Posts Tagged upper limb
[Abstract] Recovery in the Severely Impaired Arm Post-stroke after Mirror Therapy – a Randomized Controlled Study
This study aimed to examine the effectiveness of mirror therapy (MT) on recovery in the severely impaired arm after stroke.
Using single-blind randomized controlled design, patients with severely impaired arm within 1-month post-stroke were assigned to received MT (n=20) or control therapy (CT) (n=21), 30min. twice daily for 4 weeks in addition to conventional rehabilitation. During MT and CT, subjects practiced similar structured exercises in both arms, except that mirror reflection of the unaffected arm was the visual feedback for MT, but mirror was absent for CT so that subjects could watch both arms in exercise. Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT) were the outcome measurements.
After the intervention, both MT and CT groups had significant arm recovery similarly in FMA (p=0.867), WMFT-Time (p=0.947) and WMFT-Functional Ability Scale (p=0.676).
MT or CT which involved exercises concurrently for the paretic and unaffected arms during subacute stroke promoted similar motor recovery in the severely impaired arm.
[Abstract] Activity-based Rehabilitation Interventions of the Neurologically Impaired Upper Extremity: Description of a Scoping Review Protocol
Introduction: A scoping review provides a means to synthesize and present a large body of literature on a broad topic, such as methods for various upper extremity activity-based therapy (ABT) interventions.
Objectives: To describe our scoping review protocol to evaluate peer-reviewed articles focused on ABT interventions for individuals with neurologically impaired upper extremities.
Methods: At Jefferson College of Health Professions and Sidney Kimmel Medical College at Jefferson, Philadelphia, the authors will follow this protocol to conduct a scoping review by establishing a research question and conducting a search of bibliographic databases to identify relevant studies. Using specific inclusion and exclusion criteria, abstracts will be screened and full-text articles will be reviewed for inclusion in charting, summarizing, and reporting results of appropriate studies.
Conclusion: This protocol will guide the scoping review process to develop a framework for establishing a noninvasive ABT intervention informed by evidence for individuals with neurologically impaired upper extremities.
[Abstract + References] Towards a framework for rehabilitation and assessment of upper limb motor function based on Serious Games – IEEE Conference Publication
Biomechanical analysis is an important feature during the evaluation and clinical diagnosis of motor deficits caused by traumas or neurological diseases. For that reason Motion capture (MoCap) systems are widely used in biomechanical studies, in order to collect position data from anatomical landmarks with high accuracy. Their results are used to estimate joint movements, positions, and muscle forces. These quantitative results improve the tracking of changes in motor functions over time, being more accurately than clinical ratings . For clinical applications, these results are usually transformed into clinically meaningful and interpretable parameters, such as gait speed, motion range of joints and body balance.
[Abstract + Related Articles] Adaptive gameplay and difficulty adjustment in a gamified upper-limb rehabilitation – IEEE Conference Publication
The impairment of finger movements after a stroke results in a significant deficit in hands everyday performances. To face this kind of problems different rehabilitation techniques have been developed, nevertheless, they require the presence of a therapist to be executed. To overcome this issue have been designed several apparatuses that allow the patient to perform the training by itself. Thus, an easy to use and effective device is needed to provide the right training and complete the rehabilitation techniques in the best way. In this paper, a review of state of the art in this field is provided, along with an introduction to the problems caused by a stroke and the consequences for the mobility of the hand. Then follows a complete review of the low cost home based exoskeleton project design. The objective is to design a device that can be used at home, with a lightweight and affordable structure and a fast mounting system. For implementing all these features, many aspects have been analysed, starting from the rehabilitation requirements and the ergonomic issues. This device should be able to reproduce the training movements on an injured hand without the need for assistance by an external tutor.
[Abstract] Bilateral Motor Cortex Plasticity in Individuals With Chronic Stroke, Induced by Paired Associative Stimulation
Background: In the chronic phase after stroke, cortical excitability differs between the cerebral hemispheres; the magnitude of this asymmetry depends on degree of motor impairment. It is unclear whether these asymmetries also affect capacity for plasticity in corticospinal tract excitability or whether hemispheric differences in plasticity are related to chronic sensorimotor impairment.
