Soft robotics and functional electrical stimulation advances for restoring hand function in people with SCI: a narrative review, clinical guidelines and future directions.

BACKGROUND: Recovery of hand function is crucial for the independence of people with spinal cord injury (SCI). Wearable devices based on soft robotics (SR) or functional electrical stimulation (FES) have been employed to assist the recovery of hand function both during activities of daily living (ADLs) and during therapy. However, the implementation of these wearable devices has not been compiled in a review focusing on the functional outcomes they can activate/elicit/stimulate/potentiate. This narrative review aims at providing a guide both for engineers to help in the development of new technologies and for clinicians to serve as clinical guidelines based on the available technology in order to assist and/or recover hand function in people with SCI. METHODS: A literature search was performed in Scopus, Pubmed and IEEE Xplore for articles involving SR devices or FES systems designed for hand therapy or assistance, published since 2010. Only studies that reported functional outcomes from individuals with SCI were selected. The final collections of both groups (SR and FES) were analysed based on the technical aspects and reported functional outcomes. RESULTS: A total of 37 out of 1101 articles were selected, 12 regarding SR and 25 involving FES devices. Most studies were limited to research prototypes, designed either for assistance or therapy. From an engineering perspective, technological improvements for home-based use such as portability, donning/doffing and the time spent with calibration were identified. From the clinician point of view, the most suitable technical features (e.g., user intent detection) and assessment tools should be determined according to the particular patient condition. A wide range of functional assessment tests were adopted, moreover, most studies used non-standardized tests. CONCLUSION: SR and FES wearable devices are promising technologies to support hand function recovery in subjects with SCI. Technical improvements in aspects such as the user intent detection, portability or calibration as well as consistent assessment of functional outcomes were the main identified limitations. These limitations seem to be be preventing the translation into clinical practice of these technological devices created in the laboratory.

Handlebar Robotic System for Bimanual Motor Control and Learning Research.

Robotic devices can be used for motor control and learning research. In this work, we present the construction, modeling and experimental validation of a bimanual robotic device. We tested some hypotheses that may help to better understand the motor learning processes involved in the interlimb coordination function. The system emulates a bicycle handlebar with rotational motion, thus requiring bilateral upper limb control and a coordinated sequence of joint sub-movements. The robotic handlebar is compact and portable and can register in a fast rate both position and forces independently from arms, including prehension forces. An impedance control system was implemented in order to promote a safer environment for human interaction and the system is able to generate force fields, suitable for implementing motor learning paradigms. The novelty of the system is the decoupling of prehension and manipulation forces of each hand, thus paving the way for the investigation of hand dominance function in a bimanual task. Experiments were conducted with ten healthy subjects, kinematic and dynamic variables were measured during a rotational set of movements. Statistical analyses showed that movement velocity decreased with practice along with an increase in reaction time. This suggests an increase of the task planning time. Prehension force decreased with practice. However, an unexpected result was that the dominant hand did not lead the bimanual task, but helped to correct the movement, suggesting different roles for each hand during a cooperative bimanual task.

Effects of supraspinal feedback on human gait: rhythmic auditory distortion.

BACKGROUND: Different types of sound cues have been used to adapt the human gait rhythm. We investigated whether young healthy volunteers followed subliminal metronome rhythm changes during gait. METHODS: Twenty-two healthy adults walked at constant speed on a treadmill following a metronome sound cue (period 566 msec). The metronome rhythm was then either increased or decreased, without informing the subjects, at 1 msec increments or decrements to reach, respectively, a low (596 msec) or a high frequency (536 msec) plateaus. After 30 steps at one of these isochronous conditions, the rhythm returned to the original period with decrements or increments of 1 msec. Motion data were recorded with an optical measurement system to determine footfall. The relative phase between sound cue (stimulus) and foot contact (response) were compared. RESULTS: Gait was entrained to the rhythmic auditory stimulus and subjects subconsciously adapted the step time and length to maintain treadmill speed, while following the rhythm changes. In most cases there was a lead error: the foot contact occurred before the sound cue. The mean error or the absolute mean relative phase increased during the isochronous high (536 msec) or low frequencies (596 msec). CONCLUSION: These results showed that the gait period is strongly "entrained" with the first metronome rhythm while subjects still followed metronome changes with larger error. This suggests two processes: one slow-adapting, supraspinal oscillator with persistence that predicts the foot contact to occur ahead of the stimulus, and a second fast process linked to sensory inputs that adapts to the mismatch between peripheral sensory input (foot contact) and supraspinal sensory input (auditory rhythm).

