Implementation, testing and pilot clinical evaluation of superelastic splints that decrease joint stiffness

Design and custom fabrication of specialized orthoses for the upper-limb stabilization in childhood dyskinesia

BACKGROUND

Childhood dyskinesia (CD) is a complex movement disorder with components of dystonic and hyperkinetic nature, characterized by involuntary, sometimes stereotypical postures and gestures that are often impossible to control and hinder the execution of willful motion. The standard orthoses for the treatment of neurological diseases, including CD, are generally poorly differentiated for functional characteristics. The application of similar devices for movement disorders is far less generalized because of the very different symptoms, including the incapacity to control rather than initiate movement.

OBJECTIVES

This article aims to describe an innovative method to fabricate personalized orthoses for the elbow-wrist joints in CD, taking into account anatomical and functional diversities. It also proposes functional elements to implement the required dynamic postural control.

METHODS

Wearable custom-made upper-limb orthoses have been fabricated and preliminarily tested on five patients with CD. Optoelectronic stereophotogrammetry was used as an innovative tool for all-in-one-frame acquisition of limb geometry. A new process for the functional personalization of the orthoses has been developed using shape memory alloys.

CONCLUSIONS

The innovative method presented, encompassing data acquisition, virtual design, fabrication, and assembling, overcomes the problems due to the involuntary movements of the patients, which cannot be avoided during the fitting operations, providing comfortable and useful orthoses with minimal nuisance for the patients. Initial tests show that the orthoses were well tolerated by all the subjects; the promising comments of caregivers, together with improvements, were observed by the clinicians using specific clinical scales.

Overview of systematic reviews: Management of common Traumatic Brain Injury-related complications

Background

Many clinical interventions are trialled to manage medical complications following Traumatic Brain Injury (TBI). However, published evidence for the effects of those clinical interventions is limited. This article is an overview of common complications and their management from published systematic reviews in TBI.

Methods and findings

A health science electronic database search for published systematic reviews for management of common complications in TBI was conducted in the last decade till 31st January 2021. Methodological quality and evidence were critically appraised using the Grading of Recommendations, Assessment, Development and Evaluations and Revised-Assessment of Multiple Systematic review tools. Overall, only six systematic reviews complied with search criteria, these evaluated fatigue, spasticity and post traumatic seizures (29 RCTs, 13 cohort studies, n = 5639 participants). No systematic reviews for other common TBI-related complications met criteria for this review. The included reviews varied from ‘moderate to high’ in methodological quality. The findings suggest beneficial treatment effect of anti-epileptic drugs (phenytoin/levetiracetam) compared with placebo in reducing early seizure incidence, but no significant benefit of phenytoin over levetiracetam, valproate, or neuroprotective agent for early or late posttraumatic seizures. There was ‘limited’ evidence for spasticity-related interventions, and ‘insufficient’ evidence of cardiorespiratory training on fatigue levels.

Conclusions

Despite the high prevalence and associated functional impact of TBI-related complications, there is limited evidence to guide treating clinicians for management of common TBI complications. More robust studies are needed to build evidence in this population.

Application of upper-limb dynamic pseudoelastic splinting in the treatment of stroke chronic patient: a pilot assessment

PURPOSE

The chronic sequelae of stroke are often a strong limitation to patient's quality of life. New non-invasive elective treatments are required to support postural and functional improvements long after the primary insult. This study is an uncontrolled pilot evaluation of pseudoelastic orthotics for post-stroke upper-limb rehabilitation.

MATERIALS AND METHODS

Six chronic hemiplegic patients (3.8 ± 1.7 years since stroke) were evaluated with clinical scales, covering the ICF domains of body functions and structures (Modified Ashworth Score [MAS], Medical Research Council Scale for Muscle Strength, Fugl-Meyer [FM], Motricity Index [MI]), activities (Wolf Motor Function Test [WMF], Motor Activity Log [MAL]) and participation (quality of life questionnaires); sensors applied to the orthosis were used to assess changes in the articular and functional domains over a month's treatment.

RESULTS

Significant gains were achieved in elbow spasticity (MAS, p = .020), upper-limb motor function (FM, p = .005), reaching task (p = .035), and gait (p = .00046) speed. Most patients improved in functional tasks (WMF), but this did not reflect in daily-life activities as measured with MAL. Some patients reported an improved quality of life, especially the quality of sleep.

CONCLUSIONS

Pseudoelastic orthoses could be a comfortable and useful adjunct in the long-term management of stroke. Broader trials will have to confirm these preliminary observations.Implications for rehabilitationUse of new materials in neuromuscular rehabilitation.Customised and adjustable therapeutic action obtained with dynamic personalised orthoses.Non-invasive interventions could be of help for patients with chronic disability.

