Name: whole body vibration methods with survivors of polio
Uploaded: 2018-10-17T14:45:00.000+00:00
Duration: 4 min 16 s
Description: Watch this Scientific Journal Video about Whole Body Vibration Methods with Survivors of Polio at JoVE.com

The original study was funded by Post-Polio Health International in 2013, with no cost extension to 2014. Funding for this article was through Texas Woman&#39;s University Libraries&#39; Open Access Fund. The results were presented as a poster at the American Physical Therapy Association Combined Sections Meeting, Anaheim, California, US, 2016, and published as a manuscript in Physiotherapy Theory and Practice in 2018 (see reference #26).
The author wishes to acknowledge Elson &#34;Randy&#34; Robertson for his assistance during the filming of the video and participation in the original study. She also wishes to acknowledge the following people for their assistance during the original study: C Lauren Szot, PT, DPT, NCS and Natasha deSa, PT, DPT, NCS as blinded testers and co-authors for original manuscript; Arianne Stoker, PT, DPT, Kelly Hodges, PT, DPT, NCS, Mariana Sanjuan, PT, DPT, and Maggie Strange, PT, DPT for help as DPT students during vibration sessions; and Zoheb Allam, MS and Rene Paulson, PhD for statistical assistance.

The protocol being described in this article follows the protocol used in the previously published study that abided by the ethical standards for human research of the Internal Review Boards of Texas Woman&#39;s University and Baylor College of Medicine in Houston, Texas, USA26.
1. Participant Screening and Study Preparation
<ol>
	<li>Screen all participants for inclusion and exclusion criteria by phone, and then ask them again about these criteria while in person during the approved informed consent process.
	<ol>
		<li>Ask the participants about their polio history and whether they have been diagnosed with PPS.</li>
		<li>Ask if the participants have any concern about being able to bear weight through their lower extremities (LEs) at least 20 min in short blocks of time.</li>
	</ol>
	</li>
	<li>Review the exclusion criteria commonly reported in the literature and used in the previously published study26 for appropriateness for a future study. 
	NOTE: Typical exclusion criteria are body weight more than 227 kg (vibration platform maximum), current medical conditions such as cancer, infection, wound, fracture, thrombosis/embolism, epilepsy, severe migraine headaches, severe vestibular conditions, discopathy, spondylolysis, or implanted devices, metal fixators or joints.
	<ol>
		<li>Check the weight limit of the selected or available vibration platform, and weigh the participants in person if they appear close to that body weight maximum. 
		NOTE: A typical bathroom scale may not measure weights high enough. Many vibration platforms have weight limits of 227 kg or 500 lbs.</li>
	</ol>
	</li>
	<li>Determine the inclusion criteria that will be specific to the target population and clinical or laboratory setting. If a physician is not on the study team, consider requiring the participants to seek medical approval from their personal physician, for reasons similar to someone starting a new exercise program. 
	NOTE: In the previously reported study26, the participants were English speaking survivors of polio, with or without PPS, 40&#8211;85 years of age, and able to weight bear through their LEs up to 20 min. Note that their ability to walk was not an inclusion criterion.</li>
	<li>Document the reasons why the individuals do not agree to participate in the study and why they withdraw, if that occurs. Determine if the withdrawals need to be reported to the Internal Review Board of the institution or facility.</li>
	<li>Explain to the participants what the experimental design is (in lay terms), what to expect in terms of time commitment per session, how many sessions, and how many weeks or months the study will last.</li>
	<li>Explain to the participants that they will be standing up or weight bearing on the vibration platform for several short bouts for each session and what the vibration will feel like.
	<ol>
		<li>Show the participants the vibration platform. If the participants seem hesitant during the informed consent process and baseline testing, offer to turn on the platform to show the participants how it works. Inquire if he or she wishes to try it briefly prior to starting the intervention in the next session.</li>
	</ol>
	</li>
</ol>
2. Experimental Design
<ol>
	<li>Use random assignment to groups, if possible. If a randomized controlled study is selected, consider offering a delayed-start intervention for the control group to help avoid disappointment or attrition due to the lack of interest. 
	NOTE: The previously conducted study used a random-order cross-over experimental design with two weeks for a wash-out period and a two-week follow-up period; therefore, all participants received the same dosage or amount of vibration intervention with treatment block order randomized (low intensity first/high intensity second or high intensity first/low intensity second). No control group was used due to anticipated small sample size26.</li>
	<li>If the participants will use any type of written log for the symptoms such as cramping or activity levels, provide the log for them in paper or electronic version, based upon their preference. Request their log each week to help them keep up with their documentation and to avoid recall bias issues.</li>
	<li>Build in a follow-up period with repeat testing in the study design to see if any changes persist.</li>
	<li>Be available by email or phone for questions or concerns that may arise during the study period.</li>
</ol>
3. WBV Interventions
<ol>
	<li>Schedule the sessions with at least one day off in between sessions, two to three times per week to avoid undue fatigue or muscle soreness.
	<ol>
		<li>Select the number of weeks of intervention based upon the current literature and the outcome measures selected. 
		NOTE: Because the previous study was a feasibility study, two four-week intervention blocks with treatment order randomized were used to determine if the WBV would be a safe and tolerable method to achieve weight bearing exercise26. Gains in bone mineral density will require months, whereas other gains can occur immediately or in days or weeks.</li>
	</ol>
	</li>
	<li>Instruct the participants to stand on the WBV platform with the knees slightly bent and weight as evenly distributed between their two LEs as possible27,28. Allow the participants to support themselves with their arms, as needed, for balance during the vibration and when stepping up and down from the platform.</li>
	<li>If the person is not able to stand at all or stand long enough, allow him or her to sit in a chair or wheelchair, with the feet on the platform, forearms resting on thighs, leaning forward to achieve as much weight bearing through the lower body as possible, still keeping the feet on the platform.
	<ol>
		<li>If the motorized wheelchair has a seat elevator, raise the seat as high as possible.</li>
		<li>If the person will be sitting in a standard chair, ask him or her to sit on some folded blankets or pillows to raise the hips up into a higher position. 
		NOTE: The closer the LEs are to a standing position, the more weight bearing will occur through the LEs to enhance vibration stimulation into the body.</li>
	</ol>
	</li>
	<li>Ask the participants to remove their shoes and LE orthoses (braces) and wear socks (for cleanliness) during the vibration. Offer socks with rubber treads on them if the person is not wearing socks or is apprehensive of standing or stepping on the tile floor of the lab.
	<ol>
		<li>Explain to the participants that wearing only socks on their feet will enhance their nerve stimulation to their muscles, spinal cord, and brain for peak effectiveness.</li>
		<li>Explain to the participants that the orthoses are to be removed because the vibration may cause rubbing between the orthosis and their skin, putting them at risk for skin breakdown. Inform the participants that it may also cause hardware loosening of metal components of the braces.</li>
	</ol>
	</li>
	<li>Encourage each person to move into his or her optimal alignment. 
