Few research in multiple sclerosis (MS) has focused on physical rehabilitation of upper limb dysfunction, though the latter strongly influences independent performance of activities of daily living. Upper limb rehabilitation technology could hold promise for complementing traditional MS therapy. Consequently, this pilot study aimed to examine the feasibility of an 8-week mechanical-assisted training program for improving upper limb muscle strength and functional capacity in MS patients with evident paresis. A case series was applied, with provision of a training program (3×/week, 30 minutes/session), supplementary on the customary maintaining care, by employing a gravity-supporting exoskeleton apparatus (Armeo Spring). Ten high-level disability MS patients (Expanded Disability Status Scale 7.0-8.5) actively performed task-oriented movements in a virtual real-life-like learning environment with the affected upper limb. Tests were administered before and after training, and at 2-month follow-up. Muscle strength was determined through the Motricity Index and Jamar hand-held dynamometer. Functional capacity was assessed using the TEMPA, Action Research Arm Test (ARAT) and 9-Hole Peg Test (9HPT). Muscle strength did not change significantly. Significant gains were particularly found in functional capacity tests. After training completion, TEMPA scores improved (p = 0.02), while a trend towards significance was found for the 9HPT (p = 0.05). At follow-up, the TEMPA as well as ARAT showed greater improvement relative to baseline than after the 8-week intervention period (p = 0.01, p = 0.02 respectively). The results of present pilot study suggest that upper limb functionality of high-level disability MS patients can be positively influenced by means of a technology-enhanced physical rehabilitation program.

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The Armeo Spring as training tool to improve upper limb functionality in multiple sclerosis: a pilot study

Multiple sclerosis is a chronic, autoimmune and neurodegenerative disease affecting multiple functional systems and resulting in motor impairments associated with muscle weakness and lack of movement coordination. We quantified upper limb motor deficits with a robot-based assessment including behavioral and muscle synergy analysis in 11 multiple sclerosis subjects with mild to moderate upper limb impairment (9 female; 50 ± 10 years) compared to 11 age- and gender- matched controls (9 female; 50 ± 9 years). All subjects performed planar reaching tasks by moving their upper limb or applying force while grasping the handle of a robotic manipulandum that generated four different environments: free space, assistive or resistive forces, and rigid constraint. We recorded the activity of 15 upper body muscles. Multiple sclerosis subjects generated irregular trajectories. While activities in isolated arm muscles appeared generally normal, shoulder muscle coordination with arm motions was impaired and there was a marked co-activation of the biceps and triceps in extension movements. Systematic differences in timing and organization of muscle synergies have also been observed. This study supports the definition of new biomarkers and rehabilitative treatments for improving upper limb motor coordination in multiple sclerosis.

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Evaluating upper limb impairments in multiple sclerosis by exposure to different mechanical environments.

This paper presents the initial evaluation of a Virtual Peg Insertion Test developed to assess sensorimotor functions of arm and hand using an instrumented tool, virtual reality and haptic feedback. Nine performance parameters derived from kinematic and kinetic data were selected and compared between two groups of healthy subjects performing the task with the dominant and non-dominant hand, as well as with a group of chronic stroke subjects suffering from different levels of upper limb impairment. Results showed significantly smaller grasping forces applied by the stroke subjects compared to the healthy subjects. The grasping force profiles suggest a poor coordination between position and grasping for the stroke subjects, and the collision forces with the virtual board were found to be indicative of sensory deficits. These preliminary results suggest that the analyzed parameters could be valid indicators of impairment.

Upper limb assessment using a Virtual Peg Insertion Test

Quantifying and tracking upper limb impairment is of key importance to the understanding of disease progress, establishing patient-tailored therapy protocols and for optimal care provision. This paper presents the results of a pilot study on the assessment of upper limb motor function in patients with multiple sclerosis (MS) with the Virtual Peg Insertion Test (VPIT). The test consists in a goal-directed reaching task using a commercial haptic display combined with an instrumented handle and virtual environment, and allows for the extraction of objective kinematic and dynamic parameters. Ten MS patients and eight age-matched healthy subjects performed five repetitions of the VPIT with their dominant and non-dominant hand. Upper limb movements were found to be significantly slower, less smooth and less straight compared to healthy controls, and the time to complete the VPIT was well correlated with the conventional Nine Hole Peg Test (r=0.658, p<;0.01). Tremor in the range of 3-5 Hz could be detected and quantified using a frequency analysis in patients featuring intention tremor. These preliminary results illustrate the feasibility of using the VPIT with MS patients, and underline the potential of this test to evaluate upper limb motor function and discriminate characteristic MS related impairments.

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Assessment of upper limb motor function in patients with multiple sclerosis using the Virtual Peg Insertion Test: A pilot study

Neurological disorders such as stroke, traumatic brain injury, cerebral palsy, or spinal cord injury result in partial or complete sensorimotor impairments in the affected limbs. To provide an optimal rehabilitation, a detailed assessment of the nature and degree of the sensorimotor deficits is crucial. Valid, reliable, and standardized assessments are essential to define the therapy setting. Many clinical assessments suffer from limitations such as poor validity, low reliability, and low sensitivity. However, as often no alternative exists, they are widely used in clinical settings. Rehabilitation robotics is a promising technology that can provide objective measurements, which could help overcome the common drawbacks of clinical assessments. This chapter focuses on the new possibilities robotic devices offer in the field of neurorehabilitation. Different strategies to evaluate sensorimotor impairments using robotic platforms are presented. We discuss how a link between conventional scales and robotic assessments could be established, and how this could result in more objective, clinically accepted assessment scales.

Robots for Measurement/Clinical Assessment

Upper limb weakness due to Multiple Sclerosis has a major negative effect on the functional activities of the patient Promising developments in the field of rehabilitation robotics may enable additional exercise This study aims to investigate which types of robotic outcome measures are clinically relevant, in preparation of the evaluation for intervention studiesWithin this context, appropriate movement tasks and tests for the haptic PHANTOM end-effector robot were designed in a virtual environment These tasks focused on spatial accuracy, object manipulation and speed Outcome measures were: 1) virtual movement tests, recorded by the robot to quantify motor control; 2) clinical outcome measures such as the Motricity Index, Jamar and MicroFET hand-held dynamometer to evaluate muscle strength; and the Nine Hole Peg Test, Purdue Pegboard, ARAt and TEMPA to asses upper limb function and manual dexterity10 healthy controls performed the virtual movement tasks using the Phantom as interface 21 MS subjects with upper limb dysfunction caused by muscle weakness were included in an interventional training study Pearson correlations were calculated at baseline between the performance on the three virtual movement tasks and the clinical tests on impairment and activity level The virtual movement tests discriminated between healthy controls and MS patients with hand dysfunction In the MS patient group, no significant correlations were found between muscle strength tests and virtual movement tasks, while mainly significant correlations were found between specific functional measures (specifically ARAt and Purdue pegboard test) and virtual movement tasks

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O. Bert Eijnde

Papers

Arm training in Multiple Sclerosis using Phantom: Clinical relevance of robotic outcome measures