Fiber optic micro sensor for the measurement of tendon forces.

A fiber optic sensor developed for the measurement of tendon forces was designed, numerically modeled, fabricated, and experimentally evaluated. The sensor incorporated fiber Bragg gratings and micro-fabricated stainless steel housings. A fiber Bragg grating is an optical device that is spectrally sensitive to axial strain. Stainless steel housings were designed to convert radial forces applied to the housing into axial forces that could be sensed by the fiber Bragg grating. The metal housings were fabricated by several methods including laser micromachining, swaging, and hydroforming. Designs are presented that allow for simultaneous temperature and force measurements as well as for simultaneous resolution of multi-axis forces.The sensor was experimentally evaluated by hydrostatic loading and in vitro testing. A commercial hydraulic burst tester was used to provide uniform pressures on the sensor in order to establish the linearity, repeatability, and accuracy characteristics of the sensor. The in vitro experiments were performed in excised tendon and in a dynamic gait simulator to simulate biological conditions. In both experimental conditions, the sensor was found to be a sensitive and reliable method for acquiring minimally invasive measurements of soft tissue forces. Our results suggest that this sensor will prove useful in a variety of biomechanical measurements.

Multicenter randomized clinical trial evaluating the effectiveness of the Lokomat in subacute stroke.

OBJECTIVE: To compare the efficacy of robotic-assisted gait training with the Lokomat to conventional gait training in individuals with subacute stroke. METHODS: A total of 63 participants<6 months poststroke with an initial walking speed between 0.1 to 0.6 m/s completed the multicenter, randomized clinical trial. All participants received twenty-four 1-hour sessions of either Lokomat or conventional gait training. Outcome measures were evaluated prior to training, after 12 and 24 sessions, and at a 3-month follow-up exam. Self-selected overground walking speed and distance walked in 6 minutes were the primary outcome measures, whereas secondary outcome measures included balance, mobility and function, cadence and symmetry, level of disability, and quality of life measures. RESULTS: Participants who received conventional gait training experienced significantly greater gains in walking speed (P=.002) and distance (P=.03) than those trained on the Lokomat. These differences were maintained at the 3-month follow-up evaluation. Secondary measures were not different between the 2 groups, although a 2-fold greater improvement in cadence was observed in the conventional versus Lokomat group. CONCLUSIONS: For subacute stroke participants with moderate to severe gait impairments, the diversity of conventional gait training interventions appears to be more effective than robotic-assisted gait training for facilitating returns in walking ability.

Reliable assessment of lower limb motor representations with fMRI: use of a novel MR compatible device for real-time monitoring of ankle, knee and hip torques.

This study describes the use of a novel magnetic resonance imaging (MRI) compatible system capable of measuring isometric ankle, knee and hip joint torques in real-time during functional MRI (fMRI) testing in healthy volunteers. The motor representations of three isometric torques--ankle dorsiflexion, ankle plantarflexion and knee extension--were studied at two time points. The reliability of motor performance and fMRI-derived measures of brain activity across sessions was examined. Reproducible motor performance was observed for each of the tasks; torques of the requested amplitude, assisted by visual feedback, were generated at the relevant joint with good accuracy, both within and across the two sessions. Significant blood oxygen level dependent (BOLD) signal increases were observed in the left primary sensorimotor cortex (SM1) in the paracentral lobule and in secondary motor areas for all tasks. Within these areas there was substantial overlap of the motor representations though differential activation was observed in SM1, with greater activation of inferior paracentral lobule during knee extension than for either ankle task. Also, BOLD signal decreases were observed bilaterally within SM1 in the hand knob region for all tasks. No major session-related effects were identified at the group level. High intraclass correlation coefficients were observed for t-values of voxels in cortical motor areas for each contraction type for individuals, suggesting that fMRI-derived activity across time points was reliable. These findings support the use of this apparatus in serial studies of lower limb function.

Biomechanics of overground vs. treadmill walking in healthy individuals.