Biped Gait Stability Classification Based on the Predicted Step Viability.

In this paper, we address the challenge of ensuring stability in bipedal walking robots and exoskeletons. We explore the feasibility of real-time implementation for the Predicted Step Viability algorithm (PSV), a complex multi-step optimization criterion for planning future steps in bipedal gait. To overcome the high computational cost of the PSV algorithm, we performed an analysis using 11 classification algorithms and a stacking strategy to predict if a step will be stable or not. We generated three datasets of increasing complexity through PSV simulations to evaluate the classification performance. Among the classifiers, k Nearest Neighbors, Support Vector Machine with Radial Basis Function Kernel, Decision Tree, and Random Forest exhibited superior performance. Multi-Layer Perceptron also consistently performed well, while linear-based algorithms showed lower performance. Importantly, the use of stacking did not significantly improve performance. Our results suggest that the feature vector applied with this approach is applicable across various robotic models and datasets, provided that training data is balanced and sufficient points are used. Notably, by leveraging classifiers, we achieved rapid computation of results in less than 1 ms, with minimal computational cost.

Design of Low-Cost Modular Bio-Inspired Electric-Pneumatic Actuator (EPA)-Driven Legged Robots.

Exploring the fundamental mechanisms of locomotion extends beyond mere simulation and modeling. It necessitates the utilization of physical test benches to validate hypotheses regarding real-world applications of locomotion. This study introduces cost-effective modular robotic platforms designed specifically for investigating the intricacies of locomotion and control strategies. Expanding upon our prior research in electric-pneumatic actuation (EPA), we present the mechanical and electrical designs of the latest developments in the EPA robot series. These include EPA Jumper, a human-sized segmented monoped robot, and its extension EPA Walker, a human-sized bipedal robot. Both replicate the human weight and inertia distributions, featuring co-actuation through electrical motors and pneumatic artificial muscles. These low-cost modular platforms, with considerations for degrees of freedom and redundant actuation, (1) provide opportunities to study different locomotor subfunctions-stance, swing, and balance; (2) help investigate the role of actuation schemes in tasks such as hopping and walking; and (3) allow testing hypotheses regarding biological locomotors in real-world physical test benches.

Asymmetric effects of different training-testing mismatch types on myoelectric regression via deep learning.

This paper investigates how predictions of a convolutional neural network (CNN) suited for myoelectric simultaneous and proportional control (SPC) are affected when training and testing conditions differ. We used a dataset composed of electromyogram (EMG) signals and joint angular accelerations measured from volunteers drawing a star. This task was repeated multiple times using different combinations of motion amplitude and frequency. CNNs were trained with data from a given combination and tested under different combinations. Predictions were compared between situations in which training and testing conditions matched versus when there was a training-testing mismatch. Changes in predictions were assessed through three metrics: normalized root mean squared error (NRMSE), correlation, and slope of the linear regression between targets and predictions. We found that predictive performance declined differently depending on whether the confounding factors (amplitude and frequency) increased or decreased between training and testing. Correlations dropped as the factors decreased, whereas slopes deteriorated when factors increased. NRMSEs worsened when factors increased or decreased, with more accentuated deterioration for increasing factors. We argue that worse correlations could be related to differences in EMG signal-to-ratio (SNR) between training and testing, which affected the noise robustness of the CNNs' learned internal features. Slope deterioration could be a result of the networks' inability to predict accelerations outside the range seen during training. These two mechanisms may also asymmetrically increase NRMSE. Finally, our findings open further possibilities to develop strategies to mitigate the negative impact of confounding factor variability on myoelectric SPC devices.

Towards Visual-Tactile Integration of Shoulder and Hand Using Immersive Virtual Reality.

