Changes in skeletal muscle perfusion and spasticity in patients with poststroke hemiparesis treated by robotic assistance (Gloreha) of the hand

Effects of Limbs' Spasticity on Spinopelvic Alignment in Post-Stroke Patients: A Cross-Sectional Study

Objectives: This study aimed to determine the impacts of upper and lower limb (UL and LL) spasticity and impairment on spinal alignment in chronic post-stroke patients. Methods: A total of 45 consecutive chronic post-stroke patients, 18 women and 27 men, from 18 to 70 years old who presented post-stroke hemiparesis were recruited in this cross-sectional study. The clinical assessment included the Modified Ashworth Scale (UL-MAS and LL-MAS spasticity), Upper Limb Motricity Index (UL-MI), FAST-UL, and Five Times Sit-to-Stand Test (5T-STS); the Associated Reaction Rating Scale was used to measure associated reactions in the hemiparetic UL, the plumb line distance from the spinous process of C7 on the sagittal (PL-C7s) and frontal plane (Pl-C7f), the kyphosis apex (PL-AK), and the spinous process of L3 (PL-L3). Angular measures of spinal alignment were measured by a Bunnell scoliometer™ (angle of trunk rotation-ATR) and a gravity-dependent inclinometer (inclination at C7-T1 and T12-L1). Results: In chronic post-stroke patients, there was found to be an association between the 5T-STS and PL-C7f (β = 0.41, p = 0.05) and the angle of inclination at T12-L1 (β = 0.44, p = 0.01). The FAST-UL correlated with PL-C7f (β = -0.41, p = 0.05), while the UL-MI correlated with this last parameter (β = -0.36, p = 0.04) and the ATR (β = -0.31, p = 0.05). The UL-MAS showed correlation with the ATR (β = 0.38, p = 0.01). Conclusions: The results lead to the possibility that, in chronic post-stroke patients, spinal misalignment on the frontal and sagittal plane is associated both with strength impairment and UL spasticity. The improvement or restoration of spinopelvic parameters can take advantage of therapeutic interventions targeted at motor improvement and spasticity reduction of the hemiparetic side.

Acute Response to One Bout of Dynamic Standing Exercise on Blood Glucose and Blood Lactate Among Children and Adolescents With Cerebral Palsy Who are Nonambulant

PURPOSE

To investigate the acute exercise effects of dynamic standing exercise on blood glucose and blood lactate among children and adolescents with cerebral palsy who are nonambulant.

METHODS

Twenty-four participants with cerebral palsy who are nonambulant performed 30 minutes of dynamic standing exercise using a motorized device enabling assisted passive movements in an upright weight-bearing position. Capillary blood samples were taken from the fingertip for measurement of blood glucose and blood lactate at rest and at the end of exercise.

RESULTS

At rest, the participants had hyperlactatemia that was unaffected after exercise, presented as median and interquartile range at rest 1.8 (1.3:2.7) mmol/L, and after exercise 2.0 (1.1:2.5) mmol/L. Children and adolescents with Gross Motor Function Classification System, level V, had higher lactate levels at rest (2.5 [1.8:2.9] vs 1.4 [1.0:2.0]; P = .030) and after exercise (2.3 [2.0:2.6] vs 1.2 [0.9:2.2]; P = .032) compared with children and adolescents with Gross Motor Function Classification System, level IV, respectively. A statistically significant larger decrease in blood lactate levels after exercise was observed in children and adolescents with higher resting blood lactate levels (ρ = .56; P = .004). There were no statistically significant changes in blood glucose.

CONCLUSIONS

Forty percentage of the participants had mild hyperlactatemia at rest and participants with the highest blood lactate levels at rest had the greatest decrease in blood lactate levels after one bout of exercise. Children and adolescents who were classified with the highest level of the Gross Motor Function Classification Scale had higher blood lactate levels. More studies are needed on how to prevent chronically high resting levels of lactate with exercise in children with cerebral palsy who are nonambulant.

