Posts Tagged Stroke

[Abstract] Cognitive Behavioral Therapy for Sleep Disturbance and Fatigue Following Acquired Brain Injury

Predictors of Treatment Response

Abstract

Objective: 

To identify factors associated with treatment response to cognitive behavioral therapy for sleep disturbance and fatigue (CBT-SF) after acquired brain injury (ABI).

Setting: 

Community dwelling.

Participants: 

Thirty participants with a traumatic brain injury or stroke randomized to receive CBT-SF in a parent randomized controlled trial.

Design: 

Participants took part in a parallel-groups, parent randomized controlled trial with blinded outcome assessment, comparing an 8-week CBT-SF program with an attentionally equivalent health education control. They were assessed at baseline, post-treatment, 2 months post-treatment, and 4 months post-treatment. The study was completed either face-to-face or via telehealth (videoconferencing). Following this trial, a secondary analysis of variables associated with treatment response to CBT-SF was conducted, including: demographic variables; injury-related variables; neuropsychological characteristics; pretreatment sleep disturbance, fatigue, depression, anxiety and pain; and mode of treatment delivery (face-to-face or telehealth).

Main Measures: 

Pittsburgh Sleep Quality Index (PSQI) and Fatigue Severity Scale (FSS).

Results: 

Greater treatment response to CBT-SF at 4-month follow-up was associated with higher baseline sleep and fatigue symptoms. Reductions in fatigue on the FSS were also related to injury mechanism, where those with a traumatic brain injury had a more rapid and short-lasting improvement in fatigue, compared with those with stroke, who had a delayed but longer-term reduction in fatigue. Mode of treatment delivery did not significantly impact CBT-SF outcomes.

Conclusion: 

Our findings highlight potential differences between fatigue trajectories in traumatic brain injury and stroke, and also provide preliminary support for the equivalence of face-to-face and telehealth delivery of CBT-SF in individuals with ABI.

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[Abstract] Effects of Robot-assisted Upper Extremity Rehabilitation on Change in Functioning and Disability in Patients With Neurologic Impairment: A Pilot Study – Full Text PDF

Abstract

Introduction: The aim is to evaluate the effect of robot-assisted training on the most important aspects of functioning and disability in patients with upper extremity neurologic impairment.

Materials and Methods: A prospective six-week pilot study included robot-assisted training of the upper extremity and conventional neurorehabilitation in 12 participants after a stroke or traumatic brain injury. Outcome measurements were range of motion (ROM), the International Classification of Functioning, Disability and Health (ICF) Core Set for Hand and the Visual Analog Scale (VAS) for pain sensation. A Wilcoxon test was used for the analysis of pre- and post-test differences and Spearman’s correlation was used for connecting the data collected.

Results: A statistically significant difference was found for ROM (shoulder abduction/adduction, shoulder flexion/extension, shoulder internal/external rotation and forearm pronation/supination) and a number of ICF categories (Body Function: b280, b710, b715, b730, b760; Activities and Participation: d230, d430, d440, d445, d5). A significant positive correlation of medium intensity (r=0.589) was found between the duration of movement coordination training and the ICF category b760. We did not find a statistically significant difference in pain sensation (VAS) with regard to the direct use of the device. For all analyses, p<0.05 and CI was 95%.

Conclusion: Robot-assisted training and conventional neurorehabilitation improved motor and functional recovery. There was a correlation between training a specific goal on the device and one of the ICF Body Function categories.

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[ARTICLE] Effects of Specific Virtual Reality-Based Therapy for the Rehabilitation of the Upper Limb Motor Function Post-Ictus: Randomized Controlled Trial – Full Text

Abstract

This research analyzed the combined effect of conventional treatment and virtual reality exposure therapy on the motor function of the upper extremities in people with stroke. We designed a randomized controlled trial set in the rehabilitation and neurology departments of a hospital (Talavera de la Reina, Spain). The subjects included 43 participants, all randomized into experimental (conventional treatment + virtual reality exposure therapy) and control group (conventional treatment).; The main measures were Fugl-Meyer Assessment for upper extremity, Modified Ashworth Scale, and Stroke Impact Scale 3.0. The results included 23 patients in the experimental (62.6 ± 13.5 years) and 20 in the control group (63.6 ± 12.2 years) who completed the study. After the intervention, muscle tone diminished in both groups, more so in the experimental group (mean baseline/post-intervention: from 1.30 to 0.60; η2 = 0.237; p = 0.001). Difficulties in performing functional activities that implicate the upper limb also diminished. Regarding the global recovery from stroke, both groups improved scores, but the experimental group scored significantly higher than the controls (mean baseline/post-intervention: from 28.7 to 86.5; η2 = 0.633; p = 0.000). In conclusion, conventional rehabilitation combined with specific virtual reality seems to be more efficacious than conventional physiotherapy and occupational therapy alone in improving motor function of the upper extremities and the autonomy of survivors of stroke in activities of daily living.

