Publications by authors named "Jack R Engsberg"

48 Publications

An iPad-based intervention to improve visual-motor, visual-attention, and visual-perceptual skills in children with surgically treated hydrocephalus: A pilot study.

Childs Nerv Syst 2022 02 8;38(2):303-310. Epub 2021 Oct 8.

Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA.

Purpose: Develop and pilot an iPad-based intervention for improving visual-motor coordination, visual-spatial processing/reasoning, and visual attention in children with surgically treated hydrocephalus (HCP).

Methods: We developed an intervention protocol targeting visual-motor coordination, visual-spatial processing/reasoning, and visual attention. Fourteen participants with HCP completed 30 h of training over 6 weeks. The primary outcome measure was the Perceptual Reasoning Index from the Wechsler Abbreviated Scale of Intelligence, Second Edition. Secondary measures included subtests from the Wechsler Intelligence Scale for Children, Fourth Edition, Developmental NEuroPSYchological Assessment, Second Edition (NEPSY-II), and Purdue Pegboard.

Results: Children with HCP demonstrated gains with statistical significance on the Perceptual Reasoning Index. We also observed significant improvement on a timed test of visuo-motor coordination (Wechsler Intelligence Scale for Children, Fourth Edition, Coding).

Conclusion: Our iPad-application-based intervention may promote visual-motor coordination, visual-spatial processing/reasoning, and visual attention skills in children with HCP, offering an engaging and economical supplement to more conventional therapies.
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http://dx.doi.org/10.1007/s00381-021-05379-2DOI Listing
February 2022

The Validity and Reliability of the Microsoft Kinect for Measuring Trunk Compensation during Reaching.

Sensors (Basel) 2020 Dec 10;20(24). Epub 2020 Dec 10.

Program in Occupational Therapy, Washington University in St. Louis, 4444 Forest Park Ave., St. Louis, MO 63108, USA.

Compensatory movements at the trunk are commonly utilized during reaching by persons with motor impairments due to neurological injury such as stroke. Recent low-cost motion sensors may be able to measure trunk compensation, but their validity and reliability for this application are unknown. The purpose of this study was to compare the first (K1) and second (K2) generations of the Microsoft Kinect to a video motion capture system (VMC) for measuring trunk compensation during reaching. Healthy participants (n = 5) performed reaching movements designed to simulate trunk compensation in three different directions and on two different days while being measured by all three sensors simultaneously. Kinematic variables related to reaching range of motion (ROM), planar reach distance, trunk flexion and lateral flexion, shoulder flexion and lateral flexion, and elbow flexion were calculated. Validity and reliability were analyzed using repeated-measures ANOVA, paired -tests, Pearson's correlations, and Bland-Altman limits of agreement. Results show that the K2 was closer in magnitude to the VMC, more valid, and more reliable for measuring trunk flexion and lateral flexion during extended reaches than the K1. Both sensors were highly valid and reliable for reaching ROM, planar reach distance, and elbow flexion for all conditions. Results for shoulder flexion and abduction were mixed. The K2 was more valid and reliable for measuring trunk compensation during reaching and therefore might be prioritized for future development applications. Future analyses should include a more heterogeneous clinical population such as persons with chronic hemiparetic stroke.
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http://dx.doi.org/10.3390/s20247073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763626PMC
December 2020

Combining Virtual Reality Motor Rehabilitation With Cognitive Strategy Use in Chronic Stroke.

Am J Occup Ther 2019 Jul/Aug;73(4):7304345020p1-7304345020p9

Anna E. Boone, MSOT, PhD, OTR/L, is Assistant Professor, Department of Occupational Therapy, University of Missouri-Columbia;

Importance: Rehabilitation interventions for chronic stroke are largely impairment based, with results confined to the level of impairment instead of function. In contrast, cognitive strategy training interventions have demonstrated clinically meaningful improvements in functional outcomes. Integration of these approaches has yet to be explored.

Objective: To evaluate acceptability, recruitment, and retention rate and determine which outcome measures best capture the effect of the intervention.

Design: Single-group, pre-post design.

Setting: Research laboratory.

Participants: Adults with chronic stroke and hemiparesis (N = 10).

Intervention: A 12-wk intervention integrating cognitive strategy training with upper extremity motor training. Two weekly sessions used Kinect-based virtual reality to encourage high numbers of upper extremity movement repetitions. The third weekly session focused on the use of cognitive strategies with practice of client-centered goals.

Outcomes And Measures: Upper extremity motor performance was measured with the Fugl-Meyer Assessment. Occupational performance on trained and untrained goals was measured via the Performance Quality Rating Scale and the Canadian Occupational Performance Measure. Outcome data were gathered preintervention, postintervention, and at 3-mo follow-up.

Results: The intervention was perceived as acceptable. Recruitment rate was 15%, and retention rate was 100%. Large effects were found on outcomes of upper extremity motor performance, occupational performance, and participation at follow-up.

Conclusion And Relevance: MetacogVR is feasible for adults with chronic stroke. The effect of MetacogVR is best captured through measures of upper extremity motor performance, occupational performance, and participation.

What This Articles Adds: Traditional, impairment-based approaches to chronic stroke rehabilitation may require integration with cognitive-strategy training to affect performance on meaningful goals.
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http://dx.doi.org/10.5014/ajot.2019.030130DOI Listing
July 2019

A virtual reality tool for measuring and shaping trunk compensation for persons with stroke: Design and initial feasibility testing.

J Rehabil Assist Technol Eng 2019 Jan-Dec;6:2055668318823673. Epub 2019 Feb 7.

Department of Occupational Therapy, Methodist University, Fayetteville, NC, USA.

