Feasibility of a second iteration wrist and hand supported training system for self-administered training at home in chronic stroke

Telerehabilitation allows continued rehabilitation at home after discharge. The use of rehabilitation technology supporting wrist and hand movements within a motivational gaming environment could enable patients to train independently and ultimately serve as a way to increase the dosage of practice. This has been previously examined in the European SCRIPT project using a first prototype, showing potential feasibility, although several usability issues needed further attention. The current study examined feasibility and clinical changes of a second iteration training system, involving an updated wrist and hand supporting orthosis and larger variety of games with respect to the first iteration. Nine chronic stroke patients with impaired arm and hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility and arm and hand function were assessed before and after training. Median weekly training duration was 113 minutes. Participants accepted the six weeks of training (median Intrinsic Motivation Inventory = 4.4 points and median System Usability Scale = 73%). After training, significant improvements were found for the Fugl Meyer assessment, Action Research Arm Test and self-perceived amount of arm and hand use in daily life. These findings indicate that technology-supported arm and hand training can be a promising tool for self-administered practice at home after stroke.Final Accepted Versio

A Robot based Hybrid Lower-Limb System for Assist-As-Needed Rehabilitation of Stroke Patients:Technical Evaluation and Clinical Feasibility

Background: Although early rehabilitation is important following a stroke, severely affected patients have limited options for intensive rehabilitation as they are often bedridden. To create a system for early rehabilitation of lower extremities in severely affected patients, we have combined the robotic manipulator ROBERT® and EMG-triggered FES and developed a novel user-driven Assist- As-Needed (AAN) control approach. The method is based on a state machine that can detect user movement capability and provide different levels of assistance, as required by the patient (no support, FES only, and simultaneous FES and mechanical support). Methods: To technically validate the system, we tested 10 able-bodied participants who were instructed to perform specific behaviors to trigger the desired system states while conducting knee extension and ankle dorsal flexion exercise. In addition, the system was tested on two stroke patients to establish the clinical feasibility. Results: The technical validation showed that the state machine correctly detected the participants’ behavior and activated the target AAN state in more than 96% of the exercise repetitions. The clinical feasibility test showed that the system successfully recognized the patients’ movement capacity and activated assistive states according to their needs, providing the minimal level of support required to perform the exercise successfully. Conclusions: The system was technically validated and preliminarily proven clinically feasible. The present study shows that the novel system can be used to deliver exercises with a high number of repetitions while engaging the participants’ residual capabilities through an effective AAN strategy.</p

Relevance of hazards in exoskeleton applications: a survey-based enquiry

Exoskeletons are becoming the reference technology for assistance and augmentation of human motor functions in a wide range of application domains. Unfortunately, the exponential growth of this sector has not been accompanied by a rigorous risk assessment (RA) process, which is necessary to identify the major aspects concerning the safety and impact of this new technology on humans. This situation may seriously hamper the market uptake of new products. This paper presents the results of a survey that was circulated to understand how hazards are considered by exoskeleton users, from research and industry perspectives. Our analysis aimed to identify the perceived occurrence and the impact of a sample of generic hazards, as well as to collect suggestions and general opinions from the respondents that can serve as a reference for more targeted RA. Our results identified a list of relevant hazards for exoskeletons. Among them, misalignments and unintended device motion were perceived as key aspects for exoskeletons' safety. This survey aims to represent a first attempt in recording overall feedback from the community and contribute to future RAs and the identification of better mitigation strategies in the field

European evidence-based recommendations for clinical assessment of upper limb in neurorehabilitation (CAULIN): data synthesis from systematic reviews, clinical practice guidelines and expert consensus

Background: Technology-supported rehabilitation can help alleviate the increasing need for cost-effective rehabilitation of neurological conditions, but use in clinical practice remains limited. Agreement on a core set of reliable, valid and accessible outcome measures to assess rehabilitation outcomes is needed to generate strong evidence about effectiveness of rehabilitation approaches, including technologies. This paper collates and synthesizes a core set from multiple sources; combining existing evidence, clinical practice guidelines and expert consensus into European recommendations for Clinical Assessment of Upper Limb In Neurorehabilitation (CAULIN). Methods: Data from systematic reviews, clinical practice guidelines and expert consensus (Delphi methodology) were systematically extracted and synthesized using strength of evidence rating criteria, in addition to recommendations on assessment procedures. Three sets were defined: a core set: strong evidence for validity, reliability, responsiveness and clinical utility AND recommended by at least two sources; an extended set: strong evidence OR recommended by at least two sources and a supplementary set: some evidence OR recommended by at least one of the sources. Results: In total, 12 measures (with primary focus on stroke) were included, encompassing body function and activity level of the International Classification of Functioning and Health. The core set recommended for clinical practice and research: Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Action Research Arm Test (ARAT); the extended set recommended for clinical practice and/or clinical research: kinematic measures, Box and Block Test (BBT), Chedoke Arm Hand Activity Inventory (CAHAI), Wolf Motor Function Test (WMFT), Nine Hole Peg Test (NHPT) and ABILHAND; the supplementary set recommended for research or specific occasions: Motricity Index (MI); Chedoke-McMaster Stroke Assessment (CMSA), Stroke Rehabilitation Assessment Movement (STREAM), Frenchay Arm Test (FAT), Motor Assessment Scale (MAS) and body-worn movement sensors. Assessments should be conducted at pre-defined regular intervals by trained personnel. Global measures should be applied within 24 h of hospital admission and upper limb specific measures within 1 week. Conclusions: The CAULIN recommendations for outcome measures and assessment procedures provide a clear, simple, evidence-based three-level structure for upper limb assessment in neurological rehabilitation. Widespread adoption and sustained use will improve quality of clinical practice and facilitate meta-analysis, critical for the advancement of technology-supported neurorehabilitation.The European Network on Robotics for NeuroRehabilitation (Working Group 1) developed these recommendations. Their work was funded by the European Co-Operation in Science and Technology (COST Action TD1006) programme. The funding body had no role in or infuence on the selected approach and synthesis, analysis, and interpretation of data and in writing the manuscript

