Robot-assisted support combined with electrical stimulation for the lower extremity in stroke patients: a systematic review

Objective. The incidence of stroke rising, leading to an increased demand for rehabilitation services. Literature has consistently shown that early and intensive rehabilitation is beneficial for stroke patients. Robot-assisted devices have been extensively studied in this context, as they have the potential to increase the frequency of therapy sessions and thereby the intensity. Robot-assisted systems can be combined with electrical stimulation (ES) to further enhance muscle activation and patient compliance. The objective of this study was to review the effectiveness of ES combined with all types of robot-assisted technology for lower extremity rehabilitation in stroke patients.Approach. A thorough search of peer-reviewed articles was conducted. The quality of the included studies was assessed using a modified version of the Downs and Black checklist. Relevant information regarding the interventions, devices, study populations, and more was extracted from the selected articles.Main results. A total of 26 articles were included in the review, with 23 of them scoring at least fair on the methodological quality. The analyzed devices could be categorized into two main groups: cycling combined with ES and robots combined with ES. Overall, all the studies demonstrated improvements in body function and structure, as well as activity level, as per the International Classification of Functioning, Disability, and Health model. Half of the studies in this review showed superiority of training with the combination of robot and ES over robot training alone or over conventional treatment.Significance. The combination of robot-assisted technology with ES is gaining increasing interest in stroke rehabilitation. However, the studies identified in this review present challenges in terms of comparability due to variations in outcome measures and intervention protocols. Future research should focus on actively involving and engaging patients in executing movements and strive for standardization in outcome values and intervention protocols.

The Effect of Botulinum Toxin Type A Injection in the Rectus Femoris in Stroke Patients Walking With a Stiff Knee Gait: A Randomized Controlled Trial

BACKGROUND

Over activity of the rectus femoris is often cited as a main cause for stiff knee gait (SKG). Botulinum toxin (BoNT) can be used to reduce this over activity. Inconsistent results for the effect of BoNT injections were found in literature which can possibly be explained by the study design as these were uncontrolled or non-randomized studies.

OBJECTIVE

To conduct a randomized controlled trial (RCT) to investigate the effect of botulinum toxin type A (BoNT-A) injections in the rectus femoris on gait kinematics and functional outcome in adult stroke patients.

METHODS

Twenty-six participants were included in this triple-blind cross-over RCT. The intervention consisted of an injection with BoNT-A. Placebo is an injection with saline. Besides knee and hip kinematics, functional outcomes were measured.

RESULTS

Comparison of the effect of BoNT-A injection to placebo injection showed a significant increase in peak knee flexion and knee range of motion of 6.7° and 4.8° respectively. There was no difference in hip kinematics. In functional outcomes, only the 6 Minute Walking Test showed a significant increase of 18.3 m.

CONCLUSIONS

BoNT-A injections in the rectus femoris is a valuable treatment option for stroke patients walking with a SKG to improve knee kinematics. To study the effect on functional outcome more research is necessary with different functional outcome measures that can capture the effect in kinematics. It is important to use kinematic measurements to demonstrate effects in quality of movement that are not captured by commonly used functional outcome measurements post stroke.Clinical Trial Registration: https://trialsearch.who.int/Trial2.aspx?TrialID=NTR2169.

Evaluating the clinical effects of a dynamic shoulder orthosis

BACKGROUND

Shoulder orthoses reduce the gravitational pull on the shoulder by providing an upward force to the arm, which can decrease shoulder pain caused by stress on the glenohumeral structures.

OBJECTIVE

In this interventional study, the clinical effects of a recently developed dynamic shoulder orthosis were assessed in 10 patients with chronic shoulder pain. The shoulder orthosis provides an upward force to the arm with 2 elastic bands. These bands are arranged to statically balance the arm, such that the supportive force is always directed toward the glenohumeral joint and shoulder movements are not impeded.

STUDY DESIGN

Clinical effect study.

METHODS

The study population was provided with a dynamic shoulder orthosis for 2 weeks. In the week before the orthosis fitting, the participants had no intervention. The primary outcome measures were the mean shoulder pain scores before and during the intervention, and the distance between the humeral head and the acromion without and with orthosis.

RESULTS

Ultrasound evaluation showed that the shoulder orthosis resulted in a reduction of the distance between the acromion and humeral head at different levels of arm support. In addition, it was demonstrated that the mean shoulder pain scores (range 0-10) decreased from 3.6 to 3 (in rest) and from 5.3 to 4.2 (during activities) after 2 weeks of orthosis use. In general, patients were satisfied with the weight, safety, ease in adjusting, and effectiveness of the orthosis.

CONCLUSIONS

The results of this study show that the orthosis has the potential to reduce shoulder complaints in patients with chronic shoulder pain.

Feasibility of reconstructing the glenohumeral center of rotation with a single camera setup

BACKGROUND

An accurate estimation of the glenohumeral joint center of rotation (CoR) is important during alignment of braces and exoskeletons, as a misalignment will introduce undesired forces on the human body. The aim of this research was to develop a new method to estimate the glenohumeral CoR and register the location to the body using a single camera and two printed markers.

METHODS

During shoulder anteflexion, the arm roughly describes an arc in the sagittal plane, with the glenohumeral joint in the center. Two binary square-fiducial ArUco markers were secured to the upper arm and the scapula, their position and orientation were obtained, and a sphere was fitted to the coordinates of the arm marker. The sphere center position was then registered on the skin. The accuracy was assessed with a test bench with a known rotational center. The repeatability was assessed in vivo with five healthy participants.

RESULTS

The mean absolute offset between the true CoR of the test bench and the fitted sphere centers across multiple trials was 2.7 mm at a velocity of 30 degrees/s, and 2.5 mm at 60 degrees/s. The root mean squared distance from the estimated sphere centers after each trial to the mean sphere center across all trials per participant was 5.1 mm on average for the novice examiner and 5.2 mm for the expert examiner.

CONCLUSIONS

The proposed method is able to accurately and precisely estimate the glenohumeral CoR.

Amputation and prosthetics of the lower extremity: The 2020 Dutch evidence-based multidisciplinary guideline

BACKGROUND

Lower-limb amputations are rare but debilitating events in the lives of affected persons. Treatment of persons with amputation inherently involves many different health care professions at different stages leading to and after an amputation. There are prevailing clinical questions within the work field related to different facets of care including peri/postoperative aspects, prosthetic components, rehabilitation treatment, and health care processes.

OBJECTIVES

To provide an up-to-date multidisciplinary evidence-based guideline for health care professionals involved in the treatment of persons with lower-limb amputation in the Netherlands.

METHODS

Identification of key questions in a focus group, systematic review of the evidence (up to March 2019, using Embase and MEDLINE databases), and weighing considerations, culminating in clinical recommendations.

RESULTS

Twelve key questions were formulated. Recommendations of two key questions were upheld in line with the previous 2012 guideline. Ten systematic literature searches were performed, leading to the inclusion of 59 studies.

CONCLUSION

A summary of evidence-based conclusions, considerations, and recommendations of the 2020 guideline is presented.

