Active Participation Of Subjects Research Articles

Force/position-based velocity control strategy for the lower limb rehabilitation robot during active training: design and validation.

Aiming at the shortcomings of most existing control strategies for lower limb rehabilitation robots that are difficult to guarantee trajectory tracking effect and active participation of the patient, this paper proposes a force/position-based velocity control (FPVC) strategy for the hybrid end-effector lower limb rehabilitation robot (HE-LRR) during active training. The configuration of HE-LRR is described and the inverse Jacobian analysis is carried out. Then, the FPVC strategy design is introduced in detail, including normal velocity planning and tangential velocity planning. The experimental platform for the HE-LRR system is presented. A series of experiments are conducted to validate the FPVC strategy's performance, including trajectory measurement experiments, force and velocity measurement experiments, and active participation experiments. Experimental studies show that the end effector possesses good following performance with the reference trajectory and the desired velocity, and the active participation of subjects can be adjusted by the control strategy parameters. The experiments have verified the rationality of the FPVC strategy, which can meet the requirements of trajectory tracking effect and active participation, indicating its good application prospects in the patient's robot-assisted active training.

Effects of stance control via hidden Markov model-based gait phase detection on healthy users of an active hip-knee exoskeleton.

Introduction: In the past years, robotic lower-limb exoskeletons have become a powerful tool to help clinicians improve the rehabilitation process of patients who have suffered from neurological disorders, such as stroke, by applying intensive and repetitive training. However, active subject participation is considered to be an important feature to promote neuroplasticity during gait training. To this end, the present study presents the performance assessment of the AGoRA exoskeleton, a stance-controlled wearable device designed to assist overground walking by unilaterally actuating the knee and hip joints. Methods: The exoskeleton's control approach relies on an admittance controller, that varies the system impedance according to the gait phase detected through an adaptive method based on a hidden Markov model. This strategy seeks to comply with the assistance-as-needed rationale, i.e., an assistive device should only intervene when the patient is in need by applying Human-Robot interaction (HRI). As a proof of concept of such a control strategy, a pilot study comparing three experimental conditions (i.e., unassisted, transparent mode, and stance control mode) was carried out to evaluate the exoskeleton's short-term effects on the overground gait pattern of healthy subjects. Gait spatiotemporal parameters and lower-limb kinematics were captured using a 3D-motion analysis system Vicon during the walking trials. Results and Discussion: By having found only significant differences between the actuated conditions and the unassisted condition in terms of gait velocity (ρ = 0.048) and knee flexion (ρ ≤ 0.001), the performance of the AGoRA exoskeleton seems to be comparable to those identified in previous studies found in the literature. This outcome also suggests that future efforts should focus on the improvement of the fastening system in pursuit of kinematic compatibility and enhanced compliance.

Financial incentives to increase stool collection rates for microbiome studies in adult bone marrow transplant patients.

In order to study the role of the microbiome in hematopoietic stem cell transplantation (HCT), researchers collect stool samples from patients at various time points throughout HCT. However, stool collection requires active subject participation and may be limited by patient reluctance to handling stool. We performed a prospective study on the impact of financial incentives on stool collection rates. The intervention group consisted of allogeneic HCT patients from 05/2017-05/2018 who were compensated with a $10 gas gift card for each stool sample. The intervention group was compared to a historical control group of allogeneic HCT patients from 11/2016-05/2017 who provided stool samples before the incentive was implemented. To control for possible changes in collections over time, we also compared a contemporaneous control group of autologous HCT patients from 05/2017-05/2018 with a historical control group of autologous HCT patients from 11/2016-05/2017; neither autologous HCT group was compensated. The collection rate was defined as the number of samples provided divided by the number of time points we attempted to obtain stool. There were 35 allogeneic HCT patients in the intervention group, 19 allogeneic HCT patients in the historical control group, 142 autologous HCT patients in the contemporaneous control group (that did not receive a financial incentive), and 75 autologous HCT patients in the historical control group. Allogeneic HCT patients in the intervention group had significantly higher average overall collection rates when compared to the historical control group allogeneic HCT patients (80% vs 37%, p<0.0001). There were no significant differences in overall average collection rates between the autologous HCT patients in the contemporaneous control and historical control groups (36% vs 32%, p = 0.2760). Our results demonstrate that a modest incentive can significantly increase collection rates. These results may help to inform the design of future studies involving stool collection.

