Philippe S. Archambault

Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: Systematic review and meta-analysis of the literature

We systematically reviewed and analyzed the literature to find randomized controlled trials (RCTs) that employed robotic devices in upper-limb rehabilitation of people with stroke. Out of 574 studies, 12 matching the selection criteria were found. The Fugl-Meyer, Functional Independence Measure, Motor Power Scale, and Motor Status Scale outcome measures from the selected RCTs were pooled together, and the corresponding effect sizes were estimated. We found that when the duration/intensity of conventional therapy (CT) is matched with that of the robot-assisted therapy (RT), no difference exists between the intensive CT and RT groups in terms of motor recovery, activities of daily living, strength, and motor control. However, depending on the stage of recovery, extra sessions of RT in addition to regular CT are more beneficial than regular CT alone in motor recovery of the hemiparetic shoulder and elbow of patients with stroke; gains are similar to those that have been observed in intensive CT.

Recruitment and sequencing of different degrees of freedom during pointing movements involving the trunk in healthy and hemiparetic subjects.

Abstract Previous studies have shown that in neurologically normal subjects the addition of trunk motion during a reaching task does not affect the trajectory of the arm endpoint. Typically, the trunk begins to move before the onset and continues to move after the offset of the arm endpoint displacement. This observation shows that the potential contribution of the trunk to the motion of the arm endpoint toward a target is neutralized by appropriate compensatory movements of the shoulder and elbow. We tested the hypothesis that cortical and subcortical brain lesions may disrupt the timing of trunk and arm endpoint motion in hemiparetic subjects. Eight hemiparetic and six age-matched healthy subjects were seated on a stool with the right (dominant) arm in front of them on a table. The tip of the index finger (the arm endpoint) was initially at a distance of 20 cm from the midline of the chest. Wrist, elbow, and upper body positions as well as the coordinates of the arm endpoint were recorded with a three-dimensional motion analysis system (Optotrak) by infrared light-emitting diodes placed on the tip of the finger, the styloid process of the ulna, the lateral epicondyle of the humerus, the acromion processes bilaterally, and the sternal notch. In response to a preparatory signal, subjects lifted their arm 1–2 cm above the table and in response to a ”go” signal moved their endpoint as fast as possible from a near to a far target located at a distance of 35 cm and at a 45° angle to the right or left of the sagittal midline of the trunk. After a pause (200– 500 ms) they moved the endpoint back to the near target. Pointing movements were made without trunk motion (control trials) or with a sagittal motion of the trunk produced by means of a hip flexion or extension (test trials). In one set of test trials, subjects were required to move the trunk forward while moving the arm to the target (”in-phase movements”). In the other set, subjects were required to move the trunk backward when the arm moved to the far target (”out-of-phase movements”). Compared with healthy subjects, movements in hemiparetic subjects were segmented, slower, and characterized by a greater variability and by deflection of the trajectory from a straight line. In addition, there was a moderate increase in the errors in movement direction and extent. These deficits were similar in magnitude whether or not the trunk was involved. Although hemiparetic subjects were able to compensate the influence of the trunk motion on the movement of the arm endpoint, they accomplished this by making more segmented movements than healthy subjects. In addition, they were unable to stabilize the sequence of trunk and arm endpoint movements in a set of trials. It is concluded that recruitment and sequencing of different degrees of freedom may be impaired in this population of patients. This inability may partly be responsible for other deficits observed in hemiparetic subjects, including an increase in movement segmentation and duration. The lack of stereotypic movement sequencing may imply that these subjects had deficits in learning associated with short-term memory.

Evaluation of the JACO robotic arm: Clinico-economic study for powered wheelchair users with upper-extremity disabilities

Many activities of daily living, such as picking up glasses, holding a fork or opening a door, which most people do without thinking, can become insurmountable for people who have upper extremity disabilities. The alternative to asking for human help is to use some assistive devices to compensate their loss of mobility; however, many of those devices are limited in terms of functionality. Robotics may provide a better approach for the development of assistive devices, by allowing greater functionality. In this paper, we present results of a study (n=31) which objectives were to evaluate the efficacy of a new joystick-controlled seven-degree of freedom robotic manipulator and assess its potential economic benefits. Results show that JACO is easy to use as the majority of the participants were able to accomplish the testing tasks on their first attempt. The economic model results inferred that the use of the JACO arm system could potentially reduce caregiving time by 41%. These study results are expected to provide valuable data for interested parties, such as individuals with disabilities, their family or caregivers.

