Effects of Cueing on Sit to Stand Transfers in Parkinson Disease

Problem Statement: Individuals with Parkinson Disease (PD) often experience difficulty transferring from sit to stand (STS). Current evidence suggests cues which promote an external attentional focus improve gait and transfers for individuals with PD. However, this research utilizes cues which are difficult to replicate in clinical or natural environments making the findings difficult to generalize or implement. Purpose: The primary purpose of this study is to determine the effect of 3 different explicit cues on STS for individuals with PD. Additionally we sought to determine if, in this population, a relationship exists between latency of movement initiation and postural sway in early standing, changes in joint angle between conditions and postural sway in early standing, and cue provided during the transfer and postural sway in early standing. Procedures/Methodology: Thirteen individuals in both the experimental and control groups participated in this cross-over design study. Both groups completed trials of self-initiated uncued STS transfers. Those in the experimental group also completed trials of STS transfers in 3 conditions: with an external attentional focus of reaching to targets, with an external attentional focus of concurrent modeling, and with an explicit cue for an internal attentional focus. Data was collected by trained testers and utilized valid and reliable body worn inertial measurement unit sensors. ANOVAs were used to compare performance between conditions and to the performance of the healthy control group. Bonferroni corrections were completed to reduce the likelihood of accepting a false positive. Results: Both cues that elicit an external attentional focus improved motor control during the sit to stand transfer. However, only modeling was able to improve both motor control and postural control. Cueing that promoted an internal attentional focus resulted in decreased motor control and postural control. Additionally, a moderate positive correlation was found between standing taller than typical and postural sway. Clinical Implications: Our results provide evidence for clinicians to better tailor treatment methodologies to the needs of individuals with PD. Optimal cueing can be utilized as compensations that reduce caregiver burden and increase independence of individuals with PD

Development and evaluation of a haptic framework supporting telerehabilitation robotics and group interaction

Telerehabilitation robotics has grown remarkably in the past few years. It can provide intensive training to people with special needs remotely while facilitating therapists to observe the whole process. Telerehabilitation robotics is a promising solution supporting routine care which can help to transform face-to-face and one-on-one treatment sessions that require not only intensive human resource but are also restricted to some specialised care centres to treatments that are technology-based (less human involvement) and easy to access remotely from anywhere. However, there are some limitations such as network latency, jitter, and delay of the internet that can affect negatively user experience and quality of the treatment session. Moreover, the lack of social interaction since all treatments are performed over the internet can reduce motivation of the patients. As a result, these limitations are making it very difficult to deliver an efficient recovery plan. This thesis developed and evaluated a new framework designed to facilitate telerehabilitation robotics. The framework integrates multiple cutting-edge technologies to generate playful activities that involve group interaction with binaural audio, visual, and haptic feedback with robot interaction in a variety of environments. The research questions asked were: 1) Can activity mediated by technology motivate and influence the behaviour of users, so that they engage in the activity and sustain a good level of motivation? 2) Will working as a group enhance users’ motivation and interaction? 3) Can we transfer real life activity involving group interaction to virtual domain and deliver it reliably via the internet? There were three goals in this work: first was to compare people’s behaviours and motivations while doing the task in a group and on their own; second was to determine whether group interaction in virtual and reala environments was different from each other in terms of performance, engagement and strategy to complete the task; finally was to test out the effectiveness of the framework based on the benchmarks generated from socially assistive robotics literature. Three studies have been conducted to achieve the first goal, two with healthy participants and one with seven autistic children. The first study observed how people react in a challenging group task while the other two studies compared group and individual interactions. The results obtained from these studies showed that the group interactions were more enjoyable than individual interactions and most likely had more positive effects in terms of user behaviours. This suggests that the group interaction approach has the potential to motivate individuals to make more movements and be more active and could be applied in the future for more serious therapy. Another study has been conducted to measure group interaction’s performance in virtual and real environments and pointed out which aspect influences users’ strategy for dealing with the task. The results from this study helped to form a better understanding to predict a user’s behaviour in a collaborative task. A simulation has been run to compare the results generated from the predictor and the real data. It has shown that, with an appropriate training method, the predictor can perform very well. This thesis has demonstrated the feasibility of group interaction via the internet using robotic technology which could be beneficial for people who require social interaction (e.g. stroke patients and autistic children) in their treatments without regular visits to the clinical centres

