Posts Tagged UE
One of the primary reasons for long-term disabilities in the world is strokes. The causes of these cerebrovascular diseases are various, i.e., high blood pressure, heart disease, etc. For those who survive strokes, this affectation causes lose in mobility of extremities, requiring the intervention of long session with a therapeutic professional to recover the movement of the impair limb. Hence, the investment to threat this condition is usually high. Those devices permit the user a mean to conduct the therapies without the constant supervision of a professional. Furthermore, exoskeletons are capable of maintaining a detailed recording of the forces and movements developed for the patients throughout the session. However, the construction of an exoskeleton is not cheap principally for the actuation systems, especially if the exoskeleton requires the actuator to be placed at the joints of the user; thus, the actuator at a joint would have to withstand the load of the actuator of the following joint and so on.
Researchers have addressed this drawback by applying cable transmission systems that allow the exoskeleton to place their actuator at a base, reducing the weight of their design and decreasing their cost. Thus, this paper reviews the principal models of cable-driven exoskeleton for stroke rehabilitation focusing on the upper-limb. The analysis departs from the study of the anatomy of the arm in all its extension, including the shoulder, elbow, wrist, fingers, and the thumb. Besides, it also includes the mechanical consideration the researchers have to take in mind to design a proper exoskeleton. Then, the article presents a compendium of the different transmission systems found in the literature, addressing their advantages, disadvantages and their requirements for the design. Lastly, the paper reviews the cable-driven exoskeleton for stroke rehabilitation of the upper limb. Again, for this analysis, it is included the design consideration of each prototype focusing on their advantages in terms of anatomical mechanics.
[ARTICLE] Efficacy of Virtual Reality Combined With Real Instrument Training for Patients With Stroke: A Randomized Controlled Trial – Full Text
To investigate the efficacy of real instrument training in virtual reality (VR) environment for improving upper-extremity and cognitive function after stroke.
Single-blind, randomized trial.
Enrolled subjects (N=31) were first-episode stroke, assessed for a period of 6 months after stroke onset; age between 20 and 85 years; patients with unilateral paralysis and a Fugl-Meyer assessment upper-extremity scale score >18.
Both groups were trained 30 minutes per day, 3 days a week, for 6 weeks, with the experimental group performing the VR combined real instrument training and the control group performing conventional occupational therapy.
Main Outcome Measures
Manual Muscle Test, modified Ashworth scale, Fugl-Meyer upper motor scale, hand grip, Box and Block, 9-Hole Peg Test (9-HPT), Korean Mini-Mental State Examination, and Korean-Montreal Cognitive Assessment.
The experimental group showed greater therapeutic effects in a time-dependent manner than the control group, especially on the motor power of wrist extension, spasticity of elbow flexion and wrist extension, and Box and Block Tests. Patients in the experimental group, but not the control group, also showed significant improvements on the lateral, palmar, and tip pinch power, Box and Block, and 9-HPTs from before to immediately after training. Significantly greater improvements in the tip pinch power immediately after training and spasticity of elbow flexion 4 weeks after training completion were noted in the experimental group.
VR combined real instrument training was effective at promoting recovery of patients’ upper-extremity and cognitive function, and thus may be an innovative translational neurorehabilitation strategy after stroke.
Stroke is currently the leading cause of disability and death worldwide, and stroke survivors often experience chronic functional impairment and cognition deficits, which are associated with a reduced quality of life including difficulties in social and personal relationships.1, 2 It is well known that patients with stroke have a limited use of their upper extremities owing to motor dysfunction, and such patients experience sensory-motor deficits that affect their ability to perform daily activities. Stroke increases the risk of dementia 4 to 12 times,3 and up to 69% of subjects have a poststroke cognitive impairment.4 Consequently, the aims of the current rehabilitation strategies for these patients are to improve functional ability and cognitive impairments through optimal and comprehensive rehabilitation processes.
