Harold Weingarden

Safety and tolerance of the ReWalk™ exoskeleton suit for ambulation by people with complete spinal cord injury: A pilot study

Abstract Objectives The objective of the study was to evaluate the safety and tolerance of use of the ReWalk™ exoskeleton ambulation system in people with spinal cord injury. Measures of functional ambulation were also assessed and correlated to neurological spinal cord level, age, and duration since injury. Study design Case series observational study. Setting A national spinal cord injury centre. Methods Six volunteer participants were recruited from the follow-up outpatient clinic. Safety was assessed with regard to falls, status of the skin, status of the spine and joints, blood pressure, pulse, and electrocardiography (ECG). Pain and fatigue were graded by the participants using a visual analogue scale pre- and post-training. Participants completed a 10-statement questionnaire regarding safety, comfort, and secondary medical effects. After being able to walk 100 m, timed up and go, distance walked in 6 minutes and 10-m timed walk were measured. Results There were no adverse safety events. Use of the system was generally well tolerated, with no increase in pain and a moderate level of fatigue after use. Individuals with lower level of spinal cord injury performed walking more efficiently. Conclusion Volunteer participants were able to ambulate with the ReWalk™ for a distance of 100 m, with no adverse effects during the course of an average of 13–14 training sessions. The participants were generally positive regarding the use of the system.

Video-capture virtual reality system for patients with paraplegic spinal cord injury.

This article presents results from a feasibility study of a video-capture virtual reality (VR) system used with patients who have paraplegic spinal cord injury (SCI) and who need balance training. The advantages of the VR system include providing the user with natural control of movements, the ability to use as many parts of the body as are deemed suitable within the context of therapeutic goals, and flexibility in the way the system can be adapted to suit specific therapeutic objectives. Thirteen participants with SCI experienced three virtual environments (VEs). Their responses to a Short Feedback Questionnaire showed high levels of presence. We compared performance in the environments with a group of 12 nondisabled participants. Response times for the patient group were significantly higher and percentage of success was significantly lower than that for the nondisabled group. In addition, significant moderate correlations were found between performance within a VE and static balance ability as measured by the Functional Reach Test. This study is a first step toward future studies aimed at determining the potential of using this VR system during the rehabilitation of patients with SCI.

Hybrid functional electrical stimulation orthosis system for the upper limb : Effects on spasticity in chronic stable hemiplegia

A new hybrid functional electrical stimulation orthosis system for the upper limb has been designed to allow for ease of use in the home as a daily treatment modality, as well as offer the opportunity for function enhancement. In a pilot study, the system was used by ten patients with chronic stable hemiparesis secondary to cerebral vascular accident and head injuries. The patients were referred by their treating physicians or therapists after meeting the inclusion criteria of good general health, being greater than one year after head injury, or being ten months post-stroke, with no observed neurologic changes in the prior six weeks. Each of these patients had received prolonged physical therapy, either continuous from the initial inpatient rehabilitation treatment or on an intermittent basis over a period of years. The baseline status for factors related to increased muscle tone, i.e., passive range of motion at the wrist and elbow, posture at rest, posture immediately following activity, and spasticity were quantified before the treatment protocol with the functional electrical stimulation orthosis. Active range of motion and tests of functional use of the involved upper limb were also assessed. The patients were instructed in the protocol, trained in the use of the system, and then used the electrical orthosis at home for up to several hours per day. Follow-up assessments were at six months. A statistically significant improvement was noted in all muscle tone/spasticity parameters measured. A separate report will describe the effects on voluntary motion and functional capabilities.

Eliciting Upper Extremity Purposeful Movements Using Video Games A Comparison With Traditional Therapy for Stroke Rehabilitation

