Feasibility and Acceptance of a Virtual Reality System for Gait Training of Individuals with Multiple Sclerosis

4"The goals of motor rehabilitation are the improvement of mobility and the achievement of greater independence in everyday life, which requires specific multi-factorial improvements in sensory, motor, and cognitive functions. These can be addressed through multi-sensory interventions delivering stimuli, while engaging the participant in dual task activities, typical of daily living, using customized virtual reality (VR) rehabilitation tools. A prerequisite of a successful VR-based rehabilitation intervention is the patient’s engagement, motivation and satisfaction. In this study, a newly developed VR-based gait training approach for patients affected by multiple sclerosis is described and the technology required for its implementation is evaluated in terms of acceptance and feasibility. The results have shown that the use of this technology was well accepted by the participants, the system was durable and demonstrated high adaptability to patient's motor and cognitive status. This pilot study has demonstrated the usability of such a system for the training of patients with MS and suggests that VR-treadmill training could be useful to improve gait and cognitive function in such a cohort"openopenPeruzzi A; Cereatti A; Mirelman A; Della Croce UPeruzzi, A; Cereatti, A; Mirelman, A; Della Croce,

The State of Behavior Change Techniques in Virtual Reality Rehabilitation of Neurologic Populations

Background: Neurologic rehabilitation aims to restore function, address barriers to activity, and improve quality of life in those with injury to the nervous system. Virtual reality (VR) has emerged as a useful tool to enhance neurorehabilitation interventions and outcomes. However, the manner in which VR-based neurorehabilitation has been manipulated to optimize outcomes using theory-based frameworks has not been documented. Behavior Change Techniques (BCTs) are described as the smallest active ingredient in an intervention aimed to change behavior via theoretically-proposed pathways. The purpose of this review was to investigate the ways VR is being used in neurorehabilitation to improve upright mobility, and systematically code those VR interventions for active BCTs.Methods: Keyword searches were performed using database searches of PubMed, SPORTDiscus, and psycINFO. The search yielded 32 studies for inclusion. Coding for BCTs was conducted using the Behavior Change Techniques Taxonomy v1 (BCTTv1).Results: Behavioral Practice, Graded Tasks, Biofeedback, and Explicit Feedback were the most commonly used BCTs. All studies reported improvements in motor performance outcomes. However, none of the studies investigated the efficacy of each component of their VR intervention making it difficult to point to the most effective components of VR interventions overall.Conclusions: This review suggests that investigation into the specific components of VR interventions, along with purposeful implementation and reporting of BCTs will help improve understanding of the efficacy of VR as a neurorehabilitation tool. Future research could benefit from incorporating BCTs into the design process of VR interventions to produce optimal rehabilitation potential

Mechatronic Systems

Mechatronics, the synergistic blend of mechanics, electronics, and computer science, has evolved over the past twenty five years, leading to a novel stage of engineering design. By integrating the best design practices with the most advanced technologies, mechatronics aims at realizing high-quality products, guaranteeing at the same time a substantial reduction of time and costs of manufacturing. Mechatronic systems are manifold and range from machine components, motion generators, and power producing machines to more complex devices, such as robotic systems and transportation vehicles. With its twenty chapters, which collect contributions from many researchers worldwide, this book provides an excellent survey of recent work in the field of mechatronics with applications in various fields, like robotics, medical and assistive technology, human-machine interaction, unmanned vehicles, manufacturing, and education. We would like to thank all the authors who have invested a great deal of time to write such interesting chapters, which we are sure will be valuable to the readers. Chapters 1 to 6 deal with applications of mechatronics for the development of robotic systems. Medical and assistive technologies and human-machine interaction systems are the topic of chapters 7 to 13.Chapters 14 and 15 concern mechatronic systems for autonomous vehicles. Chapters 16-19 deal with mechatronics in manufacturing contexts. Chapter 20 concludes the book, describing a method for the installation of mechatronics education in schools