Robotic assistive and rehabilitation devices leading to motor recovery in upper limb: a systematic review

PURPOSE

Stroke, spinal cord injury and other neuromuscular disorders lead to impairments in the human body. Upper limb impairments, especially hand impairments affect activities of daily living (ADL) and reduce the quality of life. The purpose of this review is to compare and evaluate the available robotic rehabilitation and assistive devices that can lead to motor recovery or maintain the current motor functional level.

METHODS

A systematic review was conducted of the literature published in the years from 2016-2021, to focus on the most recent rehabilitation and assistive devices available in the market or research environments.

RESULTS

A total of 230 studies published between 2016 and 2021 were identified from various databases. 107 were excluded with various reasons. Twenty-eight studies were taken into detailed review, to determine the efficacy of robotic devices in improving upper limb impairments or maintaining the current level from getting worse.

CONCLUSION

It was concluded that with a good strategy and treatment plan; appropriate and regular use of these robotic rehabilitation and assistive devices do lead to improvements in current conditions of most of the subjects and prolonged use may lead to motor recovery.Implications for RehabilitationStroke, accidents, spinal cord injuries and other neuromuscular disorders lead to impairments. Upper limb impairments have a tremendous adverse affect on ADL and reduces quality of life drastically.Advancement in technology has led to the designing of many robotic assistive and rehabilitation devices to assist in motor recovery or aid in ADL.This review analyses different available devices for rehabilitation and assistance and points out that use of these devices in time does help in motor recovery. Most of the studies reviewed showed improvements for the user.Future devices should be more portable and easier to use from home.

Joint Angle Estimation of a Tendon-Driven Soft Wearable Robot through a Tension and Stroke Measurement

The size of a device and its adaptability to human properties are important factors in developing a wearable device. In wearable robot research, therefore, soft materials and tendon transmissions have been utilized to make robots compact and adaptable to the human body. However, when used for wearable robots, these methods sometimes cause uncertainties that originate from elongation of the soft material or from undefined human properties. In this research, to consider these uncertainties, we propose a data-driven method that identifies both kinematic and stiffness parameters using tension and wire stroke of the actuators. Through kinematic identification, a method is proposed to find the exact joint position as a function of the joint angle. Through stiffness identification, the relationship between the actuation force and the joint angle is obtained using Gaussian Process Regression (GPR). As a result, by applying the proposed method to a specific robot, the research outlined in this paper verifies how the proposed method can be used in wearable robot applications. This work examines a novel wearable robot named Exo-Index, which assists a human’s index finger through the use of three actuators. The proposed identification methods enable control of the wearable robot to result in appropriate postures for grasping objects of different shapes and sizes.

Near-infrared spectroscopy as a quantitative spasticity assessment tool: A systematic review

The purpose of this paper is to systematically review the literature on the use of near-infrared spectroscopy (NIRS) for assessing spasticity. MEDLINE, CINAHL, and EMBASE were searched for human and/or animal studies written in the English language published until November 2018. that used NIRS to examine the hemodynamics and/or metabolism of spastic musculature were included. Of the 35 articles identified, five met the inclusion criteria. Two reviewers independently extracted spasticity outcomes, NIRS instrumentation specifications, and NIRS hemodynamic and metabolic measures from each article. Risk of bias was assessed using the Downs & Black tool for non-randomized studies. Three different models of NIRS devices were used in the five studies. Four studies examined the effects of passive limb movements and one examined active hand movements on NIRS parameters in spastic and non-spastic muscle. Owing to the small number and diverse nature of the studies, statistical comparison was deemed inappropriate. Rather, descriptive comparisons were drawn and levels of evidence were assigned based on the modified Sackett Scale. There is level 4 evidence that NIRS can non-invasively detect and measure differences between spastic and non-spastic muscles in blood volume and oxidative capacity changes over time or in response to interventions, and may correlate with other, established measures of spasticity, such as the Modified Ashworth Scale (MAS) and electromyography (EMG). Future research studies should use a validated definition of spasticity for inclusion criteria, a control group, and standardized NIRS variables.

