Showing papers in "Journal of Rehabilitation Research and Development in 2011"

Electromyogram pattern recognition for control of powered upper-limb prostheses: state of the art and challenges for clinical use.

Abstract: Using electromyogram (EMG) signals to control upper-limb prostheses is an important clinical option, offering a person with amputation autonomy of control by contracting residual muscles. The dexterity with which one may control a prosthesis has progressed very little, especially when control- ling multiple degrees of freedom. Using pattern recognition to discriminate multiple degrees of freedom has shown great promise in the research literature, but it has yet to transition to a clinically viable option. This article describes the pertinent issues and best practices in EMG pattern recognition, identifies the major challenges in deploying robust control, and advocates research directions that may have an effect in the near future.

Myoelectric Forearm Prostheses: State of the Art from a User-Centered Perspective

Abstract: User acceptance of myoelectric forearm prostheses is currently low. Awkward control, lack of feedback, and difficult training are cited as primary reasons. Recently, researchers have focused on exploiting the new possibilities offered by advancements in prosthetic technology. Alternatively, researchers could focus on prosthesis acceptance by developing functional requirements based on activities users are likely to perform. In this article, we describe the process of determining such requirements and then the application of these requirements to evaluating the state of the art in myoelectric forearm prosthesis research. As part of a needs assessment, a workshop was organized involving clinicians (representing end users), academics, and engineers. The resulting needs included an increased number of functions, lower reaction and execution times, and intuitiveness of both control and feedback systems. Reviewing the state of the art of research in the main prosthetic subsystems (electromyographic [EMG] sensing, control, and feedback) showed that modern research prototypes only partly fulfill the requirements. We found that focus should be on validating EMG-sensing results with patients, improving simultaneous control of wrist movements and grasps, deriving optimal parameters for force and position feedback, and taking into account the psychophysical aspects of feedback, such as intensity perception and spatial acuity.

Activity-promoting gaming systems in exercise and rehabilitation.

Abstract: Commercial activity-promoting gaming systems provide a potentially attractive means to facilitate exercise and rehabilitation. The Nintendo Wii, Sony EyeToy, Dance Dance Revolution, and Xbox Kinect are examples of gaming systems that use the movement of the player to control gameplay. Activity-promoting gaming systems can be used as a tool to increase activity levels in otherwise sedentary gamers and also be an effective tool to aid rehabilitation in clinical settings. Therefore, the aim of this current work is to review the growing area of activity-promoting gaming in the context of exercise, injury, and rehabilitation.

Target Achievement Control Test: Evaluating real-time myoelectric pattern-recognition control of multifunctional upper-limb prostheses

Abstract: Despite high classification accuracies (~95%) of myoelectric control systems based on pattern recognition, how well offline measures translate to real-time closed-loop control is unclear. Recently, a real-time virtual test analyzed how well subjects completed arm motions using a multiple-degree of freedom (DOF) classifier. Although this test provided real-time performance metrics, the required task was oversimplified: motion speeds were normalized and unintended movements were ignored. We included these considerations in a new, more challenging virtual test called the Target Achievement Control Test (TAC Test). Five subjects with transradial amputation attempted to move a virtual arm into a target posture using myoelectric pattern recognition, performing the test with vari- ous classifier (1- vs 3-DOF) and task complexities (one vs three required motions per posture). We found no significant difference in classification accuracy between the 1- and 3-DOF classifiers (97.2% +/- 2.0% and 94.1% +/- 3.1%, respectively; p = 0.14). Subjects completed 31% fewer trials in significantly more time using the 3-DOF classifier and took 3.6 +/- 0.8 times longer to reach a three-motion posture compared with a one- motion posture. These results highlight the need for closed-loop performance measures and demonstrate that the TAC Test is a use- ful and more challenging tool to test real-time pattern-recognition performance.

Upper-limb robot-assisted therapy in rehabilitation of acute stroke patients: focused review and results of new randomized controlled trial.

Abstract: The successful motor rehabilitation of stroke patients requires early intensive and task-specific therapy. A recent Cochrane Review, although based on a limited number of randomized controlled trials (RCTs), showed that early robotic training of the upper limb (i.e., during acute or subacute phase) can enhance motor learning and improve functional abilities more than chronic-phase training. In this article, a new subacute-phase RCT with the Neuro-Rehabilitation-roBot (NeReBot) is presented. While in our first study we used the NeReBot in addition to conventional therapy, in this new trial we used the same device in substitution of standard proximal upper-limb rehabilitation. With this protocol, robot patients achieved similar reductions in motor impairment and enhancements in paretic upper-limb function to those gained by patients in a control group. By analyzing these results and those of previous studies, we hypothesize a new robotic protocol for acute and subacute stroke patients based on both treatment modalities (in addition and in substitution).

Residual limb volume change: systematic review of measurement and management.

