Haptic-based neurorehabilitation in poststroke patients: a feasibility prospective multicentre trial for robotics hand rehabilitation

Investigating Haptic Feedback in Vision-Deficient Millirobot Telemanipulation

The evolution of magnetically actuated millirobots gives rise to unique teleoperation challenges due to their non-traditional kinematic and dynamic architectures, as well as their frequent use of suboptimal imaging modalities. Recent investigations into haptic interfaces for millirobots have shown promise but lack the clinically motivated task scenarios necessary to justify future development. In this work, we investigate the utility of haptic feedback on bilateral teleoperation of a magnetically actuated millirobot in visually deficient conditions. We conducted an N=23 user study in an aneurysm coiling inspired procedure, which required participants to navigate the robot through a maze in near total darkness to manipulate beads to a target under simulated fluoroscopy. We hypothesized that users will be better able to complete the telemanipulation task with haptic feedback while reducing excess forces on their surroundings compared to the no feedback conditions. Our results showed an over 40% improvement in participants' bead scoring, a nearly 10% reduction in mean force, and 13% reduction in maximum force with haptic feedback, as well as significant improvements in other metrics. Results highlight that benefits of haptic feedback are retained when haptic feedback is removed. These findings suggest that haptic feedback has the potential to significantly improve millirobot telemanipulation and control in traditionally vision deficient tasks.

Effect of task-oriented training assisted by force feedback hand rehabilitation robot on finger grasping function in stroke patients with hemiplegia: a randomised controlled trial

BACKGROUND

Over 80% of patients with stroke experience finger grasping dysfunction, affecting independence in activities of daily living and quality of life. In routine training, task-oriented training is usually used for functional hand training, which may improve finger grasping performance after stroke, while augmented therapy may lead to a better treatment outcome. As a new technology-supported training, the hand rehabilitation robot provides opportunities to improve the therapeutic effect by increasing the training intensity. However, most hand rehabilitation robots commonly applied in clinics are based on a passive training mode and lack the sensory feedback function of fingers, which is not conducive to patients completing more accurate grasping movements. A force feedback hand rehabilitation robot can compensate for these defects. However, its clinical efficacy in patients with stroke remains unknown. This study aimed to investigate the effectiveness and added value of a force feedback hand rehabilitation robot combined with task-oriented training in stroke patients with hemiplegia.

METHODS

In this single-blinded randomised controlled trial, 44 stroke patients with hemiplegia were randomly divided into experimental (n = 22) and control (n = 22) groups. Both groups received 40 min/day of conventional upper limb rehabilitation training. The experimental group received 20 min/day of task-oriented training assisted by a force feedback rehabilitation robot, and the control group received 20 min/day of task-oriented training assisted by therapists. Training was provided for 4 weeks, 5 times/week. The Fugl-Meyer motor function assessment of the hand part (FMA-Hand), Action Research Arm Test (ARAT), grip strength, Modified Ashworth scale (MAS), range of motion (ROM), Brunnstrom recovery stages of the hand (BRS-H), and Barthel index (BI) were used to evaluate the effect of two groups before and after treatment.

RESULTS

Intra-group comparison: In both groups, the FMA-Hand, ARAT, grip strength, AROM, BRS-H, and BI scores after 4 weeks of treatment were significantly higher than those before treatment (p < 0.05), whereas there was no significant difference in finger flexor MAS scores before and after treatment (p > 0.05). Inter-group comparison: After 4 weeks of treatment, the experimental group's FMA-Hand total score, ARAT, grip strength, and AROM were significantly better than those of the control group (p < 0.05). However, there were no statistically significant differences in the scores of each sub-item of the FMA-Hand after Bonferroni correction (p > 0.007). In addition, there were no statistically significant differences in MAS, BRS-H, and BI scores (p > 0.05).

CONCLUSION

Hand performance improved in patients with stroke after 4 weeks of task-oriented training. The use of a force feedback hand rehabilitation robot to support task-oriented training showed additional value over conventional task-oriented training in stroke patients with hand dysfunction.

CLINICAL TRIAL REGISTRATION INFORMATION

NCT05841108.