Background. Video games have become popular in stroke rehabilitation; however, the nature of this intervention is not fully understood. Objectives. To compare the number of (a) purposeful and nonpurposeful repetitions of the weaker upper extremity (UE) and (b) movement accelerations as assessed by accelerometer activity counts of the weaker and stronger UEs of individuals with chronic stroke while playing video games or participating in traditional therapy. Methods. Twenty-nine individuals (mean age 59 years, 1-7 years poststroke) took part in a group intervention of video -games (n = 15) or traditional therapy (n = 14) as part of a randomized controlled trial. During 1 - 2 sessions, participants were video-taped while wearing wrist accelerometers. Assessors counted the number of repetitions and classified movements as purposeful or nonpurposeful using videotapes. The weaker UE motor impairments were correlated to movement accelerations, to determine if participants were using their potential during the sessions. Results. Participants in the video game group performed a median of 271 purposeful movements and 37 970 activity counts compared to 48 purposeful movements and 14 872 activity counts in the traditional group (z = −3.0, P = .001 and z = −1.9, P = .05, respectively). Participants in the traditional group performed a median of 26 nonpurposeful (exercises) compared with 0 in the video game group (z = −4.2, P = .000). Strong significant correlations were found between the motor ability of the weak UE to repetitions of participants in both groups (r = .86, P < .01). Participants with higher motor ability performed more repetitions. Conclusions. Video games elicited more UE purposeful repetitions and higher acceleration of movement compared with traditional therapy in individuals with chronic stroke.

Hemiplegic shoulder pain: evidence of a neuropathic origin.

Summary An underlying mechanism of hemiplegic shoulder pain might be neuropathic. Thus, treatment for neuropathic pain should be considered when treatment for nociceptive pain fails to provide an adequate solution. ABSTRACT Hemiplegic shoulder pain (HSP) is common after stroke. Whereas most studies have concentrated on the possible musculoskeletal factors underlying HSP, neuropathic aspects have hardly been studied. Our aim was to explore the possible neuropathic components in HSP, and if identified, whether they are specific to the shoulder or characteristic of the entire affected side. Participants included 30 poststroke patients, 16 with and 14 without HSP, and 15 healthy controls. The thresholds of warmth, cold, heat‐pain, touch, and graphesthesia were measured in the intact and affected shoulder and in the affected lower leg. They were also assessed for the presence of allodynia and hyperpathia, and computed tomography/magnetic resonance imaging scans of the brain were reviewed. In addition, chronic pain was characterized. Participants with HSP exhibited higher rates of parietal lobe damage (P < 0.05) compared to those without HSP. Both poststroke groups exhibited higher sensory thresholds than healthy controls. Those with HSP had higher heat‐pain thresholds in both the affected shoulder (P < 0.001) and leg (P < 0.01), exhibited higher rates of hyperpathia in both these regions (each P < 0.001), and more often reported chronic pain throughout the affected side (P < 0.001) than those without HSP. The more prominent sensory alterations in the shoulder region suggest that neuropathic factors play a role in HSP. The clinical evidence of damage to the spinothalamic‐thalamocortical system in the affected shoulder and leg, the presence of chronic pain throughout the affected side, and the more frequent involvement of the parietal cortex all suggest that the neuropathic component is of central origin.

Efficacy of a Hybrid Upper Limb Neuromuscular Electrical Stimulation System in Lessening Selected Impairments and Dysfunctions Consequent to Cerebral Damage

Objective: The purpose of this study was to test the efficacy of a new computerized neu romuscular electric stimulation system (Handmaster™) in improving selected im pairments and functional measures of patients who survived stroke and traumatic brain injury (TBI). Methods: Survivors of stroke (n = 13) and TBI (n = 7) with chronic paralysis lasting 6.8 ± 7.8 years (range 1 to 29 years) participated in a home program of elec trical stimulation. The device is a hybrid of a hand-forearm splint that incorporates five surface electrodes and a computerized electrical stimulator. The patterned stimu lation elicits finger flexion and extension, lateral pinch, and grasp of the paralyzed hand. Patients practiced daily for 3.4 ± 0.5 hours over a mean duration of 13.1 ± 6.6 weeks. Assessment included goniometric measurements of wrist and elbow rest ing posture, passive and active joints motion, linear distance of fingers to palm, Ash worth scale, and the ability to hold a 1 kg load in the affected hand. The Frenchay arm test represented hand function. Results : ANOVA tests and Wilcoxon signed rank test were employed. There were significant improvements (p = 0.01) in elbow, wrist, and fingers posture; Ash worth scale; volitional active elbow flexion (32.5 ± 12.7°); wrist extension (12.7 ± 11.1°) and flexion (9.03 ± 4.5°). Passive wrist extension improved 13.7 ± 3.6°. Thir teen patients (65 percent) had active wrist extension post stimulation compared with only three (15 percent) before study commencement. Partial completion of the Fren chay tasks were observed before stimulation in only three patients compared with partial completion of tasks by nine patients at study conclusion. Post stimulation, 16 of 20 patients were able to hold a 1 kg weight with the NESS system active, com pared with only three patients without it. Conclusions: Application of the NESS system for three to four hours daily im proves selected impairments and may help to restore partial hand functions of patients with chronic stroke or head injury. Key Words: Chronic—Stroke—Brain injury— Electrical stimulation—Motor recovery.

