THE EFFECT OF A NOVEL REHABILITATION PROGRAM ON WALKING PERFORMANCE IN PERSONS WITH MULTIPLE SCLEROSIS

The purpose of this study was to compare if the addition of the NewGait™ device to traditional therapy in comparison to traditional therapy alone would be more effective at improving walking technique and walking performance in persons with multiple sclerosis. Eighteen patients with multiple sclerosis participated in this study. Pre- and post-testing assessed kinematic gait variables (speed, step length, step width, double limb support time), toe clearance height, ankle range of motion, balance confidence, rating of perceived exertion, and hip-ankle coordination. Participants completed an 8-week physical therapy protocol aimed to improve gait and balance with the experimental group wearing the NewGait™ device. Repeated measures mixed ANOVA revealed significant improvements over time for both groups, with increased walking speed, improved balance confidence, increase in bilateral step length, and a decrease in the percent of time spent in anti-phase and an ankle-driven coordination phase during swing for the unaffected limb (p \u3c 0.05). The experimental group experienced larger improvements in balance confidence (p \u3c 0.05), and coordination (p \u3c 0.05) when compared to the control group. The results of the current study indicate that the use of the NewGait™ during rehabilitation is effective at improving balance confidence lower limb coordination

Neuroplastic Changes Following Brain Ischemia and their Contribution to Stroke Recovery: Novel Approaches in Neurorehabilitation

Ischemic damage to the brain triggers substantial reorganization of spared areas and pathways, which is associated with limited, spontaneous restoration of function. A better understanding of this plastic remodeling is crucial to develop more effective strategies for stroke rehabilitation. In this review article, we discuss advances in the comprehension of post-stroke network reorganization in patients and animal models. We first focus on rodent studies that have shed light on the mechanisms underlying neuronal remodeling in the perilesional area and contralesional hemisphere after motor cortex infarcts. Analysis of electrophysiological data has demonstrated brain-wide alterations in functional connectivity in both hemispheres, well beyond the infarcted area. We then illustrate the potential use of non-invasive brain stimulation (NIBS) techniques to boost recovery. We finally discuss rehabilitative protocols based on robotic devices as a tool to promote endogenous plasticity and functional restoration

Usability of Upper Limb Electromyogram Features as Muscle Fatigue Indicators for Better Adaptation of Human-Robot Interactions

Human-robot interaction (HRI) is the process of humans and robots working together to accomplish a goal with the objective of making the interaction beneficial to humans. Closed loop control and adaptability to individuals are some of the important acceptance criteria for human-robot interaction systems. While designing an HRI interaction scheme, it is important to understand the users of the system and evaluate the capabilities of humans and robots. An acceptable HRI solution is expected to be adaptable by detecting and responding to the changes in the environment and its users. Hence, an adaptive robotic interaction will require a better sensing of the human performance parameters. Human performance is influenced by the state of muscular and mental fatigue during active interactions. Researchers in the field of human-robot interaction have been trying to improve the adaptability of the environment according to the physical state of the human participants. Existing human-robot interactions and robot assisted trainings are designed without sufficiently considering the implications of fatigue to the users. Given this, identifying if better outcome can be achieved during a robot-assisted training by adapting to individual muscular status, i.e. with respect to fatigue, is a novel area of research. This has potential applications in scenarios such as rehabilitation robotics. Since robots have the potential to deliver a large number of repetitions, they can be used for training stroke patients to improve their muscular disabilities through repetitive training exercises. The objective of this research is to explore a solution for a longer and less fatiguing robot-assisted interaction, which can adapt based on the muscular state of participants using fatigue indicators derived from electromyogram (EMG) measurements. In the initial part of this research, fatigue indicators from upper limb muscles of healthy participants were identified by analysing the electromyogram signals from the muscles as well as the kinematic data collected by the robot. The tasks were defined to have point-to-point upper limb movements, which involved dynamic muscle contractions, while interacting with the HapticMaster robot. The study revealed quantitatively, which muscles were involved in the exercise and which muscles were more fatigued. The results also indicated the potential of EMG and kinematic parameters to be used as fatigue indicators. A correlation analysis between EMG features and kinematic parameters revealed that the correlation coefficient was impacted by muscle fatigue. As an extension of this study, the EMG collected at the beginning of the task was also used to predict the type of point-to-point movements using a supervised machine learning algorithm based on Support Vector Machines. The results showed that the movement intention could be detected with a reasonably good accuracy within the initial milliseconds of the task. The final part of the research implemented a fatigue-adaptive algorithm based on the identified EMG features. An experiment was conducted with thirty healthy participants to test the effectiveness of this adaptive algorithm. The participants interacted with the HapticMaster robot following a progressive muscle strength training protocol similar to a standard sports science protocol for muscle strengthening. The robotic assistance was altered according to the muscular state of participants, and, thus, offering varying difficulty levels based on the states of fatigue or relaxation, while performing the tasks. The results showed that the fatigue-based robotic adaptation has resulted in a prolonged training interaction, that involved many repetitions of the task. This study showed that using fatigue indicators, it is possible to alter the level of challenge, and thus, increase the interaction time. In summary, the research undertaken during this PhD has successfully enhanced the adaptability of human-robot interaction. Apart from its potential use for muscle strength training in healthy individuals, the work presented in this thesis is applicable in a wide-range of humanmachine interaction research such as rehabilitation robotics. This has a potential application in robot-assisted upper limb rehabilitation training of stroke patients

