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The effects of robot-assisted gait training on locomotor function in subjects with multiple sclerosis: A three months follow-up study
S12
Abstracts / Gait & Posture 33S (2011) S1–S66
Results As expected, for each lower limb rotation (protocol [2]), the inter-trial variability (range [deg] 0.9–4.3) was smaller than the inter-session variability (1.5–5.5), and the latter was smaller than the inter-examiner variability (1.6–6.3). Corresponding ranges for the three foot joints (protocol [3]) were 0.9–1.7, 1.9–7.8, and 2.7–11.5. In terms of inter-session variability, the performance of the four examiners with the lower limb protocol was fairly consistent, with mean values over all the variables respectively 2.2◦ , 2.5◦ , 3.0◦ , and 3.0◦ , in accordance also with the increasing experience. With the foot protocol, these were 3.3◦ , 3.6◦ , 6.0◦ and 5.4◦ ; though still in accordance with the experience, two examiners performed much better than the other two. The inter-examiner-to-inter-trial ratio was also calculated, and ranged from 1.0◦ (pelvis rotation) to 2.2◦ (pelvis tilt) in the lower limb, and from 3.1◦ (Lisfranc flexion) to 10.4◦ (Chopart flexion) in the foot. Discussion The values found for the foot protocol [3] were slightly worse than those for the lower limb [2], this perhaps accounted for the smaller areas and the awkward landmarks. The large overall variability shown by two of the examiners was found to be due to a single marker mispositioning, not fully comprehended since the beginning of the experiment. These recent protocols claimed, among other advantages, to provide more repeatable measurements and easier training of examiners because the reference frames were based only on landmarks defined in terms of bony prominences. The present results show that the lower limb protocol has a small inter-session and inter-examiner variability, particularly for rotations of the pelvis in the laboratory frame and of the three joints in the sagittal and coronal planes, which compares well with those in the previous work [1]. In addition, when the inter-examiner-to-inter-trial ratio is considered, i.e. extrinsic-to-intrinsic error, the present results are all smaller than those obtained with the Plug-in Gait protocol analysed in [1], i.e. the ‘conventional’ protocol, where these ranged between 1.4◦ and 4.2◦ . It appears that a smaller ‘proportion of error arose from methodological sources’ [1], i.e. those remaining when the inner (intra-subject) repeatability of the subjects analysed is removed. This smaller variability for each of the gait variables, within 2◦ for most of these, was achieved also by inexperienced examiners. On the other hand, for the multi-segmental foot protocols it is important to train the examiners more carefully because small marker misplacements can result in large joint rotation variability. It is recommended that current and future protocols are assessed and compared also with this technique. References [1] Schwartz MH, Trost JP, Wervey RA. Measurement and management of errors in quantitative gait data. Gait Posture 2004;20:196–203. [2] Leardini A, Sawacha Z, Paolini G, Ingrosso S, Nativo R, Benedetti MG. A new anatomically based protocol for gait analysis in children. Gait Posture 2007;26:560–71. [3] Leardini A, Benedetti MG, Berti L, Bettinelli D, Nativo R, Giannini S. Rear-foot, mid-foot and fore-foot motion during the stance phase of gait. Gait Posture 2007;25(March (3)):453–62.