The lower extremity kinematics and kinetics of stationary cycling in young children with and without cerebral palsy

Children with cerebral palsy (CP) are at risk of secondary changes, such as bone deformation. Physical activity is important to reduce these changes and to improve physical function, especially when children are young. Cycling is a great locomotor skill for this because it can be used in therapeutic and in recreational settings. Standardization of cycling protocols is needed to give therapists a better understanding how maximum improvements can be obtained. For this, we have to understand the biomechanics of cycling in young children with CP. We have investigated the kinematics and kinetics of cycling in young children with and without CP, and the influence of changes in task demands on these biomechanics. It was hypothesized that young typically developing (TD) children have altered biomechanics during cycling in comparison to older children and that young children with CP have alterations in comparison to TD peers. Furthermore, it was expected that spasticity reduction by botulinum toxin (BTX) treatment would improve these biomechanics in children with CP. In Study 1, it was shown that 4-year-olds TD children had more out-of-plane motion than 6-, 8- and 10-year olds, while motions in the sagittal plane were similar between groups. Also, 4-year-olds produced higher jerk cost when cycling at high cadences. In Study 2, analysis revealed that children with CP were only able to cycle at low resistance and low cadences and were less adaptable to changes in movement speed. Adjustments in joint angles, joint torques, jerk cost and pedal forces in all three planes of motion were observed, indicating that children with CP cycled less efficiently than TD peers. In Study 3, it was shown that CP-specific alterations in cycling biomechanics were reduced 3 weeks after BTX injections. This work has increased our understanding of the cycling ability of young children. It led to the conclusion that children with CP can cycle under reduced task demands in comparison to TD peers. When spasticity is reduced, the adaptability of children with CP against changes in task demands is increased. The findings of these studies help us understanding the influences of cycling in children with CP.Kinesiology and Health Educatio

Swayed by sound: sonic guidance as a neurorehabilitation strategy in the cerebellar ataxias

Cerebellar disease leads to problems in controlling movement. The most common difficulties are dysmetria and instability when standing. Recent understanding of cerebellar function has expanded to include non -motor aspects such as emotional, cognitive and sensory processing. Deficits in the acquisition and processing of sensory information are one explanation for the movement problems observed in cerebellar ataxia. Sensory deficits result in an inability to make predictions about future events; a primary function of the cerebellum. A question therefore, is whether augmenting or replacing sensory information can improve motor performance in cerebellar disease. This question is tested in this thesis by augmenting sensory information through the provision of an auditory movement guide.A variable described in motor control theory (tau) was used to develop auditory guides that were continuous and dynamic. A reaching experiment using healthy individuals showed that the timing of peak velocity, audiomotor coordination accuracy, and velocity of approach, could be altered in line with the movement parameters embedded in the auditory guides. The thesis then investigated the use of these sonic guides in a clinical population with cerebellar disease. Performance on neurorehabilitation exercises for balance control was tested in twenty people with cerebellar atrophy, with and without auditory guides. Results suggested that continuous, predictive, dynamic auditory guidance is an effective way of improving iii movement smoothness in ataxia (as measured by jerk). In addition, generating and swaying with imaginary auditory guides was also found to increase movement smoothness in cerebellar disease.Following the tests of instantaneous effects, the thesis then investigated the longterm consequences on motor behaviour of following a two -month exercise with auditory guide programme. Seven people with cerebellar atrophy were assessed pre - and post -intervention using two measures, weight -shifting and walking. The results of the weight -shifting test indicated that the sonic -guide exercise programme does not initiate long -term changes in motor behaviour. Whilst there were minor, improvements in walking, because of the weight -shifting results, these could not be attributed to the sonic guides. This finding confirms the difficulties of motor rehabilitation in people with cerebellar disease.This thesis contributes original findings to the field of neurorehabilitation by first showing that on -going and predictive stimuli are an appropriate tool for improving motor behaviour. In addition, the thesis is the first of its kind to apply externally presented guides that convey continuous meaningful information within a clinical population. Finally, findings show that sensory augmentation using the auditory domain is an effective way of improving motor coordination in some forms of cerebellar disease

