Carmelo Chisari

A New Gaze-BCI-Driven Control of an Upper Limb Exoskeleton for Rehabilitation in Real-World Tasks

This paper proposes a new multimodal architecture for gaze-independent brain-computer interface (BCI)-driven control of a robotic upper limb exoskeleton for stroke rehabilitation to provide active assistance in the execution of reaching tasks in a real setting scenario. At the level of action plan, the patients intention is decoded by means of an active vision system, through the combination of a Kinect-based vision system, which can online robustly identify and track 3-D objects, and an eye-tracking system for objects selection. At the level of action generation, a BCI is used to control the patients intention to move his/her own arm, on the basis of brain activity analyzed during motor imagery. The main kinematic parameters of the reaching movement (i.e., speed, acceleration, and jerk) assisted by the robot are modulated by the output of the BCI classifier so that the robot-assisted movement is performed under a continuous control of patients brain activity. The system was experimentally evaluated in a group of three healthy volunteers and four chronic stroke patients. Experimental results show that all subjects were able to operate the exoskeleton movement by BCI with a classification error rate of 89.4±5.0% in the robot-assisted condition, with no difference of the performance observed in stroke patients compared with healthy subjects. This indicates the high potential of the proposed gaze-BCI-driven robotic assistance for neurorehabilitation of patients with motor impairments after stroke since the earliest phase of recovery.

Positive effects of robotic exoskeleton training of upper limb reaching movements after stroke

This study, conducted in a group of nine chronic patients with right-side hemiparesis after stroke, investigated the effects of a robotic-assisted rehabilitation training with an upper limb robotic exoskeleton for the restoration of motor function in spatial reaching movements. The robotic assisted rehabilitation training was administered for a period of 6 weeks including reaching and spatial antigravity movements. To assess the carry-over of the observed improvements in movement during training into improved function, a kinesiologic assessment of the effects of the training was performed by means of motion and dynamic electromyographic analysis of reaching movements performed before and after training. The same kinesiologic measurements were performed in a healthy control group of seven volunteers, to determine a benchmark for the experimental observations in the patients’ group. Moreover degree of functional impairment at the enrolment and discharge was measured by clinical evaluation with upper limb Fugl-Meyer Assessment scale (FMA, 0–66 points), Modified Ashworth scale (MA, 0–60 pts) and active ranges of motion. The robot aided training induced, independently by time of stroke, statistical significant improvements of kinesiologic (movement time, smoothness of motion) and clinical (4.6 ± 4.2 increase in FMA, 3.2 ± 2.1 decrease in MA) parameters, as a result of the increased active ranges of motion and improved co-contraction index for shoulder extension/flexion. Kinesiologic parameters correlated significantly with clinical assessment values, and their changes after the training were affected by the direction of motion (inward vs. outward movement) and position of target to be reached (ipsilateral, central and contralateral peripersonal space). These changes can be explained as a result of the motor recovery induced by the robotic training, in terms of regained ability to execute single joint movements and of improved interjoint coordination of elbow and shoulder joints.

An EMG-Controlled Robotic Hand Exoskeleton for Bilateral Rehabilitation

This paper presents a novel electromyography (EMG)-driven hand exoskeleton for bilateral rehabilitation of grasping in stroke. The developed hand exoskeleton was designed with two distinctive features: (a) kinematics with intrinsic adaptability to patients hand size, and (b) free-palm and free-fingertip design, preserving the residual sensory perceptual capability of touch during assistance in grasping of real objects. In the envisaged bilateral training strategy, the patients non paretic hand acted as guidance for the paretic hand in grasping tasks. Grasping force exerted by the non paretic hand was estimated in real-time from EMG signals, and then replicated as robotic assistance for the paretic hand by means of the hand-exoskeleton. Estimation of the grasping force through EMG allowed to perform rehabilitation exercises with any, non sensorized, graspable objects. This paper presents the system design, development, and experimental evaluation. Experiments were performed within a group of six healthy subjects and two chronic stroke patients, executing robotic-assisted grasping tasks. Results related to performance in estimation and modulation of the robotic assistance, and to the outcomes of the pilot rehabilitation sessions with stroke patients, positively support validity of the proposed approach for application in stroke rehabilitation.

Skeletal muscle and nutritional assessment in chronic renal failure patients on a protein-restricted diet.

Background.  The close relationship between protein–energy malnutrition and quality of life, morbidity and mortality, makes mandatory a careful evaluation of the nutritional status and muscle mass in chronic renal failure (CRF) patients.

Transcranial Magnetic Stimulation Studies in Alzheimer's Disease

Although motor deficits affect patients with Alzheimers disease (AD) only at later stages, recent studies demonstrated that primary motor cortex is precociously affected by neuronal degeneration. It is conceivable that neuronal loss is compensated by reorganization of the neural circuitries, thereby maintaining motor performances in daily living. Effectively several transcranial magnetic stimulation (TMS) studies have demonstrated that cortical excitability is enhanced in AD and primary motor cortex presents functional reorganization. Although the best hypothesis for the pathogenesis of AD remains the degeneration of cholinergic neurons in specific regions of the basal forebrain, the application of specific TMS protocols pointed out a role of other neurotransmitters. The present paper provides a perspective of the TMS techniques used to study neurophysiological aspects of AD showing also that, based on different patterns of cortical excitability, TMS may be useful in discriminating between physiological and pathological brain aging at least at the group level. Moreover repetitive TMS might become useful in the rehabilitation of AD patients. Finally integrated approaches utilizing TMS together with others neuro-physiological techniques, such as high-density EEG, and structural and functional imaging as well as biological markers are proposed as promising tool for large-scale, low-cost, and noninvasive evaluation of at-risk populations.

