Name: development of a novel task-oriented rehabilitation program using a bimanual exoskeleton robotic hand
Uploaded: 2020-05-20T15:00:00
Description: Watch this Scientific Journal Video about Development of a Novel Task-oriented Rehabilitation Program using a Bimanual Exoskeleton Robotic Hand at JoVE.com

This project was supported by Chang Gung Medical Foundation with grant BMRP390021 and the Ministry of Science and Technology with grants MOST 107-2218-E-182A-001 and 108-2218-E-182A-001.

The training protocol and informed consent document were reviewed and approved by the Institutional Review Board of the Chang Gung Medical Foundation. The details of the study and the procedures were clearly explained to each subject.
1. Recruitment of three healthy adults
<ol>
	<li>Perform the screening process using the following inclusion criteria: (1) age 20&#8211;60 years, (2) already signed informed consent, (3) normal function in upper limbs, (4) Mini-Mental State Examination (MMSE) s...

<ol>
	<li>Hung, C. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effects+of+combination+of+robot-assisted+therapy+with+task-specific+or+impairment-oriented+training+on+motor+function+and+quality+of+life+in+chronic+stroke.">The effects of combination of robot-assisted therapy with task-specific or impairment-oriented training on motor function and quality of life in chronic stroke.</a> PM &amp; R: The Journal of Injury, Function, and Rehabilitation. 8 (8), 721-729 (2016).</li><li>SangWook, L., Landers, K. A., Hyung-Soon, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+a+biomimetic+hand+exotendon+device+(BiomHED)+for+restoration+of+functional+hand+movement+post-stroke.">Development of a biomimetic hand exotendon device (BiomHED) for restoration of functional hand movement post-stroke.</a> IEEE Transactions on Neural Systems and Rehabilitation Engineering. 22 (4), 886-898 (2014).</li><li>Johnson, M. J., Wisneski, K. J., Anderson, J., Nathan, D., Smith, R. O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+ADLER:+The+Activities+of+Daily+Living+Exercise+Robot.">Development of ADLER: The Activities of Daily Living Exercise Robot.</a> Proceedings of IEEE/RAS-EMBS International Conference. , (2006).</li><li>Pignolo, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotics+in+neuro-rehabilitation.">Robotics in neuro-rehabilitation.</a> Journal of Rehabilitation Medicine. 41 (12), 955-960 (2009).</li><li>Timmermans, A. A., Spooren, A. I., Kingma, H., Seelen, H. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+task-oriented+training+content+on+skilled+arm-hand+performance+in+stroke:+a+systematic+review.">Influence of task-oriented training content on skilled arm-hand performance in stroke: a systematic review.</a> Neurorehabilitation and Neural Repair. 24 (9), 858-870 (2010).</li><li>Schweighofer, N., Choi, Y., Winstein, C., Gordon, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Task-oriented+rehabilitation+robotics.">Task-oriented rehabilitation robotics.</a> American Journal of Physical Medicine &amp; Rehabilitation. 91, 270-279 (2012).</li><li>Almhdawi, K. A., Mathiowetz, V. G., White, M., delMas, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+occupational+therapy+task-oriented+approach+in+upper+extremity+post-stroke+rehabilitation.">Efficacy of occupational therapy task-oriented approach in upper extremity post-stroke rehabilitation.</a> Occupational Therapy International. 23 (4), 444-456 (2016).</li><li>Takahashi, C. D., Der-Yeghiaian, L., Le, V. H., Cramer, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+robotic+device+for+hand+motor+therapy+after+stroke.">A robotic device for hand motor therapy after stroke.</a> Proceedings of 9th International Conference on Rehabilitation Robotics. , (2005).</li><li>Villafa&#241;e, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+short-term+robot-assisted+rehabilitation+in+patients+with+hand+paralysis+after+stroke:+a+randomized+clinical+trial.">Efficacy of short-term robot-assisted rehabilitation in patients with hand paralysis after stroke: a randomized clinical trial.</a> Hand (NY). 13 (1), 95-102 (2018).</li><li>Cauraugh, J. H., Lodha, N., Naik, S. K., Summers, J. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bilateral+movement+training+and+stroke+motor+recovery+progress:+a+structured+review+and+meta-analysis.">Bilateral movement training and stroke motor recovery progress: a structured review and meta-analysis.</a> Human Movement Science. 29 (5), 853-870 (2010).</li><li>Brunner, I. C., Skouen, J. S., Strand, L. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+modified+constraint-induced+movement+therapy+more+effective+than+bimanual+training+in+improving+arm+motor+function+in+the+subacute+phase+post+stroke?+A+randomized+controlled+trial.">Is modified constraint-induced movement therapy more effective than bimanual training in improving arm motor function in the subacute phase post stroke? A randomized controlled trial.</a> Clinical Rehabilitation. 26 (12), 1078-1086 (2012).</li><li>Sleimen-Malkoun, R., Temprado, J. J., Thefenne, L., Berton, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bimanual+training+in+stroke:+how+do+coupling+and+symmetry-breaking+matter.">Bimanual training in stroke: how do coupling and symmetry-breaking matter.</a> BMC Neurology. 11, 11 (2011).</li><li>Yue, Z., Zhang, X., Wang, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hand+rehabilitation+robotics+on+poststroke+motor+recovery.">Hand rehabilitation robotics on poststroke motor recovery.</a> Behavioural Neurology. 2017, 1-20 (2017).</li><li>Dovat, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=HandCARE:+a+cable-actuated+rehabilitation+system+to+train+hand+function+after+stroke.">HandCARE: a cable-actuated rehabilitation system to train hand function after stroke.</a> IEEE Transactions on Neural Systems and Rehabilitation Engineering. 16 (6), 582-591 (2008).</li><li>Yoo, C., Park, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+task-oriented+training+on+hand+function+and+activities+of+daily+living+after+stroke.">Impact of task-oriented training on hand function and activities of daily living after stroke.</a> Journal of Physical Therapy Science. 27 (8), 2529-2531 (2015).</li></ol>