Abstract: Management of residual limb volume affects decisions regarding timing of fit of the first prosthesis, when a new prosthetic socket is needed, design of a prosthetic socket, and prescription of accommodation strategies for daily volume fluctuations. This systematic review assesses what is known about measurement and management of residual limb volume change in persons with lower-limb amputation. Publications that met inclusion criteria were grouped into three categories: group I: descriptions of residual limb volume measurement techniques; group II: studies investigating the effect of residual limb volume change on clinical care in people with lower-limb amputation; and group III: studies of residual limb volume management techniques or descriptions of techniques for accommodating or controlling residual limb volume. We found that many techniques for the measurement of residual limb volume have been described but clinical use is limited largely because current techniques lack adequate resolution and in-socket measurement capability. Overall, limited evidence exists regarding the management of residual limb volume, and the evidence available focuses primarily on adults with transtibial amputation in the early postoperative phase. While we can draw some insights from the available research about residual limb volume measurement and management, further research is required.

Potential of robots as next-generation technology for clinical assessment of neurological disorders and upper-limb therapy

Abstract: Robotic technologies have profoundly affected the identification of fundamental properties of brain function. This success is attributable to robots being able to control the position of or forces applied to limbs, and their inherent ability to easily, objectively, and reliably quantify sensorimotor behavior. Our general hypothesis is that these same attributes make robotic technologies ideal for clinically assessing sensory, motor, and cognitive impairments in stroke and other neurological disorders. Further, they provide opportunities for novel therapeutic strategies. The present opinionated review describes how robotic technologies combined with virtual/augmented reality systems can support a broad range of behavioral tasks to objectively quantify brain function. This information could potentially be used to provide more accurate diagnostic and prognostic information than is available from current clinical assessment techniques. The review also highlights the potential benefits of robots to provide upper-limb therapy. Although the capital cost of these technologies is substantial, it pales in comparison with the potential cost reductions to the overall healthcare system that improved assessment and therapeutic interventions offer.

A portable powered ankle-foot orthosis for rehabilitation.

Abstract: Innovative technological advancements in the field of orthotics, such as portable powered orthotic systems, could create new treatment modalities to improve the functional out come of rehabilitation. In this article, we present a novel portable powered ankle-foot orthosis (PPAFO) to provide untethered assistance during gait. The PPAFO provides both plantar flexor and dorsiflexor torque assistance by way of a bidirectional pneumatic rotary actuator. The system uses a portable pneumatic power source (compressed carbon dioxide bottle) and embedded electronics to control the actuation of the foot. We collected pilot experimental data from one impaired and three nondisabled subjects to demonstrate design functionality. The impaired subject had bilateral impairment of the lower legs due to cauda equina syndrome. We found that data from nondisabled walkers demonstrated the PPAFO's capability to provide correctly timed plantar flexor and dorsiflexor assistance during gait. Reduced activation of the tibialis anterior during stance and swing was also seen during assisted nondisabled walking trials. An increase in the vertical ground reaction force during the second half of stance was present during assisted trials for the impaired subject. Data from nondisabled walkers demonstrated functionality, and data from an impaired walker demonstrated the ability to provide functional plantar flexor assistance.

Pain Neurophysiology Education Improves Cognitions, Pain Thresholds, and Movement Performance in People with Chronic Whiplash: A Pilot Study

Abstract: Chronic whiplash is a debilitating condition characterized by increased sensitivity to painful stimuli, maladaptive illness beliefs, inappropriate attitudes, and movement dysfunctions. Previous work in people with chronic low back pain and chronic fatigue syndrome indicates that pain neurophysiology education is able to improve illness beliefs and attitudes as well as movement performance. This single-case study (A-B-C design) with six patients with chronic whiplash associated disorders (WAD) was aimed at examining whether education about the neurophysiology of pain is accompanied by changes in symptoms, daily functioning, pain beliefs, and behavior. Periods A and C represented assessment periods, while period B consisted of the intervention (pain neurophysiology education). Results showed a significant decrease in kinesiophobia (Tampa Scale for Kinesiophobia), the passive coping strategy of resting (Pain Coping Inventory), self-rated disability (Neck Disability Index), and photophobia (WAD Symptom List). At the same time, significantly increased pain pressure thresholds and improved pain-free movement performance (visual analog scale on Neck Extension Test and Brachial Plexus Provocation Test) were established. Although the current results need to be verified in a randomized, controlled trial, they suggest that education about the physiology of pain is able to increase pain thresholds and improve pain behavior and pain-free movement performance in patients with chronic WAD.

Robot-assisted upper-limb therapy in acute rehabilitation setting following stroke: Department of Veterans Affairs multisite clinical trial

Abstract: This randomized, controlled, multisite Department of Veterans Affairs clinical trial assessed robot-assisted (RA) upper-limb therapy with the Mirror Image Movement Enabler (MIME) in the acute stroke rehabilitation setting. Hemiparetic subjects (n = 54) received RA therapy using MIME for either up to 15 hours (low-dose) or 30 hours (high-dose) or received up to 15 hours of additional conventional therapy in addition to usual care (control). The primary outcome measure was the Fugl-Meyer Assessment (FMA). The secondary outcome measures were the Functional Independence Measure (FIM), Wolf Motor Function Test, Motor Power, and Ashworth scores at intake, discharge, and 6-month follow-up. Mean duration of study treatment was 8.6, 15.8, and 9.4 hours for the low-dose, high-dose, and control groups, respectively. Gains in the primary outcome measure were not significantly different between groups at follow-up. Significant correlations were found at discharge between FMA gains and the dose and intensity of RA. Intensity also correlated with FMA gain at 6 months. The high-dose group had greater FIM gains than controls at discharge and greater tone but no difference in FIM changes compared with low-dose subjects at 6 months. As used during acute rehabilitation, motor-control changes at follow-up were no less with MIME than with additional conventional therapy. Intensity of training with MIME was positively correlated with motor-control gains.

