Robotic Assisted Upper Limb Training Post Stroke: A Randomized Control Trial Using Combinatory Approach Toward Reducing Workforce Demands.

Post stroke upper limb rehabilitation is a challenging problem with poor outcomes as 40% of survivors have functionally useless upper limbs. Robot-aided therapy (RAT) is a potential method to alleviate the effort of intensive, task-specific, repetitive upper limb exercises for both patients and therapists. The present study aims to investigate how a time matched combinatory training scheme that incorporates conventional and RAT, using H-Man, compares with conventional training toward reducing workforce demands. In a randomized control trial (NCT02188628, www.clinicaltrials.gov), 44 subacute to chronic stroke survivors with first-ever clinical stroke and predominant arm motor function deficits were recruited and randomized into two groups of 22 subjects: Robotic Therapy (RT) and Conventional Therapy (CT). Both groups received 18 sessions of 90 min; three sessions per week over 6 weeks. In each session, participants of the CT group received 90 min of 1:1 therapist-supervised conventional therapy while participants of the RT group underwent combinatory training which consisted of 60 min of minimally-supervised H-Man therapy followed by 30 min of conventional therapy. The clinical outcomes [Fugl-Meyer (FMA), Action Research Arm Test and, Grip Strength] and the quantitative measures (smoothness, time efficiency, and task error, derived from two robotic assessment tasks) were independently evaluated prior to therapy intervention (week 0), at mid-training (week 3), at the end of training (week 6), and post therapy (week 12 and 24). Significant differences within group were observed at the end of training for all clinical scales compared with baseline [mean and standard deviation of FMA score changes between baseline and week 6; RT: Δ4.41 (3.46) and CT: Δ3.0 (4.0); p < 0.01]. FMA gains were retained 18 weeks post-training [week 24; RT: Δ5.38 (4.67) and week 24 CT: Δ4.50 (5.35); p < 0.01]. The RT group clinical scores improved similarly when compared to CT group with no significant inter-group at all time points although the conventional therapy time was reduced to one third in RT group. There were no training-related adverse side effects. In conclusion, time matched combinatory training incorporating H-Man RAT produced similar outcomes compared to conventional therapy alone. Hence, this study supports a combinatory approach to improve motor function in post-stroke arm paresis. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02188628.

Feature matching based ECG generative network for arrhythmia event augmentation.

Recent developments in the field of deep learning has shown a rise in its use for clinical applications such as electrocardiogram (ECG) analysis and cardiac arrhythmia classification. Such systems are essential in the early detection and management of cardiovascular diseases. However, due to privacy concerns and also the lack of resources, there is a gap in the data available to run such powerful and data-intensive models. To address the lack of annotated, high-quality ECG data for heart disease research, ECG data generation from a small set of ECG to obtain huge annotated data is seen as an effective solution. Generative Feature Matching Network (GFMN) was shown to resolve few drawbacks of commonly used generative adversarial networks (GAN). Based on this, we developed a deep learning model to generate ECGs that resembles real ECG by feature matching with the existing data.Clinical relevance- This work addresses the lack of a large quantity of good quality, publicly available annotated ECG data required to build deep learning models for cardiac signal processing research. We can use the model presented in this paper to generate ECG signals of a target rhythm pattern and also subject-specific ECG morphology that could improve their cardiac health monitoring while maintaining privacy.

Estimating Human Wrist Stiffness during a Tooling Task.

In this work, we propose a practical approach to estimate human joint stiffness during tooling tasks for the purpose of programming a robot by demonstration. More specifically, we estimate the stiffness along the wrist radial-ulnar deviation while a human operator performs flexion-extension movements during a polishing task. The joint stiffness information allows to transfer skills from expert human operators to industrial robots. A typical hand-held, abrasive tool used by humans during finishing tasks was instrumented at the handle (through which both robots and humans are attached to the tool) to assess the 3D force/torque interactions between operator and tool during finishing task, as well as the 3D kinematics of the tool itself. Building upon stochastic methods for human arm impedance estimation, the novelty of our approach is that we rely on the natural variability taking place during the multi-passes task itself to estimate (neuro-)mechanical impedance during motion. Our apparatus (hand-held, finishing tool instrumented with motion capture and multi-axis force/torque sensors) and algorithms (for filtering and impedance estimation) were first tested on an impedance-controlled industrial robot carrying out the finishing task of interest, where the impedance could be pre-programmed. We were able to accurately estimate impedance in this case. The same apparatus and algorithms were then applied to the same task performed by a human operators. The stiffness values of the human operator, at different force level, correlated positively with the muscular activity, measured during the same task.

