Relationship between clinical assessments of function and measurements from an upper-limb robotic rehabilitation device in cervical spinal cord injury

Upper limb robotic rehabilitation devices can collect quantitative data about the user's movements. Identifying relationships between robotic sensor data and manual clinical assessment scores would enable more precise tracking of the time course of recovery after injury and reduce the need for time-consuming manual assessments by skilled personnel. This study used measurements from robotic rehabilitation sessions to predict clinical scores in a traumatic cervical spinal cord injury (SCI) population. A retrospective analysis was conducted on data collected from subjects using the Armeo Spring (Hocoma, AG) in three rehabilitation centers. Fourteen predictive variables were explored, relating to range-of-motion, movement smoothness, and grip ability. Regression models using up to four predictors were developed to describe the following clinical scores: the GRASSP (consisting of four sub-scores), the ARAT, and the SCIM. The resulting adjusted R(2) value was highest for the GRASSP "Quantitative Prehension" component (0.78), and lowest for the GRASSP "Sensibility" component (0.54). In contrast to comparable studies in stroke survivors, movement smoothness was least beneficial for predicting clinical scores in SCI. Prediction of upper-limb clinical scores in SCI is feasible using measurements from a robotic rehabilitation device, without the need for dedicated assessment procedures.     

Postural arm control following cervical spinal cord injury

This study used estimates of dynamic endpoint stiffness to quantify postural arm stability following cervical spinal cord injury (SCI) and to investigate how this stability was affected by functional neuromuscular stimulation (FNS). Measurements were made in the horizontal plane passing through the glenohumeral joint on three SCI-impaired arms, which ranged in functional level from a weak C5 to a strong C6. Endpoint stiffness, which characterizes the relationship between externally imposed hand displacements and the resultant forces, was estimated during the application of planar, stochastic perturbations to each arm. These estimates were used in conjunction with voluntary endpoint force measurements to quantify stability and strength during voluntary contractions and during voluntary contractions in the presence of triceps FNS. The primary findings were: (1) the differences in the force generating capabilities of these arms were due primarily to differences in shoulder strength; (2) measurements of strength alone could not be used to predict arm stability; and (3) triceps FNS improved postural arm stability for all tested conditions. These results suggest strategies for improved control of FNS systems designed to restore arm function following cervical SCI and underscore the importance of examining the effects of FNS on both strength and stability     

Functional electrical stimulation of abdominal muscles to augment tidal volume in spinal cord injury.

Functional electrical stimulation (FES) of abdominal muscles as a method of enhancing ventilation was explored in six neurologically intact subjects and five subjects with spinal cord injury (SCI) who had levels of injury between C4 and C7. Pulmonary ventilation was augmented in both groups predominantly due to an increase in tidal volume. The average increase in tidal volume during FES for the neurologically intact group was 350 ml, while in the SCI group it was 220 ml. The FES caused active volume decreases in both the lower thorax and upper abdomen, which together appear to be the mechanism behind the increases seen in tidal volume. Therefore, the proposed method might be useful in future clinical practice. The results indicate that FES of abdominal muscles should be more thoroughly explored as a potential technique of ventilatory support in SCI. The results also point to the necessity for further studies of maintaining the condition of the chest wall in the pulmonary rehabilitation of individuals with tetraplegia.     

Design and control of RUPERT: a device for robotic upper extremity repetitive therapy.

The structural design, control system, and integrated biofeedback for a wearable exoskeletal robot for upper extremity stroke rehabilitation are presented. Assisted with clinical evaluation, designers, engineers, and scientists have built a device for robotic assisted upper extremity repetitive therapy (RUPERT). Intense, repetitive physical rehabilitation has been shown to be beneficial overcoming upper extremity deficits, but the therapy is labor intensive and expensive and difficult to evaluate quantitatively and objectively. The RUPERT is developed to provide a low cost, safe and easy-to-use, robotic-device to assist the patient and therapist to achieve more systematic therapy at home or in the clinic. The RUPERT has four actuated degrees-of-freedom driven by compliant and safe pneumatic muscles (PMs) on the shoulder, elbow, and wrist. They are programmed to actuate the device to extend the arm and move the arm in 3-D space. It is very important to note that gravity is not compensated and the daily tasks are practiced in a natural setting. Because the device is wearable and lightweight to increase portability, it can be worn standing or sitting providing therapy tasks that better mimic activities of daily living. The sensors feed back position and force information for quantitative evaluation of task performance. The device can also provide real-time, objective assessment of functional improvement. We have tested the device on stroke survivors performing two critical activities of daily living (ADL): reaching out and self feeding. The future improvement of the device involves increased degrees-of-freedom and interactive control to adapt to a user's physical conditions.     