	NOTE: For people with significant LE weakness on one or both sides, they may not be able to weight bear symmetrically or stand with knees flexed, especially without their orthoses.</li>
	<li>Use a wedge or cuff weight under the heel to accommodate leg length discrepancies or plantarflexor contractures, if necessary, to allow weight bearing through as much of the plantar surface of the foot as possible.</li>
	<li>Start with ten 1 min vibration bouts, with 1 min sitting rest periods between the vibration bouts. Increase to ten 2 min vibration bouts, and do not change the rest periods unless needed or requested by the participant. See Table 1 for a typical intervention progression.
	<ol>
		<li>Take the person&#8217;s vital signs.</li>
		<li>Observe this person who had polio as a child step up onto the platform used for the low intensity protocol.</li>
		<li>Instruct the person to stand with the knees slightly bent, weight as evenly spread between two feet as possible.</li>
		<li>Tell the person that he/she can hold onto the handle if he/she needs to balance, but to hold it as lightly as possible.</li>
		<li>Inform the person that he/she will feel the vibration in the soles of his/her feet, radiating up into his/her body.</li>
		<li>Ask the person if he/she is ready to start, and when he/she says yes, turn on the machine.</li>
		<li>Use a timer set for 1 min for the first session if the platform does not have a preset time choice.</li>
		<li>After 1 min of vibration has ended, ask the person to sit down for 1 min to rest, setting a timer, offering to answer any questions he/she may have.</li>
		<li>After the 1 min rest, ask the person if he/she is ready to step up and resume the vibration. If so, continue for total of 10 repetitions of vibration.</li>
		<li>If the person is not ready to continue, ask why, and provide more rest, as needed. Document how much rest time is required, if different than the established protocol.</li>
		<li>Repeat this sequence with the higher intensity protocol, but inform the person that the intensity is higher, and he/she may feel it spread higher into his or her body.
		<ol>
			<li>Conversely, if using a two-intensity protocol and the person starts with the higher intensity intervention first, warn him/her that the second lower intensity will be quite gentle compared to what he/she is used to. 
			Note: The platform used for higher intensity vibration actually elevated a little, and it gradually lowered during the preset time. As it reached the end of the time, returning to the starting position, the vibration intensifies, so inform the participant that this phenomenon will occur beforehand to avoid undue concern.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>WBV intensity and equipment
	<ol>
		<li>Use a medium to higher intensity (peak to peak vertical displacement 8.82 mm, 35 Hz, and g force 2.76) vibration to allow significant effects. Depending on the targeted population and selected outcome measures, choose more or less aggressive settings. 
		NOTE: The previously published study26 used settings in an attempt to simulate that reported for bone mineral density studies, thinking ahead to possible future studies. The second platform listed in the Table of Materials was used for this intensity. It is a commercial grade platform that was available in the research lab of Texas Woman&#8217;s University. The settings used were 35 Hz, &#8220;low amplitude&#8221;, and desired time.</li>
		<li>Because low intensity (peak to peak vertical displacement 4.53 mm, 24 Hz, g force 2.21) vibration did not cause any significant changes, do not use this intensity or less unless the targeted study population is very frail, fearful, or both. Then if the participants are able to tolerate this intensity, gradually increase it for each person. 
		NOTE: The first platform listed in the Table of Materials was used for this intensity. It was purchased for the original study through Post-Polio Health International. It is a unit designed for home or personal use. It has no handles, and a grab rail was installed on the laboratory wall to ensure safety. This platform had a rotating dial, and the lowest setting was selected. A separate timer was used for on and off times.</li>
		<li>Ideally, select a vibration platform that the amplitude and frequency can be set independently for individualization to the unique needs of the study population. See Table of Materials for the vibration platforms used in the previously reported study26. 
		NOTE: Both units used for the reported study had synchronous vertical displacement during vibration. Some units have asynchronous vertical displacement, rotating over a center; in these, the wider the person&#8217;s base of support is [feet further from center], the more intense the vibration16.</li>
		<li>Use an independent accelerometer to determine peak to peak displacement, frequency, and g forces. 
		NOTE: Manufacturers may not provide all required information, and it is needed for accurate reporting of methods and equipment used16. G forces reported above were measured by an accelerometer listed in Table of Materials.</li>
		<li>When reporting the amplitude of vibration platforms, be careful with the terminology due to inconsistencies in the literature. 
		NOTE: The term amplitude is to be used for equilibrium point to peak displacement. Although the term peak to peak displacement is synonymous with peak to peak amplitude, and this value will be twice that of traditional amplitude, the use of peak to peak displacement is preferred to avoid confusion16.</li>
	</ol>
	</li>
</ol>
4. Participant Testing
<ol>
	<li>Take heart rate and blood pressure prior to all testing and intervention sessions, especially if working with people with neurologic conditions. Keep in mind that hypertension is considered a &#8220;silent killer&#8221; and that many people may have this problem and not be aware of it or fail to take prescribed medications for it.
	<ol>
		<li>Take the participants&#8217; vital signs again, after at least the first few sessions to ensure safety, and during sessions if the participants experience symptoms that could indicate excessive exertion or abnormal responses to vibration.</li>
	</ol>
	</li>
	<li>Ask the participants to report perceived exertion with a standardized scale, after each intervention session. 
	NOTE: Borg&#8217;s rating of perceived exertion [RPE] is widely used and has sound psychometric properties29.</li>
	<li>To reduce testing bias, have a licensed physical therapist blinded to intervention administer selected outcome measures pre and post each intervention block and at the end of the follow-up period. 
	NOTE: A double blinded study with vibration interventions will be difficult to conduct because the participants will be able to feel the vibration.</li>
	<li>Select reliable and valid outcome measures that address more than one domain (body functions and structure, activities, and participation) of the International Classification of Functioning, Disability and Health (ICF) of the targeted population30.
	<ol>
		<li>When available, use measures that have sound psychometric properties for the population. For less common populations, use more generic measures or ones that have been tested for populations similar in some way. Consider the use of the following outcome measures for survivors of polio, although none were developed specifically for them.</li>
		<li>Measure physical performance of gait speed by 10 m walk test (10mWT)31 and gait endurance by 2 min walk test32.</li>
		<li>Administer surveys to determine pain severity and interference by the Brief Pain Inventory (BPI)33,34, sleep quality by the Pittsburgh Sleep Quality Index35, and fatigue by the Fatigue Severity Scale36,37.</li>
		<li>Measure LE strength by manual muscle test and handheld dynamometry38,39,40.</li>
		<li>Provide log forms or calendar for participants to document muscle cramping incidence. 
		NOTE: No sensory outcome measures were selected in the previously reported study due to the fact that sensory impairments in polio survivors occur only in the presence of other medical conditions or comorbidities. The original poliomyelitis infection affected the anterior horn cells of the spinal cord (lower motor neurons) impacting motor function while preserving sensory function17,18.</li>
	</ol>
	</li>
</ol>

The author has nothing to disclose.