A preliminary study on the relationship between proprioceptive deficits and motor functions in chronic stroke patients.

Although motor and sensory impairments of the upper limb after stroke have been widely studied, the relationship between sensory deficits and motor functions has been less thoroughly explored. In this ongoing study, we investigated the relationship between proprioceptive impairments and motor functions with 20 chronic stroke survivors. Their proprioceptive abilities were assessed with a passive joint position matching test using H-Man and their motor functions were assessed with ARAT (Action Research Arm Test) and FMA (Fugl Meyer Upper Extremity Assessment) clinical scores. The assessments were conducted before, during and after the therapy. Results indicated a significant difference between the proprioceptive outcomes of healthy and stroke participants (at baseline) in both matching accuracy (absolute error, p=0.02) and precision (variability of the signed error, p=0.03). Significant correlations were found between the proprioceptive assessment outcomes (assessed before the beginning of the motor rehabilitation) of stroke participants with impaired proprioception and their ARAT clinical scores assessed at the first follow-up (week 12) (rho =- 0.74 and p=0.047 for the absolute error; rho =-0.78 and p= 0.03 for the variability of the signed error). The results from this preliminary study indicated a significant relationship between proprioceptive impairments and motor function performances in proprioceptively impaired chronic stroke participants.

Work with me, not for me: Relationship between robotic assistance and performance in subacute and chronic stroke patients.

INTRODUCTION: Studies in robotic therapy which applied the performance enhancement approach report improvements in motor performance during training, though these improvements do not always transfer to motor learning. OBJECTIVES: We postulate that there exists an assistance threshold for which performance saturates. Above this threshold, the robot's input outweighs the patient's input and likely learning is not fostered. This study investigated the relationship between assistance and performance changes in stroke patients to find the assistance threshold for performance saturation. METHODS: Twelve subacute and chronic stroke patients engaged in five sessions (over two weeks, each 60 min) in which they performed a reaching task with the rehabilitation robot H-Man in presence of varying levels of haptic assistance (50 N/m to 290 N/m, randomized order). In two additional sessions, a therapist manually tuned the assistance to promote maximal motor learning. RESULTS: Higher levels of assistance resulted in smoother and faster performance that saturated at assistance levels with K ≥ 110 N/m. Also, the therapist selected assistance levels of K = 175 N/m or below. CONCLUSION: The findings of the study indicate that low levels of assistance (K ≤ 175 N/m) can sufficiently induce a significant change in performance.

Proprioceptive assessment in clinical settings: Evaluation of joint position sense in upper limb post-stroke using a robotic manipulator.

Proprioception is a critical component for motor functions and directly affects motor learning after neurological injuries. Conventional methods for its assessment are generally ordinal in nature and hence lack sensitivity. Robotic devices designed to promote sensorimotor learning can potentially provide quantitative precise, accurate, and reliable assessments of sensory impairments. In this paper, we investigate the clinical applicability and validity of using a planar 2 degrees of freedom robot to quantitatively assess proprioceptive deficits in post-stroke participants. Nine stroke survivors and nine healthy subjects participated in the study. Participants' hand was passively moved to the target position guided by the H-Man robot (Criterion movement) and were asked to indicate during a second passive movement towards the same target (Matching movement) when they felt that they matched the target position. The assessment was carried out on a planar surface for movements in the forward and oblique directions in the contralateral and ipsilateral sides of the tested arm. The matching performance was evaluated in terms of error magnitude (absolute and signed) and its variability. Stroke patients showed higher variability in the estimation of the target position compared to the healthy participants. Further, an effect of target was found, with lower absolute errors in the contralateral side. Pairwise comparison between individual stroke participant and control participants showed significant proprioceptive deficits in two patients. The proposed assessment of passive joint position sense was inherently simple and all participants, regardless of motor impairment level, could complete it in less than 10 minutes. Therefore, the method can potentially be carried out to detect changes in proprioceptive deficits in clinical settings.

Identification of shoulder muscle synergies in healthy subjects during an isometric task.

