Posts Tagged Motor

[Thesis] Post-stroke rehabilitation of hand function based on Electromyography biofeedback – Full Text PDF


The aim of my thesis work is the application and validation of an electromyographic biofeedback (EMG-BF) system in post-stroke rehabilitation setting. The absolute number of strokes is expected to dramatically increase in coming years, thus suggesting a need for strategies to improve post-stroke assistance and rehabilitation. The electromyogram (EMG) signal has shown good perspectives in the analysis of movements and motor impairment and the introduction of closed loop rehabilitation strategies revealed an increase of patient self-consciousness and motivation. Results are promising but a lack in the optimization of the devices for the application in the clinical context has been revealed. The device and the related software employed in the present research have been specifically conceived with this purpose. The device has been optimized during a clinical pilot study and then, a complete clinical trial has been started to investigate the characteristics of post stroke patients eligible for a rehabilitation therapy with the device, and the short-term clinical effect of the therapy on the recovery of the hand functionality. A statistical analysis has been performed on the dataset collected for 3 months. The data analysis included both clinical data and data collected from patients with the device during the execution of the experimental protocol. The preliminary results of the data analysis have confirmed the suitability of the system for its intended use and highlighted that the patient ability of controlling the EMG-BF based device is related to the degree of impairment with minimum p-value<0.001, depending on the patient clinical picture and on the exercise performed.
Moreover, according preliminary results observed on four patients that received a 15 hours therapy for 3 weeks, the improvement of the parameters related to the hand and fingers motor function, suggests the efficacy of the therapy. Finally, aspects related to the analysis of continuous motions of the wrist performed during the therapy have been investigated and the relevance of the temporal information in the interpretation of this type of movements has been revealed (p<<0.01).

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[Systematic Review] Trends in robot-assisted and virtual reality-assisted neuromuscular therapy: a systematic review of health-related multiplayer games – Full Text



Multiplayer games have emerged as a promising approach to increase the motivation of patients involved in rehabilitation therapy. In this systematic review, we evaluated recent publications in health-related multiplayer games that involved patients with cognitive and/or motor impairments. The aim was to investigate the effect of multiplayer gaming on game experience and game performance in healthy and non-healthy populations in comparison to individual game play. We further discuss the publications within the context of the theory of flow and the challenge point framework.


A systematic search was conducted through EMBASE, Medline, PubMed, Cochrane, CINAHL and PsycINFO. The search was complemented by recent publications in robot-assisted multiplayer neurorehabilitation. The search was restricted to robot-assisted or virtual reality-based training.


Thirteen articles met the inclusion criteria. Multiplayer modes used in health-related multiplayer games were: competitive, collaborative and co-active multiplayer modes. Multiplayer modes positively affected game experience in nine studies and game performance in six studies. Two articles reported increased game performance in single-player mode when compared to multiplayer mode.


The multiplayer modes of training reviewed improved game experience and game performance compared to single-player modes. However, the methods reviewed were quite heterogeneous and not exhaustive. One important take-away is that adaptation of the game conditions can individualize the difficulty of a game to a player’s skill level in competitive multiplayer games. Robotic assistance and virtual reality can enhance individualization by, for example, adapting the haptic conditions, e.g. by increasing haptic support or by providing haptic resistance. The flow theory and the challenge point framework support these results and are used in this review to frame the idea of adapting players’ game conditions.


Robotic assistance and virtual reality in neuromuscular therapy

Neurological deficits can result in impaired motor function that affect a person’s quality of life. Researchers have been working to restore the nervous system and reduce the neurological deficits of people suffering from stroke, spinal cord injury, or traumatic brain injury [1]. For people with neurological deficits, impaired motor function is among the most prominent factors limiting the quality of life [2]. Motor neurorehabilitation can lead to permanent improvements in motor function [3]. Robotic assistance and virtual reality have the potential to enhance rehabilitation of neuromuscular deficits beyond the levels possible with conventional training strategies [45].

Game experience and task performance in multiplayer games

Robot- and virtual reality-assisted single-player games are well integrated in neurorehabilitation schedules. Recently, multiplayer games have been tested to complement neuromuscular therapy. Multiplayer games are expected to motivate the patients and increase the potential of robot- and virtual reality-assisted neuromuscular therapy.

