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Norris TA, Augenstein TE, Rodriguez KM, Claflin ES, Krishnan C. Shaping corticospinal pathways in virtual reality: effects of task complexity and sensory feedback during mirror therapy in neurologically intact individuals. J Neuroeng Rehabil 2024; 21:154. [PMID: 39232841 DOI: 10.1186/s12984-024-01454-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 08/27/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Restoration of limb function for individuals with unilateral weakness typically requires volitional muscle control, which is often not present for individuals with severe impairment. Mirror therapy-interventions using a mirror box to reflect the less-impaired limb onto the more-impaired limb-can facilitate corticospinal excitability, leading to enhanced recovery in severely impaired clinical populations. However, the mirror box applies limitations on mirror therapy, namely that all movements appear bilateral and are confined to a small area, impeding integration of complex activities and multisensory feedback (e.g., visuo-tactile stimulation). These limitations can be addressed with virtual reality, but the resulting effect on corticospinal excitability is unclear. OBJECTIVE Examine how virtual reality-based unilateral mirroring, complex activities during mirroring, and visuo-tactile stimulation prior to mirroring affect corticospinal excitability. MATERIALS AND METHODS Participants with no known neurological conditions (n = 17) donned a virtual reality system (NeuRRoVR) that displayed a first-person perspective of a virtual avatar that matched their motions. Transcranial magnetic stimulation-induced motor evoked potentials in the nondominant hand muscles were used to evaluate corticospinal excitability in four conditions: resting, mirroring, mirroring with prior visuo-tactile stimulation (mirroring + TACT), and control. During mirroring, the movements of each participant's dominant limb were reflected onto the nondominant limb of the virtual avatar, and the avatar's dominant limb was kept immobile (i.e., unilateral mirroring). The mirroring + TACT condition was the same as the mirroring condition, except that mirroring was preceded by visuo-tactile stimulation of the nondominant limb. During the control condition, unilateral mirroring was disabled. During all conditions, participants performed simple (flex/extend fingers) and complex (stack virtual blocks) activities. RESULTS We found that unilateral mirroring increased corticospinal excitability compared to no mirroring (p < 0.001), complex activities increased excitability compared to simple activities during mirroring (p < 0.001), and visuo-tactile stimulation prior to mirroring decreased excitability (p = 0.032). We also found that these features did not interact with each other. DISCUSSIONS The findings of this study shed light onto the neurological mechanisms of mirror therapy and demonstrate the unique ways in which virtual reality can augment mirror therapy. The findings have important implications for rehabilitation for design of virtual reality systems for clinical populations.
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Affiliation(s)
- Trevor A Norris
- Neuromuscular & Rehabilitation Robotics Laboratory (NeuRRo Lab), Michigan Medicine, University of Michigan, 325 E Eisenhower Parkway (Room 3013), Ann Arbor, MI, 48108, USA
| | - Thomas E Augenstein
- Neuromuscular & Rehabilitation Robotics Laboratory (NeuRRo Lab), Michigan Medicine, University of Michigan, 325 E Eisenhower Parkway (Room 3013), Ann Arbor, MI, 48108, USA
- Robotics Department, University of Michigan, Ann Arbor, MI, USA
- Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA
| | - Kazandra M Rodriguez
- Neuromuscular & Rehabilitation Robotics Laboratory (NeuRRo Lab), Michigan Medicine, University of Michigan, 325 E Eisenhower Parkway (Room 3013), Ann Arbor, MI, 48108, USA
- Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA
| | - Edward S Claflin
- Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA
| | - Chandramouli Krishnan
- Neuromuscular & Rehabilitation Robotics Laboratory (NeuRRo Lab), Michigan Medicine, University of Michigan, 325 E Eisenhower Parkway (Room 3013), Ann Arbor, MI, 48108, USA.
- Robotics Department, University of Michigan, Ann Arbor, MI, USA.
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA.
- School of Kinesiology, University of Michigan, Ann Arbor, MI, USA.
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
- Department of Physical Therapy, University of Michigan-Flint, Flint, MI, USA.
- Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA.
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Grosmaire AG, Pila O, Breuckmann P, Duret C. Robot-assisted therapy for upper limb paresis after stroke: Use of robotic algorithms in advanced practice. NeuroRehabilitation 2022; 51:577-593. [PMID: 36530096 DOI: 10.3233/nre-220025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Rehabilitation of stroke-related upper limb paresis is a major public health issue. OBJECTIVE Robotic systems have been developed to facilitate neurorehabilitation by providing key elements required to stimulate brain plasticity and motor recovery, namely repetitive, intensive, adaptative training with feedback. Although the positive effect of robot-assisted therapy on motor impairments has been well demonstrated, the effect on functional capacity is less certain. METHOD This narrative review outlines the principles of robot-assisted therapy for the rehabilitation of post-stroke upper limb paresis. RESULTS A paradigm is proposed to promote not only recovery of impairment but also function. CONCLUSION Further studies that would integrate some principles of the paradigm described in this paper are needed.
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Affiliation(s)
- Anne-Gaëlle Grosmaire
- Unité de Neurorééducation, Médecine Physique et de Réadaptation, Centre de Rééducation Fonctionnelle Les Trois Soleils, Boissise-Le-Roi, France
| | - Ophélie Pila
- Unité de Neurorééducation, Médecine Physique et de Réadaptation, Centre de Rééducation Fonctionnelle Les Trois Soleils, Boissise-Le-Roi, France
| | - Petra Breuckmann
- Unité de Neurorééducation, Médecine Physique et de Réadaptation, Centre de Rééducation Fonctionnelle Les Trois Soleils, Boissise-Le-Roi, France
| | - Christophe Duret
- Unité de Neurorééducation, Médecine Physique et de Réadaptation, Centre de Rééducation Fonctionnelle Les Trois Soleils, Boissise-Le-Roi, France
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Washabaugh EP, Cubillos LH, Nelson AC, Cargile BT, Claflin ES, Krishnan C. Motor slacking during resisted treadmill walking: Can visual feedback of kinematics reduce this behavior? Gait Posture 2021; 90:334-339. [PMID: 34564007 PMCID: PMC8585707 DOI: 10.1016/j.gaitpost.2021.09.189] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Functional resistance training is frequently applied to rehabilitate individuals with neuromusculoskeletal injuries. It is performed by applying resistance in conjunction with a task-specific training, such as walking. However, the benefits of this training may be limited by motor slacking, a phenomenon in which the human body attempts to reduce muscle activation levels or movement excursions to minimize metabolic- or movement-related costs. While kinematic feedback could reduce one's tendency to minimize effort during training, this has not been verified experimentally. RESEARCH QUESTION Does functional resistance training during walking lead to motor slacking, and can techniques such as visual feedback be used to reduce these effects? METHODS Fourteen able-bodied individuals participated in this experiment. Participants were trained by walking on a treadmill while a bidirectional resistance was applied to the knee using a robotic knee exoskeleton. During training, participants were either instructed to walk in a manner that felt natural or were provided real-time visual feedback of their kinematics. Electromyography and knee kinematics were measured to determine if adding resistance to the limb induced slacking and if feedback could reduce slacking behavior. Kinematic aftereffects were measured after training bouts to gauge adaptation. RESULTS Functional resistance training without feedback significantly reduced knee flexion when compared to baseline walking, indicating that participants were slacking. This reduction in knee flexion did not improve with continued training. Providing visual feedback of knee joint kinematics during training significantly increased knee muscle activation and kinematic aftereffects. SIGNIFICANCE The findings indicate that individuals are susceptible to motor slacking during functional resistance training, which could affect outcomes of this training. However, motor slacking can be reduced if training is provided in conjunction with a feedback paradigm. This finding underscores the importance of using additional methods that externally motivate motor adaptation when the body is not intrinsically motivated to do so.