Compensatory movement, such as flexing the trunk during reaching, may negatively affect motor improvement during task-based practice for persons with stroke. Shaping, or incrementally decreasing, the amount of compensation used during rehabilitation may be a viable strategy with methods using virtual reality. A virtual reality tool was designed to (1) monitor upper extremity movement kinematics with an off-the-shelf motion sensor (Microsoft Kinect V2), (2) convert movements into control of widely available computer games, and (3) provide real-time feedback to shape trunk compensation. This system was tested for feasibility by a small cohort of participants with chronic stroke ( = 5) during a 1-h session involving 40 min of virtual reality interaction. Outcomes related to repetitions, compensation, movement kinematics, usability, motivation, and sense of presence were collected. Participants achieved a very high dose of reaching repetitions (461 ± 184), with an average of 81% being successful and 19% involving compensatory trunk flexion. Participants rated the system as highly usable, motivating, engaging, and safe. VRShape is feasible to use as a tool for increasing repetition rates, measuring and shaping compensation, and enhancing motivation for upper extremity therapy. Future research should focus on software improvements and investigation of efficacy during a virtual reality-based motor intervention.
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http://dx.doi.org/10.1177/2055668318823673DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582305PMC
February 2019

Reliability and validity of the Microsoft Kinect for assessment of manual wheelchair propulsion.

J Rehabil Res Dev 2016 ;53(6):901-918

2228 S 11th St, St Louis, MO 63104.

Concurrent validity and test-retest reliability of the Microsoft Kinect in quantification of manual wheelchair propulsion were examined. Data were collected from five manual wheelchair users on a roller system. Three Kinect sensors were used to assess test-retest reliability with a still pose. Three systems were used to assess concurrent validity of the Kinect to measure propulsion kinematics (joint angles, push loop characteristics): Kinect, Motion Analysis, and Dartfish ProSuite (Dartfish joint angles were limited to shoulder and elbow flexion). Intraclass correlation coefficients revealed good reliability (0.87-0.99) between five of the six joint angles (neck flexion, shoulder flexion, shoulder abduction, elbow flexion, wrist flexion). ICCs suggested good concurrent validity for elbow flexion between the Kinect and Dartfish and between the Kinect and Motion Analysis. Good concurrent validity was revealed for maximum height, hand-axle relationship, and maximum area (0.92-0.95) between the Kinect and Dartfish and maximum height and hand-axle relationship (0.89-0.96) between the Kinect and Motion Analysis. Analysis of variance revealed significant differences (p < 0.05) in maximum length between Dartfish (mean 58.76 cm) and the Kinect (40.16 cm). Results pose promising research and clinical implications for propulsion assessment and overuse injury prevention with the application of current findings to future technology.
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http://dx.doi.org/10.1682/JRRD.2015.10.0198DOI Listing
April 2018

Upper extremity movement reliability and validity of the Kinect version 2.

Disabil Rehabil Assist Technol 2018 01 19;13(1):54-59. Epub 2017 Jan 19.

a Program in Occupational Therapy , Washington University School of Medicine, Human Performance Laboratory , Saint Louis , MO , USA.

Purpose: Studies have shown that marker-less motion detection systems, such as the first generation Kinect (Kinect 1), have good reliability and potential for clinical application. Studies of the second generation Kinect (Kinect 2) have shown a large range of accuracy relative to balance and joint localization; however, few studies have investigated the validity and reliability of the Kinect 2 for upper extremity motion. This investigation compared reliability and validity among the Kinect 1, Kinect 2 and a video motion capture (VMC) system for upper extremity movements.

Design: One healthy, adult male performed six upper extremity movements during two separate sessions. All movements were recorded on the Kinect 1, Kinect 2 and VMC simultaneously. Data were analyzed using MATLAB (Natick, MA), Microsoft Excel (Redmond, WA), and SPSS (Armonk, NY).

Results: Results indicated good reliability for both Kinects within a day; results between days were inconclusive for both devices due to the inability to exactly repeat the desired movements. Range of motion (ROM) magnitudes for both Kinects were different from the VMC, yet patterns of motion were very highly correlated for both devices.

Conclusion: Simple transformations of Kinect data could bring magnitudes in line with those of the VMC, allowing the Kinects to be used in a clinical setting. Implications for Rehabilitation The clinical implications of the investigation support the notion that the Kinects could be used in the clinical setting if an understanding of their limitations exists. Using the Kinects to make assessments with a given data collection session is acceptable. Using the Kinects to make comparisons across different days such as before or after an intervention should be approached with caution. The Kinect 2 provides a more cost effective option compared to the VMC. Additionally, the Kinect is more portable, requires less time to set-up, and takes up less space, thus increasing its overall usability compared to the VMC.
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http://dx.doi.org/10.1080/17483107.2016.1278473DOI Listing
January 2018

Development of a novel virtual reality gait intervention.

Gait Posture 2017 02 14;52:202-204. Epub 2016 Nov 14.

Human Performance Laboratory, Washington University School of Medicine in St. Louis, Program in Occupational Therapy, 4444 Forest Park Ave., St. Louis, MO, USA. Electronic address:

Introduction: Improving gait speed and kinematics can be a time consuming and tiresome process. We hypothesize that incorporating virtual reality videogame play into variable improvement goals will improve levels of enjoyment and motivation and lead to improved gait performance.

Purpose: To develop a feasible, engaging, VR gait intervention for improving gait variables.

Methods: Completing this investigation involved four steps: 1) identify gait variables that could be manipulated to improve gait speed and kinematics using the Microsoft Kinect and free software, 2) identify free internet videogames that could successfully manipulate the chosen gait variables, 3) experimentally evaluate the ability of the videogames and software to manipulate the gait variables, and 4) evaluate the enjoyment and motivation from a small sample of persons without disability.