Mechanical design and feasibility of a finger exoskeleton to support finger extension of severely affected stroke patients

In this paper we presented the mechanical design and evaluation of a low-profile and lightweight exoskeleton that supports the finger extension of stroke patients during daily activities without applying axial forces to the finger. The exoskeleton consists of a flexible structure that is secured to the index finger of the user while the thumb is fixed in an opposed position. Pulling on a cable will extend the flexed index finger joint such that objects can be grasped. The device can achieve a grasp size of at least 7 cm. Technical tests confirmed that the exoskeleton was able to counteract the passive flexion moments corresponding to the index finger of a severely affected stroke patient (with an MCP joint stiffness of k = 0.63Nm/rad), requiring a maximum cable activation force of 58.8N. A feasibility study with stroke patients (n=4) revealed that the body-powered operation of the exoskeleton with the contralateral hand caused a mean increase of 46° in the range of motion of the index finger MCP joint. The patients (n=2) who performed the Box & Block Test were able to grasp and transfer maximally 6 blocks in 60 sec. with exoskeleton, compared to 0 blocks without exoskeleton. Our results showed that the developed exoskeleton has the potential to partially restore hand function of stroke patients with impaired finger extension capabilities. An actuation strategy that does not involve the contralateral hand should be implemented during further development to make the exoskeleton suitable for bimanual daily activities.

Detection thresholds for electrostimulation combined with robotic leg support in sub-acute stroke patients

Stroke is one of the leading causes of disability in adults in the European Union. It often leads to motor impairments, such as a hemiparetic lower extremity. Research indicates that early task-specific and intensive training promotes neuroplasticity and leads to recovery and/or compensation. One way to provide intensive training early after a stroke is via robot-supported training. A rehabilitation robot was designed by Life Science Robotics (Aalborg, Denmark) that can provide continuous repetitive movements of the hip, knee, and/or ankle in e.g., a lying position. In order to emphasize active contribution by the patient, actively triggered electrical stimulation (via muscle activation) can be combined with robotic assistance. The current study aims to compare different threshold estimation methods for detection of movement intention from muscle activity for actively triggered electrical stimulation during robot-supported leg movement in stroke patients. Three sub-acute stroke patients were included for a single measurement session. They performed knee extension and/or ankle dorsal flexion with four different threshold estimation methods to assess the intention detection threshold to initiate electrostimulation. The thresholds were based on the resting level of muscle activity (of m. rectus femoris or m. tibialis anterior) plus two or three times the standard deviation of the average resting value, or the resting level plus 5% or 10% of the peak muscle activity during a maximal voluntary contraction. The results showed that the method based on the resting muscle activity plus two times the standard deviation was the most stable across the three included stroke patients. This method had a detection success rate of 86.7% and was experienced as moderately comfortable. In conclusion, performing knee extension and/or ankle dorsal flexion with electromyography triggered electrostimulation is feasible in sub-acute stroke patients. Muscle activity-triggered electrostimulation combined with robotic support based on a threshold of resting levels plus two times the standard deviation seems to detect movement initiation most consistently in this small sample of sub-acute stroke patients.

Effect on Hand Function After Six-week Use of a Wearable Soft-Robotic Glove Assisting ADL: Interim Results of an Ongoing Clinical Study

In an ongoing study, an assistive wearable soft-robotic glove is tested at home for 6 weeks by subjects with decreased handgrip strength, due to different hand injuries or diseases, to assess whether use of this assistive grip-supporting glove will result in improved hand strength/ function. An interim analysis of the available dataset of 46 participants showed that (unsupported) grip strength and hand function improved after using the soft-robotic glove as assistive aid during activities of daily living (ADLs) during 6 weeks at home. After glove use is ended, this is maintained for at least 4 weeks. Considering that in the current situation the analysis is underpowered, these interim results are promising for finding a clinical (therapeutic) effect of using a soft-robotic glove as assistance during ADLs. If this is the case, this might open up entirely new opportunities for extending rehabilitation into people's homes, while also providing them with assistance to directly support performance of daily activities. Such a combination is becoming available with the development of mature and user-friendly wearable soft-robotic devices. This would enable very high doses of training throughout the day, in the most functional, task-specific way possible, and possibly prevention of learned non-use.

Design and feasibility of the T-GRIP thumb exoskeleton to support the lateral pinch grasp of spinal cord injury patients

Improving the impaired hand function of spinal cord injury patients with a robotic exoskeleton can highly impact their self-management, and ultimately their quality of life. In this paper the design and evaluation of a new, lightweight (50 gram) robotic thumb exoskeleton, called TGRIP, was presented that supports the lateral pinch grasp. The mechanism consists of a linear actuator that was mounted to the dorsal side of the hand, and a force transmission mechanism that flexes the thumb towards the side of the index finger. The thumb movement was controlled through contralateral wrist rotation. Experimental results from an evaluation with three spinal cord injury patients showed that the achieved grip force (^~ 7N) was higher and the overall performance during the Grasp and Release Test was better with the T-GRIP than without device. The device shows great potential for improving the hand function of patients with cervical spinal cord injury by actuating only a single degree of freedom.

Accurate estimation of upper limb orthosis wear time using miniature temperature loggers

OBJECTIVE

To propose and validate a new method for estimating upper limb orthosis wear time using miniature temperature loggers attached to locations on the upper body.  Design: Observational study.  Subjects: Fifteen healthy participants.  Methods: Four temperature loggers were attached to the arm and chest with straps. Participants were asked to remove and re-attach the straps at specified time-points. The labelled temperature data obtained were used to train a decision tree classification algorithm to estimate wear time. The final performance (mean error and 95% confidence interval) of the trained classifier and the wear time estimation were assessed with a hold-out data-set.  Results: The trained algorithm can correctly classify unseen temperature data with a mean classification error between 1.1% and 3.1% for the arm, and between 1.8% and 4.0% for the chest, depending on the sampling time of the temperature logger. This resulted in mean wear time errors between 0.5% and 8.3% for the arm, and 0.13% and 13.0% for the chest.  Conclusion: The proposed method based on a classifier can accurately estimate upper limb orthosis wear time. This method could enable healthcare professionals to gain insight into the wear time of any upper limb orthosis.

Does the Duncan-Ely test predict abnormal activity of the rectus femoris in stroke survivors with a stiff knee gait?

Objective

To determine the diagnostic value of the Duncan-Ely test in predicting abnormal rectus femoris activity during gait in stroke survivors walking with a stiff knee gait.

Design

Cross-sectional diagnostic study.

Subjects

A total of 95 patients with chronic stroke.

Methods

During physical examination, the Duncan- Ely test was performed and scored. Surface electromyography of the rectus femoris was then recorded during dynamic gait. To determine the diagnostic value, the results of the Duncan-Ely test and surface electromyography recordings (gold standard) were compared.

Results

The Duncan-Ely test had a sensitivity of 73%, a specificity of 29%, a positive predictive value of 60%, and a negative predictive value of 42%. The area under the curve was 0.488 (95% CI 0.355– 0.621, p = 0.862), showing that the Duncan-Ely test is not better than random guessing.

Conclusion

The Duncan-Ely test has no predictive value for determining abnormal activity of the rectus femoris during gait. Using this test can lead to incorrect identification of abnormal rectus femoris activity, which might hamper the selection of optimal treatment options. We recommend stopping use of the Duncan-Ely test to predict rectus femoris overactivity during swing, and instead use surface electromyography.

A newly designed shoulder orthosis for patients with glenohumeral subluxation: a clinical evaluation study

BACKGROUND

Shoulder complaints from glenohumeral subluxation are a common problem and limit patients during daily activities.

OBJECTIVE

To assess the clinical pros and cons and usability of a newly developed shoulder orthosis (Roessingh Omo Support [ROS]) in patients with chronic shoulder complaints.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

All patients older than 18 years who received the ROS were invited. Medical information was collected from medical records. Two questionnaires were sent to the patient: The "Shoulder Rating Questionnaire" (SRQ, max 100 points) for evaluation before and during use and a custom orthosis usability questionnaire.