Efficacy of rehabilitation robotics for walking training in neurological disorders: A review

Abstract: Robotic technologies are becoming more prevalent for treating neurological conditions in clinical settings. We conducted a literature search of original articles to identify all studies that examined the use of robotic devices for restoring walking function in adults with neurological disorders. We evaluated and rated each study using either the Physiotherapy Evidence Database scale for randomized controlled trials (RCTs) or the Downs and Black scale for non-RCTs. We reviewed 30 articles (14 RCTs, 16 non-RCTs) that examined the effects of locomotor training with robotic assistance in patients following stroke, spinal cord injury (SCI), multiple sclerosis (MS), traumatic brain injury (TBI), and Parkinson disease (PD). This review supports that locomotor training with robotic assistance is beneficial for improving walking function in individuals following a stroke and SCI. Gait speed and endurance were not found to be significantly different among patients with motor incomplete SCI after a variety of locomotor training approaches. Limited evidence demonstrates that locomotor training with robotic assistance is beneficial in populations of patients with MS, TBI, or PD. We discuss clinical implications and decision making in the area of gait rehabilitation for neurological dysfunction.

Responsiveness of the Canadian Occupational Performance Measure

Abstract: This study evaluated the responsiveness of the Canadian Occupational Performance Measure (COPM), an individualized, client-centered outcome measure for the identification and evaluation of self-perceived occupational performance problems. We recruited 152 consecutive patients with various diagnoses, admitted to the outpatient clinic of two occupational therapy departments, to complete a COPM interview and three self-reported health status questionnaires on two occasions: prior to the start of occupational therapy treatment and 3 months later. The three questionnaires were the Sickness Impact Profile (SIP68), the Disability and Impact Profile (DIP), and the Impact on Participation and Autonomy (IPA). We assessed criterion responsiveness by calculating the area under the curve (AUC) for the receiver operating characteristic curve and the optimal cutoff values for the COPM scores.To determine construct responsiveness, we calculated correlations between the change in COPM scores and the change in the SIP68, DIP, and IPA scores. The AUC ranged from 0.79 to 0.85, and the optimal cut-off values for the performance scores and satisfaction scores ranged from 0.9 to 1.9.We found significant positive correlations between the COPM scores and the SIP68, DIP, and IPA scores. The capability of the COPM to detect changes in perceived occupational performance issues is supported.

Validity of PTSD diagnoses in VA administrative data: comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores.

Abstract: Little research has been done on the validity of posttraumatic stress disorder (PTSD) diagnoses that are found in Department of Veterans Affairs (VA) administrative data, even though they are often used in VA research. We compared PTSD diagnoses found in VA administrative data with PTSD Checklist (PCL) scores self-reported by 4,777 newly diagnosed participants in a national postal survey study. Using PCL scores of at least 50 as the gold standard, we compared positive predictive values (PPVs) for at least one versus at least two PTSD diagnoses (found within 4 months of the first) in VA administrative data overall and by subgroups of interest: age, sex, and clinic where first diagnosed. The overall PPV was 75% for at least one PTSD diagnosis and 82% for at least two PTSD diagnoses. Similarly, the PPV significantly increased for all subgroup analyses when at least two PTSD diagnoses were used. The increase in PPV was greatest for those first diagnosed in primary care and for those older than 65. To select a sample of veterans with more definitive PTSD from administrative data, researchers should select those veterans with at least two PTSD diagnoses as opposed to at least one.

ZeroG: overground gait and balance training system.

Abstract: A new overground body-weight support system called ZeroG has been developed that allows patients with severe gait impairments to practice gait and balance activities in a safe, controlled manner. The unloading system is capable of providing up to 300 lb of static support and 150 lb of dynamic (or constant force) support using a custom-series elastic actuator. The unloading system is mounted to a driven trolley, which rides along an overhead rail. We evaluated the performance of ZeroG's unloading system, as well as the trolley tracking system, using benchtop and human-subject testing. Average root-mean-square and peak errors in unloading were 2.2 and 7.2 percent, respectively, over the range of forces tested while trolley tracking errors were less than 3 degrees, indicating the system was able to maintain its position above the subject. We believe training with ZeroG will allow patients to practice activities that are critical to achieving functional independence at home and in the community.

Assessing evidence supporting redistribution of pressure for pressure ulcer prevention: a review.