Electromyography-Driven Progressive Assist-as-Needed Control for Lower Limb Exoskeleton

This paper introduces a progressive assist-as-needed (pAAN) controller into our custom-made lower limb exoskeleton system. This control strategy can enhance the active participation of subjects. The controller can dynamically estimate a subject's input (voluntary joint torque) based on electromyography (EMG) without calibrations. The EMG-torque relationship learning is unsupervised. The zero-error estimation of the subject's input is guaranteed by a progressive learning strategy. The adaptive controller adjusts the control inputs of motors to complete predefined trajectories. Online torque estimation and adaptive motion control are both realised in the pAAN controller. Additionally, some practical problems of EMG application, caused by time-varying property of EMG signals and electrode displacement, would be avoided. From the simulation and experimental studies, our pAAN controller can predict the subject's input well, and the exoskeleton helps subjects move precisely. Active participation of subjects is achieved during training.

Financial Incentives to Increase Stool Collection Rates for Microbiome Studies in Adult Bone Marrow Transplant Patients

<h3>Introduction</h3> In order to learn more about the role of the microbiome in hematopoietic stem cell transplantation (HCT), researchers collect stool samples from patients at various time points throughout HCT. However, unlike blood samples or skin swabs, stool collection requires active subject participation, particularly in the outpatient setting, and may be limited by patient aversion to handling stool. <h3>Objectives</h3> By providing study participants with compensation for their stool samples, we hypothesize that we can significantly increase stool collection rates. <h3>Methods</h3> We performed a prospective cohort study on the impact of financial incentives on stool collection rates for microbiome studies. The intervention group consisted of allo-HCT patients from 05/2017-05/2018 who were compensated with a $10 gas gift card for each stool sample. The intervention group was compared to a historical control group consisting of allo-HCT patients from 11/2016-05/2017 who provided stool samples before the incentive was implemented. To control for potential changes in collections over time, we also compared a contemporaneous control group of auto-HCT patients from 05/2017-05/2018 with a historical control group of auto-HCT patients from 11/2016-05/2017; neither auto-HCT groups were compensated. Allo-HCT patients were required to give samples at pre-HCT, day 0 (the day of HCT), and days 7, 14, 21, 30, 60, and 90 post-HCT. Auto-HCT patients were required to give samples at pre-HCT and days 7, 14, and 90 post-HCT. Collection rates were defined as the number of samples provided divided by the number of time points for which we attempted to obtain samples. <h3>Results</h3> There were 35 allo-HCT patients in the intervention group, 19 allo-HCT patients in the historical control group, 142 auto-HCT patients in the contemporaneous control group, and 75 auto-HCT patients in the historical control group. Allo-HCT patients in the intervention group had significantly higher average overall collection rates when compared to the historical control group allo-HCT patients (80% vs 37%, p<0.001), as well has significantly higher average outpatient collection rates (84% vs 23%, p<0.001) and average inpatient collection rates (71% vs 46%, p=0.04). In contrast, there were no significant differences in overall average collection rates between the auto-HCT patients in the contemporaneous control and historical control groups (36% vs 32%, p=0.28), as well as the average outpatient collection rates (30% vs 28%, p=0.54) and the average inpatient collection rates (46% vs 59%, p=0.25). <h3>Conclusion</h3> Our results demonstrate that even a modest incentive can significantly increase collection rates. While this study uses a specialized HCT patient population, these results may be generalizable to informing the design of future studies and aid other researchers in obtaining stool samples needed for future microbiome studies.

