Human-activity-centered measurement system:challenges from laboratory to the real environment in assistive gait wearable robotics

Assistive gait wearable robots (AGWR) have shown a great advancement in developing intelligent devices to assist human in their activities of daily living (ADLs). The rapid technological advancement in sensory technology, actuators, materials and computational intelligence has sped up this development process towards more practical and smart AGWR. However, most assistive gait wearable robots are still confined to be controlled, assessed indoor and within laboratory environments, limiting any potential to provide a real assistance and rehabilitation required to humans in the real environments. The gait assessment parameters play an important role not only in evaluating the patient progress and assistive device performance but also in controlling smart self-adaptable AGWR in real-time. The self-adaptable wearable robots must interactively conform to the changing environments and between users to provide optimal functionality and comfort. This paper discusses the performance parameters, such as comfortability, safety, adaptability, and energy consumption, which are required for the development of an intelligent AGWR for outdoor environments. The challenges to measuring the parameters using current systems for data collection and analysis using vision capture and wearable sensors are presented and discussed

Implementation of a Comprehensive Treatment Program for a Patient with TBI to Address Balance and Gait Deviations: A Case Report

Background and Purpose: The purpose of this retrospective case report is to describe physical therapy interventions provided to improve the balance and ambulation of a 20-year-old patient with apparent lower extremity foot drop and fatigue 20 months post severe traumatic brain injury secondary to a motor vehicle accident. Case Description: The patient initially had decreased active and passive range of motion in bilateral ankles, decreased BERG balance test scores, and decreased ambulation distance without the use of an assistive device. Treatment interventions included balance and ambulation training program that incorporated stretching and joint mobilizations, balance exercises, and endurance training. Outcomes: Following 13 sessions of skilled physical therapy over a 19-day period, the patient exhibited mild improvement with ankle dorsiflexion, improved ambulation speed by 900%, improved Six-Minute Walk test ambulation distance by 250 feet, and improved BERG balance test score by 7 points. The patient was also capable of ambulating 295 feet in a crowded, public area with moderate assistance. Discussion: More research is needed to determine how mental fatigue impacts patients with acquired brain injury and impairments related to hypertonicity, balance, and ambulation distance beyond household distance (\u3e150 feet)

Locomotive Training for Motor-Incomplete SCI in the Sub-Acute Setting: A Case Study

Background: Each year there are about 17,000 new cases of spinal cord injury (SCI) in the United States. For individuals who suffer a SCI, the restoration of walking consistently ranks as a top priority. Currently, there is strong evidence to support the use of locomotive training for recovery of ambulation following an incomplete spinal cord injury in the sub-acute setting. The purpose of this case report is to demonstrate the application of multiple locomotive training interventions and discuss recommendations for locomotive training following a motor-incomplete SCI. Case description: The patient was a 32-year old male 4 months post motor-incomplete spinal cord injury with an ASIA C classification. His injury occurred at the spinal level C5. At baseline, he presented with a Walking Index for Spinal Cord Injury (WISCI) II score of 6 and was unable to complete the 10-meter walk test (10MWT). Interventions: In this study, multiple locomotive training interventions (Ekso GT, Zero-G dynamic body weight support, HydroWorx, and over ground training) were implemented to facilitate task-specific, massed practice gait training. These interventions were strategically employed to maximize the training dose to optimally influence ambulation recovery. Outcome Measures: The primary outcome measures used in this case were the WISCI II and the 10MWT. The secondary outcome measure used was walking distance. At discharge, the patient demonstrated clinically important improvements in all three outcomes. Discussion: This report was able to demonstrate the utilization of several locomotive training techniques and provide clinicians examples of possible gait training parameters following SCI. There is currently not enough data to synthesize gait training prescription guidelines for individuals with sub-acute SCI thus driving the need for additional large-scale data collection