Abstract: The formation and underlying causes of pressure ulcers (PUs) are quite complex, with multiple influencing factors. However, by definition pressure ulcers cannot form without loading, or pressure, on tissue. Clinical interventions typically target the magnitude and/or duration of loading. Pressure magnitude is managed by the selection of support surfaces and postural supports as well as body posture on supporting surfaces. Duration is addressed via turning and weight shifting frequency as well as with the use of dynamic surfaces that actively redistribute pressure on the body surfaces. This article shows that preventative interventions must be targeted to both magnitude and duration and addresses the rationale behind several common clinical interventions--some with more scientific evidence than others.

Measurement of lower-limb muscle spasticity: intrarater reliability of Modified Modified Ashworth Scale.

Abstract: The Modified Modified Ashworth Scale (MMAS) is a clinical instrument for measuring spasticity. Few studies have been performed on the reliability of the MMAS. The aim of the present study was to investigate the intrarater reliability of the MMAS for the assessment of spasticity in the lower limb. We conducted a test-retest study on spasticity in the hip adductors, knee extensors, and ankle plantar flexors. Each patient was measured by a hospital-based clinical physiotherapist. Twenty-three patients with stroke or multiple sclerosis (fourteen women, nine men) and a mean +/- standard deviation age of 37.3 +/- 14.1 years participated. The weighted kappa was moderate for the hip adductors (weighted kappa = 0.45, standard error [SE] = 0.16, p = 0.007), good for the knee extensors (weighted kappa = 0.62, SE = 0.12, p < 0.001), and very good for the ankle plantar flexors (weighted kappa = 0.85, SE = 0.05, p < 0.001). The kappa value for overall agreement was very good (weighted kappa = 0.87, SE = 0.03, p < 0.001). The reliability for the ankle plantar flexors was significantly higher than that for the hip adductors. The intrarater reliability of the MMAS in patients with lower-limb muscle spasticity was very good, and it can be used as a measure of spasticity over time.

Using virtual reality environment to facilitate training with advanced upper-limb prosthesis.

Abstract: Technological advances in upper-limb prosthetic design offer dramatically increased possibilities for powered movement. The DEKA Arm system allows users 10 powered degrees of movement. Learning to control these movements by utilizing a set of motions that, in most instances, differ from those used to obtain the desired action prior to amputation is a challenge for users. In the Department of Veterans Affairs "Study to Optimize the DEKA Arm," we attempted to facilitate motor learning by using a virtual reality environment (VRE) program. This VRE program allows users to practice controlling an avatar using the controls designed to operate the DEKA Arm in the real world. In this article, we provide highlights from our experiences implementing VRE in training amputees to use the full DEKA Arm. This article discusses the use of VRE in amputee rehabilitation, describes the VRE system used with the DEKA Arm, describes VRE training, provides qualitative data from a case study of a subject, and provides recommendations for future research and implementation of VRE in amputee rehabilitation. Our experience has led us to believe that training with VRE is particularly valuable for upper-limb amputees who must master a large number of controls and for those amputees who need a structured learning environment because of cognitive deficits.

Increasing physical activity in multiple sclerosis: replicating Internet intervention effects using objective and self-report outcomes.

Abstract: INTRODUCTION Physical activity has been associated with improvements in fatigue, spasticity, depression, quality of life, and walking mobility in persons with multiple sclerosis (MS) [1-4], and yet this population engages in substantially less physical activity than does the general population [5], who parenthetically are largely sedentary [6]. This underscores the importance of developing behavior change interventions for increasing physical activity in persons with MS. Ideally, such interventions should be based on theoretical principles that are supported by empirical research and delivered using a medium that matches the interest and usage profile of the target population. Evidence exists that constructs from social-cognitive theory [7] have been identified as determinants of physical activity in persons with MS [8-10] and, thereby, represent possible targets of a behavioral intervention. We further note that the Internet represents an appropriate means for the delivery of an intervention on the basis of the usage statistics and interests of those with MS [11]. We recently conducted a two-arm, randomized controlled trial (RCT) that tested the efficacy of a 12-week Internet intervention that was based on social-cognitive theory for increasing physical activity behavior in persons with MS [12]. The group that received the Internet intervention reported a statistically significant increase in physical activity over the 12-week period, whereas no significant change was reported by the wait-list control group. The major limitation of this pilot research was the reliance on a self-report measure of physical activity that might have reflected demand characteristics rather than an actual change in behavior. The present study examined the efficacy of the same Internet intervention for increasing physical activity in persons with MS by using both objective and self-report measures. METHODS Participants We invited 24 persons with MS who were in the control group of the aforementioned two-arm RCT to be participants in a follow-up administration of the Internet intervention for increasing physical activity. One person was uninterested in participation, and two others did not provide subsequent physician's approval for participation in physical activity. This yielded a final sample of 21 persons with MS. All participants (1) had a definite diagnosis of MS consistent with McDonald criteria [13]; (2) had a relapsing-remitting MS clinical course consistent with Lublin and Reingold criteria [14]; (3) were independently ambulatory or ambulatory with single-point assistance (i.e., cane); (4) were relapse-free in the past 30 days; (5) had Internet access; (6) were willing to complete the questionnaires and wear an accelerometer; (7) were nonactive, defined as not engaging in regular physical activity (30 minutes accumulated each day) on more than 2 days of the week during the previous 6 months; (8) were free of contraindications for physical activity (e.g., no underlying cardiovascular disease); and (9) provided physician approval for beginning a physical activity program. There were neither inclusion nor exclusion criteria for usage of disease modifying agents or changes in medication status over the course of the intervention. Measures Physical Activity * The ActiGraph model 7164 accelerometer (ActiGraph; Pensacola, Florida), Godin Leisure-Time Exercise Questionnaire (GLTEQ) [15], and short-form of the International Physical Activity Questionnaire (IPAQ) [16] served as the measures of physical activity in this study. The three measures were selected because evidence exists for the validity of their scores among persons with MS [17-19]. The ActiGraph model 7164 accelerometer consists of a single vertical-axis piezoelectric bender element, and this internal element generates an electrical signal proportional to the force acting on it. The electrical signal is digitized by an analog-to-digital converter and then numerically integrated over a specified interval. …

