2012 9th International Conference on Ubiquitous Robots and Ambient Intelligence (URAI)

The 9th International Conference on Ubiquitous Robots and Ambient Intelligence (URAI 2012)
Daejeon,
/ November
26-29, 2012
Nov.
26-28,Korea
2012 in
Daejeon Convention
Center (DCC), Daejeon, Korea

Lower-Extremity Spasticity
during Standing Up Movements: A Case Study
Hwi-Young Lee, Won-Kyung Song, Ryanghee Sohn and Jongbae Kim
National Rehabilitation Research Institute, National Rehabilitation Center, Korea
(Tel : +82-2-901-1905; E-mail: wksong@nrc.go.kr)

Abstract - The function of lower-extremity rehabilitation

robotics usually includes standing up movements. These
standing up movements can cause spasticity in people with
disabilities of the lower extremities. In this paper, we
review the spasticity and the methods of existing systems
for handling the spasticity of people with physical
disabilities. We observe and detect the spasticity via the
EMG signals of the lower extremities of a subject with
paraplegia. Through this process, we are able to suggest
ways to deal with risk factors, such as spasticity, when
using rehabilitation robots.

real environments such as interior corridors. A

lower-extremity exercise system was designed to help
patients with lost or weakened motor functions to train
their legs for motor recovery [6]. The system consists of a
robotic exoskeleton mechanism, a harness, and a mobile
platform. In manual therapy, the entire process is
performed by therapists. Using robotic systems, the basic
operations can be operated by a mechanical apparatus. The
detection and prevention of undesirable muscle activation
are required in simple operations such as standing up
movements. Thus, we will reduce spasticity as one of the
disturbances of the overall system.

Keywords - spasticity, lower extremity, rehabilitation

robot, assessment, surface EMG.

1. Introduction
Rehabilitation robots assist users with sitting and
standing movements. Therapeutic rehabilitation robots
play an important role in the neurological rehabilitation
therapies of the lower extremities by assisting with gait,
sitting, and standing motions. Patients with gait and
balance problems owing to neurological damage need
guided practice to aid in the recovery of their
lower-extremity functions [1]. During the recovery,
patients usually practice standing up movements before
gait or balance training. Several rehabilitation robots for
the lower extremities of disabled users have standing and
sitting functions, such as Lokomat [2], HAL-5 [3],
WalkTrainer [4], NaTUre-gaits (Natural and Tunnable
Rehabilitation Gait System) [5], and Lower-Extremity
Robotic Exercise System [6, 7]. These rehabilitation
robots can simultaneously reduce the physical effort of
therapists and increase training efficacy.
Standing can result in spasticity of the lower extremities
[6], and spasticity leads to an increase in the mechanical
resistance of a joint during passive movements [8]. For
instance, there is the possibility of spasticity in a patients
legs when the patient is lifted straight up. A rehabilitation
robot should carefully handle patients before the standing
up movement and while the patient is standing. In addition,
standing has been suggested as a conventional therapeutic
program to maintain the health and physical condition of
individuals with spinal cord injuries. Periodic standing has
a variety of potential physiological benefits such as
decreasing spasticity, preventing osteoporosis, managing
orthostatic hypotension, and relieving pressure sores.
The lower-extremity exercise system is one type of
dynamic gait training system that can be implemented in

978-1-4673-3112-8/12/$31.00 2012 IEEE

(a) Lokomat

(b) WalkTrainer

(c) NaTUre-gaits
(d) Lower Extremity
Robotic Exercise System

Fig. 1 Rehabilitation robots for lower-extremities.

The purpose of this paper is to introduce the spasticity

of people with disabilities and previous approaches for
robotic rehabilitation, and present methods for detecting
the spasticity during standing movement via EMG signals
from the legs of patients with paraplegia. To observe
spasticity during the standing motion, we use a standing


wheelchair instead of an actual rehabilitation robot. The
findings from this spasticity study can potentially
contribute toward the further design of lower-extremity
exercise systems for people with severe disabilities. In
Section 2, we review spasticity. Section 3 presents the
methods of existing rehabilitation systemsfor handling
spasticity. Section 4 presents the preliminary results to
detect lower-extremity spasticity. Finally, we end with
concluding remarks.

the reliability of the MAS is somewhat low, especially for

the lower extremities; the scale is subjective, and its
validity is low. Furthermore, the MAS barely detects the
increased resistance caused by tension of soft tissues
applied from passive movements. It is also difficult to
obtain the same results from other spasticity assessments
applied to the same person [12].
Table 1 Modified Ashworth Scale (MAS) [13]

