A modular low-clearance wrist orthosis for improving wrist motion in children with cerebral palsy

Children with Cerebral Palsy (CP) often exhibit impairments in the coordination of the grip and lift phases of arm movements that directly impact their ability to perform activities of daily living (ADLs). The application of assistive robotic therapy to children with spastic hemiplegic CP has shown that augmented movement training can lead to improved functional outcomes and improved arm kinematics. Assistive robotic therapy of the wrist has been shown to help improve motor skills in stroke patients, but the devices employed are often large and obtrusive, focusing on a repeated motion rather than a task-based itinerary. Here, we propose a lightweight low clearance wrist orthosis for use in children with Cerebral Palsy that actuates pronation/supination and flexion/extension of the wrist.

Adaptation of task difficulty in rehabilitation exercises based on the user's motor performance and physiological responses

Although robot-assisted rehabilitation regimens are as effective, functionally, as conventional therapies, they still lack features to increase patients' engagement in the regimen. Providing rehabilitation tasks at a "desirable difficulty" is one of the ways to address this issue and increase the motivation of a patient to continue with the therapy program. Then the problem is to design a system that is capable of estimating the user's desirable difficulty, and ultimately, modifying the task based on this prediction. In this paper we compared the performance of three machine learning algorithms in predicting a user's desirable difficulty during a typical reaching motion rehabilitation task. Different levels of error amplification were used as different levels of task difficulty. We explored the usefulness of using participants' motor performance and physiological signals during the reaching task in prediction of their desirable difficulties. Results showed that a Neural Network approach gives higher prediction accuracy in comparison with models based on k-Nearest Neighbor and Discriminant Analysis methods.

Wrist rehabilitation in chronic stroke patients by means of adaptive, progressive robot-aided therapy

Despite distal arm impairment after brain injury is an extremely disabling consequence of neurological damage, most studies on robotic therapy are mainly focused on recovery of proximal upper limb motor functions, routing the major efforts in rehabilitation to shoulder and elbow joints. In the present study we developed a novel therapeutic protocol aimed at restoring wrist functionality in chronic stroke patients. A haptic three DoFs (degrees of freedom) robot has been used to quantify motor impairment and assist wrist and forearm articular movements: flexion/extension (FE), abduction/adduction (AA), pronation/supination (PS). This preliminary study involved nine stroke patients, from a mild to severe level of impairment. Therapy consisted in ten 1-hour sessions over a period of five weeks. The novelty of the approach was the adaptive control scheme which trained wrist movements with slow oscillatory patterns of small amplitude and progressively increasing bias, in order to maximize the recovery of the active range of motion. The primary outcome was a change in the active RoM (range of motion) for each DoF and a change of motor function, as measured by the Fugl-Meyer assessment of arm physical performance after stroke (FMA). The secondary outcome was the score on the Wolf Motor Function Test (WOLF). The FMA score reported a significant improvement (average of 9.33±1.89 points), revealing a reduction of the upper extremity motor impairment over the sessions; moreover, a detailed component analysis of the score hinted at some degree of motor recovery transfer from the distal, trained parts of the arm to the proximal untrained parts. WOLF showed an improvement of 8.31±2.77 points, highlighting an increase in functional capability for the whole arm. The active RoM displayed a remarkable improvement. Moreover, a three-months follow up assessment reported long lasting benefits in both distal and proximal arm functionalities. The experimental results of th- s preliminary clinical study provide enough empirical evidence for introducing the novel progressive, adaptive, gentle robotic assistance of wrist movements in the clinical practice, consolidating the evaluation of its efficacy by means of a controlled clinical trial.

Feature dimensionality reduction for myoelectric pattern recognition: a comparison study of feature selection and feature projection methods

This study investigates the effect of the feature dimensionality reduction strategies on the classification of surface electromyography (EMG) signals toward developing a practical myoelectric control system. Two dimensionality reduction strategies, feature selection and feature projection, were tested on both EMG feature sets, respectively. A feature selection based myoelectric pattern recognition system was introduced to select the features by eliminating the redundant features of EMG recordings instead of directly choosing a subset of EMG channels. The Markov random field (MRF) method and a forward orthogonal search algorithm were employed to evaluate the contribution of each individual feature to the classification, respectively. Our results from 15 healthy subjects indicate that, with a feature selection analysis, independent of the type of feature set, across all subjects high overall accuracies can be achieved in classification of seven different forearm motions with a small number of top ranked original EMG features obtained from the forearm muscles (average overall classification accuracy >95% with 12 selected EMG features). Compared to various feature dimensionality reduction techniques in myoelectric pattern recognition, the proposed filter-based feature selection approach is independent of the type of classification algorithms and features, which can effectively reduce the redundant information not only across different channels, but also cross different features in the same channel. This may enable robust EMG feature dimensionality reduction without needing to change ongoing, practical use of classification algorithms, an important step toward clinical utility.