Shoulder-controlled hand neuroprostheses are wearable devices designed to assist hand function in people with cervical spinal cord injury (SCI). They use preserved shoulder movements to control artificial actuators. Due to the concurrent afferent (i.e., shoulder proprioception) and visual (i.e., hand response) feedback, these wearables may affect the user's body somatosensory representation. To investigate this effect, we propose an experimental paradigm that uses immersive virtual reality (VR) environment to emulate the use of a shoulder-controlled hand neuroprostheses and an adapted version of a visual-tactile integration task (i.e., Crossmodal Congruency Task) as an assessment tool. Data from seven non-disabled participants validates the experimental setup, with preliminary statistical analysis revealing no significant difference across the means of VR and visual-tactile integration tasks. The results serve as a proof-of-concept for the proposed paradigm, paving the way for further research with improvements in the experimental design and a larger sample size.

Analysis of Motor Control and Learning in Human-Robot Interaction during Game Guided Movements.

Robotic devices can be used in upper limb rehabilitation in order to help the total or partial functional recovery. Robots can perform repetitive activities for a long period of time, which may be beneficial for rehabilitation processes. In this context, this study uses a bi-manual robotic device to investigate motor learning and control for the upper limbs among different game guided tasks, and inspect the user's grip force exerted in response to perturbations. The robotic device resembles a bicycle handlebar, instrumented with load cells to measure torques and grip forces. It is equipped with a DC motor to apply external torques to the guiding system. A game was developed containing in-game and physical perturbations to the natural movement of the handlebar. Tests were carried out with 16 healthy subjects that were instructed to move the handlebar guiding a character displayed on the screen with the objective of collecting tokens to get the higher score in the game. During the trials, corresponding data from the game and the load cells were collected and used to infer the learning process, the mean error in the trajectory and the variations in the force applied to the handles of the handlebar. Analyses showed that there was learning in the first repetitions, and the learning was retained further. The higher values of the grip force occurred when there was a physical perturbation to the handlebar's natural movement. The larger errors in the trajectories occurred immediately after the perturbations ended. In conclusion, there was a performance improvement, probably related to learning. The increase of the mean error at the transitions of the perturbations indicates the need for adaptation to the new conditions of the task.

Effect of Photobiomodulation With Different Wavelengths on Radiodermatitis Treatment.

Approximately 80% of patients submitted to radiotherapy develop radiodermatitis. Photobiomodulation based on light-emitted diode (LED) is one of the therapeutic strategies for treating inflammation. This study aimed to investigate the effect of the photobiomodulation with two wavelengths, in an acute radiodermatitis animal model. Methods: Twenty rats were submitted to one radiotherapy session. After 15 days, the rats that developed radiodermatitis were divided into control groups, LED-630 nm, LED-850 nm, and LED-630 + 850 nm. The treatment regimen was one session lasting 10 minutes on alternate days for 21 days. We analyzed macroscopy aspects (RTOG scale), vascular density, dermal appendages, VEGF-a, TNF-alpha, MMP-9, and MMP-9 genic expression level. Results: All LED groups revealed a two-point reduction on the radiodermatitis severity grade compared with the baseline classification. Dermal appendage and vascular analysis showed a higher counting in all LED groups compared to control. This study showed dermal appendages twice in the 630/850 nm group compared with the control group. The 630/850 nm group showed six times more arterioles than the control group. Regarding genic expression, this study showed a 10-fold decrease between LED-630 nm versus LED-630 + 850 nm (P = 0.02) interleukin-10 expression and a 12-fold decrease between control versus LED-630 nm (P = 0.006) and LED-850 nm (P = 0.002) in TNF-alpha. Conclusion: LED (630 nm, 850 nm, and 630 nm + 850 nm) showed benefit in the treatment of radiodermatitis, and the association of the 630 nm + 850 nm and 630 nm parameters demonstrated the best macroscopic and microscopic results.

Shoulder muscle activity and perceived comfort of industry workers using a commercial upper limb exoskeleton for simulated tasks.

