility and effectiveness of intermittent theta burst stimulation aiming to stimulate bilateral leg motor cortex and promote functional improvements.
DESIGN: A single blind, randomized controlled pilot study.
SETTING: Rehabilitation ward.
POPULATION: Twenty patients with chronic stroke finally enrolled for analyzed.
METHODS: Participants were randomized into two groups to receive 10 sessions of iTBS group and sham group over a 5-week period. The iTBS was delivered over the midline of skull to stimulate bilateral leg motor cortex. The outcome measures included balance, mobility, and leg motor functions were measured before and after interventions.
RESULTS: Within-group differences were significant in the Berg Balance Scale for both groups (Z=-2.442, P=0.015 in iTBS group; Z=-2.094, P=0.036 in sham group), in the Fugl-Meyer Assessment (Z=-2.264, P=0.024) and Overall Stability Index of Biodex Balance System of iTBS group (Z=-2.124, P=0.034). However, no significant between-group differences were found.
CONCLUSIONS: There was no powerful evidence to support the effectiveness of iTBS group better than sham control group. Some essential technical issues should be considered for future studies applying iTBS to stimulate bilateral leg motor cortex.
CLINICAL REHABILITATION IMPACT: iTBS combined with stroke rehabilitation are probably expected to be useful for promote brain plasticity and functional performance but some technical issues should be carefully considered.

via Simultaneous stimulation in bilateral leg motor areas with intermittent theta burst stimulation to improve functional performance after stroke: a feasibility pilot study – European Journal of Physical and Rehabilitation Medicine 2018 Aug 27 – Minerva Medica – Journals

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[WEB SITE] Advances in robotics help patients with neurorecovery – Video

For the first time in over 14 months, 57-year-old paraplegic Greg Foti is feeling sensation in his legs.

“My mind is sending the signals down to my legs to walk, and actually I’m now getting the positive feedback to my brain saying, ‘yeah, we’re walking,’” Foti, a patient at Bacharach Institute for Rehabilitation, said.

These precious steps are thanks to a robot called the Lokomat. It is one of 13 new pieces of robotics at the Bacharach Institute for Rehabilitation’s Klinghoffer Neurorecovery Center. These machines are changing the future of physical and cognitive therapies.

“These machines can help people do the necessary exercises so many more times in a short period of time, so the brain is rewiring. They’re getting the benefit. Patients are enthusiastic. They’re engaged in the process,” said MJ Perskie, vice president of marketing and business development for Bacharach Institute for Rehabilitation.

Combined with conventional physical therapy, robotics are proving longer-lasting and farther-reaching results. Patients like Foti, who suffered from blood flowing to his spinal cord after a surgery, go through a carefully curated series of robotics, starting with a standing frame.

“From there they go to the Erigo where they’ll start to have their lower legs move and they can help that movement, as well as be in an upright, standing position,” said Jessica Cybulski, a physical therapist at Bacharach. “From there, they’ll go to the Lokomat where they have their lower extremities move for them, and again, assist in that walking motion.”

Eventually they move on their own with what’s called the Andago.

“The idea is the more I do this, the more I continue to improve the communication. And once I get past the communication blocks, there’s nothing to stop me from walking,” Foti said.

For 18-year-old Anthony Marquez, who injured his spine at a trampoline park, the interactive therapy with a Armeo robotic arm gives him extra motivation.

“When I get two stars it pushes me to get the third one, which is the highest you can get,” said Marquez.

A robot called Myro is like a life-size iPad where you have to match images. It’s all about cognitive rehabilitation and making sure it’s interactive and customized for each patient.

It’s helping patients recovering from stroke, multiple sclerosis, spinal cord or other neurological impairments.

“I mean, I couldn’t move my shoulders at first to now being able to move my arms. It’s kind of crazy,” said Marquez.

Seeing him like that gives his mother, Lori Weed, hope.

“It does, a lot of hope, seeing him moving things that we thought he never would move before,” she said.