Current Trends in Robot-Assisted Upper-Limb Stroke Rehabilitation: Promoting Patient Engagement in Therapy

Stroke is one of the leading causes of long-term disability today; therefore, many research efforts are focused on designing maximally effective and efficient treatment methods. In particular, robotic stroke rehabilitation has received significant attention for upper-limb therapy due to its ability to provide high-intensity repetitive movement therapy with less effort than would be required for traditional methods. Recent research has focused on increasing patient engagement in therapy, which has been shown to be important for inducing neural plasticity to facilitate recovery. Robotic therapy devices enable unique methods for promoting patient engagement by providing assistance only as needed and by detecting patient movement intent to drive to the device. Use of these methods has demonstrated improvements in functional outcomes, but careful comparisons between methods remain to be done. Future work should include controlled clinical trials and comparisons of effectiveness of different methods for patients with different abilities and needs in order to inform future development of patient-specific therapeutic protocols.

Applications of Brain-Machine Interface Systems in Stroke Recovery and Rehabilitation

Stroke is a leading cause of disability, significantly impacting the quality of life (QOL) in survivors, and rehabilitation remains the mainstay of treatment in these patients. Recent engineering and technological advances such as brain-machine interfaces (BMI) and robotic rehabilitative devices are promising to enhance stroke neu-rorehabilitation, to accelerate functional recovery and improve QOL. This review discusses the recent applications of BMI and robotic-assisted rehabilitation in stroke patients. We present the framework for integrated BMI and robotic-assisted therapies, and discuss their potential therapeutic, assistive and diagnostic functions in stroke rehabilitation. Finally, we conclude with an outlook on the potential challenges and future directions of these neurotechnologies, and their impact on clinical rehabilitation.

A survey on robotic devices for upper limb rehabilitation

The existing shortage of therapists and caregivers assisting physically disabled individuals at home is expected to increase and become serious problem in the near future. The patient population needing physical rehabilitation of the upper extremity is also constantly increasing. Robotic devices have the potential to address this problem as noted by the results of recent research studies. However, the availability of these devices in clinical settings is limited, leaving plenty of room for improvement. The purpose of this paper is to document a review of robotic devices for upper limb rehabilitation including those in developing phase in order to provide a comprehensive reference about existing solutions and facilitate the development of new and improved devices. In particular the following issues are discussed: application field, target group, type of assistance, mechanical design, control strategy and clinical evaluation. This paper also includes a comprehensive, tabulated comparison of technical solutions implemented in various systems.

Note: A compact three-axis optical force/torque sensor using photo-interrupters

By integrating four photo-interrupters in a cross-shaped structure, we developed a compact three-axis optical force/torque (F/T) sensor. The developed sensor has a diameter of 28 mm and a thickness of 7 mm. Despite simplicity and compactness, the experiments with a prototype of the proposed sensor demonstrate notably high accuracy. The RMS errors are 0.5% ± 0.1% of the maximum vertical force in z-axis, 1.9% ± 0.2% of the maximum torque in x-axis, and 2.0% ± 0.3% of the maximum torque in y-axis. It is expected that the proposed sensor allows cost-effective integration of robot systems requiring compact and multi-axis F/T sensors such as a walking assist robot.

Design of a series elastic actuator for a compliant parallel wrist rehabilitation robot

This paper presents the design of a novel linear series elastic actuator purposely designed to match the requirements of robots for wrist rehabilitation: backdriveability, intrinsic compliance, and capability to be controlled as ideal force/torque sources. An existing rehabilitation robot is adapted to include intrinsic compliance in the design. A novel linear compliant element is designed to meet dimensional and force/stiffness requirements; a force sensing scheme involving a Hall-effect sensor is optimized in FEM simulations and developed. Linearity tests of the compliant sensing element show a maximum of 4.5% of FSO combined nonlinearity and hysteresis errors. Characterization experiments show that the developed system introduces physical compliance, still guaranteeing accurate force control in a frequency range largely compatible with that required for wrist assistance during rehabilitation.

