The robotic Trunk-Support-Trainer (TruST) to measure and increase postural workspace during sitting in people with spinal cord injury

Characterizing the Effects of Adding Virtual and Augmented Reality in Robot-Assisted Training

Extended reality (XR) technology combines physical reality with computer synthetic virtuality to deliver immersive experience to users. Virtual reality (VR) and augmented reality (AR) are two subdomains within XR with different immersion levels. Both of these have the potential to be combined with robot-assisted training protocols to maximize postural control improvement. In this study, we conducted a randomized control experiment with sixty-three healthy subjects to compare the effectiveness of robot-assisted posture training combined with VR or AR against robotic training alone. A robotic Trunk Support Trainer (TruST) was employed to deliver assistive force at the trunk as subjects moved beyond the stability limits during training. Our results showed that both VR and AR significantly enhanced the training outcomes of the TruST intervention. However, the VR group experienced higher simulator sickness compared to the AR group, suggesting that AR is better suited for sitting posture training in conjunction with TruST intervention. Our findings highlight the added value of XR to robot-assisted training and provide novel insights into the differences between AR and VR when integrated into a robotic training protocol. In addition, we developed a custom XR application that suited well for TruST intervention requirements. Our approach can be extended to other studies to develop novel XR-enhanced robotic training platforms.

Feasibility and validity of the push-up test for synchronous and asynchronous strength tele-assessment in spinal cord injury individuals with paraplegia

OBJECTIVES

This study aimed to determine whether the synchronous and asynchronous push-up tele-assessment in individuals with spinal cord injury (SCI) is feasible and valid and to identify the relationship between the participants' self-reported asynchronous strength tele-assessment and asynchronous push-up tele-assessment.

STUDY DESIGN

Cross-sectional study.

METHODS

Thirty-three men and women with SCI were included in this study. The participants were assessed using the one-maximum repetition test (1RM), the maximum repetitions with 60% of 1RM (MRT) of the bench press exercise, and synchronous and asynchronous push-up tele-assessment. The videos and the total repetitions performed were recorded. The primary outcomes were 1RM, MRT, synchronous push-up tele-assessment and asynchronous volume loads, and the participants' self-reported asynchronous strength tele-assessment volume load.

RESULTS

The synchronous push-up tele-assessment and asynchronous volume loads presented significant correlations with 1RM (0.73 and 0.45, p < 0.001, respectively) and MRT volume loads (0.87 and 0.66, p < 0.001, respectively). The asynchronous push-up tele-assessment presented significant correlations with the synchronous version (intraclass correlation coefficient, ICC = 0.86; 95% CI: 0.72-0.93, p < 0.001) and participants' self-reported asynchronous strength tele-assessment volume loads (ICC = 0.88; 95% CI: 0.75-0.94, p < 0.001). The difference between the synchronous push-up tele-assessment and asynchronous volume load means was 254.9 kg, and the interval around the differences was 1856.1 kg. The difference between asynchronous push-up tele-assessment and participants' self-reported asynchronous strength tele-assessment means was -239.4 kg, and the interval around these was 1884.1 kg.

CONCLUSION

The synchronous push-up tele-assessment is a feasible and valid way to assess the maximum resistance strength of individuals with SCI. Although the asynchronous push-up tele-assessment demonstrated excellent and significant correlations with the synchronous push-up tele-assessment and participants' self-reported asynchronous strength tele-assessment, the test repetitions and the volume loads were underestimated by 15.5% (synchronous push-up tele-assessment vs. asynchronous) and overestimated by 17.3% (asynchronous push-up tele-assessment vs. participants' self-reported asynchronous strength tele-assessment), and the effect sizes ranged from 0.19-0.38. The authors suggest emphasizing the criteria of repetition validity to reduce test error.

Robotic upright stand trainer (RobUST) and postural control in individuals with spinal cord injury

CONTEXT/OBJECTIVE

Assessed feasibility and potential effectiveness of using a novel robotic upright stand trainer (RobUST) to deliver postural perturbations or provide assistance-as-needed at the trunk while individuals with spinal cord injury (SCI) performed stable standing and self-initiated trunk movements. These tasks were assessed with research participants' hands on handlebars for self-balance assistance (hands on) and with hands off (free hands).

DESIGN

Proof of concept study.

PARTICIPANTS

Four individuals with motor complete (n = 3) or incomplete (n = 1) SCI who were not able to achieve independent standing and presented a neurological lesion level ranging from cervical 4 to thoracic 2.

OUTCOME MEASURES

Ground reaction forces, trunk displacement, and electromyography activity of trunk and lower limb muscles.