A scoping review of scientific concepts concerning motor recovery after stroke as employed in clinical trials

The scientific literature on poststroke rehabilitation is remarkably vast. Over the last decades, dozens of rehabilitation approaches have been investigated. However, sometimes it is challenging to trace new experimental interventions back to some of the known models of motor control and sensorimotor learning. This scoping review aimed to investigate motor control models' diffusion among the literature on motor recovery after stroke. We performed a literature search on Medline, Cochrane, Web of Science, Embase, and Scopus databases. The last search was conducted in September 2023. This scoping review included full-text articles published in English in peer-reviewed journals that provided rehabilitation interventions based on motor control or motor learning frameworks for at least one individual with stroke. For each study, we identified the theoretical framework the authors used to design the experimental treatment. To this aim, we used a previously proposed classification of the known models of motor control, dividing them into the following categories: neuroanatomy, robotics, self-organization, and ecological context. In total, 2,185 studies were originally considered in this scoping review. After the screening process, we included and analyzed 45 studies: 20 studies were randomized controlled trials, 12 were case series, 4 were case reports, 8 were observational longitudinal pilot studies, and 1 was an uncontrolled trial. Only 10 studies explicitly declared the reference theoretical model. Considering their classification, 21 studies referred to the robotics motor control model, 12 to the self-organization model, 8 to the neuroanatomy model, and 4 to the ecological model. Our results showed that most of the rehabilitative interventions purposed in stroke rehabilitation have no clear theoretical bases on motor control and motor learning models. We suggest this is an issue that deserves attention when designing new experimental interventions in stroke rehabilitation.

Graph analysis of cortical reorganization after virtual reality-based rehabilitation following stroke: a pilot randomized study

Introduction

Stroke is the leading cause of functional disability worldwide. With the increase of the global population, motor rehabilitation of stroke survivors is of ever-increasing importance. In the last decade, virtual reality (VR) technologies for rehabilitation have been extensively studied, to be used instead of or together with conventional treatments such as physiotherapy or occupational therapy. The aim of this work was to evaluate the GestureCollection VR-based rehabilitation tool in terms of the brain changes and clinical outcomes of the patients.

Methods

Two groups of chronic patients underwent a rehabilitation treatment with (experimental) or without (control) complementation with GestureCollection. Functional magnetic resonance imaging exams and clinical assessments were performed before and after the treatment. A functional connectivity graph-based analysis was used to assess differences between the connections and in the network parameters strength and clustering coefficient.

Results

Patients in both groups showed improvement in clinical scales, but there were more increases in functional connectivity in the experimental group than in the control group.

Discussion

The experimental group presented changes in the connections between the frontoparietal and the somatomotor networks, associative cerebellum and basal ganglia, which are regions associated with reward-based motor learning. On the other hand, the control group also had results in the somatomotor network, in its ipsilateral connections with the thalamus and with the motor cerebellum, which are regions more related to a purely mechanical activity. Thus, the use of the GestureCollection system was successfully shown to promote neuroplasticity in several motor-related areas.

Empowering Hand Rehabilitation with AI-Powered Gesture Recognition: A Study of an sEMG-Based System

Stroke is one of the most prevalent health issues that people face today, causing long-term complications such as paresis, hemiparesis, and aphasia. These conditions significantly impact a patient's physical abilities and cause financial and social hardships. In order to address these challenges, this paper presents a groundbreaking solution-a wearable rehabilitation glove. This motorized glove is designed to provide comfortable and effective rehabilitation for patients with paresis. Its unique soft materials and compact size make it easy to use in clinical settings and at home. The glove can train each finger individually and all fingers together, using assistive force generated by advanced linear integrated actuators controlled by sEMG signals. The glove is also durable and long-lasting, with 4-5 h of battery life. The wearable motorized glove is worn on the affected hand to provide assistive force during rehabilitation training. The key to this glove's effectiveness is its ability to perform the classified hand gestures acquired from the non-affected hand by integrating four sEMG sensors and a deep learning algorithm (the 1D-CNN algorithm and the InceptionTime algorithm). The InceptionTime algorithm classified ten hand gestures' sEMG signals with an accuracy of 91.60% and 90.09% in the training and verification sets, respectively. The overall accuracy was 90.89%. It showed potential as a tool for developing effective hand gesture recognition systems. The classified hand gestures can be used as a control command for the motorized wearable glove placed on the affected hand, allowing it to mimic the movements of the non-affected hand. This innovative technology performs rehabilitation exercises based on the theory of mirror therapy and task-oriented therapy. Overall, this wearable rehabilitation glove represents a significant step forward in stroke rehabilitation, offering a practical and effective solution to help patients recover from stroke's physical, financial, and social impact.

Effects of virtual reality-based motor rehabilitation: a systematic review of fMRI studies

BACKGROUND

The use of virtual reality (VR) as a rehabilitation tool has been shown to induce motor and cognitive improvements in different populations. Functional magnetic resonance imaging (fMRI) has been used to investigate neuroplasticity resulting from these treatments. We hypothesize that VR rehabilitation induces functional improvement and brain changes that can be detected by fMRI.