And setting sights higher than they’d thought before.


via Advances in robotics help patients with neurorecovery | Video | NJTV News

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[ARTICLE] Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review – Full Text


Virtual reality (VR) based applications play an increasing role in motor rehabilitation. They provide an interactive and individualized environment in addition to increased motivation during motor tasks as well as facilitating motor learning through multimodal sensory information. Several previous studies have shown positive effect of VR-based treatments for lower extremity motor rehabilitation in neurological conditions, but the characteristics of these VR applications have not been systematically investigated. The visual information on the user’s movement in the virtual environment, also called movement visualisation (MV), is a key element of VR-based rehabilitation interventions. The present review proposes categorization of Movement Visualisations of VR-based rehabilitation therapy for neurological conditions and also summarises current research in lower limb application.


A systematic search of literature on VR-based intervention for gait and balance rehabilitation in neurological conditions was performed in the databases namely; MEDLINE (Ovid), AMED, EMBASE, CINAHL, and PsycInfo. Studies using non-virtual environments or applications to improve cognitive function, activities of daily living, or psychotherapy were excluded. The VR interventions of the included studies were analysed on their MV.


In total 43 publications were selected based on the inclusion criteria. Seven distinct MV groups could be differentiated: indirect MV (N = 13), abstract MV (N = 11), augmented reality MV (N = 9), avatar MV (N = 5), tracking MV (N = 4), combined MV (N = 1), and no MV (N = 2). In two included articles the visualisation conditions included different MV groups within the same study. Additionally, differences in motor performance could not be analysed because of the differences in the study design. Three studies investigated different visualisations within the same MV group and hence limited information can be extracted from one study.


The review demonstrates that individuals’ movements during VR-based motor training can be displayed in different ways. Future studies are necessary to fundamentally explore the nature of this VR information and its effect on motor outcome.


Virtual reality (VR) in neurorehabilitation has emerged as a fairly recent approach that shows great promise to enhance the integration of virtual limbs in one`s body scheme [1] and motor learning in general [2]. Virtual Rehabilitation is a “group [of] all forms of clinical intervention (physical, occupational, cognitive, or psychological) that are based on, or augmented by, the use of Virtual Reality, augmented reality and computing technology. The term applies equally to interventions done locally, or at a distance (tele-rehabilitation)” [3]. The main objectives of intervention for facilitating motor learning within this definition are to (1) provide repetitive and customized high intensity training, (2) relay back information on patients’ performance via multimodal feedback, and (3) improve motivation [24]. VR therapies or interventions are based on real-time motion tracking and computer graphic technologies displaying the patients’ behaviour during a task in a virtual environment.

The interaction of the user and Virtual environment can be described as a perception and action loop [5]. This motor performance is displayed in the virtual environment and subsequently, the system provides multimodal feedback related to movement execution. Through external (e.g. vision) and internal (proprioception) senses the on-line sensory feedback is integrated into the patient’s mental representation. If necessary, the motor plan is corrected in order to achieve the given goal [5].

A previous Cochrane Review from Laver, George, Thomas, Deutsch, and Crotty [2] on Virtual Reality for stroke rehabilitation showed positive effects of VR intervention for motor rehabilitation in people post-stroke. However, grouped analysis from this review on recommendation for VR intervention provides inconclusive evidence. The author further comments that “[…] virtual reality interventions may vary greatly […], it is unclear what characteristics of the intervention are most important” ([2], p. 14).

Virtual rehabilitation system provides three different types of information to the patient: movement visualisation, performance feedback and context information [6]. During a motor task the patient’s movements are captured and represented in the virtual environment (movement visualisation). According to the task success, information about the accomplished goal or a required movement alteration is transmitted through one or several sensory modalities (performance feedback). Finally, these two VR features are embedded in a virtual world (context information) that can vary from a very realistic to an abstract, unrealistic or reduced, technical environment.

Performance feedback often relies on theories of motor learning and is probably the most studied information type within VR-based motor rehabilitation. Moreover, context information is primarily not designed with a therapeutic purpose. Movement observation, however, plays an important role for central sensory stimulation therapies, such as mirror therapy or mental training. The observation or imagination of body movements facilitates motor recovery [79] and provides new possibilities for cortical reorganization and enhancement of functional mobility. Thus, it appears that movement visualisation may also play an important role in motor rehabilitation [1012], although this aspect is yet to be systematically investigated [13].

