Posts Tagged robotics

[ARTICLE] tDCS and Robotics on Upper Limb Stroke Rehabilitation: Effect Modification by Stroke Duration and Type of Stroke – Full Text

Abstract

Objective. The aim of this exploratory pilot study is to test the effects of bilateral tDCS combined with upper extremity robot-assisted therapy (RAT) on stroke survivors. Methods. We enrolled 23 subjects who were allocated to 2 groups: RAT + real tDCS and RAT + sham-tDCS. Each patient underwent 10 sessions (5 sessions/week) over two weeks. Outcome measures were collected before and after treatment: (i) Fugl-Meyer Assessment-Upper Extremity (FMA-UE), (ii) Box and Block Test (BBT), and (iii) Motor Activity Log (MAL). Results. Both groups reported a significant improvement in FMA-UE score after treatment (). No significant between-groups differences were found in motor function. However, when the analysis was adjusted for stroke type and duration, a significant interaction effect () was detected, showing that stroke duration (acute versus chronic) and type (cortical versus subcortical) modify the effect of tDCS and robotics on motor function. Patients with chronic and subcortical stroke benefited more from the treatments than patients with acute and cortical stroke, who presented very small changes. Conclusion. The additional use of bilateral tDCS to RAT seems to have a significant beneficial effect depending on the duration and type of stroke. These results should be verified by additional confirmatory studies.

1. Introduction

Stroke is a common primary cause of motor impairments and disability. Only about 15% of those with initial complete upper limb paralysis after stroke recover a functional use of their affected arm in daily life [12]. Greater intensity of upper extremity training after stroke improves functional recovery [3] as well as repetitive task training [4]. Motor practice, in turn, favors motor cortical reorganization, which is correlated with the degree of functional recovery [5]. Robotic devices for upper extremity rehabilitation after stroke have been shown to improve arm function [69]. They may enhance conventional motor therapy, increasing repetitions of well-defined motor tasks (massed practice) with an improvement of motivation due to the feedback of the device; they can be programmed to perform in different functional modalities according to the subject level of motor impairment. Robotic assistance may increase sensory inputs and reduce muscle tone with an overall improved patients’ confidence in performing movements and tasks that, without assistance, might be frustrating or even impossible to achieve [10]. In the past decade, neuromodulation approaches have been proposed with the aim of optimizing stroke motor rehabilitation. Among these, transcranial direct current stimulation (tDCS) represents a noninvasive tool to modulate motor cortical excitability inducing a brain polarization through the application of weak direct electrical currents on the scalp via sponge electrodes [11]. Transient, bidirectional, polarity-dependent modifications in motor cortical excitability can be elicited: anodal stimulation increases it, whereas cathodal stimulation decreases it [1213]. Moreover, on a behavioral viewpoint, tDCS can promote skilled motor function in chronic stroke survivors [14].

After a stroke, changes in motor cortex excitability occur leading to an unbalanced interhemispheric inhibition [11], because the depression of the contralesional hemisphere on the affected one is not balanced by a similar level of inhibition of the lesional hemisphere onto the unaffected one. It has been hypothesized that this phenomenon represents a potential maladaptive process with detrimental effects on arm motor function [15]. On this basis, to increase paretic arm function, an “interhemispheric competition model” has been adopted in noninvasive brain stimulation stroke research [1116]. Specifically, researchers applied anodal tDCS over the affected primary motor cortex (M1) [14], cathodal stimulation over the unaffected M1 [17], or, more recently, a combination of the two stimulation paradigms through a bilateral tDCS montage [18]. How noninvasive brain stimulation effects are relevant when coupled with a peripheral stimulation as rehabilitative interventions is now well established [19]. So far, tDCS effects on motor learning and arm function in stroke population have been extensively addressed in recent systematic reviews and meta-analysis reporting mixed conclusions [2024]. Indeed, the effectiveness and timing of these new rehabilitative techniques need to be defined by further investigations. We can hypothesize that tDCS primes motor cortex circuits, increasing motor cortex excitability that is sustained after a robot-assisted training [25]. Furthermore, the combination of these techniques enhances synaptic plasticity and motor relearning through long-term potentiation- (LTP-) and long-term depression- (LTD-) like phenomena on M1 [26].

