Safe Haptics-enabled Patient-Robot Interaction for Robotic and Telerobotic Rehabilitation of Neuromuscular Disorders: Control Design and Analysis

Motivation: Current statistics show that the population of seniors and the incidence rate of age-related neuromuscular disorders are rapidly increasing worldwide. Improving medical care is likely to increase the survival rate but will result in even more patients in need of Assistive, Rehabilitation and Assessment (ARA) services for extended periods which will place a significant burden on the world\u27s healthcare systems. In many cases, the only alternative is limited and often delayed outpatient therapy. The situation will be worse for patients in remote areas. One potential solution is to develop technologies that provide efficient and safe means of in-hospital and in-home kinesthetic rehabilitation. In this regard, Haptics-enabled Interactive Robotic Neurorehabilitation (HIRN) systems have been developed. Existing Challenges: Although there are specific advantages with the use of HIRN technologies, there still exist several technical and control challenges, e.g., (a) absence of direct interactive physical interaction between therapists and patients; (b) questionable adaptability and flexibility considering the sensorimotor needs of patients; (c) limited accessibility in remote areas; and (d) guaranteeing patient-robot interaction safety while maximizing system transparency, especially when high control effort is needed for severely disabled patients, when the robot is to be used in a patient\u27s home or when the patient experiences involuntary movements. These challenges have provided the motivation for this research. Research Statement: In this project, a novel haptics-enabled telerobotic rehabilitation framework is designed, analyzed and implemented that can be used as a new paradigm for delivering motor therapy which gives therapists direct kinesthetic supervision over the robotic rehabilitation procedure. The system also allows for kinesthetic remote and ultimately in-home rehabilitation. To guarantee interaction safety while maximizing the performance of the system, a new framework for designing stabilizing controllers is developed initially based on small-gain theory and then completed using strong passivity theory. The proposed control framework takes into account knowledge about the variable biomechanical capabilities of the patient\u27s limb(s) in absorbing interaction forces and mechanical energy. The technique is generalized for use for classical rehabilitation robotic systems to realize patient-robot interaction safety while enhancing performance. In the next step, the proposed telerobotic system is studied as a modality of training for classical HIRN systems. The goal is to first model and then regenerate the prescribed kinesthetic supervision of an expert therapist. To broaden the population of patients who can use the technology and HIRN systems, a new control strategy is designed for patients experiencing involuntary movements. As the last step, the outcomes of the proposed theoretical and technological developments are translated to designing assistive mechatronic tools for patients with force and motion control deficits. This study shows that proper augmentation of haptic inputs can not only enhance the transparency and safety of robotic and telerobotic rehabilitation systems, but it can also assist patients with force and motion control deficiencies

Clinical Pathways in Stroke Rehabilitation

This open access book focuses on practical clinical problems that are frequently encountered in stroke rehabilitation. Consequences of diseases, e.g. impairments and activity limitations, are addressed in rehabilitation with the overall goal to reduce disability and promote participation. Based on the available best external evidence, clinical pathways are described for stroke rehabilitation bridging the gap between clinical evidence and clinical decision-making. The clinical pathways answer the questions which rehabilitation treatment options are beneficial to overcome specific impairment constellations and activity limitations and are well acceptable to stroke survivors, as well as when and in which settings to provide rehabilitation over the course of recovery post stroke. Each chapter starts with a description of the clinical problem encountered. This is followed by a systematic, but concise review of the evidence (RCTs, systematic reviews and meta-analyses) that is relevant for clinical decision-making, and comments on assessment, therapy (training, technology, medication), and the use of technical aids as appropriate. Based on these summaries, clinical algorithms / pathways are provided and the main clinical-decision situations are portrayed. The book is invaluable for all neurorehabilitation team members, clinicians, nurses, and therapists in neurology, physical medicine and rehabilitation, and related fields. It is a World Federation for NeuroRehabilitation (WFNR) educational initiative, bridging the gap between the rapidly expanding clinical research in stroke rehabilitation and clinical practice across societies and continents. It can be used for both clinical decision-making for individuals and as well as clinical background knowledge for stroke rehabilitation service development initiatives. ; Provides evidence-based clinical practice guidelines for stroke rehabilitation Discusses clinical problems and evidence, comments on assessment, therapy and technical aids Written by experienced experts with a background in clinical practic

