Validation of a robot serious game assessment protocol for upper limb motor impairment in children with cerebral palsy.

BACKGROUND: The ROBiGAME project aims to implement serious games on robots to rehabilitate upper limb (UL) motor function in children with cerebral palsy (CP). Serious game characteristics (target position, level of assistance/resistance, level of force) are typically adapted based on the child's assessment before and continuously during the game (measuring UL working area, kinematics and muscle strength). OBJECTIVE: This study developed an UL robotic motor assessment protocol to configure the serious game. METHODS: Forty-nine healthy children and 20 CP children participated in the study. The clinical assessment consisted of the child's UL length and isometric force. The robot assessment consisted of the child's UL working area (WA), the UL isometric and isokinetic force in three directions and the UL kinematics during a pointing task toward targets placed at different distances. RESULTS: Results showed that WA and UL isometric force were moderately to highly correlated with clinical measures. Ratios between the UL isokinetic force generated on three directions were established. The velocity and straightness indexes of all children increased when they had to reach to targets placed more distant. CONCLUSIONS: This protocol can be integrated into different serious games in order to continuously configure the game characteristics to a child's performance. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (NCT02543424), 12 August 2015.

Bio-inspired design and validation of the Efficient Lockable Spring Ankle (ELSA) prosthesis.

Over the last decade, active lower-limb prostheses demonstrated their ability to restore a physiological gait for transfemoral amputees by supplying the required positive energy balance during daily life locomotion activities. However, the added-value of such devices is significantly impacted by their limited energetic autonomy, excessive weight and cost, thus preventing their full appropriation by the users. There is thus a strong incentive to produce active yet affordable, lightweight and energy efficient devices. To address these issues, we developed the ELSA (Efficient Lockable Spring Ankle) prosthesis embedding both a lockable parallel spring and a series elastic actuator, tailored to the walking dynamics of a sound ankle. The first contribution of this paper concerns the developement of a bio-inspired, lightweight and stiffness-adjustable parallel spring, comprising an energy efficient ratchet and pawl mechanism with servo actuation. The second contribution is the addition of a complementary rope-driven series elastic actuator to generate the active push-off. The system produces a sound ankle torque pattern during flat ground walking. Up to 50% of the peak torque is generated passively at a negligible energetic cost (0.1 J/stride). By design, the total system is lightweight (1.2kg) and low cost.

Robot Diagnosis Test for Egocentric and Allocentric Hemineglect.

OBJECTIVE: Patients with hemineglect fail to respond to egocentric stimuli or allocentric parts of stimuli contralateral to the brain lesion. The clinical diagnosis of hemineglect mainly involves evaluation of the egocentric form, while less sensitive standardized tests exist for other forms. Our global aim is to develop an innovative integrative robot measure, the MonAmour test, combining the assessment of egocentric, allocentric and motor hemineglect. Here, we present the egocentric and allocentric evaluations. METHODS: Thirty-five first stroke patients (25 hemineglect) and 56 age-matched healthy controls were assessed on the index test (MonAmour) and on three reference standard tests (Bells test, Apples test and Neglect subtest of the Test for Attentional Performance). Based on controls' performance, normative data were created. Validity was evaluated between the MonAmour and the reference standard tests through correlations and test sensitivity/specificity. Reliability of the MonAmour was measured with test-retest and minimal detectable change. RESULTS: Results demonstrated moderate to strong correlations between the MonAmour and the reference standard tests (r = .40-.88, p < .001 - p = .016). The sensitivity was high (50%-96%), with accurate diagnosis of patients with hemineglect, and reliability was excellent (Intraclass Correlation Coefficient = .79-.95, p < .001). CONCLUSIONS: The MonAmour robot test is a valid, sensitive and reliable tool that can diagnose egocentric and allocentric hemineglect. Future studies will deepen the assessment and understanding of the different forms of hemineglect by testing the motor component of the test in order to use this accurate and integrative measure in daily clinical routine. REGISTRATION: ClinicalTrials.gov(NCT02543424).

Age Effects on Upper Limb Kinematics Assessed by the REAplan Robot in Healthy Subjects Aged 3 to 93 Years.

Kinematics is recommended for the quantitative assessment of upper limb movements. The aims of this study were to determine the age effects on upper limb kinematics and establish normative values in healthy subjects. Three hundred and seventy healthy subjects, aged 3-93 years, participated in the study. They performed two unidirectional and two geometrical tasks ten consecutive times with the REAplan, a distal effector robotic device that allows upper limb displacements in the horizontal plane. Twenty-six kinematic indices were computed for the four tasks. For the four tasks, nineteen of the computed kinematic indices showed an age effect. Seventeen indices (the accuracy, speed and smoothness indices and the reproducibility of the accuracy, speed and smoothness) improved in young subjects aged 3-30 years, showed stabilization in adults aged 30-60 years and declined in elderly subjects aged 60-93 years. Additionally, for both geometrical tasks, the speed index exhibited a decrease throughout life. Finally, a principal component analysis provided the relations between the kinematic indices, tasks and subjects' age. This study is the first to assess age effects on upper limb kinematics and establish normative values in subjects aged 3-93 years.