Sensory Augmentation for Balance Rehabilitation Using Skin Stretch Feedback

This dissertation focuses on the development and evaluation of portable sensory augmentation systems that render skin-stretch feedback of posture for standing balance training and for postural control improvement. Falling is one of the main causes of fatal injuries among all members of the population. The high incidence of fall-related injuries also leads to high medical expenses, which cost approximately $34 billion annually in the United States. People with neurological diseases, e.g., stroke, multiple sclerosis, spinal cord injuries, and the elderly are more prone to falling when compared to healthy individuals. Falls among these populations can also lead to hip fracture, or even death. Thus, several balance and gait rehabilitation approaches have been developed to reduce the risk of falling. Traditionally, a balance-retraining program includes a series of exercises for trainees to strengthen their sensorimotor and musculoskeletal systems. Recent advances in technology have incorporated biofeedback such as visual, auditory, or haptic feedback to provide the users with extra cues about their postural sway. Studies have also demonstrated the positive effects of biofeedback on balance control. However, current applications of biofeedback for interventions in people with impaired balance are still lacking some important characteristics such as portability (in-home care), small-size, and long-term viability. Inspired by the concept of light touch, a light, small, and wearable sensory augmentation system that detects body sway and supplements skin stretch on one’s fingertip pad was first developed. The addition of a shear tactile display could significantly enhance the sensation to body movement. Preliminary results have shown that the application of passive skin stretch feedback at the fingertip enhanced standing balance of healthy young adults. Based on these findings, two research directions were initiated to investigate i) which dynamical information of postural sway could be more effectively conveyed by skin stretch feedback, and ii) how can such feedback device be easily used in the clinical setting or on a daily basis. The major sections of this research are focused on understanding how the skin stretch feedback affects the standing balance and on quantifying the ability of humans to interpret the cutaneous feedback as the cues of their physiological states. Experimental results from both static and dynamic balancing tasks revealed that healthy subjects were able to respond to the cues and subsequently correct their posture. However, it was observed that the postural sway did not generally improve in healthy subjects due to skin stretch feedback. A possible reason was that healthy subjects already had good enough quality sensory information such that the additional artificial biofeedback may have interfered with other sensory cues. Experiments incorporating simulated sensory deficits were further conducted and it was found that subjects with perturbed sensory systems (e.g., unstable surface) showed improved balance due to skin stretch feedback when compared to the neutral standing conditions. Positive impacts on balance performance have also been demonstrated among multiple sclerosis patients when they receive skin stretch feedback from a sensory augmentation walker. The findings in this research indicated that the skin stretch feedback rendered by the developed devices affected the human balance and can potentially compensate underlying neurological or musculoskeletal disorders, therefore enhancing quiet standing postural control

Sensory Augmentation for Balance Rehabilitation Using Skin Stretch Feedback

This dissertation focuses on the development and evaluation of portable sensory augmentation systems that render skin-stretch feedback of posture for standing balance training and for postural control improvement. Falling is one of the main causes of fatal injuries among all members of the population. The high incidence of fall-related injuries also leads to high medical expenses, which cost approximately $34 billion annually in the United States. People with neurological diseases, e.g., stroke, multiple sclerosis, spinal cord injuries, and the elderly are more prone to falling when compared to healthy individuals. Falls among these populations can also lead to hip fracture, or even death. Thus, several balance and gait rehabilitation approaches have been developed to reduce the risk of falling. Traditionally, a balance-retraining program includes a series of exercises for trainees to strengthen their sensorimotor and musculoskeletal systems. Recent advances in technology have incorporated biofeedback such as visual, auditory, or haptic feedback to provide the users with extra cues about their postural sway. Studies have also demonstrated the positive effects of biofeedback on balance control. However, current applications of biofeedback for interventions in people with impaired balance are still lacking some important characteristics such as portability (in-home care), small-size, and long-term viability. Inspired by the concept of light touch, a light, small, and wearable sensory augmentation system that detects body sway and supplements skin stretch on one’s fingertip pad was first developed. The addition of a shear tactile display could significantly enhance the sensation to body movement. Preliminary results have shown that the application of passive skin stretch feedback at the fingertip enhanced standing balance of healthy young adults. Based on these findings, two research directions were initiated to investigate i) which dynamical information of postural sway could be more effectively conveyed by skin stretch feedback, and ii) how can such feedback device be easily used in the clinical setting or on a daily basis. The major sections of this research are focused on understanding how the skin stretch feedback affects the standing balance and on quantifying the ability of humans to interpret the cutaneous feedback as the cues of their physiological states. Experimental results from both static and dynamic balancing tasks revealed that healthy subjects were able to respond to the cues and subsequently correct their posture. However, it was observed that the postural sway did not generally improve in healthy subjects due to skin stretch feedback. A possible reason was that healthy subjects already had good enough quality sensory information such that the additional artificial biofeedback may have interfered with other sensory cues. Experiments incorporating simulated sensory deficits were further conducted and it was found that subjects with perturbed sensory systems (e.g., unstable surface) showed improved balance due to skin stretch feedback when compared to the neutral standing conditions. Positive impacts on balance performance have also been demonstrated among multiple sclerosis patients when they receive skin stretch feedback from a sensory augmentation walker. The findings in this research indicated that the skin stretch feedback rendered by the developed devices affected the human balance and can potentially compensate underlying neurological or musculoskeletal disorders, therefore enhancing quiet standing postural control