OBJECTIVE

To systematically review the effects of VR intervention on the cortical reorganization measured by fMRI and associated with functional improvement.

METHODS

We performed a systematic review of studies published between 2005 and 2021. Papers were retrieved from six databases using the following keywords: "motor rehabilitation", "fMRI" and "virtual reality". Case studies, pre-post studies, cross-sectional studies, and randomized controlled trials published were included. Manuscripts were assessed by The NIH Study Quality Assessment Tools to determine their quality.

RESULTS

Twenty-three articles met our eligibility criteria: 18 about VR rehabilitation in stroke and five on other clinical conditions (older adults, cerebral palsy, and Parkinson's disease). Changes in neural patterns of activation and reorganization were revealed in both the ipsilesional and the contralesional hemispheres. Results were located mainly in the primary motor cortex, sensorimotor cortex and supplementary motor area in post-stroke patients in the acute, subacute, and chronic rehabilitation phases, and were associated with functional improvement after VR intervention. Similar effects were observed in older adults and in patients with other neurological diseases with improved performance.

CONCLUSION

Most stroke-related studies showed either restoration to normal or increase of activation patterns or relateralization at/to the ipsilesional hemisphere, with some also reporting a decrease in activity or extent of activation after VR therapy. In general, VR intervention demonstrated evidence of efficacy both in neurological rehabilitation and in performance improvement of older adults, accompanied by fMRI evidence of brain reorganization.

Effects of virtual reality intervention on neural plasticity in stroke rehabilitation: a systematic review

OBJECTIVE

To systematically review and examine the current literature regarding the effects of Virtual Reality (VR)-based rehabilitation on neural plasticity changes in stroke survivors.

DATA SOURCES

Six bioscience and engineering databases were searched, including Medline via Ebsco, Embase, PsycINFO, IEEE Explore, Cumulative Index of Nursing and Allied Health, and Scopus.

STUDY SELECTION

Studies reporting on the pre-post assessment of a VR intervention with neural plasticity measures published between 2000-2021 were included.

DATA EXTRACTION

Two independent reviewers conducted study selection, data extraction and quality assessment. Methodological quality of controlled trials was assessed using the Physiotherapy Evidence Database scale. Risk of bias of pre-post intervention and case studies was evaluated using the National Institutes of Health Quality Assessment Tool.

DATA SYNTHESIS

Twenty-seven studies (Total n=232) were included. Seven randomized controlled trials were rated as good quality while the two clinical controlled trials were moderate. Based on the risk of bias assessment, one pre-post study and one case study were graded as good quality, one pre-post study and one case study were poor, the other 14 studies were all at fair. After the VR intervention, main neurophysiological findings across studies include: (1) improved interhemispheric balance, (2) enhanced cortical connectivity, (3) increased cortical mapping of the affected limb muscles, (4) the improved neural plasticity measures were correlated to the enhanced behavior outcomes, (5) increased activation of regions in frontal cortex and (6) the mirror neuron system may be involved.

CONCLUSIONS

Virtual reality induced changes in neural plasticity for stroke survivors. Positive correlations between the neural plasticity changes and functional recovery elucidates the mechanisms of VR's therapeutic effects in stroke rehabilitation. This review prompts systematic understanding of the neurophysiological mechanisms of VR-based stroke rehabilitation and summarizes the emerging evidence for ongoing innovation of VR systems and application in stroke rehabilitation.

Haptic-Enabled Hand Rehabilitation in Stroke Patients: A Scoping Review

There is a plethora of technology-assisted interventions for hand therapy, however, less is known about the effectiveness of these interventions. This scoping review aims to explore studies about technology-assisted interventions targeting hand rehabilitation to identify the most effective interventions. It is expected that multifaceted interventions targeting hand rehabilitation are more efficient therapeutic approaches than mono-interventions. The scoping review will aim to map the existing haptic-enabled interventions for upper limb rehabilitation and investigates their effects on motor and functional recovery in patients with stroke. The methodology used in this review is based on the Arksey and O’Malley framework, which includes the following stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results. Results show that using three or four different technologies was more positive than using two technologies (one technology + haptics). In particular, when standardized as a percentage of outcomes, the combination of three technologies showed better results than the combination of haptics with one technology or with three other technologies. To conclude, this study portrayed haptic-enabled rehabilitation approaches that could help therapists decide which technology-enabled hand therapy approach is best suited to their needs. Those seeking to undertake research and development anticipate further opportunities to develop haptic-enabled hand telerehabilitation platforms.