Score

2. Spasticity
2.1 Definition
Spasticity has two definitions: one used by researchers
and the other used by clinicians [9]. According to Lances
definition, spasticity increases muscle tone due to
hyperexcitability of the tonic stretch reflex, characterized
by a velocity-dependent increase in phasic stretch
reflexes. Pandyan et al. [10] expanded the definition of
spasticity motor disorder to that of a sensorimotor disorder.
According to them, spasticity is a disordered
sensorimotor control, resulting from an upper motor
neuron lesion, presenting as intermittent or sustained
involuntary activation of a muscle. However, the
definition of spasticity tends to be broadly used by
clinicians to refer to the entire upper motor neuron
syndrome: paresis (decreased ability to generate the level
of force required for a task), myoplastic hyperstiffness
(excessive resistance to muscle stretch due to changes
within the muscle secondary to upper motor neuron lesion),
co-contraction (temporal overlap of agonist and antagonist
muscle contraction), and hyperreflexia (excessive phasic
and/or tonic stretch reflex response) [9].

No increase in muscle tone

Slight increase in muscle tone, manifested by a

catch and release or by minimal resistance at the
end of the range of motion when the affected
part(s) is moved in flexion or extension

1+

Slight increase in muscle tone, manifested by a

catch, followed by minimal resistance throughout
the remainder (less than half) of the ROM

More marked increase in muscle tone through

most of the ROM, but affected part(s) easily
moved

Considerable increase in muscle tone, passive

movement difficult

Affected part(s) rigid in flexion or extension

2.4 Examples of existing research related to

spasticity
The physiological mechanism of spasticity has not yet
been fully identified. Because of this, there have been
many attempts to measure separately the reflex component
caused by the stretch reflex and the mechanical component
caused by the passive-resistant torque inherent in soft
tissues such as muscles, tendons, and ligaments. Moreover,
some studies questioned the reliability of using the MAS
in measuring spasticity. Because the applied passive
velocity of each of the examiners is not identical, and
because the feeling of the catch that examiners feel is
dependent on a subjective evaluation, the MAS was
deemed inappropriate for objective assessment of
spasticity [14].

2.2 Characteristics and limitations of spasticity

The symptoms of spasticity are stiffness of the limbs,
muscle cramps with pain, uncontrolled movements, or a
series of involuntary rhythmic contractions and tension.
Pain and joint contracture due to spasticity restrict joint
movements and disrupt both gait and activities of daily
living (ADL). Spasticity tends to increase the rapid change
in a patients body position, psychological excitement,
anxiety, sensory stimulation, active movement of the
affected side, and environmental factors, such as weather
condition. The phenomenon of spasticity is particularly
remarkable in the flexors of the upper extremities and
extensors of the lower extremities. Many patients with
spasticity exhibit muscle weakness, resulting in disability.
However, in people with incomplete spinal cord injury,
spasticity prevents complications such as muscle atrophy,
osteoporosis, and deep vein thrombosis and increases
stability in sitting and standing positions [11].

3. Application of Spasticity in Rehabilitation

Robots
3.1 Detecting spasticity with robotic systems
The quantity of spasticity can be measured using
servo-controlled motor-driven devices through controlling
the applied velocity to spastic limbs and measuring the
resistance and EMG signals. There was an attempt to
minimize the effect of the value in inter-raters error
through extracting the joint angle and torque data using
Lokomat. Peng et al. [15] developed a manual spasticity
evaluator and determined that the quantity of ankle
spasticity and stiffness could be measured. They then
suggested that the proportions of the biomechanical
component and reflex component are quantifiable values.

2.3 Measurement of spasticity

The Modified Ashworth Scale (MAS) is one of the
spasticity assessments widely used in the clinical field. An
examiner measures the extent and quantity of resistance
and assigns a score between 0 and 4based on quick,
passive movement of a patients specific joint. However,

Descriptions


Because people with complete spinal cord injury are
unable to sense parts of their paralyzed body, they are
always cautious of handling their body. Because brisk
involuntary movement of the lower extremities causes a
kicking motion, spasticity can harm the patient or another
person. Spasticity can also negatively influence their
quality of life. It inhibitseffective walking and self-care,
increases the incidence of falls, and disturbs sleep [20].
Thus, controlling spasticity increases the performance of
ADL.
The rehabilitation robot for the people with physical
disabilities should handle the spasticity of users who has
spastic symptoms. Spasticity could occur in
lower-extremities when a rehabilitation robot moves the
body posture, e.g., sit-to-stand movements. Moreover,
spasticity interferes specific phases of standing up. A user
may get injured via that interference. In order to prevent an
unexpected accident, the robotic system should know
when spasticity occurs and how it manages. People with
spasticity symptom tend to show strong intensity of
spasticity in their early stage of exercise. However, the
intensity of spasticity usually tends to decrease during the
repeated practice.