Restoring ADL function after wrist surgery in children with cerebral palsy: a novel Bilateral robot system design

Cerebral palsy is a leading cause of disability in children and reducing its effects on arm function will improve quality of life. Our goal is to train children with CP after wrist tendon transfer surgery using a robotic therapy system consisting of two robot arms and wrist robots. The therapeutic goal is to determine if the robot training combined with surgery intervention improved functional outcomes significantly more than surgery alone. To accomplish this long-term goal we have developed a Bilateral ADL Exercise Robot, BiADLER aimed at training children with CP in reach to grasp coordination on ADLs. Specifically, the robot will provide active training using an assist-as-needed. This paper presents the design concepts.

A Pre-Clinical Framework for Neural Control of a Therapeutic Upper-Limb Exoskeleton

In this paper, we summarize a novel approach to robotic rehabilitation that capitalizes on the benefits of patient intent and real-time assessment of impairment. Specifically, an upper-limb, physical human-robot interface (the MAHI EXO-II robotic exoskeleton) is augmented with a non-invasive brain-machine interface (BMI) to include the patient in the control loop, thereby making the therapy 'active' and engaging patients across a broad spectrum of impairment severity in the rehabilitation tasks. Robotic measures of motor impairment are derived from real-time sensor data from the MAHI EXO-II and the BMI. These measures can be validated through correlation with widely used clinical measures and used to drive patient-specific therapy sessions adapted to the capabilities of the individual, with the MAHI EXO-II providing assistance or challenging the participant as appropriate to maximize rehabilitation outcomes. This approach to robotic rehabilitation takes a step towards the seamless integration of BMIs and intelligent exoskeletons to create systems that can monitor and interface with brain activity and movement. Such systems will enable more focused study of various issues in development of devices and rehabilitation strategies, including interpretation of measurement data from a variety of sources, exploration of hypotheses regarding large scale brain function during robotic rehabilitation, and optimization of device design and training programs for restoring upper limb function after stroke.

Design of Wrist Gimbal: a forearm and wrist exoskeleton for stroke rehabilitation

In this paper, we present design, implementation and specifications of the Wrist Gimbal, a three degree-of-freedom (DOF) exoskeleton developed for forearm and wrist rehabilitation. Wrist Gimbal has three active DOF, corresponding to pronation/supination, flexion/extension and adduction/abduction joints. We mainly focused on a robust, safe and practical device design to facilitate clinical implementation, testing and acceptance. Robustness and mechanical rigidity was achieved by implementing two bearing supports for each of the pronation/supination and adduction/abduction axes. Rubber hard stops for each axis, an emergency stop button and software measures ensured safe operation. An arm rest with padding and straps, a handle with adjustable distal distance and height and a large inner volume contribute to ease of use, of patient attachment and to comfort. We present the specifications of Wrist Gimbal in comparison with similar devices in the literature and example data collected from a healthy subject.

A comparative analysis of speed profile models for wrist pointing movements

Following two decades of design and clinical research on robot-mediated therapy for the shoulder and elbow, therapeutic robotic devices for other joints are being proposed: several research groups including ours have designed robots for the wrist, either to be used as stand-alone devices or in conjunction with shoulder and elbow devices. However, in contrast with robots for the shoulder and elbow which were able to take advantage of descriptive kinematic models developed in neuroscience for the past 30 years, design of wrist robots controllers cannot rely on similar prior art: wrist movement kinematics has been largely unexplored. This study aimed at examining speed profiles of fast, visually evoked, visually guided, target-directed human wrist pointing movements. One thousand three-hundred ninety-eight (1398) trials were recorded from seven unimpaired subjects who performed center-out flexion/extension and abduction/adduction wrist movements and fitted with 19 models previously proposed for describing reaching speed profiles. A nonlinear, least squares optimization procedure extracted parameters' sets that minimized error between experimental and reconstructed data. Models' performances were compared based on their ability to reconstruct experimental data. Results suggest that the support-bounded lognormal is the best model for speed profiles of fast, wrist pointing movements. Applications include design of control algorithms for therapeutic wrist robots and quantitative metrics of motor recovery.

