Posts Tagged robotics

[Case Report] Use of a myoelectric upper limb orthosis for rehabilitation of the upper limb in traumatic brain injury – Full Text



Upper limb motor deficits following traumatic brain injury are prevalent and effective therapies are needed. The purpose of this case report was to illustrate response to a novel therapy using a myoelectric orthosis in a person with TBI.

Case description: A 42-year-old female, 29.5 years post-traumatic brain injury with diminished motor control/coordination, and learned nonuse of the right arm. She also had cognitive deficits and did not spontaneously use her right arm functionally.


Study included three phases: baseline data collection/device fabrication (five weeks); in-clinic training (2×/week for nine weeks); and home-use phase (nine weeks). The orthosis was incorporated into motor learning-based therapy.

Outcomes: During in-clinic training, active range of motion, tone, muscle power, Fugl-Meyer, box and blocks test, and Chedoke assessment score improved. During the home-use phase, decrease in tone was maintained and all other outcomes declined but were still better upon study completion than baseline. The participant trained with the orthosis 70.12 h, logging over 13,000 repetitions of elbow flexion/extension and hand open/close.


Despite long-standing traumatic brain injury, meaningful improvements in motor function were observed and were likely the results of high repetition practice of functional movement delivered over a long duration. Further assessment in a larger cohort is warranted.


Traumatic brain injury (TBI) affects 1.7 million people in the general US population annually1 and is one of the most common neurologic disorders causing disability.2 Motor deficits are present in 30% of TBI survivors with arm and hand problems occurring in about 17%,3 limiting the ability to perform activities of daily living (ADL). However, there is less research on motor recovery in patients with TBI compared with other neurologic diseases involving the brain, such as stroke.2

Activity-based interventions hope to maximize rehabilitation outcomes and enhance adaptive neural plasticity;3 however, optimal doses and schedules of training have not been adequately established. Repetition is one parameter important for activity-dependent neural plasticity. Studies assessing US rehabilitation found that stroke and TBI survivors receive an average of 32–50 repetitions of upper extremity active and passive movement per therapy session, significantly less than the 400–600 repetitions achieved in animal studies.3 Although persons with TBI benefit from traditional therapy,4 it is clear that more is needed to attain full recovery, especially with severely affected individuals.

Consistent with this idea, Krebs and Volpe5 argued that the basis of all assistive and therapeutic devices should be to induce the intent to move followed by that movement actually happening, referred to as “intent-driven rehabilitation”. One way this can be accomplished is through myoelectric control wherein a weak electromyography (EMG) signal from the muscle of an impaired limb is detected, processed, and used to activate a motor within the orthosis. The motor then assists the user in producing the desired movement. The patient-directed “intentional” action of the device promotes patient engagement as the orthosis will only reward the patient with movement when they use the correct muscles to complete a task. Previous studies of myoelectric driven lab-based robotic interventions6 showed improved Fugl-Meyer motor control scores of the upper extremity7 and reduced spasticity as assessed by the modified Ashworth scale (MAS).8 While demonstrating a benefit of “intent-driven rehabilitation”, in-lab robotic intervention restricted the amount of practice because training was restricted to the short lab sessions only and no home practice was possible.6

While myolectrically-driven orthotic technology has been in development for many years,911 recent advances have made it more accessible and clinically deployable for rehabilitation. However, initial research has focused on persons with stroke1218 and not TBI. The ability of severely hemiplegic stroke survivors to activate a powered elbow orthosis using myoelectric control has been reported,13 along with increased elbow range of motion with orthosis use.18 Kim et al.15 reported that after a combined period of training and at home-use of an elbow-only myoelectric orthosis, a statistically significant three-point change in Fugl-Meyer motor control score was found in the upper extremity of nine persons post-stroke. We have recently reported a case series of chronic stroke survivors who used a myoelectric upper limb orthosis over a period of several months and achieved a 9.0 ± 4.8 point improvement in Fugl-Meyer.19 Since upper limb motor deficits in TBI are a problem that can lead to decreased independence in ADLs and given that there is a lack of effective therapies and supportive devices for upper limb impairment, the purpose of this case report was to illustrate the response to therapy combined with a myoelectric elbow–wrist–hand orthosis in a person with longstanding TBI.