Methods: Response to paired associative stimulation (PAS) was assessed bilaterally in 22 individuals with chronic hemiparesis. Corticospinal excitability was measured as the area under the motor-evoked potential (MEP) recruitment curve (AUC) at baseline, 5 minutes, and 30 minutes post-PAS. Percentage change in contralesional AUC was calculated and correlated with paretic motor and somatosensory impairment scores.
Results: PAS induced a significant increase in AUC in the contralesional hemisphere (P = .041); in the ipsilesional hemisphere, there was no significant effect of PAS (P = .073). Contralesional AUC showed significantly greater change in individuals without an ipsilesional MEP (P = .029). Percentage change in contralesional AUC between baseline and 5 m post-PAS correlated significantly with FM score (r = −0.443; P = .039) and monofilament thresholds (r = 0.444, P = .044).
Discussion: There are differential responses to PAS within each cerebral hemisphere. Contralesional plasticity was increased in individuals with more severe hemiparesis, indicated by both the absence of an ipsilesional MEP and a greater degree of motor and somatosensory impairment. These data support a body of research showing compensatory changes in the contralesional hemisphere after stroke; new therapies for individuals with chronic stroke could exploit contralesional plasticity to help restore function.
Understanding upper limb impairment after stroke is essential to planning therapeutic efforts to restore function. However determining which upper limb impairment to treat and how is complex for two reasons: 1) the impairments are not static, i.e. as motor recovery proceeds, the type and nature of the impairments may change; therefore the treatment needs to evolve to target the impairment contributing to dysfunction at a given point in time. 2) multiple impairments may be present simultaneously, i.e., a patient may present with weakness of the arm and hand immediately after a stroke, which may not have resolved when spasticity sets in a few weeks or months later; hence there may be a layering of impairments over time making it difficult to decide what to treat first. The most useful way to understand how impairments contribute to upper limb dysfunction may be to examine them from the perspective of their functional consequences. There are three main functional consequences of impairments on upper limb function are: (1) learned nonuse, (2) learned bad-use, and (3) forgetting as determined by behavioral analysis of tasks. The impairments that contribute to each of these functional limitations are described.
The nature of upper limb motor impairment
According to the International Classification of Functioning, Disability and Health model (ICF) (Geyh, Cieza et al. 2004), impairments may be described as (1) impairments of body function such as a significant deviation or loss in neuromusculoskeletal and movement related function related to joint mobility, muscle power, muscle tone and/or involuntary movements, or (2) impairment of body structures such as a significant deviation in structure of the nervous system or structures related to movement, for example the arm and/or hand. A stroke may lead to both types of impairments. Upper limb impairments after stroke are the cause of functional limitations with regard to use of the affected upper limb after stroke, so a clear understanding of the underlying impairments is necessary to provide appropriate treatment. However understanding upper limb impairments in any given patient is complex for two reasons: 1) the impairments are not static, i.e. as motor recovery proceeds, the type and nature of the impairments may change; therefore the treatment needs to evolve to target the impairment contributing to dysfunction at a given point in time. 2) multiple impairments may be present simultaneously, i.e., a patient may present with weakness of the arm and hand immediately after a stroke, which may not have resolved when spasticity sets in a few weeks or months later; hence there may be a layering of impairments over time making it difficult to decide what to treat first. It is useful to review the progression of motor recovery as described by Twitchell (Twitchell 1951) and Brunnstrom (Brunnstom 1956) to understand how impairments may be layered over time (Figure 1).
Understanding motor impairment from a functional perspective
The most useful way to understand how impairments contribute to upper limb dysfunction may be to examine them from the perspective of their functional consequences. There are three main functional consequences of stroke on the upper limb: (1) learned nonuse, (2) learned bad-use, and (3) forgetting as determined by behavioral analysis of a task such as reaching for a food pellet and bringing it to the mouth in animal models of stroke (Whishaw, Alaverdashvili et al. 2008). These are equally valid for human behavior. Each of the functional consequences and the underlying impairments are elaborated below.[…]
Continue —> Upper Limb Motor Impairment Post Stroke
[Abstract] A low cost kinect-based virtual rehabilitation system for inpatient rehabilitation of the upper limb in patients with subacute stroke: A randomized, double-blind, sham-controlled pilot trial.
We designed this study to prove the efficacy of the low-cost Kinect-based virtual rehabilitation (VR) system for upper limb recovery among patients with subacute stroke.