The goal of this study was to compare treadmill walking with overground walking in healthy subjects with no known gait disorders. Nineteen subjects were tested, where each subject walked on a split-belt instrumented treadmill as well as over a smooth, flat surface. Comparisons between walking conditions were made for temporal gait parameters such as step length and cadence, leg kinematics, joint moments and powers, and muscle activity. Overall, very few differences were found in temporal gait parameters or leg kinematics between treadmill and overground walking. Conversely, sagittal plane joint moments were found to be quite different, where during treadmill walking trials, subjects demonstrated less dorsiflexor moments, less knee extensor moments, and greater hip extensor moments. Joint powers in the sagittal plane were found to be similar at the ankle but quite different at the knee and hip joints. Differences in muscle activity were observed between the two walking modalities, particularly in the tibialis anterior throughout stance, and in the hamstrings, vastus medialis and adductor longus during swing. While differences were observed in muscle activation patterns, joint moments and joint powers between the two walking modalities, the overall patterns in these behaviors were quite similar. From a therapeutic perspective, this suggests that training individuals with neurological injuries on a treadmill appears to be justified.

Abnormal joint torque patterns exhibited by chronic stroke subjects while walking with a prescribed physiological gait pattern.

BACKGROUND: It is well documented that individuals with chronic stroke often exhibit considerable gait impairments that significantly impact their quality of life. While stroke subjects often walk asymmetrically, we sought to investigate whether prescribing near normal physiological gait patterns with the use of the Lokomat robotic gait-orthosis could help ameliorate asymmetries in gait, specifically, promote similar ankle, knee, and hip joint torques in both lower extremities. We hypothesized that hemiparetic stroke subjects would demonstrate significant differences in total joint torques in both the frontal and sagittal planes compared to non-disabled subjects despite walking under normal gait kinematic trajectories. METHODS: A motion analysis system was used to track the kinematic patterns of the pelvis and legs of 10 chronic hemiparetic stroke subjects and 5 age matched controls as they walked in the Lokomat. The subject's legs were attached to the Lokomat using instrumented shank and thigh cuffs while instrumented footlifters were applied to the impaired foot of stroke subjects to aid with foot clearance during swing. With minimal body-weight support, subjects walked at 2.5 km/hr on an instrumented treadmill capable of measuring ground reaction forces. Through a custom inverse dynamics model, the ankle, knee, and hip joint torques were calculated in both the frontal and sagittal planes. A single factor ANOVA was used to investigate differences in joint torques between control, unimpaired, and impaired legs at various points in the gait cycle. RESULTS: While the kinematic patterns of the stroke subjects were quite similar to those of the control subjects, the kinetic patterns were very different. During stance phase, the unimpaired limb of stroke subjects produced greater hip extension and knee flexion torques than the control group. At pre-swing, stroke subjects inappropriately extended their impaired knee, while during swing they tended to abduct their impaired leg, both being typical abnormal torque synergy patterns common to stroke gait. CONCLUSION: Despite the Lokomat guiding stroke subjects through physiologically symmetric kinematic gait patterns, abnormal asymmetric joint torque patterns are still generated. These differences from the control group are characteristic of the hip hike and circumduction strategy employed by stroke subjects.

Strength and coordination in the paretic leg of individuals following acute stroke.

The goal of this study was to determine whether acute stroke survivors demonstrate abnormal synergy patterns in their affected lower extremity. During maximum isometric contractions with subjects in a standing position, joint torques generated simultaneously at the knee and hip were measured, along with associated muscle activation patterns in eight lower limb muscles. Ten acute stroke survivors and nine age-match controls participated in the study. For all joints tested, stroke subjects demonstrated significantly less maximum isometric torque than age-matched control subjects. However, the synergistic torques generated in directions different than the direction that was being maximized were not significantly different between the two groups. According to electromyography (EMG) data, it was found that stroke subjects activated antagonistic muscle groups significantly higher than the control group subjects, suggesting that deficits in joint torque may be at least partially attributable to co-contraction of antagonistic muscles. Our findings suggest that a primary contributor to lower limb motor impairment in acute hemiparetic stroke is poor volitional torque generating capacity, which is at least partially attributable to co-contraction of antagonistic muscles. Furthermore, while we did not observe abnormal torque synergy patterns commonly found in the upper limbs, muscle activation patterns differed between groups for many of the directions tested indicating changes in the motor control strategies of acute stroke survivors.