We compared the effects of using a commercial exoskeleton on shoulder muscle activity, task completion time, perceived effort and comfort while performing four tasks in different shoulder positions. Fourteen automotive industry workers performed four simulated tasks with shoulder at A≈0°, B ≈ 45°, C ≈ 90° and D ≈ 115° flexion. The electromyographic activity of the Medial Deltoid (MD) and the Anterior Deltoid (AD) decreased when wearing the exoskeleton. The effect sizes (ES) were, for MD: ES = 0, ES = -0.2, ES = -0.6, ES = -0.3; and for AD: ES = 0.3, ES = -0.6, ES = -0.8, ES = -0.6; for tasks A, B, C and D, respectively. We also found increased Anterior Deltoid/Triceps Brachii co-contraction, a typical joint stabilization mechanism. Wearing the exoskeleton increased the completion time of task B and reduced the perceived effort of tasks A and C, improving overall comfort. These findings are useful to organize the logistics of the workstations that use upper limb exoskeletons to improve the effectiveness of this equipment.

Aging effects of haptic input on postural control under a dual-task paradigm.

Postural control relies on three principal sensory systems: vision, vestibular and proprioceptive; that are affected by aging. When performing a cognitive task concomitantly with a motor task, those sensory impairments lead to even greater deleterious effects on balance. We aimed to study the effects of a sensory aid (a light touch) on a dual task paradigm and sought to understand the different responses on balance due to aging. Fifty healthy and highly physical active women were divided in two groups: young (N = 25, 24.2 ± 4.0 years) and older adults (N = 25, 67.3 ± 4.2 years). In a random and balanced order, all participants performed five tasks: Stroop test while seated (Seated); Stroop test while standing quiet (ST); Standing quiet (BL); Standing quiet with a haptic input (LT); and Stroop test with a haptic input while standing quiet (SL). In the Stroop test, older women committed more errors (50 vs 11 errors, p < 0.001) and had higher reaction time (1.001 ± 0.191 vs 0.699 ± 0.081 s, p < 0.001). The haptic input (LT) reduced all body sway parameters, in both groups, regardless the condition. This means that postural control under a dual task paradigm (ST) deleterious effect can be mitigated by a haptic input.

Is Balance Control Affected by Sleep Deprivation? A Systematic Review of the Impact of Sleep on the Control of Balance.

Background: Sleep is a complex physiological function that should be addressed from different perspectives and consider the circadian rhythm. Sleep deprivation, either acute or chronic, negatively affects several functions, including motor control. Balance control is essential in several daily life activities and balance problems are related to falls. Research Question: This review focuses on how sleep conditions impact balance control. Methods: Systematic literature review according to PRISMA guidelines. Results: The literature provided strong evidence that acute sleep deprivation impairs postural control. Chronic sleep deprivation as well as low sleep quality had similar effects, although there is a lower number of works addressing this issue. Furthermore, time awake worsens postural controls and it can be used to detect sleepiness and fatigue. The sleep deprivation showed a stronger negative effect on postural control when removing the visual information (eyes closed) than when reducing proprioceptive feedback (soft surface). There is scarce literature about the effects of chronotype, circadian patterns and chronic sleep deprivation, a frequent problem, on balance control; however they consistently indicate that there is an relationship between them. Most of the studies only consider one-night (acute) sleep deprivation without monitoring prior sleep conditions and the circadian rhythm phase of the participants. However, a few studies indicated that these factors must be considered. Significance: These results suggest that the sleep conditions of a subject should be considered for several days prior to balance control tests. Therefore, we propose a revision of current postural measurement protocols to include sleep assessment, such as sleep quality questionnaires or actimetry, and to consider the circadian rhythm of the participants to plan the hour of the tests.

Gait kinematic analysis in patients with a mild form of central cord syndrome.