Cortical Mechanisms for Online Control of Hand Movement Trajectory: The Role of the Posterior Parietal Cortex

The parietal mechanisms for the control of hand movement trajectory were studied by recording cell activity in area 5 of monkeys making direct reaches to visual targets and online corrections of movement trajectory, after change of target location in space. The activity of hand-related cells was fitted with a linear model including hand position, movement direction, and speed. The neural activity modulation mostly led, but also followed, hand movement. When a change of hand trajectory occurred, the pattern of activity associated with the movement to the first target evolved into that typical of the movement to the second one, thus following the corresponding variations of the hand kinematics. The visual signal concerning target location in space did not influence the firing activity associated with the direction of hand movement within the first 150 ms after target presentation. This might be the time necessary for the visuo-motor transformation underlying reaching. We conclude that online control of hand trajectory not only resides in the relationships between neural activity and kinematics, but, under specific circumstances, also on the coexistence of signals about ongoing and future hand movement direction.

The cortical network for eye-hand coordination and its relevance to understanding motor disorders of parietal patients

Cortical neurons in both superior (SPL) and inferior (IPL) parietal lobules are modulated by a variety of signals concerning planning and execution of eye and hand movement. Thanks to these properties, parietal neurons are ideally suited for eye-hand coordination during reaching. In SPL, a fundamental feature of neurons is the invariance of their directional tuning properties across tasks that require different forms of spatial relationships between the eye and the hand. In such conditions, the orientation of the preferred directions (PDs) of individual SPL cells cluster within a limited sector of space, the global tuning field (GTF), to be regarded as an ideal frame to dynamically match eye and hand signals on the basis of the orientation of their PDs. At the population level, the mean vectors of the GTF cover the direction continuum in a uniform fashion. These neurons are part of a parietal network richly interconnected with the premotor and motor areas of the frontal lobe. Thus, the reaching disorders of patients with optic ataxia might be interpreted as a consequence of the breakdown of the combinatorial mechanisms of the GTF of parietal neurons, and of their interplay with premotor cortex. In IPL, the main feature of eye and/or hand related neurons is the uneven distribution of their PDs, that mostly point toward the contralateral space. This anisotropy of the representation of directional motor space might explain the movement disorders that characterize directional hypokinesia in neglect patients. In conclusion, the study of the dynamic properties of parietal neurons and of their relationships with the premotor cortex via cortico-cortical connections provides a basis for an interpretation of movement disorders of parietal patients from a neurophysiological perspective.

Online Control of Hand Trajectory and Evolution of Motor Intention in the Parietofrontal System

The frontal mechanisms of motor intention were studied in dorsal premotor and motor cortex of monkeys making direct reaches to visual targets and online corrections of hand trajectory, whenever a change of the targets location occurred. This study and our previous one of parietal cortex (Archambault et al., 2009) provide a picture on the evolution of motor intention and online control of movement in the parietofrontal system. In frontal cortex, significant relationships were found between neural activity and hand kinematics (position, speed, and movement direction). When a change of motor intention occurred, the activity typical of the movement to the first target smoothly evolved into that associated with the movement toward the second one, as observed during direct reaches. Under these conditions, parietal cells remained a more accurate predictor of hand trajectory than frontal ones. The time lags of neural activity with hand kinematics showed that motor, premotor, and parietal cortex were activated sequentially. After the first targets presentation and its change of location, the population activity signaled the change of motor plan before the hand moved to the initial targets position. This signaling occurred earlier in premotor than in motor and parietal cortex. Thus, premotor cortex encodes a higher-order command for the correction of motor intention, while parietal cortex seems responsible for estimating the kinematics of the motor periphery, an essential step to allow motor cortex to modify the hand trajectory. This indicates that the parietofrontal system can update an original and not-yet-accomplished motor plan during its execution.

Development of a whole arm wearable robotic exoskeleton for rehabilitation and to assist upper limb movements

To assist physically disabled people with impaired upper limb function, we have developed a new 7-DOF exoskeleton-type robot named Motion Assistive Robotic-Exoskeleton for Superior Extremity (ETS-MARSE) to ease daily upper limb movements and to provide effective rehabilitation therapy to the superior extremity. The ETS-MARSE comprises a shoulder motion support part, an elbow and forearm motion support part, and a wrist motion support part. It is designed to be worn on the lateral side of the upper limb in order to provide naturalistic movements of the shoulder (vertical and horizontal flexion/extension and internal/external rotation), elbow (flexion/extension), forearm (pronation/supination), and wrist joint (radial/ulnar deviation and flexion/extension). This paper focuses on the modeling, design, development, and control of the ETS-MARSE. Experiments were carried out with healthy male human subjects in whom trajectory tracking in the form of passive rehabilitation exercises (i.e., pre-programmed trajectories recommended by a therapist/clinician) were carried out. Experimental results show that the ETS-MARSE can efficiently perform passive rehabilitation therapy.