Assessment of the myelin water fraction in rodent spinal cord using T2-prepared ultrashort echo time MRI

Objective

Multi-component T2 relaxation allows for assessing the myelin water fraction in nervous tissue, providing a surrogate marker for demyelination. The assessment of the number and distribution of different T2 components for devising exact models of tissue relaxation has been limited by T2 sampling with conventional MR methods.

Materials and methods

A T2-prepared UTE sequence was used to assess multicomponent T2 relaxation at 9.4 T of fixed mouse and rat spinal cord samples and of mouse spinal cord in vivo. For in vivo scans, a cryogenically cooled probe allowed for 78-µm resolution in 1-mm slices. Voxel-wise non-negative least square analysis was used to assess the number of myelin water-associated T2 components.

Results

More than one myelin water-associated T2 component was detected in only 12 % of analyzed voxels in rat spinal cords and 6 % in mouse spinal cords, both in vivo and in vitro. However, myelin water-associated T2 values of individual voxels varied between 0.1 and 20 ms. While in fixed samples almost no components below 1 ms were identified, in vivo, these contributed 14 % of the T2 spectrum. No significant differences in MWF were observed in mouse spinal cord in vivo versus ex vivo measurements.

Conclusion

Voxel-wise analysis methods using relaxation models with one myelin water-associated T2 component are appropriate for assessing myelin content of nervous tissue.

     

Somatotopy of the motor cortex after long-term spinal cord injuryor amputation

Certain brain-computer interface (BCI) methods use intrinsic signals from the motor cortex to control neuroprosthetic devices. The organization of the motor pathways in those populations likely to use neuroprosthetic devices, therefore, needs to be determined; there is evidence that following disease or injury the representation of the body in the motor cortex may change. In this study, functional MRI measures of somatotopy following spinal cord injury (SCI) showed evidence of changes in limb representations in the motor cortex. Subjects with chronic SCI had unusual cortical patterns of activity when attempting to move limbs below their injury; amputees showed a more normal somatotopy. The functional reorganization may affect optimal implanted electrode placements for invasive BCI methods for these different populations     

Locomotion techniques for robotic colonoscopy.

Colonoscopy has become a routine procedure in many hospitals all over the world for colon cancer diagnosis. This review article discusses the work done by researchers in the quest to automate the colonoscopy procedure. In vitro and in vivo experimentation have been carried out to prove the possibilities of a robot crawling along a patient's colon, treating polyps as they are encountered. Locomotion is an essential part of robotic colonoscopy. The robot must be able to propel itself from the anus right up to the cecum without damaging the colon walls. The challenge is to design a robust locomotion technique that is able to advance through the stretchable, slippery, and mobile colon, which is always in its collapsed stage, in three-dimensional orientation. The authors believe that in the future, conventional colonoscopy will be revolutionized, giving way to robotics to assist doctors in colonoscope manipulation and performing therapeutic procedures and leaving doctors to concentrate on the diagnostic aspect of the procedure, which would encourage mass screening as more patients can be evaluated per session.     

Performance of epimysial stimulating electrodes in the lower extremities of individuals with spinal cord injury

This study describes the performance of surgically-implanted epimysial stimulating electrodes in the muscles of the lower extremities for use in functional neuromuscular stimulation (FNS) systems for standing after spinal cord injury. A total of 86 epimysial electrodes were implanted in 13 volunteers with low tetraplegia or paraplegia receiving the Case Western Reserve University/Veteran Affairs (CWRU/VA)-implanted standing/transfer neuroprosthesis. The neuroprosthesis consisted of bilateral epimysial electrodes in the knee and hip extensors (vastus lateralis, gluteus maximus, and adductor magnus or semimembranosus) and intramuscular electrodes at the T12/L1 or L1/L2 spinal roots for trunk extension. Recruitment properties, stimulated knee and hip extension moments, standing performance, and mechanical integrity over time were measured for a period up to four years post-implantation. Stimulated thresholds were stable and recruitment was sufficient to generate joint moments adequate for standing, with up to 97% body weight supported by the legs. Four mechanical failures were observed, all in the posterior muscles of the thigh, leaving 95% of all electrodes operational at all followup intervals. Probability of 24-month survival is estimated to be 93% plateauing to a steady state of 90% at four years. These results indicate that epimysial designs are appropriate for long-term clinical use in the large muscles of the lower extremities with implanted motor system neuroprostheses.     

