Robotic Postural Training With Epidural Stimulation for the Recovery of Upright Postural Control in Individuals With Motor Complete Spinal Cord Injury: A Pilot Study.

Activity-based training and lumbosacral spinal cord epidural stimulation (scES) have the potential to restore standing and walking with self-balance assistance after motor complete spinal cord injury (SCI). However, improvements in upright postural control have not previously been addressed in this population. Here, we implemented a novel robotic postural training with scES, performed with free hands, to restore upright postural control in individuals with chronic, cervical (n = 5) or high-thoracic (n = 1) motor complete SCI, who had previously undergone stand training with scES using a walker or a standing frame for self-balance assistance. Robotic postural training re-enabled and/or largely improved the participants' ability to control steady standing, self-initiated trunk movements and upper limb reaching movements while standing with free hands, receiving only external assistance for pelvic control. These improvements were associated with neuromuscular activation pattern adaptations above and below the lesion. These findings suggest that the human spinal cord below the level of injury can generate meaningful postural responses when its excitability is modulated by scES, and can learn to improve these responses. Upright postural control improvements can enhance functional motor recovery promoted by scES after severe SCI.

Robotic upright stand trainer (RobUST) and postural control in individuals with spinal cord injury.

CONTEXT/OBJECTIVE: Assessed feasibility and potential effectiveness of using a novel robotic upright stand trainer (RobUST) to deliver postural perturbations or provide assistance-as-needed at the trunk while individuals with spinal cord injury (SCI) performed stable standing and self-initiated trunk movements. These tasks were assessed with research participants' hands on handlebars for self-balance assistance (hands on) and with hands off (free hands). DESIGN: Proof of concept study. PARTICIPANTS: Four individuals with motor complete (n = 3) or incomplete (n = 1) SCI who were not able to achieve independent standing and presented a neurological lesion level ranging from cervical 4 to thoracic 2. OUTCOME MEASURES: Ground reaction forces, trunk displacement, and electromyography activity of trunk and lower limb muscles. RESULTS: Research participants received continuous pelvic assistance via RobUST, and manual trainer assistance at the knees to maintain standing. Participants were able to attempt all tasks. Free hands trunk perturbations resulted in greater load bearing-related sensory information (73% ipsilateral vertical loading), trunk displacement (57%), and muscle activation compared to hands on. Similarly, free hands stable standing with RobUST assistance-as-needed resulted in 8.5% larger bodyweight bearing, 112% larger trunk movement velocity, and higher trunk muscles activation compared to standing with hands on. Self-initiated trunk movements controlled by hands on showed 116% greater trunk displacement, 10% greater vertical ground reaction force, and greater ankle muscle activation compared to free hands. CONCLUSION: RobUST established a safe and challenging standing environment for individuals with SCI and has the potential to improve training paradigms and assessments of standing postural control.

Redistributing Ground Reaction Forces During Squatting Using a Cable-Driven Robotic Device.

Squatting is a dynamic task that is often done for strengthening and improving balance. Most squat training systems partially support body weight. However, one of the benefits of a squat exercise is efficiently distributing the body weight among the feet while maintaining stability. Several studies have shown how squatting and redistributing body weight among the feet can improve balance. The goals of this study are: (i) to show a robotic device that is transparent for studying human behavior during the squatting task, (ii) to investigate how ground reaction forces can be altered among the feet by applying a pelvic force during squatting. Seven able bodied adults underwent three squat conditions, squatting eight times per test. The first two conditions are a baseline set of squats followed by the third condition where participants received a constant lateral force on their pelvis. We use a cable-driven Robotic Upright Stand Trainer, RobUST, to deliver the lateral force on a pelvic belt. The lateral force was 5% of participants' body weight. Results show that a lateral force on the pelvis can significantly redistribute participants' ground reaction forces by increasing the symmetry index from 11.2% to 35.7% and increasing the lateral center of pressure amplitude from.07 to 0.18. The results also show that the pelvic lateral force did not add variability to the natural squat motion between repetitions, as measured by the coefficient of variability. These results are promising for future squat training paradigms to redistribute ground reaction forces and encourage specific weight distribution patterns.

