Adaptive robot training for the treatment of incoordination in Multiple Sclerosis

Robotic systems for upper-limb rehabilitation in multiple sclerosis: a SWOT analysis and the synergies with virtual and augmented environments

The robotics discipline is exploring precise and versatile solutions for upper-limb rehabilitation in Multiple Sclerosis (MS). People with MS can greatly benefit from robotic systems to help combat the complexities of this disease, which can impair the ability to perform activities of daily living (ADLs). In order to present the potential and the limitations of smart mechatronic devices in the mentioned clinical domain, this review is structured to propose a concise SWOT (Strengths, Weaknesses, Opportunities, and Threats) Analysis of robotic rehabilitation in MS. Through the SWOT Analysis, a method mostly adopted in business management, this paper addresses both internal and external factors that can promote or hinder the adoption of upper-limb rehabilitation robots in MS. Subsequently, it discusses how the synergy with another category of interaction technologies - the systems underlying virtual and augmented environments - may empower Strengths, overcome Weaknesses, expand Opportunities, and handle Threats in rehabilitation robotics for MS. The impactful adaptability of these digital settings (extensively used in rehabilitation for MS, even to approach ADL-like tasks in safe simulated contexts) is the main reason for presenting this approach to face the critical issues of the aforementioned SWOT Analysis. This methodological proposal aims at paving the way for devising further synergistic strategies based on the integration of medical robotic devices with other promising technologies to help upper-limb functional recovery in MS.

Rehabilitation on cerebellar ataxic patients with multiple sclerosis: A systematic review

Multiple Sclerosis (MS) is a chronic inflammatory, autoimmune disease of the Central Nervous System with a vast spectrum of clinical phenotypes. A major aspect of its clinical presentation is cerebellar ataxia where physiotherapy and treatment modalities play a significant role on its management. This systematic review aims to investigate the physiotherapeutic rehabilitation techniques regarding the management of cerebellar ataxia due to MS and secondary to stratify each protocol as part of a multi structural personalized rehabilitation approach based on the gravity of the symptoms. A Pubmed Medline, Scopus and Web of Science research was performed using the corresponding databases. The results were screened by the authors in pairs. In our study, six (6) non-pharmacological interventional protocols, 3 Randomized Controlled Trials and 3 pilot studies, were included with a total of 145 MS patients. Physiotherapeutic techniques, such as NDT-Bobath, robotic and visual biofeedback re-education protocols and functional rehabilitation techniques were included. In most cases cerebellar ataxic symptoms were decreased post-treatment. The overall quality of the studies included was of moderate level (level B). Rehabilitation in cerebellar ataxia due to MS should be based on multicentric studies with the scope of adjusting different types of treatments and physiotherapeutic techniques based on the severity of the symptom.

The role of feedback in the robotic-assisted upper limb rehabilitation in people with multiple sclerosis: a systematic review

INTRODUCTION

Robotic-assisted upper limb rehabilitation might improve upper limb recovery in people with multiple sclerosis (PwMS) with moderate-to-severe disability. In the few existing studies, the training effects have been related to the type of intervention, if intensive, repetitive, or task-oriented training might promote neuroplasticity and recovery. Notably, most of these devices operate within a serious game context providing different feedback. Since feedback is a key component of motor control and thus involved in motor and cognitive rehabilitation, clinicians cannot desist from considering the potential contribution of feedback in the upper limb robot-assisted rehabilitation effects.

AREA COVERED

In this systematic review, we reported the rehabilitation protocols used in the robot-assisted upper limb training in PwMS to provide state-of-the-art on the role of feedback in robotic-assisted Upper Limb rehabilitation. PubMed, the Cochrane Library, and the Physiotherapy Evidence Database databases were systematically searched from inception to March 2022. After a literature search, the classification systems for feedback and the serious game were applied.

EXPERT OPINION

There is a need for sharing standard definitions and components of feedback and serious game in technologically assisted upper limb rehabilitation. Indeed, improving these aspects might further improve the effectiveness of such training in the management of PwMS.

Upper Limb Sensory-Motor Control During Exposure to Different Mechanical Environments in Multiple Sclerosis Subjects With No Clinical Disability

Multiple sclerosis (MS) is an autoimmune and neurodegenerative disease resulting in motor impairments associated with muscle weakness and lack of movement coordination. The goal of this work was to quantify upper limb motor deficits in asymptomatic MS subjects with a robot-based assessment including performance and muscle synergies analysis. A total of 7 subjects (MS: 3 M−4 F; 42 ± 10 years) with clinically definite MS according to McDonald criteria, but with no clinical disability, and 7 age- and sex-matched subjects without a history of neurological disorders participated in the study. All subjects controlled a cursor on the computer screen by moving their hand or applying forces in 8 coplanar directions at their self-selected speed. They grasped the handle of a robotic planar manipulandum that generated four different environments: null, assistive or resistive forces, and rigid constraint. Simultaneously, the activity of 15 upper body muscles was recorded. Asymptomatic MS subjects generated less smooth and less accurate cursor trajectories than control subjects in controlling a force profile, while the end-point error was significantly different also in the other environments. The EMG analysis revealed different muscle activation patterns in MS subjects when exerting isometric forces or when moving in presence of external forces generated by a robot. While the two populations had the same number and similar structure of muscle synergies, they had different activation profiles. These results suggested that a task requiring to control forces against a rigid environment allows better than movement tasks to detect early sensory-motor signs related to the onset of symptoms of multiple sclerosis and to differentiate between stages of the disease.

Assessing proprioceptive acuity in people with multiple sclerosis

Background

Proprioceptive acuity and impairments in proprioceptively guided reaches have not been comprehensively examined in people with multiple sclerosis (MS).

Objective

To examine proprioceptive acuity in people with MS who self-report and who do not self-report upper limb (UL) impairment, and to determine how people with MS reach proprioceptive targets.

Methods

Twenty-four participants with MS were recruited into two groups based on self-reported UL impairment: MS-R (i.e. report UL impairment; n  =  12) vs. MS-NR (i.e. do not report UL impairment; n  =  12). Proprioception was assessed using ipsilateral and contralateral robotic proprioceptive matching tasks.

Results

Participants in the MS-R group demonstrated worse proprioceptive acuity compared to the MS-NR group on the ipsilateral and contralateral robotic matching tasks. Analyses of reaches to proprioceptive targets further revealed that participants in the MS-R group exhibited deficits in movement planning, as demonstrated by greater errors at peak velocity in the contralateral matching task in comparison to the MS-NR group.