The aims of this exploratory pilot study were twofold. Firstly, we wanted to test the effects of a bilateral tDCS montage combined with upper extremity robot-assisted training (RAT) compared to RAT alone on motor recovery, gross motor function, and arm functional use in a heterogeneous sample of stroke survivors. Secondly, we explored whether additional factors such as stroke duration and type could modify and also be predictors of tDCS and RAT response.[…]

Continue —->  tDCS and Robotics on Upper Limb Stroke Rehabilitation: Effect Modification by Stroke Duration and Type of Stroke

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[Abstract] Robot-assisted therapy for arm recovery for stroke patients: state of the art and clinical implication

Abstract

Introduction: Robot-assisted therapy is an emerging approach that performs highly repetitive, intensive, task oriented and quantifiable neuro-rehabilitation. In the last decades, it has been increasingly used in a wide range of neurological central nervous system conditions implying an upper limb paresis. Results from the studies are controversial, for the many types of robots and their features often not accompanied by specific clinical indications about the target functions, fundamental for the individualized neurorehabilitation program.

Areas covered: This article reviews the state of the art and perspectives of robotics in post-stroke rehabilitation for upper limb recovery. Classifications and features of robots have been reported in accordance with technological and clinical contents, together with the definition of determinants specific for each patient, that could modify the efficacy of robotic treatments. The possibility of combining robotic intervention with other therapies has also been discussed.

Expert commentary: The recent wide diffusion of robots in neurorehabilitation has generated a confusion due to the commingling of technical and clinical aspects not previously clarified. Our critical review provides a possible hypothesis about how to match a robot with subject’s upper limb functional abilities, but also highlights the need of organizing a clinical consensus conference about the robotic therapy.

Article Highlights

Robotic neurorehabilitation has the potential to improve the quality and intensity of rehabilitation treatments in order to promote motor-cognitive recovery following a central nervous system disease.

Controversial results in literature maybe generated by confusion in the use of robots related to many technological and clinical features, and emphasized by excessive optimism or scepticism about this technology.

Budgets spent for robots in rehabilitation are expected to grow dramatically in the next future, but there is the need of evidence-based proofs to balance the business push.

There is need of further researches in motor-cognitive technological rehabilitation in order to better understand the gain that robotic therapy could add to conventional therapy in relation to the patient’s cognitive reserve.

There is a need for clinical consensus conferences that might give clinical indication to end users.
via Robot-assisted therapy for arm recovery for stroke patients: state of the art and clinical implication: Expert Review of Medical Devices: Vol 0, No 0

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[Abstract] The Role of Robotic Path Assistance and Weight Support in Facilitating 3D Movements in Individuals With Poststroke Hemiparesis

Background. High-intensity repetitive training is challenging to provide poststroke. Robotic approaches can facilitate such training by unweighting the limb and/or by improving trajectory control, but the extent to which these types of assistance are necessary is not known.

Objective. The purpose of this study was to examine the extent to which robotic path assistance and/or weight support facilitate repetitive 3D movements in high functioning and low functioning subjects with poststroke arm motor impairment relative to healthy controls.

Methods. Seven healthy controls and 18 subjects with chronic poststroke right-sided hemiparesis performed 300 repetitions of a 3D circle-drawing task using a 3D Cable-driven Arm Exoskeleton (CAREX) robot. Subjects performed 100 repetitions each with path assistance alone, weight support alone, and path assistance plus weight support in a random order over a single session. Kinematic data from the task were used to compute the normalized error and speed as well as the speed-error relationship.