Case description

The protocol described in this case report complies with standards of the Declaration of Helsinki and was approved by the Institutional Review Boards of participating institutions (IRB #16039-H29 and STU00203728) and met the Health Insurance Portability and Accountability Act (HIPAA) requirements for disclosure of protected health information. Written informed consent for participation was obtained from the patient’s legal guardian.

The participant was a 42-year-old female who sustained a TBI from being struck by a motor vehicle at age 12. At study entry, she was 29.5 years post injury, dependent on caregivers for most ADL/instrumental activities of daily living (IADLs), used a manual wheelchair for mobility, resided in a group home setting, and required assistance from caregivers to help her make decisions. She attended an adult workshop where she would perform general fitness/mobility activities along with interacting with peers socially, and had done so for several years. As a result of her injury, she had abnormal tone, weakness and dysmetria/ataxia leading to decreased motor control and coordination of the right upper limb. She has avoided using her right (dominant) arm, which has led to learned nonuse of the right arm and overuse of the left arm. Furthermore, she had cognitive, short-term memory, and perceptual deficits. Right visual processing deficits made it difficult for her to read and distinguish color. Her mini mental state exam (MMSE) score at baseline was 15 out of 30. Due to these impairments, she did not spontaneously use her right upper limb functionally. Over the years since her injury, interventions including traditional physical and occupational therapy (functional mobility training, upper limb task practice, aquatic therapy provided by licensed therapists) have been implemented with limited success to increase the use of her right upper limb.


The participant underwent casting and a myoelectric elbow–wrist–hand orthosis (MyoPro Motion-G, Myomo Inc., Cambridge, MA) was custom fabricated by a certified and licensed orthotist. The orthosis is intended to help individuals with a weakened or paralyzed arm to complete patient-initiated movements and enhance function (Figure 1).

Figure 1. Functional task practice example. (a) Myoelectric elbow–wrist–hand orthosis custom fabricated to fit the participant using MyoPro Motion G components (Myomo Inc.). When the user tries to move the elbow or grasp objects, sensors in the orthosis detect the myoelectric signal generated by the user’s volitional effort, to activate the motor and move the elbow/hand in the desired direction, assisting the user to complete the desired movement. (b) Functional task practice without the orthosis donned to reinforce training. (c) Demonstration of return of functional use showing the participant spontaneously using her impaired limb to feed her pet treats.


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[ARTICLE] Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial – Full Text



Our group developed a rehabilitation robot to assist with repetitive, active reaching movement of a paretic upper extremity. The robot is equipped with a servo motor-controlled arm-weight support and works in conjunction with neuromuscular electrical stimulation and vibratory stimulation to facilitate agonist-muscle contraction. In this before-and-after pilot study, we assessed the feasibility of applying the robot to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke.


We enrolled 6 patients with chronic stroke and hemiparesis who, while sitting and without assistance, could reach 10 cm both sagitally and vertically (from a starting position located 10 cm forward from the patient’s navel level) with the affected upper extremity. The patients were assigned to receive reaching exercise intervention with the robot (Yaskawa Electric Co., Ltd. Fukuoka, Japan) for 2 weeks at 15 min/day in addition to regular occupational therapy for 40 min/day. Outcomes assessed before and after 2 weeks of intervention included the upper extremity component of the Fugl-Meyer Assessment (UE-FMA), the Action Research Arm Test (ARAT), and, during reaching movement, kinematic analysis.


None of the patients experienced adverse events. The mean score of UE-FMA increased from 44.8 [SD 14.4] to 48.0 [SD 14.4] (p = 0.026, r = 0.91), and both the shoulder–elbow and wrist–hand scores increased after 2-week intervention. An increase was also observed in ARAT score, from mean 29.8 [SD 16.3] to 36.2 [SD 18.1] (p = 0.042, r = 0.83). Kinematic analysis during the reaching movement revealed a significant increase in active range of motion (AROM) at the elbow, and movement time tended to decrease. Furthermore, trajectory length for the wrist (“hand path”) and the acromion (“trunk compensatory movement”) showed a decreasing trend.


