Lower Extremity Passive Range of Motion in Community-Ambulating Stroke Survivors

Background: Physical therapists may prescribe stretching exercises for individuals with stroke to improve joint integrity and to reduce the risk of secondary musculoskeletal impairment. While deficits in passive range of motion (PROM) exist in stroke survivors with severe hemiparesis and spasticity, the extent to which impaired lower extremity PROM occurs in community-ambulating stroke survivors remains unclear. This study compared lower extremity PROM in able-bodied individuals and independent community-ambulatory stroke survivors with residual stroke-related neuromuscular impairments. Our hypothesis was that the stroke group would show decreased lower extremity PROM in the paretic but not the nonparetic side and that decreased PROM would be associated with increased muscle stiffness and decreased muscle length. Methods: Individuals with chronic poststroke hemiparesis who reported the ability to ambulate independently in the community (n = 17) and age-matched control subjects (n = 15) participated. PROM during slow (5 degrees/sec) hip extension, hip flexion, and ankle dorsiflexion was examined bilaterally using a dynamometer that measured joint position and torque. The maximum angular position of the joint (ANGmax), torque required to achieve ANGmax (Tmax), and mean joint stiffness (K) were measured. Comparisons were made between able-bodied and paretic and able-bodied and nonparetic limbs. Results: Contrary to our expectations, between-group differences in ANGmax were observed only during hip extension in which ANGmax was greater bilaterally in people post-stroke compared to control subjects (P ≤ 0.05; stroke = 13 degrees, able-bodied = −1 degree). Tmax, but not K, was also significantly higher during passive hip extension in paretic and nonparetic limbs compared to control limbs (P ≤ 0.05; stroke = 40 Nm, able-bodied = 29 Nm). Compared to the control group, Tmax was increased during hip flexion in the paretic and nonparetic limbs of post-stroke subjects (P ≤ 0.05, stroke = 25 Nm, able-bodied = 18 Nm). K in the nonparetic leg was also increased during hip flexion (P ≤ 0.05, nonparetic = 0.52 Nm/degree, able-bodied = 0.37 Nm/degree.) Conclusion: This study demonstrates that community-ambulating stroke survivors with residual neuromuscular impairments do not have decreased lower extremity PROM caused by increased muscle stiffness or decreased muscle length. In fact, the population of stroke survivors examined here appears to have more hip extension PROM than age-matched able-bodied individuals. The clinical implications of these data are important and suggest that lower extremity PROM may not interfere with mobility in community-ambulating stroke survivors. Hence, physical therapists may choose to recommend activities other than stretching exercises for stroke survivors who are or will become independent community ambulators

Clinical and neuropathological study about the neurotization of the suprascapular nerve in obstetric brachial plexus lesions

<p>Abstract</p> <p>Background</p> <p>The lack of recovery of active external rotation of the shoulder is an important problem in children suffering from brachial plexus lesions involving the suprascapular nerve. The accessory nerve neurotization to the suprascapular nerve is a standard procedure, performed to improve shoulder motion in patients with brachial plexus palsy.</p> <p>Methods</p> <p>We operated on 65 patients with obstetric brachial plexus palsy (OBPP), aged 5-35 months (average: 19 months). We assessed the recovery of passive and active external rotation with the arm in abduction and in adduction. We also looked at the influence of the restoration of the muscular balance between the internal and the external rotators on the development of a gleno-humeral joint dysplasia. Intraoperatively, suprascapular nerve samples were taken from 13 patients and were analyzed histologically.</p> <p>Results</p> <p>Most patients (71.5%) showed good recovery of the active external rotation in abduction (60°-90°). Better results were obtained for the external rotation with the arm in abduction compared to adduction, and for patients having only undergone the neurotization procedure compared to patients having had complete plexus reconstruction. The neurotization operation has a positive influence on the glenohumeral joint: 7 patients with clinical signs of dysplasia before the reconstructive operation did not show any sign of dysplasia in the postoperative follow-up.</p> <p>Conclusion</p> <p>The neurotization procedure helps to recover the active external rotation in the shoulder joint and has a good prevention influence on the dysplasia in our sample. The nerve quality measured using histopathology also seems to have a positive impact on the clinical results.</p