4.1 Subject

3.2 Development of robotic system using spasticity

measurement for clinical training
It is very difficult to practice clinical training with
patients because ofthe difficulty in recruiting subjects
who have diverse levels of spasticity and because of safety
issues during practice. Furthermore, repeatedly measuring
the same subject could lead to fatigue. Training using a
haptic device could overcome these limitations, so that
clinicians or therapists could practice measuring spasticity
easily.
Kikuchi et al. [16] attempted to make use of the
Leg-robot using an MR clutch to reproduce virtual spastic
movements for clinical physical therapy education. Park et
al. [17] have developed a haptic device of the elbow joint
to measure spasticity objectively. To complete this device,
well-trained therapists assessed three subjects using the
MAS, and researchers created a mathematical model
based on the therapists measurement results.
3.3 Robotic exercise system for detecting spasticity
When sudden muscle tone (spasm) was detected using a
MOTOmed cycling system, a system designed by Kamps
et al. [18] smoothly stopped the pedal rotation and
changed the rotational direction of the pedals
automatically. REO, an upper-extremity robotic
rehabilitation system, used an inherent program to cease
movement automatically after detecting unexpected spasm.
Moreover, two types of safety equipment were applied to a
system, preparing for the occurrence of spasm. The
Omnicycle Elite system had a program for detecting and
managing spasticity. When the system detected
unexpected muscle tone, the rotation of the pedal stopped
immediately, and the system helped to relieve the muscle
spasm until the exercise program restarted.
Lee et al. [19] attempted to develop an upper-extremity
rehabilitation system for people who exhibited spasticity
in their elbows. However, they were unable to conduct a
clinical trial with people who exhibited spasticitybecause
of potential safety issues, and only one healthy subject was
tested. Although, the system was untested in terms of its
actual therapeutic effects, it confirmed the possibility of
using a robotic rehabilitation system for patients with
upper-limb spasticity.

A male subject, 30 years old, was diagnosed with spinal

cord injury T9, ASIA A owing to a fall. The duration since
onset was 7 years. He had lost the ability to walk because
of paraplegia and suffered from spastic movements such
as spasm and clonus. For mobility, he typically used his
manual wheelchair and car. He also used a standing
wheelchair at his workspace. Whenever he used a standing
wheelchair, involuntary movement occurred during
standing. The spasticity was more dominant in his left leg,
and he was taking daily medication to relieve the spasticity.
The subject was medically stable state and did not show
any pains and discomfort during the experiment.
4.2 Methods
Six channels of wireless surface electrodes (Delsys
TrignoTM Wireless, Boston, USA) were used to measure
the muscles that were active during the standing motion.
EMG electrodes were placed over the rectus femoris (RF),
vastus lateralis (VL), tibialis anterior (TA), biceps femoris
(BF), semitendinosus (ST), and medial gastrocnemius
(MG) when the subject sat on the powered standing
wheelchair (Able Eng Co., Seoul, Korea). The powered
standing wheelchair used in this study is a specialized
wheelchair for people with disabilities and the elderly to
support locomotion, standing, and tilting. The powered
standing wheelchair is able to substitute for the standing
up function of a human.
After the electrodes were placed (sampling at 4000 Hz),
the subject pushed the button of the wheelchair to
straighten his entire body until the highest point of the
wheelchair. The ascending velocity was constant at 0.56
m/s and the descending velocity was 0.70 m/s. We had two
protocols. The first method was sustaining a standing
position until the spasticity subsided. After confirming the
absence of spasticity, the subject was allowed to perform a

4. Detection of lower-extremity spasticity

Target users of lower-extremity rehabilitation robots
are expected to be people with paraplegia who need
assistance with standing, sit-to-stand, and walking
movements. Among them, people with paraplegia were
chosen to investigate the occurring patterns, quantity, and
duration of spasticity. Using lower-extremity robotic
rehabilitation systems in a previous study [6] was difficult
for sit-to-stand movements, so we conducted an
experiment with a powered standing wheelchair, which
has a similar mechanism to a lower-extremity robotic
rehabilitation system. Through this test, we determined
spasticity patterns, quantity of EMG activation, and the
duration of spasticity during sit-to-stand movements.


stand-to-sit motion. The second method was continuous
sit-to-stand, then stand-to-sit motions regardless of the
occurrence of spasticity. To identify the difference in
EMG activation and the duration between maintaining a
standing position in which spasticity occurred and
changing the rotational direction of movement, two
protocols were applied. After performing each motion, the
subject rested for 5 min. Each motion was performed three
times. The Institutional Review Board of the National
Rehabilitation Center of Korea approved the study
protocol.
To analyze the data, the EMG signal was band-pass
filtered within the frequency range of 10 to 450 Hz, which
is the predominant frequency range of EMG signals. After
root-mean-square data processing, thresholding was
conducted as shown in Figure 4 and Figure 5. Among the
six channels of EMG signals, we assumed that spasticity
was activating more than three channels of EMG signals.

