Anita Bardeleben

Upper and lower extremity robotic devices for rehabilitation and for studying motor control

Purpose of reviewThe successful motor rehabilitation of stroke, traumatic brain-injured and spinal cord-injured patients requires an intensive and task-specific therapy approach. Budget constraints limit a hand-to-hand therapy approach, so that intelligent machines may offer a solution to promote motor recovery and obtain a better understanding of motor control. This new field of automated or robot-assisted motor rehabilitation has emerged since the 1990s. Recent findingsThis article will present clinically viable devices for upper and lower extremity rehabilitation. The MIT-Manus and the Mirror-Image Motion Enabler robot, which enable unrestricted unilateral or bilateral shoulder and elbow movement, consistently proved superior on the motor impairment level. The ARM guide, which assisted reaching in a straight-line trajectory, and the Bi-Manu-Track, which enabled the bilateral practice of a forearm and wrist movement, are currently being tested. For gait rehabilitation after stroke, the electromechanical gait trainer, GT I, has proved effective compared with treadmill training with body weight support. The Lokomat, consisting of a treadmill and a powered exoskeleton, lessened the therapeutic effort compared with manually assisted treadmill training in spinal cord-injured patients. Future developments will see more degrees of freedom, improved man-machine interaction and the implementation of virtual reality. SummaryTechnical possibilities are one aspect, but multi-centre trials and a consideration of the unsubstantiated fears among therapists of being replaced by machines will decide on the successful implementation of this most promising field to the benefit of patients.

Treadmill training with partial body weight support and physiotherapy in stroke patients: a preliminary comparison

Treadmill training with partial body weight support can restore the gait ability of chronic non‐ambulatory hemiparetic subjects. A combination of physiotherapy and treadmill training may accelerate the rate of recovery. Therefore a randomized study was planned. Twenty‐eight non‐ambulatory hemiparetic patients were randomly assigned to group A or B. A 3‐week baseline of conventional therapy was followed by 15 sessions of physiotherapy and treadmill training in patients of group A and by 15 sessions of treadmill training in patients of group B over a period of 3 weeks. Follow‐up was 4 months later. The major outcome variables were gait ability and ground level walking velocity. Gait ability and velocity did not change during the baseline. In group B, five patients became independent walkers after the specific intervention, whereas 10 patients of group A regained independent walking ability in the same period (P < 0.05). Four months later group differences had waned. Three weeks of treadmill training plus physiotherapy accelerated the restoration of gait ability in hemiparetic subjects, however, the double amount of therapy in group A does not exclude a simple dose–response phenomenon.

An Electromechanical Gait Trainer for Restoration of Gait in Hemiparetic Stroke Patients: Preliminary Results

Modem concepts of gait rehabilitation after stroke favor a task-specific repeti tive approach. In practice, the required physical effort of the therapists limits the re alization of this approach. Therefore, a mechanized gait trainer enabling nonambula tory patients to have the repetitive practice of a gait-like movement without overstraining therapists was constructed. This preliminary study investigated whether an additional 4-week daily therapy on the gait trainer could improve gait ability in 14 chronic wheelchair-bound hemiparetic subjects. The 4 weeks of physiotherapy and gait-trainer therapy resulted in a relevant improvement of gait ability in all subjects. Velocity, cadence, and stride length improved significantly (p < 0.01). The kinesio logic electromyogram of selected lower-limb muscles revealed a more physiologic pat tern. The confounding influence of spontaneous recovery, the lack of a control group, and the double amount of therapy limit the clinical relevance of this study. Never theless, the gait trainer seems feasible as an adjunctive tool in gait rehabilitation after stroke; further studies are needed. Key Words: Qait trainer—Hemiparesis—Stroke— Treadmill training—Electromyography.

Treadmill training with partial body weight support after stroke

Treadmill therapy with partial BWS is a promising new approach to improve gait ability after stroke. This task-specific approach enables nonambulatory patients the repetitive practice of complex gait cycles instead of single-limb gait-preparatory maneuvers. Patients walk more symmetrically with less spasticity and better cardiovascular efficiency on the treadmill than with floor walking. Several controlled, clinical studies have shown the potential of treadmill training as a therapeutic intervention for nonambulatory patients with chronic stroke-related hemiplegia. Furthermore, controlled trials in acute stroke survivors have shown that treadmill training is as effective as other physiotherapy approaches that stress the repetitive practice of gait. Controlled multicenter trials comparing locomotor training with conventional therapy will be forthcoming. An electromechanical gait trainer that relieves the strenuous effort of the therapists and provides control of the trunk in a phase-dependent manner is a new technical alternative for gait training in severely impaired stroke patients.

