Kiyotaka Kamibayashi

Feasibility of rehabilitation training with a newly developed wearable robot for patients with limited mobility

OBJECTIVE To investigate the feasibility of rehabilitation training with a new wearable robot. DESIGN Before-after clinical intervention. SETTING University hospital and private rehabilitation facilities. PARTICIPANTS A convenience sample of patients (N=38) with limited mobility. The underlying diseases were stroke (n=12), spinal cord injuries (n=8), musculoskeletal diseases (n=4), and other diseases (n=14). INTERVENTIONS The patients received 90-minute training with a wearable robot twice per week for 8 weeks (16 sessions). MAIN OUTCOME MEASURES Functional ambulation was assessed with the 10-m walk test (10MWT) and the Timed Up & Go (TUG) test, and balance ability was assessed with the Berg Balance Scale (BBS). Both assessments were performed at baseline and after rehabilitation. RESULTS Thirty-two patients completed 16 sessions of training with the wearable robot. The results of the 10MWT included significant improvements in gait speed, number of steps, and cadence. Although improvements were observed, as measured with the TUG test and BBS, the results were not statistically significant. No serious adverse events were observed during the training. CONCLUSIONS Eight weeks of rehabilitative training with the wearable robot (16 sessions of 90min) could be performed safely and effectively, even many years after the subjects received their diagnosis.

Voluntary motion support control of Robot Suit HAL triggered by bioelectrical signal for hemiplegia

Our goal is to enhance the quality of life of patients with hemiplegia by means of an active motion support system that assists the impaired motion such as to make it as close as possible to the motion of an able bodied person. We have developed the Robot Suit HAL (Hybrid Assistive Limb) to actively support and enhance the human motor functions. The purpose of the research presented in this paper is to propose the required control method to support voluntarily motion using a trigger based on patients bioelectrical signal. Clinical trials were conducted in order to investigate the effectiveness of the proposed control method. The first stage of the trials, described in this paper, involved the participation of one hemiplegic patient who is not able to bend his right knee. As a result, the motion support provided by the HAL moved the paralyzed knee joint according to his intention and improved the range of the subjects knee flexion. The first evaluation of the control method with one subject showed promising results for future trials to explore the effectiveness for a wide range of types of hemiplegia.

Load‐related modulation of cutaneous reflexes in the tibialis anterior muscle during passive walking in humans

Although cutaneous reflexes are known to be strongly modulated in a phase‐dependent manner during walking in both human and cat, it is not clear whether the movement‐related or the load‐sensitive afferent feedback plays a more important role in regulating this modulation. To address this issue in humans, we investigated modulation of the cutaneous reflex in the tibialis anterior muscles (TA) of 17 subjects during passive walking with a load (0%, 33%, 66% unloading of body weight) and without a load (100% unloading). These walking tasks were performed passively with a robotic gait trainer system. Cutaneous reflexes in TA, elicited by electrical stimulation to the distal tibial (Tib) and superficial peroneal (SP) nerves, were recorded during 10 different phases of the walking cycle, and the middle latency responses (MLR, 70–120 ms) were analysed. During loaded walking, the magnitudes of the MLR induced by Tib nerve stimulation were strongly increased during the late stance‐to‐early swing phase irrespective of the amount of load (phase modulation), a phenomenon that also occurred without background electromyogram in the TA. Predominant suppression of the MLR following SP nerve stimulation at the early stance phase changed to facilitation at the late stance. By contrast, the MLR following either Tib or SP nerve stimulation was not at all modulated by the stepping phase during both unloaded walking (100% unloading) and standing. These results suggest that phasic changes in the load‐related afferent information in concert with rhythmic lower limb movement play a key role in modulating cutaneous reflexes during walking.

Effect of sensory inputs on the soleus H-reflex amplitude during robotic passive stepping in humans

We investigated the modulation of the soleus (Sol) Hoffmann (H-) reflex excitability by peripheral sensory inputs during passive stepping using a robotic-driven gait orthosis in healthy subjects and spinal cord-injured patients. The Sol H-reflex was evoked at standing and at six phases during passive stepping in 40 and 100% body weight unloaded conditions. The Sol H-reflex excitability was significantly inhibited during passive stepping when compared with standing posture at each unloaded condition. During passive stepping, the H-reflex amplitude was significantly smaller in the early- and mid-swing phases than in the stance phase, which was similar to the modulation pattern previously reported for normal walking. No significant differences were observed in the H-reflex amplitude between the two unloaded conditions during passive stepping. The reflex depression observed at the early part of the swing phase during passive stepping might be attributed to the sensory inputs elicited by flexion of the hip and knee joints. The present study provides evidence that peripheral sensory inputs have a significant role in phase-dependent modulation of the Sol H-reflex during walking, and that the Sol H-reflex excitability might be less affected by load-related afferents during walking.

Facilitation of corticospinal excitability in the tibialis anterior muscle during robot-assisted passive stepping in humans

Although phasic modulation of the corticospinal tract excitability to the lower limb muscles has been observed during normal walking, it is unclear to what extent afferent information induced by walking is related to the modulation. The purpose of this study was to test the corticospinal excitability to the lower limb muscles by using transcranial magnetic stimulation (TMS) and transcranial electrical stimulation of the motor cortex while 13 healthy subjects passively stepped in a robotic driven‐gait orthosis. Specifically, to investigate the effect of load‐related afferent inputs on the corticospinal excitability during passive stepping, motor evoked potentials (MEPs) in response to the stimulation were compared between two passive stepping conditions: 40% body weight unloading on a treadmill (ground stepping) and 100% body weight unloading in the air (air stepping). In the rectus femoris, biceps femoris and tibialis anterior (TA) muscles, electromyographic activity was not observed throughout the step cycle in either stepping condition. However, the TMS‐evoked MEPs of the TA muscle at the early‐ and late‐swing phases as well as at the early‐stance phase during ground stepping were significantly larger than those observed during air stepping. The modulation pattern of the transcranial electrical stimulation‐evoked MEPs was similar to that of the TMS‐evoked MEPs. These results suggest that corticospinal excitability to the TA is facilitated by load‐related afferent inputs. Thus, these results might be consistent with the notion that load‐related afferent inputs play a significant role during locomotor training for gait disorders.