1. Introduction

Stroke is one of the main causes of acquired disability in adulthood. The stroke epidemic is primarily driven by the aging of the world population, globalization and the urbanization of community settings [1,2]. The Stroke Alliance for Europe states that, every 20 s, a new case of stroke is detected in the adult population and predicts that the number of people affected will increase by 35% to 12 million people in 2040. As a result, it is estimated that the health and social costs for stroke diagnosis will increase to 75 million in 2030 (26% more than in 2017). In Spain, 550,941 people were diagnosed with stroke in 2017, generating a health expenditure of 1700 million euros and a total cost to the Spanish state of 3557 million euros [3].Around 80% of survivors present motor difficulties in the upper extremities, affecting the carrying out of activities of daily living (ADLs), the performance of roles in the community and the health-related quality of life (HRQoL) [4,5,6].Complications after stroke diagnosis can persist over time. Two-thirds of survivors are disabled 15 years later, two out of five are immersed in depressive states and more than a quarter develop cognitive impairment [7]. The costs derived from stroke diagnosis are high for survivors and their families, making their rehabilitation and survival processes a great challenge for health policymakers [8,9]. On average, an informal (non-professional) caregiver in Spain invests 2833 h per year in caring for the person affected by stroke and with limitations in ADLs [3].The general objective of neurological rehabilitation is to promote a rapid recovery from the multiple deficits after a stroke and the achievement of a lifestyle similar to the premorbid state [10,11]. Of all people diagnosed with stroke, only 30–40% regain certain skills in the upper limb after six months of intervention [12]. The upper limb remains non-functional for ADLs in up to 66% of survivors [13], constituting the most disabling of all residual disorders.In recent years, the use of neurorehabilitation approaches based on technology and virtual reality has increased, allowing the creation of effective rehabilitation environments and providing multimodal, controllable, and customizable stimulation [14], in which the recreation of virtual objects maximize visual feedback [15] and high intensity and high number of repetitions are key factors that influence neuroplasticity and functional improvement in patients [16]. Rehabilitation based on virtual reality offers the possibility of individualizing treatment needs, and at the same time, standardizing evaluation and training protocols [17,18]. In this sense, specific virtual reality technology for rehabilitation processes of people with neurological pathology allows working in a functional way and with specific intervention objectives, in addition to easily qualifying and documenting progress during the session [19]. Taking advantage of these characteristics, several researchers have used virtual reality exposure therapy (VRET) to recover motor function after stroke. In the treatment of the upper limb, studies indicate that this rehabilitation approach produces better motor and functional results than conventional therapy [20,21].The increasing clinical use of neurorehabilitation approaches based on technology and virtual reality leads to the assumption that spatial representations in virtual environments may vary slightly from the perceptions that the patient would experience in real spaces. In this sense, the team of Hruby et al. [22] insisted that spatial representations based in virtual reality systems should be realistic 1:1 replicas with regard to the individual characteristics of the subjects interacting with both virtual and real environments. This demand increases the validity of virtual reality techniques for therapeutic purposes, since interaction with a virtual space is safer and more profitable in the early phases of rehabilitation processes [23]. However, it is important for clinicians and researchers to consider that the interaction with a virtual environment continues to be different from the relationship that the subject maintains with the real environment [24] because people gradually build a mental representation of the geographic space that we work with or are immersed in. The locomotion techniques applied in the virtual model (software or hardware) can influence the cognitive representations of the person experiencing them [25].The present study aimed to analyze the combined effect of conventional treatment and VRET on motor function of the upper limb in people diagnosed with stroke in the acute phase and its evolution at three months in the Integrated Health Area of Talavera de la Reina.[…]

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Figure 1. (a) Selection of analytical exergames; (b) selection of functional exergames; (c) adaptation of exergames at the beginning of a treatment session; (d) graphical representation of results or progress of the patient.

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[ARTICLE] Design of a 3D printed hybrid mechanical structure for a hand exoskeleton – Full Text

By Jens Vertongen and Derek Kamper

Abstract

Stroke survivors often have difficulty performing activities of daily living (ADLs) due to hand impairments. Several assistive devices have been developed for stroke survivors to assist them with ADLs but most of these devices are difficult to don and doff for a stroke survivor due to highly flexed postures of the wrist and digits. This paper presents a hybrid 3D printed mechanical structure for an assistive hand exoskeleton created for stroke survivors. The design facilitates donning and doffing of the assistive exoskeleton by enabling an approach entirely from the dorsal side of the hand, thereby allowing the fingers to stay flexed. The design criteria, resulting design and the prototype development are presented. The initial prototype of the structure, using a hybrid combination of rigid and flexible materials, was lightweight (only 185 g), while maintaining a high range of motion. Future directions for further improvements and user studies are described.

Introduction

Stroke often results in a severe impairment of the upper limb, particularly the distal segment, in stroke survivors. In 2010 there were 6.7 million stroke survivors in the United States alone, with 795,000 new or recurring strokes occurring each year [1]. The symptoms of this impairment include paresis, involuntary muscle contraction patterns and impaired movements of the paretic hand [2]. These can make it difficult for stroke survivors to perform activities of daily living (ADLs) such as eating, bathing and dressing. Therefore, an assistive device for the distal upper limb that can assist with these activities has the potential to improve the stroke survivor’s quality of life.

Several assistive devices have been reported in literature. These devices commonly use a rigid structure [3], [4], [5] or a glove that routes tendons along the fingers [6], [7], [8]. These devices are often difficult to don and doff due to the typically flexed hand posture and the lack of voluntary finger extension. Coupling an assistive device to a stroke survivor’s hand can be especially challenging, due to the limited available contact area on the digits and the substantial resistance to even passive extension of the digits that arises from involuntary muscle activation [9].

In this paper we present the design of a hybrid, 3D printed mechanical structure of a hand exoskeleton intended to actuate the fingers of stroke survivors. The aim is to improve the donning process while providing the capability of both flexion and extension assistance from a single actuator for each finger located on the dorsal side of the hand. The actuator drives push-pull cables that can either flex or extend the joints of the digit. Thus, the mechanical structure, composed of rigid and flexible materials, must serve as the interface between the actuator and the digit.