Multiplayer games incorporate social interaction to promote the enjoyment of the involved players. The additional player adds new possibilities to the game environment, generally missed in single-player gaming against preprogrammed challenges or artificially controlled opponents. The multiplayer environment and related game mechanics can facilitate social interaction, ranging from conversation to haptic interaction. Due to the this added social interaction, the game experience is thought to be better in multiplayer compared to single-player gaming [6].

The mode of the game specifies whether the players compete or cooperate with one another [7]. In line with the flow theory, a competitive mode requires opponents of similar skill level to achieve enjoyment as the task difficulty experienced by one opponent [8]. Comparable skill levels prevent boredom or stress and result in a meaningful challenge level that leads to a flow state when training [9]. In such training conditions the players have a positive game experience.

In positive game experience players increase their game performance [910]. Increased game performance facilitates the general idea of serious games, i.e., playing for a primary purpose other than pure entertainment [11]. If enhanced game performance is achieved by increased physical activity, training intensity is also increased. In neuromuscular therapy, training intensity – alongside early treatment, user-centered, and task-oriented training – is one of the key factors in neurorehabilitation [1213]. Therefore, multiplayer gaming has great potential to further increase the benefits of robot-assisted neuromuscular and virtual reality-assisted therapy [1415].



Continue —> Trends in robot-assisted and virtual reality-assisted neuromuscular therapy: a systematic review of health-related multiplayer games | Journal of NeuroEngineering and Rehabilitation | Full Text


Fig. 4Difficulty adaptation based on individual condition setting in multiplayer games. Game experience (left) can be optimized by balancing the game performance (right). – Left: The initial game experience under nominal conditions relates to the skill level of the opponent and is non-optimal for differently skilled players (squares). Optimal game experience is perceived by the players when the condition adapts the difficulty towards the players’ skill level (circles). – Right: A common initial game performance state consists of a conditional task difficulty and its corresponding player specific game performance (square). Player specific difficulty adaptation can balance the game performances of the two players (circles)

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[Abstract] Tele-Rehabilitation after Stroke: An Updated Systematic Review of the Literature



Tele-rehabilitation for stroke survivors has emerged as a promising intervention for remotely supervised administration of physical, occupational, speech, and other forms of therapies aimed at improving motor, cognitive, and neuropsychiatric deficits from stroke.


We aimed to provide an updated systematic review on the efficacy of tele-rehabilitation interventions for recovery from motor, higher cortical dysfunction, and poststroke depression among stroke survivors.


We searched PubMed and Cochrane library from January 1, 1980 to July 15, 2017 using the following keywords: “Telerehabilitation stroke,” “Mobile health rehabilitation,” “Telemedicine stroke rehabilitation,” and “Telerehabilitation.” Our inclusion criteria were randomized controlled trials, pilot trials, or feasibility trials that included an intervention group that received any tele-rehabilitation therapy for stroke survivors compared with a control group on usual or standard of care.


This search yielded 49 abstracts. By consensus between 2 investigators, 22 publications met the criteria for inclusion and further review. Tele-rehabilitation interventions focused on motor recovery (n = 18), depression, or caregiver strain (n = 2) and higher cortical dysfunction (n = 2). Overall, tele-rehabilitation interventions were associated with significant improvements in recovery from motor deficits, higher cortical dysfunction, and depression in the intervention groups in all studies assessed, but significant differences between intervention versus control groups were reported in 8 of 22 studies in favor of tele-rehabilitation group while the remaining studies reported nonsignificant differences.


This updated systematic review provides evidence to suggest that tele-rehabilitation interventions have either better or equal salutary effects on motor, higher cortical, and mood disorders compared with conventional face-to-face therapy.


via Tele-Rehabilitation after Stroke: An Updated Systematic Review of the Literature. – PubMed – NCBI

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[Abstract] Dual-task training effects on motor and cognitive functional abilities in individuals with stroke: a systematic review

This systematic review aimed to examine the effects of dual-task balance and mobility training in people with stroke.

An extensive electronic databases literature search was conducted using MEDLINE, PubMed, EBSCO, The Cochrane Library, Web of Science, SCOPUS, and Wiley Online Library. Randomized controlled studies that assessed the effects of dual-task training in stroke patients were included for the review (last search in December 2017). The methodological quality was evaluated using the Cochrane Collaboration recommendation, and level of evidence was determined according to the criteria described by the Oxford Center for Evidence-Based Medicine.

