function. They activate a chin switch, which sends a signal to scoop up the food off a mechanized plate and present it to the user. The Handy 1 device is similar to the Winsford; however, it uses a commercially available robot that is controlled through switch operations (24).
The movements are programmed to perform a selec- tion of tasks, such as feeding, applying makeup, and shaving. The food is placed on a custom plate that has different compartments. A scanning system of lights designed into the tray section allows the user to select food from any part of the dish. For other tasks, the user selects similar programmed moves.
The Neater Eater (Neater Solutions, Buxton, UK) is a table-mounted feeding device that comes in two versions. The first is a motorized feeding arm that can be controlled by a user with little arm function, and retails for about $4,000 (Fig. 6.9). It is attached to a tabletop and can be controlled by a foot switch.
A manual version is also attached to a tabletop and is for someone with some arm movement but that may be erratic or tremulous. The arm has a built-in damper that filters out unwanted movement.
Gravity-Eliminating Orthoses
A few new devices have become commercially avail- able in this area. What makes this segment unique is that these devices are attached to an appendage (typ- ically the arm) and provide assistance to accomplish activities of daily living. They utilize the remaining residual strength of the individual to allow voluntary movements. These devices act to amplify weak move- ments of the arm and negate the effect of gravity for the user so that he or she can perform tasks such as feeding easily.
Each offers a different perspective and a different assortment of assistance.
The International Society for Augmentative and
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Alternative Communication (ISAAC) offers journals and newsletters as well as information about AAC in countries around the world. ISAAC may be con- tacted at ISAAC, 49 The Donway West, Suite 308, Toronto, Ontario, M3C 3M9, Canada, 416-385-0351, [email protected]
The U.S. Society for Augmentative and Alternative
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Communication (USSAAC) is the national chapter of ISAAC. Its members include individuals from all professions involved with AAC, including manu- facturers and researchers, as well as consumers and family members. USSAAC may be contacted at USSAAC, P.O. Box 5271, Evanston, IL 60204, 847- 869-2122, [email protected]
The American Speech-Language-Hearing Association
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(ASHA) includes a Special Interest Division in AAC for speech and language pathologists. ASHA may be contacted at ASHA, 10801 Rockville Pike, Rockville, MD 20852, 301-897-5700, www.asha.org
The Rehabilitation Engineering and Assistive
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Technology Society of North America (RESNA) is an interdisciplinary association for the advancement of rehabilitation and assistive technologies. It includes a special interest group in AAC. RESNA may be con- tacted at RESNA, 1700 North Moore Street, Suite 1540, Arlington, VA 22209, 703-524-6686, www.resna.org Every state has a special project devoted to AAC and
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assistive technology. These were originally estab- lished by federal funding through the Technology- Related Assistance Act. They are known as Tech Act Projects. Directories of them are available from organization such as USSAAC and RESNA.
The Communication Aid Manufacturers Association
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(CAMA) offers packets of manufacturer catalogs and series of local workshops on AAC devices and their applications. CAMA may be contacted at CAMA, P.O. Box 1039, Evanston, IL 60204, 800-441-2262, [email protected]
These and other organizations offer a variety of
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conferences and publications. Closing the Gap offers both; CSUN is an annual assistive technology con- ference at California State University—Northbridge.
ASSISTIVE ORTHOSES AND ROBOTS
people with arm weakness. It attaches to the forearm of the user and provides gravity balancing. The device can be attached to the wheelchair or a tabletop. The Armon does not follow the contours of the arm. It can be adjusted by a motor to compensate for the weight of a person. The second device is called the Dynamic Arm Support (DAS) made by Exact Dynamics. It is similar to the Armon, but has a vertical movement that provides the elevation. It, too, can be adjusted for different-sized people with the aid of a motor and can be attached to a wheelchair.
Robots
The Assistive Robotic Manipulator (ARM) (Fig. 6.12) is a six-degree-of-freedom wheelchair-mounted robotic Among the earliest and most accepted devices is the
balance forearm orthosis (BFO), also called the mobile arm support (Fig. 6.10). The BFO (JAECO Orthopedics, Hot Springs, AR), which is a passive (body-powered) device, was developed in 1965. It provides a person with weak musculature with the ability to move the arms in a horizontal plane through the use of two linkages that have joints along the vertical axes. One end of the BFO is attached to a wheelchair; the other end is connected to a trough into which a person places the forearm.