Conclusion

Our findings suggest that people with MS who self-report UL impairment demonstrate worse proprioceptive acuity, as well as poorer movement planning in comparison to people with MS who do not report UL impairment.

Adaptations in Muscular Strength for Individuals With Multiple Sclerosis Following Robotic Rehabilitation: A Scoping Review

Muscular weakness and loss of motor function are common symptoms of multiple sclerosis. Robotic rehabilitation can improve sensorimotor function and motor control in this population. However, many studies using robotics for rehabilitation have overlooked changes in muscular strength, despite research demonstrating its utility in combating functional impairments. The purpose of this scoping review was to critically examine changes in muscular strength following robotic rehabilitation interventions for individuals with multiple sclerosis. A literature search of five databases was conducted and search terms included a combination of three primary terms: robotic rehabilitation/training, muscular strength, and multiple sclerosis. Thirty one articles were found, and following inclusion criteria, 5 remained for further investigation. Although muscular strength was not the primary targeted outcome of the training for any of the included articles, increases in muscular strength were present in most of the studies suggesting that robotic therapy with a resistive load can be an effective alternative to resistance training for increasing muscular strength. Outcome measures of isometric knee-extensor force (kg) (right: p < 0.05, left: p < 0.05), isometric knee flexion and extension torque (Nm) (p < 0.05), ankle dorsiflexion and plantarflexion torque (Nm) (all p < 0.05) and handgrip force (kg) (p < 0.05) all improved following a robotic training intervention. These adaptations occurred with sustained low resistive loads of hand grip or during gait training. This scoping review concludes that, despite a lack of studies focusing on strength, there is evidence robotics is a useful modality to improve muscular strength in combination with motor control and neuromotor improvements. A call for more studies to document changes in strength during robotic rehabilitation protocols is warranted.

Assessing visually guided reaching in people with multiple sclerosis with and without self-reported upper limb impairment

The ability to accurately complete goal-directed actions, such as reaching for a glass of water, requires coordination between sensory, cognitive and motor systems. When these systems are impaired, like in people with multiple sclerosis (PwMS), deficits in movement arise. To date, the characterization of upper limb performance in PwMS has typically been limited to results attained from self-reported questionnaires or clinical tools. Our aim was to characterize visually guided reaching performance in PwMS. Thirty-six participants (12 PwMS who reported upper limb impairment (MS-R), 12 PwMS who reported not experiencing upper limb impairment (MS-NR), and 12 age- and sex-matched control participants without MS (CTL)) reached to 8 targets in a virtual environment while seeing a visual representation of their hand in the form of a cursor on the screen. Reaches were completed with both the dominant and non-dominant hands. All participants were able to complete the visually guided reaching task, such that their hand landed on the target. However, PwMS showed noticeably more atypical reaching profiles when compared to control participants. In accordance with these observations, analyses of reaching performance revealed that the MS-R group was more variable with respect to the time it took to initiate and complete their movements compared to the CTL group. While performance of the MS-NR group did not differ significantly from either the CTL or MS-R groups, individuals in the MS-NR group were less consistent in their performance compared to the CTL group. Together these findings suggest that PwMS with and without self-reported upper limb impairment have deficits in the planning and/or control of their movements. We further argue that deficits observed during movement in PwMS who report upper limb impairment may arise due to participants compensating for impaired movement planning processes.

Cerebellar Dysfunction in Multiple Sclerosis: Considerations for Research and Rehabilitation Therapy

Introduction. Cerebellar pathology is common among persons with multiple sclerosis (PwMS). The cerebellum is well recognized for its role in motor control and motor learning and cerebellar pathology in multiple sclerosis is associated with enhanced motor impairment and disability progression. The Problem. To mitigate motor disability progression, PwMS are commonly prescribed exercise and task-specific rehabilitation training. Yet, whether cerebellar dysfunction differentially affects rehabilitation outcomes in this population remains unknown. Furthermore, we lack rehabilitation interventions targeting cerebellar dysfunction. The Solution. Here, we summarize the current understanding of the impact of cerebellar dysfunction on motor control, motor training, and rehabilitation in persons with multiple sclerosis. Recommendations. Additionally, we highlight critical knowledge gaps and propose that these guide future research studying cerebellar dysfunction in persons with multiple sclerosis.

Personalized prediction of rehabilitation outcomes in multiple sclerosis: a proof-of-concept using clinical data, digital health metrics, and machine learning

Predicting upper limb neurorehabilitation outcomes in persons with multiple sclerosis (pwMS) is essential to optimize therapy allocation. Previous research identified population-level predictors through linear models and clinical data. This work explores the feasibility of predicting individual neurorehabilitation outcomes using machine learning, clinical data, and digital health metrics. Machine learning models were trained on clinical data and digital health metrics recorded pre-intervention in 11 pwMS. The dependent variables indicated whether pwMS considerably improved across the intervention, as defined by the Action Research Arm Test (ARAT), Box and Block Test (BBT), or Nine Hole Peg Test (NHPT). Improvements in ARAT or BBT could be accurately predicted (88% and 83% accuracy) using only patient master data. Improvements in NHPT could be predicted with moderate accuracy (73%) and required knowledge about sensorimotor impairments. Assessing these with digital health metrics over clinical scales increased accuracy by 10%. Non-linear models improved accuracy for the BBT (+ 9%), but not for the ARAT (-1%) and NHPT (-2%). This work demonstrates the feasibility of predicting upper limb neurorehabilitation outcomes in pwMS, which justifies the development of more representative prediction models in the future. Digital health metrics improved the prediction of changes in hand control, thereby underlining their advanced sensitivity.

Graphical Abstract

Preliminary Evaluation of an Adaptive Robotic Training Program of the Wrist for Persons with Multiple Sclerosis

Robotics can be used to describe wrist kinematics and assess sensorimotor impairments, while the implementation of training algorithms can be aimed at improving neuromuscular control. The purpose of this study was to use a robotic device to develop an adaptive and individualized training program of the distal upper extremity for individuals with multiple sclerosis (MS). This approach included an online assessment of performance aimed at changing the level of assistance/resistance provided during the task. Participants (N = 7) completed a robotic training program that occurred 3 times weekly for 4 weeks. The training protocol consisted of tracking a target moving along a figure by grasping the end-effector of the robotic device and moving it along the trajectory. Outcome measures were assessed pre- and post-intervention. Improvements in performance were quantified by average tracking (p = 0.028) and figural error (p = 0.028), which was significantly reduced by 26% and 43%, respectively. Isometric wrist strength significantly improved post-intervention (flexion: p = 0.043, radial and ulnar deviation: p = 0.028). The results of this work demonstrate that 4-weeks of adaptive robotic training is a feasible rehabilitative program that has the potential to improve distal upper extremity motor accuracy and muscular strength in a MS population.