Results: The Kinect sensor was able to detect stride length, cadence, and joint angles. FAAST software was able to identify predetermined gait variable thresholds and use the thresholds to play free online videogames. Videogames that involved continuous pressing of a keyboard key were found to be most appropriate for manipulating the gait variables. Five participants without disability evaluated the effectiveness for modifying the gait variables and enjoyment and motivation during play. Participants were able to modify gait variables to permit successful videogame play. Motivation and enjoyment were high.

Summary: A clinically feasible and engaging virtual intervention for improving gait speed and kinematics has been developed and initially tested. It may provide an engaging avenue for achieving thousands of repetitions necessary for neural plastic changes and improved gait.
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http://dx.doi.org/10.1016/j.gaitpost.2016.11.025DOI Listing
February 2017

A motor learning approach to training wheelchair propulsion biomechanics for new manual wheelchair users: A pilot study.

J Spinal Cord Med 2017 05 16;40(3):304-315. Epub 2015 Dec 16.

a Program in Occupational Therapy , Washington University School of Medicine , St. Louis , MO , USA.

Context/objective: Developing an evidence-based approach to teaching wheelchair skills and proper propulsion for everyday wheelchair users with a spinal cord injury (SCI) is important to their rehabilitation. The purpose of this project was to pilot test manual wheelchair training based on motor learning and repetition-based approaches for new manual wheelchair users with an SCI.

Design: A repeated measures within-subject design was used with participants acting as their own controls.

Methods: Six persons with an SCI requiring the use of a manual wheelchair participated in wheelchair training. The training included nine 90-minute sessions. The primary focus was on wheelchair propulsion biomechanics with a secondary focus on wheelchair skills.

Outcome Measures: During Pretest 1, Pretest 2, and Posttest, wheelchair propulsion biomechanics were measured using the Wheelchair Propulsion Test and a Video Motion Capture system. During Pretest 2 and Posttest, propulsion forces using the WheelMill System and wheelchair skills using the Wheelchair Skills Test were measured.

Results: Significant changes in area of the push loop, hand-to-axle relationship, and slope of push forces were found. Changes in propulsion patterns were identified post-training. No significant differences were found in peak and average push forces and wheelchair skills pre- and post-training.

Conclusions: This project identified trends in change related to a repetition-based motor learning approach for propelling a manual wheelchair. The changes found were related to the propulsion patterns used by participants. Despite some challenges associated with implementing interventions for new manual wheelchair users, such as recruitment, the results of this study show that repetition-based training can improve biomechanics and propulsion patterns for new manual wheelchair users.
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http://dx.doi.org/10.1080/10790268.2015.1120408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5472018PMC
May 2017

Important wheelchair skills for new manual wheelchair users: health care professional and wheelchair user perspectives.

Disabil Rehabil Assist Technol 2017 01 3;12(1):28-38. Epub 2015 Jul 3.

a Program in Occupational Therapy and.

Purpose: The purpose of this project was to identify wheelchair skills currently being taught to new manual wheelchair users, identify areas of importance for manual wheelchair skills' training during initial rehabilitation, identify similarities and differences between the perspectives of health care professionals and manual wheelchair users and use the ICF to organize themes related to rehabilitation and learning how to use a manual wheelchair.

Method: Focus groups were conducted with health care professionals and experienced manual wheelchair users. ICF codes were used to identify focus group themes.

Results: The Activities and Participation codes were more frequently used than Structure, Function and Environment codes. Wheelchair skills identified as important for new manual wheelchair users included propulsion techniques, transfers in an out of the wheelchair, providing maintenance to the wheelchair and navigating barriers such as curbs, ramps and rough terrain. Health care professionals and manual wheelchair users identified the need to incorporate the environment (home and community) into the wheelchair training program.

Conclusions: Identifying essential components for training the proper propulsion mechanics and wheelchair skills in new manual wheelchair users is an important step in preventing future health and participation restrictions. Implications for Rehabilitation Wheelchair skills are being addressed frequently during rehabilitation at the activity-dependent level. Propulsion techniques, transfers in an out of the wheelchair, providing maintenance to the wheelchair and navigating barriers such as curbs, ramps and rough terrain are important skills to address during wheelchair training. Environment factors (in the home and community) are important to incorporate into wheelchair training to maximize safe and multiple-environmental-setting uses of manual wheelchairs. The ICF has application to understanding manual wheelchair rehabilitation for wheelchair users and therapists for improving the understanding of manual wheelchair use.
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http://dx.doi.org/10.3109/17483107.2015.1063015DOI Listing
January 2017

MEASURING SCAPULAR MOVEMENT USING THREE-DIMENSIONAL ACROMIAL PROJECTION.

Shoulder Elbow 2013 Apr;5(2):93-99

Washington University School of Medicine, Program in Occupational Therapy, St. Louis, MO ; Washington University School of Medicine, Department of Neurosurgery, St. Louis, MO ; Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO.

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http://dx.doi.org/10.1111/sae.12008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4019455PMC
April 2013

Identification of three movement phases of the hand during lateral and pulp pinches using video motion capture.

Hand (N Y) 2013 Jun;8(2):123-31

Program in Occupational Therapy, Washington University School of Medicine, Campus Box 8505, 4444 Forest Park Avenue, St. Louis, MO 63108 USA.

Background: Hand injuries affect a person's ability to engage successfully in activities of daily living (ADLs). Video motion capture (VMC) facilitates measurement of dynamic movement. No study to date has used VMC as a means of quantifying the simultaneous movement patterns of all joints of all digits of the hand during active purposeful movement.