Two different vibration intensities were studied due to the author&#39;s clinical experience in working with survivors of polio and hearing their reports of increased muscle weakness, pain, fatigue, and other symptoms of PPS. Little evidence is present in the literature related to safe, effective weight bearing exercise parameters for people with PPS, and only one study12 was published prior to the current study26 with WBV and survivors of polio. To date, only two published articles have studied the use of WBV with polio survivors, and both used the platforms with synchronous vertical oscillations12,26. Therefore, no scientific literature exists related to the use of asynchronous vertical (rotatory) or horizontal vibration in this population.
This author was concerned about possibly worsening their symptoms during the WBV protocols, thereby selecting one intensity fairly typical of that reported in the bone density studies and one much lower, in case the participants would have difficulty tolerating the higher one. The author was vigilant during each vibration session and regularly asked if new symptoms surfaced or typical ones worsened at the beginning of the next session. Group means of RPE after higher intensity sessions were 9.4 to 9.8, or &#34;very light,&#34; although the range extended from &#34;no exertion at all&#34; to &#34;extremely hard.&#34; Although significant changes only occurred for pain severity across both groups, polio survivors and those who provide care for them may be encouraged that gait endurance, muscle strength, and typical PPS symptoms of fatigue, sleep disturbances, and muscle cramping did not significantly worsen during participation in the protocols. Therefore, a strength of the presented methods includes the use of a standard protocol with intentional monitoring of symptoms by a consistent health care provider knowledgeable about their condition. Because no significant improvements occurred with the low intensity protocol, this intensity or less could possibly be considered for use in a sham intervention in a future randomized controlled study.
Although the knowledge of the effects of WBV with survivors of polio is limited, some critical steps may exist. Due to their typical &#34;type A&#34;, hard-working, and eager-to-please personalities, one must ask them specific questions and give them explicit permission to voice concerns or potential problems, such as muscle or joint discomfort, excessive muscular fatigue, or sense of worsened balance, that may arise during the intervention period. Similarly, limiting the WBV total dosage (frequency and intensity)16 per session to no more than 20 min (in one to two min bouts with forced rests) and scheduling sessions with at least one day off in between can help reduce risk of muscle overuse-related fatigue, pain, and cramping17,18.
The mechanisms behind how WBV affects a person&#39;s neurophysiological system is poorly understood. The literature has not reported how changes due to WBV in the Hoffman, stretch, and tonic vibratory reflexes of polio survivors who have a depleted alpha motor neuron pool due to initial disease destruction are impacted42,43,44,45,46,47. Reported circulatory changes42, in addition to reports of vibration decreasing delayed-onset muscle soreness after exercise48, may enhance the polio survivors&#39; weaker muscles to work at safe levels for longer time periods during functional activities, such as walking. A limitation of the presented method in this article is that measurement of reflexes, muscular activity, and circulation did not occur.
A second limitation of the method may be that it was tested on such a small group of polio survivors. Recruitment of people to come to a university research lab in the Texas Medical Center twice a week for three months was challenging due to the time, energy, and transportation costs of commuting within a huge metropolitan city. However, a noteworthy amount of participant diversity in physical mobility existed in the 15 individuals who completed the previously reported study26, which could be considered a strength. As seen in Table 2, they ranged from not being able to walk at all, to walking &#34;5%&#34; of total locomotion, to walking full-time, and using no devices at all to utilizing a pair of knee ankle foot orthoses with crutches. All participants except one were able to independently get onto and off the vibration platforms, using the provided handles or grab bar. Even though the participants were able to use their arms for support as needed or preferred, some were unable to shift their weight onto the weaker leg or stand without mechanically locking their knees because of their weakness. Standing with the knees locked could be a potential joint safety issue for some people, and this could be considered a limitation to this method; however, locking also allows more of the vibration g force to extend more cranially27,28. However, this author was surprised by how positively the individuals responded to the vibration during the sessions, with smiles, early arrivals for appointments, requests to &#34;turn it up&#34;, and few to no complaints, even with some them dependent on orthoses or assistive devices for safe walking or appearing physically frail. Participants were noted to spontaneously shift weight and change postural alignment, apparently seeking the body position that &#34;felt best&#34; to them. The vibration was truly &#34;whole body&#34; in that it could be heard in their voices while talking during vibration, and dangling earrings or bracelets could be seen or heard to vibrate.
The presented WBV method seems to be a safe, tolerable, and feasible form of weight-bearing exercise for people with weakness or paralysis from polio and PPS. Short lasting improvements in pain and walking speed for some individuals are encouraging for polio survivors who have limited methods to exercise, especially in weight bearing positions. Further research is necessary in order to study long term use and efficacy of WBV in people with PPS and other neurological conditions, particularly to address decreasing&#160;barriers to exercise participation and active pursuit of wellness activities. An application of the presented method is the safe use of a WBV platform designed for home use to reduce the barriers of energy, time, and transportation costs associated with going to a health club or therapy clinic. Use within the home can make a longer term intervention feasible, particularly for people with mobility difficulties. Longer intervention studies (at least eight months) will be needed to determine if WBV can significantly impact bone mineral density in female and male polio survivors who have a higher prevalence of osteopenia and osteoporosis than typically aging adults49,50,51,52. Additionally, examining the application of WBV in aging adults with neurologic conditions other than post-polio and its effects on bone mineral density will be important, and the presented methods may serve as a starting point in these studies.

