José L. Pons

The H2 robotic exoskeleton for gait rehabilitation after stroke: early findings from a clinical study

AbstractBackgroundStroke significantly affects thousands of individuals annually, leading to considerable physical impairment and functional disability. Gait is one of the most important activities of daily living affected in stroke survivors. Recent technological developments in powered robotics exoskeletons can create powerful adjunctive tools for rehabilitation and potentially accelerate functional recovery. Here, we present the development and evaluation of a novel lower limb robotic exoskeleton, namely H2 (Technaid S.L., Spain), for gait rehabilitation in stroke survivors.MethodsH2 has six actuated joints and is designed to allow intensive overground gait training. An assistive gait control algorithm was developed to create a force field along a desired trajectory, only applying torque when patients deviate from the prescribed movement pattern. The device was evaluated in 3 hemiparetic stroke patients across 4 weeks of training per individual (approximately 12 sessions). The study was approved by the Institutional Review Board at the University of Houston. The main objective of this initial pre-clinical study was to evaluate the safety and usability of the exoskeleton. A Likert scale was used to measure patient’s perception about the easy of use of the device.ResultsThree stroke patients completed the study. The training was well tolerated and no adverse events occurred. Early findings demonstrate that H2 appears to be safe and easy to use in the participants of this study. The overground training environment employed as a means to enhance active patient engagement proved to be challenging and exciting for patients. These results are promising and encourage future rehabilitation training with a larger cohort of patients.ConclusionsThe developed exoskeleton enables longitudinal overground training of walking in hemiparetic patients after stroke. The system is robust and safe when applied to assist a stroke patient performing an overground walking task. Such device opens the opportunity to study means to optimize a rehabilitation treatment that can be customized for individuals.n Trial registration: This study was registered at ClinicalTrials.gov (https://clinicaltrials.gov/show/NCT02114450).

Powered exoskeletons for bipedal locomotion after spinal cord injury

OBJECTIVEnPowered exoskeletons promise to increase the quality of life of people with lower-body paralysis or weakened legs by assisting or restoring legged mobility while providing health benefits across multiple physiological systems. Here, a systematic review of the literature on powered exoskeletons addressed critical questions: What is the current evidence of clinical efficacy for lower-limb powered exoskeletons? What are the benefits and risks for individuals with spinal cord injury (SCI)? What are the levels of injury considered in such studies? What are their outcome measures? What are the opportunities for the next generation exoskeletons?nnnAPPROACHnA systematic search of online databases was performed to identify clinical trials and safety or efficacy studies with lower-limb powered exoskeletons for individuals with SCI. Twenty-two studies with eight powered exoskeletons thus selected, were analyzed based on the protocol design, subject demographics, study duration, and primary/secondary outcome measures for assessing exoskeletons performance in SCI subjects.nnnMAIN RESULTSnFindings show that the level of injury varies across studies, with T10 injuries being represented in 45.4% of the studies. A categorical breakdown of outcome measures revealed 63% of these measures were gait and ambulation related, followed by energy expenditure (16%), physiological improvements (13%), and usability and comfort (8%). Moreover, outcome measures varied across studies, and none had measures spanning every category, making comparisons difficult.nnnSIGNIFICANCEnThis review of the literature shows that a majority of current studies focus on thoracic level injury as well as there is an emphasis on ambulatory-related primary outcome measures. Future research should: 1) develop criteria for optimal selection and training of patients most likely to benefit from this technology, 2) design multimodal gait intention detection systems that engage and empower the user, 3) develop real-time monitoring and diagnostic capabilities, and 4) adopt comprehensive metrics for assessing safety, benefits, and usability.

The Phase Difference Between Neural Drives to Antagonist Muscles in Essential Tremor Is Associated with the Relative Strength of Supraspinal and Afferent Input

The pathophysiology of essential tremor (ET), the most common movement disorder, is not fully understood. We investigated which factors determine the variability in the phase difference between neural drives to antagonist muscles, a long-standing observation yet unexplained. We used a computational model to simulate the effects of different levels of voluntary and tremulous synaptic input to antagonistic motoneuron pools on the tremor. We compared these simulations to data from 11 human ET patients. In both analyses, the neural drive to muscle was represented as the pooled spike trains of several motor units, which provides an accurate representation of the common synaptic input to motoneurons. The simulations showed that, for each voluntary input level, the phase difference between neural drives to antagonist muscles is determined by the relative strength of the supraspinal tremor input to the motoneuron pools. In addition, when the supraspinal tremor input to one muscle was weak or absent, Ia afferents provided significant common tremor input due to passive stretch. The simulations predicted that without a voluntary drive (rest tremor) the neural drives would be more likely in phase, while a concurrent voluntary input (postural tremor) would lead more frequently to an out-of-phase pattern. The experimental results matched these predictions, showing a significant change in phase difference between postural and rest tremor. They also indicated that the common tremor input is always shared by the antagonistic motoneuron pools, in agreement with the simulations. Our results highlight that the interplay between supraspinal input and spinal afferents is relevant for tremor generation.