Gait Training After Delayed Prosthetic Fitting: A Case Report

Background and Purpose: Prosthetic training after below-knee amputation (BKA) is a long, collaborative process that generally begins within six months of surgery. For some patients, this process involves the use of temporary weight-bearing devices to prepare the patient for the mental and physical aspects of ambulating with a prosthesis. This case report discusses the treatment of a patient who had a prolonged period between a BKA and initialization of gait training with any prosthesis. Case Description: A 61-year-old male referred to physical therapy for prosthetic training over a year and a half after undergoing a BKA due to a gangrenous ulcer. Initial evaluation revealed strength, mobility, balance, and gait deficits that put him at a high fall risk. The patient underwent ten weeks of physical therapy with an emphasis on restoring balance, functional mobility, and optimal gait with a prosthesis. Outcomes: The patient initially progressed and then plateaued after the first month of therapy citing a fear of falling and increased pain with weight-bearing. After addressing underlying psychosocial concerns and following up with the prosthetist, the patient showed significant improvement in strength, function, and gait ability with the prosthesis. Discussion: Although this patient ultimately made progress towards his goals and improved his gait ability, a lack of trust in his prosthesis has notably prolonged his return to prior functioning. This case indicates a need for further investigation into the timing of prosthetic training and the use of temporary prostheses in patients who intend to return to ambulating following a BKA

Inpatient Rehabilitation For A 75-Year-Old Female Following A Left-Sided Pontine Infarct: A Case Report

Background and Purpose: Although cerebrovascular accidents (CVAs), or strokes, occur often in the United States, only 7% of those strokes affect the pons, an area of the brainstem that provides life-sustaining functions. Due to the rarity of pontine strokes, there is insufficient evidence supporting successful interventions that yield functional benefits for patients admitted to inpatient rehabilitation units (IRU). The purpose of this case report was to examine gait, balance and functional mobility interventions on the restoration of mobility and functional independence of a patient within an IRU.Case Description: The patient was a 75-year-old female 3 days status post a pontine stroke who was admitted into the IRU to improve independence and functional mobility after presenting with dysphagia, right-sided weakness and impaired functional mobility. Her plan of care included lower extremity (LE) strengthening, gait training with and without body-weight support, balance training and functional transfer training. Outcome measures used were the Five Times Sit to Stand (5xSTS), 10-Meter Walk Test (10MWT), Functional Gait Assessment (FGA), Inpatient Rehabilitation Unit-Performance Assessment Inventory (IRU-PAI), manual muscle testing (MMT), sensation and coordination testing.Outcomes: The patient improved right LE strength averaging 4/5, increased gait speed from 0.13 m/s to 0.4 m/s on the 10MWT, improved functional transfers from minimal contact assistance to supervision and improved ambulation from 35 feet to 350 feet without an assistive device and a contact guard assist by time of discharge.Discussion: LE strengthening, balance, gait training and transfer training were beneficial for restoring functional mobility in this patient with subacute pontine stroke. Further research should be performed to assess interventions for patients of varying demographics and stroke types within IRUs

A Task Oriented Approach For A Patient With Chronic Effects Of Stroke: A Case Report

Background and Purpose: Stroke is the leading cause of serious long-term disability for American adults. Most stroke survivors receive physical therapy (PT), and task-oriented rehabilitation is one novel approach known to benefit stroke survivors. The purpose of this case report is to illustrate the outcomes of a task-oriented approach to PT interventions on a patient \u3e12 months post stroke. The unique aims were to 1) outline possible benefits in function from repetitive task-oriented training techniques and 2) document outcomes of a patient who had received PT services \u3e12 months post stroke. Case Description: The patient was an 82 year-old female who was suffering from late effects of two separate stroke events. She was seen for outpatient PT for one hour, two times weekly for a total of 12 weeks during this episode of care. The following outcome measures were used: Function in Sitting Test (FIST), Tinetti, and a modified Gait Speed Test. Outcomes: Improvements in balance and functional mobility on the Tinetti (4/28 to 16/28) and Function in Sitting Test (43/56 to 56/56) were noted. Improved strength was noted based on manual muscle testing of the quadriceps and hamstrings. This patient was able to achieve independent bed mobility, increase her walking distance, and decrease the level of gait assistance needed (from max to contact guard) with improved quality of gait. No significant changes were noted in gait speed. Modified Ashworth Scale indicated no change in spasticity. Discussion: The findings suggest that a task-oriented approach to physical therapy intervention may have been a feasible method for this individual with chronic effects of stroke. Further research is needed to validate these results for similar patients

Review of control strategies for robotic movement training after neurologic injury