Hybrid Active Control With Human Intention Detection of an Upper-Limb Cable-Driven Rehabilitation Robot

Rehabilitation robots play an increasingly important role in the recovery of motor function for stroke. To ensure a natural physical human-robot interaction (pHRI) and enhance the active participation of subjects, it is necessary for the robots to understand the human intention and cooperate actively with humanlike characteristics. This study proposed a hybrid active control algorithm with human motion intention detection. The motion intention was defined as the desired position and velocity, which were continuously estimated according to the human upper-limb model and minimum jerk model, respectively. The motion intention was then fed into a hybrid force and position controller of an upper-limb cable driven rehabilitation robot (CDRR). And a three-dimensional reaching task without predefined trajectory was employed to validate the effectiveness of the proposed control algorithm. Experimental results showed that the control algorithm could continuously recognize the human motion intention and enabled the robot better movement performance indicated as smaller offset error, smoother trajectory, and lower impact. The proposed method could guarantee a natural pHRI and improve the engagement of the subjects, which has great potential in clinical applications.

Возможно- сти применения инструментария независимой оценки качества условий оказания услуг медицинскими организа- циями для анализа эффективности системных преобразований на амбулаторном этапе

Successful achievement of goals of the national projects «Healthcare» and «Demography» is impossible without the active participation of subjects of the Russian Federation. At the same time, choice of optimal tools for assessing the transformations carried out on a regional scale is of particular importance. The aim of the study was to analyze the effectiveness of implementation of the Standard for the organization of outpatient care in the Tomsk region using tools for independent assessment of the quality of conditions for the provision of services by medical organizations. The results of the questionnaire survey of patients of medical organizations participating in the implementation of the project were analyzed before (2018, 896 patients from 18 medical organizations) and after (2019, 252 patients from 5 medical organizations) implementation of its main activities using the Questionnaire approved by the Ministry of Health of Russia. The informativeness of the questions of the questionnaire used to assess the effectiveness of a regional project depended on their nature. It is shown that the results of a questionnaire survey on issues affecting technical aspects of the process of receiving services (waiting times for an appointment with a doctor, research) should be interpreted comprehensively in combination with an assessment of technological indicators and data on the resource availability of the processes under study. Questions related to various aspects of patient satisfaction with the services received and the conditions for their provision showed positive dynamics in a number of parameters, indicating the effectiveness of the project implementation. The questions that concretize the object of satisfaction or dissatisfaction, in comparison with the questions involving an integrated assessment of the institution, were of great information content. The survey data obtained in the course of an independent assessment of the quality of the conditions for the provision of services in medical organizations can become an effective tool for an integrated assessment of the implementation of regional projects, allowing to determine the correctness of the selected directions of systemic transformations.

Financial Incentives to Increase Stool Collection Rates for Microbiome Studies in Adult Bone Marrow Transplant Patients