The main goal of the present review is to identify various movement visualisation groups in VR-based motor interventions for lower extremities, by means of a systematic literature search. Secondarily, the included studies are further analysed for their effect on motor learning. This will help guide future research in rehabilitation using VR.

An interim analysis of the review published in 2013 showed six MV groups for upper and lower extremity training and additional two MV groups directed only towards lower extremity training. In this paper, we analysed only studies involving lower limb training, leading to a revision and expansion of the previously published MV groups findings [1315].[…]


Continue —> Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review

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[WEB SITE] The future is now – Implications of 3D technology for orthoses | Lower Extremity Review Magazine 560236789

2018 is shaping up as a breakthrough year for 3D printing in orthoses, as the industry moves from promise to reality. Experts agree: Three-dimensional printing will deliver custom clinical products, designed for individual patients at an affordable price.

By Keith Loria

3D printing is still a young technology for orthoses, and has great potential to change the way orthoses are designed and produced, say experts and specialists in the field.

The technology opens the possibility of adding value to the complete digitalization of analysis, design, and manufacture, said Blake Norquist, director of North American sales and business development for RS Print, a Paal-Beringen, Belgium–based company. He noted that combining digitized gait analysis and 3D printing may provide new standards and frameworks for experts based on objective, scientifically proven data.

One of the big game-changing aspects of this digitalization, Norquist noted, is the translation of data from objective analysis into a design that is then manufactured digitally. Expert involvement in the analysis and conversion toward design remains crucial, he said, adding, “[After] that point, the manufacturing becomes completely unbiased and reproducible.”

Gordon Styles, president and CEO of Star Rapid, a manufacturing company of 3D-printed medical applications based in Guangdong Province, People’s Republic of China, explained that 3D printing allows for orthoses manufacturers to respond quickly to requests for custom-made parts needed for rehabilitation. With this technology, he indicated, it is simple to create tailored supports, such as an insole, using high-resolution medical scans of a patient’s foot to determine arch and pressure points. By creating 3D computer-aided design (CAD) models from these scans, highly accurate sizes and shapes are built with very tight tolerances. This helps ensure optimal fit for the patient to support weak joints and limbs.

Moreover, according to Styles, 3D printing is being used to create patient-specific supports and braces, designed to enhance outcomes owing to their ability to create intricate lattice structures that can be used to create lightweight yet strong parts. “This ultimately makes orthoses more comfortable for patients,” he said. “If there is a requirement for a strong and durable brace, metal 3D printing often provides a stronger support than conventional methods.”

Clinical implications of 3D printing of orthotic devices include new possibilities of customization that have not been available with traditional methods.

The evolution

Computer-aided design of foot orthoses emerged in 1989. This method allowed creation of a digitized model of a foot, which would be sent to a laboratory to be milled from a block of plastic. Use of CAD models for orthoses was slow to evolve because equipment cost was high. With the emergence of 3D-printing machines, however, it has become easier to meet growing customer demand for highly customized parts.

Jay Raju, president of Cura BioMed, Inc., Morristown, New Jersey, noted that early 3D manufacturers offered products that did not necessarily provide the same value given by current solutions. The negatives, he added, far outweighed marginal benefits, and there was a wave of launches that never took off. One of the primary challenges, Raju said, has been the use of an entry-level printing technology called fused-deposit molding, which is “good for making prototypes but not great for industrial-level production.” Next-generation 3D printing companies have adopted a new manufacturing process that uses the more advanced selective laser sintering (SLS), which is used in other cutting-edge markets, such as the aerospace industry.

Because SLS technology incurs high fixed and operating costs, Raju added, it is not generally used for manufacturing orthoses. “But by marrying SLS technology with a robust supply chain from scan to design to manufacture to finishing, companies are now creating commercially viable products.”

With this convergence of supply chain and 3D technology, there should be a change in the functional orthotics market. Star Rapid’s Styles shared that, today, 3D CAD models are quite accurate and the cost of plastic 3D printing is relatively low, making this method better than standard methods, such as milling from a plastic block.

Commentary: We’re in a time of mass production of customized orthoses

3D printing is an accessible manufacturing option. Any other approach is just wrong.