Fig. 2Electrode attachmentpositions for EMG [21].

When the knee joint was fully extended, spasticity

occurred to a greater or lesser extent. However, there were
slight differences in the number of spasticityepisodes and
their intensity before the knee was fully extended between
each trial for the same subject.
The number of occurring involuntary movements and
their intensity were reduced by repeated trials because the
subject rested after completing each motion. We assumed
that repeated sit-to-stand motions and prolonged standing
acted as passive exercise effectsand temporally reduced
spasticity. Despite conducting an experiment with the
same person, the persons physical condition such as
fatigue, stretching exercise before the experiment,
medication for relieving spasticity, and environmental
factors might have influenced the results. Furthermore,
there might be a difference between people in terms of
spasticity patterns, joint angle, and number of spasticity
episodes. More subjects would need to be studied to
determine if there are tendencies in spasticity.

Fig. 4 EMG signals for the sit-to-stand movements. At

approximately 30 s, the standing up posture is maintained
even though spasticity occurs.

Fig. 3 Sit-to-stand motion.

4.3 Results
Figure 4 shows that there were two involuntary
movements during the sit-to-stand movements. At
approximately 18 s, the EMG signals of TA, RF, and VL
were activated, and the knee angle was 130. We assume
that a knee angle of 90 is a fully flexed posture. The
second spasm occurred at a knee angle closer to 180, the
EMG signals of RF and VL were activated, and were
followed by activation of TA, MG, BF, and ST. In
particular, BF exhibited the highest degree of activation.
On the other hand, distinctive EMG activation was not
observed during stand-to-sit movements. Spasticity tended
to decrease when the subject performed the stand-to-sit
movements immediately after fully standing up.

Fig.5 EMG signals for the sit-to-stand movements. At

approximately 30 s, spasticity occurs. At that time, the
subject changed to a sitting posture.

4.4 Discussion


At the standing posture during the sit-to-standing
movements, the subject in this study exhibited continuous
spasticity. We compared two movements for the spasticity
at the standing posture: one is pausing, and the other is
moving in the opposite direction. When maintaining a
standing posture, the duration of spasticity was
approximately 10 s. When moving in the opposite
direction, such as in stand-to-sit movements, the duration
of spasticity was approximately 5 s. The EMG signals of
BF and ST exhibited higher activation whereas the subject
maintained a standingposture. Commercialized products
such as MOTOmed are adapted to reverse their rotational
direction when muscle spasmsare detected. Based on this
phenomenon, we should consider a strategy for relieving
spasticity, for instance, by slowly changing the rotational
direction or by allowing pendulum movement through a
reduction in the torque of an exoskeleton robot.
Concerning a users safety, sufficient space for pendulum
movement should also be obtained. Furthermore, the edge
of a wheelchair or exoskeleton should be padded and
rounded with soft materials for protecting a users skin.
When the subjects legs were extended passively,
spasticity occurred in both legs. Especially, the knee flexor
(biceps femoris) showed strong EMG activation. We
surmised that this was a subject-specific phenomenon.
A few studies have measured spasticity during the
standing position with Lokomat, but most measurement
studies prefer the supine position or side-lying position.
However, these positions are different from those that
occur during actual ADL. Some studies have focused on
the number of spasticityepisodes during ADL, but this
method is unable to quantify spasticity. The sit-to-stand
movement is important for functional locomotion and
therapeutic techniques. In that sense, measuring spasticity
during ADL is meaningful to better understand real-life
risk situations. Through a previous study [6], we found
that there are some considerable risk factors using
wearable robotic rehabilitation systems. Among them,
spasticity appears to be brisk, destructive, and
uncontrolled during sit-to-stand movements using
wearable rehabilitation robots.

System for the Elderly and Disabled]. The authors thank

Mr. Won-Jin Song, Mr. Ji-Young Jeong, Dr. Kyung Kim,
Mr. Byung-Woo Ko, Dr. Dae-Sung Park for their
assistance, and for the helpful comments from the clinical
specialists at Korea National Rehabilitation Center.

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5. Concluding Remarks
Spasticity is one of the important factors when
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Acknowledgement
This work was partially supported by the R&D Program of
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