Arm Rehabilitation Research Articles

Improving Healthcare Access: A Preliminary Design of a Low-Cost Arm Rehabilitation Device

AbstractA low-cost continuous passive motion (CPM) machine, the Gannon Exoskeleton for Arm Rehabilitation (GEAR), was designed. The focus of the machine is on the rehabilitation of primary functional movements of the arm. The device developed integrates two mechanisms consisting of a four-bar linkage and a sliding rod prismatic joint mechanism that can be mounted to a normal chair. When seated, the patient is connected to the device via a padded cuff strapped on the elbow. A set of springs have been used to maintain the system stability and help the lifting of the arm. A preliminary analysis via analytical methods is used to determine the initial value of the springs to be used in the mechanism given the desired gravity compensatory force. Subsequently, a multibody simulation was performed with the software simwise 4D by Design Simulation Technologies (DST). The simulation was used to optimize the stiffness of the springs in the mechanism to provide assistance to raising of the patient's arm. Furthermore, the software can provide a finite element analysis of the stress induced by the springs on the mechanism and the external load of the arm. Finally, a physical prototype of the mechanism was fabricated using polyvinyl chloride (PVC) pipes and commercial metal springs, and the reaching space was measured using motion capture. We believed that the GEAR has the potential to provide effective passive movement to individuals with no access to postoperative or poststroke rehabilitation therapy.

Low-Cost Robotic Guide Based on a Motor Imagery Brain-Computer Interface for Arm Assisted Rehabilitation.

Motor imagery has been suggested as an efficient alternative to improve the rehabilitation process of affected limbs. In this study, a low-cost robotic guide is implemented so that linear position can be controlled via the user’s motor imagination of movement intention. The patient can use this device to move the arm attached to the guide according to their own intentions. The first objective of this study was to check the feasibility and safety of the designed robotic guide controlled via a motor imagery (MI)-based brain–computer interface (MI-BCI) in healthy individuals, with the ultimate aim to apply it to rehabilitation patients. The second objective was to determine which are the most convenient MI strategies to control the different assisted rehabilitation arm movements. The results of this study show a better performance when the BCI task is controlled with an action–action MI strategy versus an action–relaxation one. No statistically significant difference was found between the two action–action MI strategies.

Acquisition of Procedural Skills in Preregistration Physiotherapy Education Comparing Mental Practice Against No Mental Practice: The Learning of Procedures in Physiotherapy Education Trial - A Development of Concept Study.

Introduction:Procedural skills are a central element in the education of physiotherapists. Procedural skills relate to the execution of a practical task. An educational intervention, which can be used to support skill acquisition of procedural skills, is mental practice (MP). Several studies have investigated the use of MP or imaging in medical education. This pilot study evaluated the application of MP on the acquisition of procedural skills in physiotherapy education.Methods:This pilot randomised controlled study recruited a convenience sample of 37 BSc physiotherapy student participants. Two different complex task procedures (transfer and vestibular rehabilitation) were trained during this study. Participants in both the transfer (task procedure 1) and the vestibular rehabilitation (task procedure 2) arm of the study were randomly assigned to either MP or no MP.Results:For the transfer task, median performance at post-acquisition testing showed a moderate effect size in favour of the group using MP (r: −0.3), but the findings were not statistically significant (P: 0.2). Similar results were found for the vestibular rehabilitation task (r: 0.29; P: 0.21). In addition, the self-reported confidence was higher in the MP group.Conclusion:Moderate effect sizes were identified in favour of MP at post-acquisition testing. In addition, the between-group difference was higher than the minimally important difference. The feasibility of the study was high based on quantitative feasibility measures such as the recruitment rate. Both these findings suggest larger well-powered studies should be considered to confirm the findings of this pilot study.

New advances in mechanomyography sensor technology and signal processing: Validity and intrarater reliability of recordings from muscle.