BACKGROUND: Central cord syndrome (CCS) is considered the most common incomplete spinal cord injury (SCI). Independent ambulation was achieved in 87-97% in young patients with CCS but no gait analysis studies have been reported before in such pathology. The aim of this study was to analyze the gait characteristics of subjects with CCS and to compare the findings with a healthy age, sex and anthropomorphically matched control group (CG), walking both at a self-selected speed and at the same speed. METHODS: Twelve CCS patients and a CG of twenty subjects were analyzed. Kinematic data were obtained using a three-dimensional motion analysis system with two scanner units. The CG were asked to walk at two different speeds, at a self-selected speed and at a slower one, similar to the mean gait speed previously registered in the CCS patient group. Temporal, spatial variables and kinematic variables (maximum and minimum lower limb joint angles throughout the gait cycle in each plane, along with the gait cycle instants of occurrence and the joint range of motion - ROM) were compared between the two groups walking at similar speeds. RESULTS: The kinematic parameters were compared when both groups walked at a similar speed, given that there was a significant difference in the self-selected speeds (p < 0.05). Hip abduction and knee flexion at initial contact, as well as minimal knee flexion at stance, were larger in the CCS group (p < 0.05). However, the range of knee and ankle motion in the sagittal plane was greater in the CG group (p < 0.05). The maximal ankle plantar-flexion values in stance phase and at toe off were larger in the CG (p < 0.05). CONCLUSIONS: The gait pattern of CCS patients showed a decrease of knee and ankle sagittal ROM during level walking and an increase in hip abduction to increase base of support. The findings of this study help to improve the understanding how CCS affects gait changes in the lower limbs.

Lower leg muscle force prediction in gait transition.

Walking and running, the two most basic and functional gait modes, have been often addressed through EMG, kinematics and biomechanical modelling, however, there is no consensus in the literature on which factors trigger the transition from walking to running. Ankle plantarflexors and dorsiflexor were found to play an important role in gait transition due to higher muscular activation to propel the body forward to run. We tested these muscles activation during walking and running at the same speeds, through a musculoskeletal model derived from subjects' kinematic and kinetic data. Compared to EMG data frequently reported in the literature, the results yielded similar activation patterns for all muscles analyzed. Besides, across speeds, dorsiflexor activation kept increasing in walking, especially after PTS (preferred transition speed), which may indicate its contribution to gait transition, as an effort to bring the foot forward to keep up with the unnatural condition of walking at high speeds.

Sleep deprivation affects gait control.

Different levels of sleep restriction affect human performance in multiple aspects. However, it is unclear how sleep deprivation affects gait control. We applied a paced gait paradigm that included subliminal rhythm changes to analyze the effects of different sleep restriction levels (acute, chronic and control) on performance. Acute sleep deprivation (one night) group exhibited impaired performance in the sensorimotor synchronization gait protocol, such as a decrease in the Period Error between the footfalls and the auditory stimulus as well as missing more frequently the auditory cues. The group with chronic sleep restriction also underperformed when compared to the control group with a tendency to a late footfall with respect to the RAC sound. Our results suggest that partial or total sleep deprivation leads to a decrease in the performance in the sensorimotor control of gait. The superior performance of the chronic sleep group when compared to the acute group suggests that there is a compensatory mechanism that helps to improve motor performance.

Design of a bioinspired cable driven actuator with clutched elastic elements for the ankle.

Bioinspiration can be used to improve the efficiency of these assistive biomechatronic devices. In this paper, a cable driven actuator for the human ankle was designed using a bioinspired approach. The torque reduction was achieved by means of force amplifying elements such as cables with pulley, and, to reduce the power requirements for the motor, the actuator mimics a muscle using a clutched parallel elastic element. The simulations to validate the model were performed using real gait data and the results prove the viability of the device to be used in anthropomorphic legs and exoskeletons. Although the losses due to friction were not considered, the simulations showed a reduction of 60% in the force peak and 40% in the power peak.

Predictive factors of response to decongestive therapy in patients with breast-cancer-related lymphedema.

BACKGROUND: Many studies have reported the benefits of Decongestive treatment in patients with breast-cancer-related lymphedema (BCRL) but few have study what are the predictive factors of response. METHODS: We performed a prospective, multicenter controlled cohort study of 171 patients with BCRL to identify independent predictive factors of response to decongestive treatment (CDT). Demographic data and clinical and lymphedema characteristics were collected prospectively. The end point was the "percentage reduction in excess volume (PREV)." Volumes were measured prior and at the end of CDT. Factors associated with response (PREV) were tested in univariate and multivariate analyses using linear regression techniques. RESULTS: Median age was 60.4 years (range 32-84); mean lymphedema chronicity 4 years [95% confidence interval (95% CI): 3.1-5.0]; mean baseline excess volume (EV) was 936 mL (95% CI: 846-1026), and mean percentage EV was 35.3% (95% CI: 32.0-38.7); compliance to bandages was good in 81.3% of patients. PREV was 71.7% (95% CI: 65.2-78.2). After univariate screening, 11 variables were found to be associated with PREV but only 4 variables were independent predictive factors of response to CDT in the multivariate analysis: Venous insufficiency, percentage of EV (the higher the EV, the lower the reduction with CDT); compliance to bandages (a good compliance improved PREV in 25%), and treatment in autumn (better results than during the rest of the year). CONCLUSIONS: This study shows that compliance to bandages during CDT is one of the most important predictors of response. Moreover, data support the idea that more severe lymphedemas have a worse response to treatment, and it should be recommended in early stages. The association between the season of treatment and response was also very strong, so weather conditions are an additional factor that must be taken into account in further studies.