O12 The effects of robot-assisted gait training on locomotor function in subjects with multiple sclerosis: A three months follow-up study E. Venturini, L. Balugani, F. Zarattin, G. Ferraresi, S. Straudi, N. Basaglia Movement Analysis Laboratory, Department of Neuroscience and Rehabilitation Medicine, Ferrara, Italy Introduction Gait disabilities are very common in multiple sclerosis with a negative impact on personal activities and quality of life. It has been shown that human brain is capable of significant modification providing that the quantity (duration and frequency) and quality (task specificity) of rehabilitative interventions are appropriate to facilitate neuroplasticity and motor learning [1]. The aims of this study is to test the effects of robot-assisted gait training in mid-functioning multiple sclerosis subjects on spatiotemporal gait parameters and locomotor function. Materials and methods This is a pilot randomized single blind trial. Multiple sclerosis subjects with no relapse during the last 6 months and gait impairments defined as Expanded Disability Status Scale from 4.5 to 6.5 were enrolled. Participants have been randomized to robot-assisted gait training (RAGT) or conventional therapy (CT). The experimental group received 12 robot-assisted gait training session over 6 weeks (2 sessions/week). The control group received 12 conventional therapy sessions over 6 weeks (2 sessions/week). Primary outcome measures were spatiotemporal gait parameters obtained with a stereophotogrammetric system with 6 infrared cameras (VICON 460, Vicon Motion System Ltd., UK). Secondary outcome measures included clinical tests as the six-minute walking test (SMWT), the Berg Balance Test (BBT) and the Timed Up and Go test (TUG). Self-reported questionnaire on motor fatigue (Fatigue Severity Scale) was submitted. Outcome measures were assessed pre-post-training and after 3 months. Results Twenty subjects were randomized, ten to RAGT and ten to conventional therapy. Three subjects dropped out due to medical conditions. Spatiotemporal gait parameters showed an overall improvement after training in the RAGT group: walking speed improved from 0.57 ± 0.24 to 0.65 ± 0.21 (p < 0.0001) and 0.6 ± 0.23 at 3 months (Fig. 1); cadence improved after treatment from 76.9 ± 24.5 to 83.1 ± 21.1 (p < 0.0001) and was sustained (80.1 ± 21.1); double support was reduced from 0.80 ± 0.67 to 0.60 ± 0.51 (p < 0.0001) and 0.64 ± 0.57 at 3 months. There were no differences in walking speed and cadence in the conventional therapy group. Walking endurance was improved by an average of 40.2 m in the RAGT group (p < 0.01), compared to −0.1 m in the CT group after training. At 3 months RAGT group still improved in walking endurance by an average of 53.9 m (p < 0.01) in
doi:10.1016/j.gaitpost.2010.10.016
Fig. 1. Gait speed in RAGT and CT groups.
Abstracts / Gait & Posture 33S (2011) S1–S66
S13
the SMWT. Better performance was also noted in the TUG and BBT scores in the RAGT group. Subjects also reported a reduced motor fatigue after training. Discussion Robot-assisted gait training seems to be effective in restoring walking competency in mid-functioning multiple sclerosis subjects. These results were partially retained at 3 months follow-up. Reference [1] Pelletier J, Audoin B, Reuter F, Ranjeva JP. Plasticity in SM: from functional imaging to rehabilitation. Int MS J 2009;16(1):26–31.
doi:10.1016/j.gaitpost.2010.10.017 O13 A protocol for the assessment of sensory re-weighting in the development of coordination during reach-to-grasp in children M. Cazzagon 1,2 , F. Zecchini 1,2 , G. Tornatore 1,2 , D. Restuccia 1,2 , A. Merlo 1,2 1
IRCCS “E.Medea” Polo Friuli – Associazione La Nostra Famiglia, Italy LAM – Laboratorio Analisi Movimento, Dip. Riabilitazione, AUSL Reggio Emilia, Correggio (RE), Italy 2
Introduction We designed a protocol suited to assess the relative contribution to the motor output of both the visual and the proprioceptive systems during a reach-to-grasp task and tested its feasibility and sensitivity on a sample of healthy children with age 10–12 years. Materials and methods Ten healthy children (age 11 ± 0.8) were asked to repetitively reach and grasp an object placed on a table in front of them, for 20 s, at natural self-paced speed. All environmental factors were standardized as in [1]. Each task was performed in four conditions: lighted room (L), dark room with only the object visible (D), lighted room with a weight (500 g) on the forearm (LW), and dark room with the weight on the forearm (DW). The protocol is illustrated in Fig. 1. Tasks were administered in random order, for three times, after a trial session. Kinematic data were obtained from reflective markers, placed as in [1], by means of a 3D motion analysis system (SmartD, BTS, Italy). The effect of the environmental condition on the index of curvature of the finger trajectory (IC) (Fig. 2), the number of peaks in the index trajectory (NP) and the arm-trunk displacement delay (ATDD) was investigated by the non-parametric Wilcoxon test, with significance set at 5%. Results The protocol was completed by all children. The environmental condition did not significantly affect IC. The trajectory was straight in all conditions (IC = 1.1), due to the distance of the target. NP increased significantly from 1 to 2 or 3 in the DW condition, as expected. ATDD was sensitive to the lack of visual information created by the dark environment. Discussion Results suggest that the designed protocol, with minor improvements, can be used to follow the development of the visual and the proprioceptive systems and their relative contributions to motor control in reaching tasks during childhood. The proposed protocol could provide knowledge on the development of perceptual strategy in healthy children and support both the assessment of the upper extremities motor ability and the development of rehabilitative programs in impaired children, such as children with CP, C-OMA and DCD, who suffers from alterations in both coordination and postural control during reaching tasks
Fig. 1. Protocol created for the assessment of the relative contribution of both the visual and the proprioceptive systems to the motor output during a reach-to-grasp task. The reach-to-grasp task was repeated in four conditions: naturally lighted environment (L), dark environment with the target lighted (D), naturally lighted environment with a 500 g weight on the forearm (LW) and dark environment with a 500 g weight on the forearm (DW). Task are administered in a randomized order, according to block-randomized sequences. Example: DW; L; LW; D-L; LW; D; DW-D; LW; L; DW.