Clinical Pathways in Stroke Rehabilitation

This open access book focuses on practical clinical problems that are frequently encountered in stroke rehabilitation. Consequences of diseases, e.g. impairments and activity limitations, are addressed in rehabilitation with the overall goal to reduce disability and promote participation. Based on the available best external evidence, clinical pathways are described for stroke rehabilitation bridging the gap between clinical evidence and clinical decision-making. The clinical pathways answer the questions which rehabilitation treatment options are beneficial to overcome specific impairment constellations and activity limitations and are well acceptable to stroke survivors, as well as when and in which settings to provide rehabilitation over the course of recovery post stroke. Each chapter starts with a description of the clinical problem encountered. This is followed by a systematic, but concise review of the evidence (RCTs, systematic reviews and meta-analyses) that is relevant for clinical decision-making, and comments on assessment, therapy (training, technology, medication), and the use of technical aids as appropriate. Based on these summaries, clinical algorithms / pathways are provided and the main clinical-decision situations are portrayed. The book is invaluable for all neurorehabilitation team members, clinicians, nurses, and therapists in neurology, physical medicine and rehabilitation, and related fields. It is a World Federation for NeuroRehabilitation (WFNR) educational initiative, bridging the gap between the rapidly expanding clinical research in stroke rehabilitation and clinical practice across societies and continents. It can be used for both clinical decision-making for individuals and as well as clinical background knowledge for stroke rehabilitation service development initiatives. ; Provides evidence-based clinical practice guidelines for stroke rehabilitation Discusses clinical problems and evidence, comments on assessment, therapy and technical aids Written by experienced experts with a background in clinical practic

Changes in surface electromyography characteristics and foot-tapping rate of force development as measures of spasticity in patients with multiple sclerosis