Age Effects on Upper Limb Kinematics Assessed by the REAplan Robot in Healthy School-Aged Children.

The use of kinematics is recommended to quantitatively evaluate upper limb movements. The aims of this study were to determine the age effects on upper limb kinematics and establish norms in healthy children. Ninety-three healthy children, aged 3-12 years, participated in this study. Twenty-eight kinematic indices were computed from four tasks. Each task was performed with the REAplan, a distal effector robotic device that allows upper limb displacements in the horizontal plane. Twenty-four of the 28 indices showed an improvement during childhood. Indeed, older children showed better upper limb movements. This study was the first to use a robotic device to show the age effects on upper limb kinematics and establish norms in healthy children.

Upper limb robot-assisted therapy in cerebral palsy: a single-blind randomized controlled trial.

BACKGROUND: Several pilot studies have evoked interest in robot-assisted therapy (RAT) in children with cerebral palsy (CP). OBJECTIVE: To assess the effectiveness of RAT in children with CP through a single-blind randomized controlled trial. PATIENTS AND METHODS: Sixteen children with CP were randomized into 2 groups. Eight children performed 5 conventional therapy sessions per week over 8 weeks (control group). Eight children completed 3 conventional therapy sessions and 2 robot-assisted sessions per week over 8 weeks (robotic group). For both groups, each therapy session lasted 45 minutes. Throughout each RAT session, the patient attempted to reach several targets consecutively with the REAPlan. The REAPlan is a distal effector robot that allows for displacements of the upper limb in the horizontal plane. A blinded assessment was performed before and after the intervention with respect to the International Classification of Functioning framework: body structure and function (upper limb kinematics, Box and Block test, Quality of Upper Extremity Skills Test, strength, and spasticity), activities (Abilhand-Kids, Pediatric Evaluation of Disability Inventory), and participation (Life Habits). RESULTS: During each RAT session, patients performed 744 movements on average with the REAPlan. Among the variables assessed, the smoothness of movement (P < .01) and manual dexterity assessed by the Box and Block test (P = .04) improved significantly more in the robotic group than in the control group. CONCLUSIONS: This single-blind randomized controlled trial provides the first evidence that RAT is effective in children with CP. Future studies should investigate the long-term effects of this therapy.

Using the robotic device REAplan as a valid, reliable, and sensitive tool to quantify upper limb impairments in stroke patients.

OBJECTIVE: To validate a protocol assessing upper limb kinematics using a planar robot among stroke patients. DESIGN: Prospective cohort study. SUBJECTS: Age-matched healthy subjects (n = 25) and stroke patients (n = 25). METHODS: Various kinematic indices (n = 44) were obtained from 4 tasks performed by subjects with REAplan, a planar end-effector robotic device. The metrological properties of this protocol were studied. RESULTS: In stroke patients, 43 kinematic indices showed moderate to excellent reliability (intraclass correlation coefficients (ICC) range 0.40-0.95; and minimal detectable changes range 9.9-121.1%). In healthy subjects, 25 kinematic indices showed moderate to excellent reliability (ICC range 0.40-0.91) and 3 indices showed a laterality effect (p < 0.05). Many of these indices (27 of 44) were altered in stroke patients in comparison with healthy subjects (p < 0.05). The Box and Block test (manual dexterity) and Upper Limb Sub-score of the Fugl-Meyer Assessment (motor control) showed moderate to good correlations with, respectively, 13 and 4 indices (r > 0.40). Finally, a principal component analysis allowed the elaboration of a short version of the protocol, reducing the number of indices to 5 (i.e. Amplitude, CVstraightness, Speed Metric, CVjerk metric and CVspeed metric). CONCLUSION: This study provides a standardized, valid, reliable and sensitive protocol to quantify upper limb impairments in stroke patients, using a planar robot.

Optimal design of an alignment-free two-DOF rehabilitation robot for the shoulder complex.

This paper presents the optimal design of an alignment-free exoskeleton for the rehabilitation of the shoulder complex. This robot structure is constituted of two actuated joints and is linked to the arm through passive degrees of freedom (DOFs) to drive the flexion-extension and abduction-adduction movements of the upper arm. The optimal design of this structure is performed through two steps. The first step is a multi-objective optimization process aiming to find the best parameters characterizing the robot and its position relative to the patient. The second step is a comparison process aiming to select the best solution from the optimization results on the basis of several criteria related to practical considerations. The optimal design process leads to a solution outperforming an existing solution on aspects as kinematics or ergonomics while being more simple.

A robotic device as a sensitive quantitative tool to assess upper limb impairments in stroke patients: a preliminary prospective cohort study.