Results. Low functioning stroke subjects (Fugl-Meyer Scale score = 16.6 ± 6.5) showed the lowest error with path assistance plus weight support, whereas high functioning stroke subjects (Fugl-Meyer Scale score = 59.6 ± 6.8) moved faster with path assistance alone. When both speed and error were considered together, low functioning subjects significantly reduced their error and increased their speed but showed no difference across the robotic conditions.

Conclusions. Robotic assistance can facilitate repetitive task performance in individuals with severe arm motor impairment, but path assistance provides little advantage over weight support alone. Future studies focusing on antigravity arm movement control are warranted poststroke.

 

via The Role of Robotic Path Assistance and Weight Support in Facilitating 3D Movements in Individuals With Poststroke Hemiparesis – Preeti Raghavan, Seda Bilaloglu, Syed Zain Ali, Xin Jin, Viswanath Aluru, Megan C. Buckley, Alvin Tang, Arash Yousefi, Jennifer Stone, Sunil K. Agrawal, Ying Lu, 2020

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[Abstract + References] Do powered over-ground lower limb robotic exoskeletons affect outcomes in the rehabilitation of people with acquired brain injury?

Abstract

Purpose: To assess the effects of lower limb robotic exoskeletons on outcomes in the rehabilitation of people with acquired brain injury.

Materials and methods: A systematic review of seven electronic databases was conducted. The primary outcome of interest was neuromuscular function. Secondary outcomes included quality of life, mood, acceptability and safety. Studies were assessed for methodological quality and recommendations were made using the GRADE system.

Results: Of 2469 identified studies, 13 (n = 322) were included in the review. Five contained data suitable for meta-analysis. When the data were pooled, there were no differences between exoskeleton and control for 6-Minute Walk Test, Timed Up and Go or 10-Meter Walk Test. Berg Balance Scale outcomes were significantly better in controls (MD = 2.74, CI = 1.12–4.36, p = 0.0009). There were no severe adverse events but drop-outs were 11.5% (n = 37). No studies reported the effect of robotic therapy on quality of life or mood. Methodological quality was on average fair (15.6/27 on Downs and Black Scale).

Conclusions: Only small numbers of people with acquired brain injury had data suitable for analysis. The available data suggests no more benefit for gait or balance with robotic therapy than conventional therapy. However, some important outcomes have not been studied and further well-conducted research is needed to determine whether such devices offer benefit over conventional therapy, in particular subgroups of those with acquired brain injury.

  • Implications for Rehabilitation
  • There is adequate evidence to recommend that powered over-ground lower limb robotic exoskeletons should not be used clinically in those with ABI, and that use should be restricted to research.
  • Further research (controlled trials) with dependent ambulators is recommended.
  • Research of other outcomes such as acceptability, spasticity, sitting posture, cardiorespiratory and psychological function, should be considered.

References

Source: https://doi.org/10.1080/17483107.2018.1499137

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[ARTICLE] Pilot Study of a Powered Exoskeleton for Upper Limb Rehabilitation Based on the Wheelchair – Full Text

Abstract

To help hemiplegic patients with stroke to restore impaired or lost upper extremity functionalities efficiently, the design of upper limb rehabilitation robotics which can substitute human practice becomes more important. The aim of this work is to propose a powered exoskeleton for upper limb rehabilitation based on a wheelchair in order to increase the frequency of training and reduce the preparing time per training. This paper firstly analyzes the range of motion (ROM) of the flexion/extension, adduction/abduction, and internal/external of the shoulder joint, the flexion/extension of the elbow joint, the pronation/supination of the forearm, the flexion/extension and ulnar/radial of the wrist joint by measuring the normal people who are sitting on a wheelchair. Then, a six-degree-of-freedom exoskeleton based on a wheelchair is designed according to the defined range of motion. The kinematics model and workspace are analyzed to understand the position of the exoskeleton. In the end, the test of ROM of each joint has been done. The maximum error of measured and desired shoulder flexion and extension joint angle is 14.98%. The maximum error of measured and desired elbow flexion and extension joint angle is 14.56%. It is acceptable for rehabilitation training. Meanwhile, the movement of drinking water can be realized in accordance with the range of motion. It demonstrates that the proposed upper limb exoskeleton can also assist people with upper limb disorder to deal with activities of daily living. The feasibility of the proposed powered exoskeleton for upper limb rehabilitation training and function compensating based on a wheelchair is proved.