Stability of Mina v2 for Robot-Assisted Balance and Locomotion

The assessment of the risk of falling during robot-assisted locomotion is critical for gait control and operator safety, but has not yet been addressed through a systematic and quantitative approach. In this study, the balance stability of Mina v2, a recently developed powered lower-limb robotic exoskeleton, is evaluated using an algorithmic framework based on center of mass (COM)- and joint-space dynamics. The equivalent mechanical model of the combined human-exoskeleton system in the sagittal plane is established and used for balance stability analysis. The properties of the Linear Linkage Actuator, which is custom-designed for Mina v2, are analyzed to obtain mathematical models of torque-velocity limits, and are implemented as constraint functions in the optimization formulation. For given feet configurations of the robotic exoskeleton during flat ground walking, the algorithm evaluates the maximum allowable COM velocity perturbations along the fore-aft directions at each COM position of the system. The resulting velocity extrema form the contact-specific balance stability boundaries (BSBs) of the combined system in the COM state space, which represent the thresholds between balanced and unbalanced states for given contact configurations. The BSBs are obtained for the operation of Mina v2 without crutches, thus quantifying Mina v2's capability of maintaining balance through the support of the leg(s). Stability boundaries in single and double leg supports are used to analyze the robot's stability performance during flat ground walking experiments, and provide design and control implications for future development of crutch-less robotic exoskeletons