Mechanical design of a distal arm exoskeleton for stroke and spinal cord injury rehabilitation

Robotic rehabilitation has gained significant traction in recent years, due to the clinical demonstration of its efficacy in restoring function for upper extremity movements and locomotor skills, demonstrated primarily in stroke populations. In this paper, we present the design of MAHI Exo II, a robotic exoskeleton for the rehabilitation of upper extremity after stroke, spinal cord injury, or other brain injuries. The five degree-of-freedom robot enables elbow flexion-extension, forearm pronation-supination, wrist flexion-extension, and radial-ulnar deviation. The device offers several significant design improvements compared to its predecessor, MAHI Exo I. Specifically, issues with backlash and singularities in the wrist mechanism have been resolved, torque output has been increased in the forearm and elbow joints, a passive degree of freedom has been added to allow shoulder abduction thereby improving alignment especially for users who are wheelchair-bound, and the hardware now enables simplified and fast swapping of treatment side. These modifications are discussed in the paper, and results for the range of motion and maximum torque output capabilities of the new design and its predecessor are presented. The efficacy of the MAHI Exo II will soon be validated in a series of clinical evaluations with both stroke and spinal cord injury patients.

Supinator Extender (SUE): a pneumatically actuated robot for forearm/wrist rehabilitation after stroke

The robot described in this paper, SUE (Supinator Extender), adds forearm/wrist rehabilitation functionality to the UCI BONES exoskeleton robot and to the ArmeoSpring rehabilitation device. SUE is a 2-DOF serial chain that can measure and assist forearm supination-pronation and wrist flexion-extension. The large power to weight ratio of pneumatic actuators allows SUE to achieve the forces needed for rehabilitation therapy while remaining lightweight enough to be carried by BONES and ArmeoSpring. Each degree of freedom has a range of 90 degrees, and a nominal torque of 2 ft-lbs. The cylinders are mounted away from the patient's body on the lateral aspect of the arm. This is to prevent the danger of a collision and maximize the workspace of the arm robot. The rotation axis used for supination-pronation is a small bearing just below the subject's wrist. The flexion-extension motion is actuated by a cantilevered pneumatic cylinder, which allows the palm of the hand to remain open. Data are presented that demonstrate the ability of SUE to measure and cancel forearm/wrist passive tone, thereby extending the active range of motion for people with stroke.

Improving the ROM of wrist movements in stroke patients by means of a haptic wrist robot

A 3 DoFs haptic wrist robot is used to measure and/or assist the movement of the wrist on three axes: flexion/extension (F/E), abduction/adduction (A/A), pronation/ supination (P/S). An assistance scheme based on the widely used progressive splinting therapy is proposed and its efficacy is tested within a group of nine chronic stroke patients, during a pilot study consisting of 2 sessions. Preliminary outcomes show that the technique is effective with the very distal part of wrist involving F/E and A/A but results in a reduced motor improvement for the P/S where proximal part of the arm is involved.

Adaptive strategy for multi-user robotic rehabilitation games

In this paper, we discuss a strategy for the adaptation of the "difficulty level" in games intended to include motor planning during robotic rehabilitation. We consider concurrently the motivation of the user and his/her performance in a Pong game. User motivation is classified in three levels (not motivated, well motivated and overloaded). User performance is measured as a combination of knowledge of results--achieved goals and score points in the game--and knowledge of performance--joint displacement, speed, aiming, user work, etc. Initial results of a pilot test with unimpaired healthy young volunteers are also presented showing a tendency for individualization of the parameter values.

Two-Fingered Haptic Device for Robot Hand Teleoperation

A haptic feedback system is required to assist telerehabilitation with robot hand. The system should provide the reaction force measured in the robot hand to an operator. In this paper, we have developed a force feedback device that presents a reaction force to the distal segment of the operator's thumb, middle finger, and basipodite of the middle finger when the robot hand grasps an object. The device uses a shape memory alloy as an actuator, which affords a very compact, lightweight, and accurate device.

Passive velocity field control of a forearm-wrist rehabilitation robot

This paper presents design, implementation and control of a 3RPS-R exoskeleton, specifically built to impose targeted therapeutic exercises to forearm and wrist. Design of the exoskeleton features enhanced ergonomy, enlarged workspace and optimized device performance when compared to previous versions of the device. Passive velocity field control (PVFC) is implemented at the task space of the manipulator to provide assistance to the patients, such that the exoskeleton follows a desired velocity field asymptotically while maintaining passivity with respect to external applied torque inputs. PVFC is augmented with virtual tunnels and resulting control architecture is integrated into a virtual flight simulator with force-feedback. Experimental results are presented indicating the applicability and effectiveness of using PVFC on 3RPS-R exoskeleton to deliver therapeutic movement exercises.

