EUR MED PHYS 2008;44(Suppl. 1 to No.

3)

Using surface dynamic electromyography during Upper-extremity robotic training

F. MOLTENI, M. CAIMMI, A. CAZZANIGA, G. GASPERINI, E. GIANDOMENICO, C. GIOVANZANA

Introduction It has been verified that muscle weakness and degree of cocontraction correlate significantly with motor impairment and physical disability in upper-extremity hemiplegia. Robotic training is an innovative rehabilitation approach in the treatment of upper-extremity disabilities following stroke. At the state of the art no study has been done on the use of dynamic emg during robotic training and only two longitudinal studies on the effect of robotic therapy on the emg activation pattern have been reported in the literature.1,2 This preliminary study has a twofold objective: 1) to verify if surface emg may be a suitable tool for setting up a specific upperextremity robotic exercise fitted on patient; 2) to study the effect of robotic training on the emg pattern in the short term. Materials and methods Participants Five subacute stroke male patients (67.812.0 years, 3 left and 2 right) were included in the study. Assessment The following tests and evaluations were carried out during enrollment and at the end of treatment: The Motricity Index (MI),4 in which only the subtests relative to the upper limb were taken into consideration. The Modified Ashworth Scale (MAS) at elbow and shoulder Srface dynamic emg during anterior reaching of Deltoideus Anterior (DA), Deltoideus Posterior (DP), Triceps (TR) and Biceps (BI) muscles. The healthy side was evaluated too to allow comparison. Intervention Patients were given a 2 weeks therapy consisting in 10 daily sessions of half an hour of robotic training during which the patient performed reaching movements (on the medial, frontal and lateral direction) with different degrees of assistance from the robotic device. Instrumentation Electromyograph To perform surface electromyography 16 channel wireless system was used (BTS FREEEMG, BTS, Italy). The system controls 16 miniaturized probes with active electrodes weighing just 8 grams for signal acquisition and transmission. The probes amplify the EMG
Vol. 44 - Suppl. 1 to No. 3

Laboratorio di Analisi del Movimento-Centro di Riabilitazione Villa Beretta, Ospedale Valduce Costamasnaga (LC)

signals, digitize them and communicate with a receiving unit. The system is handy as the complete absence of wiring allows for quick preparation of the patient. Moreover the patient may perform movements freely and comfortably without concern for cables wedging. Robotic assistance device The REOTM therapy system (Motorika Medical Ltd, Israel), a robotic assistance device, was used in this study. The device is equipped with an axis able to move vertically and to rotate around the basis. The top of the axis, hold by the patient (or onto which the patients hand may be strapped) may thus perform movements in the 3D space. The robot may be programmed though a computer interface and exercises (series of movement from point to point) may be created. The exercises may be performed under different degrees of assistance depending on the chosen control modality. The control modalities used in this study were: 1. Guided: at start command, the robot axis begins movement and performs the whole exercise unless too high forces are applied to the axis, 2. Initiated: at start command, the robot does not move until a force above threshold and in the direction of the goal movement is applied by the patient on the axis; once the movement has begun, the robot completes the whole trajectory. When the end point is reached the robot waits for the patient to begin the movement again. 3. Step Initiated: it is like initiated, but the robots do not complete the trajectory itself and the patient must keep on applying a certain force during the whole movement; hen the forse is lacking, the robot stops and waits for the patient to begin the movement again. Study design Patients were clinically evaluated before the first training session. Dynamic emg during frontal reaching movements freely performed by the patient with the affected upper limb was acquired. The healthy limb was also evaluated to define the patient emg pattern and to allow comparison. For each patient exercises based on reaching movements were created through the robot computer interface. Exercises were fitted on the patients residual abilities. The

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USING SURFACE DYNAMIC ELECTROMYOGRAPHY DURING UPPER-EXTREMITY ROBOTIC TRAINING

igure 1. Example (patient 4). Pre treatment emg pattern during the test of respectively Guided Participated (upper traces) and Initiated modalities.

FFigure 2. Example (patient 5) of EMG pattern during free reaching movement of respectively healthy (upper traces) and affected side (lower traces).

patients was then tested for different control modalities monitoring the muscles emg activity during the whole exercise. During Guided mode they were asked to both relax (to investigate their ability to do it and the presence of stretch dependent activity) and to participate to the movement (these two modalities are further indicated as Guided Relaxed and Guided Participated). On the basis of the acquired emg patterns the best active modality (Guided Participated, Initiated and Step Initiated) was chosen for the following 10 training sessions. Two main criteria were used to evaluate the emg pattern and individualize the best control modality: 1. amplitude of agonist muscles activity 2. absence of cocontraction of antagonist muscles At the end of the 10 training sessions the patients were clinically and instrumentally evaluated again. Emg activity during free reaching movement and robotic training was compared with pretreatment results. Results Patient 1 (72 years, right hemiparesis) Pretreatment data (MI=23, MAS=0). The patient was not able to perform a free reaching movement and demonstrated poor activity of the DA muscle and no activity of the other muscles. During robot movement in Guided Participated modality, no activity of agonist muscles was present. Nevertheless he was able to execute the exercise in the Initiated modality. In this situation poor activity of the DA and DP muscles characterized by correct alternating timing was present. Activity of elbow muscle was still absent. This modality seemed to be the most appropriate and it was therefore chosen for training. Posttreatment data (MI=44, MAS=0). In free reaching DA muscle activity had increased, little cocontraction of the DP and BI muscles was present and no activity of TR was discernible. In the Initiated modality increased DA and DP muscles activity in correct alternating timing was present. Poor activity of BI muscle with correct timing had shown up. Patient 2 (79 years, left hemiparesis) Pretreatment data (MI=28, MAS=0). The patient showed normal activity of DA muscle, little cocontraction of the DP muscle, poor tonic activity of the BI muscle and no activity of the TR muscle. In Guided Participated modality, normal