A comparison of upper limb function in subjects with multiple sclerosis and healthy controls using an inertial measurement unit

Upper limbs (UL) dysfunction is frequent in people with Multiple Sclerosis (PwMS). Several objective measures of UL function are proposed; however, their use is mostly confined to assess subjects with mild-to-moderate disability and requires fine motor skills, often impaired in high disability level subjects. Thus, a tool to score UL function in the advanced disease stage is lacking. The aim of the study is to analyse and compare UL unilateral and bilateral movements of healthy control (HC) and PwMS, at different disability levels, using an instrumented version (Inertial Measurement Unit, IMU) of the 15-seconds finger-to-nose test (FNT). Each movement cycle was segmented in going/adjusting/returning phases. The inter-hand interval (IHI) allowed assessing bilateral coordination (i.e. synchrony) in each phase. The larger IHI, the more severe the bilateral coordination impairment is. After stratifying PwMS for disability level (PwMS_LOW, Expanded Disability Status Scale, EDSS≤5.5 and PwMS_HIGH, EDSS≥6), the ANOVA on IHI showed significant differences between PwMS and HC (p<0.001) in all phases. However, only the going phase IHI showed significantly higher asynchrony in PwMS_HIGH than PwMS_LOW and HC (p<0.001) and no differences between PwMS_LOW and HC. The going phase IHI seems to be a clinical marker specific for high disability level PwMS. These findings suggest inertial sensors during FNT could be an easy-to-use method for a more detailed quantitative characterization of UL function in PwMS also in subjects with EDSS greater than 6.

Effects of Hemispheric Stroke Localization on the Reorganization of Arm Movements within Different Mechanical Environments

This study investigated how stroke’s hemispheric localization affects motor performance, spinal maps and muscle synergies while performing planar reaching with and without assistive or resistive forces. A lesion of the right hemisphere affected performance, reducing average speed and smoothness and augmenting lateral deviation in both arms. Instead, a lesion of the left hemisphere affected the aiming error, impairing the feedforward control of the ipsilesional arm. The structure of the muscle synergies had alterations dependent on the lesion side in both arms. The applied force fields reduced the differences in performance and in muscle activations between arms and among populations. These results support the hypotheses of hemispheric specialization in movement control and identify potential significant biomarkers for the design of more effective and personalized rehabilitation protocols.

Straighten your back! Self-correction posture and postural balance in "non rehabilitative instructed" multiple sclerosis patients

BACKGROUD

Patients with MS, regardless of the complexity of the activity or sensory conditions, commonly present a significant postural control deficit compared to healthy subjects.

OBJECTIVE

To investigate which postural self-correction strategies are adopted by patients with Multiple Sclerosis versus a group of healthy-subjects and how self-correction can influence the control of postural balance.

METHODS

A case-control prospective observational study was conducted. Person with Multiple Sclerosis and a group of healthy volunteers were enrolled. Patients included were instructed with vocal commands, to reach a self-correction posture, and they were compared to healthy subjects. Clinical assessments including Balance, Stabilometry and Postural evaluation of the spine were performed.

RESULTS

Sixty patients (30: control-group; 30: treatment-group) were enrolled. In the treatment group, the analysis reported a significant statistical difference between path length and center of pressure speed in self-correction posture with closed-eyes (p = 0,049; 0,047) and an improvement in C7 and L3 levels in self-correction posture (p < 0,01-C7; p < 0,01-L3). There are significant statistical differences about path length between the two groups in all examined conditions (p = 0,0001). At sagittal plane evaluation, results show an increase of all measurements in both posture (C7-neutral posture p = 0,0001; L3-neutral posture p = 0,0001; C7-self-correction posture p = 0,0001; L3-self-correction posture p = 0,0001).

CONCLUSION

Further study should investigate dynamic situations and different Multiple Sclerosis forms to complete balance analysis and to establish a correct rehabilitative program with self-correction exercise as powerful focus.

Occupational therapy interventions for multiple sclerosis: A scoping review

BACKGROUND

Evidence for the effectiveness of occupational therapy for people with multiple sclerosis (MS) is yet to be established.

AIMS/OBJECTIVES

To review the evidence regarding the effectiveness of occupational therapy interventions in improving outcomes for adults with MS.

MATERIAL AND METHODS

We completed a scoping review of occupational therapy and multiple sclerosis following a scoping review methodological framework. Search included articles published up until June 2019. Studies were included if they were original research that included adults with MS published in English and assessed interventions delivered by occupational therapists.

RESULTS

The search yielded 1646 results. Following screening and review of articles, thirty papers met the inclusion criteria and were included in the review. Studies were charted and discussed in the areas of: (1) fatigue management or energy conservation; (2) upper-limb rehabilitation; (3) occupation-focussed cognitive rehabilitation; and (4) other types of interventions.

CONCLUSIONS

The quality of evidence that exists for occupational therapy with people with MS is mixed but there are studies that show that occupational therapy can improve occupational and other outcomes in this population.

Significance: Patients have reported many benefits of occupational therapy but the evidence-base to support this needs to be developed.Implications for rehabilitationOccupational therapists are well-placed to intervene with multiple sclerosis symptoms.Evidence for the effectiveness of occupational therapy for people with multiple sclerosis is yet to be established.Fatigue management programmes delivered by occupational therapists are effective in reducing symptoms.Additional training in client-centred practice is no more effective than usual occupational therapy.

Haptic vs sensorimotor training in the treatment of upper limb dysfunction in multiple sclerosis: A multi-center, randomised controlled trial

BACKGROUND

In multiple sclerosis (MS) exercise improves upper limb functions, but it is unclear what training types are more effective.

OBJECTIVE

This study compares robot-assisted training based on haptic or sensorimotor exercise.

METHODS

41clinically definite MS subjects with upper limb impairment were randomised into two groups: (i) Haptic and (ii) Sensorimotor. Subjects in the Haptic performed a robot-assisted training protocol designed to counteract incoordination and weakness. The task -interaction with a virtual mass-spring system against a resistive load- requires coordination skills. Task difficulty and magnitude of resistive load were automatically adjusted to the individual impairment. Subjects in the Sensorimotor performed reaching movements under visual control; the robot generated no forces. Both groups underwent eight training sessions (40 min/session, 2 sessions/week). Treatment outcome were 9HPT and ARAT scores.

