Biomechanical Reactions of Exoskeleton Neurorehabilitation Robots in Spastic Elbows and Wrists.

Spasticity is an important factor in designing wearable and lightweight exoskeleton neurorehabilitation robots. The proposed study evaluates biomechanical reactions of an exoskeleton robot to spasticity and establishes relevant guidelines for robot design. A two-axis exoskeleton robot is used to evaluate a group of 20 patients post-stroke with spastic elbow and/or wrist joints. All subjects are given isokinetic movements at various angular velocities within the capable range of motion for both joints. The resistance torque and corresponding angular position at each joint are recorded continuously. Maximal resistance torques caused by low (modified Ashworth scale (MAS) 0, 1), intermediate (MAS 1+), and high (MAS 2 and 3) grade spasticity were 3.68 ± 2.42, 5.94 ± 2.55, and 8.25 ± 3.35 Nm for the elbow flexor ( , between each grades) and 4.23 ± 1.75, 5.68 ± 1.96, and 5.44 ± 2.02 Nm for the wrist flexor ( , for low versus intermediate, low versus high grade spasticity). The angular velocity did not significantly influence maximal resistance torque in either joint. The catch occurred more quickly at higher velocities for low and intermediate elbow flexor spasticity ( ). Spasticity caused considerable resistance to the robots during mechanically actuated movements. The resistance range according to the degree of spasticity should be considered when designing practical neurorehabilitation robots.

The Clinical Value of Assessing Lumbar Posteroanterior Segmental Stiffness: A Narrative Review of Manual and Instrumented Methods.

Abnormal spinal segmental motion/stiffness is purported to be a cause, or an effect of, low back pain. Therefore, the assessment of posteroanterior segmental spinal stiffness is a common practice in clinical and research settings. In clinical settings, manipulative practitioners routinely assess spinal stiffness manually to guide clinical decision-making. Unfortunately, the reliability of manual segmental spinal stiffness assessment is poor. As a result, various spinal stiffness-testing devices have been developed to improve the reliability and accuracy of spinal stiffness measures. Although previous critical and systematic reviews have summarized the evidence regarding the reliability and confounding factors of manual and/or instrumented spinal stiffness measurements, no available review has summarized the principles of various spinal stiffness measurement methods nor pragmatic recommendations to optimize these measurements. Importantly, although posteroanterior segmental spinal stiffness is hypothesized to be related closely to low back pain or clinical outcomes after treatments, no review has been conducted to summarize evidence related to these premises and to discuss factors that can confound these relations. Against this background, this narrative review revisits the concept of both manual and instrumented spinal stiffness assessments, summarizes the pragmatic recommendations for minimizing measurement errors, reviews the potential relations between segmental spinal stiffness and low back pain, and provides future clinical research directions that can benefit clinicians and researchers alike. LEVEL OF EVIDENCE: Not applicable.

[New technologies in diagnostics and health-resort treatment of movement disorder in children with cerebral palsy].

The study analyses results of treatment of 196 patients, with cerebral palsy, which underwent a course of health-resort treatment is performed. Past medical history of patients for the last 10 years was also analysed. It was found that the use of botulin toxin <> (BT-A) <> as a part of complex rehabilitation of the patients significantly improved the effectiveness of the treatment. It was determined that the reasons of the lack of spasticity reduce are caused by degeneration of the muscles. The developed technique of ultrasound exam muscles allowed objectively evaluates the degree of muscle degeneration.

Upper-limb spasticity during the first year after stroke: stroke arm longitudinal study at the University of Gothenburg.