Method: The purpose of this study was to analyze all joints of all five digits during active completion of the lateral and pulp pinches. VMC data were collected from four participants during completion of two pinches. Joint angles were plotted to facilitate identification of movement patterns.

Results: Range of motion recorded in all joints with VMC, excluding flexion of the thumb carpometacarpal of both pinches, coincided with the normative goniometric data. Three phases were observed: initiation, preshaping, and pinch phases. Patterns of movement in all digits were identified for the two pinches.

Conclusion: VMC is a feasible and valid method for objectively quantifying dynamic movement of multiple joints simultaneously. The results provide new insight to the dynamics of hand movement as well as a basis for subsequent evaluations of movement patterns performed in ADLs and instrumental ADLs.
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http://dx.doi.org/10.1007/s11552-013-9517-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652995PMC
June 2013

Developing Home-Based Virtual Reality Therapy Interventions.

Games Health J 2013 Feb;2(1):34-8

1 Program in Occupational Therapy, Washington University School of Medicine , St. Louis, Missouri.

Objective: Stroke is one of the leading causes of serious long-term disability. However, home exercise programs given at rehabilitation often lack in motivational aspects. The purposes of this pilot study were (1) create individualized virtual reality (VR) games and (2) determine the effectiveness of VR games for improving movement in upper extremities in a 6-week home therapy intervention for persons with stroke.

Subjects And Methods: Participants were two individuals with upper extremity hemiparesis following a stroke. VR games were created using the Looking Glass programming language and modified based on personal interests, goals, and abilities. Participants were asked to play 1 hour each day for 6 weeks. Assessments measured upper extremity movement (range of motion and Action Research Arm Test [ARAT]) and performance in functional skills (Canadian Occupational Performance Measure [COPM] and Motor Activity Log [MAL]).

Results: Three VR games were created by a supervised occupational therapist student. The participants played approximately four to six times a week and performed over 100 repetitions of movements each day. Participants showed improvement in upper extremity movement and participation in functional tasks based on results from the COPM, ARAT, and MAL.

Conclusions: Further development in the programming environment is needed to be plausible in a rehabilitation setting. Suggestions include graded-level support and continuation of creating a natural programming language, which will increase the ability to use the program in a rehabilitation setting. However, the VR games were shown to be effective as a home therapy intervention for persons with stroke. VR has the potential to advance therapy services by creating a more motivating home-based therapy service.
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http://dx.doi.org/10.1089/g4h.2012.0033DOI Listing
February 2013

Computer Games as Therapy for Persons with Stroke.

Games Health J 2013 Feb 5;2(1):24-8. Epub 2013 Feb 5.

Washington University School of Medicine , St. Louis, Missouri.

Background: Stroke affects approximately 800,000 individuals each year, with 65% having residual impairments. Studies have demonstrated that mass practice leads to regaining motor function in affected extremities; however, traditional therapy does not include the repetitions needed for this recovery. Videogames have been shown to be good motivators to complete repetitions. Advances in technology and low-cost hardware bring new opportunities to use computer games during stroke therapy. This study examined the use of the Microsoft (Redmond, WA) Kinect™ and Flexible Action and Articulated Skeleton Toolkit (FAAST) software as a therapy tool to play existing free computer games on the Internet.

Subjects And Methods: Three participants attended a 1-hour session where they played two games with upper extremity movements as game controls. Video was taken for analysis of movement repetitions, and questions were answered about participant history and their perceptions of the games.

Results: Participants remained engaged through both games; regardless of previous computer use all participants successfully played two games. Five minutes of game play averaged 34 repetitions of the affected extremity. The Intrinsic Motivation Inventory showed a high level of satisfaction in two of the three participants.

Conclusions: The Kinect Sensor with the FAAST software has the potential to be an economical tool to be used alongside traditional therapy to increase the number of repetitions completed in a motivating and engaging way for clients.
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http://dx.doi.org/10.1089/g4h.2012.0032DOI Listing
February 2013

Cervical spine motion during extrication.

J Emerg Med 2013 Jan 15;44(1):122-7. Epub 2012 Oct 15.

Human Performance Laboratory, Program in Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri 63108, USA.

Background: It has been estimated that up to one-quarter of spinal cord injuries may be significantly worsened during extrication or early treatment after a motor vehicle accident.

Study Objectives: The purpose of this study was to analyze the planar motions of the head relative to the torso during extrication from an automobile in a laboratory setting.

Methods: Video motion capture was used to quantify the range of motion of the head relative to the torso in 10 participants as they were extricated from a mock motor vehicle during four different extrication techniques: 1) Unassisted Unprotected, 2) Unassisted Protected with a cervical collar (CC), 3) Assisted and Protected with a CC, and 4) Assisted and Protected with a CC and Kendrick Extrication Device.

Results: The results indicated a significant decrease in movement for all motions when the driver exited the vehicle unassisted with CC protection, compared to exiting unassisted and without protection. Decreases in movement were also observed for an event (i.e., Pivot in seat) during extrication with paramedic assistance and protection. However, no movement reduction was observed in another event (i.e., Recline on board) with both paramedic assistance and protection.

Conclusion: In this study, no decrease in neck movement occurred for certain extrication events that included protection and assistance by the paramedics. Future work should further investigate this finding.
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http://dx.doi.org/10.1016/j.jemermed.2012.02.082DOI Listing
January 2013

Changes in muscle activation following ankle strength training in children with spastic cerebral palsy: an electromyography feasibility case report.

Phys Occup Ther Pediatr 2013 May 26;33(2):230-42. Epub 2012 Sep 26.

Human Performance Laboratory, Washington University in St. Louis School of Medicine Program in Occupational Therapy, 5240 Oakland Avenue, St. Louis, MO 63110 USA.