By Chris Lawrie, MSc

As an engineer, I printed my first automotive part in 1989 and my first pair of insoles in 2010. It took until 2017 for the stars to align, however: 3D printing technology capable of printing a pair of shells quickly, in materials that meet the demands of the foot, at a production price point that means 3D printing is no longer just a premium offering.

It’s a fact: Today, labs can have shells made for a price that is comparable to shells manufactured by direct-milling polypropylene or positives. Scanners are off-the-shelf items that can, with the right app, give us results that make casting an insanely poor choice. Design software (such as FITFOOT360) can give you complete clinical control over a custom, print-ready device, and you can, case by case, choose whether to mill or print a shell or a positive. I describe this digital mass-customization process as simply “capture–design–make.”

What’s the key to us introducing 3D printing into our foot-health community (for good, this time)? It’s producing a device that is better clinically while being believable to both clinicians and patients; after all, 3D printing it is just another way of making something. Any strategy that presents 3D printing as a premium product or high technology is dated and flawed; it simply maintains the low-volume, high-price strategy that has slowed the evolution of 3D printing, in all markets, over the past 30 years. The recent move by Hewlett-Packard to promote the democratization of printed materials has enabled entrepreneurial companies (such as iOrthotics and FIT360) to capitalize on a wholesale approach to designing and manufacturing 3D-printed insoles. As a result, 3D-printed insoles are already the preferred choice of many labs worldwide.

This is an exciting time in the world of 3D printing—a time that we will all benefit from, as our colleagues in the dental world did nearly a decade ago. As you invest in new technology for rapidly capturing the human form to precisely represent a prescription, please, consider a digital process: from capturing the human form instantly, to creating a custom 3D prescription in seconds, to choosing the ideal “make” option for you, whether form, mill, or print.

To sum up, for the first time in this industry, 3D printing is an accessible manufacturing option. Be careful, however: Do not assume that you need to offer space-age printed devices to your customers… Some entrepreneurs have been here before, and have failed.

Chris Lawrie, MSc (Engineering Business Management), is chief executive officer of FIT360 Ltd (, developers of software, including FITFOOT360, for use by manufacturers of digital custom insoles.


Clinical implications

3D printed foot orthoses are designed and manufactured using the latest digital technologies and require limited manual intervention. Industry experts say that this not only guarantees clinical accuracy of the product, required by clinicians for their patients, but also ensures that orthoses are of consistent quality, durability, and flexibility.

From a clinical perspective, Raju stated, the orthoses produced by 3D printing will deliver all the clinical modifications needed, while also making the insoles more flexible, durable, and ultra-light compared with co-poly– or carbon-based competing products. This may broaden the range of choices in shoe type and lifestyle available to patients.

Raju offered an example of how a 3D-printed orthosis can aid in correcting a pronated foot, in which the hind foot is directed into excessive valgus and impairs efficient heel strike and toe off in the gait cycle, causing calf pain and fatigue. The 3D-printed insoles have built-in hind-foot corrections specific to the patient’s deformity to permit a stable, neutral hind foot during the gait cycle.

Andrei Vakulenko, chief business development officer at Artec 3D, Luxembourg, believes the clinical implications of using 3D scanning and 3D printing are limitless. Following the creation of personalized 3D medical solutions, such as prosthetics, back braces, and even something as intricate as an ear, orthopedists are finding an industry that is constantly creating and improving the software and expanding the tools available for the seamless creation of both ready-made and custom orthoses.

For instance, Vakulenko said, the Robotics and Multibody Mechanics research group at Vrije Universiteit Brussel (University of Brussels) has, as one of its projects, a lower body–powered exoskeleton, built using the Artec Eva 3D scanner. The design uses a tightly fitting orthotic device for the user’s leg that is created by 3D-scanning of the limb. This process replaces the use of uncomfortable, messy plaster molds to capture the shape of a limb; the molds are then shipped to a manufacturer.

“The precise 3D scan is used to digitally model an orthosis that can be 3D printed,” Vakulenko said. “Once printed, the orthotic is reinforced with carbon fibers and epoxy composite. Creating this form-fitting interface between the user and device ensures less energy is lost by the exoskeleton’s actuators and mechanical components that are built around it.”