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Affiliation(s)
- Edward P. Washabaugh
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA,Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Luis H. Cubillos
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA,Michigan Robotics Institute, University of Michigan, Ann Arbor, MI, USA
| | - Alexandra C. Nelson
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA,Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Belinda T. Cargile
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA,Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Edward S. Claflin
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA
| | - Chandramouli Krishnan
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA,Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA,Michigan Robotics Institute, University of Michigan, Ann Arbor, MI, USA,School of Kinesiology, University of Michigan, Ann Arbor, MI, USA,Address for Correspondence: Chandramouli Krishnan, PT, PhD, Director, Neuromuscular & Rehabilitation Robotics Laboratory (NeuRRo Lab), Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, 325 E Eisenhower Parkway (Suite 3013), Ann Arbor, MI - 48108, Phone: (319) 321-0117, Fax: (734-615-1770),
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Treadway E, Gillespie RB. Vector Field Control Methods for Discretely Variable Passive Robotic Devices. IEEE T ROBOT 2021. [DOI: 10.1109/tro.2020.3031255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pila O, Koeppel T, Grosmaire AG, Duret C. Comparison of active-assisted and active-unassisted robot-mediated upper limb therapy in subacute stroke. Restor Neurol Neurosci 2021; 39:1-7. [PMID: 33285649 DOI: 10.3233/rnn-201010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Upper-limb robot-mediated therapy is usually carried out in active-assisted mode because it enables performance of many movements. However, assistance may reduce the patient's own efforts which could limit motor recovery. OBJECTIVE The aim of this study was to compare the effects of active-assisted and active-unassisted robotic interactions on motor recovery in subacute stroke patients with moderate hemiparesis. METHODS Fourteen patients underwent a 6-week combined upper limb program of usual therapy and robotic therapy using either the active-unassisted (n = 8) or active-assisted (n = 6) modes. In the active-assisted group, assistance was only provided for the first 3 weeks (1st period) and was then switched off for the remaining 3 weeks (2nd period). The Fugl-Meyer Assessment (FMA) was carried out pre- and post-treatment. The mean number of movements performed and the mean working distance during the 1st and 2nd periods were compared between groups. RESULTS FMA score improved post-treatment in both groups with no between-group differences: active-assisted group: +8±6 pts vs active-unassisted group: +10±6 pts (ns). Between the 1st and 2nd periods, there was a statistical trend towards an improvement in the number of movements performed (p = 0.06) in the active-unassisted group (526±253 to 783±434, p = 0.06) but not in the active-assisted group (882±211 to 880±297, ns). Another trend of improvement was found for the working distance in the active-unassisted group (8.7±4.5 to 9.9±4.7, p = 0.09) but not in the active-assisted group (14.0±0 to 13.5±1.1, ns). CONCLUSIONS The superiority of the non-assistive over assistive robotic modes has not been demonstrated. However, the non-assistive mode did not appear to reduce motor recovery in this population, despite the performance of fewer movements on shorter working distance compared with the group who had assistance. It seems that the requirement of effort could be a determinant factor for recovery in neurorehabilitation however further well-design studies are needed to fully understand this phenomenon.
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Affiliation(s)
- Ophélie Pila
- Microentreprise Recherche Clinique, Pila, Saint-Jean-d'Illac, France
| | - Typhaine Koeppel
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Unité de Neurorééducation, Boissise-Le-Roi, France
| | - Anne-Gaëlle Grosmaire
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Unité de Neurorééducation, Boissise-Le-Roi, France
| | - Christophe Duret
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Unité de Neurorééducation, Boissise-Le-Roi, France.,Centre Hospitalier Sud Francilien, Neurologie, Corbeil-Essonnes, France
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Thomas SM, Delanni E, Christophe B, Connolly ES. Systematic review of novel technology-based interventions for ischemic stroke. Neurol Sci 2021; 42:1705-1717. [PMID: 33604762 DOI: 10.1007/s10072-021-05126-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To identify novel technologies pertinent to the prevention, diagnosis, treatment, and rehabilitation of ischemic stroke, and recommend the technologies that show the most promise in advancing ischemic stroke care. METHOD A systematic literature search on PubMed and Medscape was performed. Articles were assessed based on pre-determined criteria. Included journal articles were evaluated for specific characteristics and reviewed according to a structured paradigm. A search on www.clinicaltrials.gov was performed to identify pre-clinical ischemic stroke technological interventions. All clinical trial results were included. An additional search on PubMed was conducted to identify studies on robotic neuroendovascular procedures. RESULTS Thirty journal articles and five clinical trials were analyzed. Articles were categorized as follows: six studies pertinent to pre-morbidity and prevention of ischemic stroke, three studies relevant to the diagnosis of ischemic stroke, 16 studies about post-ischemic stroke rehabilitation, and five studies on robotic neuroendovascular interventions. CONCLUSIONS Novel technologies across the spectrum of ischemic stroke care were identified, and the ones that appear to have the most clinical utility are recommended. Future investigation of the feasibility and long-term efficacy of the recommended technologies in clinical settings is warranted.
