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. In stroke rehabilitation, bilateral upper limb training is gaining ground. As a result, a growing number of mechanical and robotic bilateral upper limb training devices have been proposed.
Objective
. To provide an overview and qualitative evaluation of the clinical applicability of bilateral upper limb training devices.
Methods
. Potentially rel...
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Citations
... Especially for the underactuated exoskeleton [23], it also introduces interjoint coordination issues between assisted and unassisted joints if patients do not know the robot's motion timing and joint angles. Although some promising human-inthe-loop controls, like master-slave control for mirroring arm movements [24], were suggested in end-effector-type robots, limited research has evaluated the control on an underactuated exoskeleton with human subjects in bimanual ADL tasks. ...
This paper introduces a lightweight bilateral underactuated upper limb exoskeleton (UULE) designed to assist chronic stroke patients with distal joint (Elbow-Wrist) impairments during bimanual activities of daily living (ADL). The UULE aims to assist patients in shoulder flexion/extension, elbow flexion/extension, forearm pronation/supination, and wrist flexion/extension. Notable features include (i) a cable-driven mechanism maintaining a lightweight structure (1.783 kg); (ii) passive joints conforming to less-impaired proximal joints, reducing restrictions on their movements; (iii) a compact design with passive ball joints enabling bilateral configuration for scapula protraction/retraction; and (iv) implementation of the master-slave joint assistance training strategy in an underactuated exoskeleton, achieving symmetric robot joint motion in bimanual ADL. Experiments with ten healthy subjects demonstrated the UULE’s effectiveness by revealing significant reductions in muscle activity in a symmetric bimanual ADL task. These advancements address critical limitations of current exoskeletons, showcasing the UULE as a promising contribution to lightweight and effective robotic rehabilitation strategies for chronic stroke patients.
... [6][7][8] Advancements in technology have expanded the capabilities of researchers studying movement to include methodologies such as augmented/virtual reality (AR/VR), videogames, and wearable or mobile devices. Previously published review articles concluded that most studies of hand function development use clinical or qualitative assessments 9,10 and that optoelectrical devices and 3D motion capture systems were the most often used technology for laboratory-based upper limb assessments. 11 Apart from the subjective nature of clinical assessments, a limitation of the laboratory remains the expensive and stationary nature of the equipment and often time-consuming analysis techniques. ...
Upper limb (UL) motor dysfunctions impact residual movement in hands/shoulders and limit participation in play, sports, and leisure activities. Clinical and laboratory assessments of UL movement can be time-intensive, subjective, and/or require specialized equipment and may not optimally capture a child's motor abilities. The restrictions to in-person research experienced during the COVID-19 pandemic have inspired investigators to design inclusive at-home studies with child participants and their families. Relying on the ubiquity of mobile devices, mobile health (mHealth) applications offer solutions for various clinical and research problems. This scoping review article aimed to aggregate and synthesize existing research that used health technology and mHealth approaches to evaluate and assess the hand function and UL movement in children with UL motor impairment. A scoping review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) model was conducted in March 2023 yielding 25 articles (0.32% of 7891 studies). Assessment characteristics included game or task-based tests (13/25, 52%), primarily for neurological disorders (e.g., autism spectrum disorder [ASD], dystonia, dysgraphia) or children with cerebral palsy (CP). Although several mHealth studies were conducted in the clinical environment (10/25, 40%), studies conducted at home or in nonclinical settings (15/25, 60%) reported acceptable and highly satisfactory to the patients as minimizing the potential risks in participation. Moreover, the remaining barriers to clinical translation included object manipulation on a touch screen, offline data analysis, real-world usability, and age-appropriate application design for the wider population. However, the results emphasize the exploration of mHealth over traditional approaches, enabling user-centered study design, family-oriented methods, and large-scale sampling in future research.
... Our finding that bilateral anti-phase and in-phase movements are differentially impaired after left and right hemispheric stroke has important implications for neurorehabilitation strategies. Bilateral movement rehabilitation approaches, such as Bilateral Arm Training with Rhythmic Auditory Cueing (BATRAC) and Bilateral Arm training (BBT), have shown inconsistent results in longitudinal studies [61][62][63]. This could be because these existing trainings usually employed a mixed protocol that included both bilateral in-phase/anti-phase movements. ...