Emergent coordination between humans and robots

Emergent coordination or movement synchronization is an often observed phenomenon in human behavior. Humans synchronize their gait when walking next to each other, they synchronize their postural sway when standing closely, and they also synchronize their movement behavior in many other situations of daily life. Why humans are doing this is an important question of ongoing research in many disciplines: apparently movement synchronization plays a role in children’s development and learning; it is related to our social and emotional behavior in interaction with others; it is an underlying principle in the organization of communication by means of language and gesture; and finally, models explaining movement synchronization between two individuals can also be extended to group behavior. Overall, one can say that movement synchronization is an important principle of human interaction behavior. Besides interacting with other humans, in recent years humans do more and more interact with technology. This was first expressed in the interaction with machines in industrial settings, was taken further to human-computer interaction and is now facing a new challenge: the interaction with active and autonomous machines, the interaction with robots. If the vision of today’s robot developers comes true, in the near future robots will be fully integrated not only in our workplace, but also in our private lives. They are supposed to support humans in activities of daily living and even care for them. These circumstances however require the development of interactional principles which the robot can apply to the direct interaction with humans. In this dissertation the problem of robots entering the human society will be outlined and the need for the exploration of human interaction principles that are transferable to human-robot interaction will be emphasized. Furthermore, an overview on human movement synchronization as a very important phenomenon in human interaction will be given, ranging from neural correlates to social behavior. The argument of this dissertation is that human movement synchronization is a simple but striking human interaction principle that can be applied in human-robot interaction to support human activity of daily living, demonstrated on the example of pick-and-place tasks. This argument is based on five publications. In the first publication, human movement synchronization is explored in goal-directed tasks which bare similar requirements as pick-and-place tasks in activities of daily living. In order to explore if a merely repetitive action of the robot is sufficient to encourage human movement synchronization, the second publication reports a human-robot interaction study in which a human interacts with a non-adaptive robot. Here however, movement synchronization between human and robot does not emerge, which underlines the need for adaptive mechanisms. Therefore, in the third publication, human adaptive behavior in goal-directed movement synchronization is explored. In order to make the findings from the previous studies applicable to human-robot interaction, in the fourth publication the development of an interaction model based on dynamical systems theory is outlined which is ready for implementation on a robotic platform. Following this, a brief overview on a first human-robot interaction study based on the developed interaction model is provided. The last publication describes an extension of the previous approach which also includes the human tendency to make use of events to adapt their movements to. Here, also a first human-robot interaction study is reported which confirms the applicability of the model. The dissertation concludes with a discussion on the presented findings in the light of human-robot interaction and psychological aspects of joint action research as well as the problem of mutual adaptation.Spontan auftretende Koordination oder Bewegungssynchronisierung ist ein häufig zu beobachtendes Phänomen im Verhalten von Menschen. Menschen synchronisieren ihre Schritte beim nebeneinander hergehen, sie synchronisieren die Schwingbewegung zum Ausgleich der Körperbalance wenn sie nahe beieinander stehen und sie synchronisieren ihr Bewegungsverhalten generell in vielen