ABSTRACT Children with cerebral palsy (CP) are likely to experience decreased participation in activities and less competence in activities of daily living. Studies of children with spastic CP have shown that strengthening programs produce positive results in strength, gait, and functional outcomes (measured by the Gross Motor Function Measure). No investigations have analyzed electromyography (EMG) activity before and after strength training to determine whether any changes occur in the GMFM.  This feasibility case report quantified dorsiflexor and plantarflexor muscle activation changes during performance of 3-5 selected GMFM items following a plantarflexor strength training in two children with cerebral palsy. Increased plantarflexor strength and increased ability to selectively activate muscles were found. Little carryover to performance on GMFM items was observed. It is feasible to use EMG during performance on selected GMFM items to evaluate motor control changes following strength training in children with CP.
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http://dx.doi.org/10.3109/01942638.2012.723116DOI Listing
May 2013

Robotics and gaming to improve ankle strength, motor control, and function in children with cerebral palsy--a case study series.

IEEE Trans Neural Syst Rehabil Eng 2013 Mar 3;21(2):165-73. Epub 2012 Jul 3.

Tele-Rehabilitation Institute, Rutgers University, Piscataway, NJ 08854, USA.

The objective of this study was to investigate the feasibility of game-based robotic training of the ankle in children with cerebral palsy (CP). The design was a case study, 12 weeks intervention, with no follow-up. The setting was a university research laboratory. The participants were a referred sample of three children with cerebral palsy, age 7-12, all male. All completed the intervention. Participants trained on the Rutgers Ankle CP system for 36 rehabilitation sessions (12 weeks, three times/week), playing two custom virtual reality games. The games were played while participants were seated, and trained one ankle at-a-time for strength, motor control, and coordination. The primary study outcome measures were for impairment (DF/PF torques, DF initial contact angle and gait speed), function (GMFM), and quality of life (Peds QL). Secondary outcome measures relate to game performance (game scores as reflective of ankle motor control and endurance). Gait function improved substantially in ankle kinematics, speed and endurance. Overall function (GMFM) indicated improvements that were typical of other ankle strength training programs. Quality of life increased beyond what would be considered a minimal clinical important difference. Game performance improved in both games during the intervention. This feasibility study supports the assumption that game-based robotic training of the ankle benefits gait in children with CP. Game technology is appropriate for the age group and was well accepted by the participants. Additional studies are needed however, to quantify the level of benefit and compare the approach presented here to traditional methods of therapy.
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http://dx.doi.org/10.1109/TNSRE.2012.2206055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4228314PMC
March 2013

Comparison of 3 different methods to analyze ankle plantarflexor stiffness in children with spastic diplegia cerebral palsy.

Arch Phys Med Rehabil 2011 Dec;92(12):2034-40

Washington University Human Performance Laboratory, St. Louis, MO, USA.

Objective: To compare 3 different methods of measuring plantarflexor stiffness in children with spastic diplegia cerebral palsy (CP) and children without disability.

Design: Case-control study.

Setting: Human performance laboratory.

Participants: A retrospective analysis was conducted with children with spastic diplegia (n=121; mean age, 8.4y) and children with typical development (TD) (n=48; mean age, 9.7y).

Interventions: Not applicable.

Main Outcome Measures: An isokinetic dynamometer was used to measure ankle plantarflexor stiffness at 10°/s using 3 methods: (1) end-range method, which applied a linear slope to the end of the torque-angle curve; (2) set-range method, which applied a linear slope from 30° to 10° plantarflexion; and (3) a linear method, which applied a slope only to the linear portion of the curve.

Results: Two-way analysis of variance revealed significant main effects for group and stiffness method. The end-range method showed no significant difference between groups for plantarflexor stiffness (P=.62), the set-range method showed the CP group with 120% greater stiffness than the TD group (P<.046), and the linear method showed the CP group with 35% greater stiffness than the TD group (P<.001).

Conclusions: The linear method appeared to resolve the issues with the previous methods; applying a linear slope to a nonlinear curve or applying a linear slope to the same range of motion for each child regardless of their range limitations. It is clear that children with CP have limited range of motion; therefore, stiffness occurs earlier in the range than would be expected for a typically developing child. Using the linear method, children with CP were 35% stiffer in the ankle plantarflexors than typically developing peers.
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http://dx.doi.org/10.1016/j.apmr.2011.06.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3232463PMC
December 2011

Use of computer games as an intervention for stroke.

Top Stroke Rehabil 2011 Jul-Aug;18(4):417-27

Washington University School of Medicine, St. Louis, MO, USA.

Current rehabilitation for persons with hemiparesis after stroke requires high numbers of repetitions to be in accordance with contemporary motor learning principles. The motivational characteristics of computer games can be harnessed to create engaging interventions for persons with hemiparesis after stroke that incorporate this high number of repetitions. The purpose of this case report was to test the feasibility of using computer games as a 6-week home therapy intervention to improve upper extremity function for a person with stroke. One person with left upper extremity hemiparesis after stroke participated in a 6-week home therapy computer game intervention. The games were customized to her preferences and abilities and modified weekly. Her performance was tracked and analyzed. Data from pre-, mid-, and postintervention testing using standard upper extremity measures and the Reaching Performance Scale (RPS) were analyzed. After 3 weeks, the participant demonstrated increased upper extremity range of motion at the shoulder and decreased compensatory trunk movements during reaching tasks. After 6 weeks, she showed functional gains in activities of daily living (ADLs) and instrumental ADLs despite no further improvements on the RPS. Results indicate that computer games have the potential to be a useful intervention for people with stroke. Future work will add additional support to quantify the effectiveness of the games as a home therapy intervention for persons with stroke.
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http://dx.doi.org/10.1310/tsr1804-417DOI Listing
October 2011

Effects of a supported speed treadmill training exercise program on impairment and function for children with cerebral palsy.