Robotic-assisted hand therapy for improvement of hand function in children with cerebral palsy: a case series study

BACKGROUND

Most types of robot-assisted training (RT) have been used in Cerebral Palsy (CP) patients only focus on proximal upper extremity. Few of study investigated the effect of distal upper extremity training.

CASE REPORT

Pediatric CP patients (N.=7) participated the RT sessions for 6 weeks (12 60-min sessions 2 times a week). Performance was assessed at 3 time points (pretest, posttest, and 1-month follow-up). RT significantly improved in body structure and function domains: FMA-UE scores (P=0.002). On electromyography, significant improvements in the mean brachioradialis muscle amplitude (P=0.015) and electrical agonist-antagonist muscle ratio (P=0.041) in the 1-inch cube-grasping task. The effects were maintained after 1 month.

CLINICAL REHABILITATION IMPACT

RT using a Gloreha device which focuses on the distal part of the upper limb benefit on body structure and function, including upper-extremity motor function, brachioradialis muscle recruitment, and coordination in children with cerebral palsy.

Effects of Neurodynamic Mobilizations on Pain Hypersensitivity in Patients With Hand Osteoarthritis Compared to Robotic Assisted Mobilization: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of the neurodynamic mobilization techniques compared with passive robotic physiologic movement in patients with hand osteoarthritis (OA).

METHODS

We conducted a randomized controlled trial. A total of 72 patients (mean ± SD age 71 ± 11 years) with dominant symptomatic hand OA were randomized in 2 groups, and both received 12 treatment sessions over 4 weeks. The experimental group received neurodynamic mobilization of the median, radial, and ulnar nerves, and the control group received robotic-assisted passive movement treatment. Both groups also participated in a program of hand stability exercises. Outcome measures included pain intensity, pressure pain thresholds (PPTs), and strength measurements. Group-by-time effects were compared using mixed-model analyses of variance.

RESULTS

After the intervention, the experimental group had statistically significant, higher PPTs than the control group at the thumb carpometacarpal joint by 0.7 kg/cm² (95% confidence interval [95% CI] 0.6, 0.8), the median nerve by 0.7 kg/cm² (95% CI 0.6, 0.7), and the radial nerve by 0.5 kg/cm² (95% CI 0.3, 0.6); however, the difference was not statistically significant at 3 months postintervention. Although mean values in the experimental group were higher than in the control group at all PPT sites at both assessments, these differences were not statistically significant. The experimental group experienced a statistically significant reduction in pain immediately postintervention, but this was not present at the 3-month follow-up. There were no statistically significant differences in pinch or grip strength between groups.

CONCLUSION

We found that neurodynamic mobilizations decreased hypersensitivity in patients with hand OA immediately after the intervention; however, differences were no longer present at 3 months. The results suggest that these techniques may have some limited value in the short term but do not have lasting effects.

Kinematic synergies of hand grasps: a comprehensive study on a large publicly available dataset

Background

Hand grasp patterns require complex coordination. The reduction of the kinematic dimensionality is a key process to study the patterns underlying hand usage and grasping. It allows to define metrics for motor assessment and rehabilitation, to develop assistive devices and prosthesis control methods. Several studies were presented in this field but most of them targeted a limited number of subjects, they focused on postures rather than entire grasping movements and they did not perform separate analysis for the tasks and subjects, which can limit the impact on rehabilitation and assistive applications. This paper provides a comprehensive mapping of synergies from hand grasps targeting activities of daily living. It clarifies several current limits of the field and fosters the development of applications in rehabilitation and assistive robotics.

Methods

In this work, hand kinematic data of 77 subjects, performing up to 20 hand grasps, were acquired with a data glove (a 22-sensor CyberGlove II data glove) and analyzed. Principal Component Analysis (PCA) and hierarchical cluster analysis were used to extract and group kinematic synergies that summarize the coordination patterns available for hand grasps.