Dimensional accuracy of ankle-foot orthoses constructed by rapid customization and manufacturing framework

Abstract: INTRODUCTION According to the Americans with Disabilities report, in 2005 approximately 27 million people over the age of 15 had a walking-related disability [1]. Ankle joint musculature is extremely important during walking and is thought to be the primary muscle group that supports upright stance and produces forward propulsion [2-3]. Individuals with muscular weakness about the ankle, an impairment often caused by upper motor neuron disorders and lower-limb injuries, are frequently prescribed ankle-foot orthoses (AFOs), which brace the ankle during gait and aim to improve gait function [4]. Passive-dynamic AFOs (PD-AFOs) constitute a class of ankle braces that rely on material properties and physical features to establish functional characteristics such as bending or rotational stiffness and the storage and return of mechanical energy [5]. PD-AFOs are traditionally composed of foot plate, strut, and cuff components, which may be fabricated using continuous material [5-7] or connected as components in various manners [8-9]. Despite the great potential for biomechanical assessment and treatment using this classification of orthoses, currently prescribed PDAFOs are often generic, having standardized size and shape (fit) and bending or rotational stiffness (functional) characteristics [10-11]. When customization of functional characteristics is sought, PD-AFOs are typically manually fabricated by orthotists--which may introduce undesired manufacturing variability in PD-AFO quality or effectiveness, depending on an orthotists' skill and experience [12]--and require substantial time and expertise to ultimately manufacture orthoses having functional characteristics that match the unique gait dynamics of each patient [6-7,13]. Furthermore, the annual cost of these devices is substantial. In 2007, the prescription of orthotics accounted for US$458,000,000 of Medicare expenditures alone [14]. Therefore, the capability to rapidly design and manufacture customized orthoses with precisely controlled characteristics would help transform the PD-AFO customization and fabrication process from a craft-based industry into a modern clinical specialty [15]. Fit customization is an important design factor for obtaining optimal function from a PD-AFO. The size and shape characteristics, which describe the fit of a PDAFO, can be customized through a variety of methods. Traditionally, an orthotist casts a patient's shank and foot to create a negative mold. A positive mold is generated from the negative mold, and then the PD-AFO is manually fabricated around this positive mold similar to methods for fabricating a foot orthosis [16]. While manual manufacturing methods can sufficiently generate a PDAFO with customized size, augmented shape, and functional characteristics, manual manufacturing methods can contribute to undesirable variability in quality of manufactured components. Recent efforts have worked to utilize computer-aided design (CAD) models and associated parameterization tools to customize orthoses. Darling and Sun designed a parameterized orthosis model that consisted of two rigid components, one for each the foot and shank, which were attached by a single-degree-of-freedom hinge [17]. Parameterization of this model was based on two anatomically relevant coordinate systems, one for each of the components. Patient-specific imaging data were fit to the parameterized model to scale the orthosis. While this CAD model was parameterized for size and ankle angle, the orthosis design lacked the organic shape characteristics and parameterization of orthosis functional characteristics. In this article, we define parameterization as the process of identifying the parameters necessary for the complete specification as well as manipulation of the PDAFO CAD model. Using parameters to specify and manipulate a PD-AFO CAD model has profound implications for the objective and precise customization of biomechanically designed orthoses that match patient needs with orthosis function [15]. …

Electromyogram-based neural network control of transhumeral prostheses

Abstract: Upper-limb amputation can cause a great deal of functional impairment for patients, particularly for those with amputation at or above the elbow. Our long-term objective is to improve functional outcomes for patients with amputation by integrating a fully implanted electromyographic (EMG) recording system with a wireless telemetry system that communicates with the patient's prosthesis. We believe that this should generate a scheme that will allow patients to robustly control multiple degrees of freedom simultaneously. The goal of this study is to evaluate the feasibility of predicting dynamic arm movements (both flexion/extension and pronation/supination) based on EMG signals from a set of muscles that would likely be intact in patients with transhumeral amputation. We recorded movement kinematics and EMG signals from seven muscles during a variety of movements with different complexities. Time-delayed artificial neural networks were then trained offline to predict the measured arm trajectories based on features extracted from the measured EMG signals. We evaluated the relative effectiveness of various muscle subsets. Predicted movement trajectories had average root-mean-square errors of approximately 15.7° and 24.9° and average R(2) values of approximately 0.81 and 0.46 for elbow flexion/extension and forearm pronation/supination, respectively.