Whole body vibration (WBV) is reported to give benefits similar to customary exercise in adults, those who are normal or with medical conditions. A vibration platform provides motorized, oscillatory movement to the whole body while the person stands on it. Improvements in pain1,2, strength3,4, balance5,6,7, bone density4,6,8,9, and flexibility5 have been reported. In del Pozo-Cruz et al.&#39;s10 systematic review of WBV studies with people with neurologic conditions, vibration frequencies ranged from 2 to 50 Hz, amplitudes from 0 to 14 mm, 1 to 11 bouts with 1&#8211;3 min of rest between bouts, total vibration time per sequence of 0.5 to 15 min, and number of sessions from 1 to 240. WBV acute significant effects were seen in functional balance tests and quadriceps isometric strength in people with multiple sclerosis, postural control and movement items on the Unified Parkinson Disease Rating Scale (UPDRS) in people with Parkinson&#39;s disease, and quadriceps isometric and eccentric strength in people post stroke. The only significant change that lasted through the follow-up period was in the UPDRS in people with Parkinson&#39;s disease. The reviewers reported that there are few high quality methodological studies available for review and poor consistency of the data between studies10. A pilot study with adults with chronic incomplete spinal cord injury showed significantly faster walking speed and improvement in various gait parameters11. However, a small study with survivors of polio was discontinued due to preliminary data analysis failing to show significant improvement in walking speed and strength12.
Because of the large variations of frequencies and magnitudes used in the WBV intervention studies in the neurologic populations10, the studies reporting the effects of WBV with bone mineral density in post-menopausal women4,6,8,9, older adults6,13,14, and people with fibromyalgia15 were reviewed due to most of the current study&#39;s population of survivors of polio being of similar ages, experiencing problems in participating in traditional weight bearing exercises, and having problems with pain and fatigue. In these review studies, 10 to 40 Hz (most in 30 to 35 Hz range) vibration frequencies, with 1-8 mm amplitude, and variable g forces were used4,6,8,9,10,13,14,15. In 2010, Rauch et al.16 published a manuscript describing the need for the standardization and recommendations for reporting WBV studies.
Survivors of polio, with or without post-polio syndrome (PPS), may be challenged in their determination of methods in which to exercise in weight bearing positions to maintain bone density or for other wellness purposes because of their residual weakness or other symptoms of PPS. Exercise has been reported to potentially overly fatigue already overused muscles and worsen symptoms of pain, fatigue, and increased weakness17,18. Few studies with small sample sizes have shown exercise to be safe and beneficial in this population19,20,21,22,23,24.
The goal of the previously conducted study was to examine the use of WBV on polio survivors, with and without PPS, as a possible safe form of weight bearing exercise. Only one prior published study had addressed the use of WBV in people with PPS. The post-polio population has unique issues of chronic muscle weakness or paralysis and joint involvement that impacts their ability to participate in weight bearing exercise; therefore, an exploratory limited-efficacy feasibility study was determined to be necessary25. This article expands upon and demonstrates the method used in the previously published study26. The purpose of this article is to highlight the strengths, limitations, and applications of the method used in that study.

<table><tbody><tr><td>WBV Platform</td><td>Soloflex, Inc</td><td></td><td>Used for low intensity WBV intervention</td></tr><tr><td>Power Plate Pro 5</td><td>Performance Health Systems, LLC</td><td></td><td>Used for higher intensity WBV intervention</td></tr><tr><td>Trigno tri-axial accelerometer</td><td>Delsys, Inc</td><td></td><td>Used to measure vibration frequencies and g forces</td></tr></tbody></table>

whole body vibration methods with survivors of polio

The purpose of the original study was to examine the use of whole body vibration (WBV) on polio survivors with and without post-polio syndrome as a form of weight bearing exercise. The goal of this article is to highlight the strengths, limitations, and applications of the method used. Fifteen participants completed two intervention blocks with a wash-out period in between the blocks. Each block consisted of twice a week (four weeks) WBV interventions, progressing from 10 to 20 min per session. Low intensity (peak to peak displacement 4.53 mm, frequency 24 Hz, g force 2.21) and higher intensity (peak to peak displacement 8.82 mm, frequency 35 Hz, g force 2.76) WBV blocks were used. Pain severity significantly improved in both groups following higher intensity vibration. Walking speed significantly improved in the group who participated in higher intensity intervention first. No study-related adverse events occurred. Even though this population can be at risk of developing overuse-related muscle weakness, fatigue, or pain from excessive physical activity or exercise, the vibration intensity levels utilized did not cause significant muscle weakness, pain, fatigue, or sleep disturbances. Therefore, WBV appears to provide a safe method of weight bearing exercise for this population. Limitations included the lack of measurement of reflexes, muscular activity, or circulation, the difficulty in participant recruitment, and insufficient strength of some participants to stand in recommended position. Strengths included a standard, safe protocol with intentional monitoring of symptoms and the heterogeneity of the participants in their physical abilities. An application of the methods is the home use of WBV to reduce the barriers associated with going to a facility for weight bearing exercise for longer term interventions, and benefits for conditions such as osteoporosis, particularly for aging adults with mobility difficulties due to paralysis or weakness. Presented method may serve as a starting point in future studies.