About 13 articles involving 457 participants were included in this systematic review. All had substantial risk of bias and thus provided level IIb evidence only. Dual-task mobility training was found to induce more improvement in single-task walking function (standardized effect size = 0.14–2.24), when compared with single-task mobility training. Its effect on dual-task walking function was not consistent. Cognitive-motor balance training was effective in improving single-task balance function (standardized effect size = 0.27–1.82), but its effect on dual-task balance ability was not studied. The beneficial effect of dual-task training on cognitive function was provided by one study only and thus inconclusive.

There is some evidence that dual-task training can improve single-task walking and balance function in individuals with stroke. However, any firm recommendation cannot be made due to the weak methodology of the studies reviewed.


via Dual-task training effects on motor and cognitive functional abilities in individuals with stroke: a systematic review – Ying He, Lei Yang, Jing Zhou, Liqing Yao, Marco Yiu Chung Pang, 2018

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Stroke is one of the leading causes for disability worldwide . Motor function deficits due to stroke affects the patient’s mobility and contribute to overall quality of life.              Neurorehabilitation training is the most effective way to reduce motor impairments in stroke patients. Conventional rehabilitation found to provide modest and sometimes delayed effects. This systematic review focuses on the impact of Virtual Reality Program on motor rehabilitation of stroke patients. The studies suggested that virtual reality is relatively recent approach that may enable practice of functional tasks at higher dosage than traditional therapies. From this review of  literature , it can be concluded that Virtual Reality is effective in improving motor functions following stroke. Use of Virtual Reality as an adjunct to conventional therapy resulted in greater motor gains than conventional therapy alone . The studies included in this review show optimal level of evidence and grade of recommendations , but further studies with larger sample sizes are needed to draw more reliable conclusion.

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[WEB SITE] Project3 – Flexo-glove


Project Description

Flexo-glove is a 3D printed soft exoskeleton robotic glove with compact and streamlined design for assistance in activities of daily livings and rehabilitation purposes of patients with hand function impairment.


  • Overall weight of 330g including battery
  • Providing 22N pinch force, 48N power grasp force and object grasp size of up to 81mm in diameter
  • Two control modes: intention-sensing via wireless surface EMG for assistive mode and externally-directed via an accompanying smartphone

Project Details: —> Visit site

My Role:

  • Initiated the project with the idea of using soft 3D printed materials in design of the Flexo-glove inspired by X-Limb
  • Performed feasibility study for using cable-driven mechanism in actuation of rehabilitation glove
  • Leading a group of four mechatronics engineering students to fabricate the prototype and characterise the grip forces


  • Received Dyason fellowship, $5000 travel fellowship awarded by Melbourne Robotic Lab. to visit Harvard BioRobotics Lab

Related Publications

 A. Mohammadi, J. Lavranos, R. D. Howe, P. Choong and D. Oetomo

  Flexo-glove: A 3D Printed Soft Exoskeleton Robotic Glove for Impaired Hand Rehabilitation and Assistance

  40th International Engineering in Medicine and Biology Conference (EMBC), 2018.

Full Text  PDF 

via Project3 – Flexo-glove

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[WEB SITE] Rutgers VR spinoff moves to NJEDA incubator

New Jersey Economic Development Authority
The New Jersey Economic Development Authority’s Commercialization Center for Innovative Technologies in North Brunswick.

Virtual reality is mostly known as a platform for gamers — allowing its users to escape from the real world by commanding the Enterprise, rescuing their child from a post-apocalyptic wasteland or being transported smack-dab into the middle of a murder mystery.

However, there’s another angle at play.

It can also help alleviate symptoms and improve the health of people who’ve suffered illnesses and injuries.

Patients who have suffered stroke, dementia and traumatic brain injuries are using virtual reality as part of their rehabilitation therapy, thanks to technology developed by Bright Cloud International Corp.

BCI, a Rutgers University spinoff, announced earlier this month it moved its operations into the New Jersey Economic Development Authority’s Commercialization Center for Innovative Technologies in North Brunswick. The move will expand the CCIT’s footprint in New Jersey as a life sciences incubator.

“Having spent the past 30 years here, I know the intrinsic value that New Jersey offers entrepreneurs, including its strong academic institutions and its dynamic life sciences community. I also wanted to maintain strong ties with Rutgers and to offer jobs for students and graduates. In return for the decades of support I have received from the university, I wanted to strengthen BCI while also benefitting Rutgers,” said Grigore “Greg” Burdea, BCI founder and president.

The rehabilitation system, known as BrightBrainer, is a self-contained and mobile rehabilitation medical device that has custom virtual reality therapy games.