RESULTS

The average 9HPT score decreased from 74±9 s to 61±8 s for the Haptic and from 49±6 s to 44±6 s. We found a significant Treatment (p=.0453) and Time differences (p=.005), but no significant Treatment×Time interactions although we found that the absolute change was only significant in the Haptic group (p=.011). We observed no significant changes in the ARAT score. Participants tolerated treatments well with a low drop-out rate. In the subjects evaluated at after 12 week (11 subject in sensory-motor and 17 in haptic group) no retention of the effect was found.

CONCLUSIONS

Task oriented training may improve upper limb function in persons with MS especially in prevalent pyramidal impaired subjects without maintain the effects after three months.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02711566 (clinicaltrial.gov).

Using an ankle robotic device for motor performance and motor learning evaluation

In this paper we performed the evaluation of ankle motor performance and motor learning during a goal-directed task, executed using the pediAnklebot robot. The protocol consisted of 3 phases (Familiarization, Adaptation, and Wash Out) repeated one time for each movement direction (plantarflexion, dorsiflexion, inversion, and eversion). During Familiarization and Wash out subjects performed goal-directed movements in unperturbed environment, whereas during Adaptation phase, a curl viscous force field was applied and it was randomly removed 10 times out of 200. Ankle motor performance was evaluated by means of a set of indices grouped into: accuracy, smoothness, temporal, and stopping indices. Learning Index was calculated to study the motor learning during the adaptation phase, which was subdivided into 5 temporal intervals (target sets). The outcomes related to the ankle motor performance highlighted that the best performance in terms of accuracy and smoothness of the trajectories was obtained in dorsiflexion movements in the sagittal plane, and in inversion rotations in the frontal plane. Differences between movement directions revealed an anisotropic behavior of the ankle joint. Results of the Learning index showed a capability of the subjects to rapidly adapt to a perturbed force field depending on the magnitude of the perceived field.

Sensor-based technology for upper limb rehabilitation in patients with multiple sclerosis: A randomized controlled trial

BACKGROUND

Sensor-based technological therapy devices may be good candidates for neuromotor rehabilitation of people with Multiple Sclerosis (MS), especially for treating upper extremities function limitations. The sensor-based device rehabilitation is characterized by interactive therapy games with audio-visual feedback that allows training the movement of shoulders, elbows, and wrist, measuring the strength and the active range of motion of upper limb, registering data in an electronic database to quantitatively monitoring measures and therapy progress.

OBJECTIVE

This study aimed to investigate the effects of sensor-based motor rehabilitation in add-on to the conventional neurorehabilitation, on increasing the upper limb functions of patients with MS.

METHODS

Thirty patients were enrolled in the study and randomly assigned to the experimental group and the control group. The training consisting of twelve sessions of upper limb training was compared with twelve sessions of upper limb sensory-motor training, without robotic support. Both rehabilitation programs were performed for 40 minutes three times a week, for 4 weeks, in addition to conventional therapy. All patients were evaluated at the baseline (T0) and after 4 weeks of training (T1).

RESULTS

The within-subject analysis showed a statistically significant improvement in both groups, in the Modified Barthel Index and in the Rivermead Mobility Index scores and a significant improvement in Multiple Sclerosis Quality of Life-54 in the experimental. The analysis of effectiveness revealed that, compared with baseline (T0), the improvement percentage in all clinical scale scores was greater in the experimental group than the control group.

CONCLUSIONS

Proposed training provides an intensive and functional-oriented rehabilitation that objectively evaluates achieved progress through exercises. Therefore, it can represent a good complementary strategy for hand rehabilitation in MS patients.

Functional connectivity in multiple sclerosis after robotic rehabilitative treatment: A case report

RATIONALE

Multiple sclerosis (MS) is an inflammatory demyelinating disease of central nervous system and it is associated with an impaired motor function status. The efficacy of rehabilitation in promoting functional recovery and increasing quality of life in MS patients has been demonstrated.

PATIENT CONCERNS

A 47-year-old woman was diagnosed with relapsing-remitting multiple sclerosis (RRMS) in November 2014 because of left upper limb hypoesthesia and weakness with difficulty in hand manipulation skills (there was a 1-point Expanded Disability Status Scale (EDSS) progression, i.e., 2.5 vs 1.5). Magnetic resonance image (MRI) showed a new frontal right cortical high-signal-intensity lesion.

DIAGNOSIS

Neurological and MRI examination were suggestive of MS diagnosis.

INTERVENTIONS

Patient was treated with robotic rehabilitation and evaluated by a Glove Analyzer for fMRI system (GAF). Functional MRI (fMRI) was acquired before and at the end of rehabilitative treatment performed with robotic device (Armeo-power).

OUTCOMES

At the end of the rehabilitation program, most of the behavioral parameters, GAF and fMRI evaluation, showed a significative improvement. Moreover, fMRI showed a significantly increased functional activation within the sensory-motor network in the active, motor task.

LESSONS

Our findings suggest a possible restorative effect of robotics on brain networks. Moreover, we may argue that GAF may be a valuable tool in assessing functional recovery after upper limb rehabilitation, especially of associated to fMRI examination.

Effects of High-intensity Robot-assisted Hand Training on Upper Limb Recovery and Muscle Activity in Individuals With Multiple Sclerosis: A Randomized, Controlled, Single-Blinded Trial

Background : Integration of robotics and upper limb rehabilitation in people with multiple sclerosis (PwMS) has rarely been investigated. Objective: To compare the effects of robot-assisted hand training against non-robotic hand training on upper limb activity in PwMS. To compare the training effects on hand dexterity, muscle activity, and upper limb dysfunction as measured with the International Classification of Functioning. Methods: This single-blind, randomized, controlled trial involved 44 PwMS (Expanded Disability Status Scale:1.5-8) and hand dexterity deficits. The experimental group (n = 23) received robot-assisted hand training; the control group (n = 21) received non-robotic hand training. Training protocols lasted for 5 weeks (50 min/session, 2 sessions/week). Before (T0), after (T1), and at 1 month follow-up (T2), a blinded rater evaluated patients using a comprehensive test battery. Primary outcome: Action Research Arm Test. Secondary outcomes: Nine Holes Peg Test; Fugl-Meyer Assessment Scale-upper extremity section; Motricity Index; Motor Activity Log; Multiple Sclerosis (MS) Quality of Life-54; Life Habits assessment-general short form and surface electromyography. Results: There were no significant between-group differences in primary and secondary outcomes. Electromyography showed relevant changes providing evidence increased activity in the extensor carpi at T1 and T2. Conclusion: The training effects on upper limb activity and function were comparable between the two groups. However, robot-assisted training demonstrated remarkable effects on upper limb use and muscle activity. https://clinicaltrials.gov NCT03561155.