The results of this study showed the following: (1) both groups could successfully grasp the objects provided with the robotic hand system. They were able to complete this task with a nearly 100% success rate, which verifies the feasibility of the proposed robot-assisted task-oriented training program. (2) There were no reports of injury or adverse events during the study period and all patients reported that the robotic hand system was helpful to manipulate objects. This confirmed the acceptability of the robotic hand s...

Most (80%) stroke patients experience a deficit in the hand and have difficulty in independently performing manual tasks that are pertinent to daily living1. However, the complex nature of manual tasks means that it is a significant challenge to design a task-oriented training program for hand rehabilitation2. In recent years, many robotic devices have been developed for hand rehabilitation3,4, but few training protocols assisted by robotic devices allow a patient to interact with real objects. It is unclear exactly how a task-oriented training program for hand function rehabilitation can be applied using robotic devices for patients who experience hand dysfunction due to stroke.
Task-oriented training is used to improve hand function5,6 and is commonly applied in the rehabilitation for upper limb dysfunction due to stroke. It is used to increase neuroplasticity and is highly dependent on individual neurological deficits and functional demands7. However, during task-oriented training, patients experience difficultly in manipulating objects if hand function is impaired. Examples of this include poor grasp or limited pinch functions. Therapists also show difficulty in guiding patients&#8217; finger movements individually, which therefore limits the variation of grasping tasks. Robotic devices are thus necessary to increase the effectiveness of task-oriented training by explicitly guiding hand movement during repetitive training2,8.
Previous studies only used rehabilitation robots for task-oriented training on upper-limb reaching tasks3. It is unclear how robot-assisted rehabilitation can be employed for task-oriented training targeting at hand function. An exoskeleton&#160;hand, HWARD, has been used to guide the fingers to grasp and release objects8. However, this device does not allow varied grasping patterns because it lacks the necessary degrees of freedom. Recently, other devices that target moving a patient&#8217;s fingers individually have been developed9. However, these devices have not previously been used for neurorehabilitation. The robotic devices mentioned above are all unilateral robots. In contrast, the robotic hand system presented here needs the cooperation of unaffected and affected hands. The robotic hand system is specifically designed for rehabilitation purposes using the master&#8211;slave mechanism to achieve symmetric bimanual hand movements. The system consists of an exoskeleton hand (worn on the affected hand), a control box, and a sensory glove (worn on the unaffected hand). Each finger module of the exoskeleton hand is driven by a motor with one degree of freedom and its joints are linked using a mechanical linkage system. Two sizes, S and M, are designed to fit different subjects. The control box provides two therapeutic modes, the passive range of motion (PROM) and mirror-guided motion modes, through which the patient&#8217;s affected hand can be manipulated by the exoskeleton hand. In the PROM mode, the control box sends input commands to the exoskeleton while moves the subject&#8217;s hand to perform full finger flexion/extension. It contains two modes: single-finger mode (acts in sequence from thumb to little finger) and five fingers mode (five fingers move together). In the mirror-guided motion mode, the master (sensor glove)&#8211;slave (exoskeleton hand) mechanism is implemented, in which the movement of each finger is detected by the sensor glove and signals of the joint angles are transmitted to the control box to manipulate the exoskeleton hand.
When equipped the robotic hand system, the subjects were instructed to move their affected hands under the guidance of the exoskeleton hand controlled by unaffected hands which is bimanual movement training (BMT)10. According to previous research, BMT is able to activate similar neural pathways in both hemispheres of the brain and prevent the trans-hemisphere inhibition that hinders the recovery of neuronal function in the lesion hemisphere10. Brunner et al.11 compared BMT to constraint-induced movement therapy (CIMT) in sub-acute stroke patients. They suggested that BMT tends to activate more neural networks in both hemispheres than CIMT, and there was no significant difference in improvement of hand function between the BMT and CIMT approaches. Sleimen-Malkoun et al.12 also suggested that through BMT, stroke patients are able to re-establish both paretic limb control and bimanual control. That is to say, training should comprise bimanual tasks that focus on using the affected arm. Moreover, the coordination of both hands is necessary for activities of daily living (ADL)11,12. Therefore, it is crucial to develop a bimanual robot-assisted task-oriented training program for post-stroke patients and objects that can be grasped or pinched by patients wearing the robotic hand system.
In this study, a variety of grasping objects were designed based on the needs of occupational therapy and the mechanical properties of rehabilitation robots. A task-oriented training protocol was developed using robotic rehabilitation devices for patients with distal upper limb dysfunction due to stroke. The purpose of this study was to investigate the feasibility, and acceptability of the task-oriented training program using an exoskeleton robot and newly designed grasping objects.

<table>
	<tbody>
		<tr>
			<td>Control Box</td>
			<td>Rehabotics Medical Technology Corporation</td>
			<td>HB01</td>
			<td>The control box includes a power supply, sensor glove signal receiver, motor signal transmitter, and exoskeletal hand motion mode selection unit.</td>
		</tr>
		<tr>
			<td>Exoskeletal Hand</td>
			<td>Rehabotics Medical Technology Corporation</td>
			<td>HS01</td>
			<td>It is a wearable device causing the patient&#39;s fingers to move and is driven by an external motor and mechanical assembly.</td>
		</tr>
		<tr>
			<td>Sensor Glove</td>
			<td>Rehabotics Medical Technology Corporation</td>
			<td>HM01</td>
			<td>Worn on the patient&#39;s unaffected side hand. The sensors in the sensor glove will detect flexing and extension of the hand, and this data will be used to control the exoskeletal hand when in bimanual mode.</td>
		</tr>
	</tbody>
</table>

development of a novel task-oriented rehabilitation program using a bimanual exoskeleton robotic hand