뒤셴느근디스트로피 환자에서의 근골격계 평가

학위논문 (박사) -- 서울대학교 대학원 : 의과대학 의과학과, 2020. 8. 신형익.Introduction: The aim of this study was to investigate systematic evaluation of limb and spinal musculoskeletal rehabilitation in accordance with the current clinical situation of early administration of steroids in patients with Duchenne muscular dystrophy (DMD). Three researches were conducted in this thesis. First, we investigated range of motion and contracture of lower extremity joints among male patients with DMD, based on the patients ambulatory status. Differences in major joint contractures, based on passive stretching exercise participation, were also investigated. Second, patients with DMD often develop scoliosis that progresses rapidly after loss of ambulation. We attempted to examine the incidence of scoliosis, flexibility of scoliosis and pelvic tilt associated with scoliosis after two years of wheelchair-bound status to identify trends over time. Finally, in persons with DMD, weakness of the upper extremity (UE) muscles has a significant impact on daily activities and body function. This problem necessitates a screening tool that can be used quickly and easily in clinical situations, such as the Upper limb short questionnaire (ULSQ). However, its validity and reliability as a clinical measure have not yet been evaluated. Methods: In the first research, total of 128 boys with DMD, followed at the DMD clinic of a tertiary care hospital, were included in this cross-sectional study. The passive ranges-of-motion of the hip, knee, and ankle joints were measured, in the sagittal plane, using a goniometer. The Vignos Scale was used to grade ambulatory function. Boys with DMD who performed stretching exercises for more than 5 min/session, >3 sessions/week, were classified into the stretching group. In the second research, we reviewed the medical records of 273 boys who were genetically identified as having DMD, and finally, 50 boys with serial records of radiographs after loss of ambulation were finally enrolled. And among them, only 31 patients developed scoliosis. Spine radiographs in sitting and supine positions were also reviewed to obtain Cobb angle, curve flexibility, and pelvic obliquity. Flexibilities (%) were calculated by the difference in angles between the sitting and supine positions divided by the angle at the sitting position, multiplied by 100. In the third research, face to face ULSQ interviews were held, and then repeated by telephone, at least four weeks later. Lower extremity and UE body function were measured by a physician using Vignos and a modified Brooke scale, respectively. Results: In the first research, the hip flexion (23.5 o), knee flexion (43.5 o), and ankle plantarflexion (34.5 o) contracture angles in the non-ambulatory group were more severe than those in the ambulatory group. Ankle plantarflexion contractures (41 patients, 52.6%) were more frequently observed early, even within the ambulatory period, than were hip (8 patients, 10.3%), and knee joint (17 patients, 21.8%) contractures. Passive stretching exercises >3 sessions/week were not associated with the degree of lower extremity joint contractures in the ambulatory or non-ambulatory group. In the second research, among 31 boys who had scoliosis, all but 2 boys with curves went through a sequential course of 1) no scoliosis, 