Interactive cueing with walk-Mate for Hemiparetic Stroke Rehabilitation

Background: Many techniques that compensate for locomotion problems in daily life using externally controlled stimulation have recently been reported. These techniques are beneficial for effortlessly supporting patients' locomotive functions, but the users of such devices must necessarily remain dependent on them. It is possible that some individuals with gait impairment may be prevented recovering locomotive function. From a rehabilitation viewpoint, it may therefore be supposed that ideally, devices that can be used in daily life to improve the locomotive functions of the body itself should be proposed. Methods: We evaluate the effectiveness of Walk-Mate, which has been used mainly as a gait compensation device, as a gait rehabilitation training device by analyzing improvement in locomotion before, during and after rehabilitation in hemiparetic patients and comparing it with a previous gait training method. Walk-Mate generates a model walking rhythm in response to a user's locomotion in real time, and by indicating this rhythm using auditory stimuli, provides a technology that supports walking by reducing asymmetries and fluctuations in foot contact rhythm. If patients can use the system to learn a regulated walking rhythm, then it may also be expected to fulfil the functions of a gait rehabilitation training device for daily life. Results: With regard to asymmetry, significantly improvements were seen for compensatory movement during training using Walk-Mate, but improvements were not retained as rehabilitative results. Regarding fluctuations in the foot contact period, significant improvement was observed for compensatory movement during training and these significant improvements were retained as rehabilitative results. In addition, it became clear that such improvement could not be adequately obtained by the previously proposed training technique utilizing constant rhythmic auditory stimulation. Conclusions: Walk-Mate effectively compensated for locomotion problems of hemiparetic patients by improving gait rhythm both during and after training, suggesting that locomotive function can be effectively recovered in some patients. The interactive mechanism of Walk-Mate may be capable of simultaneously achieving the aims of gait compensation and gait rehabilitation training methods previously developed under individual frameworks. Walk-Mate is a promising technology for assisting the reintegration of disabled persons into society

A Review on the Relationship Between Sound and Movement in Sports and Rehabilitation

The role of auditory information on perceptual-motor processes has gained increased interest in sports and psychology research in recent years. Numerous neurobiological and behavioral studies have demonstrated the close interaction between auditory and motor areas of the brain, and the importance of auditory information for movement execution, control, and learning. In applied research, artificially produced acoustic information and real-time auditory information have been implemented in sports and rehabilitation to improve motor performance in athletes, healthy individuals, and patients affected by neurological or movement disorders. However, this research is scattered both across time and scientific disciplines. The aim of this paper is to provide an overview about the interaction between movement and sound and review the current literature regarding the effect of natural movement sounds, movement sonification, and rhythmic auditory information in sports and motor rehabilitation. The focus here is threefold: firstly, we provide an overview of empirical studies using natural movement sounds and movement sonification in sports. Secondly, we review recent clinical and applied studies using rhythmic auditory information and sonification in rehabilitation, addressing in particular studies on Parkinson’s disease and stroke. Thirdly, we summarize current evidence regarding the cognitive mechanisms and neural correlates underlying the processing of auditory information during movement execution and its mental representation. The current state of knowledge here reviewed provides evidence of the feasibility and effectiveness of the application of auditory information to improve movement execution, control, and (re)learning in sports and motor rehabilitation. Findings also corroborate the critical role of auditory information in auditory-motor coupling during motor (re)learning and performance, suggesting that this area of clinical and applied research has a large potential that is yet to be fully explored

The Effectiveness, Economic Cost and Adoption of Robotic Rehabilitation for Mobility and Functional Ability in Adult Stroke Patients

Robotic rehabilitation devices have been developed to assist therapists to rehabilitate stroke patients based on intensive, high repetitions of task specific exercises to train the impaired limbs of patients. In contrast, conventional therapy is labour intensive and places physical strain on therapists when sustaining intense exercises. Hence it is hoped that with robotic assistive devices, better rehabilitation progress can be achieved for patients, together with alleviation of time and physical demands on therapists. However, there are still uncertainties regarding the use of robotic devices. Studies on the clinical effectiveness of robotic devices have presented a mixed picture. Robotic devices are high capital cost items and its economic cost effectiveness is unclear. The adoption of robotic devices into clinical settings is also an area lacking clarity, as these devices do not work alone but are part of a wider spectrum of clinical care that involves clinicians, patients, hospital administrators and device manufacturers. Inadequate, or incomplete interconnection across these domains of clinical care could affect adoption into clinical settings. Given these uncertainties, the aim of this thesis was to examine and investigate the clinical effectiveness, economic cost, and clinical adoption of robotic rehabilitation. The specific research questions were: Can robotic devices help adult stroke patients to regain motor movement of their upper and lower limbs? Can robotic devices rehabilitate adult stroke patients cost economically? What are the clinical views and experiences of utilizing robotic rehabilitation? What are the factors to consider when introducing robotic devices into the clinical care environment? How can findings from the effectiveness, economic cost and adoption studies be aggregated to create a conceptual framework of providing robotic rehabilitation? To determine the effectiveness and cost effectiveness of robotic rehabilitation, two systematic reviews were conducted according to the JBI review methodology. To seek insights regarding its clinical adoption, qualitative descriptive interviews were conducted with therapists to understand their experiences working with robotic devices. The findings of our research show that robotic rehabilitation is not only clinically effective but also economically cost effective, and especially for severely impaired lower limb patients robotic therapy provides better outcomes. The adoption study, which bridges the gap between the effectiveness and economic evidence from systematic reviews and translation into clinical practice, has uncovered a multitude of factors that need to be taken into consideration when introducing robotic rehabilitation into practice. These factors involve not just simply user training for these devices, but also aspects such as workflow processes, interfacing systems, communication strategies to influence adoption, perceived benefits, and attitudes and motivations of users. From the understandings gained from these various streams of research, a conceptual framework on implementing robotic rehabilitation was developed in order to facilitate translation of the research evidence into practice. This thesis contributes new evidence on effectiveness, cost-effectiveness and clinical integration to the global knowledge base about the use of robotic rehabilitation, and ultimately will lead to stroke patients benefiting from robotic rehabilitation and gaining better health outcomes.Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 201