Design requirements

The exoskeleton structure must fulfill multiple roles: guiding the cables actuating the hand, transmitting moments to the fingers and thumb, and preventing excessive joint rotation. The design requirements are listed in the following three categories: structural, safety and transmission requirements.

Structural requirements

The device has to fit the hand of the user while maintaining a low profile (maximum height of 25 mm above the finger) and should be easy to don and doff. The structure has to guide the push-pull cables and should keep the palmar surface free and accessible to minimize interference with the user’s sensory feedback and manipulation of objects. The device has to be lightweight with a mass under 300 g. The range of motion (ROM) of the hand with the device should be close to the normal ROM: 100, 105 and 85° for the MCP, PIP and DIP respectively and 56 (MCP) and 73° (IP) for the thumb [10]. Furthermore, the fingers should be able to abduct.

Safety requirements

The mechanical structure should prevent excessive joint flexion and extension. Moving parts have to be shielded to prevent tissue or body parts to be pinched.

Transmission requirements

Ultimately, the structure has to transmit the moments from the cables to the finger joints. The friction between the cables and the guides should be as low as possible.

Exoskeleton structure design

Full structure

The structure was designed through an iterative process of 3D design, rapid prototyping and verification. Drawing on hand dimensions from the literature [11], we designed a prototype using 3D CAD software (Figure 1). The mechanical structure is a hybrid design of rigid components, attached to the digit segments that guide the cables and prevent excessive joint rotation, and a flexible inner lining that connects the rigid components and improves comfort and functionality. The exoskeleton can be donned entirely from the dorsal side of the hand, with the rigid pieces deforming to accommodate the finger, thereby generating a clamping force against the sides of the finger. The structure extends to the forearm in order to provide bracing to maintain the wrist in a functional extended posture. This splint structure also provides housing for the actuators and electronics. Straps around the hand and wrist help to secure the location of the device on the body.

Figure 1: Full overview of the mechanical structure in red with the flexible lining in gray and actuators in black. Top: dorsal view. Bottom: palmar view.

Figure 1:

Full overview of the mechanical structure in red with the flexible lining in gray and actuators in black. Top: dorsal view. Bottom: palmar view.

Finger structure

The anatomical differences in the distal phalanx (DP) of the thumb and the pinky finger, in comparison with the index, middle and ring fingers, require a different form factor for these segments (see Figure 1). We employed conical shapes for the components of the intermediate phalanx (IP) to ensure proper fitting on the finger segment.

Adjacent cable-guide segments meet during joint extension to prevent hyperextension of the joints (Figure 2). To prevent hyperflexion of the joints, possible pinching and buckling of the cable, we attached a fabric sleeve at the ends of the cable guides around the wire. These fabrics clamp over the conical end and are secured with a metal ring (Figure 3).

Figure 2: The structure of one finger.

Figure 2:

The structure of one finger.

Figure 3: Detail of the sleeves preventing cable buckling.

Figure 3:

Detail of the sleeves preventing cable buckling.

The cable guides on the dorsal side of the fingers are easily customizable to achieve different moment arms around the joints. We used two cables for a better lateral stability to actuate the fingers. The friction of the cable, governed by the capstan Equation (1), should be minimized [12].(1)Tout= e−μϕTinTout= e−μϕ Tin

In Equation (1)μ is the friction coefficient and ϕ is the deflection angle of the cable segment that is sliding in the tube. We designed the path inside the rigid component with the smallest curvature possible in order to minimize friction along the cable. Figure 4 shows a section of the finger structure where the cable path is visible.

Figure 4: Section of the index finger showing the path of the cable within the guide.

Figure 4:

Section of the index finger showing the path of the cable within the guide.

The push-pull cable locks in the front of the structure in a groove above the DP (see Figure 3). This groove facilitates the assembly of the cable in the structure. The recess in this groove permits easy removal of the cable with a screwdriver.

Arm structure

The arm structure supports the actuators, transmission and electronics, in addition to maintaining a neutral wrist posture (see Figure 5). Velcro straps around the hand, wrist and forearm secure the location on the arm. We placed the actuators locally, on the forearm, to avoid frictional losses inherent to the use of long Bowden cables needed with remotely placed actuators.

Figure 5: The arm structure that supports the actuators. Motors and cables are represented with transparent bodies.

Figure 5:

The arm structure that supports the actuators. Motors and cables are represented with transparent bodies.

Prototype development

The final prototype, realized with acrylonitrile butadiene styrene (ABS) and thermoplastic polyurethane (TPU) through 3D printing, proved to be lightweight and comfortable. The mass of the entire mechanical structure was only 185 g. The distal portion that actually moves with the fingers and thumb was 82 g in total, or an average of roughly 16 g per digit; the forearm brace accounts for the other 103 g. The ROM of the fingers, while wearing the structure when not actuated, is very close to the normal ROM (see Table 1). The finger structures in black and the arm structure in white are shown in Figure 6.Table 1:Weight and ROM of the prototype.

WeightFingers

82 g
Arm part

103 g
Total

185 g
ROMMCP (°)PIP (°)DIP (°)
Thumb5070
Index finger808575
Middle finger859575
Ring finger909575
Pinky finger758575
Normal ROM thumb5673
Normal ROM finger10010585
Figure 6: The final prototype.

Figure 6:

The final prototype.

3D printing and material selection

We used 3D printing as a rapid prototyping method to produce the exoskeleton structure due to the various benefits such as easily available, quick and the ability to produce complex shapes.