Six weeks Use of a Wearable Soft-robotic Glove During ADL:Preliminary Results of Ongoing Clinical Study

In this ongoing study, an assistive wearable soft-robotic glove, named Carbonhand, is tested at home for 6 weeks by subjects with decreased handgrip strength to receive a first insight in the therapeutic effect of using this assistive grip-supporting glove during ADLs. Preliminary results of the first 13 participants showed that participants appreciated use of the glove to assist them with daily life activities. Even more, grip strength without glove improved and functional performance showed increases as well. These preliminary findings hold promise for observing a clinical effect of using the soft-robotic glove as assistance in ADLs upon completion of data collection

Assessing effects of exoskeleton misalignment on knee joint load during swing using an instrumented leg simulator

Background: Exoskeletons are working in parallel to the human body and can support human movement by exerting forces through cuffs or straps. They are prone to misalignments caused by simplified joint mechanics and incorrect fit or positioning. Those misalignments are a common safety concern as they can cause undesired interaction forces. However, the exact mechanisms and effects of misalignments on the joint load are not yet known. The aim of this study was therefore to investigate the influence of different directions and magnitudes of exoskeleton misalignment on the internal knee joint forces and torques of an artificial leg. Methods: An instrumented leg simulator was used to quantify the changes in knee joint load during the swing phase caused by misalignments of a passive knee brace being manually flexed. This was achieved by an experimenter pulling on a rope attached to the distal end of the knee brace to create a flexion torque. The extension was not actuated but achieved through the weight of the instrumented leg simulator. The investigated types of misalignments are a rotation of the brace around the vertical axis and a translation in anteroposterior as well as proximal/distal direction. Results: The amount of misalignment had a significant effect on several directions of knee joint load in the instrumented leg simulator. In general, load on the knee joint increased with increasing misalignment. Specifically, stronger rotational misalignment led to higher forces in mediolateral direction in the knee joint as well as higher ab-/adduction, flexion and internal/external rotation torques. Stronger anteroposterior translational misalignment led to higher mediolateral knee forces as well as higher abduction and flexion/extension torques. Stronger proximal/distal translational misalignment led to higher posterior and tension/compression forces. Conclusions: Misalignments of a lower leg exoskeleton can increase internal knee forces and torques during swing to a multiple of those experienced in a well-aligned situation. Despite only taking swing into account, this is supporting the need for carefully considering hazards associated with not only translational but also rotational misalignments during wearable robot development and use. Also, this warrants investigation of misalignment effects in stance, as a target of many exoskeleton applications

Prototype measuring device for assessing interaction forces between human limbs and rehabilitation robots - A proof of concept study

Rehabilitation robots can provide high intensity and dosage training or assist patients in activities of daily living and decrease physical strain on clinicians. However, the physical human robot interaction poses a major safety issue, as the close physical contact between user and robot can lead to injuries. Moreover, the magnitude of forces as well as best practices for measuring them, are widely unknown. Therefore, a measurement setup was developed to assess normal and tangential forces that occur in the contact area between an arm and a splint. Force sensitive resistors and a force / torque sensor were combined with two different splint shapes. Initial experiments indicated that the setup gives some insight into magnitudes and distribution of normal forces on the splint-forearm-interface. Experiment results show a dependency of force distributions on the splint shape and sensor locations. Based on these outcomes, we proposed an improved setup for subsequent investigations

Quantifying upper extremity performance with and without assistance of a soft-robotic glove in elderly patients: A kinematic analysis

Objective: To explore the direct influence of a soft-robotic glove on movement duration and movement execution in elderly people with decreased hand function during a reach-and-grasp task. Design: Cross-sectional study. Patients: Eight subjects, aged 55+ years, with decreased hand function. Methods: The direct effect of the glove was explored using kinematic analysis during a reach-and-grasp task with a light (100 g) and heavy (1,000/2,500 g) cylindrical object, performed with and without the soft-robotic glove. Results: There was no difference in total movement time between performance with and without the glove. With the glove, the relative time needed to transport the heavy object was shorter, while the relative time needed to grasp the heavy object was longer. In addition, transporting light objects involved a lower peak velocity and larger elbow extension, and grasping the object involved a larger hand opening compared with without glove. Conclusion: As expected, no positive influence of the soft-robotic glove was found on total movement duration in elderly subjects. The influence of the glove on movement execution varied with movement phase. The positive and negative effects found may be due to a perceived confidence while carrying heavy objects with the glove, or compensation for loss of sensation, respectively. This information can be used to improve the glove design