Fig. 2. Index finger trajectory for one subject in the four protocol conditions.
Reference [1] Schneiberg, et al. Exp Brain Res 2002;146:142–54.
doi:10.1016/j.gaitpost.2010.10.018 O14 Evaluation of vertical forces applied to the end-effector of a planar robot during a rehabilitation session: A case study M. Germanotta 1 , M. Petrarca 2 , S. Rossi 1,2 , P. Cappa 1,2 , E. Castelli 2 1
Department of Mechanics and Aeronautics, “Sapienza” University of Rome, Via Eudossiana, 18-00184 Rome, Italy 2 Pediatric Neuro-Rehabilitation Division, Children’s Hospital “Bambino Gesù” IRCCS, Via Torre di Palidoro, 00050 Passoscuro (Fiumicino), Rome, Italy Introduction In the present work, the vertical force applied to the end-effector of a planar robot by an ictus patient was evaluated. In literature, the force increases in the vertical direction when the arm is moving away from the trunk during reaching tasks [1]. The central ner-
Abstracts / Gait & Posture 33S (2011) S1–S66
Results As expected, for each lower limb rotation (protocol [2]), the inter-trial variability (range [deg] 0.9–4.3) was smaller than the inter-session variability (1.5–5.5), and the latter was smaller than the inter-examiner variability (1.6–6.3). Corresponding ranges for the three foot joints (protocol [3]) were 0.9–1.7, 1.9–7.8, and 2.7–11.5. In terms of inter-session variability, the performance of the four examiners with the lower limb protocol was fairly consistent, with mean values over all the variables respectively 2.2◦ , 2.5◦ , 3.0◦ , and 3.0◦ , in accordance also with the increasing experience. With the foot protocol, these were 3.3◦ , 3.6◦ , 6.0◦ and 5.4◦ ; though still in accordance with the experience, two examiners performed much better than the other two. The inter-examiner-to-inter-trial ratio was also calculated, and ranged from 1.0◦ (pelvis rotation) to 2.2◦ (pelvis tilt) in the lower limb, and from 3.1◦ (Lisfranc flexion) to 10.4◦ (Chopart flexion) in the foot. Discussion The values found for the foot protocol [3] were slightly worse than those for the lower limb [2], this perhaps accounted for the smaller areas and the awkward landmarks. The large overall variability shown by two of the examiners was found to be due to a single marker mispositioning, not fully comprehended since the beginning of the experiment. These recent protocols claimed, among other advantages, to provide more repeatable measurements and easier training of examiners because the reference frames were based only on landmarks defined in terms of bony prominences. The present results show that the lower limb protocol has a small inter-session and inter-examiner variability, particularly for rotations of the pelvis in the laboratory frame and of the three joints in the sagittal and coronal planes, which compares well with those in the previous work [1]. In addition, when the inter-examiner-to-inter-trial ratio is considered, i.e. extrinsic-to-intrinsic error, the present results are all smaller than those obtained with the Plug-in Gait protocol analysed in [1], i.e. the ‘conventional’ protocol, where these ranged between 1.4◦ and 4.2◦ . It appears that a smaller ‘proportion of error arose from methodological sources’ [1], i.e. those remaining when the inner (intra-subject) repeatability of the subjects analysed is removed. This smaller variability for each of the gait variables, within 2◦ for most of these, was achieved also by inexperienced examiners. On the other hand, for the multi-segmental foot protocols it is important to train the examiners more carefully because small marker misplacements can result in large joint rotation variability. It is recommended that current and future protocols are assessed and compared also with this technique. References [1] Schwartz MH, Trost JP, Wervey RA. Measurement and management of errors in quantitative gait data. Gait Posture 2004;20:196–203. [2] Leardini A, Sawacha Z, Paolini G, Ingrosso S, Nativo R, Benedetti MG. A new anatomically based protocol for gait analysis in children. Gait Posture 2007;26:560–71. [3] Leardini A, Benedetti MG, Berti L, Bettinelli D, Nativo R, Giannini S. Rear-foot, mid-foot and fore-foot motion during the stance phase of gait. Gait Posture 2007;25(March (3)):453–62.