RESULTS

In total, 28 patients (34 orthoses) participated in the study. Neuralgic amyotrophy was the most common diagnosis (64.3%). The SRQ showed a significant positive change of 8.9 points (from 35.0 [SD 12.6] to 43.9 [SD 14.3]). The most described goal was pain reduction (76.5%). 47.1% of the patients achieved their goal(s), and 71.4% were still using the orthosis. The mean satisfaction rate was 7.1 (SD 1.4).

CONCLUSION

The use of the ROS shows a significant functional improvement (SRQ), a decrease of pain, and a high degree of satisfaction, although the individual experiences of the patients are highly variable. Some modifications to the design to improve comfort may be needed.

Head support in wheelchairs (scoping review): state-of-the-art and beyond

BACKGROUND

Many wheelchair users experience disabilities in stabilising and positioning of the head. For these users, adequate head support is required. Although several types of head supports are available, further development of these systems is needed to improve functionality and quality of life, especially for the group of severely challenged users. For this group, user needs have not been clearly established. In this article, we provide an overview of the state-of-the-art in wheelchair mounted head supports and associated scientific evidence in order to identify requirements for the next generation of head support systems.

MATERIALS AND METHODS

A scoping review was performed including scientific literature (PubMed/Scopus), patents (Espacenet/Google Scholar) and commercial information. Types of head support and important system characteristics for future head support systems were proposed from consultations with wheelchair users (n = 3), occupational therapists (n = 3) and an expert panel.

RESULTS

Forty scientific papers, 90 patents and 80 descriptions of commercial devices were included in the scoping review. The identified head support systems were categorised per head support type. Only limited scientific clinical evidence with respect to the effectiveness of existing head support systems was found. From the user and expert consultations, a need was identified for personalised head support systems that intuitively combine changes in sitting and head position with continuous optimal support of the head to accommodate severely challenged users.

CONCLUSIONS

This study presents the state-of-the-art in head support systems. Additionally, several important system characteristics are introduced that provide guidance for the development and improvement of head supports.Implications for rehabilitationEspecially for the group of severely challenged wheelchair users, current head support systems require further development to improve their users' quality of life.The desired system characteristics which are discussed in this review are an important step in the definition of requirements for the next generation of head supports.

Effect of assist-as-needed robotic gait training on the gait pattern post stroke: a randomized controlled trial

Background

Regaining gait capacity is an important rehabilitation goal post stroke. Compared to clinically available robotic gait trainers, robots with an assist-as-needed approach and multiple degrees of freedom (AAN_mDOF) are expected to support motor learning, and might improve the post-stroke gait pattern. However, their benefits compared to conventional gait training have not yet been shown in a randomized controlled trial (RCT). The aim of this two-center, assessor-blinded, RCT was to compare the effect of AAN_mDOF robotic to conventional training on the gait pattern and functional gait tasks during post-stroke inpatient rehabilitation.

Methods

Thirty-four participants with unilateral, supratentorial stroke were enrolled (< 10 weeks post onset, Functional Ambulation Categories 3–5) and randomly assigned to six weeks of AAN_mDOF robotic (combination of training in LOPES-II and conventional gait training) or conventional gait training (30 min, 3–5 times a week), focused on pre-defined training goals. Randomization and allocation to training group were carried out by an independent researcher. External mechanical work (W_EXT), spatiotemporal gait parameters, gait kinematics related to pre-defined training goals, and functional gait tasks were assessed before training (T0), after training (T1), and at 4-months follow-up (T2).

Results

Two participants, one in each group, were excluded from analysis because of discontinued participation after T0, leaving 32 participants (AAN_mDOF robotic n = 17; conventional n = 15) for intention-to-treat analysis. In both groups, W_EXT had decreased at T1 and had become similar to baseline at T2, while gait speed had increased at both assessments. In both groups, most spatiotemporal gait parameters and functional gait tasks had improved at T1 and T2. Except for step width (T0–T1) and paretic step length (T0–T2), there were no significant group differences at T1 or T2 compared to T0. In participants with a pre-defined goal aimed at foot clearance, paretic knee flexion improved more in the AAN_mDOF robotic group compared to the conventional group (T0–T2).

Conclusions

Generally, AAN_mDOF robotic training was not superior to conventional training for improving gait pattern in subacute stroke survivors. Both groups improved their mechanical gait efficiency. Yet, AAN_mDOF robotic training might be more effective to improve specific post-stroke gait abnormalities such as reduced knee flexion during swing.

Trial registration Registry number Netherlands Trial Register (www.trialregister.nl): NTR5060. Registered 13 February 2015.

A New Shoulder Orthosis to Dynamically Support Glenohumeral Subluxation

OBJECTIVE

In this paper we presented a novel shoulder subluxation support that aims to reduce the stress on the passive structures around the shoulder of patients with glenohumeral subluxation and glenohumeral-related shoulder pain. The device applies a force to the upper arm without impeding the functional range of motion of the arm. Our design contains a mechanism that statically balances the arm with two elastic bands.

METHODS

A technical evaluation study was conducted to assess the performance of the orthosis. Additionally, two patients evaluated the orthosis.

RESULTS

The results of the technical validation confirm the working of the balancing mechanism. The pilot study demonstrated that the shoulder support increased the feeling of stability of the shoulder joint and, to a lesser extent, decreased shoulder pain. Furthermore, both patients reported that the orthosis did not impede their range of motion.

CONCLUSION

In this research we developed a shoulder orthosis based on two statically balanced springs that support the shoulder of patients with glenohumeral subluxation that have residual shoulder muscle force. Compared to existing shoulder supports, our design does not impede the range of motion of the arm, and continues to provide a stabilizing force to the shoulder, even if the arm is moved away from the neutral position. Tests with two participants showed promising results.

SIGNIFICANCE

The device presented in this work could have a significant impact on the shoulder function which may improve rehabilitation outcome and improve the quality of life of patients suffering from glenohumeral subluxation and shoulder pain.

Home rehabilitation supported by a wearable soft-robotic device for improving hand function in older adults: A pilot randomized controlled trial

Background

New developments, based on the concept of wearable soft-robotic devices, make it possible to support impaired hand function during the performance of daily activities and intensive task-specific training. The wearable soft-robotic ironHand glove is such a system that supports grip strength during the performance of daily activities and hand training exercises at home.

Design

This pilot randomized controlled clinical study explored the effect of prolonged use of the assistive ironHand glove during daily activities at home, in comparison to its use as a trainings tool at home, on functional performance of the hand.

Methods

In total, 91 older adults with self-perceived decline of hand function participated in this study. They were randomly assigned to a 4-weeks intervention of either assistive or therapeutic ironHand use, or control group (received no additional exercise or treatment). All participants performed a maximal pinch grip test, Box and Blocks test (BBT), Jebsen-Taylor Hand Function Test (JTHFT) at baseline and after 4-weeks of intervention. Only participants of the assistive and therapeutic group completed the System Usability Scale (SUS) after the intervention period.

Results

Participants of the assistive and therapeutic group reported high scores on the SUS (mean = 73, SEM = 2). The therapeutic group showed improvements in unsupported handgrip strength (mean Δ = 3) and pinch strength (mean Δ = 0.5) after 4 weeks of ironHand use (p≤0.039). Scores on the BBT and JTHFT improved not only after 4 weeks of ironHand use (assistive and therapeutic), but also in the control group. Only handgrip strength improved more in the therapeutic group compared to the assistive and control group. No significant correlations were found between changes in performance and assistive or therapeutic ironHand use (p≥0.062).

Conclusion

This study showed that support of the wearable soft-robotic ironHand system either as assistive device or as training tool may be a promising way to counter functional hand function decline associated with ageing.