1. Introduction

Upper extremity motor function disorder is one of the most common rehabilitation problems of hemiplegic patients with stroke [1]. The upper extremity motor function plays a key role in self-care and social activities. The upper extremity motor function disorder significantly lowers the life quality of hemiplegic patients with stroke [23]. Due to the complex structure and functional requirement of the upper limb, the rehabilitation process of the impaired upper extremity functionality is a long and slow process. Because of the specificity of hemiplegic patients in diagnosis, treatment, and rehabilitation, it brings a series of severe psychological and financial stress for patients [4]. The outcome of upper limb motor rehabilitation depends on duration, intensity and task orientation of the training. The therapists assisting patients have to bear a significant burden. As a result, the duration of primary upper limb rehabilitation is becoming shorter [5]. To deal with these problems, robotic rehabilitation devices with the ability to conduct repetitive tasks and provide assistive force have been proposed.

The upper limb rehabilitation robots can be divided into two types according to the service environment. One is mainly used in the hospital and shared by several patients. The upper limb rehabilitation robots used in the hospital are often designed for rehabilitation training and difficult to move. Loris et al. introduced a dual exoskeleton robot called automatic recovery arm motility integrated system. The system was developed to enable therapists to define and apply patient-specific rehabilitation exercises with multidisciplinary support by neurologist, engineers, ICT specialists and designers [6]. Farshid et al. presented the GENTLE/S system for upper limb rehabilitation. The system comprised a 3-degree-of-freedom (DOF) robot manipulator with an extra 3 DOFs passive gimbal mechanism, an exercise table, computer screen, overhead frame, and chair [7]. Dongjin Lee et al. proposed a clinically relevant upper-limb exoskeleton that met the clinical requirements. The pilot test showed that the safety for robot-aided passive training of patients with spasticity could be guaranteed [8]. The other is mainly used in the home to assist a single patient in activities of daily living. A lightweight and ergonomic upper-limb rehabilitation exoskeleton named CLEVER ARM was proposed by Zeiaee et al. The wearable upper limb exoskeleton was to provide automated therapy to stroke patients [9]. Feiyun et al. presented a seven DOFs cable-driven upper limb exoskeleton for post-stroke patients. The experimental results showed that the activation levels of corresponding muscles were reduced by using the 7 DOFs cable-driven upper limb exoskeleton in the course of rehabilitation [10]. In fact, the main function of upper extremity rehabilitation devices is to provide the physical training and assist the patients with hemiplegia to perform the activities of daily living. However, hospital or home used rehabilitation robot research has just focused on one respect. Indeed, the research on the upper extremity rehabilitation devices would focus on both aspects of assisting and training. Therefore, it is important for the design of upper limb rehabilitation robot to combine the rehabilitation training and assisting function.

The stationary upper extremity rehabilitation robot cannot solve the movability problem and perform the activities of daily living (ADL). The wearable exoskeleton devices are limited by the weight. In addition, whether the range of motion is in line with the physiological joints directly determines the rehabilitation effect. Therefore, the key questions can be summarized as follows. Can we transform the weight of the upper limb exoskeleton to another movable device instead of wearing by patients? How to guarantee the design of upper limb exoskeleton joint axis in line with the human joint movement axis?