weiteren Handlungen des täglichen Lebens. Die Frage nach dem warum ist eine Frage mit der sich die Forschung in der Psychologie, Neuro- und Bewegungswissenschaft aber auch in der Sozialwissenschaft nach wie vor beschäftigt: offenbar spielt die Bewegungssynchronisierung eine Rolle in der kindlichen Entwicklung und beim Erlernen von Fähigkeiten und Verhaltensmustern; sie steht in direktem Bezug zu unserem sozialen Verhalten und unserer emotionalen Wahrnehmung in der Interaktion mit Anderen; sie ist ein grundlegendes Prinzip in der Organisation von Kommunikation durch Sprache oder Gesten; außerdem können Modelle, die Bewegungssynchronisierung zwischen zwei Individuen erklären, auch auf das Verhalten innerhalb von Gruppen ausgedehnt werden. Insgesamt kann man also sagen, dass Bewegungssynchronisierung ein wichtiges Prinzip im menschlichen Interaktionsverhalten darstellt. Neben der Interaktion mit anderen Menschen interagieren wir in den letzten Jahren auch zunehmend mit der uns umgebenden Technik. Hier fand zunächst die Interaktion mit Maschinen im industriellen Umfeld Beachtung, später die Mensch-Computer-Interaktion. Seit kurzem sind wir jedoch mit einer neuen Herausforderung konfrontiert: der Interaktion mit aktiven und autonomen Maschinen, Maschinen die sich bewegen und aktiv mit Menschen interagieren, mit Robotern. Sollte die Vision der heutigen Roboterentwickler Wirklichkeit werde, so werden Roboter in der nahen Zukunft nicht nur voll in unser Arbeitsumfeld integriert sein, sondern auch in unser privates Leben. Roboter sollen den Menschen in ihren täglichen Aktivitäten unterstützen und sich sogar um sie kümmern. Diese Umstände erfordern die Entwicklung von neuen Interaktionsprinzipien, welche Roboter in der direkten Koordination mit dem Menschen anwenden können. In dieser Dissertation wird zunächst das Problem umrissen, welches sich daraus ergibt, dass Roboter zunehmend Einzug in die menschliche Gesellschaft finden. Außerdem wird die Notwendigkeit der Untersuchung menschlicher Interaktionsprinzipien, die auf die Mensch-Roboter-Interaktion transferierbar sind, hervorgehoben. Die Argumentation der Dissertation ist, dass die menschliche Bewegungssynchronisierung ein einfaches aber bemerkenswertes menschliches Interaktionsprinzip ist, welches in der Mensch-Roboter-Interaktion angewendet werden kann um menschliche Aktivitäten des täglichen Lebens, z.B. Aufnahme-und-Ablege-Aufgaben (pick-and-place tasks), zu unterstützen. Diese Argumentation wird auf fünf Publikationen gestützt. In der ersten Publikation wird die menschliche Bewegungssynchronisierung in einer zielgerichteten Aufgabe untersucht, welche die gleichen Anforderungen erfüllt wie die Aufnahme- und Ablageaufgaben des täglichen Lebens. Um zu untersuchen ob eine rein repetitive Bewegung des Roboters ausreichend ist um den Menschen zur Etablierung von Bewegungssynchronisierung zu ermutigen, wird in der zweiten Publikation eine Mensch-Roboter-Interaktionsstudie vorgestellt in welcher ein Mensch mit einem nicht-adaptiven Roboter interagiert. In dieser Studie wird jedoch keine Bewegungssynchronisierung zwischen Mensch und Roboter etabliert, was die Notwendigkeit von adaptiven Mechanismen unterstreicht. Daher wird in der dritten Publikation menschliches Adaptationsverhalten in der Bewegungssynchronisierung in zielgerichteten Aufgaben untersucht. Um die so gefundenen Mechanismen für die Mensch-Roboter Interaktion nutzbar zu machen, wird in der vierten Publikation die Entwicklung eines Interaktionsmodells basierend auf Dynamischer Systemtheorie behandelt. Dieses Modell kann direkt in eine Roboterplattform implementiert werden. Anschließend wird kurz auf eine erste Studie zur Mensch- Roboter Interaktion basierend auf dem entwickelten Modell eingegangen. Die letzte Publikation beschreibt eine Weiterentwicklung des bisherigen Vorgehens welche der Tendenz im menschlichen Verhalten Rechnung trägt, die Bewegungen an Ereignissen auszurichten. Hier wird außerdem eine erste Mensch-Roboter- Interaktionsstudie vorgestellt, die die Anwendbarkeit des Modells bestätigt. Die Dissertation wird mit einer Diskussion der präsentierten Ergebnisse im Kontext der Mensch-Roboter-Interaktion und psychologischer Aspekte der Interaktionsforschung sowie der Problematik von beiderseitiger Adaptivität abgeschlossen