The effect of ankle-foot orthoses on fall/near fall incidence in patients with (sub-)acute stroke: A randomized controlled trial

Falls are commonly reported post-stroke. Ankle-foot orthoses (AFOs) are often provided to improve safety and walking, but the effect of their use in the reduction of falls after stroke is unknown. A randomized controlled trial (RCT) on the effects of AFO-provision after stroke was performed. Effects on clinical scales, 3D-gait kinematics and muscle-activity were previously reported. This paper aims to study the effects of AFO-provision on occurrence and circumstances of falls/near falls. The RCT included unilateral hemiparetic stroke patients. AFOs were provided either early (study week 1) or delayed (study week 9). Both groups were compared in the first eight weeks of the study and diaries were used to register falls/near falls and their circumstances. Follow-up measurements were performed in week 9–52, in which both groups were provided with AFOs. Functional Ambulation Categories and Berg Balance Scale were assessed to determine walking independence and balance, respectively. Last known scores were noted in case of an incident. Thirty-three subjects were included (16 early, 17 delayed). In week 1–8, the early group, who were provided with AFOs, fell significantly more frequently compared with the delayed group, 11 versus 4 times, respectively (Incidence Rate Ratio = 2.9, p = 0.039). Out of the falls recorded in the early group, 63.6% occurred without wearing AFOs. Most of these falls occurred during transfers (36.4%) and standing (27.3%), and notably it were the subjects who did not have independent walking ability. No differences were found for near falls in week 1–8, or for falls/near falls in week 9–52. Six severe consequences (including fractures) were reported from a fall. To conclude, the subjects provided with AFOs early after stroke reported a higher number of falls, compared to the subjects that had not yet been provided with AFOs. However, in the subjects provided with AFOs, 63.6% of the falls occurred whilst without wearing the AFO. Furthermore, the majority of these incidents took place whilst subjects had no independent walking ability. This raises an interesting question of the importance of careful instructions to patients and their relatives, and the influence of potential cognitive impairments on the ability of the subjects to take on these instructions.

Assistive Technology for the Upper Extremities After Stroke: Systematic Review of Users' Needs

BACKGROUND

Technical innovations have the potential to compensate for loss of upper-limb motor functions after stroke. However, majority of the designs do not completely meet the needs and preferences of the end users. User-centered design methods have shown that the attention to user perspectives during development of assistive technology leads to devices that better suit the needs of the users.

OBJECTIVE

To get more insight into the factors that can bring the design of assistive technology to higher levels of satisfaction and acceptance, studies about user perspectives on assistive technology for the upper limb after stroke are systematically reviewed.

METHODS

A database search was conducted in PubMed, EMBASE, CINAHL, PsycINFO, and Scopus from inception to August 2017, supplemented with a search of reference lists. Methodological quality of the included studies was appraised. User perspectives of stroke survivors, carers, and health care professionals were extracted. A total of 35 descriptive themes were identified, from which 5 overarching themes were derived.

RESULTS

In total, 9 studies with information gathered from focus groups, questionnaires, and interviews were included. Barriers and enablers influencing the adoption of assistive technology for the upper limb after stroke emerged within 5 overarching but highly interdependent themes: (1) promoting hand and arm performance; (2) attitude toward technology; (3) decision process; (4) usability; and (5) practical applicability.

CONCLUSIONS

Expected use of an assistive technology is facilitated when it has a clear therapeutic base (expected benefit in enhancing function), its users (patients and health care professionals) have a positive attitude toward technology, sufficient information about the assistive technology is available, and usability and practical applicability have been addressed successfully in its design. The interdependency of the identified themes implies that all aspects influencing user perspectives of assistive technology need to be considered when developing assistive technology to enhance its chance of acceptance. The importance of each factor may vary depending on personal factors and the use context, either at home as an assistive aid or for rehabilitation at a clinic.

Feasibility of a wearable soft-robotic glove to support impaired hand function in stroke patients

OBJECTIVE

To investigate the feasibility of a wear-able, soft-robotic glove system developed to combine assistive support in daily life with performing therapeutic exercises on a computer at home (the HandinMind system).

DESIGN

Feasibility study.

PATIENTS

Five chronic stroke patients with limitations in activities of daily living due to impaired hand function.

METHODS

Participants performed a usability test and several functional tasks with the HandinMind system across 2 sessions. Feasibility was measured using the System Usability Scale (SUS), Intrinsic Motivation Inventory (IMI) and performance times of the functional tasks.

RESULTS

User acceptance measured by the SUS and IMI was scored high. The median SUS scores of sessions 1 and 2 were 80.0 (interquartile range (IQR) 70.0-88.8) and 77.5 (IQR 75.0-87.5), respectively, and the median IMI score was 6.3 points out of 7 points (IQR 6.2-6.3). Functional task performance was initially slower with the HandinMind glove compared with performance without the glove, but improved up to the level of performance without the glove across no more than 3 repetitions.

CONCLUSION

Chronic stroke patients with impaired hand function were positive about the feasibility of the first prototype of the HandinMind system. How-ever, performance and ease of use of the system should be improved further in future development phases.

Strong relations of elbow excursion and grip strength with post-stroke arm function and activities: Should we aim for this in technology-supported training?

Objective

To investigate the relationships between an extensive set of objective movement execution kinematics of the upper extremity and clinical outcome measures in chronic stroke patients: at baseline and after technology-supported training at home.

Methods

Twenty mildly to severely affected chronic stroke patients participated in the baseline evaluation, 15 were re-evaluated after six weeks of intensive technology-supported or conventional arm/hand training at home. Grip strength, 3D motion analysis of a reach and grasp task, and clinical scales (Fugl-Meyer assessment (FM), Action Research Arm Test (ARAT) and Motor Activity Log (MAL)) were assessed pre- and post-training.

Results

Most movement execution parameters showed moderate-to-strong relationships with FM and ARAT, and to a smaller degree with MAL. Elbow excursion explained the largest amount of variance in FM and ARAT, together with grip strength. The only strong association after training was found between changes in ARAT and improvements in hand opening (conventional) or grip strength (technology-supported).

Conclusions

Elbow excursion and grip strength showed strongest association with post-stroke arm function and activities. Improved functional ability after training at home was associated with increased hand function. Addressing both reaching and hand function are indicated as valuable targets for (technological) treatment applications to stimulate functional improvements after stroke.

Applying a soft-robotic glove as assistive device and training tool with games to support hand function after stroke: Preliminary results on feasibility and potential clinical impact

Recent technological developments regarding wearable soft-robotic devices extend beyond the current application of rehabilitation robotics and enable unobtrusive support of the arms and hands during daily activities. In this light, the HandinMind (HiM) system was developed, comprising a soft-robotic, grip supporting glove with an added computer gaming environment. The present study aims to gain first insight into the feasibility of clinical application of the HiM system and its potential impact. In order to do so, both the direct influence of the HiM system on hand function as assistive device and its therapeutic potential, of either assistive or therapeutic use, were explored. A pilot randomized clinical trial was combined with a cross-sectional measurement (comparing performance with and without glove) at baseline in 5 chronic stroke patients, to investigate both the direct assistive and potential therapeutic effects of the HiM system. Extended use of the soft-robotic glove as assistive device at home or with dedicated gaming exercises in a clinical setting was applicable and feasible. A positive assistive effect of the soft-robotic glove was proposed for pinch strength and functional task performance 'lifting full cans' in most of the five participants. A potential therapeutic impact was suggested with predominantly improved hand strength in both participants with assistive use, and faster functional task performance in both participants with therapeutic application.

