Integrating technology into clinical practice in neurological rehabilitation

Integrating technology into clinical practice in neurological rehabilitation*



After reading this chapter the student or therapist will be able to:

1. Summarize the need, demand and principles for integrating advanced robotic technology in neurological rehabilitation.

2. Define common terminology used in the field of rehabilitation robotics and technology.

3. Classify the different types of advanced technology used in neurorehabilitation.

a. Rehabilitation robots and assistive technology including:

i. Service robots for movement

ii. Service robots for physical assistance and indoor and outdoor navigation

iii. Nonwearable robotic assistive device for mobility, unweighting, and object manipulation

iv. Wearable robotic assistive device for upper-limb object manipulation

v. Wearable robotic assistive device for lower-limb mobility and gait training

vi. Communication robotics to enable interpersonal interaction

vii. Interactive entertainment robotics for companionship and emotional support

b. Advanced clinical technology including:

i. Virtual reality training systems for improved neural recovery of upper- and lower-limb function

ii. Computerized learning-based gaming systems for home training of individuals with physical disabilities and memory impairments

iii. Computerized patient simulators for teaching clinical diagnoses and intervention strategies to medical professionals

iv. Computer technology for teaching home exercise programs to patients

4. Use the guidelines for integrating robotics and assistive technology into a patient’s rehabilitation program.

5. Summarize the challenges and basic engineering principles involved in creating rehabilitation robotics and interfacing with advanced technology to help individuals to design:

a. Robots that operate independently

b. Controllers, actuators, and sensors required for service and assistive rehabilitation robots

c. Human interfaces (physical, sensory physical, cognitive, and brain machine)

d. User-friendly interfaces and controllers to maximize kinematics (e.g., force, velocity, timing)

e. Rehabilitation robotics based on the materials and control technology currently available

f. Safe robotics for rehabilitation

6. Discuss the benefits of performing a cost-effectiveness analysis when considering the application of robotic technology in rehabilitation.

7. Describe the challenges of commercializing robotic devices.

8. Discuss the future of advanced technology and rehabilitation.

This chapter presents and discusses the integration of computer-assisted technology as one approach to maximize independence and quality of life in older adults and people with moderate to severe physical impairments. Rehabilitation robotics and computer-assisted technology use brain interfaces, sensorimotor interfaces, virtual reality (VR) environments, and learning-based gaming programs to remediate sensory, motor, and cognitive impairments and improve memory skills and physical abilities required for independent mobility and self-care at home, in the community, at work, and during the performance of recreational activities.

Introduction to the application of robotics and technology in rehabilitation

General overview

The purpose of this chapter is to excite rehabilitation professionals about the integration of technology in rehabilitation and the potential to expand possibilities for healing, adaptation, compensation, and recovery for individuals with neurological impairments. Robotics and technology are considered supplemental to “one-on-one rehabilitative therapy,” not a replacement for individual therapy. This chapter will provide an overview of technology and rehabilitation robotics appropriate for consideration within neurological rehabilitation. The chapter will not provide a detailed analysis of all of the technology that is available or an exhaustive bibliography referencing all of the studies that have been carried out in the area of rehabilitation robotics.

The objective of rehabilitation technology is to empower clinicians and individuals to take responsibility and control of the environment, facilitate physical and cognitive recovery, and comply with learning-based practice to drive neural adaptation and neural reorganization. The principles underlying technology and rehabilitation are summarized in Box 38-1. Since the early 1990s, medical science has been able to minimize damage to the nervous system postinjury. It is known that the central nervous system (CNS) possesses the potential for spontaneous healing and recovery. Learning-based sensory and motor training can be used to drive recovery of function. Rehabilitation robotics are a logical addition to supervised, one-on-one therapeutic interventions.19


Principle I

Goals for advanced technology and rehabilitation robotics include the following:

Indirectly augmenting functional independence of individuals with impairments by:

Directly improving human motor skill capabilities of individuals with impairments to enable them to:

Robotic technology can provide service, unweighting, passive assistance, active assistance, variable and on-demand assistance, or a combination of service and assistance.10 Computerized and robotic technology provides the foundation for patients to practice and attend to purposeful, goal-oriented, progressive tasks spaced over time. This technology can also minimize the risk of injury during retraining. Robotic interfaces, actuators, and controllers can convert sensory, physical, and cognitive signals to control robots, permit perception of spatial relationships, mobilize individuals in space, assist in object manipulation, provide emotional support, and allow individuals to call for help and communicate with others. In addition, through creative virtual training environments and gaming technology, patients can improve memory, motor skills, and movement quality. In addition, patient simulators can help medical professionals learn diagnostic processes, treatment interventions, and manual techniques. Computer-assisted technology can also improve our ability to teach home exercise programs to patients. Over the next 10 years, robotic technology will expand the opportunities for clinicians to assist patients to achieve maximum independence and quality of life with less dependence on others.

History supporting the use of technology in neurological rehabilitation

The idea of interfacing technology with rehabilitation was introduced into practice by George J. Kelin in the 1940s. Kelin was a productive inventor from Canada who invented the power wheelchair for patients with quadriplegia, the microsurgical staple gun, and a wide range of industrial gearing systems. He also contributed to internationally important innovations in aviation and space technology. During the early 1970s, a new field emerged known as mechatronics, which combines mechanical, electrical, and control engineering design principles to produce a diverse range of useful practical devices.11,12 The science of biomechatronics then developed as a unique engineering discipline responsible for integrating neuromusculoskeletal appliances with biological systems to control and facilitate human-machine interactions as well as developing interfaces, sensors, actuators, and energy supplies to create functional devices for human use.13

The first conference on rehabilitation robotics was held in 1990. There are now multiple conferences each year on rehabilitation robotics. In 1999 the Robotics and Automation Society created the Rehabilitation Robotics Technical Committee to improve definitions and understanding about rehabilitation and assistive robotics.14 The scope of this technical committee has been recently specified as rehabilitation and assistive robotics. This modification is the direct outcome of the scientific progress and maturity reached in this broad research area. The goal of rehabilitation robotics is to investigate the application of robotics to therapeutic procedures for achieving the best possible motor, cognitive, and functional recovery for persons with impairments associated with aging, disease, or trauma (e.g., stroke, neuromotor disorders, brain trauma, orthopedic trauma, cognitive disease).

In particular, service robotics include aids for supporting independent living of persons who have chronic or degenerative limitations in motor and/or cognitive abilities, such as the severely disabled and the elderly. Such robotic devices are typically key components of more general assistive and supportive systems. These service robots usually integrate telematic, mechatronic, and other technological devices such as smart house designs and advanced human-machine interfaces. On the other hand, innovative, passive assistive, and active and dynamic assistive robotic devices are being integrated into rehabilitation programs to maximize recovery and functional independence skills.

Some clinicians have been skeptical of robotics in rehabilitation. Some health care providers worry that robots will replace therapists; others worry that robots are unsafe.8 However, researchers have persisted in developing innovative hardware, new control strategies, improved compliance, and feed-forward and adaptive control systems, as well as computerized modeling. In addition, new assistive, wearable robotic arm devices have been developed (e.g., MIT-Manus, the MIME, the ARM, and the iARM) to more carefully outline and address the engineering challenges related to what the robot can do, the logical physical targets for active assistance, and the joints and the types of movements that can safely be assisted.

There is no question that the demand for rehabilitation robotics is currently increasing, particularly with soldiers with traumatic injuries returning from war zones and with aging baby boomers. With the proliferation of innovative hardware, new control strategies, improved compliance systems, error amplification strategies, adaptive controls, and optimization of neurocomputational modeling, robotics and technology can provide assistance within virtual environments to speed up learning and recovery.

To endure, rehabilitation technology and robotic devices need to be reasonably priced, versatile, safe, reliable, durable, reparable, and easy to use. If devices are wearable, they also need to be lightweight, easy to don and doff, portable, and cosmetically acceptable. Robotic devices must also be adaptable across a variety of users and environments. Depending on their purpose, rehabilitation devices can operate at a distance from the user, be in proximity to the user, or be attached to the user. The device may be controlled through a motor, sensory, or brain interface. The device can perform tasks for individuals, passively move an individual, stabilize movement, assist and direct a movement, resist a movement, and even be “intelligent.” The primary technological challenge that remains is the complexity of controlling the accuracy, direction, balance, and force of robotic devices across the multiple body segments to successfully accomplish a task. This is a particular challenge when creating wearable robotics for human use.