脊髓损伤患者心率变异性的局部尺度指数特征

心率变异性（heart rate variability,HRV）是目前评估脊髓损伤（spinal cord injury, SCI）患者残余自主神经功能的主要依据。分析HRV的一般方法是计算心电信号R R序列的时域、频域或非线性指标,其中去趋势波动分析（detrended fluctuation analysis, DFA）是最常用的非线性方法之一,对于R R序列,通常由DFA可得两个尺度指数α1（尺度<11）和α2（尺度>11）。本研究关注局部尺度指数α(t)（t为时间尺度）揭示谱分析和尺度指数不能表征的HRV动态特性,采集12例SCI患者和15名健康者在坐姿（10 min）和俯卧姿（10 min）时的心电信号,计算R R序列的α(t)。由于α(t)在小尺度时容易被高估,本文采用一种新的校正方法计算α(t)并用仿真信号验证其有效性。将此方法应用于采集的数据,结果显示,健康者在坐姿和俯卧姿时R R序列的α(t)在4 s相似文献   

A robotic vehicle for disabled children

One of the most frequent effects of physical disability is reduced or impaired mobility. There are a number of technical aids for all the cases of physical impairment but none of the systems described in the literature address the particular problems of children affected by neuromotor disorders accompanied by mental retardation. The following addresses the development of the PALMA [(plataforma de apoyo ludico a la movilidad alternative) (assistive platform for alternative mobility)] system as a tool to assist the mobility of children affected by cerebral palsy. PALMA is specifically adapted to a personalized and early cognitive development of children affected by severe neuromotor problems. The rehabilitation process based on PALMA has an impact on the interaction between children and environment, on their motor dexterity, and on decision-making ability.     

Phase-dependent effects of spinal cord stimulation on locomotor activity.

This paper examines how electrical stimulation of the spinal cord can modulate the output of the central pattern generator (CPG) for locomotion. Application of discrete current pulses to a single spinal segment was shown to affect multiple parameters of an ongoing locomotor pattern in an in vitro spinal cord. For any given stimulus, the effects on frequency, duration, and symmetry of locomotor output were strongly dependent on the phase at which stimulation was applied within the CPG cycle. Additionally, most stimuli had an immediate impact and evinced no effects on subsequent cycles. The most dramatic changes were seen when stimulation was applied during motor bursting: stimuli applied to the ipsilateral spinal hemicord increased the burst length, while stimuli applied to the contralateral spinal hemicord decreased the burst length. Smaller changes were observed when stimulating during delays between motor bursts. Thus, phasic stimulation was shown to influence the behavior of the CPG and spinal locomotion circuits on a cycle-by-cycle basis. This work represents the first step toward our ultimate goal of developing a neuroprosthetic device to restore locomotion after a severe spinal cord injury.     

Technology for mobility and quality of life in spinal cord injury [Analyzing a Series of Options Available]

The purpose of this article is to provide a review of mobility devices available for the rehabilitation of individuals with (spinal cord injury) SCI. The technologies that improve mobility and potentially enhance community participation that will be discussed include those devices that are used to improve ambulation, wheeled mobility, and functional electrical stimulation (FES) systems. This review should provide a guide to biomedical engineers to understand the tools developed, the design characteristics, and the functionality of such technologies that strive to improve functional mobility of individuals with SCI. This review is not intended to suggest the optimal device(s) geared for a given individual with SCI. Conversely, since it is important to match the person with the technology, the purpose of this review is to offer a series of mobility options that may be available to a person with SCI.     

Development of a robotic device for facilitating learning by children who have severe disabilities

This paper presents technical aspects of a robot manipulator developed to facilitate learning by young children who are generally unable to grasp objects or speak. The severity of these physical disabilities also limits assessment of their cognitive and language skills and abilities. The CRS robot manipulator was adapted for use by children who have disabilities. Our emphasis is on the technical control aspects of the development of an interface and communication environment between the child and the robot arm. The system is designed so that each child has user control and control procedures that are individually adapted. Control interfaces include large push buttons, keyboards, laser pointer, and head-controlled switches. Preliminary results have shown that young children who have severe disabilities can use the robotic arm system to complete functional play-related tasks. Developed software allows the child to accomplish a series of multistep tasks by activating one or more single switches. Through a single switch press the child can replay a series of preprogrammed movements that have a development sequence. Children using this system engaged in three-step sequential activities and were highly responsive to the robotic tasks. This was in marked contrast to other interventions using toys and computer games.     

