[ARTICLE] The Effectiveness of Wearable Upper Limb Assistive Devices in Degenerative Neuromuscular Diseases: A Systematic Review and Meta-Analysis – Full Text

Abstract

Background: This systematic review summarizes the current evidence about the effectiveness of wearable assistive technologies for upper limbs support during activities of daily living for individuals with neuromuscular diseases.

Methods: Fourteen studies have been included in the meta-analysis, involving 184 participants. All included studies compared patients ability to perform functional tasks with and without assistive devices.

Results: An overall effect size of 1.06 (95% CI = 0.76-1.36, p < 0.00001) was obtained, demonstrating that upper limbs assistive devices significantly improve the performance in activities of daily living in people with neuromuscular diseases. A significant interaction between studies evaluating functional improvement with externally-assessed outcome measures or self-perceived outcome measures has been detected. In particular, the effect size of the sub-group considering self-perceived scales was 1.38 (95% CI = 1.08-1.68), while the effect size of the other group was 0.77 (95% CI = 0.41-1.11), meaning that patients’ perceived functional gain is often higher than the functional gain detectable through clinical scales.

Conclusion: Overall, the quality of the evidence ranged from low to moderate, due to low number of studies and participants, limitations in the selection of participants and in the blindness of outcome assessors, and risk of publication bias.

Significance: A large magnitude effect and a clear dose-response gradient were found, therefore, a strong recommendation, in favor of the use of assistive devices could be suggested.

 

1. Introduction

1.1. Background

Severe muscular weakness and chronic disability caused by neuromuscular diseases (e.g., muscular dystrophy, spinal muscular atrophy, spinal cord injuries or stroke) or neurodegenerative diseases (i.e., multiple sclerosis, amyotrophic lateral sclerosis) lead to the unavoidable loss of the possibility to perform even simple actions, such as walking, eating, and changing limbs posture. Patients suffer the consequences in terms of independence, quality of life, and self-esteem, given their need to continuously rely on assistance from their caregivers. This is particularly true for upper limbs, where independence is not primarily linked to essential tasks (e.g., eating, drinking, get dressed), but to simple actions not necessary for survival, but which increase the quality of life (e.g., pull up the glasses, scratch, use the mouse, etc.). To independently regain a lost motor function might be therefore a special experience towards a more independent daily life. Technological advancements might be a way to compensate patients’ muscular weakness through the use of Assistive Devices (ADs), which empower the user in the execution of daily life activities, and which are designed to maintain or to improve the functional capabilities of individuals with disabilities. ADs for lower limbs, such as wheelchairs and electric wheelchairs, have been successfully developed and diffused to deal with the deambulation issue. On the other side, the support of upper limbs related activities is more challenging. However, with the increased life expectancy, upper extremities functions became more and more important to be supported. Non-ambulant patients with neuromuscular disorders identified arm functions as their highest priority, indicating repositioning at night, bring hands to mouth, shift while seated, using the wheelchair joystick and the keyboard of a computer, and personal hygiene as priority functions to be regained (Janssen et al., 2014). The currently existing assistive devices to support upper limbs functions can be categorized in (i) end-effector devices, and (ii) exoskeletons. As for end-effector devices, they present a single interaction point between the user and the AD, usually located at forearm or hand level. The main disadvantage of robotic manipulator devices is the impossibility to control upper limb joints directly: the change in position of the interaction point results in unexpected movements of shoulder and elbow joints. As for exoskeletons, they are external structures worn by the patient, with joints and links placed in correspondence of human joints and bones. Patients usually prefer exoskeleton solutions, given that these devices not only help to execute the desired task, but they increase the perception of a self-executed movement. In a study conducted by Rupal et al. (2017) with 118 participants, 96.8% prefer to use an exoskeleton over other mobility aids, and 84.1% like the idea that exoskeletons should be made available in care homes (Rupal et al., 2017). In addition, from a survey conducted by the authors at Lignano Sabbiadoro (Italy) on June 2015, during the annual meeting of the UILDM Association (Italian Association of Muscular Dystrophy), 10 out of 15 interviewed patients affected by muscular dystrophy answered that they prefer exoskeleton solutions for possible upper limbs assistive devices. ADs driving technology can be either passive, working through pre-stored mechanical energy, or active, working with motors, and therefore able to exert greater forces or to control movements more precisely. However, even if a remarkable number of works have been published dealing with the development of innovative electromechanical technologies (e.g., Ragonesi et al., 2013; Jung et al., 2014; Dunning et al., 2015; Sin et al., 2015; Dalla Gasperina et al., 2018), scientific evidence for the benefits of these technologies is still lacking, which could justify costs and effort. When dealing with Assistive Devices, or in general with complex technologies, the demonstration of the effectiveness of their use is rather difficult to be demonstrated following the canonical research studies design [i.e., Randomized Control Trial (RCT) design], even if some effort in this direction is currently ongoing (Antonietti et al., 2019). This is due to several reasons, such as the difficulty to demonstrate the validity of the proposed approach independently from the users’ placebo effect (e.g., it is impossible to perform a blind session), the high cost of the technology and therefore the impossibility to recruit many volunteers contemporary, and the Ethical Committee procedures for non CE-marked devices. A recent systematic review on devices to assist and/or rehabilitate upper limbs made a quite large classification of different devices used, showing an intense research work towards the development of new technologies, which however are rarely methodologically properly tested, and therefore they have difficulties to effectively reach end-users (Onose et al., 2018). […]