The structure was produced with two different 3D printers. The rigid and flexible material of the finger structures was produced by the BCND Sigma R17 3D printer. The rigid material of the arm structure was printed by the Stratasys Dimension 1200 3D printer that has a larger build volume to produce the arm structure.

We employed ABS to produce the rigid components. This material was selected rather than polylactic acid (PLA) due to its greater toughness. A more flexible material, TPU, was chosen for the liner.

Performance

The weight and the range of motion of the exoskeleton are important for the functionality and comfort for the user. Table 1 lists the weight and the range of motion of the exoskeleton. The normal ROM values of the thumb and the fingers [10] are shown for reference. The exoskeleton proved to be comfortable to wear for extended periods of time. This was tested for a period of 1 h of use by one of the authors while performing ADLs. No pain or discomfort was reported for the duration of the test. Due to the large range of motion and slim profile, the author was able to grasp most everyday objects. There was some minor discomfort in pronation and supination, however, due to the location of the structure on the forearm.

Discussion

An actuated hand exoskeleton has the potential to improve the quality of life for stroke survivors by assisting with ADLs. The lightweight mechanical structure developed in this study helps to make such a device possible. Easily customizable to the shape of the user’s hand, the structure can accommodate the push-pull cables used to drive the fingers while preventing joint hyperextension. The ability to put on the device entirely from the dorsal side of the hand greatly improves donning for stroke survivors with a flexed resting posture and resistance to passive extension. The slim profile, high range of motion and low mass result in a functional and comfortable structure.

The major limitation of the current structure is the TPU used for the flexible liner. A material with greater elasticity could be better suited for the application and could improve user comfort. Further development of the design and user testing are needed to improve and validate the design.

References

1. Go, AS, Mozaffarian, D, Roger, VL, Benjamin, EJ, Berry, JD, Borden, WB, et al. Executive summary: heart disease and stroke statistics-2013 update: a report from the American heart association. Circulation 2013;127:143–52. https://doi.org/10.1161/CIR.0b013e318282ab8fSearch in Google Scholar

2. Gresham, GE, Stason, WB, Duncan, PW. Post-stroke rehabilitation. Darby, PA: Diane Publishing Company; 2004. Search in Google Scholar

3. Cempini, M, Cortese, M, Vitiello, N. A powered finger-thumb wearable hand exoskeleton with self-aligning joint axes. IEEE/ASME Trans Mechatron 2015;20:705–16. https://doi.org/10.1109/tmech.2014.2315528Search in Google Scholar

4. Ho, NSK, Tong, KY, Hu, XL, Fung, KL, Wei, XJ, Rong, W. An EMG-driven exoskeleton hand robotic training device on chronic stroke subjects: task training system for stroke rehabilitation. In: IEEE international conference on rehabilitation robotics. IEEE, New York City; 2011, 1–5. Search in Google Scholar

5. Chiri, A, Giovancchini, F, Vitiello, N, Cattin, E, Roccella, S, Vecchi, F, et al. HANDEXOS: towards an exoskeleton device for the rehabilitation of the hand. In: IEEE/RSJ international conference on intelligent robots and systems. IEEE, New York City; 2009, 1106–11. Search in Google Scholar

6. In, H, Kang, BB, Sin, M, Cho, KJ. Exo-glove: a wearable robot for the hand with a soft tendon routing system. IEEE Robot Autom Mag 2015;22:97–105. https://doi.org/10.1109/MRA.2014.2362863Search in Google Scholar

7. Nycz, CJ, Delph, MA, Fischer, GS. Modeling and design of a tendon actuated soft robotic exoskeleton for hemiparetic upper limb rehabilitation. In: 37th Annual international conference of the IEEE engineering in medicine and biology society (EMBC). IEEE, New York City; 2015, 3889–92. Search in Google Scholar

8. Rose, CG, O’Malley, MK. Hybrid rigid-soft hand exoskeleton to assist functional dexterity. IEEE Robot Autom Lett 2019;4:73–80. https://doi.org/10.1109/lra.2018.2878931Search in Google Scholar

9. Kamper, DG, Rymer, WZ. Quantitative features of the stretch response of extrinsic finger muscles in hemiparetic stroke. Muscle Nerve 2000;23:954–61. https://doi.org/10.1002/(sici)1097-4598Search in Google Scholar

10. Hume, M, Gellman, H, McKellop, H, Brumfield, RH. Functional range of motion of the joints of the hand. J Hand Surg 1990;15:240–3. https://doi.org/10.1016/0363-5023(90)90102-wSearch in Google Scholar

11. Buryanov, A, Kotiuk, V. Proportions of hand segments. Int J Morphol 2010;28:755–8. https://doi.org/10.4067/s0717-95022010000300015Search in Google Scholar

12. Kaneko, M, Yamashita, T, Tanie, K. Basic considerations on transmission characteristics for tendon drive robots. In: Robots in unstructured environments: IEEE, New York City; 1991, 827–32. Search in Google Scholar

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[ARTICLE] Peak Activation Shifts in the Sensorimotor Cortex of Chronic Stroke Patients Following Robot-assisted Rehabilitation Therapy – Full Text

ABSTRACT

Background:

Ischemic stroke is the most common cause of complex chronic disability and the third leading cause of death worldwide. In recovering stroke patients, peak activation within the ipsilesional primary motor cortex (M1) during the performance of a simple motor task has been shown to exhibit an anterior shift in many studies and a posterior shift in other studies.

Objective:

We investigated this discrepancy in chronic stroke patients who completed a robot-assisted rehabilitation therapy program.