Detection of the intention to grasp during reach movements

INTRODUCTION

Soft-robotic gloves have been developed to enhance grip to support stroke patients during daily life tasks. Studies showed that users perform tasks faster without the glove as compared to with the glove. It was investigated whether it is possible to detect grasp intention earlier than using force sensors to enhance the performance of the glove.

METHODS

This was studied by distinguishing reach-to-grasp movements from reach movements without the intention to grasp, using minimal inertial sensing and machine learning. Both single-user and multi-user support vector machine classifiers were investigated. Data were gathered during an experiment with healthy subjects, in which they were asked to perform grasp and reach movements.

RESULTS

Experimental results show a mean accuracy of 98.2% for single-user and of 91.4% for multi-user classification, both using only two sensors: one on the hand and one on the middle finger. Furthermore, it was found that using only 40% of the trial length, an accuracy of 85.3% was achieved, which would allow for an earlier prediction of grasp during the reach movement by 1200 ms.

CONCLUSIONS

Based on these promising results, further research will be done to investigate the possibility to use classification of the movements in stroke patients.

Manual physical balance assistance of therapists during gait training of stroke survivors: characteristics and predicting the timing

Background

During gait training, physical therapists continuously supervise stroke survivors and provide physical support to their pelvis when they judge that the patient is unable to keep his balance. This paper is the first in providing quantitative data about the corrective forces that therapists use during gait training. It is assumed that changes in the acceleration of a patient’s COM are a good predictor for therapeutic balance assistance during the training sessions Therefore, this paper provides a method that predicts the timing of therapeutic balance assistance, based on acceleration data of the sacrum.

Methods

Eight sub-acute stroke survivors and seven therapists were included in this study. Patients were asked to perform straight line walking as well as slalom walking in a conventional training setting. Acceleration of the sacrum was captured by an Inertial Magnetic Measurement Unit. Balance-assisting corrective forces applied by the therapist were collected from two force sensors positioned on both sides of the patient’s hips. Measures to characterize the therapeutic balance assistance were the amount of force, duration, impulse and the anatomical plane in which the assistance took place. Based on the acceleration data of the sacrum, an algorithm was developed to predict therapeutic balance assistance. To validate the developed algorithm, the predicted events of balance assistance by the algorithm were compared with the actual provided therapeutic assistance.

Results

The algorithm was able to predict the actual therapeutic assistance with a Positive Predictive Value of 87% and a True Positive Rate of 81%. Assistance mainly took place over the medio-lateral axis and corrective forces of about 2% of the patient’s body weight (15.9 N (11), median (IQR)) were provided by therapists in this plane. Median duration of balance assistance was 1.1 s (0.6) (median (IQR)) and median impulse was 9.4Ns (8.2) (median (IQR)). Although therapists were specifically instructed to aim for the force sensors on the iliac crest, a different contact location was reported in 22% of the corrections.

Conclusions

This paper presents insights into the behavior of therapists regarding their manual physical assistance during gait training. A quantitative dataset was presented, representing therapeutic balance-assisting force characteristics. Furthermore, an algorithm was developed that predicts events at which therapeutic balance assistance was provided. Prediction scores remain high when different therapists and patients were analyzed with the same algorithm settings. Both the quantitative dataset and the developed algorithm can serve as technical input in the development of (robot-controlled) balance supportive devices.

Paretic versus non-paretic stepping responses following pelvis perturbations in walking chronic-stage stroke survivors

Background

The effects of a stroke, such as hemiparesis, can severely hamper the ability to walk and to maintain balance during gait. Providing support to stroke survivors through a robotic exoskeleton, either to provide training or daily-life support, requires an understanding of the balance impairments that result from a stroke. Here, we investigate the differences between the paretic and non-paretic leg in making recovery steps to restore balance following a disturbance during walking.

Methods

We perturbed 10 chronic-stage stroke survivors during walking using mediolateral perturbations of various amplitudes. Kinematic data as well as gluteus medius muscle activity levels during the first recovery step were recorded and analyzed.

Results

The results show that this group of subjects is able to modulate foot placement in response to the perturbations regardless of the leg being paretic or not. Modulation in gluteus medius activity with the various perturbations is in line with this observation. In general, the foot of the paretic leg was laterally placed further away from the center of mass than that of the non-paretic leg, while subjects spent more time standing on the non-paretic leg.

Conclusions

The findings suggest that, though stroke-related gait characteristics are present, the modulation with the various perturbations remains unaffected. This might be because all subjects were only mildly impaired, or because these stepping responses partly occur through involuntary pathways which remain unaffected by the complications after the stroke.

The influence of a user-adaptive prosthetic knee on planned gait termination

The added value of user-adaptive prosthetic knees has been predominantly evaluated in level walking or ramp/stair negotiation. Previous studies indicate that the activity pattern of individuals with an amputation mainly consists of short periods of continuous walking, indicating that a high percentage of ambulatory activity involves gait termination. The potential added value of user-adaptive prosthetic knees in gait termination has not been studied yet. Ten individuals with an amputation were measured with their own non-microprocessor controlled prosthetic knee and with the Rheo Knee II (a user-adaptive prosthetic knee). Spatiotemporal, kinematic and kinetic variables were measured. We found that the Rheo Knee II had no effect on the studied outcome parameters when compared to the non-microprocessor controlled prosthetic knee. We also found that the intact leg was responsible for producing the deceleration forces irrespective whether the last step was made by the intact or prosthetic leg. In conclusion we found that the prosthetic leg is limited in producing deceleration forces. Although user-adaptive prosthetic knees claim to increase stance stability, the added value of the Rheo Knee II on the studied outcome parameters is limited.

SOFIE, a bicycle that supports older cyclists?

Older cyclists remain at high risk of sustaining an injury after a fall with their bicycle. A growing awareness for the need and possibilities to support safety of older cyclists has been leading to bicycle design ideas. However, the effectiveness and acceptance of such designs has not been studied yet. This study aims to analyse the effect of 3 support systems: an automatic adjustable saddle height, optimised frame and wheel geometry and drive-off assistance. The support systems are integrated on the SOFIE bicycle, a prototype bicycle designed to support older cyclists during (dis-)mounting and at lower cycling speeds. Nine older cyclists (65-80 years) were asked to cycle on a 'normal' and on the 'SOFIE' bicycle. They cycled on a parking lot to avoid interaction with traffic. The following tasks were analysed: cycling at comfortable and low speed avoiding an obstacle and (dis-)mounting the bicycle. Bicycle and cyclist motions were recorded with 10 Inertial Measurement Units and by 2 video cameras. FUSION software (LABVIEW) was used to assess kinematic parameters. First, a subjective analysis of the different cycling tasks was made, supported by video analysis. Second, differences in cyclist and bicycle kinematic parameters between the normal and SOFIE bicycle were studied for the various cycling tasks. The SOFIE bicycle was experienced as a 'supportive' and comfortable bicycle and objectively performed 'safer' on various cycling tasks. For example: The optimised frame geometry with low step-in enabled a faster (dis-)mounting time and less sternum roll angle and angular acceleration. The adjustable saddle height enabled the participants to keep both feet on the ground till they started cycling with the 'drive-off' support. The latter reduces steering activity: maximum steer angle and angular acceleration. During sudden obstacle avoidance, less upper body and thigh accelerations are recorded. In conclusion, the SOFIE bicycle was able to support older cyclists during various cycling tasks and may reduce fall risk.