O12 The effects of robot-assisted gait training on locomotor function in subjects with multiple sclerosis: A three months follow-up study E. Venturini, L. Balugani, F. Zarattin, G. Ferraresi, S. Straudi, N. Basaglia Movement Analysis Laboratory, Department of Neuroscience and Rehabilitation Medicine, Ferrara, Italy Introduction Gait disabilities are very common in multiple sclerosis with a negative impact on personal activities and quality of life. It has been shown that human brain is capable of significant modification providing that the quantity (duration and frequency) and quality (task specificity) of rehabilitative interventions are appropriate to facilitate neuroplasticity and motor learning [1]. The aims of this study is to test the effects of robot-assisted gait training in mid-functioning multiple sclerosis subjects on spatiotemporal gait parameters and locomotor function. Materials and methods This is a pilot randomized single blind trial. Multiple sclerosis subjects with no relapse during the last 6 months and gait impairments defined as Expanded Disability Status Scale from 4.5 to 6.5 were enrolled. Participants have been randomized to robot-assisted gait training (RAGT) or conventional therapy (CT). The experimental group received 12 robot-assisted gait training session over 6 weeks (2 sessions/week). The control group received 12 conventional therapy sessions over 6 weeks (2 sessions/week). Primary outcome measures were spatiotemporal gait parameters obtained with a stereophotogrammetric system with 6 infrared cameras (VICON 460, Vicon Motion System Ltd., UK). Secondary outcome measures included clinical tests as the six-minute walking test (SMWT), the Berg Balance Test (BBT) and the Timed Up and Go test (TUG). Self-reported questionnaire on motor fatigue (Fatigue Severity Scale) was submitted. Outcome measures were assessed pre-post-training and after 3 months. Results Twenty subjects were randomized, ten to RAGT and ten to conventional therapy. Three subjects dropped out due to medical conditions. Spatiotemporal gait parameters showed an overall improvement after training in the RAGT group: walking speed improved from 0.57 ± 0.24 to 0.65 ± 0.21 (p < 0.0001) and 0.6 ± 0.23 at 3 months (Fig. 1); cadence improved after treatment from 76.9 ± 24.5 to 83.1 ± 21.1 (p < 0.0001) and was sustained (80.1 ± 21.1); double support was reduced from 0.80 ± 0.67 to 0.60 ± 0.51 (p < 0.0001) and 0.64 ± 0.57 at 3 months. There were no differences in walking speed and cadence in the conventional therapy group. Walking endurance was improved by an average of 40.2 m in the RAGT group (p < 0.01), compared to −0.1 m in the CT group after training. At 3 months RAGT group still improved in walking endurance by an average of 53.9 m (p < 0.01) in
doi:10.1016/j.gaitpost.2010.10.016
Fig. 1. Gait speed in RAGT and CT groups.