RESULTS

Research participants received continuous pelvic assistance via RobUST, and manual trainer assistance at the knees to maintain standing. Participants were able to attempt all tasks. Free hands trunk perturbations resulted in greater load bearing-related sensory information (73% ipsilateral vertical loading), trunk displacement (57%), and muscle activation compared to hands on. Similarly, free hands stable standing with RobUST assistance-as-needed resulted in 8.5% larger bodyweight bearing, 112% larger trunk movement velocity, and higher trunk muscles activation compared to standing with hands on. Self-initiated trunk movements controlled by hands on showed 116% greater trunk displacement, 10% greater vertical ground reaction force, and greater ankle muscle activation compared to free hands.

CONCLUSION

RobUST established a safe and challenging standing environment for individuals with SCI and has the potential to improve training paradigms and assessments of standing postural control.

Study protocol for a randomised controlled trial to determine the efficacy of an intensive seated postural intervention delivered with robotic and rigid trunk support systems

INTRODUCTION

Children with cerebral palsy (CP) classified as gross motor function classification system (GMFCS) levels III-IV demonstrate impaired sitting and reaching control abilities that hamper their overall functional performance. Yet, efficacious interventions for improving sitting-related activities are scarce. We recently designed a motor learning-based intervention delivered with a robotic Trunk-Support-Trainer (TruST-intervention), in which we apply force field technology to individualise sitting balance support. We propose a randomised controlled trial to test the efficacy of the motor intervention delivered with robotic TruST compared with a static trunk support system.

METHODS AND ANALYSIS

We will recruit 82 participants with CP, GMFCS III-IV, and aged 6-17 years. Randomisation using concealed allocation to either the TruST-support or static trunk-support intervention will be conducted using opaque-sealed envelopes prepared by someone unrelated to the study. We will apply an intention-to-treat protocol. The interventions will consist of 2 hours/sessions, 3/week, for 4 weeks. Participants will start both interventions with pelvic strapping. In the TruST-intervention, postural task progression will be implemented by a progressive increase of the force field boundaries and then by removing the pelvic straps. In the static trunk support-intervention, we will progressively lower the trunk support and remove pelvic strapping. Outcomes will be assessed at baseline, training midpoint, 1-week postintervention, and 3-month follow-up. Primary outcomes will include the modified functional reach test, a kinematic evaluation of sitting workspace, and the Box and Block test. Secondary outcomes will include The Segmental Assessment of Trunk Control test, Seated Postural & Reaching Control test, Gross Motor Function Measure-Item Set, Canadian Occupational Performance Outcome, The Participation and Environment Measure and Youth, and postural and reaching kinematics.

ETHICS AND DISSEMINATION

The study was approved by the Columbia University Institutional Review Board (AAAS7804). This study is funded by the National Institutes of Health (1R01HD101903-01) and is registered at clinicaltrials.gov.

TRIAL REGISTRATION NUMBER

NCT04897347; clinicaltrials.gov.

Italian translation and reliability of Fist-Sci Scale for chronic paraplegic patients: an observational study

BACKGROUND AND AIM

Lack of trunk control following spinal cord injury implicates a worse quality of life and a higher dependence on caregivers; literature proposes several evaluation scales, but studies show poor methodological quality. This study aimed to translate and explore the significance of the Italian version of the FIST-SCI scale for chronic spinal cord injury patients.

METHODS

A longitudinal cohort study was conducted at Fiorenzuola D'Arda Hospital. After a forward/backward translation of the FIST-SCI scale in Italian content and face translational validity, intervalutator reliability was assessed. Patients were recruited by historical tracking of patients who received acute rehabilitation care at the Villanova D'Arda Spinal Unit. Two researchers administered the FIST-SCI scale to the same patients at the follow-up.

RESULTS

Ten patients took part in the study; results showed that higher inter-rater correlation coefficient (Pearson's R= 0.89, p= 0.01 Intra-class correlation coefficient= 0.94, p=0.000). Content validity was also excellent (Scale Content Validity Index = 0.91); some experts suggested future scale developments.

DISCUSSION

Italian FIST-SCI scale for assessing trunk control in chronic spinal patients appears to be an excellent assessment tool concerning intervalutator reliability. Content validity further confirms the validity of the instrument.