There is increasing interest in using robotic devices to assist in movement training following neurologic injuries such as stroke and spinal cord injury. This paper reviews control strategies for robotic therapy devices. Several categories of strategies have been proposed, including, assistive, challenge-based, haptic simulation, and coaching. The greatest amount of work has been done on developing assistive strategies, and thus the majority of this review summarizes techniques for implementing assistive strategies, including impedance-, counterbalance-, and EMG- based controllers, as well as adaptive controllers that modify control parameters based on ongoing participant performance. Clinical evidence regarding the relative effectiveness of different types of robotic therapy controllers is limited, but there is initial evidence that some control strategies are more effective than others. It is also now apparent there may be mechanisms by which some robotic control approaches might actually decrease the recovery possible with comparable, non-robotic forms of training. In future research, there is a need for head-to-head comparison of control algorithms in randomized, controlled clinical trials, and for improved models of human motor recovery to provide a more rational framework for designing robotic therapy control strategies

The Effects of Walking Poles and Training on Gait Characteristics and Fear of Falling in Community Dwelling Older Adults

BACKGROUND & PURPOSE: Walking poles are becoming popular not only in younger populations, but also with older adults. Manufacturers are promoting the health benefits of walking poles and claim that they facilitate a more normal gait pattern and increase confidence with walking in older adults. There is a lack of evidence to support these claims. The purpose of this double-blinded randomized controlled trial involving community dwelling older adults is twofold: 1) to measure the impact of walking poles on gait speed, stride length, and fear of falling; and 2) to compare the impact of walking pole use between a structured pole training group and an unstructured pole training group. METHODS: Dynamic gait analysis was performed on 12 healthy subjects (mean age 84.5 +/- 9.5 years; 8 female/4 males) using a GAITRite® mat. To determine baseline, subjects performed three walking trials without walking poles. Subjects were then randomly assigned to one of two groups, either structured or unstructured, for training in the use of walking poles. The subjects then repeated three walking trials on the GAITRite® mat utilizing the walking poles. Gait speed, stride length, fear of falling, and global rating of change within and between groups was analyzed using paired t-tests, independent 2 sample t-tests, Spearman correlations and Pearson correlations. RESULTS: When comparing walking with and without walking poles, significant differences (p\u3c0.05) were found within the unstructured training group with gait speed and stride length while no significant differences were found within the structured training group. No significant differences were found between training groups when comparing the amount of change in gait speed and stride length. A moderate inverse correlation was found between change scores of gait speed and fear of falling. CONCLUSION: Results did not support the hypothesis that the use of walking poles would impact gait speed, stride length, and fear of falling differently in subjects who participated in structured training as compared to those who did not participate in structured training. Regardless of the type of training, our research did not support advertisers’ claims that walking poles improve gait speed, stride length, or confidence with walking

How a Diverse Research Ecosystem Has Generated New Rehabilitation Technologies: Review of NIDILRR’s Rehabilitation Engineering Research Centers

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a “total approach to rehabilitation”, combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970’s, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program

Enhancing performance during inclined loaded walking with a powered ankle-foot exoskeleton

A simple ankle-foot exoskeleton that assists plantarflexion during push-off can reduce the metabolic power during walking. This suggests that walking performance during a maximal incremental exercise could be improved with an exoskeleton if the exoskeleton is still efficient during maximal exercise intensities. Therefore, we quantified the walking performance during a maximal incremental exercise test with a powered and unpowered exoskeleton: uphill walking with progressively higher weights. Nine female subjects performed two incremental exercise tests with an exoskeleton: 1 day with (powered condition) and another day without (unpowered condition) plantarflexion assistance. Subjects walked on an inclined treadmill (15 %) at 5 km h(-1) and 5 % of body weight was added every 3 min until exhaustion. At volitional termination no significant differences were found between the powered and unpowered condition for blood lactate concentration (respectively, 7.93 +/- A 2.49; 8.14 +/- A 2.24 mmol L-1), heart rate (respectively, 190.00 +/- A 6.50; 191.78 +/- A 6.50 bpm), Borg score (respectively, 18.57 +/- A 0.79; 18.93 +/- A 0.73) and peak (respectively, 40.55 +/- A 2.78; 40.55 +/- A 3.05 ml min(-1) kg(-1)). Thus, subjects were able to reach the same (near) maximal effort in both conditions. However, subjects continued the exercise test longer in the powered condition and carried 7.07 +/- A 3.34 kg more weight because of the assistance of the exoskeleton. Our results show that plantarflexion assistance during push-off can increase walking performance during a maximal exercise test as subjects were able to carry more weight. This emphasizes the importance of acting on the ankle joint in assistive devices and the potential of simple ankle-foot exoskeletons for reducing metabolic power and increasing weight carrying capability, even during maximal intensities