To deal with the above questions, some researchers have made useful explorations. Kiguchi et al. proposed a mechanism and control method of a mobile exoskeleton robot based on a wheelchair for 3 DOFs upper-limb motion assist [11]. The first problem of transforming weight can be solved by design based on a wheelchair. The physical rehabilitation training can be realized on a wheelchair instead of a stationary place. The ADL can be assisted by the powered upper limb exoskeleton on a moving platform. However, the rotation axis of each joint (shoulder joint and elbow joint) is moving with the movement of the upper limb. The gap between the exoskeleton and human arm is also changing by following their movement. It does not consider the problem about the movement consistency of the exoskeleton joint rotation axis and the human joint. As for this problem, Vitiello et al. proposed an elbow exoskeleton with double-shelled links to allow an ergonomic physical human-robot interface and a four-degree-of-freedom passive mechanism to allow the user’s elbow and robot axes to be constantly aligned during movement [12]. However, it focused on the elbow. The whole upper limb rehabilitation was not considered. In this work, we present a novel solution for the two mentioned problems. The range of motion of the upper extremity exoskeleton based on a wheelchair is defined through the normal people test. The 6 DOFs exoskeleton based on a wheelchair is designed according to the defined range of motion. The pursuit movement experiment and the assistive movement of drinking water of the prototype are done to verify the feasibility of the design.

2. Materials and Methods

2.1. Definition of ROM of Each Joint for the Specific Upper Limb Exoskeleton on a Wheelchair

To ensure the safety of using an upper limb exoskeleton on a wheelchair, it is necessary to know the ROM of the human upper limb on the wheelchair.

The parts of the upper limb taken into account in the design of an exoskeleton are shoulder, arm, elbow, wrist, and hand. Hand is excluded in an entire upper extremity exoskeleton design because of its complexity and dexterous characteristic. Therefore, this work only analyzes the ROM of the shoulder joint, elbow joint, and wrist joint. And then the upper limb exoskeleton designed in this paper must conform to the ROM of these joints.

2.1.1. Apparatus

The apparatus consists of a wheelchair and a motion analysis system. The motion analysis system can transmit data in real time. It was made in JIANGSU NEUCOGNIC MEDICAL CO., LTD. The system can measure the ROM of the shoulder joint, elbow joint and wrist joint of a person who sits on a common wheelchair. In Figure 1, there are two inertial sensors located at the upside and downside of backbone, and ten inertial sensors located at the upper limb (shoulder, upper arm, forearm, palm, and hand), respectively. All of the sensors in this system can measure the angles in x-, y– and z-axis. Sensor 1 and Sensor 4 are utilized to measure the ROM of the rear waist as the referring data. Sensor 4 and Sensor 6 are utilized to measure the ROM of the shoulder joint as the referring data. Sensor 6 and Sensor 7 are utilized to measure the ROM of the elbow joint as the referring data. Sensor 7 and hand sensor are utilized to measure the ROM of wrist joint as the referring data.[…]

Continue —-> Pilot Study of a Powered Exoskeleton for Upper Limb Rehabilitation Based on the Wheelchair

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[ARTICLE] Upper Limb Robotic Rehabilitation After Stroke: A Multicenter, Randomized Clinical Trial

Abstract

Background and Purpose: After stroke, only 12% of survivors obtain complete upper limb (UL) functional recovery, while in 30% to 60% UL deficits persist. Despite the complexity of the UL, prior robot-mediated therapy research has used only one robot in comparisons to conventional therapy. We evaluated the efficacy of robotic UL treatment using a set of 4 devices, compared with conventional therapy.

Methods: In a multicenter, randomized controlled trial, 247 subjects with subacute stroke were assigned either to robotic (using a set of 4 devices) or to conventional treatment, each consisting of 30 sessions. Subjects were evaluated before and after treatment, with follow-up assessment after 3 months. The primary outcome measure was change from baseline in the Fugl-Meyer Assessment (FMA) score. Secondary outcome measures were selected to assess motor function, activities, and participation.

Results: One hundred ninety subjects completed the posttreatment assessment, with a subset (n = 122) returning for follow-up evaluation. Mean FMA score improvement in the robotic group was 8.50 (confidence interval: 6.82 to 10.17), versus 8.57 (confidence interval: 6.97 to 10.18) in the conventional group, with no significant between-groups difference (adjusted mean difference −0.08, P = 0.948). Both groups also had similar change in secondary measures, except for the Motricity Index, with better results for the robotic group (adjusted mean difference 4.42, P = 0.037). At follow-up, subjects continued to improve with no between-groups differences.