A robot-assisted hand is used for the rehabilitation of patients with impaired upper limb function, particularly for stroke patients with a loss of motor control. However, it is unclear how conventional occupational training strategies can be applied to the use of rehabilitation robots. Novel robotic technologies and occupational therapy concepts are used to develop a protocol that allows patients with impaired upper limb function to grasp objects using their affected hand through a variety of pinching and grasping functions. To conduct this appropriately, we used five types of objects: a peg, a rectangular cube, a cube, a ball, and a cylindrical bar. We also equipped the patients with a robotic hand, the Mirror Hand, an exoskeleton&#160;hand that is fitted to the subject&#8217;s affected hand and follows the movement of the sensor glove fitted to their unaffected hand (bimanual movement training (BMT)). This study had two stages. Three healthy subjects were first recruited to test the feasibility and acceptability of the training program. Three patients with hand dysfunction caused by stroke were then recruited to confirm the feasibility and acceptability of the training program, which was conducted on 3 consecutive days. On each day, the patient was monitored during 5 min of movement in a passive range of motion, 5 min of robot-assisted bimanual movement, and task-oriented training using the five objects. The results showed that both healthy subjects and subjects who had suffered a stroke in conjunction with the robotic hand could successfully grasp the objects. Both healthy subjects and those who had suffered a stroke performed well with the robot-assisted task-oriented training program in terms of feasibility and acceptability.

A total of six subjects were enrolled in this study, including three healthy subjects and three post-stroke subjects. The demographic data of both groups are shown in Supplementary Table 1. The average age of the healthy group was 28 (range: 24&#8211;30), whereas the average age of the patient group was 49 (40&#8211;57). The average assessment scores of the patient group were as follows: (1) MMSE=27 (26&#8211;29), (2) FMA=11.3 (6&#8211;15), (3) MAS=1, (4) Brunnstrom stage=2.
I...

Watch this Scientific Journal Video about Development of a Novel Task-oriented Rehabilitation Program using a Bimanual Exoskeleton Robotic Hand at JoVE.com

Development of a Novel Task-oriented Rehabilitation Program using a Bimanual Exoskeleton Robotic Hand

This study reports the development of a novel robot-assisted task-oriented program for hand rehabilitation. The developmental process consists of experiments using both healthy subjects and subjects who have had a stroke and suffered from subsequent motor control dysfunction.

A robot-assisted hand is used for the rehabilitation of patients with impaired upper limb function, particularly for stroke patients with a loss of motor ...

This robot-assisted, task-oriented training protocol was developed for patients with hand dysfunction caused by neurological deficits. Our protocol is the first to integrate task-oriented training program with a robotic hand for hand function rehabilitation and the first to investigate the feasibility and the acceptability of the protocol. We have designed specialized objects that can be manipulated using the training protocol.Then our robotic hand system can be applied to bimanual movement training. Demonstrating the procedure will be Yi-Mei Chen and Szu-Shen Lai, occupational therapists from my department. Before beginning the analysis, place the sensor on the subject's unaffected hand, and use the hook-and-loop tape to secure the wrist.Use a clean pad to wrap the affected hand, and securely fasten the hook-and-loop tape. Loosen the thumb mechanism of the exoskeleton hand to allow adjustment of the thumb-opening angle, and place the affected hand in the