Dev Med Child Neurol 2011 Aug 17;53(8):742-50. Epub 2011 Jun 17.

Department of Physical Therapy, University of the Sciences, Philadelphia, PA 19104, USA.

Aim: To compare the effects of a supported speed treadmill training exercise program (SSTTEP) with exercise on spasticity, strength, motor control, gait spatiotemporal parameters, gross motor skills, and physical function.

Method: Twenty-six children (14 males, 12 females; mean age 9y 6mo, SD 2y 2mo) with spastic cerebral palsy (CP; diplegia, n=12; triplegia, n=2; quadriplegia n=12; Gross Motor Function Classification System levels II-IV) were randomly assigned to the SSTTEP or exercise (strengthening) group. After a twice daily, 2-week induction, children continued the intervention at home 5 days a week for 10 weeks. Data collected at baseline, after 12-weeks' intervention, and 4 weeks after the intervention stopped included spasticity, motor control, and strength; gait spatiotemporal parameters; Gross Motor Function Measure (GMFM); and Pediatric Outcomes Data Collection Instrument (PODCI).

Results: Gait speed, cadence, and PODCI global scores improved, with no difference between groups. No significant changes were seen in spasticity, strength, motor control, GMFM scores, or PODCI transfers and mobility. Post-hoc testing showed that gains in gait speed and PODCI global scores were maintained in the SSTTEP group after withdrawal of the intervention.

Interpretation: Although our hypothesis that the SSTTEP group would have better outcomes was not supported, results are encouraging as children in both groups showed changes in function and gait. Only the SSTTEP group maintained gains after withdrawal of intervention.
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http://dx.doi.org/10.1111/j.1469-8749.2011.03990.xDOI Listing
August 2011

Stroke Survivors' Gait Adaptations to a Powered Ankle Foot Orthosis.

Adv Robot 2011 Jan;25(15):1879-1901

Washington University; Saint Louis, Missouri 63130.

Background And Purpose: Stroke is the leading cause of long term disability in the United States, and for many it causes loss of gait function. The purpose of this research is to examine stroke survivors' gait adaptations to training on the Powered Ankle Foot Orthosis (PAFO). Of particular interest is the stroke survivors' ability to learn how to store and release energy properly while using the device. The PAFO utilizes robotic tendon technology and supports motion with a single degree of freedom, ankle rotation in the sagittal plane. This actuator comprises a motor and series spring. The user interacts with the output side of the spring while the robot controls the input side of the spring such that typical able body ankle moments would be generated, assuming able body ankle kinematics are seen at the output side of the spring.

Methods: Three individuals post-stroke participated in a three week training protocol. Outcome measures (temporal, kinematic, and kinetic) were derived from robot sensors and recorded for every step. These data are used to evaluate each stroke survivor's adaptations to robotic gait assistance. The robot was worn only on the paretic ankle. For validation of the kinematic results, motion capture data were collected on the third subject.

Results: All subjects showed increased cadence, ankle range of motion, and power generation capabilities. Additionally, all subjects were able to achieve a larger power output than power input from the robot. Motion capture data collected from subject three validated the robot sensor kinematic data on the affected side, but also demonstrated an unexpected gait adaptation on the unaffected ankle.

Conclusions: Sensors on the gait assisting robot provide large volumes of valuable information on how gait parameters change over time. We have developed key gait evaluation metrics based on the available robot sensor information that may be useful to future researchers. All subjects adapted their gait to the robotic assistance, and many of their key metrics moved closer to typical able body values. This suggests that each subject learned to utilize the assistive moments generated by the robot, despite having no predefined ankle trajectory input from the robot. The security of being harnessed on the treadmill led to more dramatic and favorable results.
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http://dx.doi.org/10.1163/016918611X588907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4203663PMC
January 2011

Elbow kinematics during overground manual wheelchair propulsion in individuals with tetraplegia.

Disabil Rehabil Assist Technol 2011 20;6(4):312-9. Epub 2010 Oct 20.

Program in Occupational Therapy, Washington University in St. Louis School of Medicine, St. Louis, MO 63180, USA.

Purpose: The purpose of this study was to describe horizontal and vertical translation of the elbow and elbow angle in two planes and three speeds during manual wheelchair overground propulsion in individuals with tetraplegia.

Methods: Seven individuals with tetraplegia who used manual wheelchairs wheeled overground at three different speeds were recruited for the study. Video motion capture methods quantified their movements. Video data were tracked and used to calculate variables describing three-dimensional elbow translation and angular orientation. Repeated measures ANOVA were used to determine effects of speed on elbow translation and elbow angle. Paired t-tests were used to evaluate left to right differences.

Results: Right elbow anterior-posterior translation was found to be significantly different during slow and fast and slow and normal speeds. Vertical and medial-lateral translation of the right elbow was significantly different between slow and fast speeds. No significant effects for speed during left elbow movement or side-to-side movement were found. No significant effects were found for elbow angle across speeds or from side-to-side. Three patterns of elbow movement emerged for anterior-posterior and medial-lateral translation and for elbow angle.

Conclusions: Results indicated that elbow translation was related to propulsion speed. Work involving this population is needed for further understanding of upper extremity kinematic patterns.
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http://dx.doi.org/10.3109/17483107.2010.528143DOI Listing
September 2011

Comparison of overground and treadmill propulsion patterns of manual wheelchair users with tetraplegia.

Disabil Rehabil Assist Technol 2010 ;5(6):420-7

Washington University School of Medicine, St. Louis, Missouri 63110, USA.

Purpose: The purpose of this investigation was to compare overground and treadmill propulsion patterns in persons with tetraplegia.