Greater reliance on impedance control in the nondominant arm compared with the dominant arm when adapting to a novel dynamic environment.

This study investigated differences in adaptation to a novel dynamic environment between the dominant and nondominant arms in 16 naive, right-handed, neurologically intact subjects. Subjects held onto the handle of a robotic manipulandum and executed reaching movements within a horizontal plane following a pseudo-random sequence of targets. Curl field perturbations were imposed by the robot motors, and we compared the rate and quality of adaptation between dominant and nondominant arms. During the early phase of the adaptation time course, the rate of motor adaptation between both arms was similar, but the mean peak and figural error of the nondominant arm were significantly smaller than those of the dominant arm. Also, the nondominant limb's aftereffects were significantly smaller than in the dominant arm. Thus, the controller of the nondominant limb appears to have relied on impedance control to a greater degree than the dominant limb when adapting to a novel dynamic environment. The results of this study imply that there are differences in dynamic adaptation between an individual's two arms.

MR compatible force sensing system for real-time monitoring of wrist moments during fMRI testing.

Functional magnetic resonance imaging (fMRI) of brain function is used in neurorehabilitation to gain insight into the mechanisms of neural recovery following neurological injuries such as stroke. The behavioral paradigms involving the use of force motor tasks utilized in the scanner often lack the ability to control details of motor performance. They are often limited by subjectiveness, lack of repeatability, and complexity that may exclude evaluation of patients with poor function. In this paper we describe a novel MR compatible wrist device that is capable of measuring isometric forces generated at the hand and joint moments along wrist flexion-extension and wrist ulnar-radial deviation axes. Joint moments measured by the system can be visually displayed to the individual and used during target matching block or event related paradigms. Through a small set of pilot testing both inside and outside the MR environment, we have found that the force tracking tasks and performance in the scanner are reproducible, and that high quality force and moment recordings can be made during fMRI studies without compromising the fMRI images. Furthermore, the device recordings are extremely sensitive making it possible for individuals with poor hand and wrist function to be tested.

Quantification of functional weakness and abnormal synergy patterns in the lower limb of individuals with chronic stroke.

BACKGROUND: The presence of abnormal muscle activation patterns is a well documented factor limiting the motor rehabilitation of patients following stroke. These abnormal muscle activation patterns, or synergies, have previously been quantified in the upper limbs. Presented here are the lower limb joint torque patterns measured in a standing position of sixteen chronic hemiparetic stroke subjects and sixteen age matched controls used to examine differences in strength and coordination between the two groups. METHODS: With the trunk stabilized, stroke subjects stood on their unaffected leg while their affected foot was attached to a 6-degree of freedom load cell (JR3, Woodland CA) which recorded forces and torques. The subjects were asked to generate a maximum torque about a given joint (hip abduction/adduction; hip, knee, and ankle flexion/extension) and provided feedback of the torque they generated for that primary joint axis. In parallel, EMG data from eight muscle groups were recorded, and secondary torques generated about the adjacent joints were calculated. Differences in mean primary torque, secondary torque, and EMG data were compared using a single factor ANOVA. RESULTS: The stroke group was significantly weaker in six of the eight directions tested. Analysis of the secondary torques showed that the control and stroke subjects used similar strategies to generate maximum torques during seven of the eight joint movements tested. The only time a different strategy was used was during maximal hip abduction exertions where stroke subjects tended to flex instead of extend their hip, which was consistent with the classically defined "flexion synergy." The EMG data of the stroke group was different than the control group in that there was a strong presence of co-contraction of antagonistic muscle groups, especially during ankle flexion and ankle and knee extension. CONCLUSION: The results of this study indicate that in a standing position stroke subjects are significantly weaker in their affected leg when compared to age-matched controls, yet showed little evidence of the classic lower-limb abnormal synergy patterns previously reported. The findings here suggest that the primary contributor to isometric lower limb motor deficits in chronic stroke subjects is weakness.