Previous studies have reported that a considerable amount of practice using real instruments is required to stimulate functional improvement and neuroplastic changes.5, 6 Conventional occupational therapies promote the recovery of upper-extremity dysfunction by utilizing task-oriented repetition training with real instruments.7, 8 Conventional therapy using real instruments is essential for poststroke rehabilitation, but environmental, individual, and financial limitations are associated with it.9, 10
Over the past 2 decades, the advancement of computer technology has resulted in the development of interventions that involve virtual reality (VR) devices, which are defined as computer hardware and software systems that generate simulations of imagined environments via visual, auditory, and tactile feedback.11 VR environments may be perceptual, such as creating situations with multiple sensory feedback regarding the patients’ kinematic movements, which are passive or active assisted in a virtual environment, and providing high-intensity repetitive multisensory interaction and goal-oriented tasks.12 Repetition and intensity are key factors for promoting neural plasticity in patients with brain damage.13 Additionally, studies have reported that VR training promotes motor recovery and cognition by inducing experience-dependent neural plasticity through repetitive tasks of varying time, high intensity, and complexity levels.14 Various studies have revealed that adaptive neuroplasticity, defined as the reorganization of movement representation in the motor cortex, premotor cortex, supplementary motor area, and somatosensory cortex due to synaptic efficacy and remodeling of the dendritic spines, can be induced by conducting repetitive goal-oriented tasks in VR-based interventions after stroke.15, 16, 17
Recently, various reports have highlighted the potential utility of VR-based rehabilitation strategies for improving upper-limb motor weakness,18, 19 cognitive dysfunction, and balance in patients poststroke.20, 21, 22 Furthermore, research has shown that compared to conventional therapy, VR training can improve the quality of neurologic rehabilitation and enhance productivity.23 Even more, it has more beneficial effects in poststroke rehabilitation, such as an increased motivation and engagement,24 cost, and usability.25, 26, 27 In addition, VR training is able to facilitate an increased therapy time without necessarily having to rely on a therapist.28 For these reasons, the number of complex and realistic VR-based interventions is increasing in neurorehabilitation programs in order to enhance the variability and adaptability of the intervention, as well as patients’ motivation, after stroke. However, comparing the effects of VR training with conventional therapy is still unclear. According to previous mentions, the combination of VR and real instruments is expected to have a synergy effect rather than a conventional occupational therapy in patients with stroke, and we investigated to see the clinical effect by using actual devices combined with a VR system to perform numerous tasks related to real daily activities.
In the present study, we developed a novel rehabilitation training that combined the benefits of real instrument training and VR-based intervention. The aim of this study was to investigate whether the VR combined with real instrument training would be an efficient translational intervention for improving the functional abilities of the upper-extremity and cognitive function in patients with stroke.
[Abstract + References] A Mechatronic Mirror-Image Motion Device for Symmetric Upper-Limb Rehabilitation
This paper presents an upper-limb rehabilitation device that provides symmetric bilateral movements with motion measurements using inertial sensors. Mirror therapy is one of widely used methods for rehabilitation of impaired side movements because voluntary movement of the unimpaired side facilitates reorganizational changes in the motor cortex. The developed upper-limb exoskeleton was equipped with two brushless DC motors that helped generate three axes of upper-limb movements corresponding to other arm movements that were measured using inertial sensors. In this study, inertial sensors were used to estimate the joint angles for three target upper-limb movements: elbow flexion and extension (flex/ext), wrist flex/ext, and forearm pronation and supination (pro/sup). Elbow flex/ext was performed by the actuator that was directly attached to the elbow joint. The actuation of the forearm pro/sup and wrist flex/ext shared one motor using a developed cable-driven mechanism, and two types of motion were selectively performed. We assessed the feasibility of the proposed mirror-image device with the accuracy and precision of the motion estimation and the actuation of joint movements. An individual could perform most upper-limb movements for activities of daily living using the proposed device.
