S. Mazzoleni

Robot-mediated therapy for paretic upper limb of chronic patients following neurological injury

OBJECTIVE To evaluate the effectiveness of robot-mediated therapy targeted at the motor recovery of the upper limb in chronic patients following neurological injury. DESIGN Pre-post treatment study. SUBJECTS Twenty patients were enrolled in the study. METHODS Robot-mediated therapy was provided to chronic hemiparetic patients (acute event had occurred at least one year prior to the study), 3 times a week, for 6 weeks. The therapy consisted of goal-directed, planar reaching tasks that exercised the hemiparetic shoulder and elbow. The items for the shoulder and elbow of Motor Status Score, Modified Ashworth Scale and range of motion were used as outcome measures. RESULTS Statistically significant improvements before and after treatment were found in each outcome measure. A 3-month follow-up evaluation indicated that patients maintained the improvements. CONCLUSION The results confirm that robot-mediated therapy, through short-term, but intensive, repetitive and goal-directed trials, contributes to a decrease in the upper limbs motor disability in people with a chronic neurological injury by reducing motor impairment and shoulder pain. The treatment was well accepted and tolerated by patients. No adverse events occurred.

Recovery of hand function with robot-assisted therapy in acute stroke patients: a randomized-controlled trial.

In the last few years, not many studies on the use of robot-assisted therapy to recover hand function in acute stroke patients have been carried out. This randomized-controlled observer trial is aimed at evaluating the effects of intensive robot-assisted hand therapy compared with intensive occupational therapy in the early recovery phases after stroke with a 3-month follow-up. Twenty acute stroke patients at their first-ever stroke were enrolled and randomized into two groups. The experimental treatment was performed using the Amadeo Robotic System. Control treatment, instead, was carried out using occupational therapy executed by a trained physiotherapist. All participants received 20 sessions of treatment for 4 consecutive weeks (5 days/week). The following clinical scales, Fugl-Meyer Scale (FM), Medical Research Council Scale for Muscle Strength (hand flexor and extensor muscles) (MRC), Motricity Index (MI) and modified Ashworth Scale for wrist and hand muscles (MAS), were performed at baseline (T0), after 20 sessions (end of treatment) (T1) and at the 3-month follow-up (T2). The Barthel Index was assessed only at T0 and T1. Evidence of a significant improvement was shown by the Friedman test for the FM [experimental group (EG): P=0.0039, control group (CG): P<0.0001], Box and Block Test (EG: P=0.0185, CG: P=0.0086), MI (EG: P<0.0001, CG: P=0.0303) and MRC (EG: P<0.0001, CG: P=0.001) scales. These results provide further support to the generalized therapeutic impact of intensive robot-assisted treatment on hand recovery functions in individuals with acute stroke. The robotic rehabilitation treatment may contribute toward the recovery of hand motor function in acute stroke patients. The positive results obtained through the safe and reliable robotic rehabilitation treatment reinforce the recommendation to extend it to a larger clinical practice.

Systematic review of outcome measures of walking training using electromechanical and robotic devices in patients with stroke

OBJECTIVE The aim of this systematic review was to identify appropriate selection criteria of clinical scales for future trials, starting from those most commonly reported in the literature, according to their psychometric properties and International Classification of Functioning, Disability and Health (ICF) domains. DATA SOURCES A computerized literature research of articles was conducted in MEDLINE, EMBASE, CINALH, PubMed, PsychINFO and Scopus databases. STUDY SELECTION Clinical trials evaluating the effects of electromechanical and robot-assisted gait training trials in stroke survivors. DATA EXTRACTION Fifteen independent authors performed an extensive literature review. DATA SYNTHESIS A total of 45 scales was identified from 27 studies involving 966 subjects. The most commonly used outcome measures were: Functional Ambulation Category (18 studies), 10-Meter Walking Test (13 studies), Motricity Index (12 studies), 6-Minute Walking Test (11 studies), Rivermead Mobility Index (8 studies) and Berg Balance Scale (8 studies). According to the ICF domains 1 outcome measure was categorized into Body Function and Structure, 5 into Activity and none into Participation. CONCLUSION The most commonly used scales evaluated the basic components of walking. Future studies should also include instrumental evaluation. Criteria for scale selection should be based on the ICF framework, psychometric properties and patient characteristics.