The field of rehabilitation robotics is still considered to be in its infancy. However, with the increasing demand for effective rehabilitative strategies, many new and exciting innovations are being developed. There are many robotic systems in various stages of research and development, but only a few are commercially available. Improvements in engineering, materials, human physical interfaces, software, and robotic designs will require constant analysis and adjustment in the future. It is projected that the market for personal robotic devices will be worth $15 billion by the year 2015.15,16 The challenges of robotic engineering are broad. Clinicians will need to participate in research to help document cost-effective outcomes as well as to develop efficient screening criteria to match patient needs with available robotic devices. One of these challenges will be to bridge the gap between the mechanical attributes of robotic sensors, actuators, controls, microprocessors, force, velocity, friction, unweighting, pressure tolerance, software design, and flexibility with the human limb, brain, and nervous system. Important issues related to safety, materials, technology, and the quality of matching machine and human movements must constantly be considered. These engineering issues are discussed later in this chapter.

Classification of rehabilitation robots

General principles

There is a variety of ways to classify computerized technology for rehabilitation. For this chapter, we will group robotic technology first in terms of how robotics are used with or by the client relative to rehabilitation. This classification system is summarized in Figure 38-1 and Box 38-2. Rehabilitation technology can be further classified by a variety of variables summarized in Box 38-3. Rehabilitation robotics can also be classified by type of interface used. Some classification systems classify technology by multiple parameters.

Service robots usually focus on task performance, movement assistance, and stability. These devices can be fixed, can be movable, or can be attached to a wheelchair (Box 38-4). Assistive robotic devices help patients perform a task with direct or indirect assistance. Some of the assistive robotics are nonwearable but assist through unweighting or movement assistance (Box 38-5). Wearable robotics are specifically designed to be worn by patients to assist movements. These are designed for the upper or lower limb (Box 38-6). There are some new assistive training devices for the spine such as the Valedo Shape, Valedo Motion, and Hocoma devices (Figure 38-2). Prosthetic devices help patients maintain function despite the loss of a limb. Vocational robotics can enhance performance at work either in terms of repetitive motions or high-force task production that would otherwise be dangerous to humans. Communication robotic devices are designed to improve communication potential for subjects who cannot adequately speak or hear. Emotional support robotics are designed to provide emotional support for isolated individuals at home.

VR training technology (with and without robotics) provides the opportunity to simulate simple and complex environmental and clinical situations to facilitate learning (Box 38-7). Game-oriented computerized learning systems are currently popular for fun and recreation, but they can also facilitate memory as well as sensory and motor skill development. Finally, computerized technology can also enhance teaching home exercises to patients.

In this chapter, we will not address prosthetics for amputees, vocational robotics, communication robotics, emotional support robotics, or socially assistive devices,17,18 as these areas are considered specialty oriented and may or may not be included in traditional neurorehabilitation programs coordinated by physical or occupational therapists. However, information about the impact of the sound of the robot voice on patient motivation and compliance may be relevant to effectiveness. It is also important to acknowledge there are a number of motorized chairs, lifts, and walkers available that can be used to transition a patient from sitting to standing, or provide unweighting while walking or working on balance. Examples can be found in Box 38-8. Many of these systems are electromechanical systems controlled by the patient or the therapist. These devices are not usually programmable and are not classified as “rehabilitation robotics” or “advanced technology.” However, these types of devices are very beneficial for helping patients maintain walking and training to improve safety and quality of gait at home and with supervision. It is important for therapists to be sure these types of assistive devices have been integrated into a patient’s rehabilitation program and at home before recommending more sophisticated technology.