Bruce E. Williams, DPM, DABFAS, director of gait analysis studies at the Weil Foot & Ankle Institute, Chicago, Illinois, said the potential for 3D-printed devices is huge because of the ability to control segmental stiffness in a way that has never been done before. “There are huge benefits to being able to control specific segmental elements in an orthotic. This cannot be achieved with traditional polypropylene devices,” he said. “The ability to stiffen the medial arch, create more flexibility in the medial or lateral columns has huge benefits for athletes and even day-to-day patients.”

This variation in both local and directional flexibility reflects the biomechanical data from digital, dynamic analysis. “It results in lightweight devices that last longer than traditional orthotics, giving the patient better value for money,” Williams said.

For example, Dr. Williams has made orthoses with decreased stiffness of the lateral column specifically for athletes who have had, or are at high risk of having, a 5th metatarsal fracture. After implementing this modification, the pressures and length of high pressures under the 5th metatarsal decreased markedly and greatly reduced or minimized further risk to these athletes for that type of injury.

Norquist added that from a technical perspective, using 3D printing offers new possibilities of customization that have been impossible with traditional methods. What the clinician has ordered is what is received, fostering a trusting relationship with patients.

Getting results

Photo courtesy of RS Print

The process of using 3D printing can produce high-quality results, and Vakulenko shared that, with constant technological advances and new developments in the tools and materials being used, customized solutions are becoming lighter, more ergonomic, and more cost-effective. In most cases, customized 3D-printed orthoses have the potential to improve on standard methods in terms of accuracy, cost, and procedure. Using 3D scanning to create a model that is then 3D printed delivers the exact data required for sizing the orthosis, creating a perfect fit and a durable solution. Because the process is additive, there is no wasted material when creating parts, eliminating the risk of additional costs.

Williams added that some materials, such as nylon, are largely unbreakable and allow for significant variability in stiffness and flexibility. Norquist agrees: “The choice of the material wasn’t just a lucky guess,” he said. “PA 12 [nylon powder] is a material that lasts far better than, for example, EVA [ethylene vinyl acetate] or cork and leather.”

However, Vakulenko cautioned that, just as with anything else, there is always room for improvement. “3D printing is the best option for personalized orthoses; however, if an orthotic is mass-produced, it will be more cost-effective to do so with a more traditional manufacturing process,” he said. “In addition, 3D printing can be rather slow compared to, for example, milling machines.”

Looking ahead

3D printing is already being used in orthopedics to create implants and in minimally invasive surgery to create small devices, resulting in less tissue damage during operations. With the growth of this technology, most believe that use will be more widespread in the future. 643357494

Although 3D printing for the medical industry is highly practical for the creation of customized devices, Styles noted that, regrettably, using this process for mass production of supports and braces may not become a reality in the near future. Until plastic 3D-printing machines reach commercial speed, he explained, the time needed to create a part will be days, and the size of a finished orthotic is limited to the size of the 3D machine’s print bed—typically smaller than what can be made using computer numerical control machining or custom casting.

Ultimately, Raju explained, the biggest caveat for the 3D-printed orthotics industry is not what technology is being used but, rather, how that technology is married with the entire value chain of production—from design to global supply chain to product pricing to quality control to research and to design and innovation.

One key competitive advantage of 3D printing is that it can be used to manufacture objects with complex geometry, such as an object within another object that cannot be created by any means other than 3D printing. In the long run, 3D printing may eventually replace traditional methods of manufacturing, both mass-produced and customized, in numerous industries.

Vakulenko said that most traditional methods of creating prosthetics are approaching obsolescence, and practicing orthopedists are embracing the new 3D technologies for a much cleaner, faster, and more precise process. “Today, using both high-tech 3D-printing and 3D-scanning technologies opens up a large variety of possibilities and allows for a much more flexible workflow with the use of the cutting-edge systems,” he said. “With the development of highly advanced tools to tailor to the healthcare industry, it is safe to say that we are now witnessing a significant shift in the procedures of the orthotics field.”

Keith Loria is a freelance medical writer.

via The future is now— Implications of 3D technology for orthoses | Lower Extremity Review Magazine

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