exoskeleton hand. Fasten the hook and loop to the palm through the fastening ring.After that, fasten the fingers one by one, beginning with the forefinger and finishing with the thumb. Fasten the hook-and-loop tape parallel to the wrist through the fastening ring, and adjust the thumb to a comfortable angle. Then, tighten the thumb mechanism.To set up the control box, insert the cable for the exoskeleton hand and insert the cable for the sensor glove. Insert both sets of cables into the socket in the control box, and insert the power cable into the control box. Then, connect the power cable to an outlet with the correct voltage.When the system and subject are ready, switch to the control box, and set the mode to Five Fingers to allow the exoskeleton hand to move the subject's fingers passively. Ask the subject to perform a grasp-and-release task guided by the exoskeleton hand for 2.5 minutes. Switch the mode to Single Finger.Then, let the exoskeleton hand move the subject's fingers individually and passively while the subject extends and retracts individual fingers for 2.5 minutes. For a robot-assisted bimanual movement session, switch the mode to Mirror to allow the movement of the unaffected hand wearing the sensor glove to control the exoskeleton hand movements. To conduct a trial of the subject's ability to manipulate objects using the robotic hand system, fit the exoskeleton hand to the subject's unaffected hand and the sensor glove to the unaffected hand as just demonstrated, and place a sling under the subject's elbow and exoskeleton hand to support the affected arm.Next, conduct a warm-up session as just demonstrated. After the warm-up, use the robotic hand system for five minutes to demonstrate how to manipulate the designed objects, including using palmar prehension to pick up the peg, a lateral prehension to pick up the rectangular cube, a three-point chuck to pick up the cube, a spherical grasp to pick up the ball, and a cylindrical grasp to pick up the cylindrical bar. After the demonstration, place two bases bilaterally in front of the subject's hands, and place the objects onto the top of one base to assist in their manipulation.Have the subject use the robotic hand system to grasp each object 20 times a day for three consecutive days, starting at the area of the base and lifting, moving, and releasing each object onto the midline while monitoring and recording the success rate for each attempt. In this representative analysis, three healthy subjects and three post-stroke subjects were assessed. The average age of the healthy group was 28, whereas the average age of the patient group was 49.Mini-Mental State Examination, Fugl-Meyer Assessment, Modified Ashworth Scale finger, and Brunnstrom stage scores were also obtained for each patient. The subjects in the healthy group perfectly manipulated all of the objects with and without the robotic hand system, with an average success rate of 100%for every task. All of the patients, however, exhibited difficulties in manipulating the objects without the robotic hand system, demonstrating a 0%success rate for all of the objects.In contrast, all of the patient success rates increased significantly when the robotic hand system was used, approaching rates similar to those observed in healthy subjects, supporting the feasibility of using the robotic hand system in stroke patients. Remind the subjects to concentrate on the movement control of their bilateral hands during bimanual movement training, making sure that the grasp patterns on the objects are correct. Following this procedure, a randomized controlled trial is required to determine the therapeutic effects of the training protocol.Using this technique, researchers can program rehabilitation protocols with delicate finger movement for severe hand dysfunction and can explore the effects on brain neuroplasticity and functional outcomes.