[Abstract] Comparison of Task Oriented Approach and Mirror Therapy for Poststroke Hand Function Rehabilitation
Objective: The purpose of this study was to compare the effectiveness of task-oriented therapy and mirror therapy on improving hand function in post-stroke patients.
Methods: Total subjects 30 were randomly divided into two groups: the task-oriented group (15 patients) and the mirror therapy group (15 patients). The task-oriented group underwent task-oriented training for 45 mins a day for 5 days a week for 4 weeks. The mirror therapy group underwent a mirror therapy program under the same schedule as
task-oriented therapy. The manual dexterity and motor functioning of the hand were evaluated before the intervention and 4 weeks after the intervention by using FMA (Fugl-Meyer assessment) and BBT (Box & Block test).
Results: Hand function of all patients increased significantly after the 4-week intervention program on the evaluation of motor function and manual dexterity by FMA and BBT in both the groups of Task-Oriented approach and Mirror therapy, but Group A Task-oriented approach improved more significantly when compared to Group B Mirror therapy.
Conclusion: The treatment effect was more in patients who received a Task-Oriented approach compared to Mirror therapy. These findings suggest that the Task-Oriented approach was more effective in post stoke hand function rehabilitation.
[Abstract] Improving Healthcare Access: a Preliminary Design of a Low Cost Arm Rehabilitation Device
[Abstract + References] A Novel Exoskeleton with Fractional Sliding Mode Control for Upper Limb Rehabilitation
The robotic intervention has great potential in the rehabilitation of post-stroke patients to regain their lost mobility. In this paper, firstly, we present a design of a novel, 7 degree-of-freedom (DOF) upper limb robotic exoskeleton (u-Rob) that features shoulder scapulohumeral rhythm with a wide range of motions (ROM) compared to other existing exoskeletons. An ergonomic shoulder mechanism with two passive DOF was included in the proposed exoskeleton to provide scapulohumeral motion with corresponding full ROM. Also, the joints of u-Rob have more range of motions compared to its existing counterparts. Secondly, we propose a fractional sliding mode control (FSMC) to control u-Rob. Applying the Lyapunov theory to the proposed control algorithm, we showed the stability of it. To control u-Rob, FSMC has shown effectiveness to handle unmodeled dynamics (e.g. friction, disturbance, etc.) in terms of better tracking and chatter compared to traditional SMC.
[Abstract] Upper Limb Movement Modelling for Adaptive and Personalised Physical Rehabilitation in Virtual Reality – Thesis
Stroke is one of the leading causes of disability with over three-quarters of patients experiencing an upper limb impairment varying in severity. Early, intense, and frequent physical rehabilitation is important for quicker recovery of the upper limbs and the prevention of further deterioration of their upper limb impairment. Rehabilitation begins almost immediately at the hospital. Once released from the hospital it is intended that patients continue their rehabilitation program at home supported by a community stroke team. However, there are two main barriers to rehabilitation continuing effectively at this stage. The first is limited contact with a physiotherapist or occupational therapist to guide and support an intensive rehabilitation programme. The second is that conventional rehabilitation is tough to maintain immediately after stroke due to fatigue, lack of concentration, depression and other effects. Stroke patients can find exercises monotonous and tiring, and a lack of motivation can result in patients failing to engage fully with their treatment. Lack of participation in prescribed rehabilitation exercises may affect recovery or cause deterioration of mobility.
This thesis examines the hypothesis that upper limb stroke rehabilitation can be made more accessible and enjoyable through the use of modern commercial virtual reality (VR) hardware, with personalised models of user hand motion adapted to user capability over time, and VR games with tasks that utilise natural hand gestures as input controls to execute personalised physical rehabilitation exercises. To support the investigation of this hypothesis a novel adaptive, gamebased, virtual reality (VR) rehabilitation system has been designed and developed for self-managed rehabilitation. Hands are tracked using a Leap Motion Controller, with hand movements and gestures used as in input controller for VR tasks. A user-centred design methodology was adopted, and the final version of the system was evolved through several versions and iterative testing and feedback through trials with able-bodied testers, stroke survivor volunteers, and practising clinicians.