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

Vers des environnements virtuels plus écologiques : étude des modifications du comportement moteur en réalité virtuelle lors de l'ajout d'informations haptiques par un mécanisme parallèle entraîné par câbles

Introduction : Les nouvelles technologies qui permettent de capter et d’analyser les mouvements des utilisateurs ne cessent de se développer et représentent un potentiel intéressant dans le domaine de la santé. Grâce à l’essor de ces nouvelles technologies, des systèmes de réalité virtuelle (RV) clefs en main intègrent les services de réadaptation, et les études démontrent leur capacité à optimiser la rééducation motrice et l’évaluation des clients présentant des troubles du contrôle moteur. Le marché de la RV est ainsi en pleine expansion, et l’ajout d’informations haptiques permettant de modéliser les caractéristiques physiques des entités virtuelles représente un intérêt considérable pour améliorer l’écologie des environnements virtuels (EVs) et le transfert des apprentissages aux activités quotidiennes. Toutefois, l’effet de l’ajout de ces informations sur le comportement moteur des sujets demeure très peu connu. L’objectif principal de cette thèse était ainsi d’évaluer l’impact de l’ajout d’informations haptiques, par un mécanisme parallèle entrainé par câbles (robot à câbles), sur le contrôle moteur de sujets sains, lors de la réalisation de tâches complexes et fonctionnelles dans des EVs. Les deux hypothèses principales étaient que cet ajout améliore le contrôle du mouvement lors de tâche de manutention d’objet ayant des contraintes environnementales statiques, et modifie les stratégies locomotrices proactives en présence de contraintes dynamiques. Méthode : Le comportement moteur de participants sains a été analysé lors de la réalisation de deux tâches. En premier lieu, une tâche de manutention de caisse nécessitant la préhension et le déplacement d’une caisse à partir d’une posture debout a été étudiée. Celle-ci a été réalisée dans un environnement réel et dans des EVs, en absence et en présence d’informations haptiques, relatives aux contraintes physiques de l’étagère et de la caisse manipulée, fournies grâce à un robot à câbles (Chapitre 3, N=12). En second lieu, une tâche nécessitant l’évitement d’avatars au cours de la marche sur un tapis roulant a été réalisée en présence et en absence de risque de contact physique avec les avatars, délivré par un robot à câbles (Chapitre 4, N=10). Les EVs étaient vus au travers d’un visiocasque. Résultats : La première étude a démontré une amélioration des paramètres spatiaux du mouvement réalisé dans l’EV en présente d’informations haptiques, au cours des différentes phases de la tâche de manutention (préhension, montée et descente de la caisse). L’organisation spatiale du mouvement était ainsi plus similaire à ce qui était observé dans un environnement réel, avec un meilleur respect des contraintes environnementales (éloignement plus important de la caisse avec l’étagère, trajectoire plus longue). De plus, le contrôle du mouvement était influencé par la demande de précision requise pour ne pas toucher les étagères en présence d’informations haptiques uniquement. La deuxième étude a démontré la mise en place de stratégies motrices plus précautionneuses pour éviter les avatars lors de l’ajout d’informations haptiques. Les participants tendaient à anticiper plus précocement l’évitement des avatars. Ils maintenaient une distance minimale plus importante avec les avatars et conservaient un espace péripersonnel plus large, indépendamment de l’angle d’approche de l’avatar. Conclusion : L’ajout d’informations haptiques dans les EVs impacte les stratégies motrices proactives des participants sains aussi bien lors de la tâche de manutention de caisse que de locomotion avec évitement d’avatars. Les résultats suggèrent que l’ajout d’informations haptiques favorise la prise en compte des entités virtuelles lors de la planification mouvement. Ces informations haptiques imposent en effet des restrictions plus réalistes dans les possibilités d’actions fournies par les EVs, et modifient probablement l’évaluation des conséquences que représente le contact avec les entités virtuelles. Il serait pertinent de poursuivre l’étude de l’influence de ces informations afin de proposer à des clients ayant des déficiences motrices des environnements encore plus écologiques, qui favorisent l’évaluation et la prise en compte des risques implicites que représentent les entités environnementales.Introduction: New technologies that capture and analyze user movement are constantly developing and represent a great potential in healthcare. Thanks to the recent technological advances, turnkey virtual reality (VR) systems are progressively integrated into the rehabilitation setting, and studies have demonstrated their ability to optimise sensorimotor rehabilitation and clinical assessment of people with motor control disorders. The market for VR is growing and adding haptic feedback that provides physical characteristics to virtual entities represents a great potential to improve the ecological validity of virtual environments (VE) and to the transfer of learning to daily tasks. However, the impact that adding haptic feedback has on motor behavior remains poorly understood. The main objective of this thesis was to assess the impact of adding haptic feedback, using a novel cable-driven parallel robot, on the motor control of healthy participants during complex, functional tasks in VEs. The two mains hypotheses were that haptic feedback improves motor control during a handling task with static environmental constraints and modifies proactive locomotor strategies in the presence of dynamic constraints. Method: The motor behavior of healthy participants was analysed during two tasks. First, a manual handling task was studied during which participants grasped and moved a crate while standing. This task was realised in a real environment and in VEs with the absence and the presence of haptic information. The latter simulated the physical constraints of the shelf and the crate to be manipulated using a cable-driven robot (Chapter 3, N=12). Second, avatar avoidance tasks were realised when participants walked on a self-paced treadmill in the absence and then in the presence of a risk of physical contact with avatars. Contact was simulated by a cable-driven robot (Chapter 4, N=10). VEs were viewed through a head mounted display for all tasks. Results: The first study showed that adding haptic feedback to the VE improved spatial parameters of movement realised in a VE during all phases of movement (reaching, ascent and descent phases). The spatial organisation of movement was closer to those observed in a physical environment, and better respected environmental constraints (higher clearances from the shelf and longer trajectories). Moreover, movement control was influenced by task precision required to avoid any contact with the shelf in the presence of haptic feedback only. The second study demonstrated that when avoiding avatars in VR, more cautious behavior was measured in the presence of potential physical contact. Participants tended to start their avoidance strategy earlier and increased minimum clearance along with a larger personal space regardless of the avatar’s approach angle. Conclusion: Adding haptic feedback in VEs impacts the proactive motor strategies of healthy participants during a manual handling task as well as a locomotor task involving the avoidance of avatars. These results suggest that adding haptic feedback enhances one’s consideration of virtual entities during movement planning. Haptic information imposes more realistic restrictions on the actions afforded by EVs, and likely modifies the perceived consequences of potential contact with virtual entities. It will be important to continue to study the impact of haptic feedback within VEs to provide even more ecological environments to people with motor deficits in order to improve assessment and the consideration of implicit risks posed by the environment