Innovative Technologies in the Neurorehabilitation of Traumatic Brain Injury: A Systematic Review

Motor and cognitive rehabilitation in individuals with traumatic brain injury (TBI) is a growing field of clinical and research interest. In fact, novel rehabilitative approaches allow a very early verticalization and gait training through robotic devices and other innovative tools boosting neuroplasticity, thanks to the high-intensity, repetitive and task-oriented training. In the same way, cognitive rehabilitation is also evolving towards advanced interventions using virtual reality (VR), computer-based approaches, telerehabilitation and neuromodulation devices. This review aimed to systematically investigate the existing evidence concerning the role of innovative technologies in the motor and cognitive neurorehabilitation of TBI patients. We searched and reviewed the studies published in the Cochrane Library, PEDro, PubMed and Scopus between January 2012 and September 2022. After an accurate screening, only 29 papers were included in this review. This systematic review has demonstrated the beneficial role of innovative technologies when applied to cognitive rehabilitation in patients with TBI, while evidence of their effect on motor rehabilitation in this patient population is poor and still controversial.

A motor learning-based postural intervention with a robotic trunk support trainer to improve functional sitting in spinal cord injury: case report

STUDY DESIGN

Single-subject-research-design.

OBJECTIVES

To improve seated postural control in a participant with spinal cord injury (SCI) with a robotic Trunk-Support-Trainer (TruST).

SETTING

Laboratory.

METHODS

TruST delivered "assist-as-needed" forces on the participant's torso during a motor learning-and-control-based intervention (TruST-intervention). TruST-assistive forces were progressed and matched to the participant's postural trunk control gains across six intervention sessions. The T-shirt test was used to capture functional improvements while dressing the upper body. Kinematics were used to compute upper body excursions (cm) and velocity (cm2), and sitting workspace area (cm2). Functional trunk dynamometry was used to examine muscle force (Kg). Surface electromyography (sEMG) was applied to measure trunk muscle activity. The Borg Rating of Perceived Exertion (RPE) was used to monitor physical exertion during TruST-intervention. A two-standard-deviation bandwidth method was adopted for data interpretation.

RESULTS

After TruST-intervention, the participant halved the time needed to don and doff a T-shirt, increased muscle force of trunk muscles (mean = 3 kg), acquired a steadier postural sitting control without vision (mean excursion baseline: 76.0 ± 2 SD = 5.25 cm and post-intervention: 44.1 cm; and mean velocity baseline: 3.0 ± 2 SD = 0.2 cm/s and post-intervention: 1.8 cm/s), and expanded his sitting workspace area (mean baseline: 36.7 ± 2 SD = 36.6 cm2 and post-intervention: 419.2 cm2). The participant increased his tolerance to counteract greater TruST-force perturbations in lateral and posterior directions. Furthermore, abdominal muscle activity substantially augmented after completion of TruST-intervention across all perturbation directions.

CONCLUSIONS

Our data indicate a potential effectiveness of TruST-intervention to promote functional sitting in SCI.

Reliability validity and responsiveness of the spinal cord independence measure 4th version in a multicultural setup

OBJECTIVE

To examine the fourth version of the Spinal Cord Independence Measure for reliability and validity.

DESIGN

Partly blinded comparison with the criterion standard Spinal Cord Independence Measure III, and between examiners and examinations.

SETTING

A multicultural cohort from 19 spinal cord injury units in 11 countries.

PARTICIPANTS

Six hundred and forty-eight patients with spinal cord injury.

INTERVENTION

Assessment with Spinal Cord Independence Measure (SCIM IV) and Spinal Cord Independence Measure (SCIM III) on admission to inpatient rehabilitation and before discharge.

MAIN OUTCOME MEASURES

SCIM IV interrater reliability, internal consistency, correlation with and difference from SCIM III, and responsiveness.

RESULTS

Total agreement between examiners was above 80% on most SCIM IV tasks. All Kappa coefficients were above 0.70 and statistically significant (p<0.001). Pearson's coefficients of the correlation between the examiners were above 0.90, and intraclass correlation coefficients were above 0.90. Cronbach's alpha was above 0.96 for the entire SCIM IV, above 0.66 for the subscales, and usually decreased when an item was eliminated. Reliability values were lower for the subscale of respiration and sphincter management, and on admission than at discharge. SCIM IV and SCIM III mean values were very close, and the coefficients of Pearson correlation between them were 0.91-0.96 (p<0.001). The responsiveness of SCIM IV was not significantly different from that of SCIM III in most of the comparisons.

CONCLUSIONS

The validity, reliability, and responsiveness of SCIM IV, which was adjusted to assess specific patient conditions or situations that SCIM III does not address, and which includes more accurate definitions of certain scoring criteria, are very good and quite similar to those of SCIM III. SCIM IV can be used for clinical and research trials, including international multi-center studies, and its group scores can be compared with those of SCIM III.