Quantification of the dynamic properties of EMG patterns during gait.

A technique for analyzing and comparing the dynamic properties of electromyographic (EMG) patterns collected during gait is presented. A gait metric is computed, consisting of both magnitude (amplitude) and phase (timing) components. For the magnitude component, the processed EMG pattern is compared to a normative EMG pattern obtained under similar walking conditions, where the metric is incremented if the muscle is firing during expected active regions or is silent during expected inactive regions. The magnitude metric is penalized when the EMG is silent during phases of expected activity or when the EMG is active in regions of expected inactivity. The phase component of the metric computes the percentage of the gait cycle when the muscle is firing appropriately, that is, active in expected active regions and silent in expected inactive regions. The magnitude and phase components of the metric are normalized and combined to yield the EMG pattern that demonstrates the closest characteristics compared to normative gait data collected under similar walking conditions. Using experimental data, the proposed gait metric was tested and accurately reflects the observed changes in the EMG patterns. Clinical uses for the gait metric are discussed in relation to gait therapies, such as determining optimal gait training conditions in individuals following stroke and spinal cord injury.

Alterations in muscle activation patterns during robotic-assisted walking.

OBJECTIVE: The goal of this study was to compare the muscle activation patterns in various major leg muscles during treadmill ambulation with those exhibited during robotic-assisted walking. BACKGROUND: Robotic devices are now being integrated into neurorehabilitation programs with promising results. The influence of these devices on altering naturally occurring muscle activation patterns utilized during walking have not been quantified. METHODS: Muscle activity measured during 60 s of walking was broken up into individual stride cycles, averaged, and normalized. The stride cycle was then broken up into seven distinct phases and the integrated muscle activity during each phase was compared between treadmill and robotic-assisted walking using a multi-factor ANOVA. RESULTS: Significant differences in the spatial and temporal muscle activation patterns were observed across various portions of the gait cycle between treadmill and robotic-assisted walking. Activity in the quadriceps and hamstrings was significantly higher during the swing phase of Lokomat walking than treadmill walking, while activity in the ankle flexor and extensor muscles was reduced throughout most of the gait cycle in the Lokomat. CONCLUSIONS: Walking within a robotic orthosis that limits the degrees of freedom of leg and pelvis movement leads to changes in naturally occurring muscle activation patterns. RELEVANCE: An understanding of how robotic-assisted walking alters muscle activation patterns is necessary clinically in order to establish baseline patterns against which subject's with neurological disorders can be compared. Furthermore, this information will guide further developments in robotic devices targeting gait training.

Advances in the understanding and treatment of stroke impairment using robotic devices.

The presence of robotic devices in rehabilitation centers is now becoming commonplace across the world, challenging heath care professionals to rethink treatment strategies for motor impairment in hemiparetic stroke patients. In this article, we will discuss some of the motivations for using these devices, review clinical outcomes following robotic-assisted training in both the upper and lower extremities, and detail how these devices can provide quantitative evaluations of function. We will also address the clinical issues that need to be considered when using robotic devices to treat stroke patients, and finally a vision of where this field is heading will be discussed.

Evidence for force-feedback inhibition in chronic stroke.