System Identification of Bipedal Locomotion in Robots and Humans

The ability to perform a healthy walking gait can be altered in numerous cases due to gait disorder related pathologies. The latter could lead to partial or complete mobility loss, which affects the patients’ quality of life. Wearable exoskeletons and active prosthetics have been considered as a key component to remedy this mobility loss. The control of such devices knows numerous challenges that are yet to be addressed. As opposed to fixed trajectories control, real-time adaptive reference generation control is likely to provide the wearer with more intent control over the powered device. We propose a novel gait pattern generator for the control of such devices, taking advantage of the inter-joint coordination in the human gait. Our proposed method puts the user in the control loop as it maps the motion of healthy limbs to that of the affected one. To design such control strategy, it is critical to understand the dynamics behind bipedal walking. We begin by studying the simple compass gait walker. We examine the well-known Virtual Constraints method of controlling bipedal robots in the image of the compass gait. In addition, we provide both the mechanical and control design of an affordable research platform for bipedal dynamic walking. We then extend the concept of virtual constraints to human locomotion, where we investigate the accuracy of predicting lower limb joints angular position and velocity from the motion of the other limbs. Data from nine healthy subjects performing specific locomotion tasks were collected and are made available online. A successful prediction of the hip, knee, and ankle joints was achieved in different scenarios. It was also found that the motion of the cane alone has sufficient information to help predict good trajectories for the lower limb in stairs ascent. Better estimates were obtained using additional information from arm joints. We also explored the prediction of knee and ankle trajectories from the motion of the hip joints

Fisioterapia en los déficits de equilibrio y marcha en adultos con traumatismo craneoencefálico. Una revisión bibliográfica

