Reliability of the intelligent stretching device for ankle stiffness measurements in healthy individuals

Review of ankle rehabilitation devices for treatment of equinus contracture

INTRODUCTION

Equinus contracture is a serious disability and attention should be paid to proper and effective treatment. Most attention is given to neurologically impaired patients, but the incidence of equinus contracture is much higher, for example, in post-traumatic patients. In addition to conventional physical therapy, robotic rehabilitation treatment is one of the promising procedures to precede severe contraction cases and the need for surgery.

AREAS COVERED

This study aims to cover the description of different types of stationary and wearable ankle rehabilitation devices suitable for the treatment of equinus contracture and point to deficiency in research, clinical trials, and launch of the market.

EXPERT OPINION

This review provides insight into ankle rehabilitation devices with a focus on equinus contracture. Due to the fact that robotic devices successfully restore the condition of patients, attention should not be paid only to those with neurological impairments. This paper points that future research should be effectively linked to clinical practice with the aim of covering a wider range of disabilities and make an effort to successfully introduce devices from development into the practice.

Effects of Robot-Aided Rehabilitation on the Ankle Joint Properties and Balance Function in Stroke Survivors: A Randomized Controlled Trial

Background: Stroke survivors with impaired control of the ankle due to stiff plantarflexors often experience abnormal posture control, which affects balance and locomotion. Forceful stretching may decrease ankle stiffness and improve balance. Recently, a robot-aided stretching device was developed to decrease ankle stiffness of patient post-stroke, however, their benefits compared to manual stretching exercises have not been done in a randomized controlled trial, and the correlations between the ankle joint biomechanical properties and balance are unclear.

Objective: To compare the effects of robot-aided to manual ankle stretching training in stroke survivors with the spastic ankle on the ankle joint properties and balance function post-stroke, and further explore the correlations between the ankle stiffness and balance.

Methods: Twenty inpatients post-stroke with ankle spasticity received 20 minutes of stretching training daily over two weeks. The experimental group used a robot-aided stretching device, and the control group received manual stretching. Outcome measures were evaluated before and after training. The primary outcome measure was ankle stiffness. The secondary outcome measures were passive dorsiflexion ranges of motion, dorsiflexor muscle strength, Modified Ashworth Scale (MAS), Fugl-Meyer Motor Assessment of Lower Extremity (FMA-LE), Berg Balance Scale (BBS), Modified Barthel Index (MBI), and the Pro-Kin balance test.

Results: After training, two groups showed significantly within-group improvements in dorsiflexor muscle strength, FMA-LE, BBS, MBI (P < 0.05). The between-group comparison showed no significant differences in all outcome measures (P > 0.0025). The experimental group significantly improved in the stiffness and passive range of motion of dorsiflexion, MAS. In the Pro-Kin test, the experimental group improved significantly with eyes closed and open (P < 0.05), but significant improvements were found in the control group only with eyes open (P < 0.05). Dorsiflexion stiffness was positively correlated with the Pro-Kin test results with eyes open and the MAS (P < 0.05).

Conclusions: The robot-aided and manual ankle stretching training provided similar significant improvements in the ankle properties and balance post-stroke. However, only the robot-aided stretching training improved spasticity and stiffness of dorsiflexion significantly. Ankle dorsiflexion stiffness was correlated with balance function.

Clinical Trial Registration:www.chictr.org.cn ChiCTR2000030108.

Internal consistencies of the delayed trunk muscle reaction times following a treadmill-induced slip perturbation while holding and not holding a tray

BACKGROUND

Reaction time task performance using electromyography (EMG) has been widely studied in the evaluation of motor responses. However, specific testing conditions with tray usage and the reliability of the bilateral trunk muscle reactions have not been proven.

RESEARCH QUESTIONS

Are there internal consistencies of the reaction times for a particular condition, such as a handheld task, among the examiners? Is there a delayed reaction time on the dominant abdominal muscle in response to a treadmill-induced slip perturbation while holding or not holding a tray?

METHODS

One hundred and nineteen right upper and lower limb dominant individuals (71 female and 48 male subjects) were exposed to a treadmill-induced slip perturbation (0.24 m/s velocity for 1.2 cm) for 0.10 s in standing. The EMG electrodes were placed on both sides of the rectus abdominis (RA) and erector spinae (ES) muscles. The reliability of the test was established by using Cronbach's alpha, intra-class correlation coefficients (ICC_{2, k}), and the standard error of measurements.

RESULTS

The results for holding a tray indicated a high degree of consistency based on Cronbach's alpha for the left RA (0.79), right RA (0.86), left ES (0.82), and right ES (0.73) muscles. However, there was a significant reaction time difference among trunk muscles (F = 10.58, p = 0.002) while not holding a tray. The post-hoc results indicated that the right RA muscle was delayed more than the bilateral ES muscles, although there was no significant difference with the left RA muscle.

SIGNIFICANCE

Overall, the EMG analyses for the reaction times were highly consistent with and without tray usage. The reaction times of the dominant abdominal muscles were delayed while not holding a tray. Given the high reliability, compensatory strategies by trunk dominance might be considered with a tray usage task.