Using Inertial Measurement Units and Electromyography to Quantify Movement during Action Research Arm Test Execution

In patients after stroke, ability of the upper limb is commonly assessed with standardised clinical tests that provide a complete upper limb assessment. This paper presents quantification of upper limb movement during the execution of Action research arm test (ARAT) using a wearable system of inertial measurement units (IMU) for kinematic quantification and electromyography (EMG) sensors for muscle activity analysis. The test was executed with each arm by a group of healthy subjects and a group of patients after stroke allocated into subgroups based on their clinical scores. Tasks were segmented into movement and manipulation phases. Each movement phase was quantified with a set of five parameters: movement time, movement smoothness, hand trajectory similarity, trunk stability, and muscle activity for grasping. Parameters vary between subject groups, between tasks, and between task phases. Statistically significant differences were observed between patient groups that obtained different clinical scores, between healthy subjects and patients, and between the unaffected and the affected arm unless the affected arm shows normal performance. Movement quantification enables differentiation between different subject groups within movement phases as well as for the complete task. Spearman's rank correlation coefficient shows strong correlations between patient's ARAT scores and movement time as well as movement smoothness. Weak to moderate correlations were observed for parameters that describe hand trajectory similarity and trunk stability. Muscle activity correlates well with grasping activity and the level of grasping force in all groups.

Upper limb robotics applied to neurorehabilitation: An overview of clinical practice

BACKGROUND

During the last two decades, extensive interaction between clinicians and engineers has led to the development of systems that stimulate neural plasticity to optimize motor recovery after neurological lesions. This has resulted in the expansion of the field of robotics for rehabilitation. Studies in patients with stroke-related upper-limb paresis have shown that robotic rehabilitation can improve motor capacity. However, few other applications have been evaluated (e.g. tremor, peripheral nerve injuries or other neurological diseases).

PURPOSE

This paper presents an overview of the current use of upper limb robotic systems for neurorehabilitation, and highlights the rationale behind their use for the assessment and treatment of common neurological disorders.

CONCLUSIONS

Rehabilitation robots are little integrated in clinical practice, except after stroke. Although few studies have been carried out to evaluate their effectiveness, evidence from the neurosciences and indications from pilot studies suggests that upper limb robotic rehabilitation can be applied safely in various other neurological conditions. Rehabilitation robots provide an intensity, quality and dose of treatment that exceeds therapist-mediated rehabilitation. Moreover, the use of force fields, multi-sensory environments, feedback etc. renders such rehabilitation engaging and motivating. Future studies should evaluate the effectiveness of rehabilitation robots in neurological pathologies other than stroke.

Evaluating upper limb impairments in multiple sclerosis by exposure to different mechanical environments

Multiple sclerosis is a chronic, autoimmune and neurodegenerative disease affecting multiple functional systems and resulting in motor impairments associated with muscle weakness and lack of movement coordination. We quantified upper limb motor deficits with a robot-based assessment including behavioral and muscle synergy analysis in 11 multiple sclerosis subjects with mild to moderate upper limb impairment (9 female; 50 ± 10 years) compared to 11 age- and gender- matched controls (9 female; 50 ± 9 years). All subjects performed planar reaching tasks by moving their upper limb or applying force while grasping the handle of a robotic manipulandum that generated four different environments: free space, assistive or resistive forces, and rigid constraint. We recorded the activity of 15 upper body muscles. Multiple sclerosis subjects generated irregular trajectories. While activities in isolated arm muscles appeared generally normal, shoulder muscle coordination with arm motions was impaired and there was a marked co-activation of the biceps and triceps in extension movements. Systematic differences in timing and organization of muscle synergies have also been observed. This study supports the definition of new biomarkers and rehabilitative treatments for improving upper limb motor coordination in multiple sclerosis.

Robot-assisted post-stroke motion rehabilitation in upper extremities: a survey

Recent neurological research indicates that the impaired motor skills of post-stroke patients can be enhanced and possibly restored through task-oriented repetitive training. This is due to neuroplasticity – the ability of the brain to change through adulthood. Various rehabilitation processes have been developed to take advantage of neuroplasticity to retrain neural pathways and restore or improve motor skills lost as a result of stroke or spinal cord injuries (SCI). Research in this area over the last few decades has resulted in a better understanding of the dynamics of rehabilitation in post-stroke patients and development of auxiliary devices and tools to induce repeated targeted body movements. With the growing number of stroke rehabilitation therapies, the application of robotics within the rehabilitation process has received much attention. As such, numerous mechanical and robot-assisted upper limb and hand function training devices have been proposed. A systematic review of robotic-assisted upper extremity (UE) motion rehabilitation therapies was carried out in this study. The strengths and limitations of each method and its effectiveness in arm and hand function recovery were evaluated. The study provides a comparative analysis of the latest developments and trends in this field, and assists in identifying research gaps and potential future work.

Robot-guided ankle sensorimotor rehabilitation of patients with multiple sclerosis

BACKGROUND

People with multiple sclerosis (MS) often develop symptoms including muscle weakness, spasticity, imbalance, and sensory loss in the lower limbs, especially at the ankle, which result in impaired balance and locomotion and increased risk of falls. Rehabilitation strategies that improve ankle function may improve mobility and safety of ambulation in patients with MS. This pilot study investigated effectiveness of a robot-guided ankle passive-active movement training in reducing motor and sensory impairments and improving balance and gait functions.

METHODS

Seven patients with MS participated in combined passive stretching and active movement training using an ankle rehabilitation robot. Six of the patients finished robotic training 3 sessions per week over 6 weeks for a total of 18 sessions. Biomechanical and clinical outcome evaluations were done before and after the 6-week treatment, and at a follow-up six weeks afterwards.

RESULTS

After six-week ankle sensorimotor training, there were increases in active range of motion in dorsiflexion, dorsiflexor and plantar flexor muscle strength, and balance and locomotion (p<0.05). Proprioception acuity showed a trend of improvement. Improvements in four biomechanical outcome measures and two of the clinical outcome measures were maintained at the 6-week follow-up. The study showed the six-week training duration was appropriate to see improvement of range of motion and strength for MS patients with ankle impairment.