Spasticity is a common symptom experienced by individuals with upper motor neuron lesions such as those with stroke, spinal cord injury, traumatic brain injury, cerebral palsy, amyotrophic lateral sclerosis, and multiple sclerosis. Although the etiology and progression of spasticity differs between these clinical populations, it shares many of the same consequences: muscle pain, weakness, fatigue, increased disability, depression, medication side effects, and a reduced quality of life. For this reason, there has been increased interest in the measurement and treatment of spasticity symptoms. Subjective measures of spasticity like the Modified Ashworth Scale (MAS) and Tardieu Scale have shown questionable validity/reliability and poorly correlate to functional outcome measures but continue to be used in clinical and research settings. Objective measures like myotonometry, electrogoniometry, and inertial sensors on the other hand provide much more reliable measures but at the expense of increased costs, time, and equipment. Therefore, to properly assess and treat spasticity symptoms, a timelier and cost-effective objective measure of spasticity is needed. PURPOSE: To reexamine a previously collected dataset from a sample of patients with multiple sclerosis before and after dry-needling and functional electrically stimulated walking spasticity treatments. Specifically, we wished to know whether there were: 1.) Acute (within visit) and chronic (between visit) changes in sEMG and Foot-tapping rate of force development measures after treatment, 2.) Between leg differences before and after treatments, 3.) significant correlations between EMG, foot-tapping, and functional outcome measures. METHODS: 16 MS patients (10 relapsing-remitting and 6 progressive MS) participated in the original study. The study consisted of 14 visits: 2 pre/post visits, 4 visits of dry-needling + functional electrically stimulated walking (FESW), and 8 visits with FESW only. The more spastic leg (involved leg) was given the treatment, making the other the control. Dry-needling was performed on the involved leg’s gastrocnemius medial and lateral heads by inserting monofilament needles and electrically stimming the muscles until visible twitches occurred. Dry-needling was done 30 seconds on and 30 seconds off for a total of 90 seconds of treatment. FESW was performed on the involved leg by attaching electrodes to the tibialis anterior and gastrocnemius muscles. Patients walked 20-minutes at a self-selected pace while the involved leg was stimmed. sEMG was collected before and after each treatment by having the patient perform a single maximal heel raise. Foot-tapping ability was assessed using the 10-second foot-tapping test (FTT) and a small force plate. Functional measures also included the 25-foot walk test (25FWT) 6-minute walk test (6MWT), modified fatigue impact score (MFIS), and number of heel raises performed. RESULTS: No significant between leg differences were noted for any of the sEMG measures (p>0.05). No significant chronic changes occurred in any of the sEMG measures. For the Dry-needling + FESW visits, sEMG sample entropy was significantly increased in the involved leg at post-needling (p = 0.035) and post-FESW (p = 0.027). The non-involved leg’s sample entropy was significantly higher at post-FESW only (p = 0.017). The non-involved leg’s, mean frequency was significantly higher at post-FESW compared pre-needling (p = 0.033) and post-needling (p = 0.032). For the FESW only visits, there were no significant changes in the involved leg. The Non-involved leg’s mean frequency was significantly higher at Post-FESW (p = 0.006). Median frequency was significantly higher at Post-FESW (p = 0.009). The number of foot-taps was significantly increased from Pre to Post-intervention in both the Involved (p = 0.006) and Non-involved legs (p 0.002). There was a significantly higher number of foot-taps in the Non-involved leg compared to the Involved leg at both Pre (p =0.008) and Post (p = 0.015) timepoints. AUC was significantly higher in the Involved leg at Post-treatment (p = 0.030). Time to peak was found to be higher in the Involved leg compared to the Non-involved leg at both Pre (p = 0.037) and Post-intervention (p = 0.019). Time to base was higher in the Involved leg compared to the Non-involved leg at both Pre (p = 0.031) and Post-intervention (p = 0.004). Total tap time was higher in the Involved leg at both Pre (p = 0.010) and Post-intervention (p = 0.007). Percent time to peak was significantly lower in the involved limb at Pre-intervention (p = 0.026) and Post intervention (p = 0.037). Percent time to base was significantly higher in the Involved leg at Pre-intervention (p = 0.026) and Post intervention (p = 0.037). The sEMG measures tended to poorly or non-significantly correlate with the functional outcome measures. The foot-tapping measures, especially the involved leg, tended to exhibit stronger correlations with the functional outcome measures. CONCLUSION: sEMG Sample entropy and foot-tapping ability are significantly improved by dry-needling treatments and walking. sEMG measures did not tend to correlate well with functional outcome measures but the foot-tapping measures did. This suggests that foot-tapping rate and related measures may be a useful measure of spasticity and treatment effects

Efficacy of augmented reality versus conventional physical therapy for the improvement of balance, gait, upper-limb and dual task in people with multiple sclerosis