Introduction: Dysbiosis of the gut microbiome during hematopoietic stem cell transplantation (HCT) is associated with adverse post-transplant outcomes such as graft-versus-host disease, bloodstream infections, and mortality. In order to learn more about the role of the microbiome in HCT in adverse clinical outcomes, researchers collect stool samples from patients at various time points throughout HCT. However, unlike blood samples or skin swabs, stool collection requires active subject participation, particularly in the outpatient setting, and may be limited by patient aversion to handling stool. By providing study participants with compensation for their stool samples, we hypothesize that we can significantly increase stool collection rates. Methods: We performed a prospective cohort study on the impact of financial incentives on stool collection rates for microbiome studies. The intervention group consisted of allogeneic (allo)-HCT patients from 05/2017-05/2018 who were compensated with a $10 gas gift card for each stool sample. The intervention group was compared to a historical control group consisting of allo-HCT patients from 11/2016-05/2017 who provided stool samples before the incentive was implemented. To control for potential changes in collections over time, we also compared a contemporaneous control group of autologous (auto)-HCT patients from 05/2017-05/2018 with a historical control group of auto-HCT patients from 11/2016-05/2017; neither auto-HCT groups were compensated. Allo-HCT patients were required to give samples at pre-HCT, day 0 (the day of HCT), and days 7, 14, 21, 30, 60, and 90 post-HCT. Auto-HCT patients were required to give samples at pre-HCT and days 7, 14, and 90 post-HCT. Collection rates were defined as the number of samples provided divided by the number of time points for which we attempted to obtain samples. Patient characteristics were summarized by proportions for categorical variables and median with interquartile ranges for continuous variables. Chi-square tests or Fisher's exact tests were used to compare categorical variables, as appropriate, and Wilcoxon Rank Sum tests or t-tests were used to compare continuous variables, as appropriate. This study was approved by the Duke Institutional Review Board, and informed consent was obtained from all patients. Results: There were 35 allo-HCT patients in the intervention group, 19 allo-HCT patients in the historical control group, 142 auto-HCT patients in the contemporaneous control group, and 75 auto-HCT patients in the historical control group. Groups were similar with regard to baseline demographics such as age, race, and gender. While allo-HCT patients were more likely to have leukemia and auto-HCT patients were more likely to have lymphoma and multiple myeloma, there were no differences in disease rates across the study periods. Allo-HCT patients in the intervention group had significantly higher average overall collection rates when compared to the historical control group allo-HCT patients (80% vs 37%, p&lt;0.001), as well has significantly higher average outpatient collection rates (84% vs 23%, p&lt;0.001) and average inpatient collection rates (71% vs 46%, p=0.04). In contrast, there were no significant differences in overall average collection rates between the auto-HCT patients in the contemporaneous control and historical control group (36% vs 32%, p=0.28), as well as the average outpatient collection rates (30% vs 28%, p=0.54) and the average inpatient collection rates (46% vs 59%, p=0.25). Discussion: Our results demonstrate that even a modest incentive can significantly increase collection rates. Use of a contemporaneous control group to account for potential differences in stool collection rates over time strengthens our finding that financial incentives increase stool collection rates. Furthermore, the significant increase in collection rates in the outpatient setting highlights the role of the incentive when patient participation is needed, as opposed to the inpatient setting in which the nurse assists with collection. While this study uses a specialized HCT patient population, these results may be generalizable to future studies and aid other researchers in obtaining stool samples needed for future microbiome studies. Disclosures Peled: Seres Therapeutics: Other: IP licensing fees, Research Funding. van den Brink:Acute Leukemia Forum (ALF): Consultancy, Honoraria; Juno Therapeutics: Other: Licensing; Merck &amp; Co, Inc.: Consultancy, Honoraria; Seres Therapeutics: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Therakos: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Flagship Ventures: Consultancy, Honoraria; Evelo: Consultancy, Honoraria; Jazz Pharmaceuticals: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Magenta and DKMS Medical Council: Membership on an entity's Board of Directors or advisory committees. Sung:Novartis: Research Funding; Merck: Research Funding; Seres: Research Funding.

Teaching-Service integration within the National Professional Health Education Reorientation Program.

This integrative literature review aimed at identifying the characteristics and describing how teaching-service integration is expressed in studies on Pró-Saúde (Charitable institution for social and hospital assistance) published in Brazil in the period 2007-2012. For the search, the term National Professional Health Education Reorientation Program was entered in the following databases: Virtual Health Library (BVS), Google Scholar and the Bank of Theses of the Coordination for the Improvement of Higher Education Personnel (CAPES). Forty-one publications were selected with the following inclusion criteria: scientific papers; theses and dissertations; studies in English, Portuguese or Spanish. The critical review of studies was performed through a comprehensive reading of the texts. Outcomes are presented in two categories: Dialogue and partnership as tools for teaching-service integration and Movements of change in teaching-service through Pró-Saúde. Studies have shown that changes in professional education and practice are possible and necessary, especially when supported by strategies that encourage active participation of subjects and confirm teaching-service integration as opportunity for dialogue, promoted by this inducing policy.