A double-blind, randomized, sham-controlled trial was performed. A total of 23 subjects with subacute stroke (<3 months) were allocated to sham (n = 11) and real VR group (n = 12). Both groups participated in a daily 30-minute occupational therapy for upper limb recovery for 10 consecutive weekdays. Subjects received an additional daily 30-minute Kinect-based or sham VR. Assessment was performed before the VR, immediately and 1 month after the last session of VR. Fugl-Meyer Assessment (FMA) (primary outcome) and other secondary functional outcomes were measured. Accelerometers were used to measure hemiparetic upper limb movements during the therapy.
FMA immediately after last VR session was not different between the sham (46.8 ± 16.0) and the real VR group (49.4 ± 14.2) (P = .937 in intention to treat analysis). Significant differences of total activity counts (TAC) were found in hemiparetic upper limb during the therapy between groups (F2,26 = 4.43; P = .22). Real VR group (107,926 ± 68,874) showed significantly more TACs compared with the sham VR group (46,686 ± 25,814) but there was no statistical significance between real VR and control (64,575 ± 27,533).
Low-cost Kinect-based upper limb rehabilitation system was not more efficacious compared with sham VR. However, the compliance in VR was good and VR system induced more arm motion than control and similar activity compared with the conventional therapy, which suggests its utility as an adjuvant additional therapy during inpatient stroke rehabilitation.
- PMID:29924029 DOI:10.1097/MD.0000000000011173
[ARTICLE] Translation of robot-assisted rehabilitation to clinical service: a comparison of the rehabilitation effectiveness of EMG-driven robot hand assisted upper limb training in practical clinical service and in clinical trial with laboratory configuration for chronic stroke – Full Text
Rehabilitation robots can provide intensive physical training after stroke. However, variations of the rehabilitation effects in translation from well-controlled research studies to clinical services have not been well evaluated yet. This study aims to compare the rehabilitation effects of the upper limb training by an electromyography (EMG)-driven robotic hand achieved in a well-controlled research environment and in a practical clinical service.
It was a non-randomized controlled trial, and thirty-two participants with chronic stroke were recruited either in the clinical service (n = 16, clinic group), or in the research setting (n = 16, lab group). Each participant received 20-session EMG-driven robotic hand assisted upper limb training. The training frequency (4 sessions/week) and the pace in a session were fixed for the lab group, while they were flexible (1–3 sessions/week) and adaptive for the clinic group. The training effects were evaluated before and after the treatment with clinical scores of the Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), Functional Independence Measure (FIM), and Modified Ashworth Scale (MAS).
Significant improvements in the FMA full score, shoulder/elbow and wrist/hand (P < 0.001), ARAT (P < 0.001), and MAS elbow (P < 0.05) were observed after the training for both groups. Significant improvements in the FIM (P < 0.05), MAS wrist (P < 0.001) and MAS hand (P < 0.05) were only obtained after the training in the clinic group. Compared with the lab group, higher FIM improvement in the clinic group was observed (P < 0.05).
The functional improvements after the robotic hand training in the clinical service were comparable to the effectiveness achieved in the research setting, through flexible training schedules even with a lower training frequency every week. Higher independence in the daily living and a more effective release in muscle tones were achieved in the clinic group than the lab group.
Stroke is a major cause of permanent disability in adults . By 2014, the number of stroke survivors in Hong Kong was approximately 300,000, and more than 7 million in Mainland China, with an average of 2 million new cases per year and an annual increase of 8% from 2009 to 2014 in Mainland China [2, 3]. Approximately 80% of stroke survivors experience upper extremity impairment and disability in activities of daily living (ADLs) [4, 5]. However, fewer than 25% of these can regain limited recovery on their paretic arms even after post-stroke rehabilitation . Physical treatment can result in more significant recovery of arm function during the subacute period (i.e., before 6 months after stroke onset) than in the chronic stage (i.e., more than 6 months after the stroke onset) . In current clinical practice, the professional manpower of post-stroke rehabilitation is much more concentrated on the in-patient period in the subacute stage, compared with that in the long-term service for chronic stroke. However, recent studies have demonstrated that with intensive training, significant motor improvements could also be achieved during the chronic period after stroke [8, 9]. The challenge, however, is that rehabilitation manpower is insufficient, even in developed countries with the fast-expanding stroke populations. Hence, effective techniques and services for long-term rehabilitation after stroke are in urgent need.