The Armeo Spring as training tool to improve upper limb functionality in multiple sclerosis: a pilot study

<p>Abstract</p> <p>Background</p> <p>Few research in multiple sclerosis (MS) has focused on physical rehabilitation of upper limb dysfunction, though the latter strongly influences independent performance of activities of daily living. Upper limb rehabilitation technology could hold promise for complementing traditional MS therapy. Consequently, this pilot study aimed to examine the feasibility of an 8-week mechanical-assisted training program for improving upper limb muscle strength and functional capacity in MS patients with evident paresis.</p> <p>Methods</p> <p>A case series was applied, with provision of a training program (3×/week, 30 minutes/session), supplementary on the customary maintaining care, by employing a gravity-supporting exoskeleton apparatus (Armeo Spring). Ten high-level disability MS patients (Expanded Disability Status Scale 7.0-8.5) actively performed task-oriented movements in a virtual real-life-like learning environment with the affected upper limb. Tests were administered before and after training, and at 2-month follow-up. Muscle strength was determined through the Motricity Index and Jamar hand-held dynamometer. Functional capacity was assessed using the TEMPA, Action Research Arm Test (ARAT) and 9-Hole Peg Test (9HPT).</p> <p>Results</p> <p>Muscle strength did not change significantly. Significant gains were particularly found in functional capacity tests. After training completion, TEMPA scores improved (<it>p </it>= 0.02), while a trend towards significance was found for the 9HPT (<it>p </it>= 0.05). At follow-up, the TEMPA as well as ARAT showed greater improvement relative to baseline than after the 8-week intervention period (<it>p </it>= 0.01, <it>p </it>= 0.02 respectively).</p> <p>Conclusions</p> <p>The results of present pilot study suggest that upper limb functionality of high-level disability MS patients can be positively influenced by means of a technology-enhanced physical rehabilitation program.</p

Rehabilitation robotics: pilot trial of a spatial extension for MIT-Manus

BACKGROUND: Previous results with the planar robot MIT-MANUS demonstrated positive benefits in trials with over 250 stroke patients. Consistent with motor learning, the positive effects did not generalize to other muscle groups or limb segments. Therefore we are designing a new class of robots to exercise other muscle groups or limb segments. This paper presents basic engineering aspects of a novel robotic module that extends our approach to anti-gravity movements out of the horizontal plane and a pilot study with 10 outpatients. Patients were trained during the initial six-weeks with the planar module (i.e., performance-based training limited to horizontal movements with gravity compensation). This training was followed by six-weeks of robotic therapy that focused on performing vertical arm movements against gravity. The 12-week protocol includes three one-hour robot therapy sessions per week (total 36 robot treatment sessions). RESULTS: Pilot study demonstrated that the protocol was safe and well tolerated with no patient presenting any adverse effect. Consistent with our past experience with persons with chronic strokes, there was a statistically significant reduction in tone measurement from admission to discharge of performance-based planar robot therapy and we have not observed increases in muscle tone or spasticity during the anti-gravity training protocol. Pilot results showed also a reduction in shoulder-elbow impairment following planar horizontal training. Furthermore, it suggested an additional reduction in shoulder-elbow impairment following the anti-gravity training. CONCLUSION: Our clinical experiments have focused on a fundamental question of whether task specific robotic training influences brain recovery. To date several studies demonstrate that in mature and damaged nervous systems, nurture indeed has an effect on nature. The improved recovery is most pronounced in the trained limb segments. We have now embarked on experiments that test whether we can continue to influence recovery, long after the acute insult, with a novel class of spatial robotic devices. This pilot results support the pursuit of further clinical trials to test efficacy and the pursuit of optimal therapy following brain injury

