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Gait recovery after stroke is a primary goal of rehabilitation, therefore it is imperative to develop technologies that accurately identify gait impairments after stroke. Markerless motion capture (MMC) is an emerging technology that has been validated in healthy individuals. Our study aims to evaluate the validity of MMC against an instrumented walkway system (IWS) commonly used to evaluate gait in stroke survivors. Nineteen participants performed three comfortable speed (CS) and three fastest speed (FS) walking trials simultaneously recorded with IWS and MMC system, KinaTrax (HumanVersion 8.2, KinaTrax Inc., Boca Raton, FL, USA). Pearson’s correlation coefficient and intraclass correlation coefficient (ICC (3,1), 95%CI) were used to evaluate the agreement and consistency between systems. Furthermore, Bland–Altman plots were used to estimate bias and Limits of Agreement (LoA). For both CS and FS, agreements between MMC and IWS were good to excellent in all parameters except for non-paretic single-limb support time (SLS), which revealed moderate agreement during CS. Additionally, stride width and paretic SLS showed poor agreement in both conditions. Biases eliminated systematic errors, with variable LoAs in all parameters during both conditions. Findings indicated high validity of MMC in measuring spatiotemporal gait parameters in stroke survivors. Further validity work is warranted.

Background In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors’ preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback preferences from stroke survivors. This project aims to determine the ease of understanding and movement encouragement of feedback based on wearable sensor data (both arm/hand use and mobility) for stroke survivors and to identify preferences for feedback metrics (mode, content, frequency, and timing). Methods A sample of 30 chronic stroke survivors wore a multi-sensor system in the natural environment over a 1-week monitoring period. The sensor system captured time in active movement of each arm, arm use ratio, step counts and stance time symmetry. Using the data from the monitoring period, participants were presented with a movement report with visual displays of feedback about arm/hand use, step counts and gait symmetry. A survey and qualitative interview were used to assess ease of understanding, actionability and components of feedback that users found most meaningful to drive lasting behavior change. Results Arm/hand use and mobility sensor-derived feedback metrics were easy to understand and actionable. The preferred metric to encourage arm/hand use was the hourly arm use bar plot, and similarly the preferred metric to encourage mobility was the hourly steps bar plot, which were each ranked as top choice by 40% of participants. Participants perceived that quantitative (i.e., step counts) and qualitative (i.e., stance time symmetry) mobility metrics provided complementary information. Three main themes emerged from the qualitative analysis: (1) Motivation for behavior change, (2) Real-time feedback based on individual goals, and (3) Value of experienced clinicians for prescription and accountability. Participants stressed the importance of having feedback tailored to their own personalized goals and receiving guidance from clinicians on strategies to progress and increase functional movement behavior in the unsupervised home and community setting. Conclusion The resulting technology has the potential to integrate engineering and personalized rehabilitation to maximize participation in meaningful life activities outside clinical settings in a less structured environment.

Background Individuals with hemiparesis post-stroke often have difficulty with tasks requiring upper extremity (UE) intra- and interlimb use, yet methods to quantify both are limited. Objective To develop a quantitative yet sensitive method to identify distinct features of UE intra- and interlimb use during task performance. Methods Twenty adults post-stroke and 20 controls wore five inertial sensors (wrists, upper arms, sternum) during 12 seated UE tasks. Three sensor modalities (acceleration, angular rate of change, orientation) were examined for three metrics (peak to peak amplitude, time, and frequency). To allow for comparison between sensor data, the resultant values were combined into one motion parameter, per sensor pair, using a novel algorithm. This motion parameter was compared in a group-by-task analysis of variance as a similarity score (0–1) between key sensor pairs: sternum to wrist, wrist to wrist, and wrist to upper arm. A use ratio (paretic/non-paretic arm) was calculated in persons post-stroke from wrist sensor data for each modality and compared to scores from the Adult Assisting Hand Assessment (Ad-AHA Stroke) and UE Fugl-Meyer (UEFM). Results A significant group × task interaction in the similarity score was found for all key sensor pairs. Post-hoc tests between task type revealed significant differences in similarity for sensor pairs in 8/9 comparisons for controls and 3/9 comparisons for persons post stroke. The use ratio was significantly predictive of the Ad-AHA Stroke and UEFM scores for each modality. Conclusions Our algorithm and sensor data analyses distinguished task type within and between groups and were predictive of clinical scores. Future work will assess reliability and validity of this novel metric to allow development of an easy-to-use app for clinicians.