OBJECTIVE: The aims of this study were to describe the prevalence and the severity of upper-limb spasticity during the first year after stroke and to analyze sensorimotor function, pain, reduced range of motion, and sensibility in persons with and without spasticity. DESIGN: This is a longitudinal design with assessments at days 3 and 10; week 4; and mos 3, 6, and 12. A total of 117 patients with first-ever stroke and arm paresis on day 3 were consecutively included. Sixty-five percent were assessed at 12 mos. Upper-limb spasticity was assessed with the Modified Ashworth Scale, and a score of 1 or greater was considered spastic. Sensorimotor function, pain, sensibility, and joint range of motion were assessed with the Fugl-Meyer Assessment. Impairment was defined as a score of less than maximum on the motor and nonmotor domains of the Fugl-Meyer Assessment. RESULTS: Spasticity was present in 25% of the patients at day 3 and in 46% at 12 mos. In most patients with spasticity, the severity increased during the first year after stroke. Spasticity appeared first in the elbow flexors and later in the elbow extensors and the wrist flexors. The patients with spasticity had significantly worse sensorimotor function and more pain, reduced joint range of motion, and reduced sensibility. CONCLUSIONS: Spasticity developed in almost half of the assessed patients, and the severity of spasticity increased over time. Because spasticity and impairments related to spasticity, such as pain and limitation in joint range of motion, influence upper extremity function negatively, early identification and treatment of spasticity may be warranted.

Alterations in body composition and spasticity following subtetanic neuromuscular electrical stimulation training in spinal cord injury.

The objective of this prospective cohort study was to investigate alterations in body composition variables and spasticity following subtetanic neuromuscular electrical stimulation (NMES) training in an adult population with spinal cord injury (SCI). Fourteen sedentary adults with SCI (thoracic [T]4-T11; American Spinal Injury Association Impairment Scale A/B; time since injury: 10.17 +/- 11.17 yr) were recruited from the National SCI database. Four adhesive electrodes (175 cm2 each) were placed bilaterally on the proximal and distal quadriceps and hamstrings muscle groups and subtetanic contractions were elicited using a handheld NMES device. Lean body mass (LBM) and other body composition variables were measured using dual-energy X-ray absorptiometry. Spasticity was measured using the Spinal Cord Assessment Tool for Spastic Reflexes (SCATs) and visual analog scales. Verbal and written feedback was obtained to subjectively evaluate spasticity. LBM and spasticity measurements were taken before and after an 8 wk NMES training program in order to assess change. A statistically significant increase in lower-limb LBM, i.e., muscle tissue (p > 0.001), and a reduction in SCATs (p < 0.001) score, indicating reduced spasticity, was observed. Subjective responses were positive. Improvements in body composition and SCATs scores indicate that subtetanic NMES training elicits favorable responses and may have important clinical implications for an SCI population.

[Phototherapy in rehabilitation medicine].

Rehabilitation can be classified into four types: medical, vocational, educational, and social rehabilitation. The goal of medical rehabilitation is to maintain and improve a patient's physical and mental capabilities. Phototherapy is an important means of treatment in rehabilitation medicine and is usually performed with ultraviolet, infrared, or laser light. Among them, laser light has been shown to have various biological effects, such as increasing blood flow, promoting wound healing, reducing inflammation, and improving immune function. Laser therapy is as important a treatment option as exercise therapy in rehabilitation medicine, and is considered to be worth evaluating as a therapeutic means to relieve pain in musculoskeletal disorders, promote healing in peripheral neuropathy, and alleviate muscle spasticity.

Monitoring of spasticity and functional ability in individuals with incomplete spinal cord injury with a functional electrical stimulation cycling system.

BACKGROUND: The aim of this study was to investigate the integration of motor function and spasticity assessment of individuals with spinal cord injury into cycling therapy. METHODS: Twenty-three participants with incomplete spinal cord injury performed 18 training sessions (standard deviation (SD) 14) on an instrumented tricycle combined with functional electrical stimulation. Each therapy session included a power output test to assess the participants' ability to pedal actively and a spasticity test routine that measures the legs' resistance to the pedalling motion. In addition, the required time for the therapy phases was monitored. RESULTS: The results of the power output test showed a monthly increase in power output of 4.4 W (SD 13.7) at 30 rpm and 18.2 W (SD 23.9) at 60 rpm. The results of the spasticity assessment indicate a 12.2 W (SD 9.7) reduction in resistance at 60 rpm after the FES training for the subject group with spasticity. CONCLUSION: In clinical use over a time-period of 2 years this combined form of therapy and motor function assessment was well accepted by participants. The active power output test and the spasticity test routine offered a proper tool to monitor participants' progress in functional rehabilitation and changes in spasticity.