Introducción: La Esclerosis Múltiple (EM)es un trastorno progresivo multifocal del sistema nervioso central, que a menudo resulta en diversas manifestaciones clínicas. Las personas con Esclerosis Múltiple (pcEM) a menudo sufren diferentes trastornos motores en el equilibrio, la marcha y las extremidades superiores, incluso mientras realizan alguna actividad de la vida diaria, lo que también afecta la doble tarea. La realidad aumentada (RA) se está convirtiendo en una herramienta de entrenamiento popular para la recuperación funcional en fisioterapia. Por tanto, el objetivo era demostrar la eficacia de la RA para el equilibrio, la marcha, los miembros superiores y la tarea dual, como una herramienta más en el amplio abanico de posibilidades de la EF para la EM. Métodos: 30 pcEM fueron igualmente aleatorizados en el grupo de RA o el grupo de terapia convencional (TC). Cada grupo recibió sesiones de entrenamiento de equilibrio, marcha, miembros superiores y tareas duales durante cuatro semanas consecutivas, tres sesiones por semana, sesiones de 45 minutos. Las pruebas clínicas, las medidas de resultado instrumentadas y los cuestionarios autoinformados se recopilaron al inicio de los programas de intervención y al final. Resultados: el análisis final incluyó a 23 pacientes (12F, 11M; edad media, (S.D.) = 49,83 (10,82) años; media EDSS (S.D.) = 4,64 (1,15)). ANOVA reveló cambios estadísticamente significativos en el tiempo pero no en el tiempo por interacción de grupo. Ambos grupos mostraron un efecto principal del tiempo en 36, y solo RA en 7 de las 48 variables consideradas para miembros superiores, equilibrio, marcha y tarea dual. No se observaron diferencias estadísticamente significativas a favor del RA Conclusiones: Se demuestra que el entrenamiento de miembros superiores, equilibrio, marcha y tareas duales basado en RA es un método eficaz como terapia convencional para la EM.Introduction: Multiple Sclerosis is a multifocal progressive disorder of the central nervous system, often resulting in diverse clinical manifestations. People with Multiple Sclerosis (pwMS) often suffer from different motor disturbances in balance, gait, and the upper limbs, including while they are performing some daily life activity, which also affects dual tasking. Augmented reality (AR) is becoming a popular training tool for functional recovery in physical therapy (PT). Therefore, the aim was to demonstrate the efficacy of AR for balance, gait, the upper limbs and dual task, as one more tool in the wide range of possibilities in PT for pwMS. Methods: 30 pwMS were equally randomized into the augmented reality group (ARG) or the conventional therapy group (CTG). Each group received balance, gait, upper-limb and dual task training sessions for four consecutive weeks, three sessions per week, 45-minute sessions. Clinical tests, instrumented outcome measures, and self-reported questionnaires were collected upon initiation of the intervention programs and at the end. Outcomes: Final analysis included 23 patients (12F,11M; mean age, (S.D.) = 49.83(10.82) years; mean EDSS (S.D.) = 4.64 (1.15)). ANOVA revealed statistically significant changes in time but not in the time per group interaction. Both groups showed a main effect of time in 36, and only ARG in 7 out of 48 variables considered for the upper limbs, balance, gait and dual task. No statistically significant differences in favor of the ARG were observed Conclusions: It is demonstrated that upper-limb, balance, gait and dual task training based on AR is an effective method as conventional therapy for pwMS

The role of sound in robot-assisted hand function training post-stroke

In Folge eines Schlaganfalls leiden 90% aller Patienten an einer Handparese, die sich in 30-40% als chronisch manifestiert. Derzeit wächst seitens der Neurologie und Technologie das Forschungsinteresse an der Effektivität robotergestützter Therapieansätze, welche für schwer betroffene Patienten als besonders vielversprechend eingestuft werden. Die hierfür verwendeten Therapieroboter setzen sich aus einem mechanischen Teil und einer softwaregestützten virtuellen Umgebung zusammen, welche neben dem graphischen Interface, audio-visuelles Feedback sowie Musik beinhaltet. Bisher wurden Effekte der klanglichen Anteile dieses Szenarios noch nicht hinsichtlich möglicher Einflüsse auf Motivation, Bewegungsdurchführung, motorisches Lernen und den gesamten Rehabilitationsprozess untersucht. Die vorliegende Arbeit untersucht die Rolle von Sound in robotergestütztem Handfunktionstraining. Die Hauptziele im Rahmen dessen sind es, 1) Potentiale von Sound/ Musik für den Kontext robotergestützten Handfunktionstrainings zu explorieren, 2) spezifizierte klangliche Umgebungen zu entwickeln, 3) zu untersuchen, ob Schlaganfallpatienten von diesen spezifizierten Soundanwendungen profitieren, 4) ein besseres Verständnis über Wirkmechanismen von Sound und Musik mit Potential für robotergestützte Therapie darzulegen, und 5) Folgetechnologien über eine effektive Applikation von Sound/ Musik in robotergestützter Therapie zu informieren.90% of all stroke survivors suffer from a hand paresis which remains chronic in 30-40% of all cases. Currently, there is an increasing research interest in neurology and technology on the effectiveness of robot-assisted therapies. Robotic training is considered as especially promising for patients suffering from severe limitations. Commonly, rehabilitation robots consist of a mechanical part and a virtual training environment with a graphical user interface, audio-visual feedback, sound, and music. So far, the effects of sound and music that are embedded within these scenarios have never been evaluated in particular while taking into account that it might influence motivation, motor execution, motor learning and the whole recovery process. This thesis investigates the role of sound in robot-assisted hand function training post-stroke. The main goals of this work are 1) to explore potentials of sound/ music for robotic hand function training post-stroke, 2) to develop specified sound-/ music-applications for this context, 3) to examine whether stroke patients benefit from these specified sound/ music-application, 4) to gain a better understanding of sound-/ music-induced mechanisms with therapeutic potentials for robotic therapy, and 5) to inform further arising treatment approaches about effective applications of sound or music in robotic post-stroke motor training