Robot-assisted practice of gait and stair climbing in nonambulatory stroke patients

A novel gait robot enabled nonambulatory patients the repetitive practice of gait and stair climbing. Thirty nonambulatory patients with subacute stroke were allocated to two groups. During 60 min sessions every workday for 4 weeks, the experimental group received 30 min of robot training and 30 min of physiotherapy and the control group received 60 min of physiotherapy. The primary variable was gait and stair climbing ability (Functional Ambulation Categories [FAC] score 0-5); secondary variables were gait velocity, Rivermead Mobility Index (RMI), and leg strength and tone blindly assessed at onset, intervention end, and follow-up. Both groups were comparable at onset and functionally improved over time. The improvements were significantly larger in the experimental group with respect to the FAC, RMI, velocity, and leg strength during the intervention. The FAC gains (mean +/- standard deviation) were 2.4 +/- 1.2 (experimental group) and 1.2 +/- 1.5 (control group), p = 0.01. At the end of the intervention, seven experimental group patients and one control group patient had reached an FAC score of 5, indicating an ability to climb up and down one flight of stairs. At follow-up, this superior gait ability persisted. In conclusion, the therapy on the novel gait robot resulted in a superior gait and stair climbing ability in nonambulatory patients with subacute stroke; a higher training intensity was the most likely explanation. A large randomized controlled trial should follow.

Botulinum Toxin A Treatment of Adult Upper and Lower Limb Spasticity

This article discusses the treatment of spasticity with botulinum toxin A as a new approach in the neurological rehabilitation of patients after stroke. Clinical studies have been reviewed to provide information about target groups, technical aspects and the advantages and disadvantages of treating spasticity with botulinum toxin A. Open and controlled studies showed that the intramuscular injection of Dysport® 500 to 1500U or Botox® 100 to 300U could reversibly relieve upper limb flexor and lower limb extensor spasticity. A reduced muscle tone, pain relief, better hand hygiene and improved walking function were the main benefits. Patients tolerated the treatment well. Activity or, if not possible, electrical stimulation of the injected muscles may enhance the effectiveness of the costly toxin. Serial casting is another option. With respect to the action of botulinum toxin A, it is suggested that the effect of the toxin could be mediated by paresis of both the extrafusal and intrafusal muscle fibres, thereby altering the afferent discharge in the muscle.

The Influence of Treadmill Inclination on the Gait of Ambulatory Hemiparetic Subjects

Introduction. This study evaluated the influence of the degree of treadmill belt inclination for training of ambulatory patients with hemiparetic stroke. Methods. Twelve patients were instructed to walk at 5 different levels of inclination (0%-8%) while harness-secured on the treadmill. The gait velocity was kept constant during all conditions. Dependent variables were heart rate, gait cycle-dependent parameters, and electromyographic activation patterns of the weight-bearing muscles. Results. Heart rate increased across all inclination levels, stride length increased and cadence decreased, whereas swing symmetry improved due to shortening of the relative swing phase of the affected side at the 6% and 8% inclination levels. No change in the activation pattern of the leg muscles was found. Conclusion. An inclination up to at least 8% can be accommodated for treadmill training by ambulatory stroke patients. For a given belt speed, heart rate increased without exceeding critical levels and patients walked with a more symmetric pattern. This protocol appeared to be safe in this selected group of subjects.

Management of Upper and Lower Limb Spasticity in Neuro-Rehabilitation

This article reviews the treatment of upper and lower limb spasticity in neurological rehabilitation. Botulinum toxin A proved effective in several placebo-controlled studies reducing muscle tone, easing hand hygiene and nursing, improving upper limb motor functions and gait ability. The effects are reversible and the toxin is well tolerated. Electrical stimulation, tonic stretch post injection and the active use of the treated extremity are means to increase the effectiveness of the costly therapy. Phenol 5% is an alternative in case of budget constraints, but the technique is demanding and side effects are more frequent. Further, task-specific repetitive therapy should follow the successful treatment of focal spasticity in eligible patients to get the maximum profit with regard to disability.

Magnetic Grip Facilitates Feeding With Weakened Hands After Spinal Cord Injury

We describe a simple alternative method to hold a fork when the fingers are too weak to grip it. A 56-year-old right-handed man became tetraparetic 21 months earlier, following a traumatic C7/T1, ASIA grade A, spinal cord injury. He had no useful movement in his right hand, but had voluntary left wrist extension against gravity and could extend and flex his fingers if gravity were eliminated. Left-hand sensation was moderately impaired; tone was normal. He ate with a fork held in a utensil strap on his left hand with much effort. Because of frequent spills and the associated social stigma, he often relied on his wife to feed him. He was unable to use adapted or broad-handled cutlery. The couple contacted the rehabilitation service in search of an alternative feeding technique.