Postural Control Strategies in Standing With Handrail Support and Active Assistance From Robotic Upright Stand Trainer (RobUST).

In people with severe neuromotor deficits of trunk and lower extremities, regaining balance in standing is often performed in rehabilitation with manual assistance, rigid body supports or by the use of handrails. To investigate and further expand postural control training in standing, we developed a Robotic Upright Stand Trainer (RobUST). In this study, we used RobUST to deliver trunk perturbations while simultaneously providing postural assistive forces on the pelvis in 10 able-bodied adults. Posture control responses with 'pelvic support' was then compared to 'no support' and 'hand supported' standing, with and without assistance from RobUST. We characterize postural imbalance with kinematic displacements and center of pressure (COP) outcomes, such as amplitude and root mean square of the excursions of COP. Surface electromyography (sEMG) was also applied to investigate muscle control. We additionally investigated ground reaction and handrail forces during standing to analyze how postural strategies and muscle mechanisms with 'pelvic support' via RobUST would differ from standing with 'no support' and with the 'handrail support'. Our results show that during perturbations, pelvic assistive support decreased kinematic and COP excursions compared to standing with no support. The pelvic assistance from RobUST showed similar level of COP changes as the use of handrail support but without reducing muscle activity or ground reaction forces. As expected, the maximum level of postural stability was observed when participants used the handrail and received pelvic assistive forces. In conclusion, RobUST demonstrates potential as a training device since it enhances postural balance without significantly removing muscular control mechanisms that are of interest in re-training postural control strategies in standing.

Promoting Functional and Independent Sitting in Children With Cerebral Palsy Using the Robotic Trunk Support Trainer.

Seated postural abilities are critical to functional independence and participation in children with cerebral palsy, Gross Motor Functional Classification System (GMFCS) levels III-IV. In this proof-of-concept study, we investigated the feasibility of a motor learning-based seated postural training with a robotic Trunk-Support-Trainer (TruST) in a longitudinal single-subject-design (13y, GMFCS IV), and its potential effectiveness in a group of 3 children (6-14y, GMFCS III-IV). TruST is a motorized-cable driven belt placed on the child's trunk to exert active-assistive forces when the trunk moves beyond stability limits. TruST-intervention addresses postural-task progression by tailoring the assistive-force fields to the child's sitting balance to train trunk control during independent short-sitting posture. TruST-intervention consisted of 2 training blocks of six 2hour-sessions per block (3 sessions per week). Pelvic strapping was required in the 1st block to prevent falls. As primary outcomes, we used the modified functional reach test, gross motor function measure-item set (GMFM-IS), Box & Blocks, and postural kinematics. After TruST-intervention children did not require pelvic strapping to prevent a fall, improved trunk stability during reaching (baseline = 5.49cm, 1week post-training = 16.38cm, 3mos follow-up = 14.63cm, ) and increased their sitting workspace (baseline = 127.55cm2, 1week post-training, = 409.92cm2, 3mos follow-up = 270.03cm2, ). Three children also improved in the GMFM-IS. In summary, our novel robotic TruST-intervention is feasible and can effectively maximize functional independent sitting in children with CP GMFCS III-IV.

The robotic Trunk-Support-Trainer (TruST) to measure and increase postural workspace during sitting in people with spinal cord injury.