Design and Control of Robotic Systems for Lower Limb Stroke Rehabilitation

Lower extremity stroke rehabilitation exhausts considerable health care resources, is labor intensive, and provides mostly qualitative metrics of patient recovery. To overcome these issues, robots can assist patients in physically manipulating their affected limb and measure the output motion. The robots that have been currently designed, however, provide assistance over a limited set of training motions, are not portable for in-home and in-clinic use, have high cost and may not provide sufficient safety or performance. This thesis proposes the idea of incorporating a mobile drive base into lower extremity rehabilitation robots to create a portable, inherently safe system that provides assistance over a wide range of training motions. A set of rehabilitative motion tasks were established and a six-degree-of-freedom (DOF) motion and force-sensing system was designed to meet high-power, large workspace, and affordability requirements. An admittance controller was implemented, and the feasibility of using this portable, low-cost system for movement assistance was shown through tests on a healthy individual. An improved version of the robot was then developed that added torque sensing and known joint elasticity for use in future clinical testing with a flexible-joint impedance controller

Optimal exoskeleton design and effective human-in-the-loop control frameworks for rehabilitation robotics

Attention, since they decrease the cost of repetitive movement therapies, enable quantitative measurement of the patient progress and promise development of more e ective rehabilitation protocols. The goal of this dissertation is to provide systematic frameworks for optimal design of rehabilitation robots and e ective delivery of therapeutic exercises. The design framework is built upon identification and categorization of the design requirements, and satisfaction of them through several design stages. In particular, type selection is performed to ensure imperative design requirements of safety, ergonomy and wearability, optimal dimensional synthesis is undertaken to maximize global kinematic and dynamic performance defined over the singularity-free workspace volume, while workspace optimization is performed to utilize maximum singularity-free device workspace computed via Grassmann line theory. Then, humanin- the-loop controllers that ensure coupled stability of the human-robot system are implemented in the robot task space using appropriate error metrics. The design framework is demonstrated on a forearm-wrist exoskeleton, since forearm and wrist rotations are critical in performing activities of daily living and recovery of these joints is essential for achieving functional independence of patients. In particular, a non-symmetric 3RPS-R mechanism is selected as the underlying kinematics type and the performance improvements due to workspace and multi-criteria optimizations are experimentally characterized as 27 % larger workspace volume, 32 % higher position control bandwidth and 17 % increase in kinematic isotropy when compared to a similar device in the literature. The exoskeleton is also shown to feature high passive back-driveability and accurate sti ness rendering capability, even under open-loop impedance control. Local controllers to accommodate for each stage of rehabilitation therapies are designed for the forearm-wrist exoskeleton in SO(3): trajectory tracking controllers are designed for early stages of rehabilitation when severely injured patients are kept passive, impedance controllers are designed to render virtual tunnels implementing forbidden regions in the device workspace and allowing for haptic interactions with virtual environments, and passive contour tracking controllers are implemented to allow for rehabilitation exercises that emphasize coordination and synchronization of multi degrees-of-freedom movements, while leaving the exact timing along the desired contour to the patient. These local controllers are incorporated into a multi-lateral shared controller architecture, which allows for patients to train with online virtual dynamic tasks in collaboration with a therapist. Utilizing this control architecture not only enables the shift of control authority of each agent so that therapists can guide or evaluate movements of patients or share the control with them, but also enables the implementation of remote and group therapies, as well as remote assessments. The proposed control framework to deliver e ective robotic therapies can ensure active involvement of patients through online modification of the task parameters, while simultaneously guaranteeing their safety. In particular, utilizing passive velocity field control and extending it with a method for online generation of velocity fields for parametric curves, temporal, spatial and assistive aspects of a desired task can be seamlessly modified online, while ensuring passivity with respect to externally applied forces. Through human subject experiments, this control framework is shown to be e ective in delivering evidence-based rehabilitation therapies, providing assistance as-needed, preventing slacking behavior of patients, and delivering repetitive therapies without exact repetition. Lastly, to guide design of e ective rehabilitation treatment protocols, a set of healthy human subject experiments are conducted in order to identify underlying principles of adaptation mechanism of human motor control system. In these catch-trial based experiments, equivalent transfer functions are utilized during execution of rhythmic dynamic tasks. Statistical evidence suggests that i) force feedback is the dominant factor that guides human adaptation while performing fast rhythmic dynamic tasks rather than the visual feedback and ii) as the e ort required to perform the task increases, the rate of adaptation decreases; indicating a fundamental trade-o between task performance and level of force feedback provided

Moving On:Measuring Movement Remotely after Stroke

Most persons with stroke suffer from motor impairment, which restricts mobility on one side, and affects their independence in daily life activities. Measuring recovery is needed to develop individualized therapies. However, commonly used clinical outcomes suffer from low resolution and subjectivity. Therefore, objective biomechanical metrics should be identified to measure movement quality. However, non-portable laboratory setups are required in order to measure these metrics accurately. Alternatively, minimal wearable systems can be developed to simplify measurements performed at clinic or home to monitor recovery. Thus, the goal of the thesis was ‘To identify metrics that reflect movement quality of upper and lower extremities after stroke and develop wearable minimal systems for tracking the proposed metrics’. Section Upper Extremity First, we systematically reviewed literature ( Chapter II ) to identify metrics used to measure reaching recovery longitudinally post-stroke. Although several metrics were found, it was not clear how they differentiated recovery from compensation strategies. Future studies must address this gap in order to optimize stroke therapy. Next, we assessed a ‘valid’ measure for smoothness of upper paretic limb reaching ( Chapter III ), as this was commonly used to measure movement quality. After a systematic review and simulation analyses, we found that reaching smoothness is best measured using spectral arc length. The studies in this section offer us a better understanding of movement recovery in the upper extremity post-stroke. Section Lower Extremity Although metrics that reflect gait recovery are yet to be identified, in this section we focused on developing minimal solutions to measure gait quality. First, we showed the feasibility of 1D pressure insoles as a lightweight alternative for measuring 3D Ground Reaction Forces (GRF) ( Chapter IV ). In the following chapters, we developed a minimal system; the Portable Gait Lab (PGL) using only three Inertial Measurement Units (IMUs) (one per foot and one on the pelvis). We explored the Centroidal Moment Pivot (CMP) point ( Chapter V ) as a biomechanical constraint that can help with the reduction in sensors. Then, we showed the feasibility of the PGL to track 3D GRF ( Chapters VI-VII ) and relative foot and CoM kinematics ( Chapter VIII-IX ) during variable overground walking by healthy participants. Finally, we performed a limited validation study in persons with chronic stroke ( Chapter X ). This thesis offers knowledge and tools which can help clinicians and researchers understand movement quality and thereby develop individualized therapies post-stroke