development-novel-task-oriented-rehabilitation-program-using-bimanual

Research

JoVE Journal

Medicine

A Novel Capsulorhexis Technique Using Shearing Forces with Cystotome

Purpose:
To demonstrate a capsulorhexis technique using predominantly shearing forces with a cystotome on a virtual reality simulator and on a human eye.
Method:
Our technique involves creating the initial anterior capsular tear with a cystotome to raise a flap. The flap left unfolded on the lens surface. The cystotome tip is tilted horizontally and is engaged on the flap near the leading edge of the tear. The cystotome is moved in a circular fashion to direct the vector forces. The loose flap is constantly swept towards the centre so that it does not obscure the view on the tearing edge.
Results:
Our technique has the advantage of reducing corneal wound distortion and subsequent anterior chamber collapse. The capsulorhexis flap is moved away from the tear leading edge allowing better visualisation of the direction of tear. This technique offers superior control of the capsulorhexis by allowing the surgeon to change the direction of the tear to achieve the desired capsulorhexis size.
Conclusions:
The EYESI Surgical Simulator is a realistic training platform for surgeons to practice complex capsulorhexis techniques. The shearing forces technique is a suitable alternative and in some cases a far better technique in achieving the desired capsulorhexis.

This video demonstrates a novel capsulorhexis technique in modern cataract surgery. Capsulorhexis is the most difficult and important part of phacoemulsification surgery.

Purpose:
To demonstrate a capsulorhexis technique using predominantly shearing forces with a cystotome on a virtual reality simulator and on a human eye....