EEG Analysis in Coincident Timing Task Towards Motor Rehabilitation.

The identification of specific components in EEG signals is often key when designing EEG-based brain-computer interfaces (BCIs), and a good understanding of the factors that elicit such components can be helpful when it comes to precise, energy-efficient and time-accurate actuation of exoskeletons. CNVs (Contingent Negative Variations), ERDs or ERSs (Event-Related Desynchronizations/Synchronizations) as well as ErrPs (Error-Related Potentials) are particularly important components can be identified during motor tasks and related to specific events in a Coincident Timing (CT) task. This work investigates offline EEG signals acquired during an upper limb CT task and analyzes the task protocol with the purpose of correlating the aforementioned EEG features to movement onset. CNVs and ERD/ERS were successfully identified after averaging multiple trials, and it was further concluded that complementary information about muscle activity (via EMG) as well as video tracking of arm movement play a critical role in the synchronization of EEG components with movement onset. The framework for EEG analysis presented in this paper allows for future development of a BCI on top of this CT task capable of assessing motor learning and actuating an exoskeleton to enable faster motor rehabilitation.

Kinect v2 based system for gait assessment of children with cerebral palsy in rehabilitation settings.

Cerebral palsy (CP) describes a group of disorders of movement, posture and balance caused by a non-progressive brain injury in the immature brain. It is the most prevalent cause of chronic motor disability in childhood, and although two thirds of CP children are able to walk, they show gait limitations. In this context, rehabilitation therapy can improve muscle balance and gait. Previous studies showed the importance of gait analysis as part of multidisciplinary tools for effective rehabilitation treatment. However, the high cost and the infrastructure required for the implementation of commercial gait analysis systems as well as the time-consuming preparation procedures, limit the access to this service. A low cost, non-restrictive, portable and of simple operation and installation system was developed based on Kinect v2 sensor. This study aims to validate it for capturing and analysing gait parameters in children with cerebral palsy. Several gait parameters from eleven CP patients with different levels of disability classified as a function of the Gross Motor Function Classification System (GMFCS) from II to III were recorded while they walked on a flat surface. The Kinect-based gait analysis system was compared with video-recording that yielded the same results. These results show the potential of Kinect to analyse gait in frail patient populations unobtrusively and with very low cost. More importantly, regarding to spatial parameters, the Kinect system was useful even for the worst case of GMFCS III that show a large gait variability with abnormal patterns.

Shoulder muscles electromyographic responses in automotive workers wearing a commercial exoskeleton.

Work-related musculoskeletal disorders (MSDs) are a major concern in industries and working environments. They cause not only suffering to the employee and decrease in performance, but also high economic losses to the companies and the society. Workers from assembly lines and machine operators are one of the most frequently affected working population. Moreover, one of the main types of MSDs in occupational environments are shoulder injuries. Exoskeletons have been applied and tested in rehabilitation and they are gaining ground in occupational environments as assistive devices to augment human force and minimize loads on muscles and joints. However, more evidence about the effects of several exoskeletons models in assisting different tasks is needed. We measured shoulder muscles activity (AD - anterior deltoid and MD - medial deltoid) of seven automotive workers using the SuitX® upper limb exoskeleton while performing different screwing tasks, at different shoulder levels while handling different tools. We found significant muscle activity reduction for 2 of the 4 proposed tasks, suggesting a task-specificity effectiveness. Therefore, it seems to be a viable option to reduce muscle effort in certain tasks.