Fifteen of the 21 survivors of polio who consented completed the study, with 14 of those completing the study having PPS. The six people who withdrew did so for nonstudy-related reasons (five work and/or time issues, one medical concern). See Table 2 for demographic characteristics of the participants26.
No significant differences were found between demographic characteristics and pre-intervention outcome measures between the two treatment groups using descriptive statistics and Mann-Whitney U tests. Mann-Whitney U tests were also conducted between the high and low intensity conditions on measures at pretest, posttest, and follow-up for between subject differences. Within subject changes between pretests and posttests were conducted by Wilcoxon signed-rank tests, and Friedman&#39;s analysis of variance test was used to study the change over time from pretest through follow-up due to total of five testing sessions to reduce the risk of committing a Type I error with multiple Wilcoxon signed-rank tests. Nonparametric tests were conducted due to the small sample size and lack of normality26,41. Pain severity as measured by the BPI improved significantly after the higher intensity WBV intervention regardless of treatment order (Z = -1.97, p = 0.049, Cohen&#39;s d = 0.60), with BPI pain interference trending towards significant improvement (Z = -1.92, p = 0.055, Cohen&#39;s d = 0.81). Gait speed significantly improved after the higher intensity intervention, but only for the group that participated in the higher intervention block first, even though both groups experienced both intensities of vibration in intervention blocks (Z = -2.38, p = 0.017, Cohen&#39;s d = -1.294). See Table 3 for the data and results for the 10mWT, BPI pain severity, and BPI pain interference. No significant changes occurred in the other outcome measures and following the low intensity protocol, and no changes that occurred were maintained during the two week follow-up period26.
No study-related adverse events occurred. Even though this population can be at risk of developing overuse-related muscle weakness, fatigue, or pain from excessive physical activity or exercise, the vibration intensity levels utilized did not cause significant muscle weakness, pain, fatigue, or sleep disturbances26. The representative results from the prior study need to be interpreted cautiously because of the small study sample size and the huge variability of muscle weakness, pain, walking patterns, and other issues with which survivors of polio present.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Day 1</td>
			<td>Day 2</td>
			<td>Day 3</td>
			<td>Day 4</td>
			<td>Days 5-8</td>
		</tr>
		<tr>
			<td>1 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>1 Sitting rest off</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
		</tr>
		<tr>
			<td>2 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>2 Sitting rest off</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
		</tr>
		<tr>
			<td>3 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>3 Sitting rest off</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
		</tr>
		<tr>
			<td>4 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>4 Sitting rest off</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
		</tr>
		<tr>
			<td>5 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>5 Sitting rest off</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
		</tr>
		<tr>
			<td>6 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>6 Sitting rest off</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
		</tr>
		<tr>
			<td>7 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>7 Sitting rest off</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
		</tr>
		<tr>
			<td>8 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>8 Sitting rest off</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
		</tr>
		<tr>
			<td>9 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>9 Sitting rest off</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
			<td>1 min</td>
		</tr>
		<tr>
			<td>10 WBV on</td>
			<td>1 min</td>
			<td>1.25 min</td>
			<td>1.5 min</td>
			<td>1.75 min</td>
			<td>2 min</td>
		</tr>
		<tr>
			<td>Total time on</td>
			<td>10 min</td>
			<td>12.5 min</td>
			<td>15 min</td>
			<td>17.5 min</td>
			<td>20 min</td>
		</tr>
	</tbody>
</table>
Table 1: Scheduled WBV protocol, assuming no adverse events or problems tolerating intervention.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Total Sample</td>
			<td>Completing 
			Participants</td>
		</tr>
		<tr>
			<td></td>
			<td>(N=19*)</td>
			<td>(N=15)</td>
		</tr>
		<tr>
			<td>Age (yrs, mean &#38; SD)</td>
			<td>63.53 SD 8.32</td>
			<td>63.80 SD 9.40</td>
		</tr>
		<tr>
			<td>Age onset polio (yrs, mean &#38; SD)</td>
			<td>3.55 SD 4.03</td>
			<td>3.70 SD 4.80</td>
		</tr>
		<tr>
			<td>PPS diagnosis (yes/no)</td>
			<td>18/1</td>
			<td>14/1</td>
		</tr>
		<tr>
			<td>Gender (male/female)</td>
			<td>8/11</td>
			<td>6/9</td>
		</tr>
		<tr>
			<td>Race/ethnicity</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>&#160; &#160;African American/Black</td>
			<td>2 (1 mixed)</td>
			<td>1</td>
		</tr>
		<tr>
			<td>&#160; &#160;Asian/Pacific islander</td>
			<td>1</td>
			<td>1</td>
		</tr>
		<tr>
			<td>&#160; &#160;Hispanic/Latino</td>
			<td>2</td>
			<td>2</td>
		</tr>
		<tr>
			<td>&#160; &#160;Native American</td>
			<td>1 (mixed)</td>
			<td>0</td>
		</tr>
		<tr>
			<td>&#160; &#160;White</td>
			<td>13</td>
			<td>11</td>
		</tr>
		<tr>
			<td>Walking status</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>&#160; &#160;Full-time</td>
			<td>12</td>
			<td>11</td>
		</tr>
		<tr>
			<td>&#160; &#160;Part-time</td>
			<td>6</td>
			<td>3</td>
		</tr>
		<tr>
			<td>&#160; &#160;Not able to walk</td>
			<td>1</td>
			<td>1</td>
		</tr>
		<tr>
			<td>Use of orthoses</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>&#160; &#160;None</td>
			<td>13</td>
			<td>9</td>
		</tr>
		<tr>
			<td>&#160; &#160;1 or bilateral AFOs</td>
			<td>3</td>
			<td>3</td>
		</tr>
		<tr>
			<td>&#160; &#160;1 or bilateral KAFOs</td>
			<td>2</td>
			<td>2</td>
		</tr>
		<tr>
			<td>&#160; &#160;Not applicable</td>
			<td>1</td>
			<td>1</td>
		</tr>
		<tr>
			<td>Use of assistive devices</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>&#160; &#160;None</td>
			<td>12</td>
			<td>8</td>
		</tr>
		<tr>
			<td>&#160; &#160;1 or bilateral canes/walking sticks</td>
			<td>5</td>
			<td>5</td>
		</tr>
		<tr>
			<td>&#160; &#160;Bilateral Canadian crutches</td>
			<td>1</td>
			<td>1</td>
		</tr>
		<tr>
			<td>&#160; &#160;Not applicable</td>
			<td>1</td>
			<td>1</td>
		</tr>
		<tr>
			<td>Working status</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>&#160; &#160;Full-time</td>
			<td>6</td>
			<td>5</td>
		</tr>
		<tr>
			<td>&#160; &#160;Part-time</td>
			<td>4</td>
			<td>2</td>
		</tr>
		<tr>
			<td>&#160; &#160;Retired</td>
			<td>9</td>
			<td>8</td>
		</tr>
		<tr>
			<td colspan="3">* 2 females withdrew from original 21 who consented, prior to data collection.</td>
		</tr>
		<tr>
			<td>AFO: Ankle foot orthosis</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>KAFO: Knee ankle foot orthosis</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Table modified and used with permission from original article: Copyright&#169;2018, Taylor &#38; Francis Group,</td>
		</tr>
		<tr>
			<td colspan="3">Physiotherapy Theory and Practice, Da Silva C.P., et al.26</td>
		</tr>
	</tbody>
</table>
Table 2: Demographic characteristics of the participants.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td rowspan="4">Measure</td>
			<td>Lo-Hi Group</td>
			<td>Hi-Lo Group</td>
			<td rowspan="4">Between Subject Differences p(d)</td>
			<td rowspan="4">Within Subject Differences p(dz &#38; eta squared)</td>
		</tr>
		<tr>
			<td>n=6</td>
			<td>n=9</td>
		</tr>
		<tr>
			<td>Mean (Mdn) &#38; SD</td>
			<td>Mean (Mdn) &#38; SD</td>
		</tr>
		<tr>
			<td>Min-Max</td>
			<td>Min-Max</td>
		</tr>
		<tr>
			<td>10mWT (m/s)</td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td rowspan="2">Pre-Hi</td>
			<td>1.32(1.07) SD 0.51</td>
			<td>1.11(1.03) SD 0.39</td>
			<td rowspan="2">0.346(0.46)</td>
			<td rowspan="2"></td>
		</tr>
		<tr>
			<td>0.86-2.11</td>
			<td>0.69-1.82</td>
		</tr>
		<tr>
			<td rowspan="2">Post-Hi</td>
			<td>1.24(1.09) SD 0.49</td>
			<td>1.27(1.17) SD 0.47</td>
			<td rowspan="2">0.698(0.06)</td>
			<td rowspan="2">0.087(0.52)</td>
		</tr>
		<tr>
			<td>0.76-1.96</td>
			<td>0.82-2.08</td>
		</tr>
		<tr>
			<td>BPI Interference</td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td rowspan="2">Pre-Hi</td>
			<td>3.14(2.50) SD 3.14</td>
			<td>3.62(3.57) SD 2.50</td>
			<td rowspan="2">0.796(0.17)</td>
			<td rowspan="2"></td>
		</tr>
		<tr>
			<td>0.29-7.57</td>
			<td>0.00-7.57</td>
		</tr>
		<tr>
			<td rowspan="2">Post-Hi</td>
			<td>2.26(.00) SD 3.09</td>
			<td>2.39(2.57) SD 2.40</td>
			<td rowspan="2">0.862(0.05)</td>
			<td rowspan="2">0.055(0.81)</td>
		</tr>
		<tr>
			<td>0.00-5.86</td>
			<td>0.00-5.14</td>
		</tr>
		<tr>
			<td>BPI Severity</td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td rowspan="2">Pre-Hi</td>
			<td>3.29(2.75) SD 2.57</td>
			<td>3.44(3.50) SD 1.74</td>
			<td rowspan="2">0.795(0.07)</td>
			<td rowspan="2"></td>
		</tr>
		<tr>
			<td>0.75-7.25</td>
			<td>0.00-5.50</td>
		</tr>
		<tr>
			<td rowspan="2">Post-Hi</td>
			<td>2.68(0.13) SD 3.63</td>
			<td>2.61(2.50) SD 2.65</td>
			<td rowspan="2">0.674(0.02)</td>
			<td rowspan="2">0.049*(0.60)</td>
		</tr>
		<tr>
			<td>0.00-7.25</td>
			<td>0.00-5.75</td>
		</tr>
		<tr>
			<td colspan="5">*Significant difference</td>
		</tr>
		<tr>
			<td colspan="4">Lo-Hi group: low intensity intervention first, higher intensity intervention second</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="4">Hi-Lo group: higher intensity intervention first, low intensity intervention second</td>
			<td></td>
		</tr>
		<tr>
			<td colspan="2">Hi: Higher intensity intervention</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td colspan="5">Table modified and used with permission from original article: Copyright&#169;2018, Taylor &#38; Francis Group,</td>
		</tr>
		<tr>
			<td colspan="3">Physiother Theory Pract, Da Silva C.P., et al.26</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>
Table 3: Representative results from outcome measures.

