Posts Tagged UL
[Abstract] Virtual reality therapy for upper limb rehabilitation in patients with stroke: a meta-analysis of randomized clinical trials
Background: Stroke is a major cause of life-long disability in adults, associated with poor quality of life. Virtual reality (VR)-based therapy systems are known to be helpful in improving motor functions following stroke, but recent clinical findings have not been included in the previous publications of meta-analysis studies.
Aims: This meta-analysis was based on the available literature to evaluate the therapeutic potential of VR as compared to dose-matched conventional therapies (CT) in patients with stroke.
Methods: We retrieved relevant articles in EMBASE, MEDLINE, PubMed, and Web of Science published between 2010 and February 2019. Peer-reviewed randomized controlled trials that compared VR with CT were included.
Results: A total of 27 studies met the inclusion criteria. The analysis indicated that the VR group showed statistically significant improvement in the recovery of UL function (Fugl-Meyer Upper Extremity [FM-UE]: n = 20 studies, Mean Difference [MD] = 3.84, P = .01), activity (Box and Block Test [BBT]: n = 13, MD = 3.82, P = .04), and participation (Motor Activity Log [MAL]: n = 6, MD = 0.8, P = .0001) versus the control group.
Conclusion: VR appears to be a promising therapeutic technology for UL motor rehabilitation in patients with stroke.
[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
[ARTICLE] Cost Analysis of a Home-Based Virtual Reality Rehabilitation to Improve Upper Limb Function in Stroke Survivors – Full Text PDF
Loss of arm function occurs in up to 85% of stroke survivors. Home-based telerehabilitation is a viable approach for upper limb training post-stroke when rehabilitation services are not available. Method: A costing analysis of a telerehabilitation program was conducted under several scenarios, alongside a single-blind two-arm randomized controlled trial with participants randomly allocated to control (N=25) or intervention group (N=26). Detailed analysis of the cost for two different scenarios for providing telerehabilitation were conducted. The fixed costs of the telerehabilitation are an important determinant of the total costs of the program. The detailed breakdown of the costs allows for costs of future proposed telerehabilitation programs to be easily estimated. The costs analysis found that a program supplying all required technology costs between CAD$475 per patient and CAD$482 per patient, while a program supplying only a camera would have total costs between CAD$242 per patient and $245 per patient. The findings of this study support the potential implementation of telerehabilitation for stroke survivors for improving accessibility to rehabilitation services. This cost-analysis study will facilitate the implementation and future research on cost-effectiveness of such interventions.
- Full Text: PDF
[ARTICLE] Connected Elbow Exoskeleton System for Rehabilitation Training Based on Virtual Reality and Context-Aware. – Full Text
3. Proposed System
3.1. One DOF Exoskeleton for Elbow
[ARTICLE] Comparisons between end-effector and exoskeleton rehabilitation robots regarding upper extremity function among chronic stroke patients with moderate-to-severe upper limb impairment – Full Text
End-effector (EE) and exoskeleton (Exo) robots have not been directly compared previously. The present study aimed to directly compare EE and Exo robots in chronic stroke patients with moderate-to-severe upper limb impairment. This single-blinded, randomised controlled trial included 38 patients with stroke who were admitted to the rehabilitation hospital. The patients were equally divided into EE and Exo groups. Baseline characteristics, including sex, age, stroke type, brain lesion side (left/right), stroke duration, Fugl–Meyer Assessment (FMA)–Upper Extremity score, and Wolf Motor Function Test (WMFT) score, were assessed. Additionally, impairment level (FMA, motor status score), activity (WMFT), and participation (stroke impact scale [SIS]) were evaluated. There were no significant differences in baseline characteristics between the groups. After the intervention, improvements were significantly better in the EE group with regard to activity and participation (WMFT–Functional ability rating scale, WMFT–Time, and SIS–Participation). There was no intervention-related adverse event. The EE robot intervention is better than the Exo robot intervention with regard to activity and participation among chronic stroke patients with moderate-to-severe upper limb impairment. Further research is needed to confirm this novel finding.
Upper extremity dysfunction is a common complication after stroke, and it has been reported to affect approximately 85% of stroke survivors in the early stage1 and 50% in the chronic stage2. Impaired upper extremity function limits performance of activities of daily living (ADLs) and decreases social participation3. Novel therapeutic techniques have been introduced to promote upper extremity function, and one such technique is robotic rehabilitation.
Rehabilitation robots are capable of reducing the burden on therapists by substituting human intervention and providing ideal therapies that fulfil the following main principles of stroke rehabilitation: repetition, high intensity, and task specificity4. Thus, robotic intervention has been highlighted as a promising therapy. A recent multicentre randomised controlled trial showed better improvements in FMA scores with robot-assisted training on comparing robot-assisted training with usual care, but showed no significant difference in scores on comparing robot-assisted training with enhanced upper limb therapy. These findings indicate that robot-assisted training can reduce the burden for therapists but is not a definite superior option5. Many systematic reviews and meta-analyses on rehabilitation robots have been published in the last two decades. In 2012, Norouzi-Gheidari et al. summarised 10 trials that compared robotic therapy with dose-matched conventional therapy and reported no significant differences in Fugl–Meyer Assessment (FMA) of the upper extremity and Functional Independence Measure scores between the therapies6. However, with an increase in the number of randomised controlled trials, a recent review involving 38 trials reported a significant difference in the FMA–Upper Extremity score between robotic therapy and conventional therapy, with a better score for robotic therapy7.