Influence of common synaptic input to motor neurons on the neural drive to muscle in essential tremor

Tremor in essential tremor (ET) is generated by pathological oscillations at 4-12 Hz, likely originating at cerebello-thalamo-cortical pathways. However, the way in which tremor is represented in the output of the spinal cord circuitries is largely unknown because of the difficulties in identifying the behavior of individual motor units from tremulous muscles. By using novel methods for the decomposition of multichannel surface EMG, we provide a systematic analysis of the discharge properties of motor units in nine ET patients, with concurrent recordings of EEG activity. This analysis allowed us to infer the contribution of common synaptic inputs to motor neurons in ET. Motor unit short-term synchronization was significantly greater in ET patients than in healthy subjects. Furthermore, the strong association between the degree of synchronization and the peak in coherence between motor unit spike trains at the tremor frequency indicated that the high synchronization levels were generated mainly by common synaptic inputs specifically at the tremor frequency. The coherence between EEG and motor unit spike trains demonstrated the presence of common cortical input to the motor neurons at the tremor frequency. Nonetheless, the strength of this input was uncorrelated to the net common synaptic input at the tremor frequency, suggesting a contribution of spinal afferents or secondary supraspinal pathways in projecting common input at the tremor frequency. These results provide the first systematic analysis of the neural drive to the muscle in ET and elucidate some of its characteristics that determine pathological tremulous muscle activity.

An adaptive control strategy for postural stability using a wearable robot

Wearable robots are expected to expand the use of robotics in rehabilitation since they can widen the assistance application context. An important aspect of a rehabilitation therapy, in terms of lower extremity assistance, is balance control. In this article, we propose and evaluate an adaptive control strategy for robotic rehabilitation therapies to guarantee static stability using a wearable robot. Postural balance control can be implemented either acting on the hip, on the ankle joint or on both, depending on the kind of perturbation acting on the subject: internal or external. Internal perturbations can be produced by any voluntary movement of the body, such as bending the trunk. External perturbations, in the form of an impact force, are applied by the exoskeleton without any prior notice to observe the proactive response of the subject. We have used a 6 degree of freedom planar lower limb exoskeleton, H1, to perform this analysis. The developed control strategy has been designed to provide the necessary assistance, related to balance recovery and postural stability, under the Assist-as-needed paradigm. The interaction forces between orthosis and subject are monitored, as they play a relevant role in the definition of assistive and resistive movements to be applied to the joints. The proposed method has been tested with 5 healthy subjects in presence of internal and external disturbances. The results demonstrate that knowing the stability limit of each subject, in combination with a therapeutically selected scaling factor, the proposed adaptive control helps in providing an effective assistance in therapy. This method is efficient in handling the individual and combined effect of external perturbations acting on any joint movements. Assisted exoskeleton control inspired by human balance control.Adaptive impedance control for effective postural stabilization.Postural stability in presence of external perturbations.Evaluation of control strategies based on individual joint control or combined action.Postural stability training for individuals with neuro-muscular disorders.

Biomechanical loading as an alternative treatment for tremor: a review of two approaches.

Background Tremor is the most common movement disorder and strongly increases in incidence and prevalence with aging. Although not life threatening, upper-limb tremors hamper the independence of 65% of people suffering from them affected persons, greatly impacting their quality of life. Current treatments include pharmacotherapy and surgery (thalamotomy and deep brain stimulation). However, these options are not sufficient for approximately 25% of patients. Therefore, further research and new therapeutic options are required to effectively manage pathological tremor. Methods This paper presents findings of two research projects in which two different wearable robots for tremor management were developed based on force loading and validated. The first consisted of a robotic exoskeleton that applied forces to tremulous limbs and consistently attenuated mild and severe tremors. The second was a neuroprosthesis based on transcutaneous neurostimulation. A total of 22 patients suffering from parkinsonian or essential tremor (ET) of different severities were recruited for experimental validation, and both systems were evaluated using standard tasks employed for neurological examination. The inclusion criterion was a postural and/or kinetic pathological upper-limb tremor resistant to medication. Results The results demonstrate that both approaches effectively suppressed tremor in most patients, although further research is required. The work presented here is based on clinical evidence from a small number of patients (nu200a=u200a10 for robotic exoskeleton and nu200a=u200a12 for the neuroprosthesis), but most had a positive response to the approaches. In summary, biomechanical loading is non-invasive and painless. It may be effective in patients who are insufficiently responsive (or have adverse reactions) to drugs or in whom surgery is contraindicated. Discussion This paper identifies and evaluates biomechanical loading approaches to tremor management and discusses their potential.

Maintenance of cutaneomuscular neuronal excitability after leg-cycling predicts lower limb muscle strength after incomplete spinal cord injury.