Watch this Scientific Journal Video about Whole Body Vibration Methods with Survivors of Polio at JoVE.com

Whole Body Vibration Methods with Survivors of Polio

The goal of this article is to highlight the strengths, limitations, and applications of the method used with whole body vibration on polio survivors with and without post-polio syndrome as a feasible and safe form of weight bearing exercise.

The purpose of the original study was to examine the use of whole body vibration (WBV) on polio survivors with and without post-polio syndrome as a form ...

whole-body-vibration-methods-with-survivors-of-polio

Nanyang Technological University

Research

JoVE Journal

Behavior

8.7K Views.  Texas Woman's University. Deze methode kan helpen bij het beantwoorden van belangrijke vragen op het gebied van fysieke revalidatie, over lichaamstrillingen, en de veiligheid en haalbaarheid ervan als een vorm van gewicht dragen oefening voor polio overlevenden. De belangrijkste voordelen van deze techniek zijn dat het weinig tijd vergt en het lijkt niet te verergeren typische symptomen van post-polio syndroom, zoals verhoogde spierzwakte, pijn, of vermoeidheid. Het aantonen van de procedure van vandaag is Randy Rober...

Video: Whole Body Vibration Methods with Survivors of Polio

Methods to Quantify Pharmacologically Induced Alterations in Motor Function in Human Incomplete SCI

Spinal cord injury (SCI) is a debilitating disorder, which produces profound deficits in volitional motor control. Following medical stabilization, recovery from SCI typically involves long term rehabilitation. While recovery of walking ability is a primary goal in many patients early after injury, those with a motor incomplete SCI, indicating partial preservation of volitional control, may have the sufficient residual descending pathways necessary to attain this goal. However, despite physical interventions, motor impairments including weakness, and the manifestation of abnormal involuntary reflex activity, called spasticity or spasms, are thought to contribute to reduced walking recovery. Doctrinaire thought suggests that remediation of this abnormal motor reflexes associated with SCI will produce functional benefits to the patient. For example, physicians and therapists will provide specific pharmacological or physical interventions directed towards reducing spasticity or spasms, although there continues to be little empirical data suggesting that these strategies improve walking ability.
In the past few decades, accumulating data has suggested that specific neuromodulatory agents, including agents which mimic or facilitate the actions of the monoamines, including serotonin (5HT) and norepinephrine (NE), can initiate or augment walking behaviors in animal models of SCI. Interestingly, many of these agents, particularly 5HTergic agonists, can markedly increase spinal excitability, which in turn also increases reflex activity in these animals. Counterintuitive to traditional theories of recovery following human SCI, the empirical evidence from basic science experiments suggest that this reflex hyper excitability and generation of locomotor behaviors are driven in parallel by neuromodulatory inputs (5HT) and may be necessary for functional recovery following SCI. 
The application of this novel concept derived from basic scientific studies to promote recovery following human SCI would appear to be seamless, although the direct translation of the findings can be extremely challenging. Specifically, in the animal models, an implanted catheter facilitates delivery of very specific 5HT agonist compounds directly onto the spinal circuitry. The translation of this technique to humans is hindered by the lack of specific surgical techniques or available pharmacological agents directed towards 5HT receptor subtypes that are safe and effective for human clinical trials. However, oral administration of commonly available 5HTergic agents, such as selective serotonin reuptake inhibitors (SSRIs), may be a viable option to increase central 5HT concentrations in order to facilitate walking recovery in humans. Systematic quantification of how these SSRIs modulate human motor behaviors following SCI, with a specific focus on strength, reflexes, and the recovery of walking ability, are missing.
This video demonstration is a progressive attempt to systematically and quantitatively assess the modulation of reflex activity, volitional strength and ambulation following the acute oral administration of an SSRI in human SCI. Agents are applied on single days to assess the immediate effects on motor function in this patient population, with long-term studies involving repeated drug administration combined with intensive physical interventions.

This video demonstrates modulation of reflex activity, volitional strength and ambulation through clinical and quantitative assessments in individuals with motor incomplete SCI as a result of acute oral administration of a serotonin reuptake inhibitor (SSRI).

Spinal cord injury (SCI) is a debilitating disorder, which produces profound deficits in volitional motor control. Following medical stabilization, ...

Medicine

Measurement of Vibration Detection Threshold and Tactile Spatial Acuity in Human Subjects

Tests that allow the precise determination of psychophysical thresholds for vibration and grating orientation provide valuable information about mechanosensory function that are relevant for clinical diagnosis as well as for basic research. Here, we describe two psychophysical tests designed to determine the vibration detection threshold (automated system) and tactile spatial acuity (handheld device). Both procedures implement a two-interval forced-choice and a transformed-rule up and down experimental paradigm. These tests have been used to obtain mechanosensory profiles for individuals from distinct human cohorts such as twins or people with sensorineural deafness.

Here, we present protocols to determine vibration detection thresholds and tactile acuity using psychophysical methods in man.

Tests that allow the precise determination of psychophysical thresholds for vibration and grating orientation provide valuable information about ...