GENTLE/A - Adaptive Robotic Assistance for Upper-Limb Rehabilitation

Advanced devices that can assist the therapists to offer rehabilitation are in high demand with the growing rehabilitation needs. The primary requirement from such rehabilitative devices is to reduce the therapist monitoring time. If the training device can autonomously adapt to the performance of the user, it can make the rehabilitation partly self-manageable. Therefore the main goal of our research is to investigate how to make a rehabilitation system more adaptable. The strategy we followed to augment the adaptability of the GENTLE/A robotic system was to (i) identify the parameters that inform about the contribution of the user/robot during a human-robot interaction session and (ii) use these parameters as performance indicators to adapt the system. Three main studies were conducted with healthy participants during the course of this PhD. The first study identified that the difference between the position coordinates recorded by the robot and the reference trajectory position coordinates indicated the leading/lagging status of the user with respect to the robot. Using the leadlag model we proposed two strategies to enhance the adaptability of the system. The first adaptability strategy tuned the performance time to suit the user’s requirements (second study). The second adaptability strategy tuned the task difficulty level based on the user’s leading or lagging status (third study). In summary the research undertaken during this PhD successfully enhanced the adaptability of the GENTLE/A system. The adaptability strategies evaluated were designed to suit various stages of recovery. Apart from potential use for remote assessment of patients, the work presented in this thesis is applicable in many areas of human-robot interaction research where a robot and human are involved in physical interaction

Mechanisms of Sensorimotor Impairment in Multiple Sclerosis

Sensorimotor impairments in people with multiple sclerosis (MS) might alter coordination and balance strategy during functional movements. People with MS often have symptoms such as weakness and discoordination in the lower limbs, resulting in poor walking and balance function. This decrease in function can result in falls, decreased community activity, unemployment, and reduced quality of life. As MS is a progressive disease resulting in a range of dysfunction, the amount of lower limb impairment can cause changes to walking and balance strategies to maintain functional performance. The overall objective of this dissertation was to quantify the impairment at the hip and ankle, and characterize the effects of impairment on walking and balance in MS. To quantify the lower limb impairment, a custom-built robot was used to impose movement to the legs about the hip and ankle joint separately. Joint torque and work done were used as quantitative measures of strength during isometric contraction and coordination during subject assisted leg movements in MS and healthy control subjects. To characterize the effect of impairment on functional movements, motion analysis was used to record kinematic and kinetic parameters during overground walking and during a challenging arm tracking task in standing. Hip and ankle sagittal moments were used to quantify the contribution of each joint to functional movement. The findings from these studies suggest that there is a greater sensorimotor impairment at the ankle than the hip in MS, resulting in a reduced reliance on the ankle during walking and an increased hip versus ankle strategy during upper body movements. This was observed by increased negative work at the ankle during assisted bilateral leg movements, reduced ankle moments during stance in gait, and increased hip versus ankle contribution during arm tracking movements in standing. These results indicate that differential impairment between the hip and ankle can drive changes to walking and balance strategy to maintain functional performance, highlighting the importance of joint specific rehabilitation methods in improving function in MS

Computational neurorehabilitation: modeling plasticity and learning to predict recovery

