This paper presents a novel multimodal virtual rehabilitation environment. Its design and implementation are based on principles related to intrinsic motivation and game design. The system consists of visual, acoustic, and haptic modalities. Elements contributing to intrinsic motivation are carefully joined in the three modalities to increase patients' motivation during the long process of rehabilitation. The message in a bottle (MIB) virtual scenario is designed to allow interplay between motor and cognitive challenges in the exercising patient. The user first needs to perform a motor action to receive a cognitive challenge that is finally solved by a second motor action. Visual feedback provides the most relevant information related to the task. Acoustic feedback consists of environmental sounds, music, and spoken instructions or encouraging statements for the patient. The haptic modality generates tactile information related to the environment and provides various modes of assistance for the patient's arm movements. The MIB scenario was evaluated with 16 stroke patients, who rated it positively using the Intrinsic Motivation Inventory questionnaire. Additionally, the MIB scenario seems to elicit higher motivation than a simpler pick-and-place training task.

Background. Common understanding is that adequate foot placement (stepping strategy) is crucial in maintaining stability during walking at normal speed. The aim of this study was to investigate strategies that humans use to cope with lateral perturbations during very slow walking. Methods. Ten healthy individuals underwent an experimental protocol whereby a set of perturbations directed inward (medially to a stance leg) and outward (laterally to a stance leg) of three intensities (F1=5%, F2=10%, and F3=15% of body weight), applied at three instances of a stance phase, were delivered in random order to the pelvis using a balance assessment robot while walking on a treadmill at three walking speeds (S1=0.4, S2=0.6, and S3=0.8 m/s). We analyzed the peak center of mass displacements; step length, step width, and step times; and the lateral component of ground reaction force for perturbations that were delivered at the beginning of the gait cycle. Results. Responses after inward perturbations were similar at all tested speeds and consistently employed stepping strategy that was further facilitated by a shortened stance. Wider and shorter steps were applied with increased perturbation intensity. Responses following outward perturbations were more complex. At S1, hip strategy (impulse-like increase of mediolateral ground reaction force) augmented with ankle strategy (mediolateral shift of the center of pressure) mainly contributed to responses already during the stance phase. The stance duration was significantly longer for all perturbation intensities. At S2, the relative share of hip strategy was reduced while with increased perturbation intensity, stepping strategy was gradually added. The stance duration was significantly longer for F1 and F2. At S3, stepping strategy was mainly used while the duration of stance was similar to the one in unperturbed walking. Responses following both inward and outward perturbations at all speeds were characterized by temporary slowing down movement in a sagittal plane that was more pronounced with increased perturbation intensity. Conclusions. This study provides novel insights into balancing strategies used at slower walking speeds which may be more relevant to understand the challenges of gait stability following perturbations in the frontal plane in clinical populations.

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BackgroundFor stroke survivors, balance deficits that persist after the completion of the rehabilitation process lead to a significant risk of falls. We have recently developed a balance-assessment robot (BAR-TM) that enables assessment of balancing abilities during walking. The purpose of this study was to test feasibility of using the BAR-TM in an experimental perturbed-balance training program with a selected high-functioning stroke survivor.MethodsA control and an individual with right-side chronic hemiparesis post-stroke were studied. The individual post-stroke underwent thirty sessions of balance-perturbed training that involved walking on an instrumented treadmill while the BAR-TM delivered random pushes to the participant’s pelvis; these pushes were in various directions, at various speeds, and had various perturbation amplitudes. We assessed kinematics, kinetics, electromyography, and spatio-temporal responses to outward-directed perturbations of amplitude 60 N (before training) and 60 N and 90 N (after training) commencing on contact of either the nonparetic-left foot (LL-NP/L perturbation) or the paretic-right foot (RR-P/R perturbation) while the treadmill was running at a speed of 0.4 m/s.ResultsBefore training, the individual post-stroke primarily responded to LL-NP/L perturbations with an in-stance response on the non-paretic leg in a similar way to the control participant. After training, the individual post-stroke added adequate stepping by making a cross-step with the paretic leg that enabled successful rejection of the perturbation at lower and higher amplitudes. Before training, the individual post-stroke primarily responded to RR-P/R perturbations with fast cross-stepping using the left, non-paretic leg while in-stance response was entirely missing. After training, the stepping with the non-paretic leg was supplemented by partially recovered ability to exercise in-stance responses on the paretic leg and this enabled successful rejection of the perturbation at lower and higher amplitudes. The assessed kinematics, kinetics, electromyography, and spatio-temporal responses provided insight into the relative share of each balancing strategy that the selected individual post-stroke used to counteract LL-NP/L and RR-P/R perturbations before and after the training.ConclusionsThe main finding of this case-control study is that robot-based perturbed-balance training may be a feasible approach. It resulted in an improvement the selected post-stroke participant’s ability to counteract outward-directed perturbations.Trial registrationClinicalTrials.gov Identifier: NCT03285919 – retrospectively registered.Electronic supplementary materialThe online version of this article (10.1186/s12984-018-0373-z) contains supplementary material, which is available to authorized users.

This paper presents the analysis of four psychophysiological responses in post-stroke upper extremity rehabilitation. The goal was to determine which psychophysiological responses would provide the most reliable information about subjects' psychological states during rehabilitation. Heart rate, skin conductance, respiration, and skin temperature were recorded in a stroke group and a control group during two difficulty levels of a pick-and-place task performed in a virtual environment using a haptic robot and during a cognitive task. Psychophysiological measurements were correlated with results of a self-report questionnaire. All four responses showed significant changes in response to the different tasks. Skin conductance differentiated between the two difficulty levels and was correlated with self-reported arousal in both stroke and control groups. Skin temperature differentiated between the two difficulty levels for the control group, but provided poor results for the stroke group. Heart rate and respiration increased during tasks, but their connection to psychological state was unclear. Results suggest that, of the four measured responses, skin conductance offers the most potential as a psychological state indicator, with other measures providing supplementary information. Psychophysiological measurements could thus be used in closed-loop biocooperative systems that would detect the user's psychological state and change the course of therapy accordingly.