Discussion and Conclusions: Robotic treatment using a set of 4 devices significantly improved UL motor function, activities, and participation in subjects with subacute stroke to the same extent as a similar amount of conventional therapy. Video Abstract is available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A291).

INTRODUCTION

Only 12% of stroke survivors obtain complete upper limb (UL) functional recovery after 6 months from stroke.1 In the remaining 88%, UL motor deficits persist with a negative impact on their level of activities2–4 and participation,5 according to the International Classification of Functioning, Disability and Health (ICF).6

Robotic therapy has been proposed as a viable approach for the rehabilitation of the UL, as a way to increase the amount and intensity of the therapy,7 and to standardize the treatment,8 by providing complex but controlled multisensory stimulation.7 Moreover, because of their built-in technology in terms of sensors and actuators, robotic devices can provide quantitative measure about the user’s dexterity.9 A large number of scientific articles on robot-assisted rehabilitation after stroke have been published, analyzing the effects of robotics alone,10–18 or in conjunction with conventional therapy.19–24 Nowadays, the use of robotic rehabilitation in addition to conventional therapy is recommended in some of the current stroke guidelines.25

Regarding the efficacy of robotic rehabilitation when compared with other treatments, the available scientific data are not conclusive. In comparing robotic and conventional treatment, some studies did not find an overall significant effect in favor of robotic therapy11,26,27: others showed a greater effect of robotic therapy than conventional therapy.28 However, in the latter case, the results must be interpreted with caution because the quality of the evidence was low or very low, owing to the variations between the trials in intensity, duration, and amount of training, type of treatment, participant characteristics, and measurements used. Finally, according to the most recent meta-analysis,29 it is not clear whether the difference between robotic therapy and other interventions (as conventional therapy) is clinically meaningful for the persons with stroke.

Almost all studies of robotic therapy have focused on the effects of the use of 1 device, compared with a conventional therapy approach. However, despite the complexity of the anatomy and the motor function of whole UL, especially the hand, almost all commercial devices act on a limited number of joints and a limited workspace. Conversely, during conventional therapy, the whole UL is routinely treated and the 3-dimensional space explored. Because of this, it is very difficult to compare the effects of 1 robotic device with conventional approaches. Therefore, it would be desirable to use devices that allow treatment of the entire UL (from shoulder to hand), in a workspace similar to that required in daily activities. Moreover, using more than 1 device new personnel organizational models can be adopted, wherein 1 physical therapist supervises more than 1 patient, thereby increasing the sustainability of the treatment.15,21,30

The aim of the current study was to evaluate, in subjects with subacute stroke, the efficacy of standardized UL robotic rehabilitation (using an organizational model in which 1 physical therapist supervises 3 subjects, each treated using a set of 4 robots and sensor-based devices), compared with UL conventional therapy. Outcomes of interest were selected to reflect effects on function, activities, and participation (per the ICF) […]

Continue —->  Upper Limb Robotic Rehabilitation After Stroke: A Multicente… : Journal of Neurologic Physical Therapy

 

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[Abstract] Movement kinematics and proprioception in post-stroke spasticity: assessment using the Kinarm robotic exoskeleton – Full Text PDF

Headline

Background

Motor impairment after stroke interferes with performance of everyday activities. Upper limb spasticity may further disrupt the movement patterns that enable optimal function; however, the specific features of these altered movement patterns, which differentiate individuals with and without spasticity, have not been fully identified. This study aimed to characterize the kinematic and proprioceptive deficits of individuals with upper limb spasticity after stroke using the Kinarm robotic exoskeleton.

Methods

Upper limb function was characterized using two tasks: Visually Guided Reaching, in which participants moved the limb from a central target to 1 of 4 or 1 of 8 outer targets when cued (measuring reaching function) and Arm Position Matching, in which participants moved the less-affected arm to mirror match the position of the affected arm (measuring proprioception), which was passively moved to 1 of 4 or 1 of 9 different positions. Comparisons were made between individuals with (n = 35) and without (n = 35) upper limb post-stroke spasticity.

