Robotics in the Rehabilitation of Neurological Conditions

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1 Robotics in the Rehabilitation of Neurological Conditions Gil J Cerros, MSHS The PRANAYAMA Research Group June 14, 2015 Clinical and Translational Research The PRANAYAMA Research Group fdsfsf

2 Robotics in the Rehabilitation of Neurological Conditions Introduction: The research of robotics for the rehabilitation of neurological conditions has increased in the last decade. The technological advances of the 21 st century are bringing robotics to all domains of our society (Morone et al., 2014). Our research site has been focusing upon the application of robotic technology for neurological conditions. Our current robotic research is on the upper and lower motor function in patients with stroke (CVA), spinal cord injury (SCI), and brain injury (BI). The research of robotics in the rehabilitation of neurological conditions has been constrained by cost and lack of insurance coverage. In the United States the use of robotics in health care has the potential to deliver highly intensive activity-based therapy (Scott and Dukelow, 2011). Loss of motor function is a result and consequence of neurological disorders (Moreno et al., 2011). The stroke prevalence is estimated at 2.9%, or a new stroke occurs every 40 seconds. While spinal cord injury has an incidence rate of traumatic SCI from 12.1 to 57.8 per million (Moreno et al., 2011). Additionally, other neurological diseases such as, Parkinson s, cerebral palsy, and multiple sclerosis add interest for robotic rehabilitation focusing on re-learning motor skills. Although rehabilitation is obviously significant to the well being of patients after CVA, SCI, and BI, many of these patients are unable to partake in conventional rehabilitation programs (Goldberg, 2011). Because of critical motor limitations in the form of hemiparesis or foot drop, even walking in a treadmill represents a benefit on cardiovascular endurance. The safety risks associated with unbalance, places patients in danger of further injuries. Therefore, the use of robotics to improve functional mobility in patients with neurological conditions needs more dedicated research. Moreover, robotics could be used to promote intensive therapy in the setting of a functional task or activity. Then improvements in functional mobility and overall health can be accomplished with the application of robotic devices (Tefertiller et al., 2011). Case Description: Previous research supports that robotic therapy improves upper and lower limb motor function after SCI and CVA. 2

3 Although limited research has been reported on the rehabilitation gains after robotic rehabilitation, particularly in gait and balance. Robotic applications in neurorehabilitation may have very positive effects in the motor recovery of neurological conditions. Rehabilitation robotic devices come in many designed forms such as exoskeletons, auto-ambulators, electronic stimulators, prosthetics, and computerizedmovement systems. Patients with early mobilization after a CVA, SCI, and BI have better gains in motor function (Hilder, Hamm, Lichy, and Groah, 2008). However, robotic technology advances are limited to specific selective applications in rehabilitation. With this approach leaving underprivileged populations that could benefit from robotic technology rehabilitation. Questions for Discussion: 1. Why is robotic assisted-therapy underutilized in neurorehabilitation? 2. What are the implications of robotic assisted-therapy in the future of therapist feel therapy? 3. What are the disadvantages of robotic technology? 4. How profitable is the cost of robotic technology in neurorehabilitation? Case Analysis: Hilder et al. (2008) discussed how the use of robotic technology for lower extremities of patients with no motor function below their injuries can be rehabilitated for longer periods. Nonetheless, therapists still question the consistency of longer rehabilitation periods. The future of robotics in neurorehabilitation remains problematic, even when premature indication proves that robotic-assisted gait exercise can increase ambulation as well as cardiac and metabolic performance (Hilder et al., 2008). Notably, some drawbacks are the high cost, maintenance breakdowns, routine service, and lack of therapist s feels. In 2011, Walter Reed Army Medical Center and the University of Pittsburgh created a symposium to update and educate healthcare professionals in the field of Rehabilitation Robotics (Goldberg, p.22). However, the focus from the symposium was the discussion to applications of robotic technologies that could replace therapists and how these professionals feel about the possibility of replacing caregivers. An example is the Personal Mobility and Manipulation Appliance (PerMMA), which could have the potential to improve mobility and quality of life in the 21 st century (Goldberg, 2011). 3