Muscle Synergy method has been proposed in the literature to provide a lower dimensional representation of motor commands from the central nervous system (CNS). Studies on post-stroke patients highlighted how features such as the minimum number of motor synergies accounting for most of the data variance correlate with impairments and motor function. In this study, we target healthy subjects to establish normative data in isometric tasks involving shoulder muscles. Five subjects performed an isometric, two-dimensional force-matching task in twelve planar directions with two force levels across shoulder joint. Muscle synergies and their respective activation curves were computed from nine upper limb muscles via a nonnegative matrix factorization (NNMF) algorithm. Four synergies, on an average, were able to explain 95% of the variance in EMG datasets across all subjects. The cosine similarity of the muscle synergies among the subjects on an average is found to be 0.79±0.20. Two subjects revealed the presence of subject-specific synergies which will require further investigation before examining impaired subjects.

Quantitative assessment of motor functions post-stroke: Responsiveness of upper-extremity robotic measures and its task dependence.

Technology aided measures offer a sensitive, accurate and time-efflcient approach for the assessment of sensorimotor function after neurological impairment compared to standard clinical assessments. This preliminary study investigated the relationship between task definition and its effect on robotic measures using a planar, two degree of freedom, robotic-manipulator (H-Man). Four chronic stroke participants (49.5±11.95 years, 2 Female, FMA: 37.5±13.96) and eight healthy control participants (26.25± 4.70 years, 2 Female) participated in the study. Motor functions were evaluated using line tracing and circle tracing tasks with dominant and nondominant hand of healthy and affected vs. non affected hand of stroke participants. The results show significant dependence of quantitative measures on investigated tasks.

Self-Paced Reaching after Stroke: A Quantitative Assessment of Longitudinal and Directional Sensitivity Using the H-Man Planar Robot for Upper Limb Neurorehabilitation.

Technology aided measures offer a sensitive, accurate and time-efficient approach for the assessment of sensorimotor function after neurological insult compared to standard clinical assessments. This study investigated the sensitivity of robotic measures to capture differences in planar reaching movements as a function of neurological status (stroke, healthy), direction (front, ipsilateral, contralateral), movement segment (outbound, inbound), and time (baseline, post-training, 2-week follow-up) using a planar, two-degrees of freedom, robotic-manipulator (H-Man). Twelve chronic stroke (age: 55 ± 10.0 years, 5 female, 7 male, time since stroke: 11.2 ± 6.0 months) and nine aged-matched healthy participants (age: 53 ± 4.3 years, 5 female, 4 male) participated in this study. Both healthy and stroke participants performed planar reaching movements in contralateral, ipsilateral and front directions with the H-Man, and the robotic measures, spectral arc length (SAL), normalized time to peak velocities (TpeakN ), and root-mean square error (RMSE) were evaluated. Healthy participants went through a one-off session of assessment to investigate the baseline. Stroke participants completed a 2-week intensive robotic training plus standard arm therapy (8 × 90 min sessions). Motor function for stroke participants was evaluated prior to training (baseline, week-0), immediately following training (post-training, week-2), and 2-weeks after training (follow-up, week-4) using robotic assessment and the clinical measures Fugl-Meyer Assessment (FMA), Activity-Research-Arm Test (ARAT), and grip-strength. Robotic assessments were able to capture differences due to neurological status, movement direction, and movement segment. Movements performed by stroke participants were less-smooth, featured longer TpeakN , and larger RMSE values, compared to healthy controls. Significant movement direction differences were observed, with improved reaching performance for the front, compared to ipsilateral and contralateral movement directions. There were group differences depending on movement segment. Outbound reaching movements were smoother and featured longer TpeakN values than inbound movements for control participants, whereas SAL, TpeakN , and RMSE values were similar regardless of movement segment for stroke patients. Significant change in performance was observed between initial and post-assessments using H-Man in stroke participants, compared to conventional scales which showed no significant difference. Results of the study indicate the potential of H-Man as a sensitive tool for tracking changes in performance compared to ordinal scales (i.e., FM, ARAT).

Upper extremity proprioception in healthy aging and stroke populations, and the effects of therapist- and robot-based rehabilitation therapies on proprioceptive function.

The world's population is aging, with the number of people ages 65 or older expected to surpass 1.5 billion people, or 16% of the global total. As people age, there are notable declines in proprioception due to changes in the central and peripheral nervous systems. Moreover, the risk of stroke increases with age, with approximately two-thirds of stroke-related hospitalizations occurring in people over the age of 65. In this literature review, we first summarize behavioral studies investigating proprioceptive deficits in normally aging older adults and stroke patients, and discuss the differences in proprioceptive function between these populations. We then provide a state of the art review the literature regarding therapist- and robot-based rehabilitation of the upper extremity proprioceptive dysfunction in stroke populations and discuss avenues of future research.