Upper Limb Spasticity Reduction Following Active Training: A Robot-Mediated Study In Patients With Chronic Hemiparesis

OBJECTIVE To compare the effects on spasticity of 2 robot-mediated therapies in patients with chronic hemiparesis. DESIGN Groups comparison. SUBJECTS Thirty-four patients, divided into 2 homogeneous groups. METHODS Outcome measures were: motor status score, Modified Ashworth scale, and range of motion. A pattern of reaching exercises was implemented, in which the direction and length of the movements were modified with the aim of reducing activity of the flexor muscles and improving extension of the arm. A 3-month follow-up was performed. RESULTS Statistically significant improvements were found in both groups after treatment. Some differences were found in elbow motor improvement between the 2 groups. CONCLUSION Comparison between groups confirms that active movement training does not result in increased hypertonia, but results in spasticity reduction in antagonist muscles by activating the reciprocal inhibition mechanism. Furthermore, robot-mediated therapy contributes to a decrease in motor impairment of the upper limbs in subjects with chronic hemiparesis, resulting in a reduction in shoulder pain.

Effects of proximal and distal robot-assisted upper limb rehabilitation on chronic stroke recovery

OBJECTIVE To evaluate the effects of add-on distal upper limb robot-assisted treatment on the outcome of proximal regions. DESIGN 64 chronic stroke patients divided into two groups participated in the study. Group A was assigned to the proximal robot-assisted rehabilitation, Group B to the proximal and distal. Shoulder/elbow subsection of Fugl-Meyer Assessment scale was collected for Group A, whereas for Group B wrist subsection was also collected. Motricity Index was used and a set of kinematic parameters was computed for both groups. RESULTS A decrease in impairment after the treatment in both groups of patients (Group A: Shoulder/elbow FM p < 0.001 and MI p < 0.001; Group B: Shoulder/elbow FM p < 0.001 and MI p < 0.001) was found. In the Group B wrist subsection of FM showed an improvement as well (p < 0.001). No difference between groups was found in changes of clinical scales. Movement velocity and accuracy increased after the robot-assisted treatment in both groups; group B showed a greater improvement in velocity. CONCLUSIONS Robotic treatment is effective to reduce motor impairment in chronic stroke patients even if distal training added to proximal segments in the Group B does not provide any incremental benefit to the proximal segments. It remains unclear if the effectiveness of robot-assisted treatment is directly related to the upper limb segment specifically treated and which order may lead to better outcome. Our study suggests that kinematic parameters should be computed in order to better clarify the role of distal training (wrist) on proximal segments (shoulder/elbow) as well.

On the use of divergent force fields in robot-mediated neurorehabilitation

The present study is aimed at developing new rehabilitation protocols to be used in post-stroke robotic-aided therapy. In the recent past, it has been suggested that the use of robotic training forces that enhance error instead of reducing it, could stimulate new learning and feedback strategies at the base of an effective motor recovery. Starting from these findings, in this work two different robotic-aided therapies were compared: the first was based on the constraint induced movement therapy, the second employed an unstable training force field increasing path errors performed by the subjects. The results shows that the use of the unstable divergent force field can increase the recovery, especially in people with mild level of impairment.

Upper Limb Robot-Assisted Therapy in Chronic and Subacute Stroke Patients: A Kinematic Analysis

Objective The aim of this study was to compare motor recovery in subacute and chronic stroke patients through clinical assessment scales and a set of kinematic parameters recorded using a robotic system. Design Fifty post-stroke patients, 25 subacute and 25 chronic, and 20 healthy subjects participated in this study. The InMotion 2.0 robotic system for shoulder/elbow rehabilitation was used. Clinical outcome measures were used for assessment. Kinematic parameters related to the speed measured at the robot’s end effector and to the movement’s smoothness were computed. Results The results of this study show that the robot-assisted training can contribute to reduce motor impairment in both subacute and chronic stroke patients. The evaluation of the kinematic parameters and their correlation with the clinical scales highlight some differences in mechanisms of recovery in subacute and chronic stroke patients. Conclusions The proposed set of kinematic parameters and the analysis of the reaching movements’ onset time, associated with a quantitative evaluation of motor improvement provided by the clinical outcome measures, are also able to quantify the changes in the quality of motion obtained after robot-assisted therapy in stroke patients. The higher gain in the subacute stroke patients suggests that the rehabilitative treatment provided at an earlier stage is able to avoid the development of pathologic patterns, resulting in a better quality of motion.