Background We previously characterized hemisphere-specific motor control deficits in the ipsilesional, less-impaired arm of unilaterally lesioned stroke survivors. Our preliminary data indicate these deficits are substantial and functionally limiting in patients with severe paresis. Methods We have designed an intervention (“IPSI”) to remediate the hemisphere-specific deficits in the ipsilesional arm, using a virtual-reality platform, followed by manipulation training with a variety of real objects, designed to facilitate generalization and transfer to functional behaviors encountered in the natural environment. This is a 2-site (primary site – Penn State College of Medicine, secondary site – University of Southern California), two-group randomized intervention with an experimental group, which receives unilateral training of the ipsilesional arm throughout 3 one-hour sessions per week for 5 weeks, through our Virtual Reality and Manipulation Training (VRMT) protocol. Our control group receives a conventional intervention on the contralesional arm, 3 one-hour sessions per week for 5 weeks, guided by recently released practice guidelines for upper limb rehabilitation in adult stroke. The study aims to include a total of 120 stroke survivors (60 per group) whose stroke was in the territory of the middle cerebral artery (MCA) resulting in severe upper-extremity motor impairments. Outcome measures (Primary: Jebsen-Taylor Hand Function Test, Fugl-Meyer Assessment, Abilhand, Barthel Index) are assessed at five evaluation points: Baseline 1, Baseline 2, immediate post-intervention (primary endpoint), and 3-weeks (short-term retention) and 6-months post-intervention (long-term retention). We hypothesize that both groups will improve performance of the targeted arm, but that the ipsilesional arm remediation group will show greater improvements in functional independence. Discussion The results of this study are expected to inform upper limb evaluation and treatment to consider ipsilesional arm function, as part of a comprehensive physical rehabilitation strategy that includes evaluation and remediation of both arms. Trial Registration This study is registered with ClinicalTrials.gov (Registration ID: NCT03634397 ; date of registration: 08/16/2018).

Background: Significant variation exists in post-acute care for stroke survivors. This study examines referral practices of occupational and physical therapists for patients after acute stroke. Method: Occupational therapists (OTs) and physical therapists (PTs) were surveyed either electronically or in person at a national conference. The respondents selected the most appropriate referral for each of five case vignettes. The referral choices included Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility (SNF), Long-Term Acute Care Hospital (LTACH), home with home services, or home with outpatient services. Demographic data included practice location, setting, and duration. The respondents were also asked to rate how strongly 15 clinical factors influence their referral decisions. Results: The 33 OTs and 41 PTs favored similar referrals. Consensus was observed in four of the five cases. No differences were observed among the respondents based on practice location, practice setting, or number of years in practice and the referrals. Prognosis for functional improvement and pre-stroke functional status were identified as the most important factors influencing referral decisions. Conclusion: Further studies are needed to define areas of broad consensus as well as areas of disagreement, with subsequent efforts to clarify optimal treatment algorithms for patients who currently receive variable rehabilitative care. Keywords stroke, IRF, SNF, acute care Complete Author List Kathryn M. Gulfo, Glen Gillen, Lauri Bishop, Clare C. Bassile, Randy B. Kolodny, and Joel Stein

Unilateral deficits resulting from stroke manifest as reduced velocity, decreased cadence and asymmetries in temporal, spatial and force parameters during ambulation. Gait asymmetries and compensatory strategies employed during gait result in a higher mechanical energy cost that limits activity and community participation. Despite conventional rehabilitation efforts, individuals often remain with chronic gait deficits after stroke. Robotic-based therapies have been developed as an alternative to conventional rehabilitation. These therapies offer the means to provide task-specific training at an intensity greater than that of conventional approaches; however, to date outcomes have been similar to that of conventional training. One factor potentially contributing to the limited efficacy of robotic training is the active-assist control strategy that is often employed. This type of training strategy reduces the users’ engagement in the learning process and limits skilled learning. The tethered pelvic assist device (TPAD) is a robotic device that employs actuated tethers at the pelvis to guide the user along a pre-set movement trajectory. While other robotic devices restrict movement to a fixed trajectory, the TPAD promotes shifting weight onto the paretic limb, but permits users to freely move the limb to navigate spatiotemporal aspects of training independently. This allows individuals to participate in the problem-solving process required for motor learning to occur, facilitating a more active role in the motor task itself, and thus promoting learning. Earlier work utilized the TPAD to reduce gait asymmetry in a population of individuals in the chronic phase after stroke in a single training session (Bishop et al., 2015; Vashista, 2015). Results demonstrated an increase in propulsive forces of the affected limb as a result of the intervention, but these gains did not transfer to overground gait. A follow up study explored the feasibility and efficacy of two different training strategies using the TPAD (Bishop et al., 2017). Both training strategies proved feasible and similarly efficacious. The current work examines the feasibility and preliminary efficacy of a five-day intervention using the TPAD with faded visual feedback and a short bout of task-specific overground training to reduce gait asymmetry in a population of individuals at least six months after stroke. Participants underwent a series of three Pre Test assessments within a one-week interval prior to initiating the intervention. Training occurred over five consecutive days, with a Post Test assessment administered on conclusion of Day 5 of training. A one-week Follow Up assessment was also recorded. Results demonstrated this intervention coupling TPAD training with additional tenets of motor learning including visual feedback and salient task-specific overground training was feasible in terms of safety, tolerance and adherence. Further, while participant’s load asymmetry was not significantly reduced on the treadmill from Baseline to Post Training (p >0.05), there was a significant improvement in stance symmetry during overground gait (F = 8.498, p = 0.002). These results suggest that the integration of motor learning tenets with robotic TPAD training was useful in facilitating gains to overground walking. Implications to the broader scope of robotic training suggest that creating an environment in which the user plays a more active role is useful at maximizing effects of robotic training. Future work should include comparison groups (TPAD treadmill training, overground training, and combined TPAD and overground training) with a more robust sample size for a longer duration of training to parse out contributing factors to overground gains. Future work should also consider a longer training and follow up interval in an effort to determine whether individuals are able to maintain improvements longer than the immediate post training period.