2) nonstructural scoliosis, when scoliosis was only measurable in the sitting position, and 3) structural scoliosis, when scoliosis was also detectable in the supine position. Flexibility decreased each year after detection of scoliosis in those who developed scoliosis the first year, from 75.5 ± 5.0% to 57.1 ± 10.5% and to 49.1 ± 10.0% (mean ± standard deviation). Spinal flexibility was significantly correlated with curve magnitude of scoliosis in both sitting and supine position. In the third research, 160 subjects participated in the initial ULSQ interview among 167 participants, and 132 subjects completed follow-up interviews. Construct validity was confirmed by exploratory and subsequent confirmatory factor analysis. Sum scores of UE function correlated with the modified Brooke scale (Kendalls Tau 0.64, p < .001). Total and sum scores for each ULSQ component were higher in non-ambulators than in ambulators. Reliability was acceptable, determined by internal consistency and test-retest tools. Conclusions: There have been few studies about the range of motion and the degree of contracture of the joints (hip, knee, and ankle) of the lower limb since the 2000s when steroids began to be widely used. Knowledge of lower extremity joint contracture profiles, based on ambulatory status, may be useful for developing appropriate strategies for joint management in this patient group. Regarding to scoliosis, our result suggests that in the early stage of scoliosis, wherein flexibility is maintained without structural scoliosis, interventions such as bracings should be considered in DMD scoliosis. Also, scoliosis curve in DMD patients should be evaluated dynamically to detect the scoliosis when the curve is fully reducible. This study could be a cornerstone for further studies involving application of spinal braces for neuromuscular scoliosis. Finally, ULSQ could be a valid and reliable measurement tool for persons with DMD to screen UE function, pain, and stiffness in clinical settings서론: 뒤셴느근디스트로피에서 스테로이드 치료와 비침습적 환기 보조 등의 보조적인 치료 방법으로 인해 평균 생존 기간이 크게 증가하였다. 따라서 기능을 최대한 유지하고 합병증을 최소한으로 줄이기 위한 체계적인 사지 및 척추의 근골격계 평가가 필요하다. 첫 번째 연구에서는 하지의 주요 관절 별 가동범위 및 구축 정도 그리고 보행 능력에 따른 스트레칭 중재 효과를 평가하였다. 보행 능력을 소실한 이후에 가장 흔히 발생하는 근골격계 합병증은 척주측만증으로 두 번째 연구에서는 척주측만증의 발생과 척주측만증의 유연성, 그리고 척주측만증과 연관 있는 골반 기울임을 평가하여 서로 간의 연관성 및 시간에 따른 추이를 확인하였다. 마지막으로 휠체어 의존 시기에 독립적인 일상생활 동작 영위하기 위해서는 상지 기능이 가장 중요하므로 한국의 임상적 상황에 맞는 뒤셴느근디스트로피의 상지 평가도구를 마련하고자 하였다. 방법: 첫 번째 연구에서는 과거 스테로이드 치료를 받았거나, 지속해서 치료받고 있는 128명의 뒤셴느근디스트로피 환자를 대상으로 Vginos 척도로 평가한 보행 능력 감소에 따른 관절 가동범위 및 구축 정도의 변화와 주 3회 스트레칭 중재를 시행한 경우와 그렇지 않은 군으로 나누어 각 보행 능력에 따른 스트레칭 중재의 효과를 단면적으로 조사하였다. 두 번째 연구에서는 뒤셴느근디스트로피 환자 273명을 대상으로 휠체어에 완전히 의존하게 된 시점에서부터 2년 동안 Cobb 각도 및 골반 기울임을 측정하였으며, 앉은 자세와 앙와위 자세의 Cobb 각도의 차이를 통해 척추의 유연성을 측정하였다. 더불어 각 자세에서의 Cobb 각도와 척주측만증의 유연성, 그리고 골반 기울임의 연관성을 확인하였다. 마지막으로 상지 기능 평가도구를 개발하기 위해 2018년도에 발표된 영문으로 된 상지 간단 설문지를 번역, 역번역 및 원저자 확인 후 한국어판 상지 간단 설문지를 완성하였으며, 160명의 뒤셴느근디스트로피 환자들을 대상으로 신뢰도 및 타당도를 평가하였다. 결과: 첫 번째 연구에서 보행 가능한 그룹에서는 고관절과 슬관절 굴곡 구축이 드물게 관찰되었으나 족저굴곡 구축은 보행 가능 시기에서도 52.6%에서 관찰되어, 보행 가능 시기에서도 발목의 경우 족저굴국 구축이 빈번하게 발생함을 확인하였다. 보행 가능한 그룹에서는 평균 고관절 굴곡 구축 각도와 비교하였을 때 평균 족저굴곡 구축은 4.9도 정도 더 있는 것으로 나타났다. 보행 가능한 그룹과 보행 불가능한 그룹 간의 구축 정도를 비교하였을 때 보행 불가능한 그룹에서 보행이 가능한 그룹에 비해 평균적으로 고관절 굴곡 구축은 22도, 슬관절 굴곡 구축은 40.4도, 족저굴곡 구축은 28.1도 더 구축된 것으로 나타났다. 