Methods:

Eight chronic stroke patients with an intact M1 and 13 Healthy Control (HC) volunteers underwent 300 functional magnetic resonance imaging (fMRI) scans while performing a grip task at different force levels with a robotic device. The patients were trained with the same robotic device over a 10-week intervention period and their progress was evaluated serially with the Fugl-Meyer and Modified Ashworth scales. Repeated measure analyses were used to assess group differences in locations of peak activity in the sensorimotor cortex (SM) and the relationship of such changes with scores on the Fugl-Meyer Upper Extremity (FM UE) scale.

Results:

Patients moving their stroke-affected hand had proportionally more peak activations in the primary motor area and fewer peak activations in the somatosensory cortex than the healthy controls (P=0.009). They also showed an anterior shift of peak activity on average of 5.3-mm (P<0.001). The shift correlated negatively with FM UE scores (P=0.002).

Conclusion:

A stroke rehabilitation grip task with a robotic device was confirmed to be feasible during fMRI scanning and thus amenable to be used to assess plastic changes in neurological motor activity. Location of peak activity in the SM is a promising clinical neuroimaging index for the evaluation and monitoring of chronic stroke patients.

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Fig. (2). Spatial distributions of peak brain activation during a grip task with both hands. Dots (red, left hemisphere stroke patients; green, healthy control subjects) are overlaid on an International Consortium for Brain Mapping brain surface template (ICBM-152).

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[Abstract] Effectiveness of virtual reality-based rehabilitation versus conventional therapy on upper limb motor function of chronic stroke patients: a systematic review and meta-analysis of randomized controlled trials

ABSTRACT

Objective: To systematically review the available randomized controlled trials in the literature concerning the application of virtual reality (VR) rehabilitation interventions compared to conventional physical therapy, in regaining the upper limb motor function among patients with chronic stroke. 

Methods: A systematic electronic database search was conducted for related studies published from inauguration and until June 25, 2020 in nine databases. Another new search was done on February 1, 2021 and no new studies were identified. 

Results: Six studies were included in the analysis. Significant improvement was seen following the VR therapy in patients with chronic stroke, compared to their scores prior to it (SMD = 0.28; 95% CI = 0.03–0.53; p = .03). There was neither heterogeneity (I2 = 0% and P = .5) nor a risk of bias (P = .8) among the included studies. VR interventions produced a comparable effectiveness to that of the conventional rehabilitation, with no statistically significant difference (SMD = 0.15; 95% CI = −0.14–0.44; P = .3). There was neither heterogeneity (I2 = 40% and P = .1) nor a risk of bias (P = .5) among the included studies. 

Conclusions: The upper limb motor function of patients with chronic stroke who underwent VR-based rehabilitative intervention showed significant improvement as compared to the pre-treatment state. Our analysis also revealed no superiority of VR interventions over conservative therapies; however, the difference observed did not accomplish statistical significance.

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[WEB] BGU’s Negev Lab is bringing stroke rehab into the future

Stroke is tricky. While its effects are well known, the best course of rehabilitation to return to functionality is still very much a mystery. This rehab lab turns translational science for answers.

By EHUD ZION-WALDOKS

   

 Dr. Simona Bar-Haim and Dr. Lior Shmuelof in the Negev Lab at ADI Negev (photo credit: DANI MACHLIS/BGU)
Dr. Simona Bar-Haim and Dr. Lior Shmuelof in the Negev Lab at ADI Negev(photo credit: DANI MACHLIS/BGU)‘

The return-to-work rate for people after suffering a stroke has not significantly changed since the 1970s,” says Dr. Simona Bar-Haim, founding director of the Negev Lab at the ADI Negev-Nahalat Eran Rehabilitation Village in southern Israel.

Bar-Haim is not your typical academic. She has one foot firmly in the field, and one foot firmly in the academy as a member of the department of physical therapy in the Faculty of Health Sciences at Ben-Gurion University of the Negev (BGU). She also founded a start-up based on chaos theory to help people walk after suffering a stroke.

“Many people do not recover enough to return to work or to their regular lives,” she says.

What is more, as the population ages and lives longer, there are more and more people suffering strokes and then recovering only partial functionality. In Israel, 17,000-20,000 people a year suffer a stroke.

Stroke is tricky. While its effects are well known, the best course of rehabilitation to return to functionality is still very much a mystery, to which Bar-Haim and Dr. Lior Shmuelof, also of BGU, have devoted themselves to help solve.

Driven by that impetus to help and by her out-of-the-box way of thinking, Bar-Haim recently set up a translational rehabilitation lab at the rehabilitation village. Translational science tries to find solutions for real-world problems. At ADI Negev, the problems arise from the patients themselves, their doctors and caregivers, and the solutions are tested in conjunction with the patients.

There are several theories why stroke recovery has not progressed since the 1970s and the Negev Lab has been working to test them.

“We believe there is a critical period of three to six months after the stroke where recovery is most achievable because of the brain’s plasticity during that time,” says Shmuelof of the Negev Lab, the department of brain and cognitive sciences and the Zlotowski Center for Neuroscience at BGU. “If an animal suffers a stroke, it recovers fully. Why do animals recover, while people do not? One possibility is that an animal is active from the moment it happens. Now, if a person suffers a stroke, they spend the first week to 10 days lying in bed in the hospital, and then they spend a couple of hours a day doing physical therapy that does not translate to the real world.

”To confirm these hypotheses, Shmuelof is partnering with the MRI Imaging Center at Soroka-University Medical Center and researchers Profs. Alon Friedman, Ilan Shelef, Anat Horev and Gal Ben-Arie, with the aim of identifying the neural components associated with brain plasticity after injury.