Methods: In this case series study, we recruited eight adult subjects with tetraplegia (5 men and 3 women, aged 32.5 ± 9.5). All subjects used manual wheelchairs. We used a video motion capture system to record movements as the subject manually wheeled overground and on a treadmill. We classified propulsion patterns into one of four patterns and measured five different geometric variables of each pattern. We compared them statistically using ANOVA.

Results: There were significant differences in max height/max length x 100 (H/L%) between propulsion over ground (mean 20% ± 15.3/Lhand, mean 21.3% ± 16.5/Rhand) versus propulsion on treadmill surfaces (roller: mean 30.9% ± 11.2/Lhand, mean 33.5% ± 12.8/Rhand; belted: mean 27.7% ± 8.7/Lhand, mean 34.9% ± 14.2/Rhand) and between the left and right hand.

Conclusion: Results indicated area and H/L% were different among the three surface types and between right and left sides. Caution must be used in extrapolating treadmill results to propulsion over ground or in assuming bilateral symmetry.
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http://dx.doi.org/10.3109/17483101003793420DOI Listing
June 2011

Changes in trunk and head stability in children with cerebral palsy after hippotherapy: a pilot study.

Phys Occup Ther Pediatr 2010 May;30(2):150-63

Human Performance Laboratory, Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA.

Hippotherapy (HPOT) is a therapy that uses horse movement. This pilot investigation objectively evaluated the efficacy of HPOT in improving head/trunk stability in children with cerebral palsy (CP). The participants were six children with spastic diplegia and six children without disability. Head and trunk stability was challenged by using a motorized barrel and measured by a video motion capture system before and after a 12-week intervention of 45 min of HPOT a week. The variables measured were anterior-posterior (AP) translation of the head, and spine at five points and average AP head angles. At pre-testing, children with CP demonstrated significant differences in AP translation and AP head rotation compared with children without disability. Following HPOT, children with CP demonstrated significant reductions in head rotation and AP translation at C7, eye, and vertex. At post-testing, translation at C7 did not differ significantly between children with CP and children without disability. After HPOT intervention, children with CP reduced their AP head rotation and translation, suggesting that they had increased stability of the head and trunk in response to perturbations at the pelvis. The findings suggest that HPOT might improve head and trunk stability in children with CP.
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http://dx.doi.org/10.3109/01942630903517223DOI Listing
May 2010

Normalizing lower extremity strength data for children, adolescents, and young adults with cerebral palsy.

J Appl Biomech 2009 Aug;25(3):195-202

Childrens Orthopaedic Center, Childrens Hospital Los Angeles, Los Angeles, CA, USA.

The traditional method for normalizing quantitative strength data is to divide force or torque by body mass. We have previously shown that this method is not appropriate for able-bodied children and young adults and that normalization using allometric scaling is more effective. The purpose of the current study was to evaluate the effectiveness of applying existing normalization equations for lower extremity strength to children, adolescents, and young adults with cerebral palsy (CP) and, if appropriate, to develop CP-specific normalization equations using allometric scaling. We measured the maximum torque generated during hip abduction/adduction, knee extension/flexion, and ankle dorsiflexion/plantar flexion in 96 subjects with spastic diplegia CP ages 4-23 years. Traditional mass normalization (Torque/Mass1.0) and allometric scaling equations from children without disability (Torque/Mass1.6 for hip and knee; Torque/Mass1.4 for ankle) were not effective in eliminating the influence of body mass. Normalization using CP-specific allometric scaling equations was effective using both muscle-specific and common (Torque/Mass0.8 for ankle plantar flexors; Torque/Mass1.4 for all others) scaling relationships. For the first time, normalization equations have been presented with demonstrated effectiveness in adjusting strength measures for body size in a group of children, adolescents, and young adults with CP.
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http://dx.doi.org/10.1123/jab.25.3.195DOI Listing
August 2009

Changes in dynamic trunk/head stability and functional reach after hippotherapy.

Arch Phys Med Rehabil 2009 Jul;90(7):1185-95

Human Performance Laboratory, Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA.

Objectives: To determine if hippotherapy (therapy using a horse) improves head/trunk stability and upper extremity (UE) reaching/targeting in children with spastic diplegia cerebral palsy (SDCP).

Design: Pre-postoperative follow-up with a 12-week intervention and 12-week washout period after intervention.

Setting: A human performance laboratory with 6 camera video motion capture systems for testing.

Participants: Eleven children (age 5-13y, average 8y) with SDCP, 8 children (age 5-13y, average 8y) without disabilities.

Intervention: Hippotherapy intervention performed at 3 therapeutic horseback riding centers.

Main Outcome Measures: Video motion capture using surface markers collecting data at 60 Hz, a mechanical barrel to challenge trunk and head stability, and functional reach/targeting test on static surface.

Results: Significant changes with large effect sizes in head/trunk stability and reaching/targeting, elapsed time, and efficiency (reach/path ratio) after 12 weeks of hippotherapy intervention. Changes were retained after a 12-week washout period.

Conclusions: Hippotherapy improves trunk/head stability and UE reaching/targeting. These skills form the foundation for many functional tasks. Changes are maintained after the intervention ceases providing a skill foundation for functional tasks that may also enhance occupational performance and participation.
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http://dx.doi.org/10.1016/j.apmr.2009.01.026DOI Listing
July 2009

An analysis of gait changes and functional outcome in patients surgically treated for displaced acetabular fractures.

J Orthop Trauma 2009 May-Jun;23(5):346-53

Program in Occupational Therapy, Washington University School of Medicine, St Louis, MO, USA.

