NeuroRehabilitation - Volume 33, issue 1

Authors: Krebs, Hermano Igo

Article Type: Editorial

DOI: 10.3233/NRE-130921

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 1-2, 2013

Authors: Bishop, Lauri | Stein, Joel

Article Type: Review Article

Abstract: Background: Stroke is a leading cause of disability worldwide. Many survivors of stroke remain with residual disabilities, even years later. Advances in technology have led to the development of a variety of robotic devices for use in rehabilitation. The integration of robotics in the delivery of neurorehabilitation is promising, but still not widely used in clinical settings. Objectives: The aim of this review is to discuss the general design of three typical upper limb robotic devices, and examine the practical considerations for their use in a clinical environment. Methods: Each device is described, the available clinical …literature is reviewed and a clinical perspective is given on the usefulness of these robotic devices in rehabilitation of this population. Results: Current literature supports the use of robotics in the clinical environment. However, claims that robotic therapy is more effective than traditional treatment is not substantially supported. The majority of clinical trials reported are small, and lack the use of a control group for comparison treatment. Conclusions: The use of robotics in stroke rehabilitation is still a relatively new treatment platform, and still evolving. As technological advances are made, there is much potential for growth in this field. Show more

Keywords: Neurorehabilitation, robotics, stroke

DOI: 10.3233/NRE-130922

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 3-11, 2013

Authors: Dodakian, Lucy | Sharp, Kelli G. | See, Jill | Abidi, Neil S. | Mai, Khoa | Fling, Brett W. | Le, Vu H. | Cramer, Steven C.

Article Type: Research Article

Abstract: Background: Good motor outcome after stroke has been found to correlate with increased activity in a dorsal premotor (PMd) brain circuit, suggesting that therapeutic strategies targeting this circuit might have a favorable, causal influence on motor status. Objective: This study addressed the hypothesis that a Premotor Therapy that exercises normal PMd functions would provide greater behavioral gains than would standard Motor Therapy; and that Premotor Therapy benefits would be greatest in patients with greater preservation of PMd circuit elements. Methods: Patients with chronic hemiparetic stroke (n = 15) were randomized to 2-weeks of Premotor Therapy or …Motor Therapy, implemented through a robotic device. Results: Overall, gains were modest but significant (change in FM score, 2.1 ± 2.8 points, p < 0.02) and did not differ by treatment assignment. However, a difference between Therapies was apparent when injury to the PMd circuit was considered, as the interaction between treatment assignment and degree of corticospinal tract injury was significantly related to the change in FM score (p = 0.018): the more the corticospinal tract was spared, the greater the gains provided by Premotor Therapy. Similar results were obtained when looking at the interaction between treatment assignment and PMd function (p = 0.03). Conclusions: Targeted engagement of a brain circuit is a feasible strategy for stroke rehabilitation. This approach has maximum impact when there is less stroke injury to key elements of the targeted circuit. Show more

Keywords: Stroke, premotor cortex, robot, motor recovery, corticospinal tract

DOI: 10.3233/NRE-130923

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 13-24, 2013

Authors: Ladenheim, Barbara | Altenburger, Peter | Cardinal, Ryan | Monterroso, Linda | Dierks, Tracy | Mast, Joelle | Krebs, Hermano Igo

Article Type: Research Article

Abstract: Background: Robot assisted upper extremity therapy has been shown to be effective in adult stroke patients and in children with cerebral palsy (CP) and other acquired brain injuries (ABI). The patient's active involvement is a factor in its efficacy. However, this demands focused attention during training sessions, which can be a challenge for children. Objective: To compare results of training requiring two different levels of focused attention. Differences in short term performance and retention of gains as a function of training protocol as measured by the Fugl-Meyer (FM) were predicted. Methods: Thirty-one children with CP or …ABI were randomly divided into two groups. All received 16 one hour sessions of robot-assisted therapy (twice a week for 8 weeks) where they moved a robot handle to direct a cursor on the screen toward designated targets. One group had targets presented sequentially in clockwise fashion, the other presented in random order. Thus, one group could anticipate the position of each target, the other could not. Results: Both groups showed significant functional improvement after therapy, but no significant difference between groups was observed. Conclusions: Assist-as-needed robotic training is effective in children with CP or ABI with small non-significant differences attributed to attentional demand. Show more

Keywords: Robot assisted therapy, cerebral palsy, pediatric

DOI: 10.3233/NRE-130924

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 25-31, 2013

Authors: Mazzoleni, Stefano | Sale, Patrizio | Franceschini, Marco | Bigazzi, Samuele | Carrozza, Maria Chiara | Dario, Paolo | Posteraro, Federico