Assessment of reach-to-grasp trajectories toward stationary objects.

BACKGROUND: Patients with pronounced spasticity reveal difficulties in hand opening during the approaching grasping phase. The general description and assessment procedures of reach-to-grasp movement for rehabilitation purposes is still not established. There is a necessity to develop a universal methodology to describe the approaching phase in grasping which would allow clinical evaluation of movement pathologies. METHODS: In the paper, the evaluation of approaching trajectories assessed during grasping by healthy subjects is described. The experiment, undertaken by 7 healthy volunteers, consisted of grasping three different stationary objects positioned in various poses by a robot. 3D recordings of the hand and fingertip trajectories were performed. The kinematic trajectories of the hand and finger markers were analysed in order to evaluate the reach-to-grasp movement. FINDINGS: The results of the kinematic analysis suggest that the reach-to-grasp movement of a healthy subject can be divided into 3 dominant phases (hand acceleration, hand deceleration, and final closure of the fingers). INTERPRETATION: The presented evaluation method can provide relevant information on the modalities the hand preshapes and approaches toward the object in order to obtain a stable grasp. The potential use of the approach for rehabilitation purposes is discussed.

Botulinum toxin type A: an effective treatment to restore phonation in laryngectomized patients unable to voice.

We evaluated the efficacy of Botulinum toxin type A (BTXA) as an alternative to surgical intervention to facilitate phonation in 34 laryngectomized patients (31 males and 3 women) who were unable to produce tracheoesophageal voice because of spasm of the middle and inferior pharyngeal constrictor muscles (PCM). EMG was recorded to confirm activity in these muscles during attempted vocalization. Parapharyngeal nerve block (Carbocaine 2%, 5 cc) was used to demonstrate short-term fluent voice after relaxation of the pharyngeal constrictor muscle. At a later occasion, 100 U of Botox (Allergan) in ten patients and 50 U in two patients were injected unilaterally at one location in the PCM percutaneously under EMG guidance. All patients then underwent a voice therapy program. In 11 out of 12 patients an improvement of phonation was evident after 24-48 h and it was long lasting. This result was also seen in a patient previously myotomized without improvement. Only one patient needed to be reinjected every 3 months. At a follow-up after 3 months the EMG recorded in four patients showed a low-amplitude or complete absence of activity in the treated muscle. No side effects developed. BTX therapy, especially when associated with the speech therapy, is efficacious in restoring voice to laryngectomees who are unable to voice because of spasm of the PCMs. Our results confirm previous reports. This method is our approach of choice in managing PCM spasm because it is non-invasive, not painful, has few or no side effects, and is frequently long-lasting.

Functional implication of gait after left or right-sided stroke.

OBJECTIVE: To quantify and compare parameters of muscle electrical activity and ground reaction force of lower limb during gait in post-stroke patients with left or right side functional involvement. METHOD: Fifteen post-stroke volunteers with left side functional involvement were age, gender and weight matched and compared to fifteen post-stroke volunteers with right side functional involvement. Comparison was executed by means of electromyography with four pairs of surface electrodes positioned on the affected side (spastic side), on the muscles rectus femoris, tibialis anterior, soleus, and medial portion of the hamstrings, and with a ground reaction force plate. RESULTS: There was no statistically significant difference on electromyographic activity of analyzed muscles (p = 0.6), nor on the analysis of ground reaction vertical forces, stride duration, weight bearing index, gait velocity, cadence and stride length (p = 0.53). CONCLUSION: According to the electromyographic parameters and to the ground reaction force during gait among the post-stroke volunteers with right or left side involvement; we could suggest that functional rehabilitation presented no differences for these individuals.