We studied the performance of a robotic orthosis designed to assist the paretic hand after stroke. It is wearable and fully user-controlled, serving two possible roles: as a therapeutic tool that facilitates device mediated hand exercises to recover neuromuscular function or as an assistive device for use in everyday activities to aid functional use of the hand. We present the clinical outcomes of a pilot study designed as a feasibility test for these hypotheses. 11 chronic stroke (> 2 years) patients with moderate muscle tone (Modified Ashworth Scale less than or equal to 2 in upper extremity) engaged in a month-long training protocol using the orthosis. Individuals were evaluated using standardized outcome measures, both with and without orthosis assistance. Fugl-Meyer post intervention scores without robotic assistance showed improvement focused specifically at the distal joints of the upper limb, suggesting the use of the orthosis as a rehabilitative device for the hand. Action Research Arm Test scores post intervention with robotic assistance showed that the device may serve an assistive role in grasping tasks. These results highlight the potential for wearable and user-driven robotic hand orthoses to extend the use and training of the affected upper limb after stroke.

Wearable robotic hand rehabilitation devices can allow greater freedom and flexibility than their workstation-like counterparts. However, the field is generally lacking effective methods by which the user can operate the device: such controls must be effective, intuitive, and robust to the wide range of possible impairment patterns. Even when focusing on a specific condition, such as stroke, the variety of encountered upper limb impairment patterns means that a single sensing modality, such as electromyography (EMG), might not be sufficient to enable controls for a broad range of users. To address this significant gap, we introduce a multimodal sensing and interaction paradigm for an active hand orthosis. In our proof-of-concept implementation, EMG is complemented by other sensing modalities, such as finger bend and contact pressure sensors. We propose multimodal interaction methods that utilize this sensory data as input, and show they can enable tasks for stroke survivors who exhibit different impairment patterns. We believe that robotic hand orthoses developed as multimodal sensory platforms with help address some of the key challenges in physical interaction with the user.

Wearable orthoses can function both as assistive devices, which allow the user to live independently, and as rehabilitation devices, which allow the user to regain use of an impaired limb. To be fully wearable, such devices must have intuitive controls, and to improve quality of life, the device should enable the user to perform Activities of Daily Living. In this context, we explore the feasibility of using electromyography (EMG) signals to control a wearable exotendon device to enable pick and place tasks. We use an easy to don, commodity forearm EMG band with 8 sensors to create an EMG pattern classification control for an exotendon device. With this control, we are able to detect a user's intent to open, and can thus enable extension and pick and place tasks. In experiments with stroke survivors, we explore the accuracy of this control in both non-functional and functional tasks. Our results support the feasibility of developing wearable devices with intuitive controls which provide a functional context for rehabilitation.

Tendon-driven hand orthoses have advantages over exoskeletons with respect to wearability and safety because of their low-profile design and ability to fit a range of patients without requiring custom joint alignment. However, no existing study on a wearable tendon-driven hand orthosis for stroke patients presents evidence that such devices can overcome spasticity given repeated use and fatigue, or discusses transmission efficiency. In this study, we propose two designs that provide effective force transmission by increasing moment arms around finger joints. We evaluate the designs with geometric models and experiment using a 3D-printed artificial finger to find force and joint angle characteristics of the suggested structures. We also perform clinical tests with stroke patients to demonstrate the feasibility of the designs. The testing supports the hypothesis that the proposed designs efficiently elicit extension of the digits in patients with spasticity as compared to existing baselines.