CONCLUSION

Robot-guided ankle training is potentially a useful therapeutic intervention to improve mobility in patients with MS.

Corpus Callosum Structural Integrity Is Associated With Postural Control Improvement in Persons With Multiple Sclerosis Who Have Minimal Disability

BACKGROUND

Improvement of postural control in persons with multiple sclerosis (PwMS) is an important target for neurorehabilitation. Although PwMS are able to improve postural performance with training, the neural underpinnings of these improvements are poorly understood.

OBJECTIVE

To understand the neural underpinnings of postural motor learning in PwMS.

METHODS

Supraspinal white matter structural connectivity in PwMS was correlated with improvements in postural performance (balancing on an oscillating surface over 25 trials) and retention of improvements (24 hours later).

RESULTS

Improvement in postural performance was directly correlated to microstructural integrity of white matter tracts, measured as radial diffusivity, in the corpus callosum, posterior parieto-sensorimotor fibers and the brainstem in PwMS. Within the corpus callosum, the genu and midbody (fibers connecting the prefrontal and primary motor cortices, respectively) were most strongly correlated to improvements in postural control. Twenty-four-hour retention was not correlated to radial diffusivity.

CONCLUSION

PwMS who exhibited poorer white matter tract integrity connecting the cortical hemispheres via the corpus callosum showed the most difficulty learning to control balance on an unstable surface. Prediction of improvements in postural control through training (ie, motor learning) via structural imaging of the brain may allow for identification of individuals who are particularly well suited for postural rehabilitation interventions.

Effect of Comorbidities on Outcomes of Neurorehabilitation Interventions in Multiple Sclerosis: A Scoping Review

Background: Interest in comorbidities has increased in the past few years, but the effect of comorbidities on outcomes of multiple sclerosis (MS) neurorehabilitation interventions is unclear. The aim of this review was to identify and summarize the existing evidence regarding the effect of comorbidities on outcomes of neurorehabilitation interventions targeting people with MS. Methods: Five databases (Embase, MEDLINE through Ovid, PubMed Central, Cumulative Index to Nursing and Allied Health Literature, and Web of Science) were searched using index terms and keywords relating to MS and a wide range of rehabilitation interventions. Studies screened were limited to English-language randomized controlled trials. Information related to included and excluded comorbidities and how they were reported and described was extracted from the included studies. Results: Fifty-four neurorehabilitation randomized controlled trials were included and were grouped into categories: robotics/technology-enhanced (n = 7), task-oriented training/neurorehabilitation principles (n = 7), electrical stimulation (n = 12), temperature regulation (n = 6), magnetic field therapy (n = 5), vibration (n = 9), and miscellaneous (n = 8). Although the issue of comorbidity was considered in 40 studies, it was limited to excluding individuals from participating in the trials. Only two studies reported on comorbidity, but neither examined the possible mediating or moderating effect of comorbidities on intervention outcomes. Conclusions: This review documents important knowledge gaps about the effect of comorbidity on neurorehabilitation outcomes and identifies a critical need for future studies to address this issue. Without this information, we limit our understanding of the mechanisms of comorbidity and its effects on relevant clinical and research outcomes specific to neurorehabilitation.

Sensory dynamic orthoses in mild to moderate upper limb tremor in multiple sclerosis: a mixed methods feasibility study

OBJECTIVE

To explore the feasibility of conducting a Phase III randomized controlled trial evaluating sensory dynamic orthoses for upper limb tremor in multiple sclerosis.

DESIGN

Mixed methods: double blind randomized placebo controlled pilot study and semi-structured interviews.

SETTING

Rehabilitation centre.

SUBJECTS

A total of 21 people with multiple sclerosis with upper limb tremor.

INTERVENTIONS

Participants received a sensory dynamic orthosis sleeve or a non-compressive sleeve (placebo) that they wore eight hours a day, for nine weeks.

MAIN MEASURES

Outcomes were completed at baseline and nine weeks. The primary outcome measure was the Fahn-Tolosa-Marin (FAHN) Tremor Rating Scale. Secondary outcome measures included the: Action Research Arm Test, Canadian Occupational Performance Measure, Psychological Impact of Assistive Device Scale and the Nine-hole Peg Test.

RESULTS

Both sleeves were acceptable, although achieving a good fit was an issue. There were no significant between-group differences for the primary outcome measure. The median ± interquartile range change scores were 0.5 ±6.5 and 2 ±8 for the placebo and treatment group, respectively. The median ± interquartile range Canadian Occupational Performance Measure (performance subscale) demonstrated significant improvements ( p = 0.01) for the placebo group (1.1 ±1.65) compared with the treatment group (0 ±1.2). There was no between-group differences in the satisfaction subscale. The primary outcome measure was sensitive to detect change; however the Action Research Arm Test was not responsive in this study population.

CONCLUSION

Undertaking an randomized controlled trial would be feasible and a minimum of 200 participants would be needed for a fully powered, definitive randomized controlled trial.

Upper Limb Rehabilitation in People With Multiple Sclerosis

Background. There has been an increasing research interest in upper limb rehabilitation in multiple sclerosis (MS). The current changes in the research field inquire a new literature review. Objective. This systematic review aimed to provide an overview of the upper limb rehabilitation strategies in people with MS (PwMS). Methods. Articles published in PubMed and Web of Knowledge were selected when written in English, published in the past 25 years, peer reviewed, that included at least 5 PwMS, and described the effects of an intervention study including rehabilitation strategies targeting the upper limbs. Included articles were screened based on title/abstract and full text by 2 independent reviewers. Results. Thirty articles met the criteria and were included for data extraction. Only half of the included studies investigated the effects of a training program specially targeted toward the upper limbs, while in the other studies, a general whole body therapy was used. The therapy content and dosage varied greatly between the different included studies. Multidisciplinary and robot-based rehabilitation were the most investigated rehabilitation strategies and showed to improve upper limb capacity. Strength and endurance training improved the upper limb body functions and structures but did not influence the upper limb capacity and performance. Conclusions. The results of this systematic review indicated that different types of upper limb rehabilitation strategies can improve upper limb function in PwMS. Further research is necessary to compare directly the effects of different rehabilitation strategies and to investigate the optimal therapy dosage according to the upper limb disability level.