보행 가능한 그룹과 보행 불가능한 그룹에서 각각 주 3회 스트레칭 중재를 시행한 군과 시행하지 않은 군 간에 고관절 굴곡, 슬관절 굴곡, 족저굴곡의 구축 각도를 비교하였으나, 모두 유의한 차이가 없었다. 두 번째 연구에서 뒤셴느근디스트로피 환자 273명 중 50명이 2년간 추적관찰 기간 동안의 평가를 모두 완료하였으며, 그 중 31명에서 척주측만증이 발생하였다. 2명을 제외하고 모두 척주측만증이 없는 상태에서 비구조적 척주측만증, 구조적 척주측만증 순서로 단계별로 진행하는 것을 확인하였다. 척주측만증의 유연성은 매년 추적 관찰 시 마다 감소하는 경향을 보였는데 척주측만증이 발생한 첫해는 75.5 ± 5.0 % (평균 ± 표준 편차), 그 다음 1년 후 관찰 시에는 57.1 ± 10.5 %, 마지막 추적 관찰 시 49.1 ± 10.0 % 순으로 나타났다. 또한 앉은 자세와 앙와위 자세에서 측정한 척주측만증의 유연성은 각 자세에서의 Cobb 각도와 유의한 상관관계가 관찰되었다. 마지막으로 뒤셴느근디스트로피 환자 167명 중에서 160명이 첫 번째 설문조사에 응답하였으며, 두 번째 설문조사는 132명이 응답하였다. 탐색적 요인분석 및 확인적 요인분석을 통해 구성 타당도를 검증하였으며, 상지 기능에 관련한 설문 문항들의 총합은 Brooke 척도와 높은 정도의 상관관계를 보였다. 상지 간단 설문지의 총합과 상지 기능, 통증, 뻣뻣함과 관련된 각 세부 문항들의 합 역시 보행 불가능한 그룹에서 보행 가능한 그룹에 비해 유의하게 높았다. 또한 내적 일관성과 검사-재검사 신뢰도를 통해 신뢰도를 검증하였으며, 신뢰도는 적절하였다. 결론: 뒤셴느근디스트로피에서 보행 능력을 소실할수록 고관절 굴곡 구축, 슬관절 굴곡 구축, 족저굴곡 구축의 빈도와 심각성이 높아진다. 스트레칭 중재 단독으로는 하지 관절 구축을 예방 할 수 없어 향후 스트레칭 중재 이외에 다른 중재 치료를 함께 적용 고려해야 할 것으로 사료된다. 또한, 뒤셴느근디스트로피에서 척주측만증 발생 초기에는 유연성이 있어 척주측만증의 정도를 감소시킬 수 있는 기간이 존재한다. 그러나 척주측만증 각도가 증가하면서 유연성은 저하된다. 척주측만증의 유연성을 확인하기 위해서는 적어도 앉은 자세와 앙와위 자세에서 각각 측정하여 동적으로 평가할 필요가 있다. 마지막으로 한국판 상지 간단 설문지는 타당도와 신뢰도가 검증되어 임상적으로 한국의 뒤셴느근디스트로피 환자의 상지평가 도구로 사용될 수 있을 것으로 기대된다.1. Introduction 1 1.1. Research I: Lower extremity joint contracture according to ambulatory status 1 1.2. Research II: Scoliosis in Duchenne muscular dystrophy children 2 1.3. Research III: Upper limb short questionnaire for Duchenne muscular dystrophy 3 2. Methods 7 2.1. Research I: Lower extremity joint contracture according to ambulatory status 7 2.1.1. Participants 7 2.1.2. Measures 8 2.1.3. Procedure 8 2.1.4. Data analysis 9 2.2. Research II: Scoliosis in Duchenne muscular dystrophy children 10 2.2.1. Participants 10 2.2.2. Review of medical records 11 2.2.3. Evaluation of scoliosis and pelvic obliquity 11 2.2.4. Evaluation of flexibility 12 2.2.5. Statistical analysis 13 2.3. Research III: Upper limb short questionnaire for Duchenne muscular dystrophy 13 2.3.1. Participants 13 2.3.2. Procedure 14 2.3.3. Statistical Analysis 18 3. Results 19 3.1. Research I: Lower extremity joint contracture according to ambulatory status 19 3.1.1. Demographic and clinical information 19 3.1.2. Lower extremity joint contracture comparisons 22 3.1.3. Differences in joint contracture angles, based on stretching participation 26 3.2. Research II: Scoliosis in Duchenne muscular dystrophy children 28 3.2.1. Clinical Characteristics 28 3.2.2. Development of scoliosis 31 3.2.3. Scoliosis curve type changes 33 3.2.4. Changes in curve flexibility 35 3.2.5. Correlation between spinal curve flexibility and other parameters 35 3.2.6. Development of pelvic obliquity 35 3.3. Research III: Upper limb short questionnaire for Duchenne muscular dystrophy 38 3.3.1. Clinical characteristics 38 3.3.2. The result of Upper limb short questionnaire survey 40 3.3.3. Factor analysis 42 3.3.4. Construct validity 42 3.3.5. Reliability 47 4. Discussion 49 4.1. Research I: Lower extremity joint contracture according to ambulatory status 49 4.2. Research II: Scoliosis in Duchenne muscular dystrophy children 51 4.3. Research III: Upper limb short questionnaire for Duchenne muscular dystrophy 55 4.4. Implication for clinical trial in Duchenne muscular dystrophy 58 5. Concluding Remarks 60 Acknowledgments 61 Funding 61 References 62 Appendix 70 국문 초록 72Docto