Development of the Home based Virtual Rehabilitation System (HoVRS) to remotely deliver an intense and customized upper extremity training

Background

After stroke, sustained hand rehabilitation training is required for continuous improvement and maintenance of distal function.

Methods

In this paper, we present a system designed and implemented in our lab: the Home based Virtual Rehabilitation System (HoVRS). Fifteen subjects with chronic stroke were recruited to test the feasibility of the system as well as to refine the design and training protocol to prepare for a future efficacy study. HoVRS was placed in subjects’ homes, and subjects were asked to use the system at least 15 min every weekday for 3 months (12 weeks) with limited technical support and remote clinical monitoring.

Results

All subjects completed the study without any adverse events. Subjects on average spent 13.5 h using the system. Clinical and kinematic data were collected pre and post study in the subject’s home. Subjects demonstrated a mean increase of 5.2 (SEM = 0.69) on the Upper Extremity Fugl-Meyer Assessment (UEFMA). They also demonstrated improvements in six measurements of hand kinematics. In addition, a combination of these kinematic measures was able to predict a substantial portion of the variability in the subjects’ UEFMA score.

Conclusion

Persons with chronic stroke were able to use the system safely and productively with minimal supervision resulting in measurable improvements in upper extremity function.

[New perspectives of motor rehabilitation of patients after focal brain lesions]

Rehabilitation of patients after focal brain lesions is one of the topical issues of modern medicine. Motor disorders are known to develop in more than 80% of survivors of stroke and traumatic brain injury and be one of the main causes of disability, which necessitates an active search for new effective techniques for correction of motor disorders. Modern rehabilitation includes both traditional techniques for recovery of patients with motor deficit (exercise therapy and physiotherapy) and botulinum therapy, kinesiotherapy, mechanotherapy, etc., which have been developed in recent years. Robotic technologies have been developed, improved, and implemented. Currently, due to progress in computerization, virtual reality-based rehabilitation of patients is of particular interest. The article reviews the key studies in this field. We describe various visualization methods and means of immersion in a virtual environment for recovery of upper and lower extremity function in patients with focal brain lesions. The study provides an assessment of the effectiveness and safety of various virtual reality-based rehabilitation programs in patients with motor disorders after stroke and traumatic brain injury.

Localized Fretting-Vibrotactile Sensations for Large-Area Displays

Tactile perception in large-area displays is currently attracting substantial research attention since, in conjunction with visible and auditory sensations, it provides more immersive and realistic interactions with displayed contents. Here, a new vibrotactile display based on the fretting phenomenon is developed for the first time to provide localized tactile feedback on a large-area display. Normal pressure by a human fingertip activates a locally concentrated electric field in a relaxor ferroelectric polymer (RFP) film under the contact area, which produces a localized electrostrictive strain. The synergistic interplay among the localized electric field, electrostrictive deformation of the RFP film, and contact area dramatically amplifies acoustic vibrations near the contact edge of a human fingertip. A blend of poly(vinylidene fluoride-trifluoroethylene-chlorofluoroethylene) terpolymer and poly(vinylidene fluoride-trifluoroethylene) (55:45) copolymer is proposed for the RFP to provide an enhanced actuation performance even at elevated temperatures. The fretting-vibrotactile mechanism has several interesting properties, such as tactile feedback on a stationary fingertip, pressure-responsive simple on-off mechanism, multitouch interaction, excellent transparency, and easy integration with capacitive or resistive touch sensors and friction-based haptic-feedback mechanisms. An array of RFP film vibrators can provide addressable content-related multiple tactile feedback on large-area displays by modulating the frequency, amplitude, and profile of the driving voltage signals.

The effects of error-augmentation versus error-reduction paradigms in robotic therapy to enhance upper extremity performance and recovery post-stroke: a systematic review