IntroductionThe Mechanical Muscle Activity with Real-time Kinematics project aims to develop a device incorporating wearable sensors for arm rehabilitation following stroke. These will record kinematic activity using inertial measurement units and mechanical muscle activity. The gold standard for measuring muscle activity is electromyography; however, mechanomyography offers an appropriate alterative for our home-based rehabilitation device. We have patent filed a new laboratory-tested device that combines an inertial measurement unit with mechanomyography. We report on the validity and reliability of the mechanomyography against electromyography sensors.MethodsIn 18 healthy adults (27–82 years), mechanomyography and electromyography recordings were taken from the forearm flexor and extensor muscles during voluntary contractions. Isometric contractions were performed at different percentages of maximal force to examine the validity of mechanomyography. Root-mean-square of mechanomyography and electromyography was measured during 1 s epocs of isometric flexion and extension. Dynamic contractions were recorded during a tracking task on two days, one week apart, to examine reliability of muscle onset timing.ResultsReliability of mechanomyography onset was high (intraclass correlation coefficient = 0.78) and was comparable with electromyography (intraclass correlation coefficient = 0.79). The correlation between force and mechanomyography was high (R2 = 0.94).ConclusionThe mechanomyography device records valid and reliable signals of mechanical muscle activity on different days.

Sequentially applied myoelectrically controlled FES in a task-oriented approach and robotic therapy for the recovery of upper limb in post-stroke patients: A randomized controlled pilot study.

Functional recovery of the plegic upper limb in post-stroke patients may be enhanced by sequentially applying a myoelectrically controlled FES (MeCFES), which allows the patient to voluntarily control the muscle contraction during a functional movement, and robotic therapy which allows many repetitions of movements. Evaluate the efficacy of MeCFES followed by robotic therapy compared to standard care arm rehabilitation for post-stroke patients. Eighteen stroke subjects (onset ⩾ 3 months, age 60.1 ± 15.5) were recruited and randomized to receive an experimental combination of MeCFES during task-oriented reaching followed by robot therapy (MRG) or same intensity conventional rehabilitation care (CG) aimed at the recovery of the upper limb (20 sessions/45 minutes). Change was evaluated through Fugl-Meyer upper extremity (FMA-UE), Reaching Performance Scale and Box and Block Test. The experimental treatment resulted in higher improvement on the FMA-UE compared with CG (P= 0.04), with a 10-point increase following intervention. Effect sizes were moderate in favor of the MRG group on FMA-UE, FMA-UE proximal and RPS (0.37-0.56). Preliminary findings indicate that a combination of MeCFES and robotic treatment may be more effective than standard care for recovery of the plegic arm in persons > 3 months after stroke. The mix of motor learning techniques may be important for successful rehabilitation of arm function.

Effects of reach training with Arm Rehabilitation Robot on function and everyday use of hemiplegic upper limbs

Effects of reach training with Arm Rehabilitation Robot on function and everyday use of hemiplegic upper limbs

Implementation of Dynamic Lycra® Orthoses for Arm Rehabilitation in the Context of a Randomised Controlled Feasibility Trial in Stroke: A Qualitative study Using Normalisation Process Theory.

Objective:To explore how non-research funded rehabilitation practitioners implemented dynamic Lycra® orthoses for arm recovery after stroke into rehabilitation practice, as part of a feasibility randomised controlled trial.Design:Qualitative interview study.Setting:Two in-patient stroke units and associated rehabilitation units.Subjects:Fifteen purposefully selected stroke rehabilitation practitioners involved in delivery of dynamic Lycra® orthoses as part of a feasibility randomised controlled trial.Methods:Semi-structured interviews conducted at the end of the trial. Interviews examined their experiences of orthosis implementation. Normalisation Process Theory structured the interview guide and informed data analysis. NVivo software supported data analysis.Results:Practitioners intuitively made sense of the intervention in the face of uncertainty about its precise mechanisms of action (Normalisation Process Theory construct: coherence) and espoused commitment to the research, despite uncertainty about orthosis effectiveness (cognitive participation). They did however adapt the intervention based on perceived therapeutic need, their own skillsets and stroke survivor preference (collective action). They were uncertain about benefits (reflexive monitoring). Across the 4 theoretical constructs, ambivalence about the intervention was detected.Conclusions:Ambivalence interfered with implementation – but only to an extent. ‘Good-enough’ coherence, cognitive participation, collective action and reflexive monitoring were sufficient to initiate normalisation – as long as implementation did not undermine the relationship between practitioner and stroke survivor. Ambivalence stemmed from practitioners’ uncertainty about the intervention theory and mechanisms of action. Making intervention mechanisms of action more explicit to practitioners may influence how they implement and adapt a research intervention, and may determine whether those processes undermine or enhance outcomes.