A randomized controlled trial on providing ankle-foot orthoses in patients with (sub-)acute stroke: Short-term kinematic and spatiotemporal effects and effects of timing

Initial walking function is often limited after stroke, and regaining walking ability is an important goal in rehabilitation. Various compensatory movement strategies to ensure sufficient foot-clearance are reported. Ankle-foot orthoses (AFOs) are often prescribed to improve foot-clearance and may influence these strategies. However, research studying effects of actual AFO-provision early after stroke is limited. We conducted an explorative randomized controlled trial and aimed to study the short-term effects of AFO-provision on kinematic and spatiotemporal parameters in patients early after stroke. In addition, we studied whether timing of AFO-provision influenced these effects. Unilateral hemiparetic patients maximal six weeks post-stroke were randomly assigned to AFO-provision: early (at inclusion) or delayed (eight weeks later). Three-dimensional gait-analysis with and without AFO in randomized order was performed within two weeks after AFO-provision. Twenty subjects (8 early, 12 delayed) were analyzed. We found significant positive effects of AFO-provision for ankle dorsiflexion at initial contact, foot-off and during swing (-3.6° (7.3) vs 3.0° (3.9); 0.0° (7.4) vs 5.2° (3.7); and -6.1° (7.8) vs 2.6° (3.5), respectively), all p<0.001. No changes in knee, hip and pelvis angles were found after AFO-provision, except for knee (+2.3°) and hip flexion (+1.6°) at initial contact, p≤0.001. Significant effects of AFO-provision were found for cadence (+2.1 steps/min, p=0.026), stride duration (-0.08s, p=0.015) and single support duration (+1.0%, p=0.002). Early or delayed AFO-provision after stroke did not affect results. In conclusion, positive short-term effects of AFO-provision were found on ankle kinematics early after stroke. Timing of AFO-provision did not influence the results.

TRIAL REGISTRATION NUMBER

NTR1930.

The effect of pressure and shear on tissue viability of human skin in relation to the development of pressure ulcers: a systematic review

Pressure ulcers are a significant problem in health care, due to high costs and large impact on patients' life. In general, pressure ulcers develop as tissue viability decreases due to prolonged mechanical loading. The relation between load and tissue viability is highly influenced by individual characteristics. It is proposed that measurements of skin blood flow regulation could provide good assessment of the risk for pressure ulcer development, as skin blood flow is essential for tissue viability. . Therefore, the aim of this systematic review is to gain insight in the relation between mechanical load and the response of the skin and underlying tissue to this loading measured in-vivo with non-invasive techniques. A systematic literature search was performed to identify articles analysing the relation between mechanical load (pressure and/or shear) and tissue viability measured in-vivo. Two independent reviewers scored the methodological quality of the 22 included studies. Methodological information as well as tissue viability parameters during load application and after load removal were extracted from the included articles and used in a meta-analysis. Pressure results in a decrease in skin blood flow parameters, compared to baseline; showing a larger decrease with higher magnitudes of load. The steepness of the decrease is mostly dependent on the anatomical location. After load removal the magnitude of the post-reactive hyperaemic peak is related to the magnitude of pressure. Lastly, shear in addition to pressure, shows an additional negative effect, but the effect is less apparent than pressure on skin viability.

The influence of a user-adaptive prosthetic knee across varying walking speeds: A randomized cross-over trial

Previously conducted trials comparing the gait pattern of individuals with a transfemoral amputation using a user-adaptive and a non-microprocessor-controlled prosthetic knee (NMPK) found mixed and conflicting results. Few trials, however, have compared user-adaptive to non-adaptive prosthetic knees across different walking speeds. Because of the ability of variable damping, the effect of user-adaptive knees might be more pronounced at lower or higher walking speeds. Our aim was to compare the Rheo Knee II (a microprocessor-controlled prosthetic knee) with NMPKs across varying walking speeds. In addition, we studied compensatory mechanisms associated with non-optimal prosthetic knee kinematics, such as intact ankle vaulting and vertical acceleration of the pelvis. Nine persons with a transfemoral amputation or knee disarticulation were included and measured with their own NMPK and with the Rheo Knee II. Measurements were performed at three walking speeds: preferred walking speed, 70% preferred walking speed and 115% preferred walking speed. No differences on peak prosthetic knee flexion during swing were found between prosthetic knee conditions. In addition, prosthetic knee flexion increased significantly with walking speed for both prosthetic knee conditions. At 70% preferred walking speed we found that vaulting of the intact ankle was significantly decreased while walking with the Rheo Knee II compared to the NMPK condition (P=0.028). We did not find differences in peak vertical acceleration of the pelvis during initial and mid-swing of the prosthetic leg. In conclusion, comparison of walking with the Rheo Knee II to walking with a NMPK across different walking speeds showed limited differences in gait parameters.

A wearable soft-robotic glove enables hand support in ADL and rehabilitation: A feasibility study on the assistive functionality

Background

Elderly people frequently experience a decline in hand function, due to ageing or diseases. This leads to decreased independence in activities of daily living (ADL). Assistive technology may enhance independence.

Objectives

The objective of this paper was to explore user acceptance of an affordable wearable soft-robotic glove (ironHand (iH) system), that supports grip and hand opening in ADL. In addition, functional performance with the iH system was explored.

Methods

For this study 28 elderly people used the iH system across two sessions. During these sessions, participants performed six functional tasks with and without the iH system. Outcome measures were System Usability Scale (SUS), Intrinsic Motivation Inventory (IMI) and performance time of the functional tasks.

Results

User acceptance scored highly, with a mean SUS score of at least 63.4 (SD = 19.0) and a mean IMI score of 5.1 points (SD = 0.97 points). Functional task performance improved across repetitions both with and without the glove (p ≤ 0.017), but all functional tasks were performed faster without the glove (p ≤ 0.032).

Conclusion

Participants perceived the iH system as useful, pleasant and meaningful. The learning curve in functional performance time (improvements across repetitions) is promising, since it suggests there is room for improved performance when a longer acquaintance period is applied.

Effects of training with a passive hand orthosis and games at home in chronic stroke: a pilot randomised controlled trial

OBJECTIVES

To compare user acceptance and arm and hand function changes after technology-supported training at home with conventional exercises in chronic stroke. Secondly, to investigate the relation between training duration and clinical changes.

DESIGN

A randomised controlled trial.

SETTING

Training at home, evaluation at research institute.

SUBJECTS

Twenty chronic stroke patients with severely to mildly impaired arm and hand function.

INTERVENTIONS

Participants were randomly assigned to six weeks (30 minutes per day, six days a week) of self-administered home-based arm and hand training using either a passive dynamic wrist and hand orthosis combined with computerised gaming exercises (experimental group) or prescribed conventional exercises from an exercise book (control group).

MAIN MEASURES

Main outcome measures are the training duration for user acceptance and the Action Research Arm Test for arm and hand function. Secondary outcomes are the Intrinsic Motivation Inventory, Fugl-Meyer assessment, Motor Activity Log, Stroke Impact Scale and grip strength.

RESULTS

The control group reported a higher training duration (189 versus 118 minutes per week, P = 0.025). Perceived motivation was positive and equal between groups ( P = 0.935). No differences in clinical outcomes over training between groups were found (P ⩾ 0.165). Changes in Box and Block Test correlated positively with training duration ( P = 0.001).

CONCLUSIONS

Both interventions were accepted. An additional benefit of technology-supported arm and hand training over conventional arm and hand exercises at home was not demonstrated. Training duration in itself is a major contributor to arm and hand function improvements.