OBJECTIVE: To compare kinematic indices in age-matched healthy subjects and stroke patients, by evaluating various tasks performed with a robotic device, and to provide an objective and standardized protocol to assess upper limb impairments in stroke patients. DESIGN: A prospective cohort study. SUBJECTS: Age-matched healthy subjects (n = 10) and stroke patients (n = 10). METHODS: Various kinematic indices were analysed from 3 randomly assigned tasks performed by the affected arm in stroke patients and the dominant arm in healthy subjects. These tasks, composed of large-amplitude, targeted and geometrical movements, were standardized and performed with the ReaPLAN robotic device. RESULTS: For large-amplitude movements, the stroke patients' path lengths were less constant in amplitude, less rectilinear and less smooth than those for healthy subjects (p < 0.001). For the targeted movements, the stroke patients' path lengths were less rectilinear than those of the healthy subjects (p < 0.001). For the geometrical movements, the stroke patients had greater difficulty making the requested shapes compared with the healthy subjects (p < 0.01). CONCLUSION: Our study proposes an objective and standardized protocol to assess stroke patients' upper limbs with any robotic device. We suggest that further randomized controlled trials could use this quantitative tool to assess the efficacy of treatments such as robot-assisted therapy.

ShouldeRO, an alignment-free two-DOF rehabilitation robot for the shoulder complex.

This paper presents a robot aimed to assist the shoulder movements of stroke patients during their rehabilitation process. This robot has the general form of an exoskeleton, but is characterized by an action principle on the patient no longer requiring a tedious and accurate alignment of the robot and patient's joints. It is constituted of a poly-articulated structure whose actuation is deported and transmission is ensured by Bowden cables. It manages two of the three rotational degrees of freedom (DOFs) of the shoulder. Quite light and compact, its proximal end can be rigidly fixed to the patient's back on a rucksack structure. As for its distal end, it is connected to the arm through passive joints and a splint guaranteeing the robot action principle, i.e. exert a force perpendicular to the patient's arm, whatever its configuration. This paper also presents a first prototype of this robot and some experimental results such as the arm angular excursions reached with the robot in the three joint planes.

Development and first in vivo trial of EvoLap, an active laparoscope positioner.

To determine essential specifications for an active endoscope holder, a survey of laparoscopic procedures was conducted. A review of the literature highlighted the advantages and limitations of existing scope-holding systems. From this analysis, basic requirements were listed for such devices. Pursuant to this, an ergonomic and user-friendly laparoscope manipulator was designed to assist the surgeon. A first in vivo procedure demonstrated feasibility of the device and its value in clinical practice, enabling surgeons to work more comfortably.

Design and preliminary in vivo validation of a robotic laparoscope holder for minimally invasive surgery.

BACKGROUND: Manual manipulation of the camera is a major source of difficulties encountered by surgeons while performing minimally invasive laparoscopic surgery. METHODS: A survey of laparoscopic procedures and a review of existing active and passive holders were conducted. Based on these analyses, essential requirements were highlighted for such devices. Pursuant to this, a novel active laparoscope manipulator was designed, paying particular attention to ergonomics and ease of use. Several trials on the pelvitrainer and a first in vivo procedure were performed to validate the original design of our device. RESULTS: Phantom experiments demonstrated ease of use of the robot and advantages of the intuitive joystick with omnidirectional displacements and speed control. The compactness of the device and image stability were appreciated during the surgical trial. CONCLUSIONS: A novel robotic laparoscope holder has been developed and produced. An in vivo trial proved its value in clinical practice, enabling surgeons to work more comfortably.

Surgical inaccuracy of tumor resection and reconstruction within the pelvis: an experimental study.

BACKGROUND AND PURPOSE: Osseous pelvic tumors can be resected and reconstructed using massive bone allografts. Geometric accuracy of the conventional surgical procedure has not yet been documented. The aim of this experimental study was mainly to assess accuracy of tumoral resection with a 10-mm surgical margin, and also to evaluate the geometry of the host-graft reconstruction. METHODS: An experimental model on plastic pelvises was designed to simulate tumor resection and reconstruction. 4 experienced surgeons were asked to resect 3 different tumors and to reconstruct pelvises. 24 resections and host-graft junctions were available for evaluation. Resection margins were measured. Several methods were created to evaluate geometric properties of the host-graft junction. RESULTS: The probability of a surgeon obtaining a 10-mm surgical margin with a 5-mm tolerance above or below, was 52% (95% CI: 37-67). Maximal gap, gap volume, and mean gap between host and graft was 3.3 (SD 1.9) mm, 2.7 (SD 2.1) cm3 and 3.2 (SD 2.1) mm, respectively. Correlation between these 3 reconstruction measures and the degree of contact at the host-graft junction was poor. INTERPRETATION: 4 experienced surgeons did not manage to consistently respect a fixed surgical margin under ideal working conditions. The complex 3-dimensional architecture of the pelvis would mainly explain this inaccuracy. Solutions to this might be to increase the surgical margin or to use computer- and robotic-assisted technologies in pelvic tumor resection. Furthermore, our attempt to evaluate geometry of the pelvic reconstruction using simple parameters was not satisfactory. We believe that there is a need to define new standards of evaluation.