Description of robotic systems by type

Service robotic systems that provide movement assistance

Service robotics assist individuals with severe disabilities. Most commonly, the robot performs everyday activities (e.g., assisting with eating, drinking, object replacing, ambulating). There are three main types of schemes: desktop-mounted robots, wheelchair-mounted robots, and mobile autonomous robots. In general, these robots are used in the home, are interconnected to a variety of control systems, and are programmed to the environment and consequently are not very portable.1921

These types of robotic devices are generally used by patients with severe physical impairments and are generally preprogrammed to perform certain tasks. There are also some autonomous robots in which the cognitive interface between the user and the robot is used to tell the robot to perform a new task or to help the patient perform the task. These robotic systems are successful if the robot, the user, and the manipulated objects remain in the same initial set position every time a concrete task is performed. With the wheelchair-mounted manipulator, the relative position of the user with respect to the manipulator needs to remain the same. Although there are a variety of simple service-based robotic devices, most are complex, and setting them up at home generally requires a computer or engineering specialist.

Several examples of service robotics are described in Box 38-9.2230 A major issue is patient control options for service robotic devices. For example, through the use of headpieces on robotic devices, information can be detected from flexion and extension, rotation, and side bending of the head to operate wheelchairs, TV sets, telephones, doors, and security systems. There are also some new interfaces that are sensitive to facial movements and optoelectronic detection of light-reflective head movements.31 Other interfaces are sensitive to eye movements or use voice recognition, brain control,32,33 and gesture recognition.34 These interfaces not only may allow control of the robot but also may be applied to move a limb or perform a task.


I. Fixed upper-extremity service robotic devices

The earliest robots were fixed-site robots.

Fixed robotics were located in a nonmovable workstation.

Stanford University researchers, Boeing, and researchers responsible for several advances in France made significant improvements, particularly in integrating existing robotic systems.

Later, special manipulators were constructed to better fit the environment and the task.

The most well known systems for feeding were the Handy 1, My Spoon, and Neater Eater.22

Today, these devices have been advanced with powered programmable devices (devices can provide maximum control for those with minimal voluntary ability and assistance for individuals who are trying to retrain the arm to work in a functional task).

II. Mobile service upper-limb robots

Mobile service upper-limb robots are actually mechanical slaves. They are instructed to perform tasks.

The technology must be adequate to operate autonomously.

These units are expensive both in development and maintenance and usually require an engineer to set them up in the house and maintain their function over time.

III. Wheelchair-mounted upper-extremity manipulators

Wheelchair-mounted manipulators were first designed at the VA Prosthetics Center in New York (1984).

The Raptor25 was produced at a lower cost (only 4 degrees of freedom).

Exact Dynamics has also created a robotic manipulator (iARM) that is designed to help provide independence to people with severe disabilities.

Exact Dynamics also produces the Dynamic Arm Support (DAS), which compensates for the forces of gravity, making the arm practically weightless. These devices are currently being used in rehabilitation settings for training and for research.

IV. Automatically guided wheelchairs (agws)

Powered wheelchairs can have autonomous intelligence systems attached.

AGWs are service rehabilitation robots intended to move the individual with severe disability.

Computer sensing devices can be set up to handle emergencies and assist with task performance.

The robot must receive instruction about the destination point.

V. Rehabilitation service robots: smart house design

For individuals with physical disabilities and older individuals, these smart devices allow residents to live independently with minimal or no human assistance.

There are a number of smart devices that can be installed in the house that are linked to one another to process information from the inhabitant to make decisions and take actions in case of emergency.

Smart house designs continue to be an area of development, particularly with the increasing number of aged individuals who are no longer able to manage independently.

VI. Functional integration of multiple robots in the intelligent home environment

In the intelligent home environment, there are additional rehabilitation robotics designed to work with home-installed devices.

Placed in the correct arrangement, these robotic devices are controlled in a coordinated manner.

Service robotics are recommended when patients have achieved their maximum potential and still need assistance to live independently. A therapist may continue to work with a patient at home in order to maintain range of motion, minimize skin problems, and review whether the robotic technology is still providing the necessary assistance. However, an engineer will usually assume the primary responsibility for maintaining and adjusting the robotic equipment.

Assistive robotics

Nonwearable assistive robotic devices.

Nonwearable assistive robotic technology can be programmed for unweighting, facilitating compliance, providing assistance to perform a task (at home or at work), manipulating the environment, communicating (general interaction or calling for help), or improving memory and learning. Nonwearable assistive robotic technology includes devices that can sense the user’s force and velocity of reactions and facilitate assistance. These robotic devices may also be programmed to implement different movement exercises to fit the needs of the user.