Results

Statistically significant differences in affected limb performance between groups were observed in reaching-specific measures characterizing movement time and movement speed, as well as an overall metric for the Visually Guided Reaching task. While both groups demonstrated deficits in proprioception compared to normative values, no differences were observed between groups. Modified Ashworth Scale score was significantly correlated with these same measures.

Conclusions

The findings indicate that individuals with spasticity experience greater deficits in temporal features of movement while reaching, but not in proprioception in comparison to individuals with post-stroke motor impairment without spasticity. Temporal features of movement can be potential targets for rehabilitation in individuals with upper limb spasticity after stroke.

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via Movement kinematics and proprioception in post-stroke spasticity: assessment using the Kinarm robotic exoskeleton – Researcher | An App For Academics

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

Abstract

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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[Abstract] The effects of a robot-assisted arm training plus hand functional electrical stimulation on recovery after stroke: a randomized clinical trial

Abstract

Objective

To compare the effects of unilateral, proximal arm robot-assisted therapy combined with hand functional electrical stimulation to intensive conventional therapy for restoring arm function in subacute stroke survivors.

Design

This was a single blinded, randomized controlled trial.

Setting

Inpatient Rehabilitation University Hospital.

Participants

Forty patients diagnosed with ischemic stroke (time since stroke <8 weeks) and upper limb impairment were enrolled.

Interventions

Participants randomized to the experimental group received 30 sessions (5 sessions/week) of robot-assisted arm therapy and hand functional electrical stimulation (RAT + FES). Participants randomized to the control group received a time-matched intensive conventional therapy (ICT).

Main outcome measures

The primary outcome was arm motor recovery measured with the Fugl-Meyer Motor Assessment. Secondary outcomes included motor function, arm spasticity and activities of daily living. Measurements were performed at baseline, after 3 weeks, at the end of treatment and at 6-month follow-up. Presence of motor evoked potentials (MEPs) was also measured at baseline.

Results

Both groups significantly improved all outcome measures except for spasticity without differences between groups. Patients with moderate impairment and presence of MEPs who underwent early rehabilitation (<30 days post stroke) demonstrated the greatest clinical improvements.

Conclusions

A robot-assisted arm training plus hand functional electrical stimulation was no more effective than intensive conventional arm training. However, at the same level of arm impairment and corticospinal tract integrity, it induced a higher level of arm recovery.

 

via The effects of a robot-assisted arm training plus hand functional electrical stimulation on recovery after stroke: a randomized clinical trial – ScienceDirect

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[WEB SITE] Neurorehabilitation: Fighting strokes with robotics

Having a stroke can be a scary experience, but the long road to recovery might be getting shorter, thanks to research out of ECU.

Imagine suddenly losing control of a limb or your ability to communicate.

And while this happens, excruciating pain spreads across your head.

This was Joanna’s experience when she had a  at the age of 44.

“I was sick three days up to having my stroke,” Joanna explains. “I had vomiting, headaches and was not making much sense when talking.”

“Three days later, I was sitting down and then it felt like my head was being squeezed between two vices. Excruciating pain.”

Risk factor

In Australia, strokes affect around 55,000 people a year and are the third most common cause of death and a leading cause of disability.

There’s a range of factors that increase the risk of strokes, including diet, exercise and .

But one of the most telling  is, simply, age.

From the age of 45, the risk of a stroke in men is one in four, and for women, it’s one in five.

Fortunately, our knowledge of strokes and how to combat them has improved a lot in the past few decades.

A big part of the solution is getting help quickly, according to Edith Cowan University (ECU) Professor Dylan Edwards.

“If it’s the blockage of a blood vessel, it can be treated very well by anti-coagulant therapy that will break up the blood clot and restore the blood flow to the brain,” Dylan says.