Mental health diagnosis and occupational functioning in National Guard/Reserve veterans returning from Iraq.

Abstract: Occupational functioning represents both an important outcome for military service members returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom and a predictor for long-term mental health functioning. We investigated the role of mental health diagnoses, determined by structured clinical interviews, on occupational functioning in a group of 262 National Guard/Reserve service members within 1 year of returning from a 16-month OIF combat deployment. We assessed occupational functioning at the time of diagnostic interviews and 1 year later. We hypothesized that service members with diagnoses of posttraumatic stress disorder (PTSD), depression, and/or alcohol abuse or dependence would exhibit lower rates of employment at both time points and lower rates of reported work and/or school role functioning. Service members with a diagnosis of PTSD (5%, n = 13), subthreshold PTSD (6%, n = 15), a major depressive disorder (11%, n = 29), or alcohol abuse or dependence (11%, n = 28) did not differ on employment status from service members without a diagnosis at either time point. However, those with a diagnosis of PTSD, depression, and/or alcohol abuse or dependence reported lower levels of work role functioning. In addition, service members with a diagnosis of PTSD reported greater rates of deterioration in work role functioning over time.

Psychological state estimation from physiological recordings during robot-assisted gait rehabilitation.

Abstract: Robot-assisted treadmill training is an established intervention used to improve walking ability in patients with neurological disorders Although it has been shown that atten- tion to the task is a key factor for successful rehabilitation, the psychological state of patients during robot-assisted gait ther- apy is often neglected We presented 17 nondisabled subjects and 10 patients with neurological disorders a virtual-reality task with varying difficulty levels to induce feelings of being bored, excited, and overstressed We developed an approach to automatically estimate and classify a patient's psychological state, ie, his or her mental engagement, in real time during gait training We used psychophysiological measurements to obtain an objective measure of the current psychological state Automatic classification was performed by a neural network We found that heart rate, skin conductance responses, and skin temperature can be used as markers for psychological states in the presence of physical effort induced by walking The classi- fier achieved a classification error of 14% for nondisabled subjects and 21% for patients with neurological disorders Using our new method, we processed the psychological state data in real time Our method is a first step toward real-time auto-adaptive gait training with potential to improve rehabilita- tion results by optimally challenging patients at all times dur- ing exercise

Effect of home-based exercise program on lymphedema and quality of life in female postmastectomy patients: pre-post intervention study.

Abstract: Lymphedema is a debilitating complication following mastectomy, affecting the arm functions and quality of life (QOL) of breast cancer patients Studies have shown the beneficial effects of upper-limb exercises on lymphedema in clinical set- tings However, there is a dearth of evidence regarding the effect of home-based exercises on lymphedema; therefore, we examined the effect of a home-based exercise program on lymphedema and QOL in postmastectomy patients Thirty-two female postmas- tectomy lymphedema patients participated in an individualized home-based exercise program for 8 weeks Arm circumference, arm volume, and QOL (36-Item Short Form Health Survey) were measured before and after the program Data were analyzed with the use of paired t-tests for circumferential and volumetric mea- sures and Wilcoxon signed ranks tests for QOL Significance level was set at p < 001 with Bonferroni correction (alpha/n = 005/5 = 001) Analysis showed a statistically significant improvement in the affected upper-limb circumference and vol- ume (~122 mL reduction, p < 0001) and in the QOL scores (p < 0001) at the end of the home-based exercise program The indi- vidualized home-based exercise program led to improvement in affected upper-limb volume and circumference and QOL of post- mastectomy lymphedema patients

Development of finger-motion capturing device based on optical linear encoder

Abstract: This article presents the design and validation of a wearable glove-based multifinger-motion capture device (Smart- Glove), specifically focusing on the development of a new optical linear encoder (OLE). The OLE specially designed for this project is compact and lightweight and has low-power consump- tion. The characterization tests showed that the OLE's digital out- put has good linearity and is accurate. The first prototype of SmartGlove, which uses 10 OLEs to capture the flexion/extension motion of the 14 finger joints, was constructed based on the multi- point-sensing method. A user study evaluated the SmartGlove using a standard protocol and found high repeatability and reli- ability in both the gripped and flat-hand positions compared with four other evaluated data gloves using the same protocol.

Bilateral upper-limb rehabilitation after stroke using a movement-based game controller

Abstract: This study aimed to determine the effectiveness of a bilateral, self-supported, upper-limb rehabilitation intervention using a movement-based game controller for people with chronic stroke. Fourteen participants received a control treatment, followed by a washout period, and then the intervention. The intervention comprised playing computer games with the CyWee Z (CyWee Group Ltd; Taipei, Taiwan), a movement-based game controller similar to the Nintendo Wii remote. The CyWee Z was incorporated into a handlebar, making bilateral exercises possible by allowing the unaffected side to support and assist the affected side. The intervention lasted for 8 to 10 sessions of 45 to 60 minutes over a period of 2.5 weeks. The Fugl-Meyer Assessment upper-limb section (FMA-UL) was used as the primary outcome. The Wolf Motor Function Test and the Disabilities of Arm, Shoulder, and Hand outcome measure were used as secondary outcomes. Postintervention, motor performance as measured by the FMA-UL was significantly improved compared with all preintervention assessments (p < 0.001), whereas no changes were found on both secondary outcomes. It can be concluded from this pilot study that upper-limb motor performance of adults with chronic stroke improves with repetitive, game-assisted, self-supported bilateral exercises.