Objectives: To determine the relationship between gait, muscle strength, and functional outcome in patients who underwent Open Reduction Internal Fixation (ORIF) of a displaced acetabular fracture using an anterior ilioinguinal approach and to compare gait and functional outcome in patients who have undergone ORIF via an anterior approach with a similar group of patients who have undergone ORIF of a displaced acetabular fracture via a posterior approach and a group of able-bodied cohorts and to investigate relationships between gait, strength, and functional outcome within the entire group of patients.

Design: Case series.

Setting: University Medical Center.

Patients: Thirty patients were studied, each with an isolated displaced acetabular fracture who were surgically treated; 15 patients were treated using an anterior ilioinguinal approach, and 15 were treated using a posterior Kocher-Langenbeck approach.

Main Outcome Measures: Primary outcome measures included gait analysis (speed and kinematics), hip muscle strength, and functional outcome as assessed with the Musculoskeletal Function Assessment (MFA) questionnaire.

Results: Several of the limb kinematics for the affected and the unaffected limbs was different when patients treated by an anterior surgical approach were compared with those treated from a posterior approach and able-bodied cohorts. Maximum ankle dorsiflexion was greater in the unaffected limb of the anterior group versus the posterior approach group but was equal to the able-bodied cohorts (AB). Both the affected and the unaffected limbs of the anterior group had larger angles for knee flexion at the time of initial contact compared with the posterior group and AB. Both limbs of the anterior group had significantly more knee flexion and less hip rotation than the posterior group but not from AB. There were no differences in trunk inclination between the surgical groups, but the combined group had greater inclination compared with AB. Average MFA score was 17 +/- 12 (range, 0-47) for the anterior group and 22 +/- 17 (range, 0-57) for the posterior group, respectively. MFA scores did not differ significantly based on surgical approach, fracture pattern, or sex. When gait was compared with MFA scores, an inverse relationship was discovered for the group as a whole. That is, worsening function (increased MFA) correlated with decreased kinematics and stride length. Additionally, greater hip strength was associated with additional hip rotation and increased gait speed. A multivariate regression analysis indicated that both hip rotation (which was associated with hip strength) and hip adductor work strength were important predictors of final MFA scores.

Conclusions: Detailed gait analysis and functional outcome determination indicate that patients treated surgically for a displaced acetabular fracture, either via an anterior or posterior approach, have alterations in their gait, muscle strength, and functional outcome. Maximizing hip muscle strength may improve gait, and improvement in hip muscle strength and gait is likely to improve functional outcome as measured by the MFA. Finally, because both surgical approaches seem to produce the same gait outcomes, it suggests that gait changes after injury and treatment are related to factors other than surgical approach.
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http://dx.doi.org/10.1097/BOT.0b013e3181a278ccDOI Listing
July 2009

Use of relative phase as a measure of motor control at the ankle in persons with cerebral palsy: a preliminary study.

J Appl Biomech 2008 Nov;24(4):382-90

Human Performance Lab, Washington University School of Medicine, St. Louis, MO, USA.

This investigation developed a measure of motor control at the ankle for persons with CP using relative phase. Twenty-nine subjects, 14 with spastic diplegia cerebral palsy (CP group) and 15 without disability (WD group) were tested once. Video data were collected as a seated subject performed four full range of ankle plantar and dorsiflexion movement tasks (right ankle, left ankle, ankles in-phase with each other, and ankles antiphase to each other) at four different frequencies (self-paced, 0.5, 0.75, 1.0 Hz). The relative phase measure was able to discern the differences between the two groups of children. The CP group had poorer motor control than the WD group, based upon the measure. Both groups had more difficulty performing the antiphase than the in-phase movements. The investigation adds to the body of knowledge in that the concept of relative phase was used as a measure of motor control at the ankle in persons with CP. Results indicated that the measure was adequately sensitive to quantify differences between a group with CP and a group without disability. Clinically the measure could eventually be used as both an assessment and outcome tool.
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http://dx.doi.org/10.1123/jab.24.4.382DOI Listing
November 2008

Comparison of Rectified and Unrectified Sockets for Transtibial Amputees.

J Prosthet Orthot 2008 ;18(1):1-7

Human Performance Laboratory, Department of Neurosurgery, Washington University Medical School, St. Louis, MO.

The current method for fabricating prosthetic sockets is to modify a positive mold to account for the non-homogeneity of the residual limb to tolerate load (i.e., rectified socket). We tested unrectified sockets by retaining the shape of the residual limb, except for a distal end pad, using an alginate gel process instead of casting. This investigation compared rectified and unrectified sockets. Forty-three adults with unilateral transtibial amputations were tested after randomly wearing both rectified and unrectified sockets for at least 4 weeks. Testing included a gait analysis, energy expenditure and Prosthesis Evaluation Questionnaire (PEQ). Results indicated no differences between sockets for gait speed and timing, gait kinematics and kinetics, and gait energy expenditure. There were also no differences in the Prosthetic Evaluation Questionnaire and 16 subjects selected the rectified socket, 25 selected the unrectified socket, and 2 subjects selected to use both sockets as their exit socket. Results seemed to indicate that more than one paradigm exists for shaping prosthetic sockets, and this paradigm may be helpful in understanding the mechanisms of socket fit. The alginate gel fabrication method was simpler than the traditional method. The method could be helpful in other countries where prosthetic care is lacking, may be helpful with new amputees, and may be helpful in typical clinics to reduce costs and free the prosthetist to focus more time on patient needs.
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http://dx.doi.org/10.1097/00008526-200601000-00002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2529461PMC
January 2008

Selective dorsal rhizotomy.

J Neurosurg Pediatr 2008 Mar;1(3):177; discussion 178-9

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http://dx.doi.org/10.3171/PED/2008/1/3/177DOI Listing
March 2008
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