Robot-Aided Systems for Improving the Assessment of Upper Limb Spasticity: A Systematic Review

This article belongs to the Special Issue Sensors Technology for Medical Robotics.Spasticity is a motor disorder that causes stiffness or tightness of the muscles and can interfere with normal movement, speech, and gait. Traditionally, the spasticity assessment is carried out by clinicians using standardized procedures for objective evaluation. However, these procedures are manually performed and, thereby, they could be influenced by the clinician’s subjectivity or expertise. The automation of such traditional methods for spasticity evaluation is an interesting and emerging field in neurorehabilitation. One of the most promising approaches is the use of robot-aided systems. In this paper, a systematic review of systems focused on the assessment of upper limb (UL) spasticity using robotic technology is presented. A systematic search and review of related articles in the literature were conducted. The chosen works were analyzed according to the morphology of devices, the data acquisition systems, the outcome generation method, and the focus of intervention (assessment and/or training). Finally, a series of guidelines and challenges that must be considered when designing and implementing fully-automated robot-aided systems for the assessment of UL spasticity are summarized

Treatment of progressive multiple sclerosis: what works, what does not, and what is needed.

Disease-modifying drugs have mostly failed as treatments for progressive multiple sclerosis. Management of the disease therefore solely aims to minimise symptoms and, if possible, improve function. The degree to which this approach is based on empirical data derived from studies of progressive disease or whether treatment decisions are based on what is known about relapsing-remitting disease remains unclear. Symptoms rated as important by patients with multiple sclerosis include balance and mobility impairments, weakness, reduced cardiovascular fitness, ataxia, fatigue, bladder dysfunction, spasticity, pain, cognitive deficits, depression, and pseudobulbar affect; a comprehensive literature search shows a notable paucity of studies devoted solely to these symptoms in progressive multiple sclerosis, which translates to few proven therapeutic options in the clinic. A new strategy that can be used in future rehabilitation trials is therefore needed, with the adoption of approaches that look beyond single interventions to concurrent, potentially synergistic, treatments that maximise what remains of neural plasticity in patients with progressive multiple sclerosis

Virtual Art Therapy. Application of Michelangelo Effect to Neurorehabilitation of Patients with Stroke

In neurorehabilitation, some studies reported the effective use of art therapy for reducing psychological disorders and for enhancing physical functions and cognitive abilities. Neuroaesthetical studies showed that seeing an art masterpiece can spontaneously elicit a widespread brain arousal, also involving motor networks. To combine contemplative and performative benefits of art therapy protocols, we have developed an immersive virtual reality system, giving subjects the illusion that they are able to paint a copy of famous artistic paintings. We previously observed that during this virtual task, subjects perceived less fatigue and performed more accurate movements than when they were asked to color the virtual canvas. We named this upshot the Michelangelo effect. The aim of this study was to test the rehabilitative efficacy of our system. Ten patients with stroke in the subacute phase were enrolled and trained for one month with virtual art therapy (VAT) and physiotherapy. Their data were compared with those of ten patients matched for pathology, age and clinical parameters, trained only with conventional therapy for the same amount of time. The VAT group showed a significantly higher improvements in the Barthel Index score, a measure of independency in activities of daily living (66 ± 33% vs. 31 ± 28%, p = 0.021), and in pinching strength (66 ± 39% vs. 18 ± 33%, p = 0.008), with respect to the group treated with conventional rehabilitation

An adaptive 4-week robotic training program of the upper limb for persons with multiple sclerosis

It is suggested that repetitive movements can initiate motor recovery and improve motor learning in populations with neurological impairments and this process can be optimized with robotic devices. The repetitive, reproducible and high dose motor movements that can be delivered by robotics have shown positive results in functional outcomes in stroke patients. However, there is little research on robotic neurorehabilitation for persons with multiple sclerosis (PwMS), more specifically there is lack of literature with focus on the upper extremity. Therefore, the purpose of this work was to use a robotic device to implement an adaptive training program of the forearm and wrist for PwMS. This approach is unique, as it incorporates real time learning from the robotic device to alter the level of assistance/resistance to the individual. This methodology is novel and could prove to be an effective way to properly individualize the therapy process with correct dosage and prescription. 7 individuals with varying levels of MS, placed their most affected limb (forearm) on a robotic device (Wristbot), grasped the handle, and using real-time visual feedback, traced a Lissajous curve allowing the wrist to move in flexion/extension, radial/ulnar directions. Robotic training occurred 3 times per week for 4 consecutive weeks and included 40 minutes of work. Robotic software was adaptive and updated every 3 laps to evaluate the average kinematic performance which modified the robotic assistance/resistance. Outcome measures were taken pre and post intervention. Improvements in performance were quantified by average tracking and figural error, which was significantly reduced from pre – post intervention. Isometric wrist strength and grip force endurance also significantly improved from pre to post intervention. However, maximum grip force, joint position matching, 9-hole peg test, and patient-rated wrist evaluation did not show any significant improvements. To our knowledge, this study was the first adaptive and individualized robotic rehabilitation program providing two opposing forces to the hand/wrist for PwMS. Results of this 4-week training intervention, provide a proof-of-concept that motor control and muscular strength can be improved by this rehabilitation modality. This work acts as a stepping-stone into future investigations of robotic rehabilitation for an MS population

Stretching adversely modulates locomotor capacity following spinal cord injury via activation of nociceptive afferents.