Adaptive Robust of RBF Neural Network Control Based on Model Local Approximation Method for Upper Limb Rehabilitation Robotic Arm

For the problem of patient spasm disturbance and random disturbance of external environment in rehabilitation process of upper limb rehabilitation arm, Considering the approximation ability of neural network for arbitrary functions, an adaptive robust of radial basis function (RBF) neural network control algorithm based on model local approximation is proposed. This control algorithm introduces robust term to reduce the approximation error of neural network and the robustness of the rehabilitation manipulator control system is improved. The system can also obtain good track tracking performance under the condition of patient spasm disturbance and random disturbance of external environment. The asymptotic stability of the control system is proved by the stability theory of Lyapunov. Simulation results show that the proposed control algorithm has good control performance.

Rehabilitation of the upper arm early after stroke: Video games versus conventional rehabilitation. A randomized controlled trial.

Few rehabilitation methods have proven their efficacy in increasing sensori-motor recovery and/or function of the upper limb (UL) after stroke. Video games (VGs) are promising tools in this indication. To compare UL rehabilitation by using VGs and conventional rehabilitation (CR) in patients with sub-acute stroke. Single-blind, multicentric trial, with central randomization and stratification by center. Physical and rehabilitation medicine departments of 2 university hospitals. Adults within 3 months after a first vascular cerebral accident, with UL Fugl Meyer Score (UL-FMS)<30/66 and without major cognitive impairment. A 45-min additional session of conventional occupational therapy (OT) or a VG-based OT session as add-on therapy to usual rehabilitation programs, 5 days/week for 6 weeks. Primary outcome: UL-FMS. Secondary outcome: Box and Block Test (BBT), Wolf Motor Function test (WMFT), Motor Activity Log (MAL), Barthel Index and quality of life (SF-36). We included 51 patients (20 women) at a mean (SD) of 27.2 (19.4) days post-stroke (mean age 58 years [range 24-83]), 26 in the CR group and 25 in the VG group (23 in each group at 6-month follow-up). The mean duration of the additional rehabilitation session was similar in both groups: 29.3 (4.3) vs 28.0 (4.4) min in CR and VG groups. Shoulder pain occurred in 4 patients in the VG group versus 7 in the CR group. At day 45, gain in UL-FMS did not significantly differ between the groups (CR mean 17.8 [14.6] vs VG 24.1 [14.8]; P=0.10), whereas gain in BBT was doubled in the VG group (CR 7.4 [12.2] vs VG 15.7 [16.3]; P=0.02). At 6-month follow-up, the study was inconclusive about between-group differences in UL-FMS, BBT and other criteria. Post-hoc analysis showed that gains in UL-FMS or BBT were significantly higher in the VG than CR group for patients included within 30 days post-stroke. In general, we cannot conclude that video gaming and conventional OT led to different long-term sensorimotor recovery of the UL after sub-acute stroke. However, when applied within the first month after stroke, video gaming was more efficient than conventional rehabilitation on both sensorimotor recovery and gross grasping function. ClinicalTrials.gov (NCT01554449).

Influence of bimanual exercise on muscle activation in post-stroke patients

Brain damage due to stroke often leaves survivors with lateral functional motor deficits. Bimanual rehabilitation of the paretic arm is an active field of research aimed at restoring normal functionality by making use of the complex neural bindings that exist between the arms. In search of an effective rehabilitation method, we introduced a group of post-stroke rehabilitation patients to a set of bimanual motion tasks with inter-manual coupling and phasing. The surface EMG profiles of the patients were compared in order to understand the effect of the motion conditions. The paretic arms of the patients were more strongly affected by the task conditions compared with the non-paretic arms. These results suggest that in-phase motion may activate neural circuits that trigger recovery. Coupling also had an effect on behavior, but the response of patients was divided between those whom coupling helped or hindered.