Quantifying joint stiffness in clubfoot patients

BACKGROUND

In clinical practice, clubfeet feel stiffer compared to healthy feet. Furthermore, the clinical impression is that stiffer clubfeet have a higher tendency to relapse. Until now, no objective measure has been available to determine the stiffness of clubfeet. The goal of the current project was to objectively quantify ankle and subtalar joint stiffness in clubfeet patients and to compare this stiffness between clubfeet patients and healthy controls using a newly developed measurement device.

METHODS

The newly developed Torque-Displacement-Handpiece in combination with an adjusted Abduction Dorsiflexion Mechanism clubfoot-brace, made it possible to move a foot over two rotational axis, while continuously capturing the applied torque and the achieved angulation. Based on this information, stiffness of the ankle and subtalar joint were assessed for 11 clubfoot patients with 17 clubfeet and 11 healthy subjects with 22 healthy feet.

FINDINGS

With the Torque-Displacement-Handpiece measuring device it was possible to measure torque, angulation and stiffness in a reliable and precise manner. Clubfoot patients showed less angulation and a higher stiffness for measurements over the ADM subtalar axis compared to controls. After adjusting for shoe size, the stiffness for measurements over the ADM tibiotalar axis was also significantly higher in clubfeet than controls.

INTERPRETATION

Overall, these results indicate that clubfoot patients have a higher ankle and subtalar joint stiffness in the affected joint compared to healthy controls. In the future, the Torque-Displacement-Handpiece could be used to monitor stiffness of clubfeet during treatment, and as such, play a potential role in the early detection of relapsing clubfeet.

Kinematic analysis of ankle stiffness in subjects with and without flat foot

BACKGROUND

Although the magnitude of ankle motion is influenced by joint congruence and ligament elasticity, there is a lack of understanding on ankle stiffness between subjects with and without flat foot.

OBJECTIVE

This study investigated a quantified ankle stiffness difference between subjects with and without flat foot.

METHODS

There were forty-five age- and gender-matched subjects who participated in the study. Each subject was seated upright with the tested foot held firmly onto a footplate that was attached to a torque sensor by the joint-driving device.

RESULTS

The flat foot group (mean ± standard deviation) demonstrated increased stiffness during ankle dorsiflexion (0.37 ± 0.16 for flat foot group, 0.28 ± 0.10 for control group; t=-2.11, p=0.04). However, there was no significant group difference during plantar flexion (0.35 ± 0.15 for flat foot group, 0.33 ± 0.07 for control group; t=0.64, p=0.06).

CONCLUSION

The results of this study indicated that the flat foot group demonstrated increased ankle stiffness during dorsiflexion regardless of demographic factors. This study highlights the need for kinematic analyses and joint stiffness measures during ankle dorsiflexion in subjects with flat foot.

A novel assessment technique for measuring ankle orientation and stiffness

The measurement of ankle orientation and stiffness can provide insight into improvements and allows for effective monitoring during a rehabilitation program. Existing assessment techniques have a variety of limitations. Dynamometer based methods rely on manual manipulation. The use of torque meter is usually for single degree-of-freedom (DOF) devices. This study proposes a novel ankle assessment technique that can be used for multiple DOFs devices working in both manual and automatic modes using the position sensor and the multi-axis load cell. As a preliminary evaluation, an assessment device for ankle dorsiflexion and plantarflexion was constructed. Nine subjects participated to evaluate the effectiveness of the assessment device in determining ankle orientation and stiffness. The measured ankle orientation was consistent with that from the NDI Polaris optical tracking system. The measured ankle torque and stiffness compared well with published data. The test-retest reliability was high with intraclass correlation coefficient (ICC2, 1) values greater than 0.846 and standard error of measurement (SEM) less than 1.38.

A Robot-Driven Computational Model for Estimating Passive Ankle Torque With Subject-Specific Adaptation

BACKGROUND

Robot-assisted ankle assessment could potentially be conducted using sensor-based and model-based methods. Existing ankle rehabilitation robots usually use torquemeters and multiaxis load cells for measuring joint dynamics. These measurements are accurate, but the contribution as a result of muscles and ligaments is not taken into account. Some computational ankle models have been developed to evaluate ligament strain and joint torque. These models do not include muscles and, thus, are not suitable for an overall ankle assessment in robot-assisted therapy.

METHODS

This study proposed a computational ankle model for use in robot-assisted therapy with three rotational degrees of freedom, 12 muscles, and seven ligaments. This model is driven by robotics, uses three independent position variables as inputs, and outputs an overall ankle assessment. Subject-specific adaptations by geometric and strength scaling were also made to allow for a universal model.

RESULTS

This model was evaluated using published results and experimental data from 11 participants. Results show a high accuracy in the evaluation of ligament neutral length and passive joint torque. The subject-specific adaptation performance is high, with each normalized root-mean-square deviation value less than 10%.

CONCLUSION

This model could be used for ankle assessment, especially in evaluating passive ankle torque, for a specific individual. The characteristic that is unique to this model is the use of three independent position variables that can be measured in real time as inputs, which makes it advantageous over other models when combined with robot-assisted therapy.