ALLADIN: A Novel Mechatronic Platform Assessing Post-Stroke Functional Recovery

In this paper the innovative ALLADIN platform for whole-body isometric force measurements to be used in neuro-rehabilitation for assessing post-stroke functional recovery is presented. A mechatronic approach was used in the design and development of this platform, which consists of an ergonomic mechanical structure embedding eight force/torque sensors that sample data about the performance of simulated activities of daily living in stroke patients. The overall ALLADIN system also includes a dedicated database, where all measures and other clinical scores are stored, and a PDA-based natural language system interface for the therapist. This paper only focuses on the mechatronic platform of the ALLADIN system. The proposed platform, which is currently being validated in three different clinical centers in Europe, aims at offering a brand new method for decision support in neuro-rehabilitation. It calculates and predicts the functional recovery of stroke patients and makes clinical assessments and quantitative measurements easily exchangeable among clinical stroke rehabilitation units

Human movement onset detection from isometric force and torque measurements: A supervised pattern recognition approach

OBJECTIVE Recent research has successfully introduced the application of robotics and mechatronics to functional assessment and motor therapy. Measurements of movement initiation in isometric conditions are widely used in clinical rehabilitation and their importance in functional assessment has been demonstrated for specific parts of the human body. The determination of the voluntary movement initiation time, also referred to as onset time, represents a challenging issue since the time window characterizing the movement onset is of particular relevance for the understanding of recovery mechanisms after a neurological damage. Establishing it manually as well as a troublesome task may also introduce oversight errors and loss of information. METHODS The most commonly used methods for automatic onset time detection compare the raw signal, or some extracted measures such as its derivatives (i.e., velocity and acceleration) with a chosen threshold. However, they suffer from high variability and systematic errors because of the weakness of the signal, the abnormality of response profiles as well as the variability of movement initiation times among patients. In this paper, we introduce a technique to optimise onset detection according to each input signal. It is based on a classification system that enables us to establish which deterministic method provides the most accurate onset time on the basis of information directly derived from the raw signal. RESULTS The approach was tested on annotated force and torque datasets. Each dataset is constituted by 768 signals acquired from eight anatomical districts in 96 patients who carried out six tasks related to common daily activities. The results show that the proposed technique improves not only on the performance achieved by each of the deterministic methods, but also on that attained by a group of clinical experts. CONCLUSIONS The paper describes a classification system detecting the voluntary movement initiation time and adaptable to different signals. By using a set of features directly derived from raw data, we obtained promising results. Furthermore, although the technique has been developed within the scope of isometric force and torque signal analysis, it can be applied to other detection problems where several simple detectors are available.

Physiologic response to various levels of pressure support and NAVA in prolonged weaning

Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation wherein the delivered assistance is proportional to diaphragm electrical activity (EAdi) throughout inspiration. We assessed the physiologic response to varying levels of NAVA and pressure support ventilation (PSV) in 13 tracheostomised patients with prolonged weaning. Each patient randomly underwent 8 trials, at four levels of assistance either in PSV and NAVA. i - high (no dyspnoea and/or distress); iv - low (associated with dyspnoea and/or distress; ii and iii - at ∼75% and ∼25% of the difference between high and low support respectively. We measured tidal volume (VT), peak EAdi, (EAdipeak) and airway pressure, ineffective efforts and breathing pattern variability. With both NAVA and PSV, decreasing assistance resulted in parallel significant increase in EAdipeak associated with a concomitant reduction in VT and minute ventilation in PSV, but not in NAVA. VT variability significantly increased when reducing ventilatory assistance in PSV only, while remained unchanged varying the NAVA level. The ineffective triggering index was not significantly different between the two modes. In patients with prolonged weaning, with the specific settings adopted, compared to PSV, NAVA reduced the risk of over-assistance and overall improved patient-ventilator interaction, while not significantly affecting patient-ventilator synchrony.