WITHDRAWN: Response to Commentary of Shirani and Okuda regarding “Unilateral arm rehabilitation for persons with multiple sclerosis using serious games in a virtual reality approach: Bilateral treatment effect?”

WITHDRAWN: Response to Commentary of Shirani and Okuda regarding “Unilateral arm rehabilitation for persons with multiple sclerosis using serious games in a virtual reality approach: Bilateral treatment effect?”

Response to commentary of Shirani and Okuda regarding "Unilateral arm rehabilitation for persons with multiple sclerosis using serious games in a virtual reality approach: Bilateral treatment effect?"

Response to commentary of Shirani and Okuda regarding "Unilateral arm rehabilitation for persons with multiple sclerosis using serious games in a virtual reality approach: Bilateral treatment effect?"

Mechanical Design and Kinematic Modeling of a Cable-Driven Arm Exoskeleton Incorporating Inaccurate Human Limb Anthropomorphic Parameters.

Compared with conventional exoskeletons with rigid links, cable-driven upper-limb exoskeletons are light weight and have simple structures. However, cable-driven exoskeletons rely heavily on the human skeletal system for support. Kinematic modeling and control thus becomes very challenging due to inaccurate anthropomorphic parameters and flexible attachments. In this paper, the mechanical design of a cable-driven arm rehabilitation exoskeleton is proposed to accommodate human limbs of different sizes and shapes. A novel arm cuff able to adapt to the contours of human upper limbs is designed. This has given rise to an exoskeleton which reduces the uncertainties caused by instabilities between the exoskeleton and the human arm. A kinematic model of the exoskeleton is further developed by considering the inaccuracies of human-arm skeleton kinematics and attachment errors of the exoskeleton. A parameter identification method is used to improve the accuracy of the kinematic model. The developed kinematic model is finally tested with a primary experiment with an exoskeleton prototype.

A systematic review of upper limb activity measures for 5- to 18-year-old children with bilateral cerebral palsy.

To investigate measurement properties and feasibility of upper limb activity measures in children aged 5-18years with bilateral cerebral palsy (CP). Five electronic databases were searched to identify measures of upper limb activity with published psychometric data for children with bilateral CP aged 5-18years. Measures included both Patient-Reported Outcome Measures (PROMs) and observational measures. The COnsensus-based Standards for selection of health Measurement Instruments checklist was used to evaluate methodological quality of studies for each measure. Forty-eight measures were identified, eight of which met inclusion criteria for reliability and validity. Four PROMs were included: the ABILHAND-Kids and Children's Arm Rehabilitation Measure are parent questionnaires measuring overall manual ability; the ACTIVLIM-CP is a parent questionnaire measuring global activity (upper and lower extremity) performance, and, the Pediatric Upper Limb Measure, Short Form is a child self-report questionnaire. Four observational measures were included: the Both Hands Assessment (BoHA) is an observational measure of bimanual activity performance; the Melbourne Assessment of Unilateral Upper Limb Function and the Melbourne Assessment 2 measure quality of movement of each upper limb separately, and the Peabody Developmental Motor Scales-Second Edition assesses fine motor skill capacity in young children. Based upon available evidence, the most suitable PROM for evaluation of upper limb activity in children with bilateral CP is the ACTIVLIM-CP, and the most suitable observational measure is the BoHA. Selection of upper limb measures depend on clinical information required and available resources. The BoHA is the only observational-based assessment which measures bimanual upper limb activity performance in children with bilateral CP. Recommendation for future measurement studies include familiarisation with the standards required for excellence, which include adequate sample size and content validity studies for PROMs.