Improving the ROM of wrist movements in stroke patients by means of a haptic wrist robot

A 3 DoFs haptic wrist robot is used to measure and/or assist the movement of the wrist on three axes: flexion/extension (F/E), abduction/adduction (A/A), pronation/ supination (P/S). An assistance scheme based on the widely used progressive splinting therapy is proposed and its efficacy is tested within a group of nine chronic stroke patients, during a pilot study consisting of 2 sessions. Preliminary outcomes show that the technique is effective with the very distal part of wrist involving F/E and A/A but results in a reduced motor improvement for the P/S where proximal part of the arm is involved.

Normalized movement quality measures for therapeutic robots strongly correlate with clinical motor impairment measures

In this paper, we analyze the correlations between four clinical measures (Fugl-Meyer upper extremity scale, Motor Activity Log, Action Research Arm Test, and Jebsen-Taylor Hand Function Test) and four robotic measures (smoothness of movement, trajectory error, average number of target hits per minute, and mean tangential speed), used to assess motor recovery. Data were gathered as part of a hybrid robotic and traditional upper extremity rehabilitation program for nine stroke patients. Smoothness of movement and trajectory error, temporally and spatially normalized measures of movement quality defined for point-to-point movements, were found to have significant moderate to strong correlations with all four of the clinical measures. The strong correlations suggest that smoothness of movement and trajectory error may be used to compare outcomes of different rehabilitation protocols and devices effectively, provide improved resolution for tracking patient progress compared to only pre- and post-treatment measurements, enable accurate adaptation of therapy based on patient progress, and deliver immediate and useful feedback to the patient and therapist.

Reaction force/torque sensing in a master-slave robot system without mechanical sensors

In human-robot cooperative control systems, force feedback is often necessary in order to achieve high precision and high stability. Usually, traditional robot assistant systems implement force feedback using force/torque sensors. However, it is difficult to directly mount a mechanical force sensor on some working terminals, such as in applications of minimally invasive robotic surgery, micromanipulation, or in working environments exposed to radiation or high temperature. We propose a novel force sensing mechanism for implementing force feedback in a master-slave robot system with no mechanical sensors. The system consists of two identical electro-motors with the master motor powering the slave motor to interact with the environment. A bimanual coordinated training platform using the new force sensing mechanism was developed and the system was verified in experiments. Results confirm that the proposed mechanism is capable of achieving bilateral force sensing and mirror-image movements of two terminals in two reverse control directions.

Performance adaptive training control strategy for recovering wrist movements in stroke patients: a preliminary, feasibility study

Background

In the last two decades robot training in neuromotor rehabilitation was mainly focused on shoulder-elbow movements. Few devices were designed and clinically tested for training coordinated movements of the wrist, which are crucial for achieving even the basic level of motor competence that is necessary for carrying out ADLs (activities of daily life). Moreover, most systems of robot therapy use point-to-point reaching movements which tend to emphasize the pathological tendency of stroke patients to break down goal-directed movements into a number of jerky sub-movements. For this reason we designed a wrist robot with a range of motion comparable to that of normal subjects and implemented a self-adapting training protocol for tracking smoothly moving targets in order to facilitate the emergence of smoothness in the motor control patterns and maximize the recovery of the normal RoM (range of motion) of the different DoFs (degrees of Freedom).

Methods

The IIT-wrist robot is a 3 DoFs light exoskeleton device, with direct-drive of each DoF and a human-like range of motion for Flexion/Extension (FE), Abduction/Adduction (AA) and Pronation/Supination (PS). Subjects were asked to track a variable-frequency oscillating target using only one wrist DoF at time, in such a way to carry out a progressive splinting therapy. The RoM of each DoF was angularly scanned in a staircase-like fashion, from the "easier" to the "more difficult" angular position. An Adaptive Controller evaluated online performance parameters and modulated both the assistance and the difficulty of the task in order to facilitate smoother and more precise motor command patterns.

Results

Three stroke subjects volunteered to participate in a preliminary test session aimed at verify the acceptability of the device and the feasibility of the designed protocol. All of them were able to perform the required task. The wrist active RoM of motion was evaluated for each patient at the beginning and at the end of the test therapy session and the results suggest a positive trend.

Conclusion

The positive outcomes of the preliminary tests motivate the planning of a clinical trial and provide experimental evidence for defining appropriate inclusion/exclusion criteria.