The trough uses a fulcrum at the forearm that permits the hand to elevate if the shoulder is depressed. The BFO allows a person to move horizontally, for example, over a lap tray and to use compensatory movements to attain limited movement in the vertical direction. The BFO retails for approximately $350.
The Wilmington Robotic Exoskeleton (WREX) is a body-powered orthosis that is modular and mounted to a person’s wheelchair or to a body jacket (Fig. 6.11). It is a two-segment, four-degrees-of-freedom exoskeletal arm, energized by elastic bands that aid in moving the arm in 3-D space. The WREX allows full passive range of motion of the arm and provides a sense of flotation that assists in voluntary movement (25). WREX can easily be adjusted to accommodate subjects of differ- ent weights and arm lengths by changing the number of bands or sliding the telescoping links. The device is typically mounted to a wheelchair and intended pri- marily for people with muscular weakness such as muscular dystrophy and spinal muscular atrophy. It is also being used for children with arthrogryposis who can walk independently by attaching the WREX to a body jacket (26). The WREX was conceived and devel- oped at the Alfred I. duPont Hospital for Children and is now marketed by JAECO Orthopedics, Hot Springs, AR for $2,000.
Two other passive upper extremity orthoses have recently been commercialized, and both emanate from the Netherlands. The first is the Armon made by Micro Gravity Products, which is powered by springs. It is for Figure 6.9 Neater Eater.
Figure 6.10 Balanced Forearm Orthosis (BFO).
Figure 6.11 Wilmington Robotic Exoskeleton (WREX).
to be repetitive, and evidence suggests that the dura- tion, intensity, and quality of therapy all play a role in recovery. Although functional gains remain small, the potential of machines assisting in therapy is enor- mous. These machines are ideally suited to the rig- orous and repetitive nature of therapy. The following paragraphs describe some of the devices that are cur- rently on the market.
Manually assisted treadmill walking is commonly used for regular therapy for patients with neuromus- cular impairments. This type of therapy is performed with some type of harness system that supports the patient’s weight. There are two main limitations to this type of therapy: It is labor-intensive, as it requires two therapists to move the patient’s legs, which causes therapist fatigue and back pain due to awkward the ergonomic positions. Second, manual therapy lacks repeatability and a way to objectively measure per- formance. The Locomat (Hocoma AG, Volketswil, Switzerland) is a bilateral robotic gait trainer that is used along with a weight-supported system. It can replace some of the functions of a therapist and free him or her from performing the arduous task of leg movement. The Locomat can provide customized gait training for an individual patient by defining the opti- mal trajectory of leg movements and creating a spec- ified set of force interactions between the device and the patient. The device has been commercially avail- able since 2000 and is used in numerous clinics for spinal cord injury (SCI), stroke, and traumatic brain injury (TBI) populations. There are about 150 Locomat systems in use worldwide.
InMotion Robots (Interactive Motion Technologies, Inc., Cambridge, MA) are a suite of table-mounted robotic systems that provide therapy for the shoulder, elbow, wrist, hand, and overground ankle training.
The robots are combined with a video screen to pro- vide a fun and therapeutic environment for exercise.
These robots can be programmed to vary the relative effort between the user and the robot. If, for instance, the user is weak, the robot can do most of the work.
As the patient gains strength, the robot’s effort can be decreased appropriately. The InMotion system has been developed over the last 15 years, and its strength is that it offers a low impedance system so that the effect of the robot can be imperceptible to the user.
It is primarily used for stroke and other neurological disorders.
Another upper extremity robotic-based rehabilita- tion system is the REO made by Motorika, Ltd., a com- pany established in 2004. REO is an upper extremity device made to apply robotic technology to meet the therapeutic needs of stroke patients. It offers efficient repetitive training activities. “REO Therapy” actively engages a patient in repetitive exercises to improve arm function, while therapists benefit from patient device developed in the Netherlands by Exact Dynamics,
Inc. As a result of its functionality and mobility, the ARM offers users a wide range of manipulation pos- sibilities. Example tasks include eating, pouring and drinking, playing board games, operating switches, and opening doors. The ARM manipulator features a programmable user interface and flexible input/output for interfacing with electrical wheelchairs. It folds into an unobtrusive position at the side of the wheelchair when not in use and folds out when commanded. Its present inputs include a 16-button keypad, trackball, and joystick, which performs individual joint control, integrated hand control, or programmed modes of con- trol. There are currently approximately 100 users of the ARM in Europe, and it costs approximately $40,000.