A graphics simulator for a robotic arm

A graphics robot simulator designed for an IBM PC/XT/AT or PS/2 personal computer is presented. The simulator is a terminate-and-stay resident (TSR) program that runs in the background and intercepts commands that would normally go to the robot controller through the COM1 serial communication device. With the use of the simulator, students can develop and test robot control programs offline without a physical robot present, using the language of their choice. The status of the simulated robot is available through a 3-D graphics display and a one-line text window, each of which can be activated from the keyboard or from within a user program. Data files are used to specify the robot to be simulated and the environment or workcell within which it is to operate. Currently supported robots include the Rhino XR-3 educational robot and the Adept One and Inteledex 660 industrial robots. The workcell features an overhead camera and objects that can be sensed by the camera and manipulated by the robot.<>     

Muscle recruitment through electrical stimulation of the lumbo-sacral spinal cord.

The goal of this study was to determine the feasibility of producing graded muscle contraction in individual muscles or muscle groups by electrically stimulating motor neurons in the lumbo-sacral spinal cord. Recruitment curves were obtained for quadriceps, tibialis anterior and triceps surae/plantaris by stimulating their activation pools in the ventral horn of the feline spinal cord. Mean twitch times-to-peak for quadriceps, tibialis anterior and triceps surae/plantaris were 33.0, 41.0, and 36.0 ms, respectively. Twitch duration as a function of stimulus strength demonstrated a mixed motor unit recruitment order, distinctively different from the inverse recruitment order exhibited by conventional methods of electrical stimulation of peripheral nerve. The recruitment curve slopes (expressed as a percentage of maximum force per nanocurrent of delivered charge) were shallow: 7.9 for quadriceps, 2.6 for tibialis anterior and 8.5 for triceps surae/plantaris. These results show that graded control of force in individual muscles or muscle groups can be obtained through spinal cord stimulation, and suggest that spinal cord stimulation could be used for functional neuromuscular stimulation applications.     

Arrays for chronic functional microstimulation of the lumbosacral spinal cord

Our objective is to develop neural prostheses based on an array of microelectrodes implanted into the sacral spinal cord, that will allow persons with spinal cord injuries to regain control of their bladder and bowels. For our chronic cat model, we have developed two microelectrode arrays, one type containing nine discrete activated iridium microelectrodes and the second utilizing silicon substrate probes with multiple electrode sites on each probe. Both types can elicit an increase in the pressure within the urinary bladder of more than 40-mm Hg and/or relaxation of the urethral sphincter. A stimulus of 100 microA and 400 micros/ph at 20 Hz (charge-balanced pulses) was required to induce a large increase in bladder pressure or relaxation of the urethral sphincter. We found that 24 h of continuous stimulation with these parameters induced tissue injury (disrupted neuropil, infiltration of inflammatory cells, and loss of neurons close to the tip sites). However, a neural prosthesis that is intended to restore bladder control after spinal cord injury would not operate continuously. Thus, when this stimulus was applied for 24 h, at a 10% duty cycle (1 min of stimulation, then 9 min without stimulation) only minimal histologic changes were observed.     

Modulation effects of epidural spinal cord stimulation on muscle activities during walking.

Epidural spinal cord stimulation (ESCS) combined with partial weight bearing therapy (PWBT) has been reported to facilitate recovery of functional walking for individuals after chronic incomplete spinal cord injury (ISCI). Muscle activities were analyzed in this report to examine the modulation effect of ESCS on muscle recruitment during gait training. Two ISCI individuals participated in the study and both are classified as ASIA C with low motor scores in the lower limbs. Stimulating electrodes were placed at the epidural space over T10-L2 spinal segments, along the midline in participant 1 (S1), and off-midline in participant 2 (S2). Surface electromyograms (EMGs) from leg muscles under both ESCS ON and OFF conditions recorded during treadmill gait were analyzed in time-frequency domains. ESCS application produced acute modulations in muscle activities in both participants, but the observed pattern, magnitude, and spectral content of the EMGs differed. In S1, ESCS induced a significant shift in the temporal pattern of muscle activity toward normal comparing with that when ESCS was OFF, though without eliciting noticeable change in frequency distribution between ESCS ON and OFF conditions. When ESCS was applied in S2, a modulation of EMG magnitude was observed and, consequently, improved joint kinematics during walking. In this case, a stimulation entrainment appeared in time-frequency analysis. The results suggest that ESCS activates neural structures in the dorsal aspect of the spinal cord and facilitates gait-related muscle recruitment. The exact effects of ESCS depend on the electrode placement and possibly injury history and residual functions, but in general ESCS produces a positive effect on improved walking speed, endurance, and reduced sense of effort in both ISCI subjects.