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Affiliation(s)
- Steven Mulackal Thomas
- Department of Neurological Surgery, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY, 10032, USA.
| | - Ellie Delanni
- Department of Neurological Surgery, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY, 10032, USA
| | - Brandon Christophe
- Department of Neurological Surgery, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY, 10032, USA
| | - Edward Sander Connolly
- Department of Neurological Surgery, Columbia University Irving Medical Center, 710 West 168th Street, New York, NY, 10032, USA
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Park JH, Park G, Kim HY, Lee JY, Ham Y, Hwang D, Kwon S, Shin JH. A comparison of the effects and usability of two exoskeletal robots with and without robotic actuation for upper extremity rehabilitation among patients with stroke: a single-blinded randomised controlled pilot study. J Neuroeng Rehabil 2020; 17:137. [PMID: 33076952 PMCID: PMC7574181 DOI: 10.1186/s12984-020-00763-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/20/2020] [Indexed: 12/05/2022] Open
Abstract
Background Robotic rehabilitation of stroke survivors with upper extremity dysfunction may yield different outcomes depending on the robot type. Considering that excessive dependence on assistive force by robotic actuators may interfere with the patient’s active learning and participation, we hypothesised that the use of an active-assistive robot with robotic actuators does not lead to a more meaningful difference with respect to upper extremity rehabilitation than the use of a passive robot without robotic actuators. Accordingly, we aimed to evaluate the differences in the clinical and kinematic outcomes between active-assistive and passive robotic rehabilitation among stroke survivors. Methods In this single-blinded randomised controlled pilot trial, we assigned 20 stroke survivors with upper extremity dysfunction (Medical Research Council scale score, 3 or 4) to the active-assistive robotic intervention (ACT) and passive robotic intervention (PSV) groups in a 1:1 ratio and administered 20 sessions of 30-min robotic intervention (5 days/week, 4 weeks). The primary (Wolf Motor Function Test [WMFT]-score and -time: measures activity), and secondary (Fugl-Meyer Assessment [FMA] and Stroke Impact Scale [SIS] scores: measure impairment and participation, respectively; kinematic outcomes) outcome measures were determined at baseline, after 2 and 4 weeks of the intervention, and 4 weeks after the end of the intervention. Furthermore, we evaluated the usability of the robots through interviews with patients, therapists, and physiatrists. Results In both the groups, the WMFT-score and -time improved over the course of the intervention. Time had a significant effect on the WMFT-score and -time, FMA-UE, FMA-prox, and SIS-strength; group × time interaction had a significant effect on SIS-function and SIS-social participation (all, p < 0.05). The PSV group showed better improvement in participation and smoothness than the ACT group. In contrast, the ACT group exhibited better improvement in mean speed. Conclusions There were no differences between the two groups regarding the impairment and activity domains. However, the PSV robots were more beneficial than ACT robots regarding participation and smoothness. Considering the high cost and complexity of ACT robots, PSV robots might be more suitable for rehabilitation in stroke survivors capable of voluntary movement. Trial registration The trial was registered retrospectively on 14 March 2018 at ClinicalTrials.gov (NCT03465267).
