Biomechanical Loading as an Alternative Treatment for Tremor: A Review of Two Approaches

Background: Tremor is the most common movement disorder and strongly increases in incidence and prevalence with aging. Although not life threatening, upper-limb tremors hamper the independence of 65% of people suffering from them affected persons, greatly impacting their quality of life. Current treatments include pharmacotherapy and surgery (thalamotomy and deep brain stimulation). However, these options are not sufficient for approximately 25% of patients. Therefore, further research and new therapeutic options are required to effectively manage pathological tremor. Methods: This paper presents findings of two research projects in which two different wearable robots for tremor management were developed based on force loading and validated. The first consisted of a robotic exoskeleton that applied forces to tremulous limbs and consistently attenuated mild and severe tremors. The second was a neuroprosthesis based on transcutaneous neurostimulation. A total of 22 patients suffering from parkinsonian or essential tremor (ET) of different severities were recruited for experimental validation, and both systems were evaluated using standard tasks employed for neurological examination. The inclusion criterion was a postural and/or kinetic pathological upper-limb tremor resistant to medication. Results: The results demonstrate that both approaches effectively suppressed tremor in most patients, although further research is required. The work presented here is based on clinical evidence from a small number of patients (n = 10 for robotic exoskeleton and n = 12 for the neuroprosthesis), but most had a positive response to the approaches. In summary, biomechanical loading is non-invasive and painless. It may be effective in patients who are insufficiently responsive (or have adverse reactions) to drugs or in whom surgery is contraindicated. Discussion: This paper identifies and evaluates biomechanical loading approaches to tremor management and discusses their potential

Tremor Control Devices for Essential Tremor: A Systematic Literature Review

Background: There is a growing interest in nonpharmacological approaches for essential tremor (ET), including tremor cancelation devices. However, the true efficacy of such devices in ET remains unclear. Methods: A systematic literature review was conducted using standardized criteria regarding efficacy and comfortability. Devices focused on design or experimental testing in which tremor was simulated in a robot were excluded. Results: Out of 324 articles initially identified, 12 articles were included. Orthoses using biomechanical loading and neuromodulation with electrical stimulation, and external tremor cancelation devices, were the main interventions used to suppress tremor. All devices were designed to control tremor of the upper limbs at different anatomical locations. Overall, an average tremor attenuation of 50–98% was reported (level of evidence III). Interference with voluntary movements and portability was described as the main drawback. Discussion: In conclusion, this review highlights the growing interest in emerging tremor control devices and the importance of assessing comfort without affecting voluntary movements. However, the level of evidence regarding the efficacy of these tremor control devices remains low. An integrated multidisciplinary combination approach of engineering, robotics, physiology, physiotherapy, and clinical assessment is needed to improve the quality of non-pharmacological interventions for ET

A flexible sensor technology for the distributed measurement of interaction pressure

We present a sensor technology for the measure of the physical human-robot interaction pressure developed in the last years at Scuola Superiore Sant'Anna. The system is composed of flexible matrices of opto-electronic sensors covered by a soft silicone cover. This sensory system is completely modular and scalable, allowing one to cover areas of any sizes and shapes, and to measure different pressure ranges. In this work we present the main application areas for this technology. A first generation of the system was used to monitor human-robot interaction in upper- (NEUROExos; Scuola Superiore Sant'Anna) and lower-limb (LOPES; University of Twente) exoskeletons for rehabilitation. A second generation, with increased resolution and wireless connection, was used to develop a pressure-sensitive foot insole and an improved human-robot interaction measurement systems. The experimental characterization of the latter system along with its validation on three healthy subjects is presented here for the first time. A perspective on future uses and development of the technology is finally drafted

A Wearable Mechatronic Device for Hand Tremor Monitoring and Suppression: Development and Evaluation