[Resumo] Introdución. O traumatismo cranioencefálico presenta unha elevada taxa de incidencia e prevalencia, supoñendo un importante problema socioeconómico e de saúde pública en todo o mundo, dado que representan a principal causa de consulta en urxencias, mortalidade e discapacidade en individuos novos, así como a primeira causa de anos potenciais de vida perdidos. Os déficits de equilibrio e marcha son algunhas das secuelas máis frecuentes nestes pacientes, persistindo tempo despois da lesión e limitando a participación e reintegración na sociedade. Obxectivo. Analizar a evidencia científica dispoñible sobre a fisioterapia para abordar os déficits de equilibrio e reeducar a marcha en pacientes que sufriron un traumatismo cranioencefálico. Material e métodos. Realizouse unha busca bibliográfica nas bases de datos PubMed, PEDro, Cochrane Library, Scopus e Web Of Science, incluíndo artigos publicados nos últimos seis anos en lingua inglesa, española e portuguesa. Resultados. Seleccionáronse 10 artigos que cumprían os criterios de inclusión e exclusión. A intervención levada a cabo nos distintos artigos é diversa, sendo a máis frecuente a realidade virtual. A eficacia da intervención mídese a través de escalas e test de valoración, sendo as máis empregadas a escala de equilibrio de Berg (BBS), a velocidade da marcha auto-seleccionada (SSV) e a avaliación da marcha funcional (FGA). Conclusións. Existe unha gran diversidade nos tratamentos de fisioterapia e na súa dosificación para abordar os déficits de equilibrio e reeducar a marcha. Os artigos empregan unha gran variedade de escalas e test de valoración como medida de resultados, dificultado a comparación dos artigos entre si. A intervención levada a cabo polos distintos artigos resultou ser eficaz para mellorar equilibrio e marcha nunha ampla maioría.[Abstract] Introduction. Traumatic brain injury has a high incidence and prevalence rate, representing a major socioeconomic and public health problem worldwide, since it represents the main cause of emergency consultation, mobility and disability in young adults, as well as the leading cause of lost potential years of life. Balance and gait deficits are some of the most frequent sequelae in these patients, persisting over time after the injury and limiting participation and social reintegration. Objective. To analyse the available scientific evidence on physiotherapy to address balance deficits and re-educate gait in patients who suffered a traumatic brain injury. Material and methods. A bibliographic search was conducted PubMed, PEDro, Cochrane Library, Scopus and Web Of Science databases, including articles published in the last six years in the English, Spanish and Portuguese languages. Results. Ten articles that met the inclusion and exclusion criteria were selected. The intervention carried out in the different articles is diverse, being virtual reality the most frequent. The efficacy of the intervention is measured through scales and assessment tests, being the most used Berg Balance Scale (BBS), speed of the self-selected gait (SSV) and Functional Gait Assessment (FGA). Conclusions. There is great diversity in physiotherapy treatments and in their dosage to address deficits in balance and gait. The articles use a wide variety of scales and assessment tests as an outcome measure, making it difficult to compare the studies among themselves. The intervention carried out by the different articles turned out to be effective in improving balance and gait in a large majority.[Resumen] Introducción. El traumatismo craneoecefálico presenta una elevada tasa de incidencia y prevalencia, suponiendo un importante problema socioeconómico y de salud pública en todo el mundo, dado que representa la principal causa de consulta en urgencias, mortalidad y discapacidad en adultos jóvenes, así como la primera causa de años potenciales de vida perdidos. Los déficits de equilibrio y marcha son algunas de las secuelas más frecuentes en estos pacientes, persistiendo tiempo después de la lesión y limitando la participación y la reintegración social. Objetivo. Analizar la evidencia científica disponible sobre la fisioterapia para abordar los déficits de equilibrio y reeducar la marcha en pacientes que sufrieron un traumatismo craneoencefálico. Material y métodos. Se realizó una búsqueda bibliográfica en las bases de datos PubMed, PEDro, Cochrane Library, Scopus y Web Of Science, incluyendo artículos publicados en los último seis años en lengua inglesa, española y portuguesa. Resultados. Se seleccionaron diez artículos que cumplían los criterios de inclusión y exclusión. La intervención llevada a cabo en los distintos artículos es diversa, siendo la más frecuente la realidad virtual. La eficacia de la intervención se mide a través de escalas y test de valoración como la escala de equilibrio de Berg (BBS), la velocidad de la marcha autoseleccionada (SSV) y la evaluación de la marcha funcional (FGA), entre otras. Conclusiones. Existe una gran diversidad en los tratamientos de fisioterapia y en su dosificación para abordar los déficits de equilibrio y marcha. Los artículos utilizan una gran variedad de escalas y test de valoración como medida de resultados, dificultando la comparación de los estudios entre sí. La intervención llevada a cabo por los distintos artículos resultó ser eficaz para mejorar el equilibrio y la marcha en una amplia mayoría.Traballo fin de grao (UDC.FCS). Fisioterapia. Curs

Physical Diagnosis and Rehabilitation Technologies

The book focuses on the diagnosis, evaluation, and assistance of gait disorders; all the papers have been contributed by research groups related to assistive robotics, instrumentations, and augmentative devices