Hemispheric specialization in the co-ordination of arm and trunk movements during pointing in patients with unilateral brain damage.

During pointing movements involving trunk displacement, healthy subjects perform stereotypically, selecting a strategy in which the movement is initiated with either the hand or trunk, and where the trunk continues after the end of the hand movement. In a previous study, such temporal co-ordination was not found in patients with left-hemispheric brain lesions reaching with either their dominant paretic or with their non-dominant non-paretic arm. This co-ordination deficit may be associated in part with the presence of a lesion in the dominant left hemisphere. If so, then no deficit should be observed in patients with stroke-related damage in their non-dominant right hemisphere moving with their ipsilesional arm. To verify this, 21 right-hand dominant adults (7 who had had a stroke in the right hemisphere, 7 who had had a stroke in the left hemisphere and 7 healthy subjects) pointed to two targets located on a table in front of them in the ipsilateral and contralateral workspace. Pointing was done under three movement conditions: while not moving the trunk, while bending the trunk forward and while bending the trunk backwards. The experiment was repeated with the non-paretic arm of patients with stroke and for the right and left arms of healthy subjects. Kinematic data were recorded (Optotrak). Results showed that, compared to healthy subjects, arm-trunk timing was disrupted in patients with stroke for some conditions. As in patients with lesions in the dominant hemisphere, arm-trunk timing in those with lesions in the non-dominant hemisphere was equally more variable than movements in healthy subjects. However, patients with dominant hemisphere lesions used significantly less trunk displacement than those with non-dominant hemisphere lesions to accomplish the task. The deficit in trunk displacement was not due to problems of trunk control or sitting balance since, in control experiments, all subjects were able to move the trunk the required distance, with and without the added weight of the limb. Results support the hypothesis that the temporal co-ordination of trunk and arm recruitment during pointing movements is mediated bilaterally by each hemisphere. However, the difference in the range of trunk displacement between patients with left and right brain lesions suggests that the left (dominant) hemisphere plays a greater role than the right in the control of movements involving complex co-ordination between the arm and trunk.

Basic elements of arm postural control analyzed by unloading

To address the question of how arm posture is controlled, we analyzed shoulder–elbow unloading responses in the horizontal plane for different directions of the initial load. The initial load, produced by a double-joint manipulandum, was suddenly diminished to 1of 12 randomly presented levels (60 to −10% of the initial load; in 6 out of 12 cases the final load direction varied by ±20°). Subjects were instructed “not to intervene” in response to unloading. Neither the unloading onset nor the final load level was predictable and we assumed that the responses to rapid unloading were involuntary. Unloading elicited a smooth hand movement characterized by a bell-shaped velocity profile. The changes in hand position, joint angles, and joint torques generally increased with greater amounts of unloading. For each direction of the initial load, tonic electromyographic activity of the shoulder and elbow muscles also changed, depending on the amount of unloading. The shoulder and elbow joint torques before and after unloading were a function of the difference between the actual configuration of the arm and its referent configuration (R) described by the angles at which each joint torque was zero. The R configuration changed depending on the direction of the initial load. Our electromyographic data imply that these changes result from a central modification of muscle activation thresholds. The nervous system may thus control the R configuration in a task-specific way by leaving it unchanged to generate involuntary responses to unloading or modifying it to accommodate a new load direction at the same initial position. It is concluded that the R configuration is a major variable in both intentional and involuntary control of posture.

Vestibular contribution to combined arm and trunk motion

Recent studies have shown that the hand-pointing movements within arms reach remain invariant whether the trunk is recruited or not or its motion is unexpectedly prevented. This suggests the presence of compensatory arm-trunk coordination minimizing the deflections of the hand from the intended trajectory. It has been postulated that vestibular signals elicited by the trunk motion and transmitted to the arm motor system play a major role in the compensation. One prediction of this hypothesis is that vestibular stimulation should influence arm posture and movement during reaching. It has been demonstrated that galvanic vestibular stimulation (GVS) can influence the direction of pointing movements when body motion is restrained. In the present study, we analyzed the effects of GVS on trunk-assisted pointing movements. Subjects either moved the hand to a target or maintained a steady-state posture near the target, while moving the trunk forward with the eyes closed. When GVS was applied, the final position of the hand was deviated in the lateral and sagittal direction in both tasks. This was the result of two independent effects: a deviation of the trunk trajectory and a modification of the arm position relative to the trunk. Thus, the vestibular system might be directly involved not only in the control of trunk motion but also in the arm-trunk coordination during trunk-assisted reaching movements.