Neurorehabilitation for Stroke: The Case for Robot-Assisted Therapy of the Upper Limb

Transcription

1 Neurorehabilitation for Stroke: The Case for Robot-Assisted Therapy of the Upper Limb? Efficacy and Mechanisms: Animal Models of Neuroplasticity; Motor Learning and the Brain; Recovery from Stroke = Motor Learning?; Clinical Neuroplasticity (Basic Sciences). Definition of Clinical Effectiveness: Persistent neuro-anatomical and neurophysiological changes that occur during recovery from stroke (Type 1 research).? Definition of Cost Effectiveness: Equal or less expensive than existing treatment programmes (Clinical Trials). Optimization and Prediction: Account for direct and indirect health costs for each component step of intervention and follow-up healthcare needs (HS research). Objective: Use a better model of clinical neuroplasticity to drive effective treatment (Delivery). from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)

2 Neurorehabilitation for Stroke - Feasibility: The Case for Robot-Assisted Therapy of the Upper Limb Ref Active Y X NW S Robot-mediated reaching can be partnered with state-of-the-art technologies to study mechanisms responsible for motor learning during healthy development and in clinical populations. Turner et al Frontiers in Neurology 8:184

3 Neurorehabilitation for Stroke Feasibility: The Case for Robot-Assisted Therapy of the Upper Limb? Efficacy and Mechanisms: Animal Models of Neuroplasticity; Motor Learning and the Brain; Recovery from Stroke = Motor Learning?; Clinical Neuroplasticity (Basic Sciences). Definition of Clinical Effectiveness: Persistent neuro-anatomical and neurophysiological changes that occur during recovery from stroke (Type 1 research).? Definition of Cost Effectiveness: Equal or less expensive than existing treatment programmes (Clinical Trials). Optimization and Prediction: Account for direct and indirect health costs for each component step of intervention and follow-up healthcare needs (HS research). Objective: Use a better model of clinical neuroplasticity to drive effective treatment (Delivery). from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)

4 Neurorehabilitation for Stroke - Feasibility: Clinical effectiveness: Robot therapy for everyone? TOTAL FM Score TOTAL FM Score PRE MID POST FOL1 70 RM ANOVA F=15.8; P= * UPPER ARM FM Score UPPER ARM FM Score PRE MID POST FOL1 RM ANOVA F=14.3; P=0.001 * LOWER ARM FM Score LOWER ARM FM Score RRA0001 RRA0002 RRA0004 RRA0006 RRA0007 RRA0008 RRA0010 RRA0011 RRA0013 RRA0014 PRE MID POST FOL1 RM ANOVA F=13.9; P=0.002 Values are mean ± SD; N=10 *, Sig. Diff. vs. All Others Bonferroni p=0.016 * 0 PRE MID POST FOL1 0 PRE MID POST FOL1 0 PRE MID POST FOL1 Early robot therapy is feasible at the population level, but not for all individuals. Turner et al Clin Neurophysiol.;123,

5 Neurorehabilitation for Stroke - Feasibility: Clinical effectiveness: Robot Measures Y position (m) Y position (m) Y position (m) FORCE (N) FORCE RATE (N s -1 ) ERROR (m) RRA3 1ST FM = 11 RRA3 2ND RRA3 3RD FM = 54 RRA3 5TH FM = 61 RRA3 4TH H S2 0 O O RRA3 1ST RRA3 5TH H S2 1ST H S2 2ND UP DOWN 90 O 180 O 270 O O 90 O TIME (s) X position (m) 180 O X position (m) Early robot therapy may improve position-holding control after stroke Turner et al Clin Neurophysiol.;123,

6 Neurorehabilitation for Stroke Group Evidence: The Case for Robot-Assisted Therapy of the Upper Limb? Efficacy and Mechanisms: Animal Models of Neuroplasticity; Motor Learning and the Brain; Recovery from Stroke = Motor Learning?; Clinical Neuroplasticity (Basic Sciences). Definition of Clinical Effectiveness: Persistent neuro-anatomical and neurophysiological changes that occur during recovery from stroke (Type 1 research).? Definition of Cost Effectiveness: Equal or less expensive than existing treatment programmes (Clinical Trials). Optimization and Prediction: Account for direct and indirect health costs for each component step of intervention and follow-up healthcare needs (HS research). Objective: Use a better model of clinical neuroplasticity to drive effective treatment (Delivery). from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)

7 Neurorehabilitation for Stroke Group Evidence: Clinical Effectiveness Functional Outcome (F-M) Robot-assisted upper limb therapy improves motor impairment Norouzi-Gheidari et al JRRD, 49,479,-496

8 Neurorehabilitation for Stroke Group Evidence: Clinical Effectiveness: Meta-analysis Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient: A Scientific Statement From the American Heart Association [Stroke 2010; 41: ] Statement regarding ICF: Body function and structure Varied repetitive task practice (e.g. CIMT, robot-assisted therapy) to improve UE motor coordination in individuals with some voluntary finger extension in outpatient and chronic care settings is recommended; it is reasonable to do so in inpatient settings. No recommendations are made for one type of varied repetitive task practice over another. Robustness of Useful Impact for function and structure In-Patient Setting - Class IIa; Level of Evidence A Out-Patient Setting - Class I; Level of Evidence A Community Care Setting - Class I; Level of Evidence A Robotics Can Deliver for Upper Limb Functional Recovery. Stroke 2010; 41:

9 Neurorehabilitation for Stroke Group Evidence: The Case for Robot-Assisted Therapy of the Upper Limb? Efficacy and Mechanisms: Animal Models of Neuroplasticity; Motor Learning and the Brain; Recovery from Stroke = Motor Learning?; Clinical Neuroplasticity (Basic Sciences). Definition of Clinical Effectiveness: Persistent neuro-anatomical and neurophysiological changes that occur during recovery from stroke (Type 1 research).? Definition of Cost Effectiveness: Equal or less expensive than existing treatment programmes (Clinical Trials). Optimization and Prediction: Account for direct and indirect health costs for each component step of intervention and follow-up healthcare needs (HS research). Objective: Use a better model of clinical neuroplasticity to drive effective treatment (Delivery). from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)

10 Neurorehabilitation for Stroke Group Evidence: Cost Effectiveness: How much does the therapy cost? Robot-assisted therapy costs are cheaper than matched intensive physical therapy for chronic stroke. Wagner et al Stroke 42,

11 Neurorehabilitation for Stroke Group Evidence: Cost Effectiveness: What are the follow-up costs? Robot-assisted therapy costs are competitive for chronic stroke Wagner et al Stroke 42,

12 Neurorehabilitation for Stroke RCT Design: The Case for Robot-Assisted Therapy of the Upper Limb? Efficacy and Mechanisms: Animal Models of Neuroplasticity; Motor Learning and the Brain; Recovery from Stroke = Motor Learning?; Clinical Neuroplasticity (Basic Sciences). Definition of Clinical Effectiveness: Persistent neuro-anatomical and neurophysiological changes that occur during recovery from stroke (Type 1 research).? Definition of Cost Effectiveness: Equal or less expensive than existing treatment programmes (Clinical Trials). Optimization and Prediction: Account for direct and indirect health costs for each component step of intervention and follow-up healthcare needs (HS research). Objective: Use a better model of clinical neuroplasticity to drive effective treatment (Delivery). from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)

13 Neurorehabilitation for Stroke RCT Design: Pragmatic Testing of Robot-Assisted Therapy - RATULS Robot therapy comprises a comprehensive programme of adaptive assisted reaching, wrist movements and grasping over 12 weeks. Rodgers et al funded by NIHR-HTA

14 Neurorehabilitation for Stroke - Issues: The Case for Robot-Assisted Therapy of the Upper Limb? Efficacy and Mechanisms: Animal Models of Neuroplasticity; Motor Learning and the Brain; Recovery from Stroke = Motor Learning?; Clinical Neuroplasticity (Basic Sciences).? Definition of Clinical Neuro-Effectiveness: Minimal but promising evidence. Definition of Cost Effectiveness: Promising in certain healthcare systems. May save 300m of 64b EU cost per year. Optimization: Patient-centred modelling lacking. Prediction: Neural correlates of successful treatment lacking. Framework Objective: Use a better model of clinical neuroplasticity to drive effective treatment. from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)

15 Neurorehabilitation for Stroke - Future: Reaching for a Metropolitan Robot Therapy Service NRU-UEL cf. Hunter et al PLOS One 2013; 8:e70420; Morris et al BMJ 2014;349:g4757

16 Neurorehabilitation for Stroke - Drivers: Embedded in the Greater Context of RAS-UK

17 Neurorehabilitation for Stroke: The Case for Robot-Assisted Therapy of the Upper Limb? Efficacy and Mechanisms: Animal Models of Neuroplasticity; Motor Learning and the Brain; Recovery from Stroke = Motor Learning?; Clinical Neuroplasticity (Basic Sciences). Definition of Clinical Effectiveness: Persistent neuro-anatomical and neurophysiological changes that occur during recovery from stroke (Type 1 research).? Definition of Cost Effectiveness: Equal or less expensive than existing treatment programmes (Clinical Trials). Optimization and Prediction: Account for direct and indirect health costs for each component step of intervention and follow-up healthcare needs (HS research). Objective: Use a better model of clinical neuroplasticity to drive effective treatment (Delivery). from Nature Reviews Neurology (2011) Dimyan and Cohen; Cumberland Consensus in NNR (2009)