Elements: clinical design and evaluation of a virtual reality augmented workspace for upper-limb rehabilitation of traumatic brain injury

Traumatic Brain Injury (TBI) refers to cerebral damage caused by external physical force, and results in a range of cognitive, and physical impairments. Accordingly, developing new technologies to further TBI rehabilitation is a central focus of research. One technology that offers significant advantages is Virtual Reality (VR). This thesis describes the design and initial testing of an upper-limb VR-rehabilitation program for TBI (called Elements). The aims with the Elements system were to create virtual workspaces that were theoretically sound, challenging, and engaging, yet could be tailored to participants’ individual needs. The system has both rehabilitation and assessment functions. The rehabilitation package consists of two sets of virtual environments (VEs) viewed on a 1020 mm (44 in.) horizontal LCD monitor. The four goal-based VEs utilise a stimulus-response format, where participants move real objects to cued locations on the screen. The difficulty of these VEs is scaled to place greater requirements on motor planning by varying task constraints (e.g. randomising the presentation order of movement cues). Additional visual and auditory movement feedback is provided in these VEs to facilitate functional movement. In contrast, the three exploratory VEs have no clear ‘goal’. Here participants freely (even creatively) interact with these VEs, which encourages them to devise and execute their own motor plans. For assessment the system automatically tracks movement accuracy, speed, and efficiency during the goal-based VEs. Feedback plots from this data are used to provide participants with knowledge of their results. Participants underwent 12 one-hour sessions of VR-rehabilitation over 4 weeks. Two empirical trials were conducted to assess the system. Study 1 was a multiple case-study (with 3 participants), and applied an ABA design. Participants were assessed on the system-measured variables and tests of unimanual, and bimanual function over baseline and treatment phases. Participants improved on movement accuracy, efficiency and unimanual function over the treatment period. These improvements were largely maintained in the second baseline phase. Mixed improvement was seen on speed and bimanual coordination. Accordingly, based on these generally positive results, a further larger sample trial was conducted. Study 2 was a within-groups investigation. Our 9 participants’ upper-limb and neurobehavioural function were measured before and after one month of normal therapies alone, and following one month of normal and VR-rehabilitation. Participants demonstrated no significant improvements over the normal rehabilitation period (except for the speed variable). Statistically significant improvements in movement accuracy, speed, efficiency, general upper-limb, and neurobehavioural function (especially memory/attention) followed VR-training. Finally, a discussion on these findings and their implication for the VR-rehabilitation field, and the application of the ITE model in system design is presented. Possible areas for future research (e.g. inclusion of other patient groups, use of brain imaging technology) are also outlined. It was concluded that the results of these trials provide good initial support for the Elements system, and justify further larger sample studies. These are the necessary next steps in trialling the system, and supporting VR’s application in TBI rehabilitation