4 Robotic rehabilitation is transforming the way we deliver future rehabilitative services. This includes the integration of robotics for the daily activities such as walking, driving, motor function, and brain controlled interfaces. Mechatronic extremities are opening to advance the physical abilities of the human limbs. Loss of motor function is a result and consequence of neurological disorders (Moreno et al., 2011). However, at this time is still difficult to support what the ideal rehabilitation benefit may be. Evidence supports the rehabilitation of the entire limb at the same time, which is done with robotic-assisted therapy. This additionally helps to transfer skills from therapy to activities of daily living (Guidali et al., 2011). Sicuri, Porcellini, and Merolla (2014) added that at this time of technological advances, robotics have proven to be beneficial in the domain of neurorehabilitation, but not in the orthopedic domain. Although the orthopedic domain is not considered in the current research, it is important for future orthopedic rehabilitation. Robotic-assisted therapy methodologies unquestionably allow for similarly fast, possibly even quicker, but positively more attention-grabbing rehabilitation devices. Regrettably, the area of robotic-assisted rehabilitation market will be a smaller than the current market for computer gaming. This represents a significant weakness in the investment of robotic devices for neurorehabilitation (Wirz et al., 2005). Munih and Bajd (2011) explained that although the quantity of robotic-assisted rehabilitation is significant, the amount of clinical trials is still very limited. In reality, the rehabilitation types are not yet integrated in a therapeutic robotic-assisted program (Munih & Bajd, 2011). In the case of stroke hemiparesis, early rehabilitation is important for the use of affected-limb in daily living activities (Iqbal and Baizid, 2015). The intensity of rehabilitation has an increased staff cost and the limited time is a constraint. In this scenario, robotic-assisted rehabilitation may offer an option to increase the intensity of limb rehabilitation (Hesse et al., 2014). In this particular case, the Fugl-Meyer Score and Action Research Arm Test improved with robotic-assisted therapy. Moreover, Iqbal and Baizid (2015) added that rehabilitation scholars predicted that in 2024, individuals will use fashionable and portable exoskeleton robots to interact with objects in society (p. 197). 4

5 Robotic-assisted rehabilitation provides optimal improvements in terms of accuracy, precision, and repetition with high intensity therapy. Additionally, the integration of virtual reality elements offers to transform a boring rehabilitation into an exciting and interesting activity (Iqbal and Baizid, 2011). These activities are very similar to playing challenging games online or television access games. In the near future it is anticipated that we will see an increase in the innovations of robotic-assisted neurorehabilitation strategies. The next generation of rehabilitation devices will increase for the home-base, designed specifically for the patient s specific rehabilitation therapy (Morone et al., 2014). Considering stroke the second leading cause of death and the third leading cause of disability world-wide (Morone et al., 2014, p.1), the public health system and the scientific communities must take seriously and consider the increased number of stroke survivors. The costs associated with the disability and treatment after strokes are imperative to be reduced with cost-effective neurorehabilitation systems (Sicuri et al., 2014). New technologies with robotic-assisted devices becomes a clear path for new strategies developed in the future rehabilitation of individuals after stroke (Guidali et al., 2011). However, this does not eliminate the divisive arguments for the present and future application of robotics in rehabilitation. Guidali and colleagues described the drawbacks in other domains like orthopedic rehabilitation, which was identified previously in the literature. Nonetheless, researchers continue working in more generalized application programs to be integrated in multi-purpose robotic devices that support other domains like orthopedic and prosthetics for amputations (Scott and Dukelow, 2011). The clinical assessment of stroke continues measuring disability very traditionally. However, the tools to improve upper and lower limbs motor function is left for poor and under developed nursing home rehabilitation programs. While hightechnology neurorehabilitation remains underutilized due to the poor understanding of robotic-assisted technologies, healthcare providers and insurance plans decreased the opportunity for those who are severely impaired from a stroke (Tefertiller et al., 2011). Better treatment plans in neurorehabilitation are necessary at the point of injury. Many factors included the type of CVA, SCI, and BI. The time for early delivery and intensity of rehabilitation, the 5

6 duration of therapy, and the selection of best robotic-assisted devices are critical factors for good outcomes (Hidler et al., 2008). In general, the current literature supports the value of increased intensity and time of rehabilitation with robotic-assisted therapy and hands on with therapists who provide the human feel are the best approaches to a neurorehabilitation program. Robotic-assisted rehabilitation optimizes the delivery of high-intensity movement repetition. The mechanism of the physical human-robotic interaction depends on the device modality. A plethora of problems need to take in consideration the safety and reliable physical human-robot interaction. In the future development of robotic-assisted rehabilitation, the metrics for safety and reliability must be introduced for the efficacious utilization of roboticdevices in daily physical rehabilitation clinical settings. The mental perception of the human involved with the robotic-device is critical to the interaction and acceptance of the physical mechanical rhythm connection. The interactions are considerations for the researchers and future work of scientific involvement to complete the study and apply components designed for sharing within a human environment (Kiesler and Hinds, 2011). In the meantime, the number of robotic devices will continue to increase based on the demand and utilization of these products. The challenges and future direction in robotic-assisted therapy will be part of the new generations of healthcare researchers and providers. The continuity of clinical trials to make robotic technology available and safe needs further worldwide scientific interest. 6 Clinical and Translational Research The PRANAYAMA Research Group

7 References Goldberg, M. R. (2011). Rehabilitation robotics. PVA Publications, Guidali, M. R., Duschau-Wickle, A., Broggi, S., Klamroth-Marganska, V., Nef, T., & Riener, R. (2011). A robotic system to train activities of daily living in a virtual environment. Med Biol Eng Comput, 49, doi: /s Hesse, S., Heb, A., Werner, C., Kabbert, N., & Bushfort, R. (2014). Effect on arm function and cost of robot-assisted group therapy in subacute patients with stroke and a moderately to severely affected arm: a randomized controlled trial. Clinical Rehabilitation, 28(7), doi: / Hidler, J. M., Hamm, L. F., Lichy, A. L., & Groah, S. L. (2008). Automating activity-based interventions: The role of robotics. Journal of Rehabilitation Research and Development, 45(2), doi: /JRRD Iqbal, J., & Baizid, K. (2015). Stroke rehabilitation using exoskeleton-based robotic exercises: mini review. Biomedical Research, 26(1), Kiesler, S., & Hinds, P. (2011). Introduction to this special issue on human--robot interaction. Human-Computer Interaction, 19(1), 1-8. doi: / Moreno, J. C., Del Alma, A. J., Reyes-Guzman, A., Gil-Agudo, A. L., Ceres, R., & Pons, J. L. (2011). Neurorobotic and hybrid management of lower limb motor disorders: a review. Med Biol Eng Comput, 49, doi: /s Morone, G., Masiero, S., Werner, C., & Paolucci, S. (2014). Advances in neuromotor stroke rehabilitation. BioMed Research International, 2014(236043), 1-2. Munih, M., & Bajd, T. (2011). Rehabilitation robotics. Technology and Health Care, 19, doi: /THC

8 Scott, S. H., & Dukelow, S. P. (2011). Potential of robots as next-generation technology for clinical assessment of neurological disorders and upper-limb therapy. Journal of Rehabilitation Research and Development, 48(4), doi: /JRRD Sicuri, C., Porcellini, G., & Merolla, G. (2014). Robotics in shoulder rehabilitation. Muscles, Ligaments, and Tendons Journal, 4(2), Tefertiller, C., Pharo, B., Evans, N., & Winchester, P. (2011). Efficacy of rehabilitation robotics for walking training in neurological disorders: A review. Journal of rehabilitation Research and Development, 48(4), doi: /JRRD Wirz, M., Zemon, D. H., Rupp, R., Scheel, A., Colombo, G., Dietz, V., & Hornby, T. G. (2005). Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: A multicenter trial. ArchPhys Med Rehabil, 86, doi: /j.apmr Clinical and Translational Research The PRANAYAMA Research Group 8

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