Shmuelof will then take what he learns from MRI imaging and bring it back to the Negev Lab.

ADI NEGEV-Nahalat Eran is a fully equipped facility in a village setting, with residential care for people with multiple disabilities and complex medical conditions, an intensive care hospital wing for babies and adults, a paramedical center, hydrotherapy pool, special education school, green care farm, and a therapeutic horse stable and petting zoo.

It is set in an ideal and idyllic location. Winding paths run alongside the residents’ cottages. A stable for therapeutic riding anchors one side, while the Negev Lab anchors the other. The atmosphere is calm, quiet, happy and optimistic – a far cry from rehabilitation wards in large hospitals.

The ADI Negev-Nahalat Eran Rehabilitation Village was named in memory of Eran Almog, the late son of Didi and Maj.-Gen. (ret.) Doron Almog.

Fueled by his love for Eran, who was born with severe autism and intellectual disabilities, Doron Almog guided the creation of a residential and rehabilitative complex in Israel’s south, which has since become a home and family for more than 150 children and young adults with severe disabilities and complex medical conditions and provides a host of rehabilitative solutions for individuals from all backgrounds and levels of need.

While care is important, the vision is to provide cutting-edge treatment as well. The first step was the creation of the Negev Lab. Not far in the future, the village will also boast a rehabilitation hospital, which will be the biggest in southern Israel.

“ADI Negev is the ideal place to see what happens when people spend many more hours rehabilitating,” says Shmuelof. “What if they spend three hours a day or five hours a day? Would they recover faster and better? These are the kinds of questions we ask ourselves and have the ability to answer because of this unique lab.

”Existing movement tracking methods are not advanced enough to meet Shmuelof’s needs. Therefore, to track patients’ motion over the course of the day, the Negev Lab is developing methods to track not just walking but also arm movements.

“One of the things we noticed is that arm motion might not be completely impaired, but weakness causes people to compensate in other ways rather than moving their arms to regain functionality,” says Shmuelof.

“Putting a research lab in a rehabilitation village makes a lot of sense,” says Bar-Haim. “There, we can go directly to the residents and ask them what their needs are. We can also test out our technologies, which we make sure are fun and pleasant, on the residents and get their feedback.”

 A stroke patient walks (photographer: Negev Lab)

THAT IMMEDIATE feedback appealed to Prof. Ilana Nisky of BGU’s department of biomedical engineering, who has joined Bar-Haim in developing a belt that helps stroke patients improve their walking. She is an expert in haptics, which is the body’s sense of touch. Their project is being funded by the Israel Innovation Authority.

“When you design medical devices, you need to think beyond engineering and understand how they [the patients] will be using the devices,” says Nisky.

“One of the most important elements in walking is being able to feel the ground and knowing where your legs are without looking at them. That ability, which we take for granted, can be damaged by a stroke. So, we are designing a belt that is worn on the person’s skin under their clothes that will massage the person’s waist and help them with their terra sense – the sense of where the ground is and where their legs are,” she explains.

“What is truly groundbreaking in our belt is that it does not need to measure where the legs are relative to the ground. Instead, we rely on an artificial intelligence algorithm that we train on many examples of past walking to guess where the ground and legs should be at a given moment in time, based on a very simple sensor that is placed on the belt and in the center of the body. This way the only thing the person after stroke will need is the belt itself.

”The researchers have already developed a prototype, but in the future each belt will be customized to the individual person’s needs.

“We hope they will use the belt, and that the information it provides to them will be helpful,” Nisky says. “We also hope that if they use it a lot, then perhaps they will eventually be able to walk on their own without it.

”To make sure that they will indeed wear it a lot rather than buy it just to have it collect dust in the closet, the team also works with Ofer Canfi, a designer who graduated from the Bezalel Academy of Arts and Design and the Royal Academy of Arts, London, to make the belt look and feel nice, using advanced manufacturing procedures and hi-tech fabrics.

Nisky notes that now is the ideal moment for such research. Haptic devices have become much more pleasant to use. “It’s like a massage. What’s not to like?” she says, while artificial intelligence has reached the point where it can be harnessed for purposes such as physical therapy.

A future entrepreneurial hub

Another important advantage offered by the Negev Lab is its multidisciplinary nature.“We have clinicians, clinician-researchers, engineers and programmers, all working together,” says Nisky.Bar-Haim also envisions the Negev Lab as an entrepreneurial hub, a space where technologies from around the world can be tested and receive feedback from the people who stand to benefit from them.In fact, this vision is already a reality. The Negev Lab collaborates with Swiss-based Mindmaze, which designs virtual reality and computer simulations. It sends its latest technologies to the lab, where Shmuelof puts them through their paces with patients.One such program lets the patient control a dolphin on a screen by raising or lowering their arms. It has been a big hit with patients.“Seeing the dolphin move in response to my arm movements shows me how much I have improved,” one says.“Using the vest gives me hope that I will return to moving my hand easily,” another says. “At the end of a treatment session, I feel like my whole body got into it,” says a third.“People instinctively understand how to control the dolphin, and they enjoy it,” explains Shmuelof.“The simulation makes me feel like I’m playing a computer game at home, and I just want to pass level after level,” says a patient.That is encouraging feedback, because the Negev Lab wants to develop programs that people will actually use.

