Training modalities in robot-mediated upper limb rehabilitation in stroke : A framework for classification based on a systematic review

© 2014 Basteris et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The work described in this manuscript was partially funded by the European project ‘SCRIPT’ Grant agreement no: 288698 (http://scriptproject.eu). SN has been hosted at University of Hertfordshire in a short-term scientific mission funded by the COST Action TD1006 European Network on Robotics for NeuroRehabilitationRobot-mediated post-stroke therapy for the upper-extremity dates back to the 1990s. Since then, a number of robotic devices have become commercially available. There is clear evidence that robotic interventions improve upper limb motor scores and strength, but these improvements are often not transferred to performance of activities of daily living. We wish to better understand why. Our systematic review of 74 papers focuses on the targeted stage of recovery, the part of the limb trained, the different modalities used, and the effectiveness of each. The review shows that most of the studies so far focus on training of the proximal arm for chronic stroke patients. About the training modalities, studies typically refer to active, active-assisted and passive interaction. Robot-therapy in active assisted mode was associated with consistent improvements in arm function. More specifically, the use of HRI features stressing active contribution by the patient, such as EMG-modulated forces or a pushing force in combination with spring-damper guidance, may be beneficial.Our work also highlights that current literature frequently lacks information regarding the mechanism about the physical human-robot interaction (HRI). It is often unclear how the different modalities are implemented by different research groups (using different robots and platforms). In order to have a better and more reliable evidence of usefulness for these technologies, it is recommended that the HRI is better described and documented so that work of various teams can be considered in the same group and categories, allowing to infer for more suitable approaches. We propose a framework for categorisation of HRI modalities and features that will allow comparing their therapeutic benefits.Peer reviewedFinal Published versio

Design, development and deployment of a hand/wrist exoskeleton for home-based rehabilitation after stroke - SCRIPT project

YesChanges in world-wide population trends have provided new demands for new technologies in areas such as care and rehabilitation. Recent developments in the the field of robotics for neurorehabilitation have shown a range of evidence regarding usefulness of these technologies as a tool to augment traditional physiotherapy. Part of the appeal for these technologies is the possibility to place a rehabilitative tool in one’s home, providing a chance for more frequent and accessible technologies for empowering individuals to be in charge of their therapy. Objective: this manuscript introduces the Supervised Care and Rehabilitation Involving Personal Tele-robotics (SCRIPT) project. The main goal is to demonstrate design and development steps involved in a complex intervention, while examining feasibility of using an instrumented orthotic device for home-based rehabilitation after stroke. Methods: the project uses a user-centred design methodology to develop a hand/wrist rehabilitation device for home-based therapy after stroke. The patient benefits from a dedicated user interface that allows them to receive feedback on exercise as well as communicating with the health-care professional. The health-care professional is able to use a dedicated interface to send/receive communications and remote-manage patient’s exercise routine using provided performance benchmarks. Patients were involved in a feasibility study (n=23) and were instructed to use the device and its interactive games for 180 min per week, around 30 min per day, for a period of 6 weeks, with a 2-months follow up. At the time of this study, only 12 of these patients have finished their 6 weeks trial plus 2 months follow up evaluation. Results: with the “use feasibility” as objective, our results indicate 2 patients dropping out due to technical difficulty or lack of personal interests to continue. Our frequency of use results indicate that on average, patients used the SCRIPT1 device around 14 min of self-administered therapy a day. The group average for the system usability scale was around 69% supporting system usability. Conclusions: based on the preliminary results, it is evident that stroke patients were able to use the system in their homes. An average of 14 min a day engagement mediated via three interactive games is promising, given the chronic stage of stroke. During the 2nd year of the project, 6 additional games with more functional relevance in their interaction have been designed to allow for a more variant context for interaction with the system, thus hoping to positively influence the exercise duration. The system usability was tested and provided supporting evidence for this parameter. Additional improvements to the system are planned based on formative feedback throughout the project and during the evaluations. These include a new orthosis that allows a more active control of the amount of assistance and resistance provided, thus aiming to provide a more challenging interaction.This work has been partially funded under Grant FP7-ICT-288698(SCRIPT) of the European Community Seventh Framework Programme

A double-blinded randomised controlled trial exploring the effect of anodal transcranial direct current stimulation and uni-lateral robot therapy for the impaired upper limb in sub-acute and chronic stroke

BACKGROUND:Neurorehabilitation technologies such as robot therapy (RT) and transcranial Direct Current Stimulation (tDCS) can promote upper limb (UL) motor recovery after stroke. OBJECTIVE:To explore the effect of anodal tDCS with uni-lateral and three-dimensional RT for the impaired UL in people with sub-acute and chronic stroke. METHODS:A pilot randomised controlled trial was conducted. Stroke participants had 18 one-hour sessions of RT (Armeo®Spring) over eight weeks during which they received 20 minutes of either real tDCS or sham tDCS during each session. The primary outcome measure was the Fugl-Meyer assessment (FMA) for UL impairments and secondary were: UL function, activities and stroke impact collected at baseline, post-intervention and three-month follow-up. RESULTS:22 participants (12 sub-acute and 10 chronic) completed the trial. No significant difference was found in FMA between the real and sham tDCS groups at post-intervention and follow-up (p = 0.123). A significant ‘time’ x ‘stage of stroke’ was found for FMA (p = 0.016). A higher percentage improvement was noted in UL function, activities and stroke impact in people with sub-acute compared to chronic stroke. CONCLUSIONS:Adding tDCS did not result in an additional effect on UL impairment in stroke. RT may be of more benefit in the sub-acute than chronic phase

Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke

© 2015 Nijenhuis et al. Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.BACKGROUND: Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke. METHODS: A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up. RESULTS: Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log. CONCLUSIONS: Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings. TRIAL REGISTRATION: This study has been registered at the Netherlands Trial Registry (NTR): NTR3669 .Peer reviewe

Toward 'optimal' schemes of robot assistance to facilitate motor skill learning

We investigate whether and on what circumstances physical interaction with a robot may facilitate the acquisition of a novel motor skill. We focus on two different motor tasks: (i) intermanual transfer of cursive handwriting and (ii) acquisition of a putting skill. In the case of handwriting, we found that intermanual transfer is facilitated by forms of interaction that account for the temporal aspects of the movements. In the case of putting, we found that guidance is helpful in improving longitudinal error (a matter of speed accuracy), but not directional error (a matter of position accuracy). Based on these results, we draw some tentative conclusions on which tasks can benefit from guidance, and how robots should be programmed to maximize their effect

Adaptive human-robot interaction based on lag-lead modelling for home-based stroke rehabilitation : Novel mechanisms for assessment and performance based adaptation of task difficulty

In this work we present three interaction algorithms developed under the EU project SCRIPT in order to evaluate stroke patients' capabilities, evaluate their performance during robot-assisted exercise and consequently adapt the difficulty of the exercise to each individual. The first procedure assesses movement amplitude and duration with the subject making only a few repetitions of the motion. The second algorithm, aimed at evaluation of subject performance, is based on whether that the subject is lagging or leading with respect to a target reference trajectory. Finally, the third procedure aims at modifying the task difficulty (time allowed to reach the target, in this case) based on a performance indicator. The proposed mechanisms are completely independent from each other and could thus be exploited as single units. Furthermore, all of them are generalizable to any movement. These components have been adopted in the SCRIPT system, which is currently being tested in patients' home

Robot-assisted acquisition of a motor skill: evolution of performance and effort

Robots are widely used to promote the neuromotor recovery of stroke survivors, but it is unclear whether robots might be useful to facilitate the acquisition of novel motor skills. In principle, robots could be used to guide a trainee to experiment the correct movements and/or by preventing him/her from performing incorrect ones (the guidance hypothesis). Here we investigate whether and on what circumstances physical interaction with a robot may facilitate the acquisition of a novel motor skill. We focused on a simulated putting task, consisting of gently hitting an object (e.g. a ball) by means of a tool (the pad, e.g. the golf putter) to move it to a desired final position. A virtual environment, created through a planar robot manipulandum and a computer screen, was used to simulate the physics involved in the putting task. Putting is a redundant task, as the same final position of the ball can be obtained by different combinations of pad velocity, acceleration and point of impact. Two groups of subjects were analyzed: in an assisted group, the robot guided subjects toward the correct movement, whereas a control group performed the task without assistance. In both groups we looked at the subjects' performance and its evolution with exercise at several levels of description, namely: (i) final error (distance between final ball position and center of the target area); (ii) ball velocity just after impact; and (iii) hand position and velocity just before impact. In all cases, we looked at both mean value and variability (variance). We found that guidance is helpful in decreasing longitudinal error (a matter of speed accuracy), but not directional error (a matter of position accuracy). These results are consistent with the notion that guidance can help with the dynamic, but not the geometric components of a task

Concurrent adaptation to force fields and visual rotations

An important issue in sensorimotor adaptation is what drives adaptation, and whether different types of perturbations are mediated by different adaptation mechanisms. Here we assess whether any interference is observed among the joint adaptation to visual (i.e. kinematic) and force (i.e. dynamic) perturbations. Subjects adapted their reaching movements to rotations of the display. During adaptation, we perturbed their movements with a rotational force field, whose direction was either the same or the opposite of the visual perturbation (RF and R-F groups). In the two groups, we compared the outcomes of both adaptation modalities. In addition, we analyzed the dynamics of the adaptation processes in terms of a number of linear dynamical models, based on different assumptions. We conclude that the two adaptation processes occur largely in parallel, with little interaction, and exhibit similar time constants, which suggests common underlying memory mechanisms. In addition, we found that subjects in the RF group exhibit a significantly smaller hand compliance, which suggests that the different combinations of disturbances affect the regulation of arm impedance

Adaptive regulation of assistance 'as needed' in robot-assisted motor skill learning and neuro-rehabilitation

We propose a general adaptive procedure to select the appropriate degree of assistance based on a Bayesian mechanism used to estimate psychophysical thresholds. This technique does not need an accurate model of learning and recovery processes. This procedure is validated in the context of a motor skill learning problem (control of a virtual object), in which the controller is used to gradually increase task difficulty as learning proceeds. These automatic adjustments of task difficulty or the degree of assistance can be used to promote not only motor skill learning but also neuromotor recovery