Rehabilitation robots have been valuable for human therapists in delivering the labor-demanding physical training with the advantages of higher repetition and lower cost than professional manpower . Various robots have been proposed for the upper limb rehabilitation after stroke, and the robots’ effectiveness has been evaluated by clinical trials [11, 12, 13]. Among them, robot-assisted rehabilitation controlled by the voluntary inputs of the user exhibited more significant efficacy than that with continuous passive motions, i.e., no voluntary input was required from a user and the robots dominated the motion of a paralyzed limb . In a voluntary intention driven robot designed by Song et al. , electromyography (EMG) from the residual muscle of the upper limb was used as the indicator of the voluntary motor intention from a stroke survivor. In the related randomized clinical trial, it was found that patients with chronic stroke obtained more significant motor gain when assisted with the EMG-driven robot than with passive motion assistance alone . Another representative study was the large randomized multi-center trial by Lo et al. which compared the MIT-Manus robotic system for upper limb training with the conventional physical treatments by a human therapist . The results suggested that the robot could achieve the equivalent motor improvements to those of the conventional treatment . Thus, according to the findings, robot-assisted post-stroke training could be a cost-effective alternative to the conventional rehabilitation service when human manpower is insufficient.
However, almost all positive reports on robot-assisted rehabilitation were obtained through research-oriented clinical trial studies and not in a real clinical service configuration, with the assumption that the positive improvements reported in the trial studies would be naturally carried on into the real services after commercialization. Differences, or even discounts, in the rehabilitation effectiveness during the translation from well-controlled research studies to more flexible services have not yet been intensely evaluated. Actually, the feasibility and effectiveness of rehabilitation robots in the clinical service setting have been questioned when trial-quality management was difficult to achieve in a real long-term service [18, 19, 20, 21, 22]. There are several factors that increase the difficulty of head-to-head comparison on the training effectiveness in robot-assisted rehabilitation services with the clinical trials. For instance: (1) In a real service setting, the rehabilitation schedule is relatively flexible with payment from a client. In contrast, trial studies have restricted training schedules (are usually free of charge, or in some cases, participants are even paid for their involvement in the trial); (2) Participant (client) variability is large in the service. In the trials, participant inclusion criteria are usually targeted, and therefore, are difficult to replicate and implement exactly in the service management (particularly in the private sectors) due to the financial sustainability required; (3) In a clinical trial, the participants would usually not be allowed to receive other treatments that might interfere with the prescribed physical program under investigation. However, in a service setting, it is impossible to restrict a client and stop him/her from receiving other physical treatments he/she considers useful. An EMG-driven robotic hand was designed in our previous work, and its rehabilitation effectiveness on the upper limb functions in chronic stroke has been reported by a single group clinical trial . From 2011, the EMG-driven robotic hand service open to local communities has been available in a self-financed university clinic in a private sector. The purpose of this work was to quantitatively evaluate the difference between the rehabilitation effects of an EMG-driven robot hand-assisted upper limb training program conducted as a research trial in a laboratory configuration and as real clinical practice in a private clinic, with minimum disturbance to the routine clinical management and service provided to the clients.
EMG-driven robotic hand
Continue —> Translation of robot-assisted rehabilitation to clinical service: a comparison of the rehabilitation effectiveness of EMG-driven robot hand assisted upper limb training in practical clinical service and in clinical trial with laboratory configuration for chronic stroke | BioMedical Engineering OnLine | Full Text
This document presents the development of a first proposal prototype of a rehabilitation exoskeleton hand. The idea was to create a lighter, less complex and cheaper exoskeleton than the existing models in the market but efficient enough to carry out rehabilitation therapies.The methodology implemented consists of an initial literature review followed by data collection resulting in a pre-design in two dimensions using two different software packages, MUMSA and WinmecC. First, MUMSA provides the parameters data of the movement of the hand to be done accurately. With these parameters, the mechanisms of each finger are designed using WinmecC. Once the errors were solved and the mechanism was achieved, the 3D model was designed.The final result is presented in two printed 3D models with different materials. The models perform a great accurate level on the motion replica of the fingers by using rotary servos. The properties of the model can change depending on the used material. ABS material gives a flexible prototype, and PLA material does not achieve it. The use of distinct methods to print has a high importance on the difficulties of development throughout the entire process of production. Despite found difficulties in the production, the model was printed successfully, obtaining a compact, strong, lightweight and eco-friendly with the environment prototype.
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