Design and fabrication of a three dimensional printable non-assembly articulated hand exoskeleton for rehabilitation

Robotic rehabilitation has proven to be cost-effective in accelerating the rehabilitation process by eliminating the constant need for supervision by a therapist. This work aimed to design and develop a novel three-dimensional (3D) printable non-assembly five-fingered robotic hand exoskeleton for rehabilitation. A single degree-of-freedom (DOF) linkage was designed to actuate each finger with 3 output links that correspond to the three phalanxes of the human finger. We used a parametric modelling approach that suits the dimensions of individual's hand. The fabrication of this dynamic model was achieved by printing the complete assembly including all the driving links, output links, and joints. We manufactured a prototype and developed real-time actuation and control. The reported unique linkage design, combined with parametric modelling and 3D printing technology, will pave the way for mass customization of active assistive and resistive hand exoskeletons.

Treatment of progressive multiple sclerosis: what works, what does not, and what is needed

Disease-modifying drugs have mostly failed as treatments for progressive multiple sclerosis. Management of the disease therefore solely aims to minimise symptoms and, if possible, improve function. The degree to which this approach is based on empirical data derived from studies of progressive disease or whether treatment decisions are based on what is known about relapsing-remitting disease remains unclear. Symptoms rated as important by patients with multiple sclerosis include balance and mobility impairments, weakness, reduced cardiovascular fitness, ataxia, fatigue, bladder dysfunction, spasticity, pain, cognitive deficits, depression, and pseudobulbar affect; a comprehensive literature search shows a notable paucity of studies devoted solely to these symptoms in progressive multiple sclerosis, which translates to few proven therapeutic options in the clinic. A new strategy that can be used in future rehabilitation trials is therefore needed, with the adoption of approaches that look beyond single interventions to concurrent, potentially synergistic, treatments that maximise what remains of neural plasticity in patients with progressive multiple sclerosis.

Robotic and clinical evaluation of upper limb motor performance in patients with Friedreich's Ataxia: an observational study

BACKGROUND

Friedreich's ataxia (FRDA) is the most common hereditary autosomal recessive form of ataxia. In this disease there is early manifestation of gait ataxia, and dysmetria of the arms and legs which causes impairment in daily activities that require fine manual dexterity. To date there is no cure for this disease. Some novel therapeutic approaches are ongoing in different steps of clinical trial. Development of sensitive outcome measures is crucial to prove therapeutic effectiveness. The aim of the study was to assess the reliability and sensitivity of quantitative and objective assessment of upper limb performance computed by means of the robotic device and to evaluate the correlation with clinical and functional markers of the disease severity.

METHODS

Here we assess upper limb performances by means of the InMotion Arm Robot, a robot designed for clinical neurological applications, in a cohort of 14 children and young adults affected by FRDA, matched for age and gender with 18 healthy subjects. We focused on the analysis of kinematics, accuracy, smoothness, and submovements of the upper limb while reaching movements were performed. The robotic evaluation of upper limb performance consisted of planar reaching movements performed with the robotic system. The motors of the robot were turned off, so that the device worked as a measurement tool. The status of the disease was scored using the Scale for the Assessment and Rating of Ataxia (SARA). Relationships between robotic indices and a range of clinical and disease characteristics were examined.

RESULTS

All our robotic indices were significantly different between the two cohorts except for two, and were highly and reliably discriminative between healthy and subjects with FRDA. In particular, subjects with FRDA exhibited slower movements as well as loss of accuracy and smoothness, which are typical of the disease. Duration of Movement, Normalized Jerk, and Number of Submovements were the best discriminative indices, as they were directly and easily measurable and correlated with the status of the disease, as measured by SARA.

CONCLUSIONS

Our results suggest that outcome measures obtained by means of robotic devices can improve the sensitivity of clinical evaluations of patients' dexterity and can accurately and efficiently quantify changes over time in clinical trials, particularly when functional scales appear to be no longer sensitive.

Intention tremor and deficits of sensory feedback control in multiple sclerosis: a pilot study

BACKGROUND

Intention tremor and dysmetria are leading causes of upper extremity disability in Multiple Sclerosis (MS). The development of effective therapies to reduce tremor and dysmetria is hampered by insufficient understanding of how the distributed, multi-focal lesions associated with MS impact sensorimotor control in the brain. Here we describe a systems-level approach to characterizing sensorimotor control and use this approach to examine how sensory and motor processes are differentially impacted by MS.

METHODS

Eight subjects with MS and eight age- and gender-matched healthy control subjects performed visually-guided flexion/extension tasks about the elbow to characterize a sensory feedback control model that includes three sensory feedback pathways (one for vision, another for proprioception and a third providing an internal prediction of the sensory consequences of action). The model allows us to characterize impairments in sensory feedback control that contributed to each MS subject's tremor.

RESULTS

Models derived from MS subject performance differed from those obtained for control subjects in two ways. First, subjects with MS exhibited markedly increased visual feedback delays, which were uncompensated by internal adaptive mechanisms; stabilization performance in individuals with the longest delays differed most from control subject performance. Second, subjects with MS exhibited misestimates of arm dynamics in a way that was correlated with tremor power. Subject-specific models accurately predicted kinematic performance in a reach and hold task for neurologically-intact control subjects while simulated performance of MS patients had shorter movement intervals and larger endpoint errors than actual subject responses. This difference between simulated and actual performance is consistent with a strategic compensatory trade-off of movement speed for endpoint accuracy.

CONCLUSIONS

Our results suggest that tremor and dysmetria may be caused by limitations in the brain's ability to adapt sensory feedback mechanisms to compensate for increases in visual information processing time, as well as by errors in compensatory adaptations of internal estimates of arm dynamics.

Quantitative assessment of upper limb motor function in Multiple Sclerosis using an instrumented Action Research Arm Test

BACKGROUND

Arm impairment in Multiple Sclerosis (MS) is commonly assessed with clinical scales, such as Action Research Arm Test (ARAT) which evaluates the ability to handle and transport smaller and larger objects. ARAT provides a complete upper limb assessment, as it considers both proximal arm and hand, but suffers from subjectivity and poor sensitivity to mild impairment. In this study an instrumented ARAT is proposed to overcome these limitations and supplement the assessment of arm function in MS.

METHODS

ARAT was executed by 12 healthy volunteers and 21 MS subjects wearing a single inertial sensor on the wrist. Accelerometers and gyroscopes signals were used to calculate the duration of each task and its sub-phases (reaching, manipulation, transport, release and return). A jerk index was computed to quantify movement smoothness. For each parameter, z-scores were calculated to analyze the deviation from normative data. MS subjects were clinically assessed with ARAT score, Nine-Hole Peg test (9HPT) and Fahn Tremor Rating Scale (FTRS).