Despite upper extremity function playing a crucial role in maintaining one's independence in activities of daily living, upper extremity impairments remain one of the most prevalent post-stroke deficits. To enhance the upper extremity motor recovery and performance among stroke survivors, two training paradigms in the fields of robotics therapy involving modifying haptic feedback were proposed: the error-augmentation (EA) and error-reduction (ER) paradigms. There is a lack of consensus, however, as to which of the two paradigms yields superior training effects. This systematic review aimed to determine (i) whether EA is more effective than conventional repetitive practice; (ii) whether ER is more effective than conventional repetitive practice and; (iii) whether EA is more effective than ER in improving post-stroke upper extremity motor recovery and performance. The study search and selection process as well as the ratings of methodological quality of the articles were conducted by two authors separately, and the results were then compared and discussed among the two reviewers. Findings were analyzed and synthesized using the level of evidence. By August 1st 2017, 269 articles were found after searching 6 databases, and 13 were selected based on criteria such as sample size, type of participants recruited, type of interventions used, etc. Results suggest, with a moderate level of evidence, that EA is overall more effective than conventional repetitive practice (motor recovery and performance) and ER (motor performance only), while ER appears to be no more effective than conventional repetitive practice. However, intervention effects as measured using clinical outcomes were under most instance not 'clinically meaningful' and effect sizes were modest. While stronger evidence is required to further support the efficacy of error modification therapies, the influence of factors related to the delivery of the intervention (such as intensity, duration) and personal factors (such as stroke severity and time of stroke onset) deserves further investigations as well.

A review: Motor rehabilitation after stroke with control based on human intent

Strokes are a leading cause of acquired disability worldwide, and there is a significant need for novel interventions and further research to facilitate functional motor recovery in stroke patients. This article reviews motor rehabilitation methods for stroke survivors with a focus on rehabilitation controlled by human motor intent. The review begins with the neurodevelopmental principles of motor rehabilitation that provide the neuroscientific basis for intuitively controlled rehabilitation, followed by a review of methods allowing human motor intent detection, biofeedback approaches, and quantitative motor rehabilitation assessment. Challenges for future advances in motor rehabilitation after stroke using intuitively controlled approaches are addressed.

Functional performance comparison between real and virtual tasks in older adults: A cross-sectional study

INTRODUCTION

Ageing is usually accompanied by deterioration of physical abilities, such as muscular strength, sensory sensitivity, and functional capacity, making chronic diseases, and the well-being of older adults new challenges to global public health.

OBJECTIVE

The purpose of this study was to evaluate whether a task practiced in a virtual environment could promote better performance and enable transfer to the same task in a real environment.

METHOD

The study evaluated 65 older adults of both genders, aged 60 to 82 years (M = 69.6, SD = 6.3). A timing coincident task was applied to measure the perceptual-motor ability to perform a motor response. The participants were divided into 2 groups: started in a real interface and started in a virtual interface.

RESULTS

All subjects improved their performance during the practice, but improvement was not observed for the real interface, as the participants were near maximum performance from the beginning of the task. However, there was no transfer of performance from the virtual to real environment or vice versa.

CONCLUSIONS

The virtual environment was shown to provide improvement of performance with a short-term motor learning protocol in a timing coincident task. This result suggests that the practice of tasks in a virtual environment seems to be a promising tool for the assessment and training of healthy older adults, even though there was no transfer of performance to a real environment.

TRIAL REGISTRATION

ISRCTN02960165. Registered 8 November 2016.

Illusory movements induced by tendon vibration in right- and left-handed people

Frequency-specific vibratory stimulation of peripheral tendons induces an illusion of limb movement that may be useful for restoring proprioceptive information in people with sensorimotor disability. This potential application may be limited by inter- and intra-subject variability in the susceptibility to such an illusion, which may depend on a variety of factors. To explore the influence of stimulation parameters and participants' handedness on the movement illusion, we vibrated the right and left tendon of the biceps brachii in a group of right- and left-handed people with five stimulation frequencies (from 40 to 120 Hz in step of 20 Hz). We found that all participants reported the expected illusion of elbow extension, especially after 40 and 60 Hz. Left-handers exhibited less variability in reporting the illusion compared to right-handers across the different stimulation frequencies. Moreover, the stimulation of the non-dominant arm elicited a more vivid illusion with faster onset relative to the stimulation of the dominant arm, an effect that was independent from participants' handedness. Overall, our data show that stimulation frequency, handedness and arm dominance influence the tendon vibration movement illusion. The results are discussed in reference to their relevance in linking motor awareness, improving current devices for motor ability recovery after brain or spinal damage and developing prosthetics and virtual embodiment systems.

Electroencephalography as a post-stroke assessment method: An updated review

Given that stroke is currently a serious problem in the population, employing more reliable and objective techniques for determining diagnosis and prognosis is necessary in order to enable effective clinical decision-making. EEG is a simple, low-cost, non-invasive tool that can provide information about the changes occurring in the cerebral cortex during the recovery process after stroke. EEG provides data on the evolution of cortical activation patterns which can be used to establish a prognosis geared toward harnessing each patient's full potential. This strategy can be used to prevent compensation and maladaptive plasticity, redirect treatments, and develop new interventions that will let stroke patients reach their new maximum motor levels.