OBJECTIVEnControlled leg-cycling modulates H-reflex activity after spinal cord injury (SCI). Preserved cutaneomuscular reflex activity is also essential for recovery of residual motor function after SCI. Here the effect of a single leg-cycling session was assessed on cutaneomuscular-conditioned H-reflex excitability in relation to residual lower limb muscle function after incomplete SCI (iSCI).nnnMETHODSnModulation of Soleus H-reflex activity was evaluated following ipsilateral plantar electrical stimulation applied at 25-100ms inter-stimulus intervals (ISIs), before and after leg-cycling in ten healthy individuals and nine subjects with iSCI.nnnRESULTSnLeg-cycling in healthy subjects increased cutaneomuscular-conditioned H-reflex excitability between 25 and 75ms ISI (p<0.001), compared to a small loss of excitability at 75ms ISI after iSCI (p<0.05). In addition, change in cutaneomuscular-conditioned H-reflex excitability at 50ms and 75ms ISI in subjects with iSCI after leg-cycling predicted lower ankle joint hypertonia and higher Triceps Surae muscle strength, respectively.nnnCONCLUSIONnLeg-cycling modulates cutaneomuscular-conditioned spinal neuronal excitability in healthy subjects and individuals with iSCI, and is related to residual lower limb muscle function.nnnSIGNIFICANCEnCutaneomuscular-conditioned H reflex modulation could be used as a surrogate biomarker of both central neuroplasticity and lower limb muscle function, and could benchmark lower-limb rehabilitation programs in subjects with iSCI.

One central oscillatory drive is compatible with experimental motor unit behaviour in essential and Parkinsonian tremor

OBJECTIVEnPathological tremors are symptomatic to several neurological disorders that are difficult to differentiate and the way by which central oscillatory networks entrain tremorogenic contractions is unknown. We considered the alternative hypotheses that tremor arises from one oscillator (at the tremor frequency) or, as suggested by recent findings from the superimposition of two separate inputs (at the tremor frequency and twice that frequency).nnnAPPROACHnAssuming one central oscillatory network we estimated analytically the relative amplitude of the harmonics of the tremor frequency in the motor neuron output for different temporal behaviors of the oscillator. Next, we analyzed the bias in the relative harmonics amplitude introduced by superimposing oscillations at twice the tremor frequency. These findings were validated using experimental measurements of wrist angular velocity and surface electromyography (EMG) from 22 patients (11 essential tremor, 11 Parkinsons disease). The ensemble motor unit action potential trains identified from the EMG represented the neural drive to the muscles.nnnMAIN RESULTSnThe analytical results showed that the relative power of the tremor harmonics in the analytical models of the neural drive was determined by the variability and duration of the tremor bursts and the presence of the second oscillator biased this power towards higher values. The experimental findings accurately matched the analytical model assuming one oscillator, indicating a negligible functional role of secondary oscillatory inputs. Furthermore, a significant difference in the relative power of harmonics in the neural drive was found across the patient groups, suggesting a diagnostic value of this measure (classification accuracy: 86%). This diagnostic power decreased substantially when estimated from limb acceleration or the EMG. SIGNFICANCE: The results indicate that the neural drive in pathological tremor is compatible with one central network providing neural oscillations at the tremor frequency. Moreover, the regularity of this neural oscillation varies across tremor pathologies, making the relative amplitude of tremor harmonics a potential biomarker for diagnostic use.

Detection of the Onset of Voluntary Movements Based on the Combination of ERD and BP Cortical Patterns

The electroencephalographic activity allows the characterization of movement-related cortical processes. This information may lead to novel rehabilitation technologies with the patients’ cortical activity taking an active role during the intervention. For such applications, the reliability of the estimations based on the electroencephalographic activity is critical both in terms of specificity and temporal accuracy. In this study, a detector of the onset of voluntary upper-limb reaching movements based on cortical rhythms and slow cortical potentials is proposed. To that end, upper-limb movements and cortical activity were recorded while participants performed self-paced movements. A logistic regression combined the output of two classifiers: a) a naive Bayes trained to detect the event-related desynchronization at the movement onset, and b) a matched filter detecting the bereitschaftspotential. On average, 74.5±10.8 % of the movements were detected and 1.32 ± 0.87 false detections were generated per minute. The detections were performed with an average latency of -89.9 ± 349.2 ms with respect to the actual movements. Therefore, the combination of two different sources of information (event-related desynchronization and bereitschaftspotential) is proposed as a way to boost the performance of this kind of systems.

Introduction: Exoskeletons in Rehabilitation Robotics

Rehabilitation Robotics has been defined as the combination of industrial robotics and medical rehabilitation, thus encompassing many areas, including mechanical and electrical engineering, biomedical engineering, artificial intelligence and sensor and actuator technology. Medical rehabilitation often refers to the process by which human function, be it physical or cognitive, is restored at least partially to their “normal” condition.