The Raptor is also a lightweight wheelchair-mounted robot arm that controls each joint individually. It has four degrees of freedom and a gripper. It is sold by Kersten RT in the Netherlands.
Therapy Robots
The term “rehabilitation robot” has been around for a good 30 years, when it was first applied to assistive motorized devices that performed tasks of daily living for people with physical impairments. As shown, these applications are continually being developed; however, the term is being increasingly applied to machines that assist in the recovery from a condition such as stroke.
This shift in emphasis from assistive to rehab in robot- ics is largely driven by an aging population, resulting in a far greater number of potential beneficiaries.
There are approximately 600,000 new cases of stroke in the United States every year. The “gray- ing” of the population is even more pronounced in countries such as Japan. Patients undergo physical therapy to restore lost function. The therapy tends Figure 6.12 The ARM manipulator.
http://www.med.unc.edu/ahs.clds/FILES/PROJECTS/
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The SMART wrist hand orthosis (WHO) for quadriplegic patients. J of Prosth and Orth. 1992;5(3):73–76.
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15. Pellow TR. A comparison of interface pressure readings to wheelchair cushions and positioning: a pilot study. Can J of Occup Ther. 1999;66(3):140–147.
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17. Stavness C. The effect of positioning for children with cere- bral palsy on upper-extremity function: a review of the evi- dence. Phys and Occup Ther in Ped. 2006;26(3):39–53.
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progress monitoring and practice efficiency. A video screen accompanies the device to provide progress and visual stimulation during exercise. The company also offers a REO Ambulator for lower extremities that is a robotic gait trainer similar to the Locomat. It has been used for a few years in rehabilitation clinics; however, there is still insufficient data to support its findings.
Other robotic therapy devices being developed for the upper extremity include the T-WREX (27), iMove Reacher (iMove Support, Hengelo, Netherlands), and McArm (Focal Revalidatietechniek, Netherlands), HapticMASTER (Moog FCS, Netherlands). A lower extremity device under development is KineAssist (Chicago P, Chicago, IL).
PEARLS OR PERILS
Multidisciplinary approaches to evaluating a child’s
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needs are most effective. You may have all the tools you need, but the family story is what’s important.
The goal of all assistive communication technology
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is to help people with disabilities overcome the limi- tations of those disabilities and to become more inde- pendent and more efficient, to become faster and to experience longer stamina, and to be able to become active members of their social communities.
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Closing the Gap Conference, October 2006. Available at
Electromyography (EMG), nerve conduction studies (NCS), and evoked potentials, including somatosensory- evoked potentials (SSEPs) and motor-evoked potentials (MEPs), provide useful information to assist the clini- cian in the localization of pathology within the lower motor neuron and selected areas of the central nervous system. In the case of acquired or hereditary disorders of the lower motor neuron—anterior horn cell, periph- eral nerve, neuromuscular junction (presynaptic or postsynaptic region), or muscle—electrodiagnostic studies are a useful tool as an extension of the clini- cian’s physical examination. The information gained from electrodiagnostic studies may be invaluable in planning subsequent, more invasive diagnostic stud- ies (eg, muscle and nerve biopsy, cerebrospinal fluid [CSF] examination, [magnetic resonance] MR imaging, which at times requires general anesthesia), allow for more cost-effective and specific molecular genetic test- ing, or aid in the surgical management of peripheral nerve trauma, compressive lesions, or entrapments. In the case of immune-mediated disorders such as myas- thenia gravis or Guillain-Barré syndrome, electrodiag- nostic studies may permit prompt treatment.
Pediatric electrodiagnosis must be approached with knowledge of peripheral neuromuscular devel- opment and thoughtful planning of the study with regard to most likely diagnostic possibilities, develop- mental status of the child, and the likelihood that the pediatric electrodiagnostic practitioner will be able to provide clinicians and family with useful diagnostic
information. The physical examination and develop- mental level of the infant or child directs the study.
The examination requires the patience and technical competence of an electrodiagnostic clinician experi- enced and skilled in the evaluation of children. This chapter will focus on considerations specific to the electrodiagnostic evaluation of infants and children, with an emphasis on practical suggestions that may facilitate the completion of an accurate pediatric elec- trodiagnostic examination with a minimum of dis- comfort and distress to the child, parent, and pediatric electrodiagnostic specialist.