A Complete Expression Profile of Matrix-Degrading Metalloproteinases in Dupuytren’s Disease

Dupuytren’s disease (DD) is a common fibrotic condition of the palmar fascia, leading to deposition of collagen-rich cords and finger contractions. The metzincin superfamily contains key enzymes in the turnover of collagen and other extracellular matrix macromolecules. A number of broad-spectrum matrix metalloproteinase inhibitors, used in cancer clinical trials, caused side effects of DD-like contractures. We tested the hypothesis that changes in the expression of specific metalloproteinases underlie or contribute to the fibrosis and contracture seen in DD. We collected tissue from patients with DD and used normal palmar fascia as a control. We profiled the expression of the entire matrix metalloproteinase (MMP), tissue inhibitor of metalloproteinases (TIMP), and a disintegrin and metalloproteinase domain with thrombospondin motif (ADAMTS) gene families in these tissues using real-time reverse-transcription polymerase chain reaction. A number of metalloproteinases and inhibitors are regulated in DD. The expression of 3 key collagenases, MMP1, MMP13, and MMP14 is increased significantly in the DD nodule, as is the expression of the collagen biosynthetic enzyme ADAMTS14. The expression of MMP7, an enzyme with broad substrate specificity, is increased in the DD nodule and remains equally expressed in the DD cord. TIMP1 expression is increased significantly in DD nodule compared with normal palmar fascia. This study measured the expression of all MMP, ADAMTS, and TIMP genes in DD. Contraction and fibrosis may result from: (1) increased collagen biosynthesis mediated by increased ADAMTS-14; (2) an increased level of TIMP-1 blocking MMP-1– and MMP-13–mediated collagenolysis; and (3) contraction enabled by MMP-14–mediated pericellular collagenolysis (and potentially MMP-7), which may escape inhibition by TIMP-1. The complete expression profile will provide a knowledge-based approach to novel therapeutics targeting these genes

Identification of Histological Patterns in Clinically Affected and Unaffected Palm Regions in Dupuytren's Disease