This robot-assisted modality is feasible and our preliminary findings suggest it improved motor control and motor function of the hemiparetic upper extremity in patients with chronic stroke. Training with this robot might induce greater AROM for the elbow and decrease compensatory trunk movement, thus contributing to movement efficacy and efficiency.


Stroke is a leading cause of death and disability. In 2017, the number of patients treated for stroke in Japan was 1,115,000, with 109,844 deaths [12]. Many survivors of stroke require nursing care to some extent; in fact, patients with stroke account for the largest percentage of claims under the Japanese Long-term Care Insurance System [3]. In a previous review, about 90% of patients with stroke had hemiparesis on admission, and less than 15% of them experienced complete motor recovery [4]. In stroke rehabilitation, some principles are well accepted: high-intensity, task-specific, goal-setting, and multidisciplinary-team care are needed to be effective [5]. Among these principles, “task-specific” might be controversial, because some theories of motor control suggest that, on the contrary, motor learning improves, and acquires greater generalizability, when a training program offers variability [67]. The appropriate approach probably depends on the aim of rehabilitation (which can be subject-dependent): for example, a reaching movement with the arm is frequently needed in activities of daily living.

Robotic rehabilitation is a novel intervention method, and several reviews have noted that it leads to improved muscle strength and motor control of the affected upper extremity [89]. A recent Cochrane review suggests that electromechanical and robot-assisted arm training might improve arm function, muscle strength of the upper extremity, and even activity of daily living after stroke [10]. Robotic devices can enable patients to perform task-specific, high-intensity rehabilitation due to increased repetition or amount of training.

At the same time, neuromuscular electrical stimulation (NMES) is widely employed as a rehabilitation technique. According to a previous study, NMES is effective at improving motor control and motor function of affected arms of patients with acute stroke [11], and the NMES system was more efficient when applied with a high-voltage pulsed current [12]. Although few studies have investigated untriggered NMES for the hemiparetic upper limb, continuous electrical stimulation with robotic training improved active range of motion and motor control [13], and we employed the NMES system without triggered electromyography (EMG) [14]. Continuous stimulation with NMES has been considered to be effective in facilitating contraction of paretic muscles [14]. Furthermore, the latest meta-analysis showed that electrical stimulation was effective for arm function and activity regardless of the stimulation type (NMES, EMG triggered, or sensory) [15].

Functional vibratory stimulation (FVS) is known to produce a favorable effect on spasticity, motor control, and gait after stroke [16]. Regarding hemiparetic upper extremities, previous studies have shown that focal vibration applied to paretic muscles is effective at decreasing spasticity with an amplitude of 91 Hz [17], and that it probably improves motor control with an amplitude of 120 Hz, especially in terms of smoothness of movement [18]. For the lower extremity, a previous study revealed that focal vibration improved gait by promoting contraction of the target muscle [19]. Moreover, not only did it promote contraction of the agonist muscle, low amplitude vibratory stimulation (80 Hz) also facilitated focused motorcortical activation [2021]. In addition, tendon or muscle vibration produces a tonic vibration reflex through both spinal and supraspinal pathways via repetitive activation of Ia afferent fibers [2223]. It is possible to artificially elicit the illusion of movement by vibrating the tendons or the muscles through the skin [24]; the illusion is probably mediated by the activation of muscle spindles [25]. This phenomenon indicates that vibration induces a strong proprioceptive feedback. On the other hand, it has been reported that the vastus lateralis muscle demonstrates a shift toward more appropriate muscle timing when vibration is applied during stance phase and transition to stance of the gait cycle in patients with spinal cord injury [26]. This indicates that strong sensory feedback from quadriceps vibration caused increased muscle excitation [26]. Thus, the combination of muscle vibration with NMES might help to recruit Ia afferent fibers and increase muscle force production. This phenomenon has already been demonstrated in healthy people in the plantar flexors [27]. To the best of our knowledge, however, the use of a robotic device equipped with electrical stimulation and vibration has not been reported.