Results

Twelve synergies were found to account for > 80% of the overall variation. The first three synergies accounted for more than 50% of the total amount of variance and consisted of: the flexion and adduction of the Metacarpophalangeal joint (MCP) of fingers 3 to 5 (synergy #1), palmar arching and flexion of the wrist (synergy #2) and opposition of the thumb (synergy #3). Further synergies refine movements and have higher variability among subjects.

Conclusion

Kinematic synergies are extracted from a large number of subjects (77) and grasps related to activities of daily living (20). The number of motor modules required to perform the motor tasks is higher than what previously described. Twelve synergies are responsible for most of the variation in hand grasping. The first three are used as primary synergies, while the remaining ones target finer movements (e.g. independence of thumb and index finger). The results generalize the description of hand kinematics, better clarifying several limits of the field and fostering the development of applications in rehabilitation and assistive robotics.

Usability Assessment of a Cable-Driven Exoskeletal Robot for Hand Rehabilitation

Study design: Case series.

Background: Robot-assisted rehabilitation mediated by exoskeletal devices is a popular topic of research. The biggest difficulty in the development of rehabilitation robots is the consideration of the clinical needs. This study investigated the usability of a novel cable-driven exoskeletal robot specifically designed for hand rehabilitation.

Methods: The study consists of three steps, including prototype development, spasticity observation, and usability evaluation. First, we developed the prototype robot DexoHand to manipulate the patient's fingers based on the clinical needs and the cable-driven concept established in our previous work. Second, we applied DexoHand to patients with different levels of spasticity. Finally, we obtained the system usability scale (SUS) and assessed its usability.

Results: Two healthy subjects were recruited in the pre-test, and 18 patients with stroke and four healthy subjects were recruited in the formal test for usability. The total SUS score obtained from the patients and healthy subjects was 94.77 ± 2.98 (n = 22), indicating an excellent level of usability. The satisfaction score was 4.74 ± 0.29 (n = 22), revealing high satisfaction with DexoHand. The tension profile measured by the cables showed the instantaneous force used to manipulate fingers among different muscle tone groups.

Conclusions:DexoHand meets the clinical needs with excellent usability, satisfaction, and reliable tension force monitoring, yielding a feasible platform for robot-assisted hand rehabilitation.

Muscle Synergy Analysis of a Hand-Grasp Dataset: A Limited Subset of Motor Modules May Underlie a Large Variety of Grasps

Background: Kinematic and muscle patterns underlying hand grasps have been widely investigated in the literature. However, the identification of a reduced set of motor modules, generalizing across subjects and grasps, may be valuable for increasing the knowledge of hand motor control, and provide methods to be exploited in prosthesis control and hand rehabilitation.

Methods: Motor muscle synergies were extracted from a publicly available database including 28 subjects, executing 20 hand grasps selected for daily-life activities. The spatial synergies and temporal components were analyzed with a clustering algorithm to characterize the patterns underlying hand-grasps.

Results: Motor synergies were successfully extracted on all 28 subjects. Clustering orders ranging from 2 to 50 were tested. A subset of ten clusters, each one represented by a spatial motor module, approximates the original dataset with a mean maximum error of 5% on reconstructed modules; however, each spatial synergy might be employed with different timing and recruited at different grasp stages. Two temporal activation patterns are often recognized, corresponding to the grasp/hold phase, and to the pre-shaping and release phase.

Conclusions: This paper presents one of the biggest analysis of muscle synergies of hand grasps currently available. The results of 28 subjects performing 20 different grasps suggest that a limited number of time dependent motor modules (shared among subjects), correctly elicited by a control activation signal, may underlie the execution of a large variety of hand grasps. However, spatial synergies are not strongly related to specific motor functions but may be recruited at different stages, depending on subject and grasp. This result can lead to applications in rehabilitation and assistive robotics.

Efficacy of Short-Term Robot-Assisted Rehabilitation in Patients With Hand Paralysis After Stroke: A Randomized Clinical Trial

BACKGROUND

We evaluated the effectiveness of robot-assisted motion and activity in additional to physiotherapy (PT) and occupational therapy (OT) on stroke patients with hand paralysis.