The presence of force-feedback inhibition was explored during reflex responses in five subjects with known incidence of stroke. Using constant velocity stretches, it was previously found that after movement onset, active reflex force progressively increases with increasing joint angle, at a rate proportional to a fractional exponent of the speed of stretch. However, after the reflex force magnitude exceeds a particular level, it begins rolling off until maintaining a steady-state value. The magnitudes of these force plateaus are correlated with the speed of stretch, such that higher movement speeds result in higher steady-state forces. Based upon these previous studies, we hypothesized that force plateau behavior could be explained by a force-feedback inhibitory pathway. To help facilitate an understanding of this stretch reflex force roll off, a simple model representing the elbow reflex pathways was developed. This model contained two separate feedback pathways, one representing the monosynaptic stretch reflex originating from muscle spindle excitation, and another representing force-feedback inhibition arising from force sensitive receptors. It was found that force-feedback inhibition altered the stretch reflex response, resulting in a force response that followed a sigmoidal shape similar to that observed experimentally. Furthermore, simulated reflex responses were highly dependent on force-feedback gain, where predicted reflex force began plateauing at decreasing levels with increases in this force-feedback gain. The parameters from the model fits indicate that the force threshold for force-sensitive receptors is relatively high, suggesting that the inhibition may arise from muscle free nerve endings rather than Golgi tendon organs. The experimental results coupled with the simulations of elbow reflex responses suggest the possibility that after stroke, the effectiveness of force-feedback inhibition may increase to a level that has functional significance. Practical implications of these findings are discussed in relation to muscle weakness commonly associated with stroke.

Role of Robotics in Neurorehabilitation.

Over the past decade, rehabilitation hospitals have begun to incorporate robotics technologies into the daily treatment schedule of many patients. These interventions hold greater promise than simply replicating traditional therapy, because they allow therapists an unprecedented ability to specify and monitor movement features such as speed, direction, amplitude, and joint coordination patterns and to introduce controlled perturbations into therapy. We argue that to fully realize the potential of robotic devices in neurorehabilitation, it is necessary to better understand the specific aspects of movement that should be facilitated in rehabilitation. In this article, we first discuss neurorecovery in the context of motor control and learning principles that can provide guidelines to rehabilitation professionals for enhancing recovery of motor function. We then discuss how robotic devices can be used to support such activities.

ZeroG: overground gait and balance training system.

A new overground body-weight support system called ZeroG has been developed that allows patients with severe gait impairments to practice gait and balance activities in a safe, controlled manner. The unloading system is capable of providing up to 300 lb of static support and 150 lb of dynamic (or constant force) support using a custom-series elastic actuator. The unloading system is mounted to a driven trolley, which rides along an overhead rail. We evaluated the performance of ZeroG's unloading system, as well as the trolley tracking system, using benchtop and human-subject testing. Average root-mean-square and peak errors in unloading were 2.2 and 7.2 percent, respectively, over the range of forces tested while trolley tracking errors were less than 3 degrees, indicating the system was able to maintain its position above the subject. We believe training with ZeroG will allow patients to practice activities that are critical to achieving functional independence at home and in the community.

Kinematic trajectories while walking within the Lokomat robotic gait-orthosis.

Background One of the most popular robot assisted rehabilitation devices used is the Lokomat. Unfortunately, not much is known about the behaviors exhibited by subjects in this device. The goal of this study was to evaluate the kinematic patterns of individuals walking inside the Lokomat compared to those demonstrated on a treadmill. Methods Six healthy subjects walked on a treadmill and inside the Lokomat while the motions of the subject and Lokomat were tracked. Joint angles and linear motion were determined for Lokomat and treadmill walking. We also evaluated the variability of the patterns, and the repeatability of measuring techniques. Findings The overall kinematics in the Lokomat are similar to those on a treadmill, however there was significantly more hip and ankle extension, and greater hip and ankle range of motion in the Lokomat (P<0.05). Additionally, the linear movement of joints was reduced in the Lokomat. Subjects tested on repeated sessions presented consistent kinematics, demonstrating the ability to consistently setup and test subjects. Interpretation The reduced degrees of freedom in the Lokomat are believed to be the reason for the specific kinematic differences. We found that despite being firmly attached to the device there was still subject movement relative to the Lokomat. This led to variability in the patterns, where subjects altered their gait pattern from step to step. These results are clinically important as a variable step pattern has been shown to be a more effective gait training strategy than one which forces the same kinematic pattern in successive steps.

Automating activity-based interventions: the role of robotics.