A Simple Non-invasive Method for Temporary Knockdown of Upper Limb Proprioception

Proprioception may be the least well measured of all contributors to the neural control of movement. New precise, reliable measures of proprioception are needed for clinical diagnosis of impairment, and to measure outcomes of proprioceptive training. The purpose of this simple, non-invasive method is to temporarily knockdown upper limb proprioception in healthy adults, to an extent that would be useful in the development and testing of upper limb proprioception measures. Knockdown models have two main advantages over studying humans with impaired proprioception: participant availability and the ability to control the extent of impairment across participants. Current published methods of temporary proprioception knockdown of the upper limb, such as ischemic nerve blocks and cryotherapy, are invasive, impractical, or uncomfortable for the participant. Here, vibration over the ulnar groove was used to reduce upper limb proprioception. High frequency vibration may reduce proprioceptive acuity by inhibiting pacinian corpuscle-induced input. The effect of vibration used in this protocol was confirmed using two quantitative measures. This method was simple to administer, comfortable for participants, and practical.

The goal of this protocol is to demonstrate a practical method to temporarily interfere with proprioception in the upper limb of healthy humans.

Proprioception may be the least well measured of all contributors to the neural control of movement. New precise, reliable measures of proprioception are ...

A Vibrotactile Feedback Device for Seated Balance Assessment and Training

Postural perturbations, motion tracking, and sensory feedback are modern techniques used to challenge, assess, and train upright sitting, respectively. The goal of the developed protocol is to construct and operate a sitting platform that can be passively destabilized while an inertial measurement unit quantifies its motion and vibrating elements deliver tactile feedback to the user. Interchangeable seat attachments alter the stability level of the device to safely challenge sitting balance. A built-in microcontroller allows fine-tuning of the feedback parameters to augment sensory function. Posturographic measures, typical of balance assessment protocols, summarize the motion signals acquired during timed balance trials. No dynamic sitting protocol to date provides variable challenge, quantification, and sensory feedback free of laboratory constraints. Our results demonstrate that non-disabled users of the device exhibit significant changes in posturographic measures when balance difficulty is altered or vibrational feedback provided. The portable, versatile device has potential applications in rehabilitation (following skeletal, muscular, or neurological injury), training (for sports or spatial awareness), entertainment (via virtual or augmented reality), and research (of sitting-related disorders).

A sitting platform has been developed and assembled that passively destabilizes sitting posture in humans. During the user&#39;s stabilizing task, an inertial measurement unit records the device&#39;s motion, and vibrating elements deliver performance-based feedback to the seat. The portable, versatile device may be used in rehabilitation, assessment, and training paradigms.

Postural perturbations, motion tracking, and sensory feedback are modern techniques used to challenge, assess, and train upright sitting, respectively. ...

Using Unidirectional Rotations to Improve Vestibular System Asymmetry in Patients with Vestibular Dysfunction

The vestibular system provides information about head movement and mediates reflexes that contribute to balance control and gaze stabilization during daily activities. Vestibular sensors are located in the inner ear on both sides of the head and project to the vestibular nuclei in the brainstem. Vestibular dysfunction is often due to an asymmetry between input from the two sides. This results in asymmetrical neural inputs from the two ears, which can produce an illusion of rotation, manifested as vertigo. The vestibular system has an impressive capacity for compensation, which serves to rebalance how asymmetrical information from the sensory end organs on both sides is processed at the central level. To promote compensation, various rehabilitation programs are used in the clinic; however, they primarily use exercises that improve multisensory integration. Recently, visual-vestibular training has also been used to improve the vestibulo-ocular reflex (VOR) in animals with compensated unilateral lesions. Here, a new method is introduced for rebalancing the vestibular activity on both sides in human subjects. This method consists of five unidirectional rotations in the dark (peak velocity of 320&#176;/s) toward the weaker side. The efficacy of this method was shown in a sequential, double-blinded clinical trial in 16 patients with VOR asymmetry (measured by the directional preponderance in response to sinusoidal rotations). In most cases, VOR asymmetry decreased after a single session, reached normal values within the first two sessions in one week, and the effects lasted up to 6 weeks. The rebalancing effect is due to both an increase in VOR response from the weaker side and a decrease in response from the stronger side. The findings suggest that unidirectional rotation can be used as a supervised rehabilitation method to reduce VOR asymmetry in patients with longstanding vestibular dysfunction.

A new rehabilitation method is presented for rebalancing the vestibular system in patients with asymmetric responses, which consists of unidirectional rotations toward the weaker side. By directly modifying the vestibular pathway rather than enhancing the multisensory aspects of compensation, asymmetry can be normalized within 1-2 sessions and show lasting effects.

The vestibular system provides information about head movement and mediates reflexes that contribute to balance control and gaze stabilization during ...

Training Persons with Spinal Cord Injury to Ambulate Using a Powered Exoskeleton

Powered exoskeletons have become available for overground ambulation in persons with paralyses due to spinal cord injury (SCI) who have intact upper extremity function and are able to maintain upright balance using forearm crutches. To ambulate in an exoskeleton, the user must acquire the ability to maintain balance while standing, sitting and appropriate weight shifting with each step. This can be a challenging task for those with deficits in sensation and proprioception in their lower extremities. This manuscript describes screening criteria and a training program developed at the James J. Peters VA Medical Center, Bronx, NY to teach users the skills needed to utilize these devices in institutional, home or community environments. Before training can begin, potential users are screened for appropriate range of motion of the hip, knee and ankle joints. Persons with SCI are at an increased risk of sustaining lower extremity fractures, even with minimal strain or trauma, therefore a bone mineral density assessment is performed to reduce the risk of fracture. Also, as part of screening, a physical examination is performed in order to identify additional health-related contraindications. 
Once the person has successfully passed all screening requirements, they are cleared to begin the training program. The device is properly adjusted to fit the user. A series of static and dynamic balance tasks are taught and performed by the user before learning to walk. The person is taught to ambulate in various environments ranging from indoor level surfaces to outdoors over uneven or changing surfaces. Once skilled enough to be a candidate for home use with the exoskeleton, the user is then required to designate a companion-walker who will train alongside them. Together, the pair must demonstrate the ability to perform various advanced tasks in order to be permitted to use the exoskeleton in their home/community environment.

Training a person with paralysis to ambulate using a powered exoskeleton may present challenges. The goals are to present the candidate selection criteria and the training procedures for exoskeletal-assisted walking and other mobility skills that can be progressed as the participant's skill level improves.

Powered exoskeletons have become available for overground ambulation in persons with paralyses due to spinal cord injury (SCI) who have intact upper ...