Many rehabilitation robots for the upper extremity have been released and are available for clinical use. These robots have shown positive clinical results. Thus, healthcare professionals and patients have multiple choices among many kinds of robots; however, there is limited evidence to guide their choices. Physicians tend to prescribe ‘robot intervention’ rather than specify a particular robot, unlike medication prescription, when selecting robotic rehabilitation. So far, different rehabilitation robots have been considered broadly as rehabilitation robots per se, despite some differences in effectiveness.
Rehabilitation robots are generally categorised into end-effector (EE) and exoskeleton (Exo) types according to their mechanical structures8. EE robots are connected to patients at one distal point, and their joints do not match with human joints. Force generated at the distal interface changes the positions of other joints simultaneously, making isolated movement of a single joint difficult8,9. Exo robots resemble human limbs as they are connected to patients at multiple points and their joint axes match with human joint axes. Training of specific muscles by controlling joint movements at calculated torques is possible8,9. Recent systematic reviews have performed indirect comparisons by subgroup analysis and have demonstrated contradictory results for EE and Exo robots. Veerbeek et al. reported significant favourable results with regard to FMA–Upper Extremity for EE robots but not for Exo robots7. On the other hand, Bertani et al. reported significant favourable results with regard to arm function for Exo robots but not for EE robots; however, the risk of bias should be considered owing to the smaller sample size of Exo robots when compared with that of EE robots10. Although these indirect comparisons are helpful, they are limited by the heterogeneity in clinical studies, including design, population, outcomes, and intervention protocols.
Many new robotic devices have been developed; however, there are no guidelines or standard requirements with regard to the most appropriate robot subtype, extent of degrees of freedom, and approach (functionality based or impairment based) for favourable outcomes. To our knowledge, no head-to-head clinical trial comparing different types of rehabilitation robots has been performed. Such a comparison may help in the decision making of healthcare professionals with regard to rehabilitation robots and may ultimately offer more optimal rehabilitation for patients. In particular, there is a great need for a direct comparison study to clarify effects according to the types of robots, as robots are expensive.
Therefore, we performed a randomised controlled trial to directly compare EE and Exo robots in a selected population of chronic stroke patients with moderate-to-severe upper limb impairment. The InMotion2 (Interactive Motion Technologies, Watertown, MA, USA) and Armeo Power (Hocoma, Volketswil, Switzerland) robots were selected as representative EE and Exo robots, respectively, among commercially available robots for their proven efficacy and safety, as well as accessibility around hospitals11,12,13,14.
This single-blinded, randomised controlled trial was conducted at a single rehabilitation hospital. Participants were randomly allocated to an EE group and Exo group (1:1 ratio) by using concealed envelopes with a card representing the group assignment. Occupational therapists who carried out assessments were blinded to group allocation. The study was approved by the Ethics Committee of the National Rehabilitation Center, Korea and was carried out in accordance with the approved guidelines. Written informed consent was provided by all participants. The study was registered at ClinicalTrials.gov (NCT03104881).
For enrolment, the study considered 92 patients with stroke who were admitted to the rehabilitation hospital between March 2015 and August 2016. The inclusion criteria were as follows: (1) unilateral hemiplegic upper extremity dysfunction secondary to a unilateral ischaemic or haemorrhagic brain lesion; (2) stroke duration > 3 months; (3) FMA–Upper Extremity score of 8–30 for the affected upper extremity; and (4) ability to follow simple instructions. The exclusion criteria were as follows: (1) age < 20 years or > 80 years; (2) previous ischaemic or haemorrhagic stroke; (3) shoulder or elbow spasticity with a modified Ashworth scale (MAS) score ≥ 2; (4) severe upper extremity pain that could interfere with rehabilitation therapy; (5) neurological disorders other than stroke that can cause motor deficits, such as Parkinson’s disease, spinal cord injury, traumatic brain lesion, brain tumour, and peripheral neuropathy; and (4) uncontrolled severe medical conditions. Of the 92 patients, 53 did not meet the inclusion criteria or declined to participate. Thus, 39 patients were finally enrolled.
All participants received robot-assisted therapy with InMotion2 (EE group) or Armeo Power (Exo group) (30 minutes of active therapy 5 days a week for 4 weeks [total 20 sessions]) along with conventional occupational therapy (30 minutes of therapy [total 20 sessions]). Both robot-assisted therapies were managed by the same experienced research physical therapist. The therapy period was quantified by considering the active intervention time and not the time for preparations, such as attaching the robot to the patient and aligning the axis of the robot to that of the patient. Conventional occupational therapy involved range of motion exercises, strengthening exercises for the affected upper extremity, and basic ADL training. Overall, the same dosing parameters, including frequency and duration, were applied in the EE and Exo groups.
The EE robot InMotion2 was used in the EE group. In the seated position, each participant held the handle attached to an arm support and performed goal-directed reaching movements in the gravity-compensated horizontal plane with two degrees of freedom, including the shoulder and elbow joints. From the starting point in the centre, the participant was instructed to move the handle toward eight targets positioned 45 degrees apart in circular arrangements, and the position of the handle was marked on the screen for real-time visual feedback (Fig. 1A). Reaching movements were supported through an assist-as-needed control system when targets could not be reached independently.
via Comparisons between end-effector and exoskeleton rehabilitation robots regarding upper extremity function among chronic stroke patients with moderate-to-severe upper limb impairment | Scientific Reports
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.
[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.