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Affiliation(s)
- Jin Ho Park
- Department of Rehabilitation Medicine, National Rehabilitation Center, Ministry of Health and Welfare, 58, Samgaksan-ro, Gangbuk-gu, Seoul, Republic of Korea
| | - Gyulee Park
- Translational Research Program for Rehabilitation Robots, National Rehabilitation Center, Ministry of Health and Welfare, Seoul, Republic of Korea
| | - Ha Yeon Kim
- Translational Research Program for Rehabilitation Robots, National Rehabilitation Center, Ministry of Health and Welfare, Seoul, Republic of Korea
| | - Ji-Yeong Lee
- Department of Rehabilitation Medicine, National Rehabilitation Center, Ministry of Health and Welfare, 58, Samgaksan-ro, Gangbuk-gu, Seoul, Republic of Korea
| | - Yeajin Ham
- Department of Rehabilitation Medicine, National Rehabilitation Center, Ministry of Health and Welfare, 58, Samgaksan-ro, Gangbuk-gu, Seoul, Republic of Korea
| | - Donghwan Hwang
- Translational Research Program for Rehabilitation Robots, National Rehabilitation Center, Ministry of Health and Welfare, Seoul, Republic of Korea
| | - Suncheol Kwon
- Translational Research Program for Rehabilitation Robots, National Rehabilitation Center, Ministry of Health and Welfare, Seoul, Republic of Korea
| | - Joon-Ho Shin
- Department of Rehabilitation Medicine, National Rehabilitation Center, Ministry of Health and Welfare, 58, Samgaksan-ro, Gangbuk-gu, Seoul, Republic of Korea. .,Translational Research Program for Rehabilitation Robots, National Rehabilitation Center, Ministry of Health and Welfare, Seoul, Republic of Korea.
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Krishnan C. Effect of paired-pulse stimulus parameters on the two phases of short interval intracortical inhibition in the quadriceps muscle group. Restor Neurol Neurosci 2020; 37:363-374. [PMID: 31306142 DOI: 10.3233/rnn-180894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Short interval intracortical inhibition (SICI) is commonly used to assess inhibition in the motor cortex and is known to be affected by the paired-pulse stimulus parameters (i.e., interstimulus interval [ISI], conditioning stimulus intensity [CSI] and test stimulus intensity [TSI]) used during testing. While the effects of stimulus parameters are well-studied in the upper-extremity, evidence in the lower-extremity is lacking. OBJECTIVE To comprehensively examine the effects of alterations in paired-pulse stimulus parameters on the two phases of SICI in the quadriceps muscle group. METHODS Seventeen adults (8 males, 9 females) volunteered to participate in this study. SICI was examined over a range of CSIs (70-90% active motor threshold [AMT]), TSIs (100-140% AMT), and ISIs (1.0-3.0 ms) using both EMG and torque responses elicited by transcranial magnetic stimulation (TMS). RESULTS The results indicated that SICI at 1.0 ms ISI was best revealed with a CSI of 70% and TSI ≥110% AMT, whereas SICI at 2.5 ms ISI was best revealed with a CSI of 80-90% and a TSI of ≥130% AMT. Unlike upper-extremity muscles, evaluating SICI with a CSI of 70% AMT and an ISI of 1.0 ms produced the greatest inhibition for all TSIs. In general, inhibitory effects were contaminated by facilitatory effects when using a TSI of 100% AMT. CONCLUSIONS The amount of inhibition was dependent on the stimulation parameters used during testing. A CSI of 70% AMT, ISI of 1.0 ms, and TSI of ≥110% AMT appear to be optimal for measuring SICI in the quadriceps muscle; however, other parameters can be used if careful consideration is given to the described interaction between the parameters.
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Affiliation(s)
- Chandramouli Krishnan
- NeuRRo Lab, Department of Physical Medicine and Rehabilitation, Michigan Medicine, Ann Arbor, MI, USA.,Michigan Robotics Institute, University of Michigan, Ann Arbor, MI, USA.,School of Kinesiology, University of Michigan, Ann Arbor, MI, USA.,Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
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