Article Type: Research Article

Abstract: Objective: To evaluate the effects of add-on distal upper limb robot-assisted treatment on the outcome of proximal regions. Design: 64 chronic stroke patients divided into two groups participated in the study. Group A was assigned to the proximal robot-assisted rehabilitation, Group B to the proximal and distal. Shoulder/elbow subsection of Fugl-Meyer Assessment scale was collected for Group A, whereas for Group B wrist subsection was also collected. Motricity Index was used and a set of kinematic parameters was computed for both groups. Results: A decrease in impairment after the treatment in both groups of patients (Group …A: Shoulder/elbow FM p < 0.001 and MI p < 0.001; Group B: Shoulder/elbow FM p < 0.001 and MI p < 0.001) was found. In the Group B wrist subsection of FM showed an improvement as well (p < 0.001). No difference between groups was found in changes of clinical scales. Movement velocity and accuracy increased after the robot-assisted treatment in both groups; group B showed a greater improvement in velocity. Conclusions: Robotic treatment is effective to reduce motor impairment in chronic stroke patients even if distal training added to proximal segments in the Group B does not provide any incremental benefit to the proximal segments. It remains unclear if the effectiveness of robot-assisted treatment is directly related to the upper limb segment specifically treated and which order may lead to better outcome. Our study suggests that kinematic parameters should be computed in order to better clarify the role of distal training (wrist) on proximal segments (shoulder/elbow) as well. Show more

Keywords: Rehabilitation, robotics, stroke, upper limb, assessment

DOI: 10.3233/NRE-130925

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 33-39, 2013

Authors: Duret, Christophe | Hutin, Emilie

Article Type: Research Article

Abstract: Background: High intensity and early initiation of rehabilitation have been extensively demonstrated to enhance neural plasticity and motor recovery after stroke. However, the optimal duration of rehabilitation programs in order to have the highest impact on motor outcomes has not been established. Objectives: To evaluate motor outcomes in subacute stroke survivors with moderate to severe upper limb paresis over an extended period of rehabilitation consisting of usual care augmented with a large number of upper limb robot-assisted sessions (54 ± 13 sessions). Methods: Retrospective study in 10 inpatients. Results: The results showed a gradual …decrease in motor and functional impairments throughout the training period with a clinically meaningful increase in the Fugl-Meyer Assessment scores and in the Motor Status Scores (1st vs 37th day of the training, FMA,+ 48%, p = 0.018, MSS,+ 64%, p = 0.012; 37th vs. 79th day, FMA,+ 23%, p = 0.012, MSS,+ 30%, p = 0.017). In addition, there were improvements in hand kinematics recorded by the robot during a pointing task, with quantitative improvement (1st vs 40th day, movement efficacy,+ 97%, p = 0.0499; hand velocity,+ 335%, p = 0.013) prior to qualitative improvement (1st vs 80th day, number of hand trajectory reversals, −50%, p = 0.028; root mean square error of the trajectory/linear displacement, −52%, p = 0.059). Conclusions: Although this study was a retrospective analysis of a small sample of patients, the results suggested that a prolonged period of intensive upper limb rehabilitation, including robot-assisted training incorporated into a multidisciplinary program throughout the subacute phase after stroke resulted in significant improvements in patients with moderate to severe motor impairments. Show more

Keywords: Hemiparesis, upper limb, subacute stroke, prolonged robot-assisted training

DOI: 10.3233/NRE-130926

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 41-48, 2013

Authors: Giacobbe, V. | Krebs, H.I. | Volpe, B.T. | Pascual-Leone, A. | Rykman, A. | Zeiarati, G. | Fregni, F. | Dipietro, L. | Thickbroom, G.W. | Edwards, D.J.

Article Type: Research Article

Abstract: Background: Combining tDCS with robotic therapy is a new and promising form of neurorehabilitation after stroke, however the effectiveness of this approach is likely to be influenced by the relative timing of the brain stimulation and the therapy. Objective: To measure the kinematic and neurophysiological effects of delivering tDCS before, during and after a single session of robotic motor practice (wrist extension). Methods: We used a within-subjects repeated-measurement design in 12 chronic (>6 months) stroke survivors. Twenty minutes of anodal tDCS was delivered to the affected hemisphere before, during, or after a 20-minute session of robotic …practice. Sham tDCS was also applied during motor practice. Robotic motor performance and corticomotor excitability, assessed through transcranial magnetic stimulation (TMS), were evaluated pre- and post-intervention. Results: Movement speed was increased after motor training (sham tDCS) by ∼20%. Movement smoothness was improved when tDCS was delivered before motor practice (∼15%). TDCS delivered during practice did not offer any benefit, whereas it reduced speed when delivered after practice (∼10%). MEPs were present in ∼50% of patients at baseline; in these subjects motor practice increased corticomotor excitability to the trained muscle. Conclusions: In a cohort of stroke survivors, motor performance kinematics improved when tDCS was delivered prior to robotic training, but not when delivered during or after training. The temporal relationship between non-invasive brain stimulation and neurorehabilitation is important in determining the efficacy and outcome of this combined therapy. Show more

Keywords: tDCS, TMS, stroke, robotic training, timing

DOI: 10.3233/NRE-130927

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 49-56, 2013

Authors: Cortes, Mar | Elder, Jessica | Rykman, Avrielle | Murray, Lynda | Avedissian, Manuel | Stampas, Argyrios | Thickbroom, Gary W. | Pascual-Leone, Alvaro | Krebs, Hermano Igo | Valls-Sole, Josep | Edwards, Dylan J.