activity of the DA muscle was preserved, cocontraction of the DP muscle disappeared and the BI muscle activity became to be in phase. This modality was preferred to Initiated and Step Initiated modalities as in these cases cocontraction of the BI muscle appeared. Posttreatment data (MI=28, MAS=0). During free reaching cocontraction of the DP muscle had disappeared and the tonic activity of the BI muscle had reduced. After treatment the patient was able to better use the robot in Initiated modality; no cocontraction of the BI muscle was present anymore and on the contrary a poor but in phase activity was shown. Also an in phase poor activity of the DP and TR muscles had appeared. The DA muscle activity was preserved. Patient 3 (78 years, right hemiparesis) Pretreatment data (MI=72, MAS_shoulder=1+, MAS_elbow=3). The patient presented little pathological activity of the DP and BI muscles during Guided Relaxed modality. During free reaching cocontraction of both the DP and BI muscles was evident. No control modality could be found to totally eliminate this pathological behavior. Guided Participated seemed the best modality and was therefore chosen for treatment. Posttreatment data (MI=70, MAS_shoulder=1, MAS_elbow=3). Emg pattern in free reaching movement and during movement assisted by the robot in different control modalities was quite unchanged compared to the pretreatment behavior. Patient 4 (55 years, right hemiparesis) Pretreatment data (MI=39, MAS=0) The patient was not able to perform more than 3 frontal reaching movements. Emg pattern was characterized by a slight and strong cocontraction of respectively the DP and BI muscles. The patient who was able to completely relax during Guided Relaxed modality, still presented increased cocontraction of the DP and BI muscles during Guided Participated modality. Degree of cocontractions had reduced in Initiated modality (see Figure 1). Posttreatment data (MI=60, MAS=0). At the end of the treatment the patient was able to perform at least 10 complete reaching movements. A good and in phase TR muscle activity had appeared. Cocontractions of the DP and BI muscles were still present but the ratio between agonist and antagonist muscles had definitely improved.
October 2008

EUROPA MEDICOPHYSICA

USING SURFACE DYNAMIC ELECTROMYOGRAPHY DURING UPPER-EXTREMITY ROBOTIC TRAINING

MOLTENI

Patient 5 (55 years, left hemiparesis) Pretreatment data (MI=44, MAS_shoulder=1, MAS_elbow=1+) The patient presented pathological activity of the BI muscle during Guided Relaxed modality. During free reaching cocontraction of both the DP and BI muscles was evident (see figure 2). Like in the situation of patient 3, no control modality could be found to totally eliminate this pathological behavior. In this case Step Initiated seemed the best modality and was therefore chosen for treatment. Posttreatment data (MI=70, MAS=0). After treatment the patient was able to better relax and the pathological activity of the BI muscle during Guided Relaxed modality had almost totally disappeared. Emg pattern in free reaching movement and during movement assisted by the robot in different control modalities was quite unchanged compared to the pretreatment behavior. Results show that, independently from the patients degree of impairment, the emg activation pattern is sensible to the robot control modality. The degree of cocontraction of agonist and antagonist muscles showed by some patients during free reaching movement had reduced during robotic training when the appropriate modality was selected. Posttreatment data showed mixed results. Due to the small size of the sample, the high heterogeneity of the patients functioning level and the short duration of the training, it is difficult to explain

the results. It probably would be helpful to acquire upper limb kinematics and dynamic emg during free reaching movement. Conclusions The main conclusion refers to the usefulness of dynamic emg for creating specific robotic training programs by monitoring the patients muscular activity during exercise. No general conclusion may be drawn, on the basis of the emg pattern, on the short term effect of the therapy. Upper limb kinematic analysis combine to dynamic surface emg should be probably be a more adequate method.
References
1. Chae J, Yang G, Park BK, Labatia I. Muscle weakness and cocontraction in upper limb hemiparesis: relationship to motor impairment and physical disability. Neurorehabil Neural Repair. 2002 Sep;16(3):241-8 2. Hu X, Tong KY, Song R, Tsang VS, Leung PO, Li L. Variation of muscle coactivation patterns in chronic stroke during robot-assisted elbow training.Arch Phys Med Rehabil. 2007 Aug;88(8):1022-9. 3. Lum PS, Burgar CG, Shor PC. Evidence for improved muscle activation patterns after retraining of reaching movements with the MIME robotic system in subjects with post-stroke hemiparesis. IEEE Trans Neural Syst Rehabil Eng. 2004 Jun;12(2):186-94 4. Demeurisse G, Demol O, Robaye E.Motor evaluation in vascular hemiplegia. Eur Neurol. 1980;19:382-389.

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