Application of NiTi in Assistive and Rehabilitation Devices: A Review

Shape memory alloys (SMAs) have found widespread applications as biomedical devices. Biocompatibility, corrosion resistance, and ductility make these alloys attractive for medical devices such as stents and filters. For these implants, the superelastic property is the primary function of SMAs. Additionally, these alloys, such as NiTi as the prime example, can be used for actuation. Several modes of actuation such as displacement control, force control, and compliance control have been used as harnesses with SMA devices. These two unique properties have opened another application in the form of neurosurgery and robot-assisted surgery devices, as well as controlled assistive and rehabilitation devices. This paper reviews the state of the art of application of SMAs in the latter category where control is applied to harness innovative medical devices. To this end, two major subsets of these devices: prosthesis and orthosis which take the advantage of SMAs in assistive and rehabilitation devices are studied. These devices are further categorized to hand prosthetics, elbow, knee and ankle orthotics. In most of these designs, SMA wires act as artificial muscles to mimic the motion of limbs in the target joints. The evolution of each category is explained, and the specific results of them are reported. The paper also reviews the SMA applications for neurological and neuromuscular rehabilitation. To this end, different categories of rehabilitation devices as a passive and aided exercise for the ankle, knee, and elbow are highlighted. The SMA actuator in these devices can be EMG-controlled to improved patient outcome. In addition to providing a comprehensive overview of the biomedical devices, this paper identifies several possible future directions of SMA related research in the area of assistive and rehabilitation devices.

Mobile Mechatronic/Robotic Orthotic Devices to Assist-Rehabilitate Neuromotor Impairments in the Upper Limb: A Systematic and Synthetic Review

This paper overviews the state-of-the-art in upper limb robot-supported approaches, focusing on advancements in the related mechatronic devices for the patients' rehabilitation and/or assistance. Dedicated to the technical, comprehensively methodological and global effectiveness and improvement in this inter-disciplinary field of research, it includes information beyond the therapy administrated in clinical settings-but with no diminished safety requirements. Our systematic review, based on PRISMA guidelines, searched articles published between January 2001 and November 2017 from the following databases: Cochrane, Medline/PubMed, PMC, Elsevier, PEDro, and ISI Web of Knowledge/Science. Then we have applied a new innovative PEDro-inspired technique to classify the relevant articles. The article focuses on the main indications, current technologies, categories of intervention and outcome assessment modalities. It includes also, in tabular form, the main characteristics of the most relevant mobile (wearable and/or portable) mechatronic/robotic orthoses/exoskeletons prototype devices used to assist-rehabilitate neuromotor impairments in the upper limb.

Interventions for managing skeletal muscle spasticity following traumatic brain injury

BACKGROUND

Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI.

OBJECTIVES

To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI.

SEARCH METHODS

In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data.

MAIN RESULTS

We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes.

AUTHORS' CONCLUSIONS

The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.

Two single cases treated by a new pseudoelastic upper-limb orthosis for secondary dystonia of the young

The study proposes a new treatment for dystonia based on a dynamic wearable orthosis equipped with metallic materials of non-linear mechanical characteristics. Two boys with upper-limb dystonia were enrolled, as well as six healthy children. Fully-customised devices were made for the patients. They used the orthosis for one month and their performances were evaluated before and after the treatment. The assessment was done with clinical scales (Modified Ashworth Score, Melbourne Upper Limb Assessment, PedsQL), interviews and optoelectronic kinematic analysis. Normal kinematics was obtained from the healthy group for comparison. Kinematic analysis showed modifications in motor patterns for both patients, with increases in the ranges of motion of initially stiff segments, improvements in posture, emergence of multi-joint strategies. Clinical scales did not always show similar trends in the two cases. The changes in control strategies could be linked to the force field dynamically applied by the device and appear to be learnable. This interpretation will be further tested with larger groups and longer treatments.

Applications of shape memory alloys for neurology and neuromuscular rehabilitation

Shape memory alloys (SMAs) are a very promising class of metallic materials that display interesting nonlinear properties, such as pseudoelasticity (PE), shape memory effect (SME) and damping capacity, due to high mechanical hysteresis and internal friction. Our group has applied SMA in the field of neuromuscular rehabilitation, designing some new devices based on the mentioned SMA properties: in particular, a new type of orthosis for spastic limb repositioning, which allows residual voluntary movement of the impaired limb and has no predetermined final target position, but follows and supports muscular elongation in a dynamic and compliant way. Considering patients in the sub-acute phase after a neurological lesion, and possibly bedridden, the paper presents a mobiliser for the ankle joint, which is designed exploiting the SME to provide passive exercise to the paretic lower limb. Two different SMA-based applications in the field of neuroscience are then presented, a guide and a limb mobiliser specially designed to be compatible with diagnostic instrumentations that impose rigid constraints in terms of electromagnetic compatibility and noise distortion. Finally, the paper discusses possible uses of these materials in the treatment of movement disorders, such as dystonia or hyperkinesia, where their dynamic characteristics can be advantageous.