Sarcolemmal excitability in myotonic dystrophy: Assessment through surface EMG

A motor point stimulation protocol was carried out on the tibialis anterior of myotonic dystrophy (MyD) patients. The surface myoelectric signal was monitored to record average rectified value (ARV), median frequency of power spectrum (MDF), and conduction velocity (CV) parameters. The ARV curve showed a decreasing trend that reveals a reduction in the M‐wave amplitude during stimulation. MDF presented a significant decrement in the first seconds of sustained contraction, probably caused by abnormal lengthening of the depolarization zone. CV was significantly lower in patients, suggesting reduced mean fiber size.

Haptoglobin is required to prevent oxidative stress and muscle atrophy.

Background Oxidative stress (OS) plays a major role on tissue function. Several catabolic or stress conditions exacerbate OS, inducing organ deterioration. Haptoglobin (Hp) is a circulating acute phase protein, produced by liver and adipose tissue, and has an important anti-oxidant function. Hp is induced in pro-oxidative conditions such as systemic inflammation or obesity. The role of systemic factors that modulate oxidative stress inside muscle cells is still poorly investigated. Results We used Hp knockout mice (Hp-/-) to determine the role of this protein and therefore, of systemic OS in maintenance of muscle mass and function. Absence of Hp caused muscle atrophy and weakness due to activation of an atrophy program. When animals were stressed by acute exercise or by high fat diet (HFD), OS, muscle atrophy and force drop were exacerbated in Hp-/-. Depending from the stress condition, autophagy-lysosome and ubiquitin-proteasome systems were differently induced. Conclusions Hp is required to prevent OS and the activation of pathways leading to muscle atrophy and weakness in normal condition and upon metabolic challenges.

Neuroplastic Changes Following Brain Ischemia and their Contribution to Stroke Recovery: Novel Approaches in Neurorehabilitation

Ischemic damage to the brain triggers substantial reorganization of spared areas and pathways, which is associated with limited, spontaneous restoration of function. A better understanding of this plastic remodeling is crucial to develop more effective strategies for stroke rehabilitation. In this review article, we discuss advances in the comprehension of post-stroke network reorganization in patients and animal models. We first focus on rodent studies that have shed light on the mechanisms underlying neuronal remodeling in the perilesional area and contralesional hemisphere after motor cortex infarcts. Analysis of electrophysiological data has demonstrated brain-wide alterations in functional connectivity in both hemispheres, well beyond the infarcted area. We then illustrate the potential use of non-invasive brain stimulation (NIBS) techniques to boost recovery. We finally discuss rehabilitative protocols based on robotic devices as a tool to promote endogenous plasticity and functional restoration.

A Robotic System for Quantitative Assessment and Poststroke Training of Forelimb Retraction in Mice

Background. Neurorehabilitation protocols based on the use of robotic devices have recently shown to provide promising clinical results. However, their efficacy is still limited because of the poor comprehension of the mechanisms at the basis of functional enhancements. Objective. To increase basic understanding of robot-mediated neurorehabilitation by performing experiments on a rodent model of stroke. Methods. Mice were trained to pull back a handle on a robotic platform and their performances in the task were evaluated before and after a focal cortical ischemic stroke. The platform was designed for the quantitative assessment of forelimb function via a series of parameters (time needed to complete the task, t-target; average force; number of sub-movements). Results. The animals rapidly learned the retraction task and reached asymptotic performance by the fifth session of training. Within 2 to 6 days after a small, endothelin-1-induced lesion in the caudal forelimb area, mice showed an increase in t-target and number of sub-movements and a corresponding decrease in the average force exerted. These parameters returned to baseline, pre-lesion values with continued platform training (10-14 days after stroke). Conclusions. These results highlight the utility of the devised platform for characterizing post-infarct deficits and improvements of forelimb performance. Further research is warranted to widen the understanding of device-dependent rehabilitation effects.

The effects of robot-assisted gait training in progressive multiple sclerosis: A randomized controlled trial

Background: Gait and mobility impairments are common in progressive multiple sclerosis (MS), leading to reduced quality of life (QoL). Objective: In this randomized controlled study, we tested the effects of robot-assisted gait training (RAGT) and compared it to conventional physiotherapy, measuring walking ability, depression, fatigue, and QoL in patients with progressive MS and severe gait disability. Methods: Fifty-two participants (Expanded Disability Status Scale score 6–7) completed the study protocol. They received two sessions/week over 6 weeks of RAGT or conventional walking therapy. Outcome measures were Six-Minute Walk Test, Ten-Meter Walk Test, Timed Up and Go Test, Berg Balance Scale, Fatigue Severity Scale, Patient Health Questionnaire, and Short Form 36. They were performed pre-treatment, post-treatment, and at 3 months. Results: Walking endurance (p < 0.01) and balance (p < 0.01) were improved among those in the RAGT group. Positive effects on depression in both treatment groups were highlighted. However, only among those in the RAGT group was perceived physical functioning QoL increased. No significant effects on fatigue were found. Conclusion: RAGT is a treatment option in progressive MS patients with severe gait impairments to induce short-lasting effects on mobility and QoL.