A variety of parameters such as range of motion, sequential motions, force, and speed can be adjusted. A few of these devices have become commercially available, but many continue to be used for testing in the laboratory. At present and in the foreseeable future, the emphasis is on enabling devices that encourage dynamic patient movements for training or for enabling independence. These types of devices do not include electromechanical devices such as motorized bicycles in which different speeds can be set (see the discussion of screening patients for service robotics).

Types of nonwearable assistive robotic devices.

There is a variety of nonwearable assistive robotic devices. Some of these nonwearable assistive robotic devices are summarized in Box 38-10.3543 This group of robotic devices primarily includes powered wheelchairs with autonomous intelligence, body-weight–supported mobile walking aids, robots for body support with indoor and outdoor navigation, hands-off service robotic devices, and body-weight–supported treadmill systems (BWSTSs) with and without robotics.37,4145


I. Body-weight–supported mobile walking aids

Newly designed rehabilitation robotic systems can function as walking aids to help those who cannot walk independently.

Some mobile walking aids can walk the client, but others can also be used for training the patient to walk.

1. There are several electric motor-based gait rehabilitation systems.

2. Generally, gait rehabilitation systems include a robotic manipulator, a mobile platform, and a sensor system.

3. The robotic manipulator controls the amount of body-weight support.

4. The robot is mounted on a mobile platform that not only can support the user’s weight but can be adjusted to the height of the subject and provide stability when walking.

5. The robot has sensors to detect the status of the user (direction and velocity).

6. The mobile platform moves the whole system according to the subject’s motion with objects in the way of the moving platform detected by ultrasonic sensors on the front of the system.43

a. The mobile platform can vary from having a carlike design to having a mobile base with driving and steering wheels and differential driving mobile bases.

b. The front-wheel-drive carlike model has a complex mechanical design and can be very expensive.

c. The synchronous driving and steering mechanisms are complex but can approximate human walking, especially when the path is not linear.

d. Differential driving mechanisms require two independent driving wheels.

e. The mechanical architecture is simple and practical to implement but may require more maintenance.

f. There are training and following modes.

g. The challenge is to have sensors that can control stop and go of the user.

h. The supervisor can push an emergency stop button, but if the user is generally weak and does not have adequate balance reaction, the patient could fall when the mobile unit stops suddenly.

i. Example: the gait rehabilitation system:

(a) Used to study the impact of unweighting on gait parameters and patient exertion and heart rate.37

(b) Researchers have demonstrated that with increasing amounts of unweighting, there is an increase in single leg support and a decrease in double leg support, in terms of the percentage of time a given leg contacts the ground during steady-state walking.

(c) With increased unweighting and comfortable walking speed, there is a decrease in heart rate.

If the device is primarily used to facilitate standing to prevent contractures and skin ulcers, it may be classified as a stander rather than a walking aide.

II. Robots for physical support

Indoor navigation

Indoor and outdoor navigation

Unweighting with robotic-controlled stepping

Unweighting with robotic-controlled destabilization

1. One device that has been tested at the University of Chicago is the KineAssist (IMAGE).40 (See Figure 38-6.)

2. The KineAssist is a robotic gait training device that emphasizes balance recovery training during gait training.

3. The goal is to provide partial body-weight support and postural control on the torso while the patient walks over ground.

a. This device is on a mobile, multidirectional base that allows the patient to walk over ground, indoors or outdoors.

b. The trunk and pelvis are free to move, the legs are accessible, and the arms are free.

c. A servomotor follows the patient in forward, rotation, and sideways walking.

d. It has a robotic arm that is linked to the patient’s trunk.

e. The robotic arm can be set to allow the patient to move easily and even exceed the limit of stability.

f. The robot can also be programmed to specifically interfere with stability.

g. The patient can lose balance and “fall,” but the robotic arm will stop the fall after a defined range.

h. The patient can experience what is needed to keep from falling when the limit of stability has been reached.

i. With practice the patient can improve postural righting and balance.

III. Hands-off service robots

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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Integrating technology into clinical practice in neurological rehabilitation

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