A Novel Technique of Rescuing Capsulorhexis Radial Tear-out using a Cystotome

Part 1 : Purpose: To demonstrate a capsulorhexis radial tear out rescue technique using a cystotome on a virtual reality cataract surgery simulator and in a human eye. Part 2 : Method: Steps: When a capsulorhexis begins to veer radially towards the periphery beyond the pupillary margin the following steps should be applied without delay. 2.1) Stop further capsulorhexis manoeuvre and reassess the situation. 2.2) Fill the anterior chamber with ophthalmic viscosurgical device (OVD). We recommend mounting the cystotome to a syringe containing OVD so that the anterior chamber can be reinflated rapidly. 2.3) The capsulorhexis flap is then left unfolded on the lens surface. 2.4) The cystotome tip is tilted horizontally to avoid cutting or puncturing the flap and is engaged on the flap near the leading edge of the tear but not too close to the point of tear. 2.5) Gently push or pull the leading edge of tear opposite to the direction of tear. 2.6) The leading tearing edge will start to do a 'U-Turn'. Maintain the tension on the flap until the tearing edge returns to the desired trajectory. Part 3 : Results: Using our technique, a surgeon can respond instantly to radial tear out without having to change surgical instruments. Changing surgical instruments at this critical stage runs a risk of further radial tear due to sudden shallowing of anterior chamber as a result of forward pressure from the vitreous. Our technique also has the advantage of reducing corneal wound distortion and subsequent anterior chamber collapse. Part 4 : Discussion The EYESI Surgical Simulator is a realistic training platform for surgeons to practice complex capsulorhexis tear-out techniques. Capsulorhexis is the most important and complex part of phacoemulsification and endocapsular intraocular lens implantation procedure. A successful cataract surgery depends on achieving a good capsulorhexis. During capsulorhexis, surgeons may face a challenging situation like a capsulorhexis radial tear-out. A surgeon must learn to tackle the problem promptly without making the situation worse. Some other methods of rescuing the situation have been described using a capsulorhexis forceps. However, we believe our method is quicker, more effective and easier to manipulate as demonstrated on the EYESi surgical simulator and on a human eye. Acknowledgments: List acknowledgements and funding sources. We would like to thank Dr. Wael El Gendy, for video clip. Disclosures: describe potential conflicting interests or state We have nothing to disclose. References: 1. Brian C. Little, Jennifer H. Smith, Mark Packer. J Cataract Refract Surg 2006; 32:1420 1422, Issue-9. 2. Neuhann T. Theorie und Operationstechnik der Kapsulorhexis. Klin Monatsbl Augenheilkd. 1987; 1990: 542-545. 3. Gimbel HV, Neuhann T. Development, advantages and methods of the continuous circular capsulorhexis technique. J Cataract Refract Surg. 1990; 16: 31-37. 4. Gimbel HV, Neuhann T. Continuous curvilinear capsulorhexis. (letter) J Cataract Refract Sur. 1991; 17: 110-111.

Capsulorhexis is an important step in phacoemulsification surgery. A surgeon creates a continous curvilinear tear on the anterior lens capsule by controlling the tearing vector forces. A peripherally extended tear is a serious complication. This video demonstrates a novel technique of rescuing capsular radial tear out using a cystotome.

Part 1 : Purpose:   To demonstrate a capsulorhexis radial tear out rescue technique using a cystotome on a virtual reality cataract surgery simulator and ...

Manual Muscle Testing:  A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, and persistent nerve and muscle impairments after hospital discharge.1-6 Using an explicit protocol with a structured approach to training and quality assurance of research staff, manual muscle testing (MMT) is a highly reliable method for assessing strength, using a standardized clinical examination, for patients following ARDS, and can be completed with mechanically ventilated patients who can tolerate sitting upright in bed and are able to follow two-step commands. 7, 8 
This video demonstrates a protocol for MMT, which has been taught to &ge;43 research staff who have performed &gt;800 assessments on &gt;280 ARDS survivors. Modifications for the bedridden patient are included. Each muscle is tested with specific techniques for positioning, stabilization, resistance, and palpation for each score of the 6-point ordinal Medical Research Council scale.7,9-11 Three upper and three lower extremity muscles are graded in this protocol: shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, and ankle dorsiflexion. These muscles were chosen based on the standard approach for evaluating patients for ICU-acquired weakness used in prior publications. 1,2.

Survivors of acute respiratory distress syndrome (ARDS) and critical illness frequently develop long-lasting muscle weakness. Manual muscle testing (MMT) is a standardized clinical examination commonly used to measure strength of peripheral skeletal muscle groups. This video demonstrates MMT using the 6-point Medical Research Council scale.

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, ...