Robot-Assisted Arm Training in Chronic Stroke: Addition of Transition-to-Task Practice

Background. Robot-assisted therapy provides high-intensity arm rehabilitation that can significantly reduce stroke-related upper extremity (UE) deficits. Motor improvement has been shown at the joints trained, but generalization to real-world function has not been profound. Objective. To investigate the efficacy of robot-assisted therapy combined with therapist-assisted task training versus robot-assisted therapy alone on motor outcomes and use in participants with moderate to severe chronic stroke-related arm disability. Methods. This was a single-blind randomized controlled trial of two 12-week robot-assisted interventions; 45 participants were stratified by Fugl-Meyer (FMA) impairment (mean 21 ± 1.36) to 60 minutes of robot therapy (RT; n = 22) or 45 minutes of RT combined with 15 minutes therapist-assisted transition-to-task training (TTT; n = 23). The primary outcome was the mean FMA change at week 12 using a linear mixed-model analysis. A subanalysis included the Wolf Motor Function Test (WMFT) and Stroke Impact Scale (SIS), with significance P <.05. Results. There was no significant 12-week difference in FMA change between groups, and mean FMA gains were 2.87 ± 0.70 and 4.81 ± 0.68 for RT and TTT, respectively. TTT had greater 12-week secondary outcome improvements in the log WMFT (−0.52 ± 0.06 vs −0.18 ± 0.06; P = .01) and SIS hand (20.52 ± 2.94 vs 8.27 ± 3.03; P = .03). Conclusion. Chronic UE motor deficits are responsive to intensive robot-assisted therapy of 45 or 60 minutes per session duration. The replacement of part of the robotic training with nonrobotic tasks did not reduce treatment effect and may benefit stroke-affected hand use and motor task performance.

Unilateral arm rehabilitation for persons with multiple sclerosis using serious games in a virtual reality approach: Bilateral treatment effect?

Impairedarm function and loss of manual dexterity can lead to decreased independence in activities of daily living in persons with Multiple Sclerosis (MS). In this study we verified the feasibility and efficacy of a serious games approach to supervised upper limb rehabilitation of the more affected arm in persons with MS and the cross-over effect to the nontreated arm. MethodsEighteen persons with moderate to severe MS symptoms participated (mean age 56.1 (range 28–73) years; mean disease duration 17.6 (4–35) years). Each participant received 12 supervised sessions of serious games (45 min, 12 sessions) aimed at improving the most affected upper limb. Primary outcomes were the Nine Hole Peg Test (9HPT) and the Box and Blocks Test (BBT). Perceived health was evaluated pre and post intervention with SF-12 and the VAS of the EuroQual-5DL. Non parametric tests were used and P was set at 0.05. ResultsAfter the serious games training participants improved dexterity and arm function bilaterally (10–18%), however, there was a statistically significant improvement only in the treated arm (P<0.05). Perceived menthal health improved follwing training (P<0.05) but not perceived physical health. ConclusionAn in clinic intervention with a serious-games virtual reality approach positively influenced arm recovery in persons moderately to severely affected by MS, improving mainly the treated arm but with positive effects on the nontreated arm. The persons were motivated during the intervention and expressed being willing to continue this kind of training at home as part of continuity of care.

Dosage and predictors of arm practice during inpatient stroke rehabilitation: an inception cohort study

Purpose To describe the amount/type of arm practice completed by stroke survivors during inpatient rehabilitation; and establish predictors of arm practice dose achieved. Materials and methods Inception cohort study including 99 consecutively admitted stroke survivors. Amount (repetitions) and type of arm practice completed during inpatient rehabilitation and possible predictors of dose were recorded. Results Average length-of-stay was 36.9 days (standard deviation (SD) = 30.0, median = 28.0, interquartile range = 39.5) and days of therapy provided was 11.1 days (SD = 13.3, median = 6.0, IQR = 12.0). Mean number of arm practice sessions completed overall was 12.8 (SD = 15.3, median = 7.0, interquartile range = 15.0), or 2.0 sessions per week (SD = 1.5, median = 1.5, interquartile range = 1.7). Mean repetitions of practice completed per therapy day was 86.1 (SD = 76.5, median = 68.5, interquartile range = 88.2). Variation in practice dose was best explained by age (−1.3 repetitions per year of age, p = 0.04) and cognitive impairment (−34.9 repetitions, p = 0.03). In participants without cognitive impairment (n = 73) variation in dose was best explained by stroke severity (modified Rankin Sale = 5, –48.4 repetitions, p = 0.01), and the inability to grasp/release (Box and Block Test = 0, +48.3 repetitions, p = 0.03). Conclusions The amount of arm practice completed was low. Daily sessions were often not provided as recommended in clinical guidelines. Clinicians should focus on strategies to increase intensity and opportunities for arm practice. Implications for Rehabilitation Dose (repetitions) of arm practice varied greatly during inpatient rehabilitation. Number of arm rehabilitation sessions provided was lower than levels recommended in clinical guidelines. Therapists and researchers should focus on strategies to increase amount of therapy and opportunities for arm practice.