Exploration of shoulder load during hand-rim wheelchair start-up with and without power-assisted propulsion in experienced wheelchair users

BACKGROUND

Frequent start movements occurred during the day, yielding high upper-extremity stress. The high incidence and impact of shoulder injury on daily life wheelchair use made it clinically relevant to investigate whether power-assisted propulsion is beneficial during the start.

METHODS

Eleven hand-rim wheelchair users performed a start-movement in an instrumented wheelchair on a flat surface. Test order was randomly assigned to propulsion with and without power-assist. For each subject, parameters were averaged over 3 repeated starts. For statistical analysis Wilcoxon Signed Rank test was used.

FINDINGS

Intensity of mechanical shoulder loading decreased during power-assisted propulsion for anterior (147.0 (44.8) versus 121.9 (27.4) N; effect size (r)=-.75), posterior (4.8 (14.1) versus 2.7 (11.6) N; r=-.64) and inferior directed forces (82.6 (27.9) versus 68.9 (22.6) N; r=-.78) and abduction (20.2 (14.6) versus 12.9 (7.8) Nm; r=-.88) and extension moments (20.3 (10.7) versus 13.7 (9.1 Nm; r=-.88). Peak resultant force at the rim significantly decreased from 133.5 (38.4) N to 112.2 (25.4) N (r=-.64) and was accompanied by significant decreased shoulder abduction (35.3 (6.7) versus 33.3 (6.8); r=-.67) and significant increased shoulder extension (13.6 (16.3) versus 20.3 (19.1); r=-.78) during power-assisted start-up.

INTERPRETATION

Power-assist hand-rim wheelchairs are effective in reducing external shoulder load and partly effective in reducing force generation in extremes of shoulder motion during start-up. The use of power-assist wheels might reduce the risk of developing shoulder overuse injuries.

CLINICAL TRIAL REGISTRATION NUMBER

NTR2661.

Application of the Teager-Kaiser Energy Operator in an autonomous burst detector to create onset and offset profiles of forearm muscles during reach-to-grasp movements

PURPOSE

The primary aim of this study is to investigate the potential benefit of the Teager-Kaiser Energy Operator (TKEO) as data pre-processor, in an autonomous burst detection method to classify electromyographic signals of the (fore)arm and hand. For this purpose, optimal settings of the burst detector, leading to minimal detection errors, need to be known. Additionally, the burst detector is applied to real muscle activity recorded in healthy adults performing reach-to-grasp movements.

METHODS

The burst detector was based on the Approximated Generalized Likelihood Ratio (AGLR). Simulations with synthesized electromyographic (EMG) traces with known onset and offset times, yielded optimal settings for AGLR parameters "window width" and "threshold value" that minimized detection errors. Next, comparative simulations were done with and without TKEO data pre-processing. Correct working of the burst detector was verified by applying it to real surface EMG signals obtained from arm and hand muscles involved in a submaximal reach-to-grasp task, performed by healthy adults.

RESULTS

Minimal detection errors were found with a window width of 100 ms and a detection threshold of 15. Inclusion of the TKEO contributed significantly to a reduction of detection errors. Application of the autonomous burst detector to real data was feasible.

CONCLUSIONS

The burst detector was able to classify muscle activation and create Muscle Onset Offset Profiles (MOOPs) autonomously from real EMG data, which allows objective comparison of MOOPs obtained from movement tasks performed in different conditions or from different populations. The TKEO contributed to improved performance and robustness of the burst detector.

The effect of 'device-in-charge' versus 'patient-in-charge' support during robotic gait training on walking ability and balance in chronic stroke survivors: A systematic review

This review describes the effects of two control strategies - used in robotic gait-training devices for chronic stroke survivors - on gait speed, endurance and balance. Control strategies are classified as 'patient-in-charge support', where the device 'empowers' the patient, and 'device-in-charge support', where the device imposes a pre-defined movement trajectory on the patient. Studies were collected up to 24 June 2015 and were included if they presented robotic gait training in chronic stroke survivors and used outcome measures that were indexed by the International Classification of Functioning, Disability and Health. In total, 11 articles were included. Methodological quality was assessed using the PEDro scale. Outcome measures were walking speed, endurance and balance. Pooled mean differences between pre and post measurements were calculated. No differences were found between studies that used device-in-charge support and patient-in-charge support. Training effects were small for both groups of control strategies, and none were considered to be clinically relevant as defined by the Minimal Clinically Important Difference. However, an important confounder is the short training duration among all included studies. As control strategies in robotic gait training are rapidly evolving, future research should take the recommendations that are made in this review into account.

Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke

Background

Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke.

Methods

A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up.

Results

Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log.

Conclusions

Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings.

Trial registration

This study has been registered at the Netherlands Trial Registry (NTR): NTR3669.

Predictive Value of Upper Limb Muscles and Grasp Patterns on Functional Outcome in Cervical Spinal Cord Injury

Objective. To determine which single or combined upper limb muscles as defined by the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI); upper extremity motor score (UEMS) and the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP), best predict upper limb function and independence in activities of daily living (ADLs) and to assess the predictive value of qualitative grasp movements (QlG) on upper limb function in individuals with acute tetraplegia. Method. As part of a Europe-wide, prospective, longitudinal, multicenter study ISNCSCI, GRASSP, and Spinal Cord Independence Measure (SCIM III) scores were recorded at 1 and 6 months after SCI. For prediction of upper limb function and ADLs, a logistic regression model and unbiased recursive partitioning conditional inference tree (URP-CTREE) were used. Results. Logistic regression and URP-CTREE revealed that a combination of ISNCSCI and GRASSP muscles (to a maximum of 4) demonstrated the best prediction (specificity and sensitivity ranged from 81.8% to 96.0%) of upper limb function and identified homogenous outcome cohorts at 6 months. The URP-CTREE model with the QlG predictors for upper limb function showed similar results. Conclusion. Prediction of upper limb function can be achieved through a combination of defined, specific upper limb muscles assessed in the ISNCSCI and GRASSP. A combination of a limited number of proximal and distal muscles along with an assessment of grasping movements can be applied for clinical decision making for rehabilitation interventions and clinical trials.

Changes in Strength, Sensation, and Prehension in Acute Cervical Spinal Cord Injury

Objective. To investigate the internal and external responsiveness and recovery profiles of the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) instrument in revealing changes in upper limb function within the first year following cervical spinal cord injury (SCI). Method. A European prospective, longitudinal, multicenter study assessing the GRASSP at 1, 3, 6, and 12 months after cervical SCI. Subtests of GRASSP were compared to the upper extremity motor (UEMS) and light touch scores (LT) according to the International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI), the Spinal Cord Independence Measure self-care subscore (SCIM-SS), as well as a clinician-rated outcome measure (CROM) of clinical relevance. Data were analyzed for GRASSP responsiveness and recovery rate over time. Results. Seventy-four participants entered the study. GRASSP subtests proved responsive (standardized response mean [SRM] ranged from 0.79 to 1.48 for strength, 0.50 to 1.03 for prehension, and 0.14 to 0.64 for sensation) between all examination time points. In comparison, UEMS and LT showed lower responsiveness (SRM UEMS ranged from 0.69 to 1.29 and SRM LT ranged from 0.30 to −0.13). All GRASSP subtests revealed significant, moderate-to-excellent correlations with UEMS, LT, and SCIM-SS at each time point, and changes in GRASSP subtests were in accordance with the CROM. GRASSP prehension and motor recovery was largest between 1 and 3 months. Conclusion. The GRASSP showed excellent responsiveness, detecting distinct changes in strength and prehension relating to the severity of cervical SCI. It detected clinically significant changes complimentary to the ISNCSCI and SCIM-SS assessments.