Using military friendships to optimize postdeployment reintegration for male Operation Iraqi Freedom/Operation Enduring Freedom veterans

Abstract: INTRODUCTION The role of social relationships in health outcomes is an area of growing research importance. The Veterans Health Administration (VHA) has begun to encourage research programs that explore the role of family members in veterans' health outcomes, particularly after the deployed veteran has been away from the family for an extended time. Research shows that contentious postdeployment interactions with civilian family members are linked with poor mental health outcomes [1-3]. However, supportive and emotionally intimate civilian family interactions with the returning veteran seem to protect against mental health problems. Family therapy sessions that include both the veteran and his or her family have been shown to successfully improve returning veterans' mental health outcomes [4-7]. Postdeployment family reintegration literature focuses on the family's role in helping the veteran transition from Active Duty military deployment to civilian society. This focus may miss other important personal connections that affect the veteran's life. One such connection is the relationship many veterans have with former military unit members who served with them when deployed. Former military unit members are typically cited as obstacles to civilian family reintegration [8] because of the emotional and experiential ties that bind military unit members. However, we argue that these same ties could be used strategically to create a supportive transition from Active Duty to civilian society. Drawing on interviews with Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans conducted from 2008 to 2009, we propose that the members of a military unit, especially those who participated as a group during a period of armed conflict, should be considered a resource to help rather than impede family reintegration. This proposal has implications for current reintegration policy and for the best way to help veterans transition into civilian society. Postdeployment Reintegration As of December 2009, 179,090 Active Duty (i.e., fulltime) and 71,217 Reserve Component servicemembers were on Active Duty as part of OIF/OEF [9]. In all, about 2,052,405 servicemembers have been deployed to the Iraq and Afghanistan wars [10]. An estimated 2 to 3 percent of the total American population, including family members, has been directly touched by the Afghanistan and Iraq wars. Postdeployment reintegration is stressful for veterans and their families, and family upheaval is common [8,11]. When the family environment is acrimonious, anger, distrust, and alienation can create veteran mental states that contribute to negative mental health outcomes [12]. Posttraumatic stress disorder (PTSD) diagnoses are more likely for those veterans whose family lives are characterized by low levels of expressiveness, low family cohesiveness, and high interpersonal conflict [1-3]. Contentious family relationships are also related to veteran interpartner violence [13], increased rates and severity of child abuse [14], marital dissolution, and divorce [15-17]. At the worst, family dysfunction and dissolution are linked to veteran homelessness [18-22]. Reintegration and Former Military Unit Members "We few, we happy few, we band of brothers. For he today that sheds his blood with me, shall be my brother...." [23]. Western culture has long recognized military friendships to be among the strongest relationships a veteran forms. The ancient Greek philosopher Aristotle noted that military camaraderie was essential for dealing with the emotional strains of combat [24]. Research supports the idea that being part of a military unit creates an uncommonly strong bond between military members. Both formal military training and military culture are built around the concept of servicemembers developing profound reliance on their comrades [25], and reliance can foster deep friendships. Physical and social isolation, an experience of shared risks, and deprivations of deployment encourage servicemembers to rely heavily on military unit members for social and emotional support, forging strong friendships [25-27]. …

Prosthetic sockets stabilized by alternating areas of tissue compression and release.