Clinical factors that affect walking level and performance in chronic spinal cord lesion patients.

STUDY DESIGN: Observational Study. OBJECTIVE: To evaluate the effects of neurologic and non-neurologic factors on walking level and performance in chronic spinal cord lesion (SCL) patients. SUMMARY OF BACKGROUND DATA: Walking is one of the primary goals of patients after a SCL. Several studies have demonstrated that different neurologic and non-neurologic factors can affect walking level and performance. However, in SCL age and muscle strength have always been considered the major determinants of walking. METHODS: Sixty-five patients with chronic SCL were included. Their demographic, neurologic status (ASIA standards), balance, and spasticity were recorded. Pearson and Spearman correlations were adopted to quantify the association between patients' characteristics and walking ability. The relationship between functional walking measures, Timed Up and Go, Six Minutes Walking Test (SMWT), Ten Meters Walking Test, and Walking Index for Spinal Cord Injury, and demographic and neurologic factors were measured by regression analyses. RESULTS: Strength, balance, spasticity, and age were strictly correlated with walking level and walking performance. They also were the best predictors of walking features. CONCLUSION: Results confirm the recognized importance of age and upper and lower extremity strengths for walking after a SCL. They also highlight the role of 2 other factors, i.e., balance and spasticity, seldom considered as thoroughly in SCL.

[Scuba diving -- a therapeutic option for patients with paraplegia]. / Tauchen als therapeutische Option bei Patienten mit Querschnittsyndrom.

OBJECTIVE: Spasticity is often a handicap in paraplegics and interferes with quality of life. Medical therapeutic options (e.g. baclofen, tizanidin) lead to drowsiness, fatigue and loss in activity. On the other hand paraplegics are increasingly active in daily life and leisure (paralympics). Neurorehabilitation is effective in reduction of spasticity, gaining motor function and enhancing quality of life. Hippotherapy (Lechner et al 2003) and aquatic rehabilitation are additive methods. Already 15 years ago Madorsky et al pointed out SCUBA diving as a positive neurorehabilitation procedure. The study group around Stanghelle reported also beneficial aspects on spasticity of patients with spinal cord injuries. These references inspired to introduce a prospective study. METHODS: After obtaining an ethic votum and evaluation assessment for diving permission 6 volunteers with paraplegia entered the pilot study. Medication was kept stable throughout the study time. Supervised by diving instructors and a diving trained doctor the volunteers dived to a platform in the depth of 7.2 meters. The daily diving time was exactly 30 minutes. Stabilized on the platform physiotherapeutic assessment took place in different positions to reduce spasticity. Ashworth Scale and spasm frequency scale were noted daily and at beginning and end of the study the WHO Quality of life Test had to be completed. For objective reasons a locomat training happened before, within a week after and 4 weeks after the study week. RESULTS: All patients did the daily dives without any difficulties. The statistics included the assessment of day 1 versus day 7 of 5 patients and showed a significant reduction of Modified Ashwoth Scale (p=0.04). Quality of life showed an improvement. CONCLUSION: The improvement rationale can only be supposed. A correlation to the ambient pressure suggests itself. Therefore deeper depths should increase the good spasticity results or manage to achieve those faster. Many questions remain, so further studies are necessary to ascertain the ideal standard options.

[Kinesitherapy in the treatment of muscle spasm]. / Kineziterapija u tretmanu misicnog spazma.