Dupuytren's disease is a fibro-proliferative disease characterized by a disorder of the extracellular matrix (ECM) and high myofibroblast proliferation. However, studies failed to determine if the whole palm fascia is affected by the disease. The objective of this study was to analyze several components of the extracellular matrix of three types of tissues—Dupuytren's diseased contracture cords (DDC), palmar fascia clinically unaffected by Dupuytren's disease contracture (NPF), and normal forehand fascia (NFF). Histological analysis, quantification of cells recultured from each type of tissue, mRNA microarrays and immunohistochemistry for smooth muscle actin (SMA), fibrillar ECM components and non-fibrillar ECM components were carried out. The results showed that DDC samples had abundant fibrosis with reticular fibers and few elastic fibers, high cell proliferation and myofibroblasts, laminin and glycoproteins, whereas NFF did not show any of these findings. Interestingly, NPF tissues had more cells showing myofibroblasts differentiation and more collagen and reticular fibers, laminin and glycoproteins than NFF, although at lower level than DDC, with similar elastic fibers than DDC. Immunohistochemical expression of decorin was high in DDC, whereas versican was highly expressed NFF, with no differences for aggrecan. Cluster analysis revealed that the global expression profile of NPF was very similar to DDC, and reculturing methods showed that cells corresponding to DDC tissues proliferated more actively than NPF, and NPF more actively than NFF. All these results suggest that NPF tissues may be affected, and that a modification of the therapeutic approach used for the treatment of Dupuytren's disease should be considered.This work was supported by CTS-115 (Tissue Engineering Group), University of Granada/Spain

CONSERVATIVE TREATMENT OF PLANTAR FASCIITIS WITH DORSIFLEXION NIGHT SPLINTS AND MEDIAL ARCH SUPPORTS: A PROSPECTIVE RANDOMIZED STUDY

Background: Plantar fasciitis is an overuse injury causing inflammation at the origin of the plantar fascia and is characterized by plantar heel pain that is provoked by taking the first few steps in the morning and by prolonged standing. Dorsiflexion night splints are used to address early morning pain by preventing contracture of the plantar fascia and Achilles tendon overnight. Medial arch supports, on the other hand, address the end of the day pain by preventing overstretch of the plantar fascia during prolonged weight bearing. Therefore, both night splints and arch supports may be necessary to treat plantar fasciitis as they complement each other by both controlling nocturnal contracture of the plantar fascia and Achilles tendon and reducing stresses imposed on the plantar fascia during the day, respectively. Hypotheses: We hypothesized that the night splint and arch support together would be more effective in the treatment of plantar fasciitis than a night splint or arch support alone in terms of increasing the range of pain-free passive ankle dorsiflexion, relieving heel tenderness and pain, and reducing disability imposed by the heel pain/plantar fasciitis. A secondary hypothesis of this study was that those with less passive dorsiflexion of the ankle would benefit from a night splint more than those with greater passive dorsiflexion of the ankle and those with a lower medial longitudinal arch would benefit from an arch support more than those with a higher medial longitudinal arch in terms of the previously mentioned outcome measures. Methodology: Subjects of this study were randomly assigned to one of three treatment groups. Group I was treated with night splints, group II with arch supports, and group III with a combination of night splints and arch supports. Range of motion was measured with a goniometer; heel tenderness was measured with a pressure algometer; and pain and disability were measured by the Foot Function Index before and after six weeks of treatment. Results: Ninety patients with plantar fasciitis (23 men and 67 women) were enrolled in the study, 30 in each group. Demographic, compliance and baseline evaluation data showed no significant differences between the groups. Analysis of the post-intervention evaluation data demonstrated significant differences between group I and III and group II and III, but not between group I and II, for all outcome measures. The range of pain-free passive ankle joint dorsiflexion and medial longitudinal arch height were not useful predictors of the success of treatment with a night splint and arch support for all outcome measures. Discussion: Using night splints and arch supports together may speed time to recovery by accelerating the healing process. Limitations of the study include observer's bias, subjects' bias, and short follow-up period. Conclusion: It was concluded that a night splint and arch support together may be more effective in the treatment of plantar fasciitis than either a night splint or arch support alone. Patients with plantar fasciitis who have less passive dorsiflexion of the ankle joint do not benefit from a night splint more than those with greater passive dorsiflexion of the ankle joint. Patients with plantar fasciitis who have a lower medial longitudinal arch do not benefit from an arch support more than those with a higher medial longitudinal arch