Background
A stroke frequently results in impaired performance of activities of daily life. Many of these are highly dependent on effective coordination between the two arms. In the context of bimanual movements, cyclic rhythmical bilateral arm coordination patterns can be classified into two fundamental modes: in-phase (bilateral homologous muscles contract simultaneously) and anti-phase (bilateral muscles contract alternately) movements. We aimed to investigate how patients with left (LHS) and right (RHS) hemispheric stroke are differentially affected in both individual-limb control and inter-limb coordination during bilateral movements.
Methods
We used kinematic measurements to assess bilateral coordination abilities of 18 chronic hemiparetic stroke patients (9 LHS; 9 RHS) and 18 age- and sex-matched controls. Using KINARM upper-limb exoskeleton system, we examined individual-limb control by quantifying trajectory variability in each hand and inter-limb coordination by computing the phase synchronization between hands during anti- and in-phase movements.
Results
RHS patients exhibited greater impairment in individual- and inter-limb control during anti-phase movements, whilst LHS patients showed greater impairment in individual-limb control during in-phase movements alone. However, LHS patients further showed a swap in hand dominance during in-phase movements.
Conclusions
The current study used individual-limb and inter-limb kinematic profiles and showed that bilateral movements are differently impaired in patients with left vs. right hemispheric strokes. Our results demonstrate that both fundamental bilateral coordination modes are differently controlled in both hemispheres using a lesion model approach. From a clinical perspective, we suggest that lesion side should be taken into account for more individually targeted bilateral coordination training strategies.
Trial registration: the current experiment is not a health care intervention study.
... Balasubramanian et al. (Balasubramanian et al. 2010) reviewed robots dedicated to hand rehabilitation. Delden et al. (Van Delden et al. 2012) performed a systematic review of the bilateral upper extremity rehabilitation devices and highlighted the qualitative evaluation of these devices. Gull et al. (Gull et al. 2020) highlighted critical challenges in developing the exoskeletons and discussed future directions for the research. ...
Rehabilitation programs promote functional recovery among disabled individuals. Robot-aided rehabilitation is a systematic way to use robotics systems for rehabilitation purposes. Recently it has received much research attention due to its efficacy in tirelessly offering various types of physical therapies. Robot-assisted rehabilitation technology is advancing at such a high pace that it may replace human-assisted physical therapy in the future. Currently, robot-assisted rehabilitation is dominated by end-effector-type and exoskeleton-type rehabilitation robots. Understanding both types of systems is essential to escalating the development and use of robot-assisted rehabilitation technologies. This paper presented the broad categorization, comparisons, and overview of the end-effector type and exoskeleton type rehabilitation robots based on the recently developed human upper extremity rehabilitation robots. By contrasting the available options, the major challenges associated with developing and commercializing assistive upper extremity robots are brought to light. While reviewing the articles, the focus is given to the robots’ mechanical design and control architecture. Current advancements and future directions are logically evaluated regarding their standard features and functional variances.
... Design and control: This robot is a 1-degree-of-freedom (DOF) device created for bilateral passive and active exercises, allowing hemiparetic patients to perform two distinct movement cycles bilaterally (Van Delden et al., 2012). The robot handles rotate in either a mirror image or parallel mode, similar to a rocker. ...
... During these tasks, cooperative action can benefit task performance. For example, the two hands can compensate for each other's errors [1] or, as exploited by rehabilitation interfaces for hemiplegia [2,3], one hand can take a higher share of effort. Such redundancy can be introduced into bimanual tasks by defining a common goal for the hands [4], for example by allowing them to act on the same object, which results in the hands being coupled. ...
... slicing bread requires one hand to cut and one to hold), other tasks, such as using a steering wheel, are fully redundant and can be performed with any effort sharing strategy between the hands. This has been used in bilateral training devices, which can provide bimanual assistance by allowing the non-affected hand to drive the affected [2,3,6], where haptic feedback can facilitate performance [7]. However, motor learning may be hindered by the enforcement of symmetric motions [8], or by overcompensation with the non-affected hand [9,10]. ...
Bilateral training systems look to promote the paretic hand´s use in individuals with hemiplegia. While this is normally achieved using mechanical coupling (i.e., a physical connection between the hands), a virtual reality system relying on virtual coupling (i.e., through a shared virtual object) would be simpler to use and prevent slacking. However, it is not clear whether different coupling modes differently impact task performance and effort distribution between the hands. We explored how 18 healthy right-handed participants changed their motor behaviours in response to the uninstructed addition of mechanical coupling, and virtual coupling using a shared cursor mapped to the average hands' position. In a second experiment, we then studied the impact of connection stiffness on performance, perception, and effort imbalance. The results indicated that both coupling types can induce the hands to actively contribute to the task. However, the task asymmetry introduced by using a cursor mapped to either the left or right hand only modulated the hands' contribution when not mechanically coupled. The tracking performance was similar for all coupling types, independent of the connection stiffness, although the mechanical coupling was preferred and induced the hands to move with greater correlation. These findings suggest that virtual coupling can induce the hands to actively contribute to a task in healthy participants without hindering their performance. Further investigation on the coupling types' impact on the performance and hands' effort distribution in patients with hemiplegia could allow for the design of simpler training systems that promote the affected hand's use.
... Bilateral training devices are of many types, ranging from very simple pulleys or mirrors to large mechanical devices. Stoykov et al. describe a few simple bilateral training devices [10], and Delden et al. have reviewed mechanical and robotic devices that have been used in recent years for bilateral arm training [11]. Brackenridge et al. reviewed 141 mechanical and robotic devices for stroke and concluded that an effective device is any simple device that can promote neuroplasticity and does not have to be unnecessarily complex and expensive [12]. ...
Upper limb impairment following stroke is often characterized by limited voluntary control in the affected arm. In addition, significant motor coordination problems occur on the unaffected arm due to avoidance of performing bilateral symmetrical activities. Rehabilitation strategies should, therefore, not only aim at improving voluntary control on the affected arm, but also contribute to synchronizing activity from both upper limbs. The encoder-controlled functional electrical stimulator, described in this paper, implements precise contralateral control of wrist flexion and extension with electrical stimulation. The stimulator is calibrated for each individual to obtain a table of stimulation parameters versus wrist angle. This table is used to set stimulation parameters dynamically, based on the difference in wrist angle between the set and stimulated side, which is continuously monitored. This allows the wrist on the stimulated side to follow flexion and extension patterns on the set side, thereby mirroring wrist movements of the normal side. This device also gives real-time graphical feedback on how the stimulated wrist is performing in comparison to the normal side. A study was performed on 25 normal volunteers to determine how closely wrist movements on the set side were being followed on the stimulated side. Graphical results show that there were minor differences, which were quantified by considering the peak angles of flexion and extension on the set and stimulated side for each participant. The mean difference in peak flexion and extension range of movement was 2.3 degrees and 1.9 degrees, respectively, with a mean time lag of 1 s between the set and the stimulated angle graphs.
... Force feedback provided by haptics is utilized by robotassisted surgery devices and has applications in training motor tasks. 23 The combination of VR, AR, and haptic technology has been successful in the rehabilitation of upper extremity impairment [24][25][26] and has shown promise for use as assessment tools. 27 Extended reality (XR), an extension of this approach that combines VR or AR with devices such as wearables, sensors, and robots, has been used in telerehabilitation and shows promise for more personalized medicine. ...
Introduction:
Utilization of telemedicine for health care delivery increased rapidly during the coronavirus disease 2019 (COVID-19) pandemic. However, physical examination during telehealth visits remains limited. A novel telerehabilitation system-The Augmented Reality-based Telerehabilitation System with Haptics (ARTESH)-shows promise for performing synchronous, remote musculoskeletal examination.
Objective:
Tssess the potential of ARTESH in remotely examining upper extremity passive range of motion (PROM) and maximum isometric strength (MIS).
Design:
In this cross-sectional pilot study, we compared the in-person (reference standard) and remote evaluations (ARTESH) of participants' upper extremity PROM and MIS in 10 shoulder and arm movements. The evaluators were blinded to each other's results.
Setting:
Participants underwent in-person evaluations at a Veterans Affairs hospital's outpatient Physical Medicine and Rehabilitation (PM&R) clinic, and underwent remote examination using ARTESH with the evaluator located at a research lab 30 miles away, connected via a high-speed network.
Patients:
Fifteen participants with upper extremity pain and/or weakness.
Interventions:
Not applicable.
Main outcome measures:
Inter-rater agreement between in-person and remote evaluations on 10 PROM and MIS movements and presence/absence of pain with movement was calculated.
Results:
The highest inter-rater agreements were noted in shoulder abduction and protraction PROM (kappa (κ) = 0.44, confidence interval (CI): -0.1 to 1.0), and in elbow flexion, shoulder abduction, and shoulder protraction MIS (κ = 0.63, CI: 0 to 1.0).
Conclusions:
This pilot study suggests that synchronous tele-physical examination using the ARTESH system with augmented reality and haptics has the potential to provide enhanced value to existing telemedicine platforms. With the additional technological and procedural improvements and with an adequately powered study, the accuracy of ARTESH-enabled remote tele-physical examinations can be better evaluated.
... We observed (in healthy adults) that a visual disturbance can modulate the effort between the hands in a bimanual tracking task. Previous findings have suggested that simpler bimanual rehabilitation devices may be as efficient as more complex interfaces [18], [19]. Our findings indicate that the design of rehabilitation robots for bimanual training may be simplified by using visual feedback to alter the effort distribution between the hands, while actuation targets other training aspects (e.g. ...
Robotic bimanual training can benefit from understanding how to modify human motor effort in bimanual tasks. We addressed this issue by carrying out a study to investigate whether and how penalizing the use of one hand could alter the hands’ effort distribution. Actuated haptic perturbations and alterations of the visual feedback of the right hand were tested on a bimanual tracking task with 16 healthy right-handed participants. For each feedback modality (haptic or visual), both a disturbance and a perturbation requiring additional effort from the right hand were implemented. The results showed that the participants were able to adjust to these four perturbations, and perceived them correctly as something that disturbed the dominant hand. Contrary to our expectations, the bimanual effort distribution changes induced by the haptic perturbations were not uniform across subjects. However, the visual disturbance induced most participants to use only their unperturbed left hand (with only 2/16 participants reporting a different behaviour). This suggests that a visual disturbance could be used to alter the effort distribution among the two hands. Clinical validation of these findings on hemiplegic patients may help simplify the design of robotic training interfaces.
... Thus, the augmenting effects of computer gaming observed in this study could have been produced because the computer gaming interface created sensory stimulations that engaged and encouraged the study participants to practice their training tasks eagerly, repetitively and bilaterally. This intensive repetition of training of the upper limbs probably brought about cortical reorganization that contributed to functional recovery, as reflected in the treatment effects of BMCG in this study (25,26). ...
Background:
Previous studies have reported that movement-based computer gaming is more effective than conventional intervention in enhancing upper limb rehabilitation.
Objective:
To evaluate whether the use of bilateral movement-based computer games could augment the effects of conventional intervention in improving the upper limb motor function, grip strength and health-related quality of life of subacute stroke survivors.
Methods:
A total of 93 subjects with subacute stroke were randomized into 2 groups receiving one of two 3.5-h interventions for 2 days per week over 8 weeks: (i) "bilateral movement-based computer games + conventional rehabilitation"; and (ii) "video-directed exercise + conventional rehabilitation" (control group).
Results:
A total of 83 subjects completed the interventions and follow-up assessments. Compared with video-directed exercise + conventional rehabilitation, bilateral movement-based computer games + conventional rehabilitation produced greater improvements in upper limb motor impairment from mid-treatment to follow-up 1 month post-intervention, greater improvements in upper limb function from post-intervention to 1 month follow-up, and earlier improvements in grip strength (paretic) from mid-intervention to follow-up 1 month post-intervention. Subjects who received bilateral movement-based computer games + conventional rehabilitation also continued to improve in motor function from post-intervention to 1 month post-intervention.
Conclusion:
Bilateral movement-based computer games may serve as an adjuvant therapy to conventional rehabilitation programmes for improving upper limb recovery among stroke survivors.