Muscular spasm is type of the increased muscle tone which is common in the upper motor neuron lesion and it can be developed due to disease (stroke, MS, tumors, infection, intoxication) and trauma. This research included 30 patients with muscular spasm after upper motor neuron lesion. All of the patients were treated by passive exercises and stretching of agonists and antagonists. All patients were males, with age between 25 and 45 years (average 26.9 years). Applying t-test, in testing significant differences in changing muscular spasm, in relationship to the length of the kinesitherapy treatment, there were no significant differences between 1st and 15th day of treatment. Significant difference in spasm grades was after 30th day of treatment compare to 1st and 15th day. This research showed that decreasing muscle spasm we could be expected by applying the kinesitherapy procedures for a longer time.

Influence of standardized mobilization on the posteroanterior stiffness of the lumbar spine in asymptomatic subjects.

BACKGROUND AND PURPOSE: Spinal mobilization is commonly used to relieve pain and assist recovery of mobility in individuals with low back pain. Fundamental to this concept is the belief that spinal mobilization will influence the mechanical properties of the symptomatic motion segment. The objective of the present study was to examine the segmental effects of a standardized mobilization procedure on the posteroanterior (PA) stiffness of the lumbar spine. METHOD: Audio and visual feedback was used to train a physiotherapist to perform PA mobilization at a consistent load and frequency. After training, twenty-four subjects without low back pain were recruited for the intervention phase of the study. The spinal posteroanterior mobilization (SPAM) apparatus was used to measure the PA stiffness of the lumbar spine at three measurement sites (L1, L3 and L5). The trained physiotherapist then applied the standardized PA mobilization technique via the L3 spinous process for two minutes. Following mobilization, PA stiffness was measured three times at the three locations. RESULTS: The physiotherapist was able to apply a standardized mobilization with a mean force of 146 N (standard deviation (SD) 8 N) at a frequency of 1.5 Hz. The first trial on each assessment demonstrated a pre-condition effect. Two minutes' PA mobilization resulted in no significant change in the PA stiffness of the lumbar spine at the level to which the mobilization was applied, or at the L1 and L5 segments. The 95% confidence intervals (CI) of the difference in PA stiffness before and after testing included zero at each measurement site. CONCLUSIONS: Clinicians should pre-condition the spine when assessing PA stiffness both before and after interventions. A standardized mobilization of 150 N at 1.5 Hz for two minutes had no segmental effect on spinal PA stiffness. Subsequent studies need to consider other mechanisms that may contribute to the changes that occur after PA spinal mobilization.

Acupuncture and rehabilitation (II) study in cases of snapping finger.

We found that "juci" appearing in "Wangdinlijingsumen" is very effective in the treatment of snapping fingers: It was revealed that the finger became able to move immediately after the acupuncture had been carried out on the healthy side at the symmetrical part to the lesion. The snapping fingers were improved by the flection-extension exercise and the massage carried out while the effect of acupuncture continued because the joint could move normally during this period. Since this result accords with the principle that the exercises with the extending motility allow an augmentation in effects of rehabilitation (Reha), authors think this therapy is extremely valuable. In this paper, some cases of difficult snapping finger treated with this therapy were reported.

Acupuncture and rehabilitation (I) effect of acupuncture on normal side to snapping finger.

The snapping finger condition has increased recently. And this condition is difficult to recover in most cases. The snapping finger condition was improved quite remarkably by the rehabilitation (Reha) of the leison performed immediately after acupuncture in the symmetrical part of the leison on the normal side and Chu-chih (LI-11), Shou-son-li (LI-10), Wai-kuan (TH-5), Ho-ku (LI-4) and Yang-chih (TH-4) on the normal side. But the favorable effect could not be obtained when Reha had not been performed on the leison. The effects were slight either in the combination therapy of Reha of the leison with the acupuncture of the leison and Chu-chih (LI-11), Shou-san-li (LI-10), Wai-kuan (TH-5), Ho-ku (LI-4) and Yang-chih (TH-4) on the abnormal side or in the simple treatment with Reha or with the acupuncture on the abnormal side. The acupuncture in the normal side resulted in a more remarkable result after Reha (Reha-effect) because Reha of the leison could easily contend with it. It is a valuable means of therapy as the snapping finger condition is presently on the increase.