Limited Joint Mobility Progression In Type 1 Diabetes: A 15-year Follow-up Study

Objective. To assess the evolution of joint mobility over a period of 15 years in type 1 diabetic patients and healthy controls and to determine whether microalbuminuria is associated with a different evolution of joint mobility. Methods. Joint mobility of hand and wrist was determined in 63 patients with type 1 diabetes and 63 healthy subjects. Fifteen years later, 37 (58.7%) diabetic patients and 16 (25.4%) healthy subjects were studied again. Joint mobility was assessed with the Prayer sign and by measuring the angle of maximal flexion of the fifth and third metacarpophalangeal (MCP) joints and wrist. Patients with diabetes were visited 2-4 times every year with regular assessment of glycated hemoglobin (HbA1(c)), urinary albumin excretion (UAE), and ophthalmoscopy. Results. Fifteen years after the initial exam, diabetic patients showed reduced flexion of the fifth MCP joint (82.6 +/- 5.8 versus 76.0 +/- 6.4 degrees, p < 0 001) and wrist (75.9 +/- 8.1 versus 73.2 +/- 7.4 degrees, p = 0 015) compared to baseline examination. Joint mobility did not change significantly in healthy subjects. Patients with microalbuminuria showed greater reduction in hand joint mobility than diabetic patients with normal UAE or than healthy subjects (p < 0 001). Conclusions. In type 1 diabetic patients, the severity of LJM progresses with time, and the progression is enhanced in patients with microalbuminuria

Assessment of a hand exoskeleton on proximal and distal training in virtual environments for robot mediated upper extremity rehabilitation

Stroke is the leading cause of disability in the United States with approximately 800,000 cases per year. This cerebral vascular accident results in neurological impairments that reduce limb function and limit the daily independence of the individual. Evidence suggests that therapeutic interventions with repetitive motor training can aid in functional recovery of the paretic limb. Robotic rehabilitation may present an exercise intervention that can improve training and induce motor plasticity in individuals with stroke. An active (motorized) hand exoskeleton that provides support for wrist flexion/extension, abduction/adduction, pronation/supination, and finger pinch is integrated with a pre-existing 3-Degree of Freedom (DOF) haptic robot (Haptic Master, FCS Moog) to determine the efficacy of increased DOF during proximal and distal training in Upper Extremity (UE) rehabilitation. Subjects are randomly assigned into four groups to evaluate the significance of increased DOF during virtual training: Haptic Master control group (HM), Haptic Master with Gripper (HMG), Haptic Master with Wrist (HMW), and Haptic Master with Gripper and Wrist (HMWG). Each subject group performs a Pick and Place Task in a virtual environment where the distal hand exoskeleton is mapped to the virtual representation of the hand. Subjects are instructed to transport as many virtual cubes as possible to a specified target in the allotted time period of 120s. Three cube sizes are assessed to determine efficacy of the assistive end-effector. An additional virtual task, Mailbox Task, is performed to determine the effect of training and the ability to transfer skills between virtual settings in an unfamiliar environment. The effects of viewing mediums are also investigated to determine the effect of immersion on performance using an Oculus Rift as an HMD compared to conventional projection displays. It is hypothesized that individuals with both proximal and complete distal hand control (HMWG) will see increased benefit during the Pick and Place Task than individuals without the complete distal attachment, as assisted daily living tasks are often accomplished with coordinated arm and hand movement. The purpose of this study is to investigate the additive effect of increased degrees of freedom at the hand through task-specific training of the upper arm in a virtual environment, validate the ability to transfer skills obtained in a virtual environment to an untrained task, and determine the effects of viewing mediums on performance. A feasibility study is conducted in individuals with stroke to determine if the modular gripper can assist pinch movements. These investigations represent a comprehensive investigation to assess the potential benefits of assistive devices in a virtual reality setting to retrain lost function and increase efficacy in motor control in populations with motor impairments