The system, which is available for lease or purchase, targets motor skills such as motor control, speed of movement, endurance, hand-eye coordination and task sequencing. It also targets cognitive abilities, including attention, short-term visual and auditory memory, working memory, reading comprehension and dual tasking.

The virtual reality system, according to BCI, is useful in a variety of health care settings, including outpatient clinics, skilled nursing facilities and medical adult day programs.

“Our biggest success to date is the BrightBrainer rehabilitation system. I am proud that it reduces care costs, increases access to care and improves therapy outcomes,” Burdea said.

A team of researchers, engineers, physicians, therapists and game developers created the games, which adapt to each individual patient.

According to BCI, BrightBrainer has been found to benefit a patient’s motor and cognitive skills, as well as a patient’s emotional state, leading to an increased quality of life.

“We know that the brain can rewire itself to bypass non-working neurons, so our technology helps patients build that bypass to regain use of their bodies,” Burdea said. “It also puts a new and interactive spin on the monotony of occupational therapy, bringing an age-old industry into the 21st century.”

Burdea said he moved the incubator to CCIT because of its environment, access to networking and investors, and opportunities for increased visibility.

“Understanding and responding to the needs of the market is imperative to the state’s ability to retain and attract innovative companies and top talent,” EDA CEO Tim Sullivan said. “Nurturing early-stage companies is just one facet of Gov. (Phil) Murphy’s vision of a more robust and equitable economy, and CCIT offers a model of what can be achieved through collaboration between the private, public and academic sectors.”

via Rutgers VR spinoff moves to NJEDA incubator – ROI-NJ

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[BOOK] Emerging Therapies in Neurorehabilitation II – [Chapter] Virtual Rehabilitation – Request PDF


This chapter addresses the current state of the art of virtual rehabilitation by summarizing recent research results that focus on the assessment and remediation of motor impairments using virtual rehabilitation technology. Moreover, strengths and weaknesses of the virtual rehabilitation approach and its technical and clinical implications will be discussed. This overview is an update and extension of a previous virtual rehabilitation chapter with a similar focus. Despite tremendous advancements in virtual reality hardware in the past few years, clinical evidence for the efficacy of virtual rehabilitation methods is still sparse. All recent meta-analyses agree that the potential of virtual reality systems for motor rehabilitation in stroke and traumatic brain injury populations is evident, but that larger clinical trials are needed that address the contribution of individual aspects of virtual rehabilitation systems on different patient populations in acute and chronic stages of neurorehabilitation.

Virtual Rehabilitation | Request PDF. Available from:

via Virtual Rehabilitation | Request PDF

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[ARTICLE] Low-Frequency Repetitive Transcranial Magnetic Stimulation for Stroke-Induced Upper Limb Motor Deficit: A Meta-Analysis – Full Text


Background and Purpose. This meta-analysis aimed to evaluate the therapeutic potential of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) over the contralesional hemisphere on upper limb motor recovery and cortex plasticity after stroke. Methods. Databases of PubMed, Medline, ScienceDirect, Cochrane, and Embase were searched for randomized controlled trials published before Jun 31, 2017. The effect size was evaluated by using the standardized mean difference (SMD) and a 95% confidence interval (CI). Resting motor threshold (rMT) and motor-evoked potential (MEP) were also examined. Results. Twenty-two studies of 1 Hz LF-rTMS over the contralesional hemisphere were included. Significant efficacy was found on finger flexibility (SMD = 0.75), hand strength (SMD = 0.49), and activity dexterity (SMD = 0.32), but not on body function (SMD = 0.29). The positive changes of rMT (SMD = 0.38 for the affected hemisphere and SMD = −0.83 for the unaffected hemisphere) and MEP (SMD = −1.00 for the affected hemisphere and SMD = 0.57 for the unaffected hemisphere) were also significant. Conclusions. LF-rTMS as an add-on therapy significantly improved upper limb functional recovery especially the hand after stroke, probably through rebalanced cortical excitability of both hemispheres. Future studies should determine if LF-rTMS alone or in conjunction with practice/training would be more effective. Clinical Trial Registration Information. This trial is registered with unique identifier CRD42016042181.