Influence of a user-adaptive prosthetic knee on quality of life, balance confidence, and measures of mobility: a randomised cross-over trial

OBJECTIVE

To study the influence of a transition from a non-microprocessor controlled to the Rheo Knee(®) II on quality of life, balance confidence and measures of mobility.

DESIGN

Randomised crossover trial.

SETTING

Research department of a rehabilitation centre.

SUBJECTS

Persons with a transfemoral amputation or knee disarticulation (n=10).

INTERVENTIONS

Participants were assessed with their own non-microprocessor controlled knee and with the Rheo Knee(®) II. The low-profile Vari-Flex with EVO foot was installed in both knee conditions, followed by eight weeks of acclimatisation. The order in which knees were tested was randomised.

MAIN MEASURES

Prosthesis Evaluation Questionnaire with addendum, Activities-specific Balance Confidence scale, Timed "up & go" test, Timed up and down stairs test, Hill Assessment Index, Stairs Assessment Index, Standardized Walking Obstacle Course and One Leg Balance test.

RESULTS

Significant higher scores were found for the Rheo Knee(®) II on the Residual Limb Health subscale of the Prosthesis Evaluation Questionnaire when compared to the non-microprocessor controlled prosthetic knee (median [interquartile range] resp. 86.67 [62.21-93.08] and 68.71 [46.15-94.83]; P=0.047) In addition, participants needed significantly more steps to complete an obstacle course when walking with the Rheo Knee(®) II compared to the non-microprocessor controlled prosthetic knee (median [interquartile range] resp. 23.50 [19.92-26.25] and 22.17 [19.50-25.75]; P=0.041). On other outcome measures, no significant differences were found.

CONCLUSIONS

Transition towards the Rheo Knee(®) II had little effect on the studied outcome measures.

The effect of arm support combined with rehabilitation games on upper-extremity function in subacute stroke: a randomized controlled trial

BACKGROUND

Use of rehabilitation technology, such as (electro)mechanical devices or robotics, could partly relieve the increasing strain on stroke rehabilitation caused by an increasing prevalence of stroke. Arm support (AS) training showed improvement of unsupported arm function in chronic stroke.

OBJECTIVE

To examine the effect of weight-supported arm training combined with computerized exercises on arm function and capacity, compared with dose-matched conventional reach training in subacute stroke patients.

METHODS

In a single-blind, multicenter, randomized controlled trial, 70 subacute stroke patients received 6 weeks of training with either an AS device combined with computerized exercises or dose-matched conventional training (CON). Arm function was evaluated pretraining and posttraining by Fugl-Meyer assessment (FM), maximal reach distance, Stroke Upper Limb Capacity Scale (SULCS), and arm pain via Visual Analogue Scale, in addition to perceived motivation by Intrinsic Motivation Inventory posttraining.

RESULTS

FM and SULCS scores and reach distance improved significantly within both groups. These improvements and experienced pain did not differ between groups. The AS group reported higher interest/enjoyment during training than the CON group.

CONCLUSIONS

AS training with computerized exercises is as effective as conventional therapy dedicated to the arm to improve arm function and activity in subacute stroke rehabilitation, when applied at the same dose.

The effect of impedance-controlled robotic gait training on walking ability and quality in individuals with chronic incomplete spinal cord injury: an explorative study

Background

There is increasing interest in the use of robotic gait-training devices in walking rehabilitation of incomplete spinal cord injured (iSCI) individuals. These devices provide promising opportunities to increase the intensity of training and reduce physical demands on therapists. Despite these potential benefits, robotic gait-training devices have not yet demonstrated clear advantages over conventional gait-training approaches, in terms of functional outcomes. This might be due to the reduced active participation and step-to-step variability in most robotic gait-training strategies, when compared to manually assisted therapy. Impedance-controlled devices can increase active participation and step-to-step variability. The aim of this study was to assess the effect of impedance-controlled robotic gait training on walking ability and quality in chronic iSCI individuals.

Methods

A group of 10 individuals with chronic iSCI participated in an explorative clinical trial. Participants trained three times a week for eight weeks using an impedance-controlled robotic gait trainer (LOPES: LOwer extremity Powered ExoSkeleton). Primary outcomes were the 10-meter walking test (10MWT), the Walking Index for Spinal Cord Injury (WISCI II), the six-meter walking test (6MWT), the Timed Up and Go test (TUG) and the Lower Extremity Motor Scores (LEMS). Secondary outcomes were spatiotemporal and kinematics measures. All participants were tested before, during, and after training and at 8 weeks follow-up.

Results

Participants experienced significant improvements in walking speed (0.06 m/s, p = 0.008), distance (29 m, p = 0.005), TUG (3.4 s, p = 0.012), LEMS (3.4, p = 0.017) and WISCI after eight weeks of training with LOPES. At the eight-week follow-up, participants retained the improvements measured at the end of the training period. Significant improvements were also found in spatiotemporal measures and hip range of motion.

Conclusion

Robotic gait training using an impedance-controlled robot is feasible in gait rehabilitation of chronic iSCI individuals. It leads to improvements in walking ability, muscle strength, and quality of walking. Improvements observed at the end of the training period persisted at the eight-week follow-up. Slower walkers benefit the most from the training protocol and achieve the greatest relative improvement in speed and walking distance.

Prediction and Stratification of Upper Limb Function and Self-Care in Acute Cervical Spinal Cord Injury With the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP)

Background. There is inherent heterogeneity within individuals suffering from cervical spinal cord injury (SCI), and early prediction of upper limb function and self-care is challenging. As a result, considerable uncertainty exists regarding the prediction of functional outcome following cervical SCI within 1 year of injury. Objective. To evaluate the value of Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) in predicting upper limb function and self-care outcomes in individuals with cervical SCI. Method. A prospective longitudinal multicenter study was performed. Data from the GRASSP, the Spinal Cord Independence Measure (SCIM III), and the American Spinal Injury Association (ASIA) Impairment Scale were recorded at 1, 6, and 12 months after cervical SCI. For prediction of functional outcome at 6 and 12 months, a logistic regression model, receiver operating characteristics (ROC), and unbiased recursive partitioning conditional inference tree (URP-CTREE) were used with 8 different predictor variables. Results. Logistic regression analysis, ROC analysis, and URP-CTREE all revealed that the strength subtest within GRASSP is the strongest predictor for upper limb function and self-care outcomes. URP-CTREE provides useful information on the distribution of different outcomes in acute cervical SCI and can be used to predict cohorts with homogeneous outcomes. Conclusion. The GRASSP at 1 month can accurately predict upper limb function and self-care outcomes even in a heterogeneous group of individuals across a wide spectrum of neurological recovery. The application of URP-CTREE can reveal the distribution of outcome categories and, based on this, inform trial protocols with respect to outcomes analysis and patient stratification.

Comparison of muscle activity patterns of transfemoral amputees and control subjects during walking

Background

Only few studies have looked at electromyography (EMG) during prosthetic gait. Differences in EMG between normal and prosthetic gait for stance and swing phase were never separately analyzed. These differences can give valuable information if and how muscle activity changes in prosthetic gait.

Methods

In this study EMG activity during gait of the upper leg muscles of six transfemoral amputees, measured inside their own socket, was compared to that of five controls. On and off timings for stance and swing phase were determined together with the level of co-activity and inter-subject variability.

Results and conclusions

Gait phase changes in amputees mainly consisted of an increased double support phase preceding the prosthetic stance phase. For the subsequent (pre) swing phase the main differences were found in muscle activity patterns of the prosthetic limb, more muscles were active during this phase and/or with prolonged duration. The overall inter-subject variability was larger in amputees compared to controls.