METHODS

A randomized controlled trial was conducted. Thirty-two patients, 34.4% female (mean ± SD age: 68.9 ± 11.6 years), with hand paralysis after stroke participated. The experimental group received 30 minutes of passive mobilization of the hand through the robotic device Gloreha (Brescia, Italy), and the control group received an additional 30 minutes of PT and OT for 3 consecutive weeks (3 d/wk) in addition to traditional rehabilitation. Outcomes included the National Institutes of Health Stroke Scale (NIHSS), Modified Ashworth Scale, Barthel Index (BI), Motricity Index (MI), short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and the visual analog scale (VAS) measurements. All measures were collected at baseline and end of the intervention (3 weeks).

RESULTS

A significant effect of time interaction existed for NIHSS, BI, MI, and QuickDASH, after stroke immediately after the interventions (all, P < .001). The experimental group had a greater reduction in pain compared with the control group at the end of the intervention, a reduction of 11.3 mm compared with 3.7 mm, using the 100-mm VAS scale.

CONCLUSIONS

In the treatment of pain and spasticity in hand paralysis after stroke, robot-assisted mobilization performed in conjunction with traditional PT and OT is as effective as traditional rehabilitation.

A method of hand motor control assessment in patients with post-stroke spasticity

Introduction: In order to assess hand spasticity in post-stroke patients, it is necessary to apply an objective and sensitive method which allows for characterising motor control. It is significant due to the necessity to monitor the effects of the therapeutic process according to the requirements of Evidence-Based Medicine (EBM). The aim of the study was to assess the usefulness of the measurement of pressure generated during a maximal palmar grasp and after its release for evaluating the level of hand motor control in poststroke patients compared to subjective scales. Material and methods: In order to characterise motor control, a numerical indicator calculated on the basis of the measurements of pressure generated during a maximal palmar grasp and after its release was suggested. To perform the measurements, 12 poststroke patients with hemiparesis were included in the study. In the research, the level of hand paresis was assessed with Brunnström Approach, the intensity of spasticity was graded with Modified Ashworth Scale, while hand motor function was classified with Fugl-Meyer Assessment (FMA). Pressure generated during a palmar grasp and after its release as well as palm area were measured with the use of a photometric method. The assessment was made twice, i.e. on the day of admission to the in-patient rehabilitation ward and after a three-week hospital treatment. Results: In the second measurement, a slight decrease in paresis intensity according to Brunnström Approach and lower intensity of spasticity according to Ashworth Scale were noted. A higher number of points in the FMA scale was observed. The values of the suggested indicator changed; however, in no case were these changes statistically significant. Conclusions: 1. Compared to other subjective scales, the usefulness of the measurement of pressure generated during a maximal palmar grasp and after its release for assessing the level of hand motor control in post-stroke patients was not confirmed. 2. The usefulness of the recommended method of spastic hand motor control assessment needs to be verified in further research carried out according to EBM requirements.

Neural manual vs. robotic assisted mobilization to improve motion and reduce pain hypersensitivity in hand osteoarthritis: study protocol for a randomized controlled trial

[Purpose] The aim of the present study is to detail the protocol for a randomised controlled trial (RCT) of neural manual vs. robotic assisted on pain in sensitivity as well as analyse the quantitative and qualitative movement of hand in subjects with hand osteoarthritis. [Subjects and Methods] Seventy-two patients, aged 50 to 90 years old of both genders, with a diagnosis of hand Osteoarthritis (OA), will be recruited. Two groups of 36 participants will receive an experimental intervention (neurodynamic mobilization intervention plus exercise) or a control intervention (robotic assisted passive mobilization plus exercise) for 12 sessions over 4 weeks. Assessment points will be at baseline, end of therapy, and 1 and 3 months after end of therapy. The outcomes of this intervention will be pain and determine the central pain processing mechanisms. [Result] Not applicable. [Conclusion] If there is a reduction in pain hypersensitivity in hand OA patients it can suggest that supraspinal pain-inhibitory areas, including the periaqueductal gray matter, can be stimulated by joint mobilization.