RESULTS

ARAT tasks executed by MS patients were significantly slower (duration increase: 70%) and less smooth (jerk increase: 16%) with respect to controls. These anomalies were mainly related to manipulation, transport and release sub-movements, with the former showing the greatest alterations. A statistically significant decrease in movement velocity and smoothness was also noticed in patients with normal ARAT score. Z-scores related to duration and jerk were strongly correlated with ARAT rating (r < -0.80, p < 0.001) and 9HPT (r < -0.75, p < 0.001) and were significantly different among MS sub-groups with different levels of arm impairments (p < 0.001). Moreover, Z-score related to manipulation-phase jerk was significantly correlated with the FTRS rating of intention tremor (r = 0.84, p < 0.001).

CONCLUSIONS

The present study showed that the proposed method is able to discriminate between control and MS groups and to reveal subtle arm alterations not detectable from ARAT score. Validity was shown by high correlations between instrumental variables and clinical ratings. These results suggested that instrumented ARAT could be a valid quick and easy-to-use method for a sensitive quantification of arm function in MS. Inclusion of finger-mounted sensors could complement present findings and provide further indications about hand function in MS.

Upper limb assessment in multiple sclerosis: a systematic review of outcome measures and their psychometric properties

OBJECTIVE

To provide an overview of applied upper limb outcome measures in multiple sclerosis (MS) according to the International Classification of Functioning, Disability and Health (ICF) levels and to review their psychometric properties in MS.

DATA SOURCES

PubMed and Web of Knowledge.

STUDY SELECTION

Articles published until June 2013 were selected when written in English, published in the last 25 years, peer reviewed, including >5 persons with MS, and including standardized clinical upper limb outcome measures. Included articles were screened based on title/abstract and full text by 2 independent reviewers. In case of doubt, feedback from a third independent reviewer was obtained. Additionally, references lists were checked for relevant articles. Of the articles, 109 met the selection criteria and were included for data extraction.

DATA EXTRACTION

All reported clinical upper limb outcome measures were extracted from the included studies and classified according to the ICF levels by 2 independent reviewers. In addition, available psychometric properties (reliability, validity, responsiveness) in MS were summarized and discussed.

DATA SYNTHESIS

A diversity of outcome measures assessing impairments on the body functions and structures level (n=33), upper limb capacity (n=11), and performance (n=8) on the activity level were extracted from 109 articles. Hand grip strength and the nine-hole peg test (NHPT) were the most frequently used outcome measures. However, multiple outcome measures are necessary to encapsulate the multidimensional character of the upper limb function. The psychometric properties were insufficiently documented for most of the outcome measures, except for the NHPT.

CONCLUSIONS

The results of this review may help with the selection of appropriate outcome measures and may guide future research regarding the psychometric properties in MS.

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.

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

Background. Haptic robots allow the exploitation of known motor learning mechanisms, representing a valuable option for motor treatment after stroke. The aim of this feasibility multicentre study was to test the clinical efficacy of a haptic prototype, for the recovery of hand function after stroke. Methods. A prospective pilot clinical trial was planned on 15 consecutive patients enrolled in 3 rehabilitation centre in Italy. All the framework features of the haptic robot (e.g., control loop, external communication, and graphic rendering for virtual reality) were implemented into a real-time MATLAB/Simulink environment, controlling a five-bar linkage able to provide forces up to 20 [N] at the end effector, used for finger and hand rehabilitation therapies. Clinical (i.e., Fugl-Meyer upper extremity scale; nine hold pegboard test) and kinematics (i.e., time; velocity; jerk metric; normalized jerk of standard movements) outcomes were assessed before and after treatment to detect changes in patients' motor performance. Reorganization of cortical activation was detected in one patient by fMRI. Results and Conclusions. All patients showed significant improvements in both clinical and kinematic outcomes. Additionally, fMRI results suggest that the proposed approach may promote a better cortical activation in the brain.

A tailored exercise of manipulation of virtual tools to treat upper limb impairment in Multiple Sclerosis

We developed a robot-assisted rehabilitation protocol, specifically designed to treat cerebellar and motor symptoms in subjects with Multiple Sclerosis. The task consists of controlling a `virtual' tool (a mass-spring system), under the effect of a resistive force. The exercise is designed in such a way that task difficulty and the degree of resistance are automatically adjusted to the individual patients' impairment. The protocol included a total of eight 40 min training sessions (2 sessions/week), and automatic regulation of difficulty and resistance was repeated at the beginning of each session. Preliminary results suggest that subjects improve their performance, both within and between sessions. Moreover, task difficulty and resistance tend to increase across sessions, indicating that subjects gradually improve their ability to deal with more challenging versions of the task.

The Armeo Spring as training tool to improve upper limb functionality in multiple sclerosis: a pilot study

Background

Few research in multiple sclerosis (MS) has focused on physical rehabilitation of upper limb dysfunction, though the latter strongly influences independent performance of activities of daily living. Upper limb rehabilitation technology could hold promise for complementing traditional MS therapy. Consequently, this pilot study aimed to examine the feasibility of an 8-week mechanical-assisted training program for improving upper limb muscle strength and functional capacity in MS patients with evident paresis.

Methods

A case series was applied, with provision of a training program (3×/week, 30 minutes/session), supplementary on the customary maintaining care, by employing a gravity-supporting exoskeleton apparatus (Armeo Spring). Ten high-level disability MS patients (Expanded Disability Status Scale 7.0-8.5) actively performed task-oriented movements in a virtual real-life-like learning environment with the affected upper limb. Tests were administered before and after training, and at 2-month follow-up. Muscle strength was determined through the Motricity Index and Jamar hand-held dynamometer. Functional capacity was assessed using the TEMPA, Action Research Arm Test (ARAT) and 9-Hole Peg Test (9HPT).

Results

Muscle strength did not change significantly. Significant gains were particularly found in functional capacity tests. After training completion, TEMPA scores improved (p = 0.02), while a trend towards significance was found for the 9HPT (p = 0.05). At follow-up, the TEMPA as well as ARAT showed greater improvement relative to baseline than after the 8-week intervention period (p = 0.01, p = 0.02 respectively).

Conclusions

The results of present pilot study suggest that upper limb functionality of high-level disability MS patients can be positively influenced by means of a technology-enhanced physical rehabilitation program.