Article Type: Research Article

Abstract: Background: Recovering upper-limb motor function has important implications for improving independence of patients with tetraplegia after traumatic spinal cord injury (SCI). Objective: To evaluate the feasibility, safety and effectiveness of robotic-assisted training of upper limb in a chronic SCI population. Methods: A total of 10 chronic tetraplegic SCI patients (C4 to C6 level of injury, American Spinal Injury Association Impairment Scale, A to D) participated in a 6-week wrist-robot training protocol (1 hour/day 3 times/week). The following outcome measures were recorded at baseline and after the robotic training: a) motor performance, assessed by robot-measured kinematics, b) …corticospinal excitability measured by transcranial magnetic stimulation (TMS), and c) changes in clinical scales: motor strength (Upper extremity motor score), pain level (Visual Analog Scale) and spasticity (Modified Ashworth scale). Results: No adverse effects were observed during or after the robotic training. Statistically significant improvements were found in motor performance kinematics: aim (pre 1.17 ± 0.11 raduans, post 1.03 ± 0.08 raduans, p = 0.03) and smoothness of movement (pre 0.26 ± 0.03, post 0.31 ± 0.02, p = 0.03). These changes were not accompanied by changes in upper-extremity muscle strength or corticospinal excitability. No changes in pain or spasticity were found. Conclusions: Robotic-assisted training of the upper limb over six weeks is a feasible and safe intervention that can enhance movement kinematics without negatively affecting pain or spasticity in chronic SCI. In addition, robot-assisted devices are an excellent tool to quantify motor performance (kinematics) and can be used to sensitively measure changes after a given rehabilitative intervention. Show more

Keywords: Spinal cord injury, transcranial magnetic stimulation, robotic training, kinematics

DOI: 10.3233/NRE-130928

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 57-65, 2013

Authors: Danzl, Megan M. | Chelette, Kenneth C. | Lee, Kara | Lykins, Dana | Sawaki, Lumy

Article Type: Research Article

Abstract: Objectives: 1) To investigate the feasibility of combining transcranial direct current stimulation (tDCS) to the lower extremity (LE) motor cortex with novel locomotor training to facilitate gait in subjects with chronic stroke and low ambulatory status, and 2) to obtain insight from study subjects and their caregivers to inform future trial design. Methods: Double-blind, randomized controlled study with additional qualitative exploratory descriptive design. One-month follow-up.10 subjects with stroke were recruited and randomized to active tDCS or sham tDCS for 12 sessions. Both groups participated in identical locomotor training with a robotic gait orthosis (RGO) following each tDCS session. …RGO training protocol was designed to harness cortical neuroplasticity. Data analysis included assessment of functional and participation outcome measures and qualitative thematic analysis. Results: Eight subjects completed the study. Both groups demonstrated trends toward improvement, but the active tDCS group showed greater improvement than the sham group. Qualitative analyses indicated beneficial effects of this combined intervention. Conclusions: It is feasible to combine tDCS targeting the LE motor cortex with our novel locomotor training. It appears that tDCS has the potential to enhance the effectiveness of gait training in chronic stroke. Insights from participants provide additional guidance in designing future trials. Show more

Keywords: Neuronal plasticity, electric stimulation, robotics, lower extremity

DOI: 10.3233/NRE-130929

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 67-76, 2013

Authors: Hesse, S. | Schattat, N. | Mehrholz, J. | Werner, C.

Article Type: Research Article

Abstract: Background: A task-specific repetitive approach in gait rehabilitation after CNS lesion is well accepted nowadays. To ease the therapists' and patients' physical effort, the past two decades have seen the introduction of gait machines to intensify the amount of gait practice. Two principles have emerged, an exoskeleton- and an endeffector-based approach. Both systems share the harness and the body weight support. With the end-effector-based devices, the patients' feet are positioned on two foot plates, whose movements simulate stance and swing phase. Objective: This article provides an overview on the end-effector based machine's effectiveness regarding the restoration of gait. …Methods: For the electromechanical gait trainer GT I, a meta analysis identified nine controlled trials (RCT) in stroke subjects (n = 568) and were analyzed to detect differences between end-effector-based locomotion + physiotherapy and physiotherapy alone. Results: Patients practising with the machine effected in a superior gait ability (210 out of 319 patients, 65.8% vs. 96 out of 249 patients, 38.6%, respectively, Z = 2.29, p = 0.020), due to a larger training intensity. Only single RCTs have been reported for other devices and etiologies. Conclusion: The introduction of end-effector based gait machines has opened a new succesful chapter in gait rehabilitation after CNS lesion. Show more

Keywords: Gait rehabilitation, robotics, physiotherapy, locomotion, stroke

DOI: 10.3233/NRE-130930

Citation: NeuroRehabilitation, vol. 33, no. 1, pp. 77-84, 2013