Physiological reactions in single-player and competitive arm rehabilitation games.

This study aims to explore the relationship between the stress level and the exercise intensity performing a rehabilitation task, aided by an upper limb rehabilitation robot, in a game in single-player mode and competitive mode. The stress level has been estimated by means of the Galvanic Skin Response(GSR). The results prove that to employ a social game mode like the competitive one, makes possible to increase the intensity level increasing the stress level to a lesser extent than in single-player modes.

Designing Configurable Arm Rehabilitation Games: How Do Different Game Elements Affect User Motion Trajectories?

For successful rehabilitation of a patient after a stroke or traumatic brain injury, it is crucial that rehabilitation activities are motivating, provide feedback and have a high rate of repetitions. Advancements in recent technologies provide solutions to address these aspects where needed. Additionally, through the use of gamification, we are able to increase the motivation for participants. However, many of these systems require complex set-ups, which can be a big challenge when conducting rehabilitation in a home-based setting. To address the lack of simple rehabilitation tools for arm function for a home-based application, we previously developed a system, Cellulo for rehabilitation, that is comprised of paper-supported tangible robots that are orchestrated by applications deployed on consumer tablets. These components enable different features that allow for gamification, easy setup, portability, and scalability. To support the configuration of game elements to patients' level of motor skills and strategies, their motor trajectories need to be classified. In this paper, we investigate the classification of different motor trajectories and how game elements impact these in unimpaired, healthy participants. We show that the manipulation of certain game elements do have an impact on motor trajectories, which might indicate that it is possible to adapt the arm remediation of patients by configuring game elements. These results provide a first step towards providing adaptive rehabilitation based upon patients' measured trajectories.

Reduced Upper Limb Recovery in Subcortical Stroke Patients With Small Prior Radiographic Stroke.

Background: Research imaging costs limit lesion-based analyses in already expensive large stroke rehabilitation trials. Despite the belief that lesion characteristics influence recovery and treatment response, prior studies have not sufficiently addressed whether lesion features are an important consideration in motor rehabilitation trial design.Objective: Using clinically-obtained neuroimaging, evaluate how lesion characteristics relate to upper extremity (UE) recovery and response to therapy in a large UE rehabilitation trial.Methods: We reviewed lesions from 297 participants with mild-moderate motor impairment in the Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) study and their association with motor recovery, measured by the UE Fugl-Meyer (UE-FM). Significant lesion features identified on correlational and bivariate analysis were further analyzed for associations with recovery and therapy response using longitudinal mixed models.Results: Prior radiographic stroke was associated with less recovery on UE-FM in participants with motor impairment from subsequent subcortical stroke (−5.8 points) and in the overall sample (−3.6 points), but not in participants with cortical or mixed lesions. Lesion volume was also associated with less recovery, particularly after subcortical stroke. Every decade increase in age was associated with 1 less point of recovery on UE-FM. Response to specific treatment regimens varied based on lesion characteristics. Subcortical stroke patients experienced slightly less recovery with higher doses of upper extremity task-oriented training. Participants with cortical or mixed lesions experienced more recovery with higher doses of usual and customary therapy. Other imaging features (leukoaraiosis, ischemic vs. hemorrhagic stroke) were not significant.Conclusions: ICARE clinical imaging revealed information useful for UE motor trial design: stratification of persons with and without prior radiographic stroke may be required in participants with subcortical stroke, the majority of motor rehabilitation trial participants. Most of the prior radiographic strokes were small and cortically-based, suggesting even minor prior brain injury remote to the acute stroke lesion may limit spontaneous and therapy-related recovery. Lesion location may be associated with response to different therapy regimens, but the effects are variable and of unclear significance.