Development of an Algorithm to Perform a Comprehensive Study of Autonomic Dysreflexia in Animals with High Spinal Cord Injury Using a Telemetry Device

Spinal cord injury (SCI) is a debilitating neurological condition characterized by somatic and autonomic dysfunctions. In particular, SCI above the mid-thoracic level can lead to a potentially life-threatening hypertensive condition called autonomic dysreflexia (AD) that is often triggered by noxious or non-noxious somatic or visceral stimuli below the level of injury. One of the most common triggers of AD is the distension of pelvic viscera, such as during bladder and bowel distension or evacuation. This protocol presents a novel pattern recognition algorithm developed for a JAVA platform software to study the fluctuations of cardiovascular parameters as well as the number, severity and duration of spontaneously occurring AD events. The software is able to apply a pattern recognition algorithm on hemodynamic data such as systolic blood pressure (SBP) and heart rate (HR) extracted from telemetry recordings of conscious and unrestrained animals before and after thoracic (T3) complete transection. With this software, hemodynamic parameters and episodes of AD are able to be detected and analyzed with minimal experimenter bias.

The catheter of a telemetry device is implanted into the abdominal aorta in order to continuously collect beat-by-beat hemodynamic data from animals pre and post-high thoracic spinal cord transection. A novel JAVA software was employed to analyze hemodynamic parameters as well as frequency and intensity of spontaneous episodes of autonomic dysreflexia.

Spinal cord injury (SCI) is a debilitating neurological condition characterized by somatic and autonomic dysfunctions. In particular, SCI above the ...

Design, Fabrication, and Administration of the Hand Active Sensation Test (HASTe)

The concept of personalizing neurologic rehabilitation, based on individual impairments, has experienced a recent surge. In parallel, the number of outcome measures of upper extremity motor performance has grown. However, clinicians and researchers lack practical, quantitative measures of the hand&#8217;s natural role as a receptor of the environment. The Hand Active Sensation Test (HASTe), developed by Williams and colleagues in 2006, is a valid and reliable measure of haptic performance. Though not available commercially, the HASTe can be fabricated from inexpensive materials, and it has been used successfully to identify impairments in haptic touch in individuals with stroke. (Williams, 2006). This paper presents the methods of design and fabrication of the HASTe testing kit, as well as a visual screen to be used during administration, and instructions for the tests administration and scoring.

Design, Fabrication, and Administration of the Hand Active Sensation Test HASTe

The Hand Active Sensation Test (HASTe) is a valid and reliable measure of haptic performance, which has been used successfully to identify impaired haptic touch in individuals with stroke. The purpose of this paper is to describe the design, fabrication and administration of the HASTe.

The concept of personalizing neurologic rehabilitation, based on individual impairments, has experienced a recent surge. In parallel, the number of ...

Minimally Invasive Muscle Embedding (MIME) - A Novel Experimental Technique to Facilitate Donor-Cell-Mediated Myogenesis

Skeletal muscle possesses regenerative capacity due to tissue-resident, muscle-fiber-generating (myogenic) satellite cells (SCs), which can form new muscle fibers under the right conditions. Although SCs can be harvested from muscle tissue and cultured in vitro, the resulting myoblast cells are not very effective in promoting myogenesis when transplanted into host muscle. Surgically exposing the host muscle and grafting segments of donor muscle tissue, or the isolated muscle fibers with their SCs onto host muscle, promotes better myogenesis compared to myoblast transplantation. We have developed a novel technique that we call Minimally Invasive Muscle Embedding (MIME). MIME involves passing a surgical needle through the host muscle, drawing a piece of donor muscle tissue through the needle track, and then leaving the donor tissue embedded in the host muscle so that it may act as a source of SCs for the host muscle. Here we describe in detail the steps involved in performing MIME in an immunodeficient mouse model that expresses a green fluorescent protein (GFP) in all of its cells. Immunodeficiency in the host mouse reduces the risk of immune rejection of the donor tissue, and GFP expression enables easy identification of the host muscle fibers (GFP+) and donor-cell-derived muscle fibers (GFP-). Our pilot data suggest that MIME can be used to implant an extensor digitorum longus (EDL) muscle from a donor mouse into the tibialis anterior (TA) muscle of a host mouse. Our data also suggest that when a myotoxin (barium chloride, BaCl2) is injected into the host muscle after MIME, there is evidence of donor-cell-derived myogenesis in the host muscle, with approximately 5%, 26%, 26% and 43% of the fibers in a single host TA muscle showing no host contribution, minimal host contribution, moderate host contribution, and maximal host contribution, respectively.