Minimal Assist-as-Needed Controller for Upper Limb Robotic Rehabilitation

Robotic rehabilitation of the upper limb following neurological injury is most successful when subjects are engaged in the rehabilitation protocol. Developing assistive control strategies that maximize subject participation is accordingly an active area of research, with aims to promote neural plasticity and, in turn, increase the potential for recovery of motor coordination. Unfortunately, state-of-the-art control strategies either ignore more complex subject capabilities or assume underlying patterns govern subject behavior and may therefore intervene suboptimally. In this paper, we present a minimal assist-as-needed (mAAN) controller for upper limb rehabilitation robots. The controller employs sensorless force estimation to dynamically determine subject inputs without any underlying assumptions as to the nature of subject capabilities and computes a corresponding assistance torque with adjustable ultimate bounds on position error. Our adaptive input estimation scheme is shown to yield fast, stable, and accurate measurements regardless of subject interaction and exceeds the performance of current approaches that estimate only position-dependent force inputs from the user. Two additional algorithms are introduced in this paper to further promote active participation of subjects with varying degrees of impairment. First, a bound modification algorithm is described, which alters allowable error. Second, a decayed disturbance rejection algorithm is presented, which encourages subjects who are capable of leading the reference trajectory. The mAAN controller and accompanying algorithms are demonstrated experimentally with healthy subjects in the RiceWrist-S exoskeleton.

Using drinking data and pharmacokinetic modeling to calibrate transport model and blind deconvolution based data analysis software for transdermal alcohol biosensors.

Alcohol researchers/clinicians have two ways to collect subject /patient field data, standard-drink self-report and the breath analyzer, neither of which is passive or accurate because active subject participation is required. Transdermal alcohol sensors have been developed to measure transdermal alcohol concentration (TAC), but they are used primarily as abstinence monitors because converting TAC into more meaningful blood/breath alcohol concentration (BAC/BrAC) is difficult. In this paper, BAC/BrAC is estimated from TAC by first calibrating forward distributed parameter-based convolution models for ethanol transport from the blood through the skin using patient-collected drinking data for a single drinking episode and a nonlinear pharmacokinetic metabolic absorption/elimination model to estimate BAC. TAC and estimated BAC are then used to fit the forward convolution filter. Nonlinear least squares with adjoint-based gradient computation are used to fit both models. Calibration results are compared with those obtained using BAC/BrAC from alcohol challenges and from standard, linear, metabolic absorption, and zero order kinetics-based elimination models, by considering peak BAC, time of peak, and area under the BAC curve. Our models (with population parameters) could be included in a smart phone app that makes it convenient for the subject/patient to enter drinking data for a single episode in the field.

Community-Based Enterprises in Italy: Definition and Governance Models

In recent years, a new form of co-operative business is taking shape in Italy: the community-based enterprise, a community acting collectively at both management and business level, to pursue common goals. Community-based enterprises grow on a system of networks of free relationships among the members of a local community, with a high degree of reciprocity; when individuals work together in a business systems, relationships become social relationships. The complex of the community members’ relationships, objectives and expectations towards the company reflects necessarily on governance models that should follow a multistakeholder pattern. Multistakeholdership implies a direct and active participation of subjects bearing conflicting interests in the decisional process. This paper describes community-based enterprises in Italy, draws their governance models, and emphasizes how the passage from opening to different stakeholders to implementation of multistakeholder governance is very slow and difficult to put into practice.

Quantitative Assessment of Cortical Auditory-tactile Processing in Children with Disabilities

Objective and easy measurement of sensory processing is extremely difficult in nonverbal or vulnerable pediatric patients. We developed a new methodology to quantitatively assess children's cortical processing of light touch, speech sounds and the multisensory processing of the 2 stimuli, without requiring active subject participation or causing children discomfort. To accomplish this we developed a dual channel, time and strength calibrated air puff stimulator that allows both tactile stimulation and sham control. We combined this with the use of event-related potential methodology to allow for high temporal resolution of signals from the primary and secondary somatosensory cortices as well as higher order processing. This methodology also allowed us to measure a multisensory response to auditory-tactile stimulation.