Robotic-assisted stepping modulates monosynaptic reflexes in forearm muscles in the human

Although the amplitude of the Hoffmann (H)-reflex in the forelimb muscles is known to be suppressed during rhythmic leg movement, it is unknown which factor plays a more important role in generating this suppression-movement-related afferent feedback or feedback related to body loading. To specifically explore the movement- and load-related afferent feedback, we investigated the modulation of the H-reflex in the flexor carpi radialis (FCR) muscle during robotic-assisted passive leg stepping. Passive stepping and standing were performed using a robotic gait-trainer system (Lokomat). The H-reflex in the FCR, elicited by electrical stimulation to the median nerve, was recorded at 10 different phases of the stepping cycle, as well as during quiet standing. We confirmed that the magnitude of the FCR H-reflex was suppressed significantly during passive stepping compared with during standing. The suppressive effect on the FCR H-reflex amplitude was seen at all phases of stepping, irrespective of whether the stepping was conducted with body weight loaded or unloaded. These results suggest that movement-related afferent feedback, rather than load-related afferent feedback, plays an important role in suppressing the FCR H-reflex amplitude.

Invariable H-reflex and sustained facilitation of stretch reflex with heightened sympathetic outflow

Stretch reflex shows sustained (3-min) increase with heightened sympathetic outflow [Hjortskov N, Skotte J, Hye-Knudsen C, Fallentin N. Sympathetic outflow enhances the stretch reflex response in the relaxed soleus muscle in humans. J Appl Physiol 2005;98:1366-70], but it is unknown if it accompanies a sustained increase in H-reflex. The purpose of the study was to test if there is a sustained facilitation in the H-reflex in the human soleus muscle during a variety of sustained tasks that are known to elevate sympathetic outflow. Mean arterial blood pressure, heart rate, and H- and stretch reflexes in the relaxed soleus muscle were obtained in healthy young adults who performed mental arithmetic, static handgrip exercise, post-handgrip ischemia, and cold stimulation. Each task lasted 3 min with a 3-min rest in between tasks. Data were analyzed for the initial 30 s and entire 3 min of each task. There was a heightened cardiovascular response in all tasks for both durations of analysis. An increase in H-reflex amplitude was not observed for either the initial or entire duration of the analysis. The tasks increased stretch reflex amplitude for both durations of analysis. Invariable H-reflex and sustained facilitation of stretch reflex with heightened sympathetic outflow would imply sympathetic modulation of muscle spindle sensitivity.

Facilitation of the soleus stretch reflex induced by electrical excitation of plantar cutaneous afferents located around the heel

Previous studies have demonstrated that plantar cutaneous afferents can adjust motoneuronal excitability, which may contribute significantly to the control of human posture and locomotion. However, the role of plantar cutaneous afferents with respect to their location specificity in modulating the mechanically induced stretch reflex still remains unclear. In the present study, it was hypothesized that electrical stimulation of the ipsilateral heel region of the foot is followed by a modulation of spinal excitability, leading to a facilitation of the soleus motor output. The study was performed to investigate the effect of excitation of plantar cutaneous afferents located around the heel on the soleus stretch reflex. The soleus stretch reflex was evoked by rotating the ankle joint in dorsiflexion direction at two different angular velocities of 50 and 200 degrees s(-1). A conditioning pulse train of non-noxious electrical stimulation was delivered to the plantar surface of the heel at different conditioning test intervals ranging from 5 to 100 ms. Excitation of plantar cutaneous afferents around the heel resulted in a pronounced facilitation of the soleus stretch reflex with magnitude and time course comparable for both velocities. This facilitation was manifested by a significant increase of reflex size for conditioning test intervals from 30 to 70 ms. The observed effect implies a potential functional role of cutaneous afferents in balance control conditions where the ankle is naturally disturbed, e.g., during step reactions to external perturbations.

Evaluation of fingertip force accuracy in different support conditions of exoskeleton

This paper investigates force accuracy of a human finger in three types of support conditions of an exoskeleton. The exoskeleton augments pinching force of a wearers index finger in proportion to it based on surface electromyography. Three supporting manners of the pinching force are evaluated by switching a fingertip part of the exoskeleton. One is that the assistive force is applied to the wearers finger so that the force could be sensible by the wearer. Another case is that the assistive force is directly delivered to a grasping object without a wearers fingertip. The other is that a part of the force directly affects the object and the rest affects the wearers finger. Through pilot experiments, transitions of the accuracy through training in these cases are compared each other.

Changes in corticospinal excitability during observation of walking in humans.

To address whether the passive observation of walking would induce an increase in motor cortical excitability, we examined the responses of motor-evoked potential elicited by transcranial magnetic stimulation in the tibialis anterior and soleus muscles as the participants observed naturally performed walking. Motor-evoked potentials in these muscles were significantly increased during the observation of walking throughout the entire step-cycle periods, but not during specific step periods. These findings indicate that cortical excitability can be increased not only during the observation of voluntary hand/arm movements, but also during the observation of automatic movements such as walking. It is also suggested that the present results may reflect the increased cortical excitability during the entire walking cycle.