Minimally Invasive Muscle Embedding MIME - A Novel Experimental Technique to Facilitate Donor-Cell-Mediated Myogenesis

We describe a novel experimental technique that we call Minimally Invasive Muscle Embedding (MIME), which is based on the evidence that skeletal muscle tissue contains viable myogenic cells that can facilitate donor-cell-mediated myogenesis when implanted into a host muscle.

Skeletal muscle possesses regenerative capacity due to tissue-resident, muscle-fiber-generating (myogenic) satellite cells (SCs), which can form new ...

Structured Motor Rehabilitation After Selective Nerve Transfers

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning.
Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation.

Here, we present a protocol for the motor rehabilitation of patients with severe nerve injuries and selective nerve transfer surgery. It aims at restoring the motor function proposing several stages in patient education, early-stage therapy after surgery and interventions for rehabilitation after successful re-innervation of the nerve&#8217;s target.

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

A Training Program Using an Agility Ladder for Community-Dwelling Older Adults

Aging impairs physical and cognitive functions and limits daily activities. Agility training can improve or maintain physical functioning in older people. The purpose of this study is to report the physical fitness benefits of a training program for independent community-dwelling older adults using an agility ladder. Each training session lasted approximately 30 minutes, and the benefits were achieved with two sessions per week for 14 weeks. Training was timed and involved four different drills and varying levels of difficulty through time. The exercises were performed at the School of Physical Education of the University of Campinas, S&#227;o Paulo state, Brazil. The study participants (n = 16; mean age of 66.9 &#177; 5.0 years) were instructed to perform the exercises as quickly as possible without making mistakes and were assisted by a physical trainer when they made mistakes. Assessments were performed both before and after training using five functional tests (i.e., Illinois agility, five times sit-to-stand, timed up-and-go, walking usual speed, and one-leg stand). Although the study sample was not compared with a control group, the results indicate that training protocols using an agility ladder are easy and practical and improve physical function performance in older adults.

The aim of this study is to present an agility training program for older people. The feasibility of this program is described, and the training protocol demonstrated by video imaging.

Aging impairs physical and cognitive functions and limits daily activities. Agility training can improve or maintain physical functioning in older people. ...

A Murine Model of Hemodialysis Access-Related Hand Dysfunction

Chronic kidney disease is a major public health problem, and the prevalence of end-stage renal disease (ESRD) requiring chronic renal replacement therapies such as hemodialysis continues to increase. Autogenous arteriovenous fistula (AVF) placement remains a primary vascular access option for ESRD patients. Unfortunately, approximately half of the hemodialysis patients experience dialysis access-related hand dysfunction (ARHD), ranging from subtle paresthesia to digital gangrene. Notably, the underlying biologic drivers responsible for ARHD are poorly understood, and no adequate animal model exists to elucidate the mechanisms and/or develop novel therapeutics for the prevention/treatment of ARHD. Herein, we describe a new mouse model in which an AVF is created between the left common iliac artery and vein, thereby facilitating the assessment of limb pathophysiology. The microsurgery includes vessel isolation, longitudinal venotomy, creation of arteriovenous anastomosis, and venous reconstruction. Sham surgeries include all the critical steps except for AVF creation. Iliac AVF placement results in clinically relevant alterations in central hemodynamics, peripheral ischemia, and impairments in hindlimb neuromotor performance. This novel preclinical AVF model provides a useful platform that recapitulates common neuromotor perturbations reported by hemodialysis patients, allowing researchers to investigate the mechanisms of ARHD pathophysiology and test potential therapeutics.

This protocol details the surgical steps of murine common iliac arteriovenous fistula creation. We developed this model to study hemodialysis access-related limb pathophysiology.