Community-based Enterprises in Italy: Definition and Governance Models

In recent years, a new form of co-operative business is taking shape in Italy: the community-based enterprise, a community acting collectively at both management and business level, to pursue common goals. Community-based enterprises grow on a system of networks of free relationships among the members of a local community, with a high degree of reciprocity; when individuals work together in a business systems, relationships become social relationships. The complex of the community members’ relationships, objectives and expectations towards the company reflects necessarily on governance models that should follow a multistakeholder pattern. Multistakeholdership implies a direct and active participation of subjects bearing conflicting interests in the decisional process. This paper describes community-based enterprises in Italy, draws their governance models, and emphasizes how the passage from opening to different stakeholders to implementation of multistakeholder governance is very slow and difficult to put into practice.

Non-contact under-mattress sleep monitoring

Sleep quality and duration are increasingly recognised as being important prognostic parameters in the assessment of an individual’s health. However, reliable non-invasive long-term monitoring of sleep in a non-clinical setting remains a challenging problem. This paper describes the validation of a novel under mattress pressure sensing sleep monitoring modality that can be seamlessly integrated into existing home environments and provides a pervasive and distributed solution for monitoring longterm changes in sleep patterns and sleep disorders in adults. 410 minutes of concomitant Under Mattress Bed Sensor (UMBS) and strain gauge data were analysed from eight healthy adults lying passively. In this analysis, customised respirations rate detection algorithms yielded a mean difference of −0.12 breaths per five minutes and a mean percentage error (MPE) of 0.16% when the sensor was placed beneath the mattress. 1,491 minutes of UMBS and video data were recorded simultaneously from four participants in order to assess the movement detection efficacy of customised UMBS algorithms. These algorithms yielded accuracies, sensitivities and specificities of over 90% when compared to a video-based movement detection gold standard. A reduced data set (267 minutes) of wrist actigraphy, the gold standard ambulatory sleep monitor, was recorded. The UMBS was shown to outperform the movement detection ability of wrist actigraphy and has the added advantage of not requiring active subject participation.

A Pilot Study on the Feasibility of Robot-Aided Leg Motor Training to Facilitate Active Participation

Robot-aided gait therapy offers a promising approach towards improving gait function in individuals with neurological disorders such as stroke or spinal cord injury. However, incorporation of appropriate control strategies is essential for actively engaging the patient in the therapeutic process. Although several control algorithms (such as assist-as-needed and error augmentation) have been proposed to improve active patient participation, we hypothesize that the therapeutic benefits of these control algorithms can be greatly enhanced if combined with a motor learning task to facilitate neural reorganization and motor recovery. Here, we describe an active robotic training approach (patient-cooperative robotic gait training combined with a motor learning task) using the Lokomat and pilot-tested whether this approach can enhance active patient participation during training. Six neurologically intact adults and three chronic stroke survivors participated in this pilot feasibility study. Participants walked in a Lokomat while simultaneously performing a foot target-tracking task that necessitated greater hip and knee flexion during the swing phase of the gait. We computed the changes in tracking error as a measure of motor performance and changes in muscle activation as a measure of active subject participation. Repeated practice of the motor-learning task resulted in significant reductions in target-tracking error in all subjects. Muscle activation was also significantly higher during active robotic training compared to simply walking in the robot. The data from stroke participants also showed a trend similar to neurologically intact participants. These findings provide a proof-of-concept demonstration that combining robotic gait training with a motor learning task enhances active participation.

Assessing Smart Phones for Generating Life-space Indicators.

Life-space is a promising method for estimating older adults' functional status. However, traditional life-space measures are costly and time consuming because they often rely on active subject participation. This study assesses the feasibility of using the global positioning system (GPS) function of smart phones to generate life-space indicators. We first evaluated the location accuracy of smart phone collected GPS points versus those acquired by a commercial GPS unit. We then assessed the specificity of the smart phone processed life-space information against the traditional diary method. Our results suggested comparable location accuracy between the smart phone and the standard GPS unit in most outdoor situations. In addition, the smart phone method revealed more comprehensive life-space information than the diary method, which leads to higher and more consistent life-space scores. We conclude that the smart phone method is more reliable than traditional methods for measuring life-space. Further improvements will be required to develop a robust application of this method that is suitable for health-related practices.