Bioengineering

A Method for Evaluating Timeliness and Accuracy of Volitional Motor Responses to Vibrotactile Stimuli

Artificial sensory feedback (ASF) systems can be used to compensate for lost proprioception in individuals with lower-limb impairments. Effective design of these ASF systems requires an in-depth understanding of how the parameters of specific feedback mechanism affect user perception and reaction to stimuli. This article presents a method for applying vibrotactile stimuli to human participants and measuring their response. Rotating mass vibratory motors are placed at pre-defined locations on the participant's thigh, and controlled through custom hardware and software. The speed and accuracy of participants' volitional responses to vibrotactile stimuli are measured for researcher-specified combinations of motor placement and vibration frequency. While the protocol described here uses push-buttons to collect a simple binary response to the vibrotactile stimuli, the technique can be extended to other response mechanisms using inertial measurement units or pressure sensors to measure joint angle and weight bearing ratios, respectively. Similarly, the application of vibrotactile stimuli can be explored for body segments other than the thigh.

This article describes a technique for applying vibrotactile stimuli to the thigh of a human participant, and measuring the accuracy and reaction time of the participant&#39;s volitional response for various combinations of stimulation location and frequency.

Artificial sensory feedback (ASF) systems can be used to compensate for lost proprioception in individuals with lower-limb impairments.  Effective design ...

Quantifying Arms and Legs Contributions during Repetitive Electrically-Assisted Sit-To-Stand Exercise in Paraplegics: A Pilot Study

Execution of Sit-to-Stand (SitTS) in incomplete spinal cord injury (SCI) patients involves motor function in both upper and lower extremities. The use of arm support, in particular, is a significant assistive factor while executing SitTS movement in SCI population. In addition, the application of functional electrical stimulation (FES) onto quadriceps and gluteus maximus muscles is one of the prescribed management for incomplete SCI to improve muscle action for simple lower limb movements. However, the relative contribution of upper and lower extremities during SitTS has not been thoroughly investigated. Two motor incomplete SCI paraplegics performed repetitive SitTS to fatigue exercise challenge. Their performance was investigated as a mixed-method case-control study comparing SitTS with and without the assistance of FES. Three sets of SitTS tests were completed with 5-min resting period allocated in between sets, with mechanomyography (MMG) sensors attached over the rectus femoris muscles bilaterally. The exercise was separated into 2 sessions; Day 1 for voluntary SitTS and Day 2 for FES-assisted SitTS. Questionnaires were conducted after every session to gather the participants&#39; input about their repetitive SitTS experience. The analysis confirmed that a SitTS cycle could be divided into three phases; Phase 1 (Preparation to stand), Phase 2 (Seat-off), and Phase 3 (Initiation of hip extension), which contributed to 23% &#177; 7%, 16% &#177; 4% and 61% &#177; 6% of the SitTS cycle, respectively. The contribution of arms and legs during SitTS movement varied in different participants based on their legs&#39; Medical Research Council (MRC) muscle grade. In particular, the applied arm forces start to increase clearly when the leg forces start to decline during standing. This finding is supported by the significantly reduced MMG signal indicating leg muscle fatigue and their reported feeling of tiredness.

Arms contribution in Sit-To-Stand (SitTS) is determined by the legs' muscle condition. Several compensating strategies were discovered in efforts to achieve complete SitTS cycles. These findings triangulate the spinal cord injury (SCI) persons' biomechanical measures with their subjective feeling of load borne by both their limbs throughout the SitTS approaches.

Execution of Sit-to-Stand (SitTS) in incomplete spinal cord injury (SCI) patients involves motor function in both upper and lower extremities. The use of ...

Engineering

Integrating VR and Biosensors for Quantitative Motion-Muscle Activity Assessment

Setup for the Quantitative Assessment of Motion and Muscle Activity During a Virtual Modified Box and Block Test

The ability to move allows us to interact with the world. When this ability is impaired, it can significantly reduce one's quality of life and independence and may lead to complications. The importance of remote patient evaluation and rehabilitation has recently grown due to limited access to in-person services. For example, the COVID-19 pandemic unexpectedly resulted in strict regulations, reducing access to non-emergent healthcare services. Additionally, remote care offers an opportunity to address healthcare disparities in rural, underserved, and low-income areas where access to services remains limited. 
Improving accessibility through remote care options would limit the number of hospital or specialist visits and render routine care more affordable. Finally, the use of readily available commercial consumer electronics for at-home care can enhance patient outcomes due to improved quantitative observation of symptoms, treatment efficacy, and therapy dosage. While remote care is a promising means to address these issues, there is a crucial need to quantitatively characterize motor impairment for such applications. The following protocol seeks to address this knowledge gap to enable clinicians and researchers to obtain high-resolution data on complex movement and underlying muscle activity. The ultimate goal is to develop a protocol for remote administration of functional clinical tests. 
Here, participants were instructed to perform a medically-inspired Box and Block task (BBT), which is frequently used to assess hand function. This task requires subjects to transport standardized cubes between two compartments separated by a barrier. We implemented a modified BBT in virtual reality to demonstrate the potential of developing remote assessment protocols. Muscle activation was captured for each subject using surface electromyography. This protocol allowed for the acquisition of high-quality data to better characterize movement impairment in a detailed and quantitative manner. Ultimately, these data have the potential to be used to develop protocols for virtual rehabilitation and remote patient monitoring.

Author Spotlight: Enhancing Remote Rehabilitation with Virtual Reality and Electromyography

The protocol described here aims to enhance the quantitative evaluation of upper limb deficits, with the goal of developing additional technology for remote assessment both in the clinic and at home. Virtual reality and biosensor technologies are combined with standard clinical techniques to provide insights into the functioning of the neuromuscular system.

The ability to move allows us to interact with the world. When this ability is impaired, it can significantly reduce one's quality of life and ...

A Method for Quantifying Upper Limb Performance in Daily Life Using Accelerometers

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. It has become important to measure a person's activities in daily life, and not just measure their capacity for activity in the structured environment of a clinic or laboratory. A wearable sensor that is now enabling measurement of daily movement is the accelerometer. Accelerometers are commercially-available devices resembling large wrist watches that can be worn throughout the day. Data from accelerometers can quantify how the limbs are engaged to perform activities in peoples' homes and communities. This report describes a methodology to collect accelerometry data and turn it into clinically-relevant information. First, data are collected by having the participant wear two accelerometers (one on each wrist) for 24 h or longer. The accelerometry data are then downloaded and processed to produce four different variables that describe key aspects of upper limb activity in daily life: hours of use, use ratio, magnitude ratio, and the bilateral magnitude. Density plots can be constructed that visually represent the data from the 24 h wearing period. The variables and their resultant density plots are highly consistent in neurologically-intact, community-dwelling adults. This striking consistency makes them a useful tool for determining if upper limb daily performance is different from normal. This methodology is appropriate for research studies investigating upper limb dysfunction and interventions designed to improve upper limb performance in daily life in people with stroke and other patient populations. Because of its relative simplicity, it may not be long before it is also incorporated in clinical neurorehabilitation practice.

This protocol describes a method to quantify upper limb performance in daily life using wrist-worn accelerometers.

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. ...

Whole Body Vibration Methods with Survivors of Polio

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