We have seen a continued growth of robotic devices being tested in neurorehabilitation settings over the last decade, with the primary goal to improve upper- and lower-motor function in individuals following stroke, spinal cord injury, and other neurological conditions. Interestingly, few studies have investigated the use of these devices in improving the overall health and well-being of these individuals despite the capability of robotic devices to deliver intensive time-unlimited therapy. In this article, we discuss the use of robotic devices in delivering intense, activity-based therapies that may have significant exercise benefits. We also present preliminary data from studies that investigated the metabolic and cardiac responses during and after 6 months of lower-limb robotic training. Finally, we speculate on the future of robotics and how these devices will affect rehabilitation interventions.

Altered trunk position sense and its relation to balance functions in people post-stroke.

OBJECTIVE: To determine whether trunk position sense is impaired in people with poststroke hemiparesis. BACKGROUND: Good trunk stability is essential for balance and extremity use during daily functional activities and higher level tasks. Dynamic stability of the trunk requires adequate flexibility, muscle strength, neural control, and proprioception. While deficits of trunk muscle strength have been identified in people post-stroke, it is not clear whether they have adequate postural control and proprioception to ensure a stable foundation of balance to enable skilled extremity use. Trunk position sense is an essential element of trunk postural control. Even a small impairment in trunk position sense may contribute to trunk instability. However, a specific impairment of trunk position sense has not been reported in people post-stroke. SUBJECTS: Twenty subjects with chronic stroke and 21 nonneurologically impaired subjects participated in the study. MAIN OUTCOME MEASURES: Trunk repositioning error during sitting forward flexion movements was assessed using an electromagnetic movement analysis system, Flock of Birds. Subjects post-stroke were also evaluated with clinical measures of balance (Berg Balance Scale), postural control (Postural Assessment Scale for Stroke), and extremity motor impairment severity (Fugl-Meyer Assessment-Motor Score). RESULTS: There were significant differences in absolute trunk repositioning error between stroke and control groups in both the sagittal (P = 0.0001) and transverse (P = 0.0012) planes. Mean sagittal plane error: post-stroke: 6.9 +/- 3.1 degrees, control: 3.2 +/- 1.8 degrees; mean transverse plane error: post-stroke 2.1 +/- 1.3 degrees, control: 1.0 +/- 0.6 degrees. There was a significant negative correlation between sagittal plane absolute repositioning error and the Berg Balance Scale score (r = -0.49, P = 0.03), transverse plane absolute repositioning error and Berg Balance Scale score (r = -0.48, P = 0.03), and transverse plane repositioning error and the Postural Assessment Scale for Stroke score (r = -0.52, P = 0.02) CONCLUSIONS: Subjects with poststroke hemiparesis exhibit greater trunk repositioning error than age-matched controls. Trunk position sense retraining, emphasizing sagittal and transverse movements, should be further investigated as a potential poststroke intervention strategy to improve trunk balance and control.

Quantification of reflex activity in stroke survivors during an imposed multi-joint leg extension movement.

The goal of this study was to compare short- and long-latency reflex responses in eight major lower-extremity muscle groups following an imposed multi-joint leg movement between a group of 14 chronic (>1 year) stroke survivors and 10 healthy age-matched controls, and to investigate the influence of joint velocities and muscle excitation levels on these reflex responses in each respective group. Subjects were seated with their foot anchored to a sliding footplate that could extend their leg. Prior to the leg being moved, subjects were instructed to pre-activate hip and knee flexors and extensors. Feedback of joint torque was used to help subjects activate muscles over a range of excitation levels. Following pre-activation, the subject's leg was passively extended so the knee or hip joint rotated at one of three different speeds (30, 60, and 120 degrees /s). In general, it was found that the magnitude of stroke survivors' reflex response was greater compared to controls' in certain biarticular muscles, notably the gastrocnemius and medial hamstring, and the uniarticular adductor longus, and that the long-latency reflex component (between 40 and 150 ms post-movement) accounted for most of the observed differences. Furthermore, while reflex response amplitudes increased in both groups with increasing movement speed, the rate of increase was significantly larger in stroke subjects than in controls. Clinically, these findings may help explain why stroke survivors walk slowly since it is under these conditions that reflex responses better emulate those of their able-bodied counterparts.