Abstract: INTRODUCTION Traditional upper-limb prosthetic sockets share certain problems Most sockets simply contain the tissue of the remaining limb Since a prosthetist produces them by slightly modifying casts taken by wrapping plaster bandages around the limb, the sockets are usually circular in cross section and thus encapsulate the limb The advent of myoelectric control led to new socket designs Transradial (TR) sockets were needed that would stabilize the location of the electrodes, and the Muenster and Northwestern sockets were introduced [1-3] These sockets are self-suspending but nonetheless still display a number of problems They do not permit the user to fully flex or extend the elbow, they do not prevent lost motion between the bones of the remaining limb and the distal prosthetic structure during active lifting, and they do not load the bone uniformly but rather concentrate the load near the ends Myoelectric control also changed transhumeral (TH) sockets with the introduction of the Dynamic Socket [4-6] It has a low lateral trim line to prevent the lifting of the electrodes during the extremes of flexion and abduction It also has anterior and posterior wings that stabilize the prosthesis against rotation around the long axis Similarly, the X-frame socket [7-9] has replaced the full contact socket for amputations at the shoulder level, because it permits the user to bend forward and to move the shoulder while maintaining good contact with electrodes It also stabilizes the prosthesis against rotation at its superior and inferior borders and covers far less surface area of the thorax for increased heat dissipation In this article, we review the evolution of these designs with additional references by Lake [7] LONGITUDINAL DEPRESSIONS AND RELEASE AREAS DEFINE COMPRESSION/RELEASE STABILIZED SOCKET This article will introduce improved sockets for persons with TR, TH, and transfemoral (TF) amputations created with longitudinal depressions added in the socket walls with open release areas between the depressions that receive the displaced tissue When the depressions and release areas are correctly located, they reduce motion of the underlying bony structures with respect to both the socket and the rest of the prosthesis One can define the depressions and releases during cast-taking but only by radically changing the way casts are taken Traditionally, the prosthetist uses a plaster wrap to define the shape of the remaining limb The typical plaster wrap results in a shell that is almost circular in cross section throughout most of its length When the shell is filled with plaster, the prosthetist modifies the resulting positive model before creating a socket over it by laminating or by thermoforming plastic The prosthetist then adds extra plaster to the model to create space in the socket to accommodate bony prominences and removes the plaster to tighten up the fit The experienced prosthetist can speed up the rectification process by contouring the original cast while it is setting Creating a compression/release stabilized (CRS) socket requires one to apply selective pressure during cast-taking, but this pressure must be applied in a specific way A definition of terms will help the reader to follow the discussion We only briefly summarize the casting process here, because prosthetists must be fully trained and certified in the application of this design such that patients are not harmed because of an incomplete understanding of the process If during the cast-taking, the technician pushes inward toward the bone, he or she will create a depression in the resulting cast When the depressed area is parallel to the length of the underlying bone, it will appear as a channel or longitudinal depression Further use of the word depression in this article will describe any shape created by pushing inward and use of longitudinal depression will describe long depressions parallel to the bones underneath …

Falls requiring medical attention among veterans with multiple sclerosis: A cohort study

Abstract: The purpose of this study was to estimate the rela- tive risk of an injurious fall requiring medical attention in vete- rans with multiple sclerosis (MS) compared with veterans without MS after controlling for sex, age, and healthcare use. The sample included 195,417 veterans treated at Veterans Health Administration (VHA) facilities in the Northwest United States in fiscal year 2008. We obtained information regarding MS diag- nosis, injurious falls (operationalized as International Classifi- cation of Diseases-9th Revision-Clinical Modification codes E880-E888), and demographic and healthcare use data from the VHA Consumer Health Information Performance Set database. Using logistic regression, we determined the adjusted odds ratio (OR) of an injurious fall to be three times higher in female veter- ans with MS than in female veterans without MS (OR = 3.0, 95% confidence interval (CI) = 1.6-5.5). The adjusted OR of an injurious fall for men with MS was also higher than for men without MS, but this difference was not statistically significant (OR = 1.2, 95% CI = 0.8-2.1). We recommend further studies evaluating the medical, social, and economic consequences of injurious falls, as well as interventions to prevent injurious falls, to improve the independence and quality of life of veterans and others living with MS.

Translating measurement findings into rehabilitation practice: an example using Fugl-Meyer Assessment-Upper Extremity with patients following stroke.

Abstract: Standardized assessments are critical for advancing clinical rehabilitation, yet assessment scores often provide little information for rehabilitation treatment planning. A keyform recovery map is an innovative way for a therapist to record patient responses to standardized assessment items. The form enables a therapist to view the specific items that a patient can or cannot perform. This information can assist a therapist in tailoring treatments to a patient's individual ability level. We demonstrate how a keyform recovery map can be used to inform clinical treatment planning for individuals with stroke-related upper-limb motor impairment. A keyform map of poststroke upper-limb recovery defined by items of the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) was generated by a previously published Rasch analysis. Three individuals with stroke enrolled in a separate research study were randomly selected from each of the three impairment strata of the FMA-UE. Their performance on each item was displayed on the FMA-UE keyform. The forms directly connected qualitative descriptions of patients' motor ability to assessment measures, thereby suggesting appropriate shorter and longer term rehabilitation goals. This study demonstrates how measurement theory can be used to translate a standardized assessment into a useful, evidence-based tool for making clinical practice decisions.

Self-management in neurological disorders: systematic review of the literature and potential interventions in multiple sclerosis care.

Abstract: Our objective was to review the current body of evidence supporting the efficacy of self-management programs in individuals with multiple sclerosis (MS) and other chronic neurological conditions. We reviewed published literature using standardized search terms; examined self-management interventions in a variety of chronic neurological disorders, including MS; and classified studies using the evidence classifi- cation established by the American Academy of Neurology. We reviewed 527 abstracts, of which 39 met our inclusion crite- ria for evaluation. Of the 39 studies, 3 provided class I evidence assessing the efficacy of self-management interventions: a ran- domized controlled trial of a telephone counseling program for health promotion in MS, a home-based exercise program for reducing falls in people with Parkinson disease, and the compari- son of a fitness center program versus a home-based exercise pro- gram for people with traumatic brain injury. The remaining studies provided additional support for self-management interventions with a lesser degree of methodologic rigor (class II, class III, or class IV evidence). We concluded that self-management strategies are applicable to chronic neurological diseases, but a need exists for more rigorous studies in this area. We provide recom- mendations for future intervention study methodologies with a specific emphasis on MS care.