Interactive Rhythmic Auditory Stimulation Reinstates Natural 1/f Timing in Gait of Parkinson's Patients

Parkinson's disease (PD) and basal ganglia dysfunction impair movement timing, which leads to gait instability and falls. Parkinsonian gait consists of random, disconnected stride times—rather than the 1/f structure observed in healthy gait—and this randomness of stride times (low fractal scaling) predicts falling. Walking with fixed-tempo Rhythmic Auditory Stimulation (RAS) can improve many aspects of gait timing; however, it lowers fractal scaling (away from healthy 1/f structure) and requires attention. Here we show that interactive rhythmic auditory stimulation reestablishes healthy gait dynamics in PD patients. In the experiment, PD patients and healthy participants walked with a) no auditory stimulation, b) fixed-tempo RAS, and c) interactive rhythmic auditory stimulation. The interactive system used foot sensors and nonlinear oscillators to track and mutually entrain with the human's step timing. Patients consistently synchronized with the interactive system, their fractal scaling returned to levels of healthy participants, and their gait felt more stable to them. Patients and healthy participants rarely synchronized with fixed-tempo RAS, and when they did synchronize their fractal scaling declined from healthy 1/f levels. Five minutes after removing the interactive rhythmic stimulation, the PD patients' gait retained high fractal scaling, suggesting that the interaction stabilized the internal rhythm generating system and reintegrated timing networks. The experiment demonstrates that complex interaction is important in the (re)emergence of 1/f structure in human behavior and that interactive rhythmic auditory stimulation is a promising therapeutic tool for improving gait of PD patients

Building Better Exoskeletons: Understanding How Design Affects Robot Assisted Gait Training

Physical therapy is a field with ever increasing demands as the population ages, resulting in a larger number of individuals living with impairments. Therapy is both physically intensive and time intensive for physical therapists, and can require more than one therapist per patient. The use of technology can reduce both these physical and time demands if appropriately applied, while improving repeatability and providing quantitative evaluation of performance. Through these abilities, it may also improve the quality of life for patients. The work presented here explores how the mechanical and controller design of exoskeletons can be used to improve adaptations to new gait patterns in healthy individuals. Armed with this knowledge, new treatment methods can be adapted, applied, and validated for impaired populations with the intention of recovering a more natural gait pattern. First, the ALEX II device is presented. It is a unilateral device, designed to aid in gait training for stroke survivors. The previous version, ALEX I, had several limitations in terms of pelvic freedom, leg range of motion, and the support of the gravitational load. ALEX II was designed to address these issues. Next, a study is presented, using healthy young adults (N=30), in which ALEX II was used to explore how the amount of freedom allowed at the pelvis during gait training affects the level of adaptation subjects are able to achieve. This was evaluated for five separate configurations which resemble existing exoskeletons. It was found that intermediate levels of pelvic freedom degrade the amount of adaptation and that pelvic translation contributes more to this effect than hip abduction/adduction. The next work concerns the design of ALEX III, a bilateral device with twelve active degrees-of-freedom. ALEX III was created to increase the ability to explore the functionality required for gait training, which is why it is capable of controlling 4 degrees-of-freedom at each leg, and 4 degrees-of-freedom at the pelvis. This is followed by the the design of a new type of haptic feedback which utilizes a variable, viscous damping field, which increases the damping coeffiecent as the subject moves away from a specified path. This feedback type was tested in a set of experiments in healthy young adults. The first study (N=32) compared four different settings for the new feedback, finding that while all groups demonstrated adaptations in gait, the lowest rate of change of the damping field exhibited less adaptation. The final study (N=36) compared this haptic feedback to two previously used haptic feedback types. The previously used feedback strategies used a force that pushed the leg either towards or away from the desired path. All three of these strategies were found to produce similar levels of adaptation, however the damping field used much less external force. These findings may change the way exoskeletons for gait training are designed and increase their accessibility. While all the findings need to be validated in impaired populations they can still inform the design of future exoskeletons. The first finding, that providing an intermediate amount of freedom to the pelvis can interfere with gait training, suggests that future devices should have very high amounts of freedom or very restricted pelvic motions. The final finding, that damping fields can be used to induce gait adaptations using a much lower force, can drastically change exoskeleton design and how robotic therapy is provided. Exoskeletons can be made lighter as a result of the force being highly reduced so that lighter weight components can be used, and the dissipative nature of the force reduces dependence on heavy power sources because regenerative breaking can be used to power the device. These factors also make it possible to for devices to be used overground, which may make training more transferable to the real world