Feasibility and tolerance of a robotic postural training to improve standing in a person with ambulatory spinal cord injury

An ambulatory elder with SCI, AIS C, balance deficits, and right ankle-foot-orthosis participated. RobUST-intervention comprised six 90 min-sessions of postural tasks with pelvic assistance and trunk perturbations. We collected three baselines and two 1 week post-training assessments-after the first four sessions (PT1) and after the last two sessions (PT2). We measured Berg Balance Scale (BBS), four-stage balance test (4SBT)-including a 30 s-window with and without vision-standing workspace area, and reactive balance (measured as body weight%). Kinematics, center-of-pressure (COP), and electromyography (EMG) were analyzed to compute root-mean-square-COP (RMS-COP), the margin of stability (MoS), ankle range of motion, and integrated EMG (iEMG) normalized to baseline. The Borg Rating of Perceived Exertion (BRPE), and change in the Mean Arterial Pressure (MAP) and heart rate (HR) compared with baseline were collected to address training tolerance. A 2SD-bandwidth method was selected for data interpretation. The maximum BBS was achieved (1-point improvement). In the 4SBT, the participant completed 30 s (baseline = 20 s) with reduced balance variability during semi-tandem position without vision (RMS-COP baseline = 50.32 ± 2 SD = 19.64 mm; PT1 = 21.29 mm; PT2 = 19.34 mm). A trend toward increase was found in workspace area (baseline = 996 ± 359 cm²; PT1 = 1539 cm²; PT2 = 1138 cm²). The participant tolerated higher perturbation intensities (baseline mean = 25%body weight, PT2 mean = 44% body weight), and on average improved his MoS (3 cm), ankle range of motion (4°), and gluteus medius activity (iEMG = 10). RobuST-intervention was moderate-sort of hard (BRPE = 3-4). A substantial reduction in MAP (9%) and HR (30%) were observed. In conclusion, RobUST-intervention might be effective in ambulatory SCI.

Promoting Functional and Independent Sitting in Children With Cerebral Palsy Using the Robotic Trunk Support Trainer

Seated postural abilities are critical to functional independence and participation in children with cerebral palsy, Gross Motor Functional Classification System (GMFCS) levels III-IV. In this proof-of-concept study, we investigated the feasibility of a motor learning-based seated postural training with a robotic Trunk-Support-Trainer (TruST) in a longitudinal single-subject-design (13y, GMFCS IV), and its potential effectiveness in a group of 3 children (6-14y, GMFCS III-IV). TruST is a motorized-cable driven belt placed on the child's trunk to exert active-assistive forces when the trunk moves beyond stability limits. TruST-intervention addresses postural-task progression by tailoring the assistive-force fields to the child's sitting balance to train trunk control during independent short-sitting posture. TruST-intervention consisted of 2 training blocks of six 2hour-sessions per block (3 sessions per week). Pelvic strapping was required in the 1^st block to prevent falls. As primary outcomes, we used the modified functional reach test, gross motor function measure-item set (GMFM-IS), Box & Blocks, and postural kinematics. After TruST-intervention children did not require pelvic strapping to prevent a fall, improved trunk stability during reaching (baseline = 5.49cm, 1week post-training = 16.38cm, 3mos follow-up = 14.63cm, ) and increased their sitting workspace (baseline = 127.55cm², 1week post-training, = 409.92cm², 3mos follow-up = 270.03cm², ). Three children also improved in the GMFM-IS. In summary, our novel robotic TruST-intervention is feasible and can effectively maximize functional independent sitting in children with CP GMFCS III-IV.

Spinal Deformities and Advancement in Corrective Orthoses

Spinal deformity is an abnormality in the spinal curves and can seriously affect the activities of daily life. The conventional way to treat spinal deformities, such as scoliosis, kyphosis, and spondylolisthesis, is to use spinal orthoses (braces). Braces have been used for centuries to apply corrective forces to the spine to treat spinal deformities or to stabilize the spine during postoperative rehabilitation. Braces have not modernized with advancements in technology, and very few braces are equipped with smart sensory design and active actuation. There is a need to enable the orthotists, ergonomics practitioners, and developers to incorporate new technologies into the passive field of bracing. This article presents a review of the conventional passive braces and highlights the advancements in spinal orthoses in terms of improved sensory designs, active actuation mechanisms, and new construction methods (CAD/CAM, three-dimensional (3D) printing). This review includes 26 spinal orthoses, comprised of passive rigid/soft braces, active dynamics braces, and torso training devices for the rehabilitation of the spine.