Long-term morbidity and mortality after spinal cord injury: 50 years of follow-up.

Objective: To determine the long-term mortality rate and the types of morbidity among all people with spinal cord injuries (SCI) that occurred during the 1948 Israel War of Independence.Method: Chart review and telephone interviews for collecting demographic data, injury characteristics, marital status, physical activities, employment, morbidity and mortality.Results: Twenty individuals with SCI (19 males, one female). There was no regular follow-up during the first 20 years post injury. The most frequent morbidities were genito-urinary, cardiovascular and decubiti. Ten (50%) had died during this overall follow-up interval. The average age at death was 60 years. The cause of death was cardiovascular in six, neoplastic disease in two, pneumonia in one, and one died from an unknown cause.Conclusions: The data analysis showed that those who died participated less in physical activity and fewer were employed as compared to the survivors.

Functional and environmental factors affecting work status in individuals with longstanding poliomyelitis

Abstract Introduction Remunerative employment is a major concern of individuals with chronic disabilities, among them, those with longstanding poliomyelitis (LSP). Although LSP is not rare there are almost no data related to work participation. Purpose The aims of the current study were to determine the effects of a number of social and functional variables as barriers or facilitators to work participation in persons with LSP. Patients and methods Charts of 123 LSP patients of working age that were seen in the post-polio outpatient clinic, between the years 2000 and 2005 were reviewed for the study. Data on age, gender, family status, level of function in activities of daily living, basic, and extended (B-ADL and E-ADL), and mobility were then analyzed for correlation to the vocational status. Results Seventy-two people (58.5%) were employed at the time of the survey. Gender and marital status were not found to significantly differ as regard to employment. Using assistive devices for mobility or being dependent for basic ADL were associated with lower levels of employment. Driving was positively associated with the employment status of the LSP individuals. Conclusion Persons with LSP encounter important barriers to work participation, particularly on the International Classification of Functioning, Disability, and Health (ICF) components of activity and environment.

Video-games used in a group setting is feasible and effective to improve indicators of physical activity in individuals with chronic stroke: a randomized controlled trial

Objectives: To investigate the feasibility of using video-games in a group setting and to compare the effectiveness of video-games as a group intervention to a traditional group intervention for improving physical activity in individuals with chronic stroke. Design: A single-blind randomized controlled trial with evaluations pre and post a 3-month intervention, and at 3-month follow-up. Compliance (session attendance), satisfaction and adverse effects were feasibility measures. Grip strength and gait speed were measures of physical activity. Hip accelerometers quantified steps/day and the Action Research Arm Test assessed the functional ability of the upper extremity. Results: Forty-seven community-dwelling individuals with chronic stroke (29-78 years) were randomly allocated to receive video-game (N=24) or traditional therapy (N=23) in a group setting. There was high treatment compliance for both interventions (video-games-78%, traditional therapy-66%), but satisfaction was rated higher for the video-game (93%) than the traditional therapy (71%) (χ2=4.98, P=0.026). Adverse effects were not reported in either group. Significant improvements were demonstrated in both groups for gait speed (F=3.9, P=0.02), grip strength of the weaker (F=6.67, P=0.002) and stronger hands (F=7.5, P=0.001). Daily steps and functional ability of the weaker hand did not increase in either group. Conclusions: Using video-games in a small group setting is feasible, safe and satisfying. Video-games improve indicators of physical activity of individuals with chronic stroke.

Neuromodulation by functional electrical stimulation (FES) of limb paralysis after stroke

Functional Electrical Stimulation (FES) in stroke patients has been demonstrated to provide clinical benefits such as improvement in movement, skills, function and decrease of spasticity. Imaging and neurophysiological studies have shown cortical excitability and reorganization. After injury, the parameters of timing, intensity, frequency, and duration of FES are still to be determined. Additional issues that should be determined are whether the changes induced by FES are long-lasting, and which clinical and electrophysiological parameters are important and to what extent.