The rehabilitation hospital

In a welcome development, the ADI Negev-Nahalat Eran Neuro-Orthopedic Rehabilitative Hospital is nearing completion. Thanks to the support of multiple government ministries, JNF-USA and international donors, the hospital is set for completion late this year.It will have more than 100 beds and will provide unique research opportunities.“It will also be a unique research hospital, with an ethical and information technology infrastructure that will allow us to study most of the activities that will be carried out there,” says Bar-Haim.“In other words, a large proportion of what goes on in the hospital will be able to be researched and incorporated into academic studies. That is not the case in most hospitals around the world currently, not even in teaching hospitals.“Once the hospital is completed, the Negev Lab will move into its new space and become the largest and most advanced lab of its kind in Israel.” Bar-Haim and Shmuelof are excited about the opportunities to advance their understanding of how to rehabilitate stroke patients using the knowledge they will gain from researching at the hospital.“How active was the patient during the day? How well did she sleep? How long did she sit for? Measuring patients’ activity during the day will allow us to better understand how it affects their recovery, and to find ways to increase their activity during rehabilitation,” explains Shmuelof.“We are already receiving inquiries from around the world about this new lab,” he adds.

The future

While the South has lagged behind the Center in terms of medical and rehabilitative care, Bar-Haim and Doron Almog’s vision does not stop at achieving parity with the Center, but, rather, aims to exceed it.“We believe that residents of the South deserve the same quality of care as those in every other part of the country, and we believe that we can set the bar higher for rehabilitative care,” says Almog.“This village was founded on the principle that a person is a person no matter what, and this hospital and research lab are finally starting to realize our full vision. In this place, all people will be provided with the best possible care and loved beyond measure.“In the age of corona, the importance of the Negev Lab is clearer than ever before. Each and every day, our rehabilitation professionals empower people of all ages, backgrounds, and levels of need, giving them a new lease on life and returning them to their families in good health and renewed spirit.“But we can expedite this process and make it even more powerful through collaborative translational research. There are so many people hurting right now, and the groundbreaking research being done at the Negev Lab can change the face of rehabilitative care across Israel and around the world.”“I envision the Negev Lab and the ADI Negev-Nahalat Eran Neuro-Orthopedic Rehabilitative Hospital as the core of the future National Rehabilitative Institute of Israel,” declares Bar-Haim.

The writer is deputy spokesperson, international media at Ben-Gurion University. 

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[Abstract] The Value of Exercise Rehabilitation Program Accompanied by Experiential Music for Recovery of Cognitive and Motor Skills in Stroke Patients

Abstract

Background

The aim of this study was to systematically assess the effects of exercise rehabilitation program accompanied by experiential music for clinical recovery.

Methods

This was a prospective randomized study with 65 stroke survivor patients. All cases underwent a neuropsychological assessment first as a prescreening test, during the admission at the Rehabilitation center (baseline), and 6 months poststroke. All patients received standard treatment for stroke in terms of medical care and rehabilitation. Additionally, all patients were separated into 2 Groups: a music Group (daily listening to experiential/traditional music), and a control Group (CG) with no experiential/traditional music therapy (standard care only). Computed tomography perfusion and full neurological examination including GCS were assessment. As Recovery was defined the improvement of cognitive and motor skills of the limb in the affected site, with an increase of muscle strength at least by 1/5 and with emotional progress.

Results

Statistically significant differences were found between the Group CG and the rest of the patients in respect of Lesion size (P = .001) and CBF in affected area (P = .001). Μultivariate analysis revealed that only Group and Lesion size were independent predictors for Recovery (odd ratio [OR][95%confidence interval]) .11(.001-.133) and .798(.668-.954) respectively.

Conclusion

The findings of this study suggest that the music-based exercise program has a positive effect on mood profile in stroke patients and Recovery rate is higher when exercise rehabilitation program was accompanied by an enriched sound environment with experiential music.

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[WEB] Effect of Rhythm of Music Therapy on Gait in Patients with Stroke: Several Questions

Recently, we read with great interest the paper entitled “Effect of rhythm of music therapy on gait in patients with stroke” published in Journal of Stroke and Cerebrovascular Diseases. Wang et al. reported that, music therapy to ischemic stroke patients can improve their gait, walking ability, lower limb motor function, balance ability and treatment satisfaction. 1 This study is a valuable and interesting article but we have several queries about this article.

  • 1.In the exclusion criteria, patients who had or were inclined to have cerebral hemorrhage were excluded. But in the “general data” of “results”, it seems a little confused and paradoxical that the control group and study group have included patients with cerebral hemorrhage. Is this a clerical error or an experimental design error?
  • 2.The patients in each group were ranged in age from 40 to 80 approximately. As we know, they had different faculty to distinguish and comprehend sounds due to their age difference. That is, the younger patients may perform better than older ones, so would the study be more accurate in dividing groups according to their age?
  • 3.Are you sure that the serial number is wrong of “Walking ability”, “Lower extremity motor function”, “Balance ability” and “Degree of treatment satisfaction” in “outcome measures”? What’s more, it seems there are some spelling mistakes in the last paragraph of discussion, such as “improve their walking ability, lower their extremity motor function, balance their ability”.
  • 4.George et al. reported that the recovery rate is higher when exercise rehabilitation program was accompanied by an enriched sound environment with experiential music after 6 months of treatment 2. For improvement of lower limb motor function, it seems insufficient to prove significant differences about 4 weeks in this research. So, long-term period of treatment and further prospective comparative studies should also be taken into consideration.

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[ARTICLE] Design and evaluation of a novel upper limb rehabilitation robot with space training based on an end effector – Full Text

Abstract

The target of this paper is to design a lightweight upper limb rehabilitation robot with space training based on end-effector configuration and to evaluate the performance of the proposed mechanism. In order to implement this purpose, an equivalent mechanism to the human being upper limb is proposed before the design. Then, a 4 degrees of freedom (DOF) end-effector-based upper limb rehabilitation robot configuration is designed to help stroke patients perform space rehabilitation training of the shoulder flexion/extension and adduction/abduction and elbow flexion/extension. Thereafter, its kinematical model is established together with the proposed equivalent upper limb mechanism. The Monte Carlo method is employed to establish their workspace. The results show that the overlap of the workspace between the proposed mechanism and the equivalent mechanism is 96.61 %. In addition, this paper also constructs a human–machine closed-chain mechanism to analyze the flexibility of the mechanism. According to the relative manipulability and manipulability ellipsoid, the highly flexible area of the mechanism accounts for 67.6 %, and the mechanism is far away from the singularity on the drinking trajectory. In the end, the single-joint training experiments and a drinking water training trajectory planning experiment are developed and the prototype is manufactured to verify it.

1 Introduction

Strokes affect thousands of people around the world, and nearly half of stroke survivors suffer from upper limb defects, which makes it difficult for them to perform activities of daily living (ADL) independently. For most patients, exercise therapy has the potential to partially restore the loss of motor function (Béjot et al., 2016). Studies indicated that long-term intensive training and practice would be beneficial to the rehabilitation process of patients (Bertani et al., 2017). Robot-assisted therapy equipment can provide high-intensity, repetitive, interactive treatments for the affected upper limbs and obtain physiological data of patients, which has been increasingly used in rehabilitation training (Manna and Dubey, 2017).

The human upper limbs have a complex physiological structure. With the cooperation of multiple bones and muscles, the upper limbs are very flexible, which puts forward many requirements for the structural design of the rehabilitation robot (Pons, 2008). At present, there are mainly two types of upper limb rehabilitation robots, i.e., an end-effector-based type and an exoskeleton type. The end-effector-based-type upper limb rehabilitation robots support and pull the end of the patients through a closed-loop linkage mechanism or a series mechanism, so as to realize the rehabilitation training of the upper limb. The most representative of the robots with the closed-loop linkage mechanisms include MIT-MANUS (Hogan et al., 1992), D-SEMUL (Kikuchi et al., 2018), CASIA-ARM (Luo et al., 2019), and SepaRRo (Chang et al., 2018). They could perform plane compound training for the human shoulder and elbow joints, mainly the adduction/abduction of the shoulder and the flexion/extension of the elbow. The working mode of the robots with the series mechanism is to drive the human upper limbs through the mechanical arms, such as MIME (Lum et al., 2002) and GENTLE/s (Loureiro et al., 2003). Compared to the robots with the closed-chain linkage mechanisms, this type of robot increases the function of assisting the human shoulder joints in performing flexion and extension training, so it can drive the human upper limbs to move in three-dimensional space.

A characteristic of the end-effector-based-type upper limb rehabilitation robots is that it does need to be aligned with the physiological axes of the human joints during training, but it also means that it cannot implement accurate single-joint rehabilitation training for patients. Moreover, the structures of the end-traction robots are relatively simple, most of which are desktop type, that cause the robot’s range of motion (ROM) to be limited, especially the insufficient flexion and extension training of the human shoulder.

The exoskeleton-type upper limb rehabilitation robot has a kinematic structure similar to that of the human upper limb, and it generates driving force on each joint of the patient’s upper limb to drive limb rehabilitation training, such as CADEN-7 (Perry et al., 2007), Harmony (Kim and Deshpande, 2017), ARMin III (Nef et al., 2009), Co-EXos (Zhang et al., 2019), Armeo Power (Jarrase et al., 2015), and LIMPACTA (Otten et al., 2015). Compared with the end-effector-based robot, the exoskeleton robot can drive the patient’s limbs to perform three-dimensional rehabilitation training, especially the large-ROM flexion/extension training of the human shoulder. In addition, the driving force of the exoskeleton directly acts on the patient’s single joint, which can perform accurate single-joint training on the upper limbs. However, this feature also causes the exoskeleton to require more joints and motors, making the exoskeleton bulky and costly. Since the joint axes of the human upper limb is constantly changing during the rehabilitation exercise, the misalignment of the mechanical axes of the exoskeleton and the biological axes of the upper limb will lead to the mismatching of the movement of the exoskeleton with the upper limb, thus causing discomfort for the patients.

In this paper, a novel 4 DOF end-effector-based upper limb rehabilitation robot with space training is proposed by combining the end-effector-based-type and exoskeleton-type robot. The robot can assist the human upper limb in performing rehabilitation training of the shoulder flexion/extension and adduction/abduction and elbow flexion/extension. Different from the desktop-type end-effector-based robot, the proposed robot can provide a wide range of shoulder flexion/extension training for the human upper limb and cover the ROM of the upper limb. Through the mutual restriction of three mutually perpendicular active joints, the robot can perform single-joint and unidirectional rehabilitation training on the human upper limb.

The rest of this paper is structured as follows. In Sect. 2, we introduce the configuration design and mechanical design of a 4 DOF end-effector-based upper limb rehabilitation robot. In Sects. 3 and 4, the kinematical performance of the proposed configuration is analyzed in a global and local area. In Sect. 5, a 4 DOF end-effector-based robot is developed for upper limb rehabilitation, and the pursuit movement experiment and the multi-joint exercise test of the prototype are done to verify the dexterity of the design.

https://ms.copernicus.org/articles/12/639/2021/ms-12-639-2021-f01
Figure 1The configuration of robot and the human–machine closed-chain mechanism.

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