Spinal cord injury (SCI) is the second leading cause of paralysis in the United States, affecting around 282,000 people with 17,000 new cases each year. Initial and secondary damage to the spinal cord disrupts multiple descending pathways that modulate the function of sympathetic preganglionic neurons and central pattern generating circuitry. Resulting loss of autonomic and locomotor functions, as well as decreased levels of physical activity, lead to a myriad of complications that affect multiple organ systems and significantly reduce both quality of life and life expectancy in individuals with SCI. Spasticity and muscle contractures are two common secondary conditions that develop in the chronic stages of SCI as a result of neurobiological and soft tissue adaptations. Stretching is the widely accepted initial therapy for the treatment of both spasticity and muscle contractures. Unlike humans, rats with experimental incomplete SCI have robust locomotor recovery and do not develop significant muscle contractures or spasticity. One of the long-standing operating principles in the Magnuson laboratory is that rats retrain or rehabilitate themselves through large amounts of in-cage activity. A previous graduate student in our lab, Krista Caudle, tested this hypothesis using custom designed wheelchairs to immobilize Sprague Dawley rats with mild-moderate SCIs. As expected, the immobilized SCI animals did not recover their locomotor function and, in addition, developed muscle contractures. To mimic the approach used in the clinic for the treatment of contractures, a hindlimb stretching protocol was developed and implemented as part of our daily care routine. As a control, non-immobilized SCI rats also received stretching therapy. Surprisingly, stretched rats and wheelchair immobilized rats showed similar impairments in locomotor recovery. This finding was alarming and warranted further studies. The work presented in this thesis is a continuation of the stretching projects in the Magnuson laboratory. Four major studies were carried out in order to improve our understanding of this stretching phenomenon and to begin uncovering the underlying physiological mechanisms. The following experiments revealed that hindlimb stretching disrupts locomotor function in rats with acute and chronic moderately-severe SCI. We also determined that dynamic “range of motion” stretching resulted in a similar pattern of locomotor impairment as our standard static stretch-and-hold protocol in rats with moderate sub-acute SCIs. Furthermore, using kinematics and electromyography (EMG), we determined that one of the most frequent responses to stretch in the rat hindlimbs is similar to human clonus. The significance of these findings are three-fold. First, to our knowledge, there has not been a specific description of clonus in the rat model of the SCI previously. Second, the similarity of the responses to stretch between rats and humans make a compelling argument for the clinical relevance of the stretching phenomenon. Finally, we determined that stretch-induced locomotor deficits depend on the presence of nociceptive afferents. Speculations about the specific physiological mechanisms of the stretching phenomenon and future directions are discussed. Comprehensive review of the stretching literature revealed a major problem in the rationale that is frequently provided for the use of stretching in the management of muscle contractures after SCI. In light of this work, a perspective on the future of stretching therapy in the rehabilitation after SCI is provided

Rehabilitation of gait after stroke: a review towards a top-down approach

This document provides a review of the techniques and therapies used in gait rehabilitation after stroke. It also examines the possible benefits of including assistive robotic devices and brain-computer interfaces in this field, according to a top-down approach, in which rehabilitation is driven by neural plasticity

A novel paired associative stimulation protocol with a high-frequency peripheral component : A review on results in spinal cord injury rehabilitation

In recent decades, a multitude of therapeutic approaches has been developed for spinal cord injury (SCI), but few have progressed to regular clinical practice. Novel non-invasive, cost-effective, and feasible approaches to treat this challenging condition are needed. A novel variant of paired associative stimulation (PAS), high-PAS, consists of non-invasive high-intensity transcranial magnetic stimulation (TMS) and non-invasive high-frequency electrical peripheral nerve stimulation (PNS). We observed a therapeutic effect of high-PAS in 20 patients with incomplete SCI with wide range of injury severity, age, and time since injury. Tetraplegic and paraplegic, traumatic, and neurological SCI patients benefited from upper- or lower-limb high-PAS. We observed increases in manual motor scores (MMT) of upper and lower limbs, functional hand tests, walking tests, and measures of functional independence. We also optimized PAS settings in several studies in healthy subjects and began elucidating the mechanisms of therapeutic action. The scope of this review is to describe the clinical experience gained with this novel PAS approach. This review is focused on the summary of our results and observations and the methodological considerations for researchers and clinicians interested in adopting and further developing this new method.Peer reviewe

Changes in Post-Stroke Skeletal Muscles: an Ultrasonographic Evaluation

Background: Stroke is the second leading cause of death worldwide, with chronic disability remaining in up to 50% of survivors. Ultrasonography studies to examine disruptions in the normative architecture of post-stroke muscles have documented changes in muscle thickness, fascicle length, pennation angle, and echo intensity (EI) in patients in chronic patients Purpose: Assessing early modification in paretic muscles could ameliorate the comprehension of the prognosis and address a better rehabilitation program. Methods: Adult patients admitted in Physical Medicine and Rehabilitation with acute ischemic stroke from January 2019 to January 2022 were identified as the study population. Muscle thickness (MT), ACSA (anatomical cross sectional area) in Biceps Brachii (BB), Rectus Femoris(RF), Gastrocnemius Medialis (GM) in the both sides were assessed with ultrasound at admission, after 60, 90 days and at 6 months. The influence of comorbidities and echo intensity was also assessed. Results: Twenty-two patients were finally enrolled. Most of patients were male (54,5%), the mean age was 71 (55-83). BB thickness decreased during the first 30 days and in the following time intervals. At 6 months, mean thickness decreased with a variation of 12.66% in the paretic side. RF thickness decreased from 15.95 to 14.75, with a difference of 7.52% from baseline to T3 [95% CI, .0272; 0.817], p < 0.001. GM thickness decreased from 15.86 to 14,39, with a difference of 9.27% from baseline to T3 [95% CI, . ,033; 0. ,058], p = 0.001. No significant different was found in T2-T3 and T0-T3. The age had a significant negative correlations with MT RF and ACSA RF. Charlson index had a negative correlation with MT GM. Conclusion: Early research at the patient's bedside for insights that can improve the outcome and prevent irreversible and useless muscle modification in paretic side in post-stroke patients