Tremor, one of the most disabling symptoms of Parkinson\u27s disease (PD), significantly affects the quality of life of the individuals who suffer from it. These people live with difficulties with fine motor tasks, such as eating and writing, and suffer from social embarrassment. Traditional medicines are often ineffective, and surgery is highly invasive and risky. The emergence of wearable technology facilitates an externally worn mechatronic tremor suppression device as a potential alternative approach for tremor management. However, no device has been developed for the suppression of finger tremor that has been validated on a human. It has been reported in the literature that tremor can be selectively suppressed by mechanical loading. Therefore, the objectives of this thesis were to develop a wearable tremor suppression device that can suppress tremor at the wrist and the fingers, and to evaluate it on individuals with PD in a pre-clinical trial. To address these objectives, several experiments were performed to quantify hand tremor; an enhanced high-order tremor estimator was developed and evaluated for tremor estimation; and a wearable tremor suppression glove (WTSG) was developed to suppress tremor in the index finger metacarpophalangeal (MCP) joint, the thumb MCP joint, and the wrist. A total of 18 individuals with PD were recruited for characterizing tremor. The frequencies and magnitudes of the linear acceleration, angular velocity, and angular displacement of tremor in the index finger MCP joint, the thumb MCP joint, and the wrist were quantified. The results showed that parkinsonian tremor consists of multiple harmonics, and that the second and third harmonics cannot be ignored. With the knowledge of the tremor characteristics, an enhanced high-order tremor estimator was developed to acquire better tremor estimation accuracy than its lower-order counterpart. In addition, the evaluation of the WTSG was conducted on both a physical tremor simulator and on one individual with PD. The results of the simulation study proved the feasibility of using the WTSG to suppress tremor; and the results of the evaluation on a human subject showed that the WTSG can suppress tremor motion while allowing the user to perform voluntary motions. The WTSG developed as a result of this work has demonstrated the feasibility of managing hand tremor with a mechatronic device, and its validation on a human subject has provided useful insights from the user\u27s perspectives, which facilitate the transition of the WTSG from the lab to the clinic, and eventually to commercial use. Lastly, an evaluation studying the impact of suppressed tremor on unrestricted joints was conducted on 14 individuals with PD. The results showed a significant increase in tremor magnitude in the unrestricted distal joints when the motions of the proximal joints were restricted. The average increase of the tremor magnitude of the index finger MCP joint, the thumb MCP joint, the wrist and the elbow are 54%, 96%, 124%, and 98% for resting tremor, and 50%, 102%, 49%, and 107% for postural tremor, respectively. Such a result provided additional clinical justification for the significance of the development of a wearable mechatronic device for hand tremor management. Although the focus of this thesis is on hand tremor management, the development and evaluation of a full upper-limb tremor suppression device is required as a future step, in order to advance the use of wearable mechatronic devices as one of the valid tremor treatment approaches

Rehabilitation Engineering

Population ageing has major consequences and implications in all areas of our daily life as well as other important aspects, such as economic growth, savings, investment and consumption, labour markets, pensions, property and care from one generation to another. Additionally, health and related care, family composition and life-style, housing and migration are also affected. Given the rapid increase in the aging of the population and the further increase that is expected in the coming years, an important problem that has to be faced is the corresponding increase in chronic illness, disabilities, and loss of functional independence endemic to the elderly (WHO 2008). For this reason, novel methods of rehabilitation and care management are urgently needed. This book covers many rehabilitation support systems and robots developed for upper limbs, lower limbs as well as visually impaired condition. Other than upper limbs, the lower limb research works are also discussed like motorized foot rest for electric powered wheelchair and standing assistance device

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

Towards the Development of a Wearable Tremor Suppression Glove

Patients diagnosed with Parkinson’s disease (PD) often associate with tremor. Among other symptoms of PD, tremor is the most aggressive symptom and it is difficult to control with traditional treatments. This thesis presents the assessment of Parkinsonian hand tremor in both the time domain and the frequency domain, the performance of a tremor estimator using different tremor models, and the development of a novel mechatronic transmission system for a wearable tremor suppression device. This transmission system functions as a mechatronic splitter that allows a single power source to support multiple independent applications. Unique features of this transmission system include low power consumption and adjustability in size and weight. Tremor assessment results showed that the hand tremor signal often presents a multi-harmonics pattern. The use of a multi-harmonics tremor model produced a better estimation result than using a monoharmonic tremor model

Analysis of the human interaction with a wearable lower-limb exoskeleton

The design of a wearable robotic exoskeleton needs to consider the interaction, either physical or cognitive, between the human user and the robotic device. This paper presents a method to analyse the interaction between the human user and a unilateral, wearable lower-limb exoskeleton. The lower-limb exoskeleton function was to compensate for muscle weakness around the knee joint. It is shown that the cognitive interaction is bidirectional; on the one hand, the robot gathered information from the sensors in order to detect human actions, such as the gait phases, but the subjects also modified their gait patterns to obtain the desired responses from the exoskeleton. The results of the two-phase evaluation of learning with healthy subjects and experiments with a patient case are presented, regarding the analysis of the interaction, assessed in terms of kinematics, kinetics and/or muscle recruitment. Human-driven response of the exoskeleton after training revealed the improvements in the use of the device, while particular modifications of motion patterns were observed in healthy subjects. Also, endurance (mechanical) tests provided criteria to perform experiments with one post-polio patient. The results with the post-polio patient demonstrate the feasibility of providing gait compensation by means of the presented wearable exoskeleton, designed with a testing procedure that involves the human users to assess the human-robot interaction