1. Introduction

Stroke is a global disease with high rates of long-term disability [1]. Around the world, 25%–74% of stroke survivors require different levels of assistance for daily living mainly due to upper limb hemiplegia [2]. In search for better therapies, scientists have been trying to understand the relationship between stroke motor recovery and cortical reorganization [3]. The equilibrium of cortical excitability between the two hemispheres is often disrupted after stroke. In the affected hemisphere, both the cortical excitability and the homonymous motor representation of the affected hemisphere decrease; whereas the excitability in the unaffected hemisphere increases [4].

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive stimulation to induce electrical currents in the brain tissues. Currently, rTMS is being explored as a novel therapy in modulating cortical excitability to improve motor functions in stroke patients [5]. Of the two forms of rTMS, high-frequency rTMS (HF-rTMS > 1.0 Hz), applied over the ipsilesional hemisphere, facilitates cortical excitability [6], whereas, low-frequency rTMS (LF-rTMS ≤ 1.0 Hz), applied over the contralesional hemisphere, decreases cortical excitability [7].

The effect of rTMS is primarily determined by the stimulation frequency [8] and targeted region [3]. Although both LF-rTMS and HF-rTMS could treat motor dysfunction in poststroke patients, LF-rTMS is considered safer and superior to HF-rTMS in motor function recovery [912]. Lomarev et al. [13] reported increased risk for seizures by HF-rTMS of 20–25 Hz. To date, the majority of rTMS trials on motor recovery after stroke used the protocol of LF-rTMS with 1 Hz. In comparison, the HF-rTMS studies involved only a small number of trials and applied varied frequency protocols (3 Hz to 25 Hz). According to Cho et al. [14], the primary motor cortex (M1) forms a main part of the motor cortices and contributes to the high order control of motor behaviors. Until now, most studies about the efficacy of LF-rTMS on functional rehabilitation have focused on the M1. In healthy subjects, LF-rTMS applied over the M1 increased the resting motor threshold (rMT) and decreased the motor-evoked potential (MEP) size of the ipsilateral hemisphere, suggesting a suppressive effect of LF-rTMS in the intact M1 [15].

Multiple studies have investigated the therapeutic effect of LF-rTMS after stroke [81619], with the outcomes of pinch force [1922], grip force [102225], finger tapping [892629], and overall function [153034]. Other studies also explored the impact of rTMS on cortical excitability [10181926]. However, inconsistent reports exist regarding the benefits of LF-rTMS: Some studies showed no beneficial effect of LF-rTMS [162329] and one study reported worsening effects of LF-rTMS such as decreased finger-tapping speed; [35] other investigators proposed that inhibition of the contralesional motor areas may lead to deterioration of the function of the unaffected hand [2426]. Although a few previous meta-analyses had investigated the therapeutic effect of rTMS after stroke [113638], they focused on the mixed effect of combined LF-rTMS and HF-rTMS interventions or on the combined outcomes of varying motor measurements. So far, there is a lack of in-depth systematic meta-analysis about the efficacy of LF-rTMS on upper limb function recovery.

The primary objective of this study was to evaluate the effects of LF-rTMS on upper limb motor recovery after stroke in several aspects: “finger flexibility,” “hand strength,” “activity dexterity,” and “body function level.” The effects of LF-rTMS on motor cortex excitability which were represented by MEP and rMTin poststroke patients were also evaluated. […]

Continue —>  Low-Frequency Repetitive Transcranial Magnetic Stimulation for Stroke-Induced Upper Limb Motor Deficit: A Meta-Analysis

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[Abstract] Motor Recovery Beginning 23 Years After Ischemic Stroke


It is widely believed that most stroke recovery occurs within 6 months, with little benefit of physiotherapy or other modalities beyond a year. We report a remarkable case of stroke recovery beginning 23 years after a severe stroke due to embolization from the innominate artery and subclavian artery, resulting from compression of the right subclavian artery by a cervical rib. The patient had a large right fronto-parietal infarction with severe left hemiparesis, and a totally non-functional spastic left hand. He experienced some recovery of hand function that began 23 years after the stroke, a year after he took up regular swimming. As a result, intensive physiotherapy was initiated, with repetetive large muscle movement and a spring-loaded mechanical orthosis that provides resistance to finger flexors and supports finger extensors. Within two years he could pick up coins with the previously useless left hand. Functional MRI studies document widespread distribution of the recovery in both hemispheres. This case provides impetus not only to more intensive and prolonged physiotherapy, but also to treatment with emerging modalities such as stem cell therapy, exosome and micro-RNA therapies.

Source: ARTICLES | Journal of Neurophysiology

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