Abstracts / Gait & Posture 33S (2011) S1–S66
S13
the SMWT. Better performance was also noted in the TUG and BBT scores in the RAGT group. Subjects also reported a reduced motor fatigue after training. Discussion Robot-assisted gait training seems to be effective in restoring walking competency in mid-functioning multiple sclerosis subjects. These results were partially retained at 3 months follow-up. Reference [1] Pelletier J, Audoin B, Reuter F, Ranjeva JP. Plasticity in SM: from functional imaging to rehabilitation. Int MS J 2009;16(1):26–31.
doi:10.1016/j.gaitpost.2010.10.017 O13 A protocol for the assessment of sensory re-weighting in the development of coordination during reach-to-grasp in children M. Cazzagon 1,2 , F. Zecchini 1,2 , G. Tornatore 1,2 , D. Restuccia 1,2 , A. Merlo 1,2 1
IRCCS “E.Medea” Polo Friuli – Associazione La Nostra Famiglia, Italy LAM – Laboratorio Analisi Movimento, Dip. Riabilitazione, AUSL Reggio Emilia, Correggio (RE), Italy 2
Introduction We designed a protocol suited to assess the relative contribution to the motor output of both the visual and the proprioceptive systems during a reach-to-grasp task and tested its feasibility and sensitivity on a sample of healthy children with age 10–12 years. Materials and methods Ten healthy children (age 11 ± 0.8) were asked to repetitively reach and grasp an object placed on a table in front of them, for 20 s, at natural self-paced speed. All environmental factors were standardized as in [1]. Each task was performed in four conditions: lighted room (L), dark room with only the object visible (D), lighted room with a weight (500 g) on the forearm (LW), and dark room with the weight on the forearm (DW). The protocol is illustrated in Fig. 1. Tasks were administered in random order, for three times, after a trial session. Kinematic data were obtained from reflective markers, placed as in [1], by means of a 3D motion analysis system (SmartD, BTS, Italy). The effect of the environmental condition on the index of curvature of the finger trajectory (IC) (Fig. 2), the number of peaks in the index trajectory (NP) and the arm-trunk displacement delay (ATDD) was investigated by the non-parametric Wilcoxon test, with significance set at 5%. Results The protocol was completed by all children. The environmental condition did not significantly affect IC. The trajectory was straight in all conditions (IC = 1.1), due to the distance of the target. NP increased significantly from 1 to 2 or 3 in the DW condition, as expected. ATDD was sensitive to the lack of visual information created by the dark environment. Discussion Results suggest that the designed protocol, with minor improvements, can be used to follow the development of the visual and the proprioceptive systems and their relative contributions to motor control in reaching tasks during childhood. The proposed protocol could provide knowledge on the development of perceptual strategy in healthy children and support both the assessment of the upper extremities motor ability and the development of rehabilitative programs in impaired children, such as children with CP, C-OMA and DCD, who suffers from alterations in both coordination and postural control during reaching tasks
Fig. 1. Protocol created for the assessment of the relative contribution of both the visual and the proprioceptive systems to the motor output during a reach-to-grasp task. The reach-to-grasp task was repeated in four conditions: naturally lighted environment (L), dark environment with the target lighted (D), naturally lighted environment with a 500 g weight on the forearm (LW) and dark environment with a 500 g weight on the forearm (DW). Task are administered in a randomized order, according to block-randomized sequences. Example: DW; L; LW; D-L; LW; D; DW-D; LW; L; DW.
Fig. 2. Index finger trajectory for one subject in the four protocol conditions.
Reference [1] Schneiberg, et al. Exp Brain Res 2002;146:142–54.
doi:10.1016/j.gaitpost.2010.10.018 O14 Evaluation of vertical forces applied to the end-effector of a planar robot during a rehabilitation session: A case study M. Germanotta 1 , M. Petrarca 2 , S. Rossi 1,2 , P. Cappa 1,2 , E. Castelli 2 1
Department of Mechanics and Aeronautics, “Sapienza” University of Rome, Via Eudossiana, 18-00184 Rome, Italy 2 Pediatric Neuro-Rehabilitation Division, Children’s Hospital “Bambino Gesù” IRCCS, Via Torre di Palidoro, 00050 Passoscuro (Fiumicino), Rome, Italy Introduction In the present work, the vertical force applied to the end-effector of a planar robot by an ictus patient was evaluated. In literature, the force increases in the vertical direction when the arm is moving away from the trunk during reaching tasks [1]. The central ner-