Study design: Cross-sectional study. Objectives: To measure and expand the sitting workspace of participants with spinal cord injury (SCI) with the Trunk-Support-Trainer (TruST). Setting: Columbia University. Methods: TruST is a motorized-cable belt placed around the torso. Participants performed maximal trunk excursions along eight directions, radiating in a star-shape, to define their seated postural limits and workspace area (cm2). TruST was configured to apply "assist-as-needed" forces when the trunk moved beyond these postural limits. Kinematics were collected to examine trunk control. The clinical features of the sample (n = 5) were documented by neurological injury, dynamometry, the American Spinal Injury Association Impairment Scale, and Spinal Cord Independence Measure-III. Results: Statistical significance was examined with paired t-tests. TruST successfully recreated the postural limits of participants and expanded their active sitting workspace (Mean: 123.3 ± SE: 42.8 cm2, p < 0.05). Furthermore, participants improved their trunk excursions to posterior (Mean: 5.1 ± SE: 0.8 cm, p < 0.01), right (Mean: 3.1 ± SE: 1.1 cm, p < 0.05), and left (Mean: 5.0 ± SE: 1.7 cm, p = 0.05) directions with TruST-force field. Conclusions: TruST can accurately define and expand the active seated workspace of people with SCI during volitional trunk movements. The capacity of TruST to deliver continuous force-feedback at the user's postural limits opens new frontiers to implement motor learning-based paradigms to retrain functional sitting in people with SCI.

Stand Trainer With Applied Forces at the Pelvis and Trunk: Response to Perturbations and Assist-As-Needed Support.

Functional rehabilitation of patients with spinal cord injury remains a current challenge. Training these patients to successfully stand is the first step towards restoring advanced skills such as walking. To address this need, we have developed a novel robotic stand trainer that can apply controlled forces on the trunk and the pelvis of a user, while controlling the knee angle. The stand trainer utilizes cables to apply assistive, resistive, or perturbation forces at the trunk, pelvis, and the knees, simultaneously. We have conducted a human study to validate the system. In this study, we applied multi-direction perturbation forces either at the pelvis or the trunk while assist-as-needed forces were applied to the other segment to keep balance. This study characterizes the human kinematics and measures of balance under the perturbations and assistive forces on the human body. Results shows that the level of force-field assistance (trunk or pelvis) directly affects the motion of the trunk, pelvis, and center of pressure. This provides a quantitative framework to restore balance in patients while providing assistance only when needed. This stand trainer can potentially free up therapists to attend to higher level rehabilitation goals and objectively assist patients to engage in interventions that challenge both their musculoskeletal and sensorimotor impairments.

Antibiotic treatment for ocular toxoplasmosis: a systematic review and meta-analysis: study protocol.

BACKGROUND: Ocular toxoplasmosis (OT) is the most common cause of posterior uveitis, leading to visual impairment in a high proportion of patients. Antibiotics and corticosteroids lower the risk of permanent visual impairment by reducing the size of the retinochoroidal scar, the risk of recurrence, and the severity and duration of acute symptoms. Although OT is a very common cause of infectious posterior uveitis, its treatment remains controversial. Through our systematic review and meta-analysis, we aim to provide the best possible evidence-based information on the safety and effectiveness of the different antibiotic regimes for OT. METHODS: This systematic review protocol has been developed based on PRISMA-P guidelines for reporting systematic reviews evaluating health care interventions. We will include all published and unpublished randomized controlled trials (RCTs) comparing different antibiotics used for the treatment of OT. We will consider changes in visual acuity, number of recurrences, improvement or worsening of ocular inflammation, size of lesion, and adverse effects as our outcomes. Screening, data extraction, and quality assessment will be undertaken by two reviewers with disagreements resolved through discussion. Studies that compared antibiotics with placebo will be excluded. The reviews will be assessed for quality and relevance. We will assess the risk of bias in five domains according to Cochrane group's tool. The type of data will dictate measures of treatment effect. We will use a random-effects model to calculate our meta-analysis, as eligible studies represent clinically varied populations of participants. DISCUSSION: The strength of our study will lie in the exhaustive and systematic nature of the literature search, as well as in its methods for assessing quality and analyzing RCT data. Considering the controversial efficacy of the treatment for OT, our study will contribute to improving the existing evidence on the effectiveness of different antibiotics. Future studies may be conducted to increase physicians' awareness of antibiotic therapies, improving the health of patients with OT. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018085468.