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[ARTICLE] Electromyographic Activity of the Upper Limb in Three Hand Function Tests – Full Text

Summary

Objective/Background

Occupational therapists usually assess hand function through standardised tests, however, there is no consensus on how the scores assigned to hand dexterity can accurately measure hand function required for daily activities and few studies evaluate the movement patterns of the upper limbs during hand function tests. This study aimed to evaluate the differences in muscle activation patterns during the performance of three hand dexterity tests.

Methods

Twenty university students underwent a surface electromyographic (sEMG) assessment of eight upper limb muscles during the performance of the box and blocks test (BBT), nine-hole peg test (9HPT), and functional dexterity test (FDT). The description and comparison of each muscle activity during the test performance, gender differences, and the correlation between individual muscles’ sEMG activity were analysed through appropriate statistics.

Results

Increased activity of proximal muscles was found during the performance of BBT (p < .001). While a higher activation of the distal muscles occurred during the FDT and 9HPT performance, no differences were found between them. Comparisons of the sEMG activity revealed a significant increase in the muscle activation among women (p = .05). Strong and positive correlations (r > .5; p < .05) were observed between proximal and distal sEMG activities, suggesting a coordinate pattern of muscle activation during hand function tests.

Conclusion

The results suggested the existence of differences in the muscle activation pattern during the performance of hand function evaluations. Occupational therapists should be aware of unique muscle requirements and its impact on the results of dexterity tests during hand function evaluation.

Introduction

Hand and upper extremity function is essential to humans as it allows for the performance of a wide range of self-care, productive, and leisure activities (Chan & Spencer, 2004). Due to its importance, impairments in the upper extremities lead to restrictions on activity performance and impacts participation in social activities and engagements in meaningful occupations, ultimately affecting overall wellbeing and quality of life (van de Ven-Stevens et al., 2016).

Treating patients with hand and upper limb injuries is a common situation for occupational therapists; hand and wrist lesions account for approximately 20% of all cases seen in hospital emergency departments (Dias & Garcia-Elias, 2006), with most patients presenting further limitations to upper extremity function due to a restricted range of motion, pain, oedema, and muscle weakness caused by the trauma (Ydreborg, Engstrand, Steinvall, & Larsson, 2015). In addition to acute situations, restricted hand function also represents one of the leading causes of limited participation in daily activities by patients with chronic diseases, such as rheumatoid arthritis (Andrade, Brandão, Pinto, & Lanna, 2016) and stroke (Dawson, Binns, Hunt, Lemsky, & Polatajko, 2013).