Educação para a promoção da saúde no contexto da atenção primária

To investigate whether the educational initiatives carried out in basic health units in Belo Horizonte, Minas Gerais, Brazil, follows the principles of health promotion. This descriptive study examined 33 educational health promotion initiatives to determine whether they were guided by five principles, used as categories of analysis: multicausality of the health-disease process, intersectoriality, social engagement, sustainability, and use of dialogic teaching methods (active participation of subjects in the learning process, planning the activity to generate new knowledge, and use of various teaching strategies). Structured observation was used for data collection. The frequency of each category was evaluated in each initiative. Multicausality was the most frequent category observed (73.0%), and intersectoriality the least frequent (9.0%). Regarding the use of dialogic methods, 38.0% of the initiatives promoted the active engagement of subjects, 6.0% promoted knowledge generation, and 40.0% employed a variety of teaching strategies. Most educational initiatives were not actively oriented toward health promotion, understood as the strengthening of autonomy and self-management of health processes, social engagement, and employment of dialogic teaching approaches. However, some progress has been made moving away from hegemonic models of education in primary health care.

Recovery of cortical effective connectivity and recovery of consciousness in vegetative patients

Patients surviving severe brain injury may regain consciousness without recovering their ability to understand, move and communicate. Recently, electrophysiological and neuroimaging approaches, employing simple sensory stimulations or verbal commands, have proven useful in detecting higher order processing and, in some cases, in establishing some degree of communication in brain-injured subjects with severe impairment of motor function. To complement these approaches, it would be useful to develop methods to detect recovery of consciousness in ways that do not depend on the integrity of sensory pathways or on the subject's ability to comprehend or carry out instructions. As suggested by theoretical and experimental work, a key requirement for consciousness is that multiple, specialized cortical areas can engage in rapid causal interactions (effective connectivity). Here, we employ transcranial magnetic stimulation together with high-density electroencephalography to evaluate effective connectivity at the bedside of severely brain injured, non-communicating subjects. In patients in a vegetative state, who were open-eyed, behaviourally awake but unresponsive, transcranial magnetic stimulation triggered a simple, local response indicating a breakdown of effective connectivity, similar to the one previously observed in unconscious sleeping or anaesthetized subjects. In contrast, in minimally conscious patients, who showed fluctuating signs of non-reflexive behaviour, transcranial magnetic stimulation invariably triggered complex activations that sequentially involved distant cortical areas ipsi- and contralateral to the site of stimulation, similar to activations we recorded in locked-in, conscious patients. Longitudinal measurements performed in patients who gradually recovered consciousness revealed that this clear-cut change in effective connectivity could occur at an early stage, before reliable communication was established with the subject and before the spontaneous electroencephalogram showed significant modifications. Measurements of effective connectivity by means of transcranial magnetic stimulation combined with electroencephalography can be performed at the bedside while by-passing subcortical afferent and efferent pathways, and without requiring active participation of subjects or language comprehension; hence, they offer an effective way to detect and track recovery of consciousness in brain-injured patients who are unable to exchange information with the external environment.

Towards more effective robotic gait training for stroke rehabilitation: a review

BackgroundStroke is the most common cause of disability in the developed world and can severely degrade walking function. Robot-driven gait therapy can provide assistance to patients during training and offers a number of advantages over other forms of therapy. These potential benefits do not, however, seem to have been fully realised as of yet in clinical practice.ObjectivesThis review determines ways in which robot-driven gait technology could be improved in order to achieve better outcomes in gait rehabilitation.MethodsThe literature on gait impairments caused by stroke is reviewed, followed by research detailing the different pathways to recovery. The outcomes of clinical trials investigating robot-driven gait therapy are then examined. Finally, an analysis of the literature focused on the technical features of the robot-based devices is presented. This review thus combines both clinical and technical aspects in order to determine the routes by which robot-driven gait therapy could be further developed.ConclusionsActive subject participation in robot-driven gait therapy is vital to many of the potential recovery pathways and is therefore an important feature of gait training. Higher levels of subject participation and challenge could be promoted through designs with a high emphasis on robotic transparency and sufficient degrees of freedom to allow other aspects of gait such as balance to be incorporated.