Considering these facts, our group undertook to develop a rehabilitation robot to assist with repetitive, active reaching movement of the paretic upper extremity; patent acquisitions [28,29,30] and product development were accomplished with a medical–engineering collaboration within Kagoshima University and collaboration between industry (Yaskawa Electric Co., Ltd., Fukuoka, Japan) and academia (Kagoshima university). The robot is equipped with a servo motor-controlled arm-weight support via a wire—the system is programmed to assist the patient’s paretic arm to move between two switches (sensors) located at various three-dimensional positions, which provide a variety of reaching tasks—and works in conjunction with NMES and vibratory stimulation to facilitate agonist-muscle contraction, because the combination might strengthen proprioceptive feedback and tonic vibration reflex. Indeed, this device was applicable and beneficial for a patient with incomplete spinal cord injury [31]. In the before-and-after pilot study reported here, we assessed the feasibility of our novel approach of applying the robot equipped with electrical stimulation and vibration to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke.[…]

Continue —-> Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial | SpringerLink

Fig. 5

Fig.5 Setting for training with the robot. A wire (a) connecting the device to the forearm cuff adjusts the amount of arm-weight support. The patient repeats a reaching movement from the start button (b) to the target button (c), accompanied with the arm-weight support, electrical stimulation (d), and vibratory stimulation (e). Two video cameras (f) on the upper frame of the device record the reaching movement for kinematic analysis

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[Abstract] Myoelectric Sensing for Intent Detection and Assessment in Upper-Limb Robotic Rehabilitation – Thesis


This thesis explores how surface electromyography (EMG) — the measurement of muscle force through voltage changes at the skin surface – can be of use to the field of upper-limb robotic rehabilitation. We focus on two main aspects: detecting human intention from measured muscle activity and assessing human motor coordination through synchronous muscle activations known as muscle synergies – each examples of the bidirectional communication found in tightly integrated human-robot interaction. EMG-based intent detection presents an opportunity to examine and promote human engagement at the neuromuscular level, enabling new protocols for intervention that could be combined with robotic rehabilitation, particularly for the most impaired of users. Meanwhile, the latest research in motor control proposes that natural, healthy human movement can be characterized by the presence of certain muscle synergies, and that the alteration of these synergies indicates a disruption, from neurological impairment or some other physical constraints, in natural movement. Wearable robotic devices are capable of altering muscle synergies, and though the mechanisms are not yet understood, a focus on altering muscle synergies is a promising new approach to neurorehabilitation. This thesis employs a robotic exoskeleton for the elbow and wrist joints designed for research in robotic rehabilitation of individuals with neurological impairments and now integrated with a myoelectric control interface. We first demonstrate the ability of a myoelectric interface to discern the user’s intended direction of motion in single-degree-of-freedom (DoF) and multi-DoF control modes with 10 able-bodied participants and 4 participants with incomplete cervical spinal cord injury (SCI). Predictive accuracy was high for able-bodied participants (averages over 99% for single-DoF and near 90% for multi-DoF), and performance in the SCI group was promising (averages ranging from 85% to 95% for single-DoF, and variable multi-DoF performance averaging around 60%), which is encouraging for the future use of myoelectric interfaces in robotic rehabilitation for SCI. Second, we explore the identification of synchronous muscle synergies in the muscles controlling the elbow and wrist, and the possible effects of robot-imposed task constraints on the neural constrains represented by synergy patterns. Our results indicate that constraining the unused degrees of freedom during a single-DoF movement inside the exoskeleton does not have a significant effect on the underlying muscle synergies in the task, and that methodological choices in muscle synergy analysis also do not have a large effect on the outcome. With all of these findings, we have achieved a deeper understanding of the value myoelectric sensing can bring to upper-limb robotic rehabilitation, and how much potential it has to advance the field toward greater accessibility to individuals of all levels of impairment.

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via Myoelectric Sensing for Intent Detection and Assessment in Upper-Limb Robotic Rehabilitation

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


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


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?


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.



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


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


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:


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



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.


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.


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.


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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