An ankle robot for a modular gait rehabilitation system

Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Mechanical Engineering, 2004.Includes bibliographical references (p. 111-112).Patients with neurological disorders, such as stroke survivors, can be treated with physical rehabilitation to regain motor control and function. Conventional therapy techniques are labor intensive and non-standardized. This is especially true in gait rehabilitation. The robotic therapy paradigm developed in the Newman Lab for Hu- man Rehabilitation uses low impedance robots, such as the MIT-MANUS, to provide assistive therapy in a repeatable and measurable fashion. A system is now being designed to assist gait rehabilitation using a series of lower extremity and pelvis robots that can be used together or independently. The focus of this document is ankle rehabilitation. Ankle function is typically not targeted in conventional or other robotic therapy systems. The result is often that the patient is required to wear a brace or orthosis after therapy. The proposed module allows all normal ankle movements and is capable of driving the two most important movements in gait, dorsi/plantar flexion and inversion/eversion. It is designed to provide sufficient force to position the foot in swing phase while still being as lightweight and backdriveable as possible. The kinematics consist of two parallel two-link mechanisms. The robot is driven by two DC brushless motors with planetary gearheads to amplify the torque output.by Jason W. Wheeler.S.M

A robot for gait rehabilitation

Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Mechanical Engineering, 2004.Includes bibliographical references (p. 216-220).After a stroke, persons suffer from neurological impairments that affect gait, and so require rehabilitation to regain ambulatory function. While 82% of patients recover the ability to walk, current methods including physiotherapy and partial body-weight supported treadmill training (PBWSTT) are monotonous and require intense therapist effort. The Mechanized Gait Trainer and the LOKOMAT are two robotic devices that have been developed to improve gait rehabilitation, but neither provides the facilitation of pelvis movements afforded by traditional methods. In addition, neither device is truly backdrivable. As shown by Hogan and Krebs, backdrivable, impedance-controlled robots are ideal for rehabilitation because of their stable interaction properties. Robots for the arm/shoulder, wrist, ankle, and hand have already been developed. This thesis describes the design of a robot for gait rehabilitation through the facilitation of pelvis movements. Four degrees of freedom (DOF) are actuated: vertical, lateral, and frontal translations as well as the rotation about the vertical axis. Vertical forces support part of the patient's weight. Lateral forces assist the weight shift from stance leg to swing leg and are a part of physiotherapy and treadmill training.(cont.) Frontal forces help pace the subject as on a treadmill. Pelvic rotations can impart energy into the swing leg without direct actuation of the hip and knee muscles. A four DOF mechanism was designed to control these movements, consisting of a three-DOF planar linkage with a vertical prismatic translation. A mockup of the configuration was designed and tested to show that the non-actuated pelvis DOFs are not adversely affected by the device. Design calculations include finding the optimal linkage configuration, selecting ballspline shafts for the vertical DOF, selecting actuators, and designing the robot arm cross-sections and joints. A final design for the four-DOF module is presented.by Michael H. Roberts.S.M

ARCTiC LawE: armed robotic control for training in civilian law enforcement

Much of this thesis looked at performing a cogent literature review of exoskeletons to determine the state-of-the-art and to determine the remaining needs in exoskeletal design. The literature review of over 80 journals, allowed the researcher to determine the lack of research in upper body exoskeletons for training in civilian, military, and law enforcement personnel. Thus the genesis of the Armed Robotic Control for Training in Civilian Law Enforcement, or ARCTiC LawE, an upper body exoskeleton designed to assist civilian, military, and law enforcement personnel in accurate, precise, and reliable handgun techniques. This exoskeleton training utilizes a laser based handgun with similar dimensions, trigger pull, and break action to a Glock ® 19 pistol, common to both public and private security sectors. The project aims to train and test subjects with no handgun training/experience with the ARCTiC LawE, and without, and compare the results of accuracy, precision, and speed. Ultimately, the exoskeleton greatly impacts sensory motor learning and the biomechanical implications are confirmed via both performance and physiological measurements. The researchers believe the ARCTiC LawE to be a viable substitute for training with live fire hand guns to reduce the cost of training time and munitions and will increase accuracy and precisions for typical law enforcement and military live fire drills. Additionally, this project increases the breadth of knowledge for exoskeletons as a tool for training

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

Background: Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses. Methods: A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit. Results: Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality–based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality–based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight–supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. Discussion: The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy. Limitations: As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance. Summary: The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury. Disclaimer: These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance