Did your doctor and hospital do anything with this in the past 10 years? Nothing? Because they already have 100% recovery protocols for the upper limb? Or do they incompetently have nothing but useless guidelines? YOU need to be screaming in their faces that they need to do their job(GETTING YOU RECOVERED COMPLETELY).
Positive effects of robotic exoskeleton training of upper limb reaching movements after stroke
Journal of NeuroEngineering and Rehabilitation volume 9, Article number: 36 (2012)
Abstract
This study, conducted in a group of nine chronic patients with right-side hemiparesis after stroke, investigated the effects of a robotic-assisted rehabilitation training with an upper limb robotic exoskeleton for the restoration of motor function in spatial reaching movements. The robotic assisted rehabilitation training was administered for a period of 6 weeks including reaching and spatial antigravity movements. To assess the carry-over of the observed improvements in movement during training into improved function, a kinesiologic assessment of the effects of the training was performed by means of motion and dynamic electromyographic analysis of reaching movements performed before and after training. The same kinesiologic measurements were performed in a healthy control group of seven volunteers, to determine a benchmark for the experimental observations in the patients’ group. Moreover degree of functional impairment at the enrolment and discharge was measured by clinical evaluation with upper limb Fugl-Meyer Assessment scale (FMA, 0–66 points), Modified Ashworth scale (MA, 0–60 pts) and active ranges of motion. The robot aided training induced, independently by time of stroke, statistical significant improvements of kinesiologic (movement time, smoothness of motion) and clinical (4.6 ± 4.2 increase in FMA, 3.2 ± 2.1 decrease in MA) parameters, as a result of the increased active ranges of motion and improved co-contraction index for shoulder extension/flexion. Kinesiologic parameters correlated significantly with clinical assessment values, and their changes after the training were affected by the direction of motion (inward vs. outward movement) and position of target to be reached (ipsilateral, central and contralateral peripersonal space). These changes can be explained as a result of the motor recovery induced by the robotic training, in terms of regained ability to execute single joint movements and of improved interjoint coordination of elbow and shoulder joints.
Background
Impairment of upper limb function is one of the most common sequelae following stroke; in particular arm function is found to be altered in 73% to 88% of first time stroke survivors (infarctions only), and 55% to 75% still experience problems that impair their activities of daily living for up to 3 to 6 months or more [1, 2].
Impairments limit the patient’s autonomy in daily living and may lead to permanent disability [3]. The deficits are typically characterized by weakness of specific muscles [4], lack of mobility between structures at the shoulder girdle [5], incorrect timing of components within a movement pattern [6, 7] and loss of interjoint coordination [8]. Consequently goal directed movements in hemiplegic patients are characterized by lower movement amplitude, prolonged movement time, segmented trajectories and abnormal pattern of muscle activation. Compensatory motor strategies, characterized by adaptations to muscle imbalance [9], are commonly adopted by stroke patients in attempt to overcome these impairments.
Various rehabilitation interventions to improve skill reacquisition have shown promising results in overcoming motor impairment after stroke [10].
High intensity and task specific upper limb treatment consisting of active, highly repetitive movement is one of the most effective approaches to arm function post-stroke restoration [11–13]. Recent studies moreover suggest that given appropriate training, motor improvements of the upper limb can continue well into the chronic stage of stroke [14–16].
The use of robot devices in rehabilitation can provide high intensity, repetitive, task specific and interactive treatment of the impaired upper limb and an objective, reliable mean of monitoring patients progress. Systematic review confirms the potential for robotic assisted devices to elicit improvements in upper limb function [17, 18]. Moreover virtual reality provided a unique medium where therapy can be provided within a functional, purposeful and motivating context and can be readily graded and documented [19]. The cortical reorganization and associated functional motor recovery after virtual reality in patient with chronic stroke are documented also by fMRI [20].
While several studies have already investigated the effects of robot assisted training in planar movements performed in the horizontal plane [21], the effect of training on the control and production of multi-joint and spatial functional arm movements, including movements against gravity, in hemiparetic subjects has received less attention.
It has been already shown that stereotyped movement patterns [8] due to abnormal muscle co-activation result in a reduced active range of motion against gravity. In particular providing antigravity limb support, leads to a reduction of the abnormal coupling between shoulder abduction/elbow flexion [22] and promising results have been found in the robotic training of patients with antigravity vertical movements that involve shoulder elevation [23]. Moreover orthoses providing only passive gravity assistance to the arm in reaching movements can induce comparable clinical improvements to those obtained with robotic training [24].
In this study we have investigated the effects of robot aided training on the recovery of spatial reaching movements, with a focus on point-to-point reaching movements performed in different directions, analysing how muscle imbalance in stroke influences the process of motor recovery in terms of regain of smooth movement, interjoint coordination and agonistic/antagonistic muscle recruitment.
A robotic treatment was administered through the L-EXOS [25, 26], a robotic exoskeleton for the upper limb, in a group of nine patients with chronic hemiparetic stroke. Exoskeleton robotic systems allow to execute full spatial multi-joint functional arm movements, including elevation movements with shoulder abduction, providing either variable gravity support or active assistance to the impaired arm [27].
To assess the carry-over of the observed improvements in movement during training into improved function, changes in movement execution and smoothness of motion were analysed through a kinesiologic assessment, consisting in the motion and dynamic electromyographic analysis of reaching movements performed before and after training.
The kinesiologic performance (movement time, smoothness of motion) was then analysed in relation to the changes in the EMG pattern of agonist–antagonist muscle co-activation and shoulder-elbow interjoint coordination.
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