“Typically, you notice somebody is having a stroke by them having issues with their speech or they have a weakness or funny sensation in one side of their body.”

But surviving a stroke is only part of the journey, and with 65% of stroke survivors suffering from some form of disability, restoring motor skills is a critical part of rehabilitation.

Road to recovery

Recovery from stroke can be a long and frustrating road for even the smallest paralysation.

For stroke survivor Joanna, the frustration she felt not being able to move normally made the recovery process even more challenging.

“The emotional side of having the stroke has affected me more than anything else,” Joanna says.

“You slowly get used to the fact that you can’t move your left side, and you know that you’ll get therapy. But when I had people come visit, when they left, I was in tears [out of frustration].”

Joanna eventually started to get some feeling back in her left side, just to her thumb at first.

“It was still a shock that I had lost all of that, so just a little bit of movement was enough to keep me going and stay motivated.”

Fighting back with technology

At ECU’s Lab for NeuroRehabilitation and Robotics, Dylan and his team have been researching how to help people recover their motor control after a brain or spinal cord injury.

Part of their research focuses on understanding the recovery of stroke survivors, using a robotic sensory platform called the Kinarm Exoskeleton Lab.

“The Kinarm looks like a fancy piece of gym equipment,” Dylan explains. “You sit inside the device and position your arms on top of movable handles, and you’re wheeled into this virtual reality environment.”

For the user in the chair, it feels like you’re playing a series of games, moving the chair’s arms to get a response on the screen—such as bouncing balls off paddles.

But the real work is happening behind the scenes.

“All of this information is acquired by these high-powered computers and analysed for how the person is performing,” Dylan says. “This [helps] identify the precise proprioceptive issue with an individual stroke survivor so we can prescribe therapy more effectively.”

In simplest terms, the Kinarm helps identify issues where the user is telling their arm to move but the resulting movement is not what they were trying to do.

This could be an arm not extending the full distance or slower reaction times.

With strokes usually affecting one side of the body more than the other, the unaffected side can provide a good baseline for what their normal reactions should be.

But what if both sides of the body have been affected? The Kinarm can pick up on that too, detecting deficits in what would be considered the unaffected side and showing this in the test results.

R&R—Robotics and Recovery

For Joanna, using the Kinarm has been a challenging experience, even three years after her stroke.

“It actually made you concentrate more in the game to hit the balls coming down,” she explains.

“I think that made you use the brain to try and keep up with your eye, which it didn’t, but I gave it my best shot. I also noticed my peripheral vision has gone.”

“It highlighted for me the improvements I have got since my stroke, which is nice for me three years on to see how it was then to what I could actually achieve on the Kinarm now.”

The data collected helps doctors prescribe the most beneficial treatment for their patients, based on the results of the tests.

Whether it’s heading towards recovering the function in a limb or something as simple as the mobility of a single joint, Dylan believes even small changes are worth pursuing.

“Some degree of independence—even though it might be apparent to an onlooker or a carer—can be very meaningful for a patient.”

“Small changes that we have made in the past through prescribing therapies effectively are things like being able to stabilise yourself on the train and send a text message.”

Recovering movement and lives

While full recovery from a stroke is not guaranteed, any improvement to quality of life can mean everything for survivors. Restoring simple movements can help patients build up their self-confidence to return to their everyday lives.

“Often stroke patients are in the older age bracket, and many of them are working,” Dylan says. “It’s very depressing to be disengaged from a functional work life, and going back to work might just be having the confidence of turning over a page of paper at your desk.”

As we learn more about how the body and brain recover after these , there’s hope we can find ways to better support those who have experienced extensive motor damage.

While there’s medication and training regimes to follow, at its core, it comes down to the drive to actively engage in recovering.

And even if it’s just through small victories, a spark from ECU’s Lab for NeuroRehabilitation and Robotics could help light the fire of determination in .


Explore further

Regulating blood supply to limbs improves stroke recovery

 

via Neurorehabilitation: Fighting strokes with robotics

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