Despite progress in using computational approaches to inform medicine and neuroscience in the last 30 years, there have been few attempts to model the mechanisms underlying sensorimotor rehabilitation. We argue that a fundamental understanding of neurologic recovery, and as a result accurate predictions at the individual level, will be facilitated by developing computational models of the salient neural processes, including plasticity and learning systems of the brain, and integrating them into a context specific to rehabilitation. Here, we therefore discuss Computational Neurorehabilitation, a newly emerging field aimed at modeling plasticity and motor learning to understand and improve movement recovery of individuals with neurologic impairment. We first explain how the emergence of robotics and wearable sensors for rehabilitation is providing data that make development and testing of such models increasingly feasible. We then review key aspects of plasticity and motor learning that such models will incorporate. We proceed by discussing how computational neurorehabilitation models relate to the current benchmark in rehabilitation modeling – regression-based, prognostic modeling. We then critically discuss the first computational neurorehabilitation models, which have primarily focused on modeling rehabilitation of the upper extremity after stroke, and show how even simple models have produced novel ideas for future investigation. Finally, we conclude with key directions for future research, anticipating that soon we will see the emergence of mechanistic models of motor recovery that are informed by clinical imaging results and driven by the actual movement content of rehabilitation therapy as well as wearable sensor-based records of daily activity

Cerebral Palsy

Nowadays, cerebral palsy (CP) rehabilitation, along with medical and surgical interventions in children with CP, leads to better motor and postural control and can ensure ambulation and functional independence. In achieving these improvements, many modern practices may be used, such as comprehensive multidisciplinary assessment, clinical decision making, multilevel surgery, botulinum toxin applications, robotic ambulation applications, treadmill, and other walking aids to increase the quality and endurance of walking. Trainings are based on neurodevelopmental therapy, muscle training and strength applications, adaptive equipment and orthotics, communication, technological solves, and many others beyond the scope of this book. In the years of clinical and academic experiences, children with cerebral palsy have shown us that the world needs a book to give clinical knowledge to health professionals regarding these important issue. This book is an attempt to fulfill and to give “current steps” about CP. The book is intended for use by physicians, therapists, and allied health professionals who treat/rehabilitate children with CP. We focus on the recent concepts in the treatment of body and structure problems and describe the associated disability, providing suggestions for further reading. All authors presented the most frequently used and accepted treatment methods with scientifically proven efficacy and included references at the end of each chapter

Effectiveness of intensive physiotherapy for gait improvement in stroke: systematic review

Introduction: Stroke is one of the leading causes of functional disability worldwide. Approximately 80% of post-stroke subjects have motor changes. Improvement of gait pattern is one of the main objectives of physiotherapists intervention in these cases. The real challenge in the recovery of gait after stroke is to understand how the remaining neural networks can be modified, to be able to provide response strategies that compensate for the function of the affected structures. There is evidence that intensive training, including physiotherapy, positively influences neuroplasticity, improving mobility, pattern and gait velocity in post-stroke recovery. Objectives: Review and analyze in a systematic way the experimental studies (RCT) that evaluate the effects of Intensive Physiotherapy on gait improvement in poststroke subjects. Methodology: Were only included all RCT performed in humans, without any specific age, that had a clinical diagnosis of stroke at any stage of evolution, with sensorimotor deficits and functional gait changes. The databases used were: Pubmed, PEDro (Physiotherapy Evidence Database) and CENTRAL (Cochrane Center Register of Controlled Trials). Results: After the application of the criteria, there were 4 final studies that were included in the systematic review. 3 of the studies obtained a score of 8 on the PEDro scale and 1 obtained a score of 4. The fact that there is clinical and methodological heterogeneity in the studies evaluated, supports the realization of the current systematic narrative review, without meta-analysis. Discussion: Although the results obtained in the 4 studies are promising, it is important to note that the significant improvements that have been found, should be carefully considered since pilot studies with small samples, such as these, are not designed to test differences between groups, in terms of the effectiveness of the intervention applied. Conclusion: Intensive Physiotherapy seems to be safe and applicable in post-stroke subjects and there are indications that it is effective in improving gait, namely speed, travelled distance and spatiotemporal parameters. However, there is a need to develop more RCTs with larger samples and that evaluate the longterm resultsN/