Although the cause of injury varies in different countries (Che Daud, Yau, Barnett, Judd, Jones, & Muhammad Nawawi, 2016), the majority of the upper limb trauma affects working adults aged between 20 years and 64 years (de Putter et al., 2016), thereby causing a significant economic impact. Studies completed in the past decade have estimated the healthcare and productivity costs of upper limb lesions to be US$ 410–740 million per year (de Putter et al., 2012 ;  de Putter et al., 2016), with increased absenteeism and early retirement age observed among patients (Shi et al., 2014 ;  Tiippana-Kinnunen et al., 2013).

Assessment procedures that allow occupational therapists to obtain accurate and reliable information regarding patients’ hand function are essential for setting realistic goals and measuring patients’ progression during the rehabilitation of upper limb injuries (Carrasco-Lopez et al., 2016). Amongst the several resources available, standardised manual tests are extensively used during the evaluations of hand function to assess the upper limb coordination and skill through a series of tasks involving the manipulation of objects in established patterns (Ekstrand et al., 2016; Srikesavan et al., 2015 ;  van de Ven-Stevens et al., 2016).

Despite focusing on the measurements of body functions and structures, standardised dexterity tests provide valid and reliable data that aids therapists in understanding the impact of hand injuries on patients’ activities of daily life. Commonly used standardised tests have high inter-rater and test-retest reliability, usually with an intraclass correlation coefficient (ICC) greater than 0.85 (Aaron and Jansen, 2003; Desrosiers et al., 1994 ;  Earhart et al., 2011).

However, given the existence of multiple standardised dexterity tests and an even greater variety of structured tasks involved in each assessment, there is no consensus on which test is more suitable for evaluating the entire function of upper extremities (van de Ven-Stevens et al., 2016). Moreover, there is an increasing concern regarding the way by which the scores assigned to hand dexterity can accurately measure hand function required for daily activities (Rallon and Chen, 2008; Rand and Eng, 2010 ;  van de Ven-Stevens et al., 2016).

The study of muscle activation through surface electromyography (sEMG) allows a real-time, noninvasive assessment of the activation pattern of muscles during the activity performance (Gurney et al., 2016). Although sEMG has been used to evaluate the muscle activation patterns in several self-care (Meijer et al., 2014), productivity (Almeida et al., 2013 ;  Ferrigno et al., 2009), and leisure activities (Donoso Brown, McCoy, Fechko, Price, Gilbertson, & Moritz, 2014), few studies have analysed the different recruitment of muscle fibres during the performances of different hand function tests (Brorsson et al., 2014 ;  Calder et al., 2011).

Considering the lack of studies describing the muscle activities of the upper extremities in standardised hand assessments, this study aimed to evaluate and compare the differences in muscle activation patterns during the performance of the box and blocks test (BBT), nine-hole peg test (9HPT), and functional dexterity test (FDT)—the three hand dexterity tests used by occupational therapists during hand function evaluation.

Continue —> Electromyographic Activity of the Upper Limb in Three Hand Function Tests

Figure 1. Experimental setting. (A) Box and blocks test; (B) Nine-hole peg test; (C) functional dexterity test.

[REVIEW] On the assessment of coordination between upper extremities: towards a common language between rehabilitation engineers, clinicians and neuroscientists – Full Text

Abstract

Well-developed coordination of the upper extremities is critical for function in everyday life. Interlimb coordination is an intuitive, yet subjective concept that refers to spatio-temporal relationships between kinematic, kinetic and physiological variables of two or more limbs executing a motor task with a common goal. While both the clinical and neuroscience communities agree on the relevance of assessing and quantifying interlimb coordination, rehabilitation engineers struggle to translate the knowledge and needs of clinicians and neuroscientists into technological devices for the impaired. The use of ambiguous definitions in the scientific literature, and lack of common agreement on what should be measured, present large barriers to advancements in this area. Here, we present the different definitions and approaches to assess and quantify interlimb coordination in the clinic, in motor control studies, and by state-of-the-art robotic devices. We then propose a taxonomy of interlimb activities and give recommendations for future neuroscience-based robotic- and sensor-based assessments of upper limb function that are applicable to the everyday clinical practice. We believe this is the first step towards our long-term goal of unifying different fields and help the generation of more consistent and effective tools for neurorehabilitation.