A key finding of the research was that an adapted form of Fitts’s law, that models difficulty of reaching and touching objects in 3D interaction spaces, could be used to profile movement capability for able-bodied people and stroke patients vii in upper arm VR stroke rehabilitation. It was also found that even when Fitts’s law was less effective, that the statistics of the regression quality were still informative in profiling users. Fitts law regression statistics along with information on task performance (such as percentage of hits) could be used to adapt task difficulty or advising rest. Further, it was found that multiple regression could provide better movement capability profiles with a modified form of Fitts law to account for varying degrees of difficulty due to the angles of motion in 3D space. In addition, a novel approach was developed which profiled sectors of the 3D VR interaction space separately, rather than treat movement through the whole space as being equally difficult. This approach accounts for some stroke patients having more difficulty moving in some directions than others, e.g. up and left. Results demonstrate that this has potential but may need to be investigated further with stroke patients and with larger numbers of people.
The VR system that utilised the movement capability model was evolved over time with a user-centred design methodology, with input from able-bodied people, stroke patients, and clinicians. A final longitudinal study investigated the suitability of three bespoke games, the usability of the system over a longer time, and the effectiveness of the movement profiler and adaptive system. Throughout this experiment, the system provided informative user movement profile variations that could identify unique movement behaviour traits in individuals. Results showed that user performance varied over time and the adaptive system proved effective in changing the difficulty of the tasks for individuals over multiple sessions. The VR rehabilitation games incorporated enhanced gameplay and feedback, and users expressed enjoyment with the interactive experience. Throughout all of the experiments, users enjoyed wearing a VR headset, preferring it over a standard PC monitor. Most users subjectively felt that they were more effective in completing tasks within VR, and results from experiments provided empirical evidence to support this view. Results within this thesis support the proposal that an appropriately designed, adaptive gamebased VR system can provide an accessible, personalised and enjoyable rehabilitation system that can motivate more regular rehabilitation participation and promote improved motor function.
[Abstract] Pushing the limits of recovery in chronic stroke survivors: User perceptions of the Queen Square Upper Limb Neurorehabilitation Programme – Full Text PDF
Introduction: The Queen Square Upper Limb (QSUL) Neurorehabilitation Programme is a clinical service within the National Health Service in the United Kingdom that provides 90 hours of therapy over three weeks to stroke survivors with persistent upper limb impairment. This study aimed to explore the perceptions of participants of this programme, including clinicians, stroke survivors and carers.
Design: Descriptive qualitative.
Setting: Clinical outpatient neurorehabilitation service.
Participants: Clinicians (physiotherapists, occupational therapists, rehabilitation assistants) involved in the delivery of the QSUL Programme, as well as stroke survivors and carers who had participated in the programme were purposively sampled. Each focus group followed a series of semi-structured, open questions that were tailored to the clinical or stroke group. One independent researcher facilitated all focus groups, which were audio-recorded, transcribed verbatim and analysed by four researchers using a thematic approach to identify main themes.
Results: Four focus groups were completed: three including stroke survivors (n = 16) and carers (n = 2), and one including clinicians (n = 11). The main stroke survivor themes related to psychosocial aspects of the programme (″ you feel valued as an individual ″), as well as the behavioural training provided (″ gruelling, yet rewarding& [Prime]). The main clinician themes also included psychosocial aspects of the programme (″ patient driven ethos − no barriers, no rules ″), and knowledge, skills and resources of clinicians (″ it is more than intensity, it is complex ″).
Conclusions: As an intervention, the QSUL Programme is both comprehensive and complex. The impact of participation in the programme spans psychosocial and behavioural domains from the perspectives of both the stroke survivor and clinician.