Background

This work was developed as part of the project “State of the Art Robot-Supported assessments (STARS)” in the frame of the COST Action TD1006 “European Network on Robotics for NeuroRehabilitation” [1]. The goal of STARS is to give neurorehabilitation clinical practitioners and scientists recommendations for the development, implementation, and administration of different indices of robotic assessments, grounded on scientific evidence.

Well-coordinated movements are a characteristic feature of well-developed motor behavior. From neuroscientists to clinicians, quantifying coordination of an individual is of critical importance. Not only does this help in understanding the neurophysiological components of movement (neuroscience field), but it can also help us identify and assess underlying neurological problems of a patient with movement disorders, and guide therapeutic interventions (clinical field).

The term ‘coordination’ is so strongly ingrained in our common language that we do not typically stop to think about the key underlying features that characterize good and bad coordination–even though we can all distinguish the well-coordinated movements of a trained dancer from those of a novice. What exactly is meant by coordination? And how should it be measured? Addressing these questions is particularly difficult when considering such an abstract concept, which encompasses many different aspects that are not straightforward to define formally.

Indeed, coordinated movements are multidimensional and require the organization of multiple subsystems, e.g., eye-hand coordination [2], intersegmental coordination [3], intralimb coordination [4], interlimb coordination [5]. Given the multiple connotations and associations to the word coordination, in this paper, we attempt to summarize how coordination between upper extremities-a form of interlimb coordination-is interpreted and measured by clinicians, neuroscientists and rehabilitation engineers.

As the reader will see in the following pages, the descriptors of interlimb coordination and how it is assessed vary considerably from field to field, and even within a field. This lack of a common language and standard terminology is a huge barrier to relate the observations from different fields, hindering the understanding and discussion needed to move forward. Further, such definitions are critical for engineers working in translational neurorehabilitation, who harness knowledge from basic and clinical neuroscience to produce technological tools (e.g., robotic devices, instrumented tools) to aid clinicians in their everyday practice. The lack of a common understanding has fostered the use of dozens of ad-hoc algorithms and assessment tools (see section 3), most of which have had limited transfer to everyday clinical applications.

Our long-term goal is to standardize the administration of robotic-and sensor-based assessments of sensory-motor function. Towards this end, we present a summary of different ways in which interlimb coordination has been studied and quantified. We start by presenting a general overview of why the study of coordination between upper limbs is relevant for clinicians and behavioral neuroscientists. We then present a summary of how interlimb coordination is typically assessed in clinical environments and during related motor control experiments. This is followed by a proposal of categorization of interlimb tasks and different outcome measures that are applicable to each task. We believe that the growing scientific community in translational neurorehabilitation research would benefit from this condensed review. …

Continue —> On the assessment of coordination between upper extremities: towards a common language between rehabilitation engineers, clinicians and neuroscientists | Journal of NeuroEngineering and Rehabilitation | Full Text

[Systematic Review] Integration of emerging motion capture technologies and videogames for human upper-limb telerehabilitation – Full Text PDF

Abstract

Integrating emerging technologies has shown to have the potential to improve access to rehabilitation services and the adherence for physical therapy when they are applied into telemedicine environments.

This systematic review aims to explore telerehabilitation systems that use motion capture and video games for upper-limb rehabilitation purposes. Motion capture was focused on the information fusion from inertial sensors and other technologies. The search was limited to 2010-2013, from which 667 papers were obtained; afterwards,
duplicate papers were removed, thus, reducing the sample to 57 papers with full text availability. Finally, only 3 of them were selected by approaching the subject of this study.

We conclude that the fusion information from inertial sensors and other motion capture technologies appears to be a new tendency in remote monitoring of motor rehabilitation process. However, the combination of them with active video games in physiotherapy programs is only an emerging research area with promising results.

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[ARTICLE] A Mirror Therapy-Based Action Observation Protocol to Improve Motor Learning After Stroke

…Conclusions

A mirror therapy-based AO protocol significantly contributes to motor learning of the affected in patients in the chronic stage after stroke…

